As COVID-19 hit in the Spring of 2020, substantial challenges began to emerge for individuals around the world. In this empirical piece we examine the impacts of COVID-19 in the sport for development (SFD) context, as it relates to the individual participant, as well as how those individual needs impact the organization itself. This case study, explores a hybrid SFD organization, Highway of Hope (HOH) in Kenya, and the actions of local leadership in response to emergent participant needs during the onset of the pandemic. Using a case study approach, involving journal responses from program youth participants and local program leadership, along with other field and meeting notes, themes were generated to highlight the most salient challenges and experiences faced by individual participants, as well as the means of addressing those challenges by HOH. Participant journals consisted of both positive and negative thematic findings. Positive experiences included Family Time, Rest, and Practicing Better Hygiene, while negative experiences revolved around Restriction of Activity, and Difficulty at Home. The overall impact on participant lives were expressed in themes such as Socio-emotional, Physical, and Sport-Specific. Further, practical implications for grassroots and hybrid SFD programs during times of unprecedented challenge and notable turning points are highlighted. When the first COVID-19 case was confirmed and announced, there was evident panic and fear that engulfed the whole crowd at Upperhill school where the games were being hosted. That one announcement changed a lot of things, within a few minutes people started to treat each other as strangers, there were quick and regular visits to the open public water points (taps) to hand-wash, and people began self-distancing. On the same day as Highway of Hope (HOH) girls were playing their final game, the government, through the ministry of education and ministry of sports issued a directive to close all public events and sports around Nairobi. That was the beginning of a new normal in my life. (HOH Kenyan Program Director).During the Spring of 2020, the COVID-19 pandemic wreaked havoc on everyday life for over 7.5 Billion people around the globe. While the initial declaration of the outbreak was announced in January, it was not until March that regulations on social distancing, group gatherings, business operations, and various facility closures (including sport training facilities) were put into place , it failed to consider Sport for Development (SFD) programs or organizations. SFD organizations provide sport in various forms to millions of young people around the world, and sport is often only one component of more broadly designed programs that impact both individuals and communities  operates in Nairobi, Kenya in the informal settlement of Kibera. It exists as a partnership between local community members and several U.S. partners who help design, implement, and refine the program. Prior to COVID-19, the program had grown from one team of 12 adolescent girls from one school in Kibera, to 5 teams across 3 schools, with 59 young women taking part in the sport and mentoring activities. Pre-COVID-19, the programming consisted of basketball training 5 days/week for each team, and weekly mentoring sessions. The teams participated in their school-based basketball leagues, typically playing several games per week, until these were abruptly suspended in early March.The program (co-created and supported by Kenyan and U.S. partners) was delivered by local coaches and mentors. These coaches and mentors had relationships with the participants that spanned several months to 3 years. The U.S. partners have been involved with the project for since its inception, spending extensive time on-site with the participants, coaches, mentors, and program leaders. No site visits were conducted during the time of this study (March 2020- August 2020).From April 2020 to date, the program decreased from 59 girls in 3 schools to 16 young women from one school, based on physical space capacity of the organization. As of mid-May, these young women participated in academic tutoring and mentoring three times a week in a safe environment that allowed for social distancing. Initially, all sport training was discontinued, but as time passed, some restrictions were lifted, and the team could practice 1–2 times per week in small groups. They could eventually participate in some 1-h scrimmages, but the courts were limited to only 15 players at a time. The participants also took part in individual physical training, but did not have access to any basketballs, goals, or sport equipment for basketball skill development.Case studies rely on a variety of data collection methods in order to understand the case in as much depth as possible. These collection methods can include archives, observations, field notes, journals, and interviews . In the second step, we developed pattern coding, which pulled the overall first-level comments into groups or preliminary themes. Essentially, the goal in this step was to identify patterns and key excerpts from the data (representative themes) that described the overall essence of what the participants collectively communicated through their journals, interviews, or field notes  will be first be presented followed by the challenges (Restriction of Activity and Difficult Home Life). After this, the impact on participant lives  will be presented.The results are presented by research question and while not all the participants' views can be represented the most salient ones are provided. The results of RQ1, “What were the salient changes in participants' lives created by the onset of COVID-19 and how did those changes impact participant lives?,” revealed the COVID-19 impact on the lives of the young participants in the SDP program. While COVID-19 has presented a number of challenges for individuals around the globe, there have been emergent opportunities for positive takeaways, as well. The positive changes Due to the pandemic, everybody in our family is now at home starting from my parents to my brothers and sisters. In my family, since COVID-19 started we have been just staying at the home with my family with nothing to do at all. The only thing we have been doing is just to eat and read with each other. (Victoria)COVID-19 has impacted my relationship with my family members by avoiding talking to them. Before we used to meet and socialize together, I have missed them and would like to see them and talk to them. (Priscilla).Restriction of Activity in addition to their Difficult Home Lives. COVID-19 was clearly an unwelcome change in their lives.The participants experience of COVID-19 revolved around severe Socio-emotional, Physical, and Sport-specific.After describing their experiences, the participants went further to discuss the impact that the disruptions related to COVID-19 had on their lives. These impacts, both in and out of sport were profound. The participants expressed impacts on multiple life areas including Socio-emotional impacts include the feelings of sadness, loneliness, and disappointment that the girls are experiencing as a result of not being able to play, and interact with their friends, teammates, and supporting network program coaches and mentors, but also not being able to hug, share physical contact with those same individuals. The following three quotes illustrate this theme:COVID-19 has affected my mental health, especially quarantine. It has affected my usual activities. My level of loneliness, and feeling alienated has also gone up. This has saddened me a lot, but things will get better soon. (Melissa)So many problems have been disturbing my mind, like peer pressure. COVID-19 has affected me mentally and it is because I miss training with my teammates and going to school. (Jennifer)For my mental health, it has made me to be emotionally unstable, since I can no longer be with my fellow teammates, coaches, and beloved ones. I feel depressed on what is going on and I do wish that things would go back to how they were. (Mila).Interestingly, many of the participants expressed their feelings about the impact of COVID-19 in terms of regrets or things they took for granted prior to the regulations. As Savannah stated, “This makes me feel regretful of the time I wasted when the changes I left to go by. I really miss getting out of the house for tournaments.” Sarah added, “Life before COVID-19 pandemic was such a blessing, that we all took for granted.” In particular, the participants missed basketball and their teammates. As one example, Veronica said, “What I took for granted was that I did not think that my teammates will 1 day be separated from me.” And Melissa said, “I miss my coaches, my teammates, and even my opponents since we can no longer meet and have fun together and we cannot plan and train together.”COVID-19 also impacted physical aspects of the participants lives. In fact, every participant commented on the impact of COVID-19 on their fitness levels and physical well-being. These are illustrated in the following quotes:I used to have fun with my mates but right now we cannot meet and I really miss them. I feel so bad. I feel as if I'm growing fat on the inside. I just miss the court, the balls, our coaches, and my mates. (Theresa).COVID has impacted my physical health by making my body weak, and impacted my mental health by being idle, hence making my thinking capacity to be low. Training exercise also improved my mental health and kept me busy. (Priscilla).I used to have a flat belly, but now that I have to stay at home my belly is enlarging and becoming a pot. (Savannah).Sport-specific. As Grace explained, “COVID-19 impacted the closing of schools, which led to no accessibility of basketball courts, training facilities, and coaches. This has led to the slow decline of my basketball skills and abilities as a player.” Vanessa added, “Personally, my skills now have deteriorated and I can't handle the ball like I used to before. I miss my shooting, like three-point shooting, and defense.” Similarly, Savannah said, “My skills in basketball are stagnant and have started to wear-out for I have no access to improve my skills.” The athletes expressed frustration at having worked very hard to gain a skill, then watching it deteriorate over time. As Priscilla said, “When this is over, I hope I don't have to start from square one.”Related, the lack of basketball activity impacted participants' development of basketball skills; these are expressed in the theme Family, Rest, and Practicing Better Hygiene) and struggles  as well as the various ways that COVID-19 impacted their lives in and out of sport. The emerging participant experiences highlighted core participant needs as well as opportunities for HOH local leadership to take on new ways of helping their participants, and the organizational adjustments it would take to do so.Overall, the participants' articulated both positive experiences  Educational Advancement, and (3) Provision of Essential Supplies. In the words of the Head Basketball Coach:Research Question 2 asked, “What were the emergent participant needs, and in what ways