Overweight or obesity during adolescence affects almost 25% of Australian youth, yet limited research exists regarding recruitment and engagement of adolescents in weight-management or healthy lifestyle interventions, or best-practice for encouraging long-term healthy behaviour change. A sound understanding of community perceptions, including views from adolescents, parents and community stakeholders, regarding barriers and enablers to entering and engaging meaningfully in an intervention is critical to improve the design of such programs.This paper reports findings from focus groups and semi-structured interviews conducted with adolescents (n?=?44), parents (n?=?12) and community stakeholders (n?=?39) in Western Australia. Three major topics were discussed to inform the design of more feasible and effective interventions: recruitment, retention in the program and maintenance of healthy change. Data were analysed using content and thematic analyses.Data were categorised into barriers and enablers across the three main topics. For recruitment, identified barriers included: the stigma associated with overweight, difficulty defining overweight, a lack of current health services and broader social barriers. The enablers for recruitment included: strategic marketing, a positive approach and subsidising program costs. For retention, identified barriers included: location, timing, high level of commitment needed and social barriers. Enablers for retention included: making it fun and enjoyable for adolescents, involving the family, having an on-line component, recruiting good staff and making it easy for parents to attend. For maintenance, identified barriers included: the high degree of difficulty in sustaining change and limited services to support change. Enablers for maintenance included: on-going follow up, focusing on positive change, utilisation of electronic media and transition back to community services.This study highlights significant barriers for adolescents and parents to overcome to engage meaningfully with weight-management or healthy lifestyle programs. A number of enablers were identified to promote ongoing involvement with an intervention. This insight into specific contextual opinions from the local community can be used to inform the delivery of healthy lifestyle programs for overweight adolescents, with a focus on maximising acceptability and feasibility. It is estimated that one quarter of adolescents in Australia are overweight or obese,2 with a.There have been a small number of high-quality long-term trials to evaluate family-based obesity management in adolescence, with most reporting limited success-16. The Nguyen et al. reportedFor those who do seek treatment, there is limited evidence regarding prevention of attrition and ways of keeping adolescents engaged. A review of the literature relating to attrition from paediatric weight management programs suggest that between 27% and 73% of participants drop out of interventions. It appeThere is also a gap in the literature about how to encourage maintenance of healthy behaviour change post-program. In adults, clinical trials focussing on lifestyle components (activity and dietary behaviours) have demonstrated long term successes with maintained reduction in weight,27. The Qualitative research exploring the barriers and enablers to complex health interventions can provide a better evidence base to inform practitioners and policy makers about what is needed to achieve successful interventions,32. A reIn this study, focus groups and semi-structured interviews were conducted with adolescents, parents and community stakeholders to provide rich insights into the experiences and perceptions of these groups. The aim of the study was to identify key individual, family and community enablers and barriers to the implementation of a multi-disciplinary family-centred intervention for overweight adolescents to be delivered in a community setting; particularly in relation to recruitment of families, retention of families and maintenance of healthy changes. The insight into specific contextual opinions from the local community can be used to inform the delivery of healthy lifestyle programs for overweight adolescents, with a focus on maximising acceptability and feasibility.Participants for the current study were recruited from families who had completed the Curtin University Activity, Food and Attitudes Program (CAFAP), potential CAFAP participant families and community stakeholders. CAFAP is an 8-week healthy lifestyle program for adolescents and their parents and was run as a pilot program during school terms in 2009 and 2010 in Perth, Western Australia. The resIn this study, past participant inclusion criteria was an adolescent aged 12–16 years with a previous attendance of at least 6 CAFAP sessions and a BMI-for-age greater than the 85th percentile when theAll families who had completed CAFAP (n?=?30) were invited to participate and we aimed to recruit 7 adolescents and 7 parents. Adolescents and their parents/carers were initially offered a written invitation to attend focus groups, and follow-up emails and telephone calls were used to maximise attendance, along with a voucher incentive. Participants were given the option of completing a survey electronically if unable to attend a focus group due to timing or transport issues. Separate focus groups for adolescents and parents were planned to encourage open discussion. Past participants were invited to participate to provide a range of opinions based on their experience of a healthy lifestyle program.Potential participants who had not been influenced by previous involvement in a healthy lifestyle program were invited to participate to provide a range of opinions based on their naïve perceptions of such a program. Recruitment was by referral from General Practitioners, school nurses, and other health professionals, as well as advertisement through community newspapers, school newsletters and radio. As for past participants, separate groups were planned for adolescents and parents. We aimed to recruit 24 adolescents and 24 parents.Stakeholders with an interest in youth, childhood obesity or community services were invited to participate in a one-off interview. Health professionals in Western Australia and researchers from across Australia, as well as community organisation representatives and policy makers from two metropolitan areas and a regional town were approached based on their experience or interest in overweight and obesity during adolescence. The metropolitan areas chosen included areas of low socio-economic status and were the likely sites for a future intervention, thus providing appropriate local context to inform future delivery. Stakeholders were chosen to reflect a range of diverse views from professionals with an interest or experience in adolescent obesity. We aimed to initially interview 12 community stakeholders and based on their recommendations would interview others identified as having useful experience or insight.Ethical approval for this research has been obtained from Curtin University Human Research Ethics Committee (HR105/2011). Written informed consent was provided by all participants. This research was conducted in accordance with the Helsinki Declaration of Human Rights.The theoretical foundation for this study was based on the Ecological Systems Theory (EST) proposed by Brofenbrenner, which sAs per the focus group schedules, the stakeholder interview questions were developed then reviewed by an expert panel until consensus was reached. The stakeholder interviews were conducted by members of the research team. All interviews were recorded and transcribed verbatim.With permission from participants, each focus group and interview was audio-recorded for accuracy of transcription and analysis. Confidentiality was ensured by not mentioning participant names whilst the audio-recorder was operating. Transcribed data were also de-identified with subject identifiers assigned to each participant. Data analysis was undertaken in stages, with focus groups and interviews dealt with separately. As soon as practicable following each focus group or interview (within 48 hours), responses to the questions were transcribed and initial thematic analysis conducted. All focData from focus groups and interviews were amalgamated and the major themes detailed in a report using deTwo focus groups were held with parents (n?=?4) and adolescents (n?=?4) who had participated in CAFAP, with written feedback provided by one adolescent and four additional parents who were not able to attend a scheduled focus group. All past participants who responded to the invitation had completed the full 8 week program. Four focus groups involving parents (n?=?4) and adolescents (n?=?13 per group) were conducted with potential participants. A total of 56 adolescents and adults provided feedback to the study, including13 past participants  and 43 potential participants . Adolescents were aged 12–16 years, with females comprising 52% of the sample. Of the parents, 82% were female. The majority of participants were white Australians from middle-low socio-economic areas. Details regarding household characteristics were not further explored. Focus groups typically lasted around 60 minutes.A total of 26 interviews were conducted with 39 health professionals, local service providers and researcher stakeholders Participants highlighted that adolescents can be a difficult group to recruit to healthy lifestyle programs for different reasons. For some adolescents, the fear of humiliation or bullying can make seeking help confronting, and for others, the promotion of a healthy lifestyle was not enticing if they weren’t overly concerned about their weight. In most cases, participants suggested that adolescent views regarding healthy lifestyle programs would be a barrier in itself.I don’t think that adolescents would like to admit that they’re overweight.  Yeah. The reputation of having to go there [the program] and stuff. I don’t think that you should believe that young people will see those advertisements and say this is something I want to do. Even if it is something they want to do, they’re probably unlikely to say it. (Researcher)It was identified that most parents don’t recognise if their adolescent is overweight, with overweight being almost normal in today’s society. This was thought to have the potential to reduce parent and adolescent receptivity to the offer of health services.