did the SFD organization adapt to meet the emerging participant needs? The review of the participant data and daily interactions with the participants led the local program leaders to suggest that the three main needs of the participants were the following: (1) The pandemic has exposed most of the students, especially girls, to a lot of situations which has left them vulnerable to fall into wrong hands and make bad choices. The lack of safer space in the slums and support has caused a lot of pressure for the students.Multiple youth participants expressed gratitude toward the organization in their journal entries, saying that “the organization helped [give them] mentorship classes, which helped my life because outside there are young teenagers engaged in bad company,” and “since we are on a long holiday [they] are more likely to be engaged in bad things like prostitution, getting pregnant, and stealing.”Love, Safety, and Support—the organization arranged a safe space and began to offer small-group and individual mentorship. This has assisted the students in having time in a safe space away from slum pressure as well as positive engagement with their teammates, coaches, and mentors. As stated by the Kenyan Program Director:To address the first need—The other challenge that was presented to us was to have girls' teenagers, those who did not travel to the countryside, sit idle and move around their neighborhood without any serious engagement. We have had a nationwide outcry of teenage pregnancies that is worrying during this COVID-19 period, which was documented and aired in our national televisions. This called upon the HOH team to think of a rapid response toward engaging the girls in a meaningful tutorials, training and mentorship out of the normal school program. We've not been able to meet to all the girls in the program but we are grateful for the opportunity to reach out to the small number, which has been made possible due to the long working relationship we've had with the girls and their parents. This has presented me as a leader in the program to rethink of the design as we implement this program and other similar programs in the future: Parental/guardian involvement is very key and important at the onset of every sport program targeting youths/children below 18 years in our context.The mentoring and tutoring structure, delivery and actual content is a departure from the original HOH program design, which follows a weekly group mentoring model and pre-developed curriculum. However, based on notes from the bi-monthly team meetings, the entire program team felt the adaptation was true to the organizational mission, and presented a valuable opportunity to build deeper relationships with a smaller number of young women. The team members agreed that the socio-emotional, physical, and mental health of the girls was of primary importance. As explained by the Head Basketball Coach, “The coaches and mentors have also maintained love and support to the kids by being the go-to person whenever they have issues they would want to share.” Participant journals were full with statements like, “I would like to thank HOH for how they mentored us, because they make our future safer than those young youth idling outside and having nowhere to be helped,” “they have given me support and love, and shared everything with us,” and “they have supported me and mentored me in such a way that not to give up on life.”As an additional measure to address a desire to have some physical activity and interactions with coaches, HOH has also been able to secure a training ground and the students get to play thrice a week which is helping them to stay active, fit, and out of any possible trouble. It is clear that providing Love, Safety, and Support are fundamental to HOH, and this was a participant need that the organization had to adapt to providing.Second, it became obvious that educational needs were not being met for many of the participants. As explained by the Head Mentor:The government closed schools and most of the children could not access online classes due to lack of gadgets and Wi-Fi. This meant that most of the students were heavily disadvantaged. The coaches and mentors have now been forced to step up and be the teachers to the kids to ensure their education continues. The program has gone a long way to use the coaches and mentors to personally tutor the kids and provide them with practical job skills training that will help them in the future.Specifically, HOH helped by setting up a study group for the students where they can come and learn together. The program implementers, of their own initiative and through their local community networks, secured a sufficiently large space for the study group. The teaching is done by the coaches and a few invited individuals who have come out to support the study group. The students also have access to a library through the partnership of several local organizations. Grace expressed her concern about home schooling by saying:Before we learned by going to school, hence now we have to learn through the internet and television. This story makes me feel uncomfortable about learning through the internet and television because not all students can afford those materials… and the teacher may explain something that we cannot understand without asking questions.The young women's appreciation for the HOH response to these needs was overwhelmingly positive. Journal entries included statements like those from Vanessa,My biggest needs during this time is to really study hard so that when I go back to school I can catch up with the teachers lessons and my mind won't be shut down. HOH has really helped me because by now I would be at home and studying alone, which is boring, and they helped me by creating a study group.From a program development perspective, the HOH program implementers took the initiative not only to secure the space, but also to design the tutoring program as well as the practical skills/leadership training component. Interestingly, the development of this practical skills/leadership component was something that was a strategic goal of the organization for 2020 and had not received much attention or traction due to the rapid growth of the program and the emphasis on basketball during the inter-school season which takes place from February to April. The reduction of the program size and scope actually allowed for more focus on this aspect of the program. As the US Program Director said:One good thing, from my perspective was that we were able to develop the senior leadership curriculum, and to really dig-in on the relationships of the senior girls who had been involved for three years now. To watch what the Kenyan team built and delivered, and thinking how we might utilize that in the future, was a huge step forward for our organization.Educational Advancement was also something HOH needed to adapt in their delivery to ensure participant needs were being met during the pandemic.It was clear from the data that Provision of Essential Supplies became immediately apparent as the pandemic led to most of the participants' parents losing their casual labor jobs. This meant that most parents were home without money. Most of the parents do not have savings and had little way to provide for their children. As Diana shared,Finally, the need for the Due to the pandemic, everyone has been forced to stay home and when this happened many people lost their jobs and unemployment increased. There is a need for food and shelter, which are the main things. The food prices have also raised. However, there is still hope because HOH came at the right time to help people. They assist people by giving them food and other necessities. I am really grateful for their help.Mila added, “What I have been needing is food, studies, and sanitary towels. I want to thank HOH because they have provided what I needed.”The HOH program responded by organizing food/supply distributions within 2 weeks of the government shut-down. Since then, the HOH program staff has continued shopping for food stuffs and other essentials like sanitary pads at least twice a month to relieve the pressure from the parents and the families. In the words of the Kenyan Program Director:Working with the coaches and mentors and with consultation and financial support from our U.S. partners, we have been able to redirect some funds that were budgeted for appreciating mentors. This money has been used to buy food supplies for the girls in the program whose families have been hardly hit by this pandemic. The food supplies have helped to cushion the girls and their families, from hunger, hustles of child labor and sexual exploitation in search of daily bread. This has greatly aided to keep our girls safe from sexual transmitted diseases, teenage pregnancies, child labor and sexual assaults and abuse.The program implementors were ambitious and creative in developing plans for food distribution and in raising the funding for much of the initiative. In addition, the program leaders suggest that this distribution helped develop closer relationships with the participants' families, which will continue to build trust not only in these families, but also across the community.Love, Safety, and Support, Educational Advancement, and Provision of Essential Supplies were the most salient participants needs. To meet those needs, HOH, at the direction of grassroots providers adapted both content and delivery of their SFD programming to provide for these needs during the COVID-19 pandemic.In summation, Core Values, (2) Process Tensions, (3) Delivery. Each of these is discussed below.Research Question 3 addressed how the program changes might affect the future of the organization. There were three main themes related to the future of the organization: (1) Core Values of the organization that will continue to inform its future. That is, the core value of loving and supporting young people was strongly reified through the experiences with COVID-19. As the Head Program Mentor and Head Basketball Coach discussed, “The main program interest when dealing with kids is the love, care, and support. When this is achieved any other challenges can be tackled.” This sentiment was affirmed in the bi-monthly conference calls where the entire program staff discussed that the actual content and specific delivery mechanisms of the HOH program were all flexible as long as they were directed toward loving and serving local young people.First, the HOH program response to changing participant needs highlighted the Process Tensions within the organization. These were mainly related to discussions about which organizational members were responsible for what program aspects , and how funding and other resources would be distributed to the various stakeholders. As documented in the internal program documents, bi-monthly conference calls, prior to COVID-19, the program staff agreed to a set of organizational goals with a timeline and designated personnel. The drastic shift in participant needs coupled with government restrictions essentially negated the entire program plan that had been agreed upon.Second, the organization's response