‘If your family think it’s ok to live like that, like nothing’s happened now, what would happen like three years later. And also if they’re already used to the fact that they’re obese, if they see someone suffering, say, going to the gym, and if their daughter or son’s getting stressed out from the exercise, they’ll think ‘oh, you’re ok being obese, let’s not do it’. (Adolescent)Fundamentally in the general population, it’s not recognised as being a problem [that requires] something to be done about. (Researcher)A hesitance to identify overweight and obesity by health professionals was raised. A number of health professionals identified the sensitive nature of obesity as a barrier to referral. A number of researchers identified other issues with health professionals not being able to measure children and adolescents to correctly identify overweight and obesity.It’s a very sensitive issue. GPs said it is a really difficult thing to raise with parents if they haven’t raised it with you…They don’t want to jeopardise the relationship. (Researcher)We wanted overweight and mildly obese young people…but we were being sent overly obese young people because these were the ones they saw…GPs don’t have a good way of assessing it…They don’t measure height and weight. GPs don’t know how to talk about it and paediatricians shy away from it. (Researcher)The hesitancy of health professional referrals was reinforced by a lack of current community services. Researchers identified that new programs often struggled initially with attracting participants, particularly if there was no current referral base.Up until now we haven’t really targeted obese kids because if we did, we had nowhere to go with it. OK we identify them but now what? I was looking for other things, particularly as she’s getting older and [dropping], tending to want to drop out of team sports and things like that or out of some of the programs at school that were keeping her very active. There’s nothing out there… Most gyms don’t even take them until they’re 15. (Parent)Participants also identified that families often had a lot of social issues to contend with including; busy schedules, family problems, poor budgeting skills, a lack of healthy food preparation skills and other financial restrictions. It was expressed that often, healthy lifestyles were not a priority for these families.It’s usually things are happening with social determinants or things are happening at home, yeah they’d like to eat healthy but Mum’s only got $20 for the rest of the fortnight and that kind of takes precedence. Participants recommended a wide-reaching and personalised advertising campaign to reach adolescents and parents. There was an emphasis on ‘selling the message’.Face-to-face selling things goes a long way as well. It’s easy to put a brochure at the bottom of a school bag but if you actually talk to people and engage them…we can try and sell it. Just generalised feedback about the whole group and what’s come out of it… If I see that someone I’ve referred has got something out of it, then [I’ll] definitely keep referring. Promoting a positive message and trying to avoid embarrassing weight connotations were highlighted as important recruitment strategies.[Do] anything you can to avoid the stigma of this being a project for overweight and obese. (Researcher)If you promote it to help out their sport and improve their performance in that. Those sort of angles might be a good way. Say ‘we’re about a lifestyle change’, not a diet, ‘cause that’s what you need to do, actually, a lifestyle change, otherwise you’re just gonna yo-yo for your whole life. Like feeling healthier, more than looking healthier. And feeling better within yourself’. (Parent)Making a healthy lifestyle program available and accessible for all community members was an identified as an important enabler for recruiting adolescents and families. Participants recommended making the program free or very low cost to increase interest.So you’re not forced to drop out for lack of money. (Adolescent)Other parents suggested that making the program free would encourage attendance by families who weren’t totally committed to the program.I think it was made free too, you might get people who might not really wanna be there for the right reasons, and it might be a bit too overcrowded. (Parent)Participants described a need for healthy lifestyle programs to employ strategies to keep families engaged and interested, to help prevent drop out. Most researchers in particular had experienced the difficulties of keeping participants motivated to attend.Following the initial sessions, attendance really dwindled, and sometimes yeah we had only one person. (Researcher)The location and ease of access for participants was highlighted as important potential barriers for families to stay engaged with a program.For many families that is a commitment, in our rather time poor community, that is quite difficult. And that’s why, presumably, success is partly due to having a site of study where it’s easy to get to. (Researcher)Another program-specific factor of start and finish times was identified as a barrier that may make it difficult for some families to stay engaged. Participants were conflicted in their view for the most appropriate start time, wanting to include adolescents immediately after school, but noting that parents are often not available at this time with work and family commitments.So many parents, if not full time, are working part time… People struggle to pick up their kids from school and get there. (Researcher)Stakeholders were quick to acknowledge that attending an ongoing healthy lifestyle program and making healthy lifestyle changes were difficult things to do. They noted that the program needed to be a priority for the family and facilitators would have to work hard to try and keep families motivated.Bigger the body mass, the bigger the resistance to change- partly through a sense of being overwhelmed. Like how am I ever going to be a size 10 if I’m a size 24. If I can’t be a size 10 then I’m not going to bother. This is difficult and emphasising that this hasn’t happened overnight and it isn’t going to go away overnight. You need to commit as a family and so we emphasise that family thing. (Researcher)Participants identified that the environment we live in makes it difficult to stay engaged and make healthy changes.McDonalds has come out with an ad for under $5 they can get a burger and this and that and the other. You’ve got the convenience and low cost of high salt, high fat junk food. How do you get healthy food choices that are cost effective, easy to prepare and that they’re interested in, when there’s all the attractiveness of this junk food. Stakeholders recommended focussing on making the program enjoyable and rewarding for adolescents to increase the chance that the family would remain in the program.Would be great to train with someone else in the group. Random assignment would mean you meet more people. [You] could ‘tag-team’ one exercise until you can’t go anymore. (Adolescent)Just a group type session, particularly teenagers- they’re one of those groups, and if you get together and they’ve all got similar problems then it’s a lot easier for them to work through those problems and come up with solutions… It’s really hard when they’re on their own, if they feel like they’re on their own. There were suggestions for the program content, such as using activities that are fun and active, as well as providing practical skills like cooking.I think once they get engaged and see that it’s practical, then they’ll be fine…and when it gets a name for itself and they can see changes in other teenagers. It was really very easy to knock up snacks and do stuff that was appropriate for teenagers. And I still maintain that you can eat healthily at a reasonable price, I like [this kind of program] as adapted to a teenage market, not for a mum and a couple of kids. The importance of including the whole family was highlighted by all focus group participants, even by the adolescents themselves.Cause it’s also a lot about the parents. You need to get the parent involved because, like you said, they’re in control of the food and, like, the computer playing and stuff. So basically you have to talk to the parent I guess, and then make them see what they’re doing to their child- they have to do this. (Adolescent)Participants described program staff as one of the key enablers for keeping families engaged in a program. Passionate, interested and motivated facilitators were seen to increase the engagement of parents and adolescents in the program. Researchers described the development of a good relationship between facilitator and participant as one of the most critical aspects of the program.I think the only thing that would really stop somebody would be a huge personality conflict, right, with the kids with the trainers, instructors, whoever is running it, ‘cause if the child doesn’t like the person, they’re not gonna sit there and listen’. (Parent)Certainly how well a group runs and how well it all goes does depend on the facilitator and the relationship they build. (Researcher)The use of goal setting during programs was discussed as a good way for adolescents and parents to make small changes and see the progress they make.I think goal setting is really important because people can get confused and they can get overloaded. And so it’s the sort of standard suggestions that are made in CBT and other things, you pick a goal that’s achievable. You pick a goal that somebody will understand. You look at pathways to achieve that goal. It is important to let teens personalise things… it should be simple and attempting the goal is praised in some way. (Researcher)To account for the effort required to stay engaged in a program, participants recommended making it as easy as possible for families to attend and rewarding their attendance with incentives or teaching them new and practical skills.With disadvantaged families in particular, those kind of altruistic ‘your life’s going to wonderful if you do this’, isn’t going to get them there. You’ve got to have practical things like we’re going to give you a gift card or you’re going to get a shopping voucher…That’s actually the kind of thing you’re going to need with disadvantaged parents. Participants unanimously agreed that maintaining healthy behaviour changes after being involved in a healthy lifestyle program was difficult and required a lot of motivation and commitment from families. It was acknowledged that for adolescents, ways to encourage sustainable change is lacking good evidence and there is still plenty of work to be done in identifying enablers in this maintenance period.We know little about, except for