to the participant needs highlighted a few This created some tension within the organization based on internal agreements about what activities each stakeholder would be responsible for conducting and contributing to the organizational goals. As reflected in an informal interview with the Head Mentor:It's difficult because we want to do the best thing for the girls, but we are not able to receive the support from the organization as a whole because they cannot come here where we are. We cannot leave the girls with nothing, but we are not sure what to do. So that is troublesome.The field notes from the U.S. Program Director echo this tension,I am in uncharted waters. I feel that we should just release all obligations from the time COVID started, but I am not sure if that is the right way to go. It seems unreasonable to hold people accountable for activities they have NO WAY of carrying through. I think the best way forward is to start fresh with expectations from everyone.According to the field notes, the organization essentially did that, collectively revamping the roles and responsibilities of the US Program Director, Kenyan Program Director, Head Basketball Coach, and Head Mentor according to the newly defined participant needs, and the activities that seemed reasonable and feasible to conduct at least for the remainder of 2020. The organization quickly moved forward at the direction of the program implementers.Program Delivery. For example, the Kenyan Program Director mentioned that prior to COVID-19 the program focus “has been solely school based and child/teen centered/oriented. So, COVID-19 has challenged our working/implementation model.” This presented a challenge, in terms of delivery because schools were closed. This also created an opportunity to reconsider delivery. In her words,Finally, the adaptations necessary to work through COVID-19 provided an opportunity to revisit and reconsider the future of HOH In future this calls for a more holistic approach, and includes parents and caregivers/guardians at the onset of the program implementation, especially at recruitment level. This makes follow-ups easier, and trust is built and enhanced during earlier stages of the program.Because the program has been operating almost entirely through communication with the schools, the closing of schools created a massive communication gap between HOH and their participants, which can be addressed through those recommended changes.Another challenge that the Kenyan Program Director expressed during the COVID-19 season was technology. While they had put together “plans and projections to conduct e-mentoring sessions with mentees,” they experienced “major setbacks due to the lack of necessary quotient and technology know-how of some mentors and mentees.” For future delivery of the HOH program she recommended increased investment “on building the capacities of the volunteers, and both mentors and coaches on matters of IT and social media.” Further she notes that it would be helpful to also empower the program participants on “responsible, disciplined, use and access to social media platforms.”Love, Safety, and Security, Education, and Provision of Essential Supplies. The focal case organization, Highway of Hope, responded in multiple ways, demonstrating flexibility in content, place, and delivery model. Consistent with Warner and Martin (The COVID-19 pandemic represented a turning point both for individuals and organizations around the world (Giele and Elder, d Martin  COVID-19The framing of COVID-19 as both an individual and organizational turning point supports the use of life course theory for understanding individual's sport experiences. Clearly, these sport experiences are shaped and constrained by historical and social forces beyond their control, and exploring both the impact and the response can provide a richer understanding of the lived experiences of SFD participants around the globe.Socio-emotional and Physical Health, and their Sport-specific skills. Prior to COVID-19, sport was clearly making a positive impact on their lives and the removal of sport was felt well-beyond the act of playing the game.Further, this study extends Warner and Martin  by addinAt an organizational level the results demonstrated the ability of grassroots SFD organization to rapidly identify and respond to emerging participant needs. This organizational response highlights both the tensions and the adaptability of a hybrid grassroots organizations (see Dixon and Svensson, It appears that the organizational structure and values were flexible enough to adapt to the organizational changes, but it is not entirely clear what other factors led to the ability of the organization to adapt quickly. Previous scholars have suggested that trust, cultural sensitivity, and openminded organizational leadership are essential for maximizing the strengths of hybrid organizations (Smith et al., The study was limited to the examination of one SFD organization, and the participant experiences of young women in a high school setting. Because the study was focused on life course theory and on understanding organizational responses to turning points, it was not focused specifically on women's experiences. However, it is possible that the life course experiences of these young women are gendered in nature (see Bruening and Dixon, The results from this study suggest that SFD organizations need to continue to focus on identifying the core needs of their constituents in program design, and also ensure that the programming meets those needs first, rather than the demands imposed by external stakeholders who may not understand or value the core needs of those participating in the programs (Giulianotti et al., Second, this study points to the need for ongoing capacity building of grassroots providers for several reasons. First grassroots providers need to be able to respond to participant needs without “strong” dependency on external organizations. For example, in this organization, the primary program providers were able to initiate food distributions and secure a location for tutoring based on their own internal community networks. Then, the organization as a whole was able to support those needs and help broaden and sustain them. But the capability of the primary providers allowed for the most flexibility and rapid response from the organization. This could be a sign of the organizations' path toward sustainability, as the very definition of organizational sustainability according to Lindsey , p. 283 Building capacity of grassroots providers also enhances their capability to respond to a broader array of participant needs. For example, within this organization, basketball coaches were able to at least provide rudimentary tutoring and educational programming. If they had broader skills and/or training, they might have been able to provide even better educational components or more mental health support than a “listening ear.”Third, the study points to the need for continuing to build SFD programming that enables and bolsters capacity and independence of the participants themselves. That is, some SFD organizations by the design of their programming, actually develop a dependency on the organization (Schulenkorf, Along with the practical implications, this work also offers some important theoretical insights related to life course theory and turning points (Giele and Elder, The results also extend theory in the area of organizational hybridity, whereby the events created opportunities for the organizational partners to continually renegotiate partner roles, expectations, and organizational logics. The study illuminated the need for organizational hybridity to be viewed not as a static state to which organizations arrive, but as a continuously responsive and dynamic process (see also Battilana et al., The clear story of this study is the central role that sport plays in the lives of participants in a grassroots setting. The role of sport in this context extends well-beyond the playing of a game, but instead anchors the participants' individual and social lives. The participants' lived experience of COVID-19 is that it took away sport from them, which impacted not only their sport skills, but also their physical and socio-emotional well-being. Therefore, it is imperative that grassroots organizations are prepared, adaptable, creative, and participant-centric such that they can seamlessly continue to carry out their operations in the face of challenges, turning them instead into opportunities for new ways of advancing sport as a positive impact in individuals and communities around the world.madixon@tamu.edu.The datasets presented in this article are not readily available because these are confidential data per IRB requirements, particularly because the organization is named in the study. Requests to access the datasets should be directed to Marlene A. Dixon, The studies involving human participants were reviewed and approved by Texas A&M University IRB. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.MD conceptualized the study, helped with the design of data collection, analyzed, interpreted, and wrote much of the manuscript and was the lead author. AH helped with conceptualization and framing, data analysis, and also contributed to technical aspects of the manuscript. SW helped with conceptualization, framing, and writing the results. EO and DO helped with conceptualization, design of the case study, research questions/journal prompts, and also collected and analyzed the data. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Computer vision-based approaches are very useful for dynamic displacement measurement, damage detection, and structural health monitoring. However, for the application using a large number of existing cameras in buildings, the computational cost of videos from dozens of cameras using a centralized computer becomes a huge burden. Moreover, when a manual process is required for processing the videos, prompt safety assessment of tens of thousands of buildings after a catastrophic earthquake striking a megacity becomes very challenging. Therefore, a decentralized and fully automatic computer vision-based approach for prompt building safety assessment and decision-making is desired for practical applications. In this study, a prototype of a novel stand-alone smart camera system for measuring interstory drifts was developed. The proposed system is composed of a single camera, a single-board computer, and two accelerometers with a microcontroller unit. The system is capable of compensating for rotational effects of the camera during earthquake excitations. Furthermore, by fusing the camera-based interstory drifts with the accelerometer-based ones, the interstory drifts can be measured accurately even when residual interstory drifts exist. Algorithms used to compensate for the camera’s rotational effects, algorithms used to track the movement of three targets within three regions of interest, artificial neural networks used to convert the interstory drifts to engineering units, and some necessary signal processing algorithms, including interpolation, cross-correlation, and filtering algorithms, were embedded in the smart camera system. As a result, online processing of the video data and acceleration data using decentralized computational resources is achieved in each individual smart camera system to obtain interstory drifts. Using the maximum interstory drifts measured during an earthquake, the safety of a building can be assessed right after the earthquake excitation. We validated the feasibility of the prototype of the proposed smart camera system through the use of large-scale shaking table tests of a steel building. The results show that the proposed smart camera system had very promising results in terms of assessing the safety of steel building specimens after earthquake excitations. After a large earthquake, it is very important to perform damage assessments of affected buildings in order to ensure public safety during aftershocks. Fast and sound post-earthquake evaluations can not only prevent people from returning to unsafe buildings, but also reduce the time spent waiting for experts to determine whether buildings are safe or not, thereby accelerating the recovery of building functions and improving overall earthquake resilience. In practice, the acceleration responses of buildings are often used to calculate the maximum interstory drift during earthquake excitations for post-earthquake damage assessments. For example, Naeim et al.  proposedHowever, as has been pointed out by many researchers, the low-frequency range of displacements estimated using acceleration signals will be inaccurate when the displacements are not close to a zero mean process because a high-pass filter is required to remove the low-frequency drift after the double integration of acceleration measurements is conducted ,4. TrapaThanks to the rapid advances in computer vision in recent years and the advent of inexpensive high-resolution cameras, the camera-based noncontact approach has emerged as a promising alternative to the use of conventional accelerometers for structural dynamic response measurements. The merits of computer vision-based dynamic displacement measurement include its low cost, ease of setup and operation, and the ability to measure displacements of many locations using a single video measurement. Many studies have already employed computer vision-based approaches for dynamic displacement measurement, damage detection, and structural health monitoring. Most of the techniques in question measure dynamic displacement using cameras located outside the target structures. Among them, the majority of the applications have been in full-scale bridge structures ,7,8. ForMeanwhile, there have only been a few studies involving the application of computer vision-based approaches to measure interstory drift using cameras installed inside structures. For instance, Hsu et al.  demonstrIn this study, we combined a single camera, a single-board computer (SBC), and two accelerometers with a microcontroller unit (MCU) to produce a novel stand-alone smart camera system for fully automatic decentralized video processing and decision-making supporting right after an earthquake event. The PDP method, data fusion algorithm, and necessary artificial neural networks (ANNs) and signal processing algorithms are embedded into the smart camera. Hence, the smart camera has the ability to convert the targets within three regions of interest (ROI) in a video into camera-based displacement time histories of the three targets in real-time. The camera-based interstory drifts without rotational effects of the camera are then obtained using these three time histories and the PDP method. After the vibration has stopped, the final interstory drifts are then calculated using data fusion of the camera-based interstory drifts with the accelerometer-based ones. The level of damage to the story can then be estimated using the maximum interstory drift based on the threshold suggested by the FEMA . The detThe hardware of the smart camera system consists of an SBC, an MCU, two sensor boards with one accelerometer on each board, and a camera. The prototype and main component diagram of the smart camera system are illustrated in TM-T764 GPU , four USB 2.0, 10/100/1000 Ethernet, WiFi 802.11 b/g/n, Bluetooth 4.0 interface, and 4K H.264 video playback capabilities. The overall performance of the Tinker Board is approximately twice as fast as the Raspberry Pi 3; hence, it was deemed suitable for this study because of the desired real-time processing of video images. In addition, the TinkerOS includes a number of popular applications, e.g., the libraries of Python functions; hence, it offers high versatility and allows for easy programming and development.The SBC used in this study was the Tinker Board development board based on the ARM architecture. It employs the Quad-core RockChip RK3288 SoC  with ARM MaliThe main tasks of the SBC include (a) calculating the short-term average over long-term average (STA/LTA) values of the accelerations to determine the trigger and de-trigger of an earthquake event; (b) converting the movements of targets within three ROIs of the video signals into the dynamic pixel displacements of the three targets based on the patch-based tracking approach, after which the dynamic pixel displacements are converted to the ones in engineering units using the embedded ANNs; (c) calculating the camera-based interstory drift time history without rotational effects of the camera from the three dynamic engineering displacements based on the PDP method; (d) calculating the accelerometer-based interstory drifts by subtracting the accelerations recorded by the floor-mounted sensor board from those recorded by the ceiling-mounted sensor board after double integration and high-pass filtering of the accelerations; (e) performing data fusion of the camera-based interstory drifts with the accelerometer-based ones after time synchronization based on the cross-correlation approach; (f) calculating the fused maximum interstory drift value and then estimating the damage status based on the predefined thresholds. The first four tasks are processed in real-time, while the last two tasks are processed right after the earthquake event is de-triggered. The details of the algorithms used to perform these tasks are described in The camera used in this study was a consumer-grade camera, the Microsoft LifeCam Studio . Its spatial resolution is 1080 p (1920 × 1080 pixel) with an autofocus, wide-angle high-precision glass element lens and CMOS image sensors. The video signals of the camera are transmitted to the SBC via the USB interface in real-time.The accelerometers used were EVAL-ADXL203 accelerometers . They are two-axis, low-noise, temperature-stable accelerometers with a small size (1” × 1”). The analog signals of the accelerations are converted to digital ones on each sensor board using the 16-bit analog to digital converter ADS8326. The ADS8326 requires very little power, even when operating at its full data rate. Because the ADS8326 transmits the digital signals via the SPI interface, whose communication code is not compatible with the one of the Tinker Board, the MCU board is designed as a relay to transmit the acceleration signals in real-time to the SBC. The MCU board mainly consists of an NXP LPC1768 development board with a 32-bit ARM Cortex-M3, 512 kB flash, 64 kB SRAM, 4 UARTs, USB Device, ultra-low power Real-Time Clock with separate battery supply, and up to 70 general purpose I/O pins. Hence, the real-time operating system can easily transmit the acceleration signals to the SBC in real-time.The algorithms embedded in the SBC of the smart camera are introduced in this section.On-board real-time processing of the raw video is required to be conducted in the smart camera system within each frame interval because no video will be recorded in the stand-alone system during an earthquake event. Since the computational resources in the SBC board are limited, the dynamic pixel displacements of the target points within the ROIs in the raw video are tracked based on a patch-based approach that requires limited computational efforts, but not other non-target-based methods which require much more computational resources. The targets of the video are the cross patches attached on the floor and on the ceiling, as shown in Before the cross patches are attached on the floor and ceiling, a chessboard panel is placed within the ROI for calibration. The displacement between the camera and the target points is basically only two-dimensional; in other words, it is located within the plane of the chessboard. The size of the chessboard, which consists of 9 × 9 intersections with the sides of each block being 1.85 cm in length, covers the area of possible displacement during an earthquake excitation. The mapping between the pixel coordinates The pseudo displacement points (PDP) approach was proposed by Hsu and Kuo  as a metSpecifically, the displacement calculated using the camera images The first step of the PDP method consists of calculating the initial position of the virtual point using the cross product of the known positions of the two target points on the ceiling, as in Equation (1):At time step Once the rotation matrix Finally, the true relative displacement between the target point on the floor and the camera on the ceiling The interstory drift time history, i.e., the true relative displacement between the target point and the camera at each time step during the earthquake excitation, is recorded in the smart camera system for further calculation.