some work from the States from the obesity register of why adults keep the weight off, we really don’t know what happens in adolescents. (Researcher)The difficulty in sustaining healthy changes, especially in the context of other family issues was noted by stakeholders. Researchers in particular identified that it was difficult to organise convenient times or interesting activities to encourage adolescents to come back to review or booster sessions to keep up the support from the program.Some families go great guns, you know they’ll keep going with things. I guess that’s when there’s no conflict, no social issues and the kid’s really motivated…but there’s some families that you probably know, because of the kid or the parent or both, they’re going to fall in a heap. (Psychologist)One thing is, as the adolescents got older they ended up getting part-time jobs, or they had greater study commitments, so I think that’s one reason why attendance tapered off in the booster sessions. (Researcher)Participants identified a lack of supportive services in the community to encourage overweight adolescents to maintain healthy changes. They noted that these adolescents were unlikely to re-engage in team sports but there are few activities available in the community for them to access instead.We struggle when families get to the end of those twelve months and they want more support, there’s not really anything to refer them onto. (Researcher)My daughter’s doing Year 8, she’s doing home economics. Guess what they’re cooking? Chocolate cake, simple as that. I mean, it’s nice to have, but they’re not taught that it’s nice to have a little bit, yes, and once in a blue moon it’s ok; but they don’t, they sit there and they have it for morning tea, chocolate cake. (Parent)A number of factors were suggested by participants that could facilitate maintenance of healthy lifestyle changes. An ongoing link to facilitators or program staff was identified as a potential enabler after the program has finished.We use things like postcards at Christmas time…maybe here’s some things to think about at Christmas. Trying to get that connection. (Researcher)An email or check in point where a couple of months down the track…they send a coordinator a message saying these were my goals and this is what I’m doing. Just to sort of make them still take ownership of those goals that they’ve set. Participants highlighted the importance of adolescents and parents feeling like they were capable of achieving their own healthy change and having these positive changes recognised by themselves and others when they occurred.They’ve got to have buy in. And it’s absolutely essential that the parents are involved in it if you want to change things. And you want them to have seen changes…and believe they can do it. (Researcher)Communicating with adolescents using their preferred means of contact, particularly by SMS and online communication, was highlighted as a good way to encourage maintenance of healthy change.IT- It’s a cheap, simple and effective way of maintaining engagement. (Psychologist)I think we really need to explore all of those forms of e-communication that young people do, and just use them as much as we can because they’re forever SMS-ing and Facebooking and so on. And we just need to be using that as part of our ongoing ways of connecting to them. And the dose we were thinking is just way too small. (Researcher)Participants agreed that transitioning adolescents into local services and groups after the programs was an important part of maintenance. They were able to identify some local services that may be accessed to provide opportunities for encouraging kids to stay active (e.g. sporting clubs) and mentally well (e.g. youth services) but highlighted the need for alternative options for adolescents who didn’t enjoy sport.I think the kids at 12–16 that aren’t involved in sport, I’d dare to say they’re probably not going to be interested in sport in the future. So you probably need to think maybe like the nature play type activities, the trail bike riding or the bushwalking or canoeing or those sort of sports. .Some kids just don’t like sport… It’s trying to educate them on what they enjoy doing. Sometimes you might do things at home so they can set up a little system at home or an aerobics video- lots of videos and things out there now. Past CAFAP participants, future potential CAFAP participants and community stakeholders involved in supporting health interventions articulated a rich description of possible barriers and enablers to recruit and retain future adolescent healthy lifestyle program participants. They also discussed possible enablers for overweight adolescents to maintain a healthy lifestyle after the completion of a program like CAFAP. Some ideas were consistent across informants and supported by existing literature, whilst other emergent ideas and opinions differed between groups and participants.A strong theme emerged regarding the need for a positive awareness-raising campaign to encourage recruitment. The stigma associated with being overweight or obese was identified as a major barrier by all participant groups, and potentially prevented adolescents looking for help. This is consistent with the literature suggesting overweight adolescents are at greater risk of social