π/180, and the translation of the camera due to the rotation of the ceiling will be approximately only 1.75 mm, which is only 5.8% of the interstory drift ratio. Based on this condition, the relative displacement between the camera and the floor is mainly contributed by the interstory drift after the rotation of the camera is corrected. As a result, the error due to rotational effects will be greatly reduced after the PDP method is applied.Note that the PDP method assumes there is little relative displacement between the camera and the ceiling where the camera is mounted on. This can be realized in practice provided the support of the camera is rigid and the length of the support is short. As a result, even when there is a small rotation of the ceiling on which the camera is mounted because both the rotation of the ceiling and the length of the support are very small, the translation of the camera due to the rotation of the ceiling will be relatively very small compared to the interstory drift. For instance, when a 1% drift ratio occurred in the story 3000 mm in height, the interstory drift is approximately 30 mm. Assuming the length of the support is approximately 100 mm, the rotation of the ceiling is approximately 1The computational resources in the smart camera are limited; hence, the frame rate of the interstory drifts measured by the camera is approximately 13 Hz. Generally, because the image will be blurred more seriously when the speed of the interstory drift is faster, the error of the interstory drift measurement will be larger. When the frame rate of the video is low, the error of the interstory drift measurement will be even larger, especially when the vibration speed is high during an earthquake with large intensity. Therefore, the accuracy of the interstory drift measurements made by the camera may not be high enough.On the other hand, because no reference is required when using acceleration to estimate displacement time history in an indirect way, acceleration-based approaches are among the engineering practices used to estimate the interstory drifts of buildings during earthquake excitations . HoweveThe data fusion procedure for combining the vision-based interstory drifts with the acceleration-based interstory drifts is summarized here. The sampling rate of the acceleration data in this study was 100 Hz. Hence, the interstory drifts measured by the camera were upsampled to 100 Hz using cubic interpolation. Cross-correlations of the vision-based and acceleration-based interstory drifts were then calculated, and the time shift with the largest cross-correlation value was used to synchronize the data. An FIR filter with stable poles and a linear phase delay was employed to perform low-pass and high-pass filtering of the vision-based and acceleration-based interstory drifts, respectively. The filter order was designated as four for the data fusion, as suggested by Park et al. . BecauseNote that the appropriate cut-off frequency could be different case by case. In the present study, we measure both the vision-based and acceleration-based interstory drifts together with a baseline measurement of LVDT during earthquake excitations for tuning. In reality, it is not practical to determine the appropriate cut-off frequency using similar approaches. In order to provide suggestions for the determination of the appropriate cut-off frequency for practical applications to real buildings, a large number of numerical studies based on different measurement qualities and structural characteristics are required in future study.The maximum absolute fused interstory drift during an earthquake excitation was used to estimate the damage state of the building specimen. Five damage states, i.e., no damage, slight damage, moderate damage, extensive damage, and complete damage, as defined by FEMA, are employed to describe the damage state of a building after an earthquake excitation. Different thresholds of interstory drift ratios of different building types, heights, and seismic design levels can be found in the tables of the technical manual of the earthquake model of the multi-hazard loss estimation methodology (HAZUS-MH) .A scaled six-story steel building structure designed and constructed at the National Center for Research on Earthquake Engineering (NCREE) in Taiwan was used to experimentally test the proposed smart camera system, as shown in The dimensions of each story of the building were 2.0 m wide × 2.0 m deep × 2.0 m high, and the mass of each floor was 2000 kg. Each beam and column were made of A572Gr50 steel and had a customized I-shaped cross-section with 125 mm × 6.9 mm web and 125 mm × 9 mm flanges. The weak axis of the column was along the X-direction. By installing a weaker cross section of the beams with flanges cut along the Y-direction in the first story see c, the daThe camera (Microsoft LifeCam Studio) was mounted on the bottom surface of a beam of the first floor, as shown in According to the HAZUS-MH technical manual, the building specimen belongs to the category of a mid-rise steel moment frame with a high-code seismic design level. Hence, the thresholds of the slight, moderate, extensive, and complete damage levels for the specimen are 0.40%, 0.80%, 2.00%, and 5.33%, respectively.Due to the limited computational resources in the Tinker Board, recording the video and calculating the interstory drifts during earthquake excitation at the same time would make the frame rate much lower; hence, only the calculated interstory drifts of the target points were recorded.First of all, the calculated interstory drifts between the camera and the target points before the correction of rotational effects were observed. Although five earthquake excitations were conducted, only the interstory drifts of the smallest and the largest excitations, i.e., those with PGA values of 50 gal and 250 gal, respectively, are shown in The interstory drifts between the camera and the target points after the correction of the rotational effects using the PDP method, i.e., For post-earthquake damage assessment of the building specimen, the maximum absolute interstory drifts during the earthquake excitations play a critical role. The maximum absolute interstory drifts measured by the smart camera system and the LVDTs are summarized in Using the maximum absolute fused interstory drifts during the earthquake excitations, the damage level after the excitation of each earthquake was estimated according to the thresholds provided in the HAZUS-MH technical manual. The estimated maximum interstory drift values using the camera without correction, the camera with correction, the accelerometers, and the camera fused with the accelerometers are listed in In this study, the prototype of a novel stand-alone smart camera system for decision-making about building safety after an earthquake was developed. The hardware of the system was designed to enable the online processing of the video to obtain interstory drifts. The PDP algorithm used to compensate for camera’s rotational effects, the algorithm used to track the movement of three targets within three ROIs, the ANNs used to convert the interstory drifts of pixels to engineering units, and some necessary signal processing algorithms, including interpolation, cross-correlation, and filtering algorithms, were embedded in the smart camera system. In addition, both the interstory drifts measured by the video data of the single camera and the acceleration data of two accelerometers were fused together to measure the interstory drifts during an earthquake excitation with high accuracy, even when nonlinear low-frequency and residual interstory drifts existed. By utilizing this approach, the smart camera system has the ability to obtain the maximum interstory drifts during an earthquake right after the earthquake excitation using the decentralized computational resources of the smart camera system itself. Based on the thresholds provided in the HAZUS-MH technical manual, the safety of a building can then be assessed immediately after an earthquake.The developed prototype of the smart camera system was validated in large-scale shaking table tests of a six-story steel building. In this study, we focused only on establishing a proof of concept for the developed smart camera system; hence, only one set of the smart camera system was installed in the first story of the steel building where the interstory drift was anticipated to be the largest. Based on the results, we concluded that the errors due to rotational effects were decreased substantially after correction using the PDP method, and the errors of the interstory drift measurements were reduced even more when the interstory drifts measured by the camera were fused with the interstory drifts measured by the accelerometers. The damage levels estimated using the maximum absolute fused interstory drifts during the earthquake excitations measured by the smart camera system were identical to the ones measured by the LVDTs, whereas some of the damage levels estimated using the camera with and without the correction of rotational effects were underestimated. Nevertheless, the results show that the developed smart camera system had very promising results in terms of assessing the safety of the steel building specimen after earthquake excitations. As pointed out by the review paper by Spencer et al. , the rea


Stepped wedge cluster randomized trials (SW-CRT) are increasingly used to evaluate new clinical programs, yet there is limited guidance on practical aspects of applying this design. We report our early experiences conducting a SW-CRT to examine an inpatient mobility program (STRIDE) in the Veterans Health Administration (VHA). We provide recommendations for future research using this design to evaluate clinical programs.Based on data from study records and reflections from the investigator team, we describe and assess the design and initial stages of a SW-CRT, from site recruitment to program launch in 8 VHA hospitals.Site recruitment consisted of thirty 1-h conference calls with representatives from 22 individual VAs who expressed interest in implementing STRIDE. Of these, 8 hospitals were enrolled and randomly assigned in two stratified blocks  to a STRIDE launch date. Block 1 randomization occurred in July 2017 with first STRIDE launch in December 2017; block 2 randomization occurred in April 2018 with first STRIDE launch in January 2019. The primary study outcome of discharge destination will be assessed using routinely collected data in the electronic health record (EHR). Within randomized blocks, two hospitals per sequence launched STRIDE approximately every 3 months with primary outcome assessment paused during the 3-month time period of program launch. All sites received 6–8 implementation support calls, according to a pre-specified schedule, from the time of recruitment to program launch, and all 8 sites successfully launched within their assigned 3-month window. Seven of the eight sites initially started with a limited roll out (for example on one ward) or modified version of STRIDE .Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate rollout of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a “ramp-up” period. Successful execution of SW-CRT designs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out.NCT03300336. Prospectively registered on 3 October 2017.ClinicalsTrials.gov  The stepped wedge cluster randomized controlled trial (SW-CRT) design has been recommended as a useful tool for evaluating innovations in health care delivery . In SW-CSW-CRT designs have been mainly applied to evaluate interventions that have been shown to be effective in previous research in other settings and/or where there is a strong belief that dissemination of the intervention will do more good than harm . One exaWe share our experiences conducting the initial stages of a SW-CRT to evaluate a hospital mobility program (STRIDE) in VHA. A SW-CRT design with all sites receiving the intervention was selected as the most efficient approach to achieve our goals of a mixed method evaluation of both implementation and effectiveness. In this paper, we describe the components of the SW-CRT for STRIDE, focusing on decisions related to trial design and their impact on the study to date. We present lessons learned from STRIDE recruitment through the time of program launch and provide recommendations for design considerations for future studies utilizing SW-CRTs to evaluate clinical programs in hospitals. These considerations represent some key points that may be overlooked and, if not considered carefully, may jeopardize successful program implementation and study completion.p = 0.007) and had a reduced length of stay by 1 day, consistent with findings from other similar hospital mobility programs [We describe a SW-CRT that