isolation and depression,7. This An important theme relating to keeping adolescents and parents engaged in the program was to make it accessible and enjoyable for participants. The importance of a local venue and a convenient time was emphasised by all groups interviewed, supported by Brennan et al. who founAll groups raised the issue of difficulties committing to healthy lifestyle changes and suggested that adolescent ‘buy in’ was critical. Maintenance of healthy lifestyle behaviours are often associated with motivation fostered during the process of attaining goal-related behaviours, and reqA strong theme emerged regarding the lack of local, accessible, affordable and enjoyable physical activity options for adolescents in the community to support maintenance of healthy behaviour change following a healthy lifestyle program. This presents a significant barrier for adolescents who may have the skills and motivation to change but are restricted in their environment. This fits with the proposed Ecological Systems Theory Model of predictors of childhood overweight, where lOpinions differed regarding the cost for families to attend a healthy lifestyle program, with some parents and stakeholders suggesting a small monetary fee would encourage more ‘dedicated’ attendees and help people to place more value on the program. Other stakeholders and parents indicated that parents would be put off attending if there was a cost associated with the program and these differing opinions are highlighted in two reports of stakeholder views,53.Common barriers for parents of adolescents who dropped out of a recent lifestyle intervention included a lack of interest/motivation and lack of time available to participate. ParentsThere were a number of limitations with this study. Firstly, difficulties with recruitment resulted in fewer adolescent and parent participants than planned. However, an absence of new topics emerging from the final transcriptions suggested saturation had been reached for parents and adolescents as well as stakeholders. This research explored the opinions of adolescents, parents and stakeholders in low-middle socio-economic regions of Western Australia and thus results need to be taken in context. We had some minority ethnic groups represented but no indigenous participants in the focus groups, so findings cannot necessarily be generalised to different communities. The views of researchers were open to bias as they were reporting on their experiences with overweight adolescent interventions. However, researchers were only included in the interviews if they had extensive and direct experience in this field, which the authors feel is of high clinical significance. Further, lifestyle interventions may only reach the sub-group of obese adolescents willing and able to attend such programs and thus other interventions such as active desks are needThe strengths of this study include consultation with, and direct input from adolescents, their parents and key stakeholders around the prevention and/or management of adolescent overweight and obesity. Trained facilitators led the discussions and the homogenous groupings permitted honest and open discussion in a supportive environment. The discussion schedules were based on a sound theoretical framework with questions tailored to explore individual, familial and broader societal factors associated with adolescent obesity. Other strengths of this study were consultation with a wide range of informants with relevant experience in the area, and the collection of in-depth information about the challenges associated with the implementation and evaluation of interventions for overweight adolescents by examining the whole spectrum of recruitment, retention and maintenance.Despite accumulating research into perceptions of adolescents, parents and stakeholders regarding the causes of overweight and suggested management strategies; there has been limited evidence to inform the actual implementation of a community-based healthy lifestyle program. This study makes unique a contribution to the evidence base by describing the barriers and enablers to implementing a successful healthy lifestyle program for overweight adolescents as perceived by families and community stakeholders. This understanding will be useful to improve acceptance, attendance and completion of programs thus improve their feasibility within a community setting.Based on the valuable information provided by past participants, potential participants and stakeholders, a number of recommendations are made to maximise the effectiveness of a family-centred, community-based intervention for overweight adolescents. These recommendations have already guided the protocol for one such program.Recruitment is one of the most difficult parts of any lifestyle program. Researchers and health professionals need to utilise a number of strategic marketing approaches to attract parent and adolescent interest including: online advertising and web-based information; advertising in newspapers and on radio; repeated exposure; and development of links with schools and health professionals. PotentiTo retain families and keep them engaged with a healthy lifestyle program, facilitators need to be passionate and engaged themselves, with time and focus given to fostering relationships with