is ongoing in 8 VHA hospitals as part of the Optimizing Function and Independence Quality Enhancement Research Initiative program (Function QUERI) . STRIDE programs , 15.An overview of our original study design is presented in Fig. Three important early and related design decisions regarding the timing of our study were (1) whether to conduct a single randomization or randomize in blocks, (2) how many clusters would be randomized within each sequence, and (3) how long each time period would last.In the Function QUERI STRIDE SW-CRT, we enrolled and randomized hospitals to their sequence in 2 distinct blocks  to each sequence, meaning 2 hospitals were assigned the same start date and overall study schedule. A main consideration in this decision was estimating how many hospitals we could support in both implementation and data collection activities at the same time based on available study staff. We selected 3 months as the duration of each time period because we estimated this would give hospitals a reasonable window of time in which to launch their programs and also be long enough to assess the impact of intervention on our primary outcome (discharge destination). The duration of the time period along with the number of clusters per randomization sequence determines how many time periods are needed to complete the SW design to conduct the trial and this can have implications for other design decisions .In Function QUERI STRIDE, hospitals were eligible to participate if they had a minimum average daily census of 20 general medicine patients per day (approximately 250 in a 3-month window) and agreed to start a STRIDE program within their randomly assigned 3-month window for program launch. The primary outcome, discharge destination (home vs. other), will be assessed at the patient-hospitalization level using routinely collected data in the electronic health record (EHR) and health care claims data. Other clinical outcomes include length of stay and patient-reported measures such as self-rated physical and psychosocial function, collected via telephone survey in a subset of participants. A description of the mixed methods evaluation plan has been previously published . STRIDE In the following sections we describe our experiences with implementing the initial stages of the trial. Based on data from study records and reflections from the investigator team, we present our experiences from site recruitment to program launch and implications for design decisions in future SW-CRTs.Table Figure Site characteristics for the 8 participating sites are presented in Table Due to the small number of clusters in our trial, a potential benefit of randomization may be lost as the balance of known and unknown confounders may not be possible . TherefoThe eight hospitals implemented their STRIDE programs following the blocked randomized stepped wedge design according to 4 sequences over a total of 24 months. As noted earlier, an important consideration in determining the number of hospitals assigned to each sequence was the amount of study resources needed to support sites in achieving program launch within their assigned window. The Function QUERI team used the Replicating Effective Programs (REP) framework to support each site team in developing and launching their STRIDE program . REP conWith each subsequent sequence, program launches went more smoothly as the implementation team honed the content of support calls and became more adept at assisting hospital teams with problem-solving. Study implementation specialists reported that when a site assigned to a later program launch date reported a challenge, they were able to share lessons learned from prior site’s implementation or facilitate communication between participating sites for counsel. These learnings had to do with tips on how to get the program off the ground, for example, programming progress notes for the electronic health record. The core elements of the clinical program were held constant across sequences, consistent with the REP framework.The Function QUERI STRIDE SW-CRT has an incomplete design, meaning that for each sequence, the evaluation does not include primary outcome data during the 3-month time period devoted to starting the program  is assessed very soon after the intervention; therefore, the primary driver of time period length was estimating the window hospitals would need to start their programs. Determining time period length is a critically important decision in a SW-CRT , becauseThird, will sites begin with a modified version of the program? Some types of interventions can begin on a specific date that is under the control of the study team, for example, activation of a new alert or clinical dashboard within an electronic health record . In our Finally, we highlight some positive aspects of SW-CRTs specifically for implementation studies. From a pragmatic perspective, in a SW design, aspects of the implementation can be modified or improved as the study team learns from past sites and new sites are activated. As noted earlier, our initial plan was that the STRIDE rollout using the 2-block design would have occurred with the same timing as if all 8 hospitals had been recruited and randomized simultaneously. However, there was a delay in the start of recruitment for block 2. An unexpected advantage of the delay was that it allowed the implementation team time to process their experience with supporting the first 4 sites and improve procedures for supporting the final 4 sites. An important aspect of our mixed method evaluation plan is to explore implementation experience and outcomes over time so that we can further understand this aspect of our study design. Importantly, we did not observe any changes in the intervention itself over time, consistent with our use of the REP implementation framework which is explicitly designed to promote fidelity to core elements of evidence-based programs. Another unanticipated, but welcome occurrence, was the sequential rollout design provided an opportunity for sites randomized to earlier implementation of STRIDE to serve as mentors to later sites. Building on this experience, we have since developed diffusion networks to support both initial implementation and sustainment of STRIDE at hospitals across VHA. The goals are to capture and share local knowledge and create a collaborative environment for peer-to-peer sharing of experiences and best practices to support implementation via regular teleconferences.Early experiences executing a SW-CRT pragmatic trial in VHA suggest several key design considerations to evaluate rollout of a new clinical program. Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate roll-out of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a “ramp-up” period. Site enrollment in blocks may help with engagement by reducing the amount of time sites are asked to wait to launch their programs; however, further study is needed to understand all the statistical implications of the blocked randomization. An incomplete SW-CRT design that incorporates pause periods for data collection during implementation is recommended when clinical programs are likely to include a ramp-up period. Implementation studies should consider whether incorporating peer mentoring strategies would be an effective means to leverage the sequential design. In sum, successful execution of SW-CRT designs to evaluate implementation of clinical programs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out.


Suchana is a large-scale program to prevent malnutrition in children in Sylhet division, Bangladesh by improving the livelihoods and nutrition knowledge of poor and very poor households. Suchana is being implemented in 157 unions, the smallest administrative unit of government, in two districts of Sylhet. Suchana will deliver a package of interventions to poor people in about 40 randomly selected new unions annually over 4 years, until all are covered. All beneficiaries will receive the normal government nutrition services. For evaluation purposes the last 40 unions will act as a control for the first 40 intervention unions. The remaining unions will receive the program but will not take part in the evaluation. A baseline survey was conducted in both intervention and control unions; it will be repeated after 3 years to estimate the impact on the prevalence of stunted children and other indicators. This stepped wedge design has several advantages for both the implementation and evaluation of services, as well as some disadvantages. The units of delivery are randomized, which controls for other influences on outcomes; the program supports government service delivery systems, so it is replicable and scalable; and the program can be improved over time as lessons are learned. The main disadvantages are the difficulty of estimating the impact of each component of the program, and the geographical distribution of unions, which increases program delivery costs. Stepped implementation allows a cluster randomized trial to be achieved within a large-scale poverty alleviation program and phased-in and scaled-up over a period of time. This paper may encourage evaluators to consider how to estimate attributable impact by using stepped implementation, which allows the counterfactual group eventually to be treated.Evidence of the impact of community-based nutrition programs is uncommon for two main reasons: the lack of untreated controls, and implementation does not account for the evaluation design.  Suchana, a 7-year program that aims to prevent chronic malnutrition by delivering a package of nutrition-specific interventions through the government system plus nutrition-sensitive development interventions delivered by international and local non-government organizations (NGOs) to up to 250,000 poor and very poor households in two districts of Sylhet division.In 2015, the World Health Assembly set a target to reduce by 40% the number of stunted children worldwide by 2025  or iii) the total business assets of the household was worth no more than BDT. 15,000 (excluding homestead land and pond or dyke) or iv) the homestead land of the household was no more than 10 decimals or v) cultivable land was no more than 50 decimals. Additionally, all households satisfied one of the following four conditions: i) has a married women between 15 to 45 years-of-age or ii) has a pregnant women, including divorcees and widows or iii) has at least one child under 2 years-of-age or iv) has at least one female living in the household and aged between 15 to 19 years [Villages in each union were selected for the program based on their vulnerability to poverty and natural disasters such as lack of development programs, remoteness and risk of flooding. This was done by a process of discussions with local government officials, representatives of unions, and experts, and field visits by It is to be noted that since the ability to implement new or scaled-up livelihoods and homestead gardens by a household would likely depend on their degree of poverty, the program provide assets to the poorest to ensure that all beneficiaries would be in a position to engage in livelihood activities and take equal advantage of the participatory training offered. It is expected that the ratio of asset-transfer to non-asset transfer beneficiaries will be 1:1.5.Suchana is working with households which contain a married women aged between 15 to 45 years or the household has a pregnant women or the household has at least one female adolescent, for the purposes of evaluation only households with at least one child under 2 years-of-age was selected, as the primary aim of the evaluation was to assess changes in the prevalence of stunted children among Suchana household beneficiaries.The primary outcome indicator is the mean z-score of height-for-age from which the percentage of children who are stunted (z-score < − 2) is derived. The secondary indicators are mostly related to infant feeding: how long after delivery the child was first breastfed; whether the child was exclusively breastfed for the first 6 months of life; whether a child aged > 1 year is still being breastfed; the age at which solid, semisolid, or soft foods were introduced; the diversity of the diet in the last 24 h; the number of meals in the last 24 h; whether a minimum acceptable diet was given; whether iron-rich or iron-fortified foods were given ; and theA calculation was done to estimate the sample size of children required, in three age groups: 0–5 months, 6–11 months and 12–23 months. This age range was chosen to be able to assess the impact of interventions in the first 1000 days after conception, the period during which undernutrition typically has its greatest effect on linear growth.For children aged 0–5 months the calculation was based on the prevalence of exclusive breastfeeding (EBF) of 55.3% from an unpublished study in Sylhet district, an intra-cluster correlation coefficient (ICC) of 0.0293, an assumed increase of EBF of 10% points, a power of 80% and a level of significance of 0.05. The sample size estimated was 520 subjects per group so the minimum total sample size for the baseline survey was 1040 and for the final survey was 2080, to allow for disaggregation of data into groups which did and did not receive asset transfers.For children aged 6–11 months the primary outcome indicator was optimal infant and young child feeding (IYCF) practices. Using the information from the same unpublished survey which estimated a prevalence of 12.6%, an ICC of 0.0235, an assumed increase of 7%, and the same power and level of significance the sample size was estimated at 600 per arm, so 1200 in total and 2400 in the final survey, to allow for disaggregation.For children aged 12–23 months the sample size calculation was based on the main derived outcome indicator, the percentage of stunted children. In order to detect a difference of 6% points between the intervention and the untreated control group in 40 unions in each group after 3 years, the sample size required was estimated to be 1520 children in each group assuming a power of 80%, 5% precision, 40 clusters per group and an ICC of 0.01. Due to refusals or data collection errors, the sample size was estimated 3200 in total for baseline survey, and 6400 in the final survey to allow for disaggregation.Suchana in 40 Phase 1 unions (intervention) and among potential beneficiaries in 40 phase 4 unions (control) in 2017. The survey included children aged 0 to 23 months and their parents, plus 1200 adolescent boys and 1200 girls aged 15 to 19 years to assess their knowledge of health and nutrition, to assess their decision making power, and to estimate the proportion who are already married, though the sample of the adolescents were themselves unmarried. Systematic sampling was used to select beneficiary or potential beneficiary households to be assessed using the Suchana beneficiary/potential beneficiary list as the sampling frame. The final survey will be carried out in 2020. The evaluation was registered at the Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-5d5678361809b) on16/08/2019, before starting the end-line survey.Simple randomization was used to allocate the unions to four different phases or clusters. A baseline survey was carried out among beneficiaries of Programs adopt an evaluation design which best fits the program context and objectives, and the funding available. Some designs aim for plausible results rather than requiring statistical probability . PROCOMISuchana allowed a randomized cluster-controlled trial of a package of interventions that has been designed to improve livelihoods, provide income, inform and empower girls and women, and improve the nutritional status of their children in area of Bangladesh that is lagging behind the country in an important indicator of national development, the percentage of stunted children.The stepped wedge design to implement A program cannot easily be delivered to beneficiaries in individual households and at the same time have similar neighbours as controls, as this could lead to contamination or resentment. It also does not test the government service delivery mechanism. The best option is to deliver the program through the smallest unit of government, which in Bangladesh is the union. The staff of the union can then deliver the interventions to all beneficiaries in their union, selected on the basis of need by the community themselves using participatory methods, and the population understands that all beneficiaries in that union have been chosen based on those criteria. The program and the evaluation use the smallest unit of service delivery by the government, so the processes developed can be replicated and scaled up, while the union also provides rational clusters for the evaluation. The design is consistent with normal government processes.The design allows for a counterfactual while delivering a program in a phased approach that is eventually received by all communities. Governments are rarely able to implement a new program in all areas from the same start date, so a phased approach allows the program to be scaled up over time. The rationale for this is understood by program staff, which is why it needs to be integrated into the design from the start of the planning process.This method of program delivery allows a counterfactual, which is provided by a control group of future beneficiaries in 40 unions. This allows changes that would have occurred anyway to be subtracted from the change in the beneficiaries in the intervention group, and thus estimate the impact that is attributable to the intervention. The prevalence of stunted children is generally going down in Bangladesh, but with the program it should to go down more. The measurement of a single group before and after the program, the typical method used to evaluate program , would nSuchana and the unit of randomization for the evaluation, so creating a cluster randomized controlled trial. The randomization process, by which the phases of involvement of unions in the program was decided, was done transparently, with representatives of the unions present as observers, so they could see that there is no bias in the selection process, which is sometimes the case in programs.There is no untreated control group in this design and no placebo is needed (or possible). Every union gets the program eventually, so there are no ethical issues due to withholding treatment. Randomization is crucial, as in all controlled trials, to distribute differences between the units of delivery in the intervention and control groups. As the smallest unit of delivery of services by the government is the union, this was identified as the unit of delivery of All unions will receive the program for the same number of years but, as the program is delivered in annual phases, but it can be changed for unions in phases 2, 3 and 4 as lessons are learned and improvements are made. It is not a fixed intervention, unlike a normal randomized controlled trial of a standard treatment, even if the interventions delivered to households in phase 1 are sustained. This is good for the program, which can be developed based on learning and experience, while the evaluation of its impact on the first beneficiaries continues.The rate of reduction in the prevalence of stunted children is quite slow, even without a program; to achieve a difference between children in intervention and control unions that is statistically significant takes time. Three years was estimated to be the minimum period needed to show a difference and this influenced the scale of the program, the number of unions necessary for a cluster randomized trial, and the total budget, both for the program and the evaluation.Suchana interventions, as well as to measure and capture contextual factors among Suchana workers, mothers, households, and communities, all of which could influence the effectiveness of the interventions.The advantages and benefits of the proposed evaluation design led the donors to fund a separate evaluation both in terms of the evaluators, to ensure objective and independent data were collected, and to fund it separately, so that it did not come out of the funding for the main program. This separation enhances credibility and strengthens the process. There was also close consultation between program managers and evaluators during the planning of implementation and during service delivery. The challenges of implementing a large and complex program led to delays which had to be accommodated by the evaluation agency, so flexibility was required to undertake the baseline survey. The evaluation instruments were grounded in the specific program theory of each component of the intervention, to capture and record access to Suchana, the randomization process led to unions in phase 1 that are distributed throughout two districts, which increases the travel time of project staff from their base office to program unions, increases the cost of training government staff if they have to travel outside their unions to a central training venue, and increases program support costs. This makes it hard to estimate the cost effectiveness of implementing the program, as it will be higher than it need have been, and it also increases evaluation costs for the same reasons. The most cost-efficient way to implement a program would be to involve unions in contiguous blocks close to the project office in the first phase, and then spread out across the two districts, also in blocks. The issue was partially addressed by stratifying unions by geographical location before randomization.There are however several noted disadvantages of a stepped wedge design in the context of program implementation , 15. In Suchana program will cost GBP 50 million over 7 years while the evaluation will cost around GBP 1.5 million. This is a substantial investment by donors, but it could generate high quality evidence. It is not an appropriate or possible design for all evaluations of programs to improve government services.The randomization process increases the risks of contamination of people in control unions from people in intervention unions, especially with public health messages that are specific to the program. Due to the scale of the program in terms of the number of unions required to achieve a sufficient number for a stepped