both adolescents and parents. This sense of belonging and opportunity to share similar problems plays an important role in a successful group. Adolescents also need to have opportunities to make choices about what they do and provide feedback about the program. The sessions need to be fun, with a positive focus on practical activities. Goal setting based on these factors also plays an important role to help participants work towards realistic and achievable goals, whilst having the potential to demonstrate progress and promote autonomous motivation. The activity component of the sessions should be fun, with a number of activities that adolescents may not have done before and may be interested in continuing with once the program has finished. Ultimately, parents and adolescents need to feel that the program meets their needs, with content relevant and useful for the families who attend.There has been little research into maintenance of healthy behaviours after adolescent participation in a healthy lifestyle program. This study found that to maintain ongoing positive change, follow up contact needs to be regular and appropriate to assist with goals set during the program. Participants should stay linked to the program after it has concluded and programs may need to explore online support as a strategy to do this. Setting up a website with recipes, tips for exercise, goal-setting activities, and testimonials from former participants could keep families engaged with the healthy lifestyle changes and an ability to interact with other participants, for example through a blog or social network site, would provide networking opportunities for both parents and adolescents. Special attention should be given to developing multi-media strategies to suit adolescents. Maintenance of healthy changes after program conclusion could be supported further by linking adolescents with existing community services that promote being active, eating healthily or engaging in community activities. This should be promoted during the program and adolescents could choose activities or programs they enjoy. Overweight adolescents may be reluctant to re-engage in organised sport, so other options like cycling or fitness classes should be encouraged..Assessment burden needs to be minimised or compensated for where possible. It should be recognised that lengthy or invasive assessments have the potential to dissuade participants from staying engaged in an intervention program. Assessments need to be kept as short as possible, only measure the specific outcomes associated with the program and be completed at a local site that can be easily accessed by participants. Compensation or incentives for completing assessments may need to be provided if the burden cannot be minimised sufficientlyBeing overweight in adolescence is a major problem; however, limited evidence is available regarding effective and appealing intervention programs for overweight adolescents. Previous studies note difficulties with recruitment or high drop-out rates, however, there is limited evidence identifying specific barriers and enablers to engaging overweight adolescents in a healthy lifestyle program, how to keep them engaged and how to maintain healthy behaviour changes post intervention. This study outlines a number of key barriers to recruiting adolescents and families, and suggests ways to maintain engagement and behaviour change during and following a healthy lifestyle program for overweight adolescents and their families. These findings can be used by researchers to enhance recruitment, retention and maintenance in community-based intervention studies with the target group. The findings can also be used by health service policy makers, planners and service providers to improve feasibility and acceptability of these types of programs and their long term institutionalisation within community settings.The authors declare that they have no competing interests.KS conducted focus groups and the interviews, analysed the data and drafted the manuscript. LS conceived of the study, and participated in its design and coordination and helped to review the manuscript. AM conducted focus groups, transcribed data, assessed themes and helped to review the manuscript. AAF contributed to the interpretation of the results and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/14/53/prepubParent and adolescent focus group prompts. Discussion points for past and potential participants.Click here for fileStakeholder interview prompts. Discussion points for health professionals, local service providers and researchers.Click here for file


Background. Dissemination of health promotion interventions generally has followed an efficacy, effectiveness to full scale paradigm, and most programs have failed to traverse that sequence. Objective. Report national dissemination of a health promotion program and juxtapose sequential case study observations with the current technology transfer literature. Design. Multiple department-level case studies using contact logs, transcribed interactions, augmented with field notes and validated by respondent review; at least two investigators independently generated site summaries, which were compared to formulate a final report. Results. Adoption was facilitated with national partners and designing