wedge design and for a controlled evaluation, the program is expensive. However, considering the costs per beneficiary, the potential impact on households, the impact on the government delivery systems, and the potential evidence generated, the program arguably provides better value-for-money than a traditional delivery approach, which cannot yield results of the same magnitude or potential value. The number of clusters in an evaluation is equally as important as the sample size of subjects studied, in order to control for inter-cluster differences. The The design does not easily allow the separate impact of each element of a package of interventions to be estimated. Development programs rarely deliver a single, pure intervention, such as a drug, and typically contain several elements, some supporting each other, while others may be independent of each other but may still be nutrition-sensitive. The only way to assess whether an element contributes to the difference in outcomes is to try to measure indicators of participation in the program or the quantity of intervention received, if it can be measured, and factors that might influence uptake and utilization by households. The challenge for the evaluators is to identify the indicators with the implementers and then make sure that they are recorded accurately throughout the program. This requires planning and coordination.It is also a challenge to identify potential beneficiaries in control unions during the baseline survey who have the same characteristics as potential beneficiaries in the intervention unions, and then not provide interventions. The same criteria used by the implementers to identify beneficiaries need to be used by evaluators to identify subjects for study in all unions in both surveys. At the final survey this is easier as the subjects for study could be included in the program when it begins in phase 4.Suchana, which has a separate evaluation design and evaluation process, so that all elements of the process related to the evaluation are separated from the current evaluation design.The main element of the program that is not evaluated by the stepped wedge design is the process of implementation. This is being conducted through the MEAL system of Suchana will be able to actively use its impact evaluation for program learning and adjustment but also for advocacy to government and other partners for 3 years before the program finishes. The baseline evaluation started during November 2016 and ended in February 2017. This evaluation design is not suitable or feasible for all programs but, when it is finished in 2020, it may constitute one of the largest ever randomized controlled cluster trials of efforts to prevent stunting ever attempted.The randomization of 157 unions in two Districts of northern Bangladesh into four phases has allowed an evaluation to be designed to estimate the impact of interventions intended to prevent chronic malnutrition in children during the first 1000 days of children’s lives. The timing of the evaluation is also important because, unlike in most programs in which the impact evaluation is completed at the end of the program and by the time the results are available the program has finished, Suchana which is particularly suited to evaluations of service delivery. The design allows the intervention to be phased-in and scaled-up over a period of time. The phased or ‘stepped’ process of implementation enables a cluster randomized controlled trial to be achieved without having a permanently untreated control group. However, the design does not allow the impact of each individual component of intervention to be estimated. But the design of the evaluation of Suchana and the lessons learned in doing so, which will be reported, could help and encourage other evaluators to consider this design in the right circumstances, and improve the quality and value of program evaluations.A stepped wedge design for implementation was used to


Patients and Methods. Pertinent data for 44 patients treated for IGM from 2002 to 2018 were analyzed and compared to data prior to 2002.  Iidiopathic granulomatous mastitis (IGM) is stereotypically described as a mysterious entity that mimics breast carcinoma imposing management challenges. In 2002, we established a multidisciplinary team to treat patients with IGM. This study aimed to evaluate the role of this team in improving patient outcomes. Also, a review of literature is provided to highlight recent disease trends. χ2 = 5.598; p = 0.018). Chi-square analysis showed no significant association between BMI and recurrence .  Mean age at diagnosis was 37.9 years ± 6.4. The diagnosis of IGM was confirmed by True-cut biopsy (TCB), Frozen section (FS), and surgical biopsy in 70.5%, 25%, and 4.5% of patients, respectively. FS was used to assess the resection margins in three patients. Suspicion for malignancy was raised in one out of 39 ultrasound reports, and one out of 20 mammography reports. Wide local excision was the main treatment modality (95.5%). 19 patients (43.2%) received corticosteroids. Prior to 2002, IGM was only recognized after surgical resection with a 71% initial false impression of carcinoma. After 2002, the initial false clinical impression of carcinoma dropped to 29.5%. Recurrence rate was 31.82%. Younger age at diagnosis was significantly associated with recurrence ( The establishment of a multidisciplinary team for IGM was associated with a reduced erroneous impression of breast cancer, and a reduced false positive radiological diagnosis of breast carcinoma. FS was a useful confirmatory procedure. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Recent literature indicates that IGM is changing its face. IGM is being reported in all age groups, and even in males. The clinical manifestations have markedly expanded. Diagnosis by TCB has replaced blind surgical excision. More data regarding predictors of recurrence is accumulating. The term granulomatous mastitis (GM) describes two main entities: idiopathic granulomatous mastitis (IGM) and secondary (specific) GM. IGM is a rare disease of the breast. It was recognized as a different entity from other types of mastitis in 1972 . Interestingly, the age at diagnosis was significantly associated with the presence of nipple retraction . None of the patients diagnosed with IGM at the age of 20–40 years presented with nipple retraction. Of patients diagnosed at age more than 40 years, half presented with nipple retraction. Chi-square analysis for associations between BMI group and recurrence status showed no significant association . In addition, obesity was not associated with disease presentation in terms of side of the disease, site, skin redness, nipple retraction, lymphadenopathy, and the need for prednisolone treatment [data not shown].Association analysis for categorical variables indicated that age at diagnosis was significantly associated with disease recurrence among IGM patients  is a recently identified entity that stimulated the reconsideration of an underlying infectious bacterial etiology for IGM –30. The  or FNAC , 31. A m or FNAC . They ob or FNAC .In brief, when the characteristic histological findings of CNGM are encountered, the pathologist should make every effort to look for an associated primary bacterial infection. Culture of fresh specimens, Gram staining, or rRNA gene sequencing of specimens obtained at surgery might be considered in these cases , 30. CNGAmong our study group, we observed a trend toward an increased occurrence of IGM during the warm seasons. No statistical evidence could be drawn in this regard in view of the small number of cases . We did Many questions are raised when treating a patient with IGM: Shall we treat by surgery, corticosteroids, or both? If both, shall we start by surgery or corticosteroids? What is the optimal dose and duration of corticosteroid therapy? What is the reflection of a given treatment on the likelihood of recurrence ? Does thCurrently there are no clear-cut answers for these questions. However, some clues can be extrapolated from recent literature. In any institution, the treatment decision should be the responsibility of a multidisciplinary team. Individual patient needs should be taken into consideration.Wide local excision has stood the test of time as being a corner stone in the treatment of IGM , 9, 14. A growing number of publications over the last two decades have also shown the effectiveness of corticosteroid treatment in reducing the extent of surgery, or even alleviating the need for surgery in selected cases , 7, 11. Among our study group, wide local excision was the sole treatment for IGM in the absence of local signs of inflammation and extramammary manifestations. Steroids were administered if local signs of inflammation or extramammary manifestations were present. Our trend toward a wider use of systemic immunotherapy when significant local inflammation is present is supported by recent literature , 15, 34.Prior to the year 2002 only 16.7% of the patients treated at our center received prednisolone therapy, and those were patients who developed recurrence of IGM . The proGunduz et al. evaluated the role of topical corticosteroids in 11 patients with IGM . He repoχ2 = 5.598; p = 0.018). There was a trend for increased recurrence rate of IGM among obese patients, and patients with comorbidity (IGM recurrence rate among our study group was 31.8%. Our data showed that a younger age at diagnosis was significantly associated with a higher disease recurrence (orbidity . In addiorbidity . At our More data is accumulating regarding the risk of recurrence of IGM. Uysal et al. found a statistically significant association between IGM recurrence and history of pregnancy, breastfeeding, and breast infection; however, comorbidity and obesity were not . Yılmaz In a previous report, we proposed a clinically based classification for IGM that serves as a prognostic value . We suggA comprehensive clinical, radiological, and pathological classification system that provides clues for treatment and predicts the likelihood of recurrence is still lacking.Our study is of retrospective nature. The number of cases is not adequate to obtain regression analysis for all potential variables. These weaknesses are shared by other reports on IGM. On the other hand, our results reflect the benefits of establishing a dedicated multidisciplinary team for the management of IGM.Our review of the recent literature showed that IGM is departing from its stereotypic description. In summary, IGM is being reported in all age groups and in both sexes , 18, 19.The establishment of a multidisciplinary team for the management of IGM was associated with clinical benefits: the rate of erroneous initial clinical impression of breast cancer was markedly reduced, more patients received corticosteroid treatment, and the false positive radiological diagnosis of breast carcinoma was reduced. We introduced FS as a useful diagnostic tool in IGM that might also help in assessing the resection margins. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Our review of the recent literature showed that IGM is departing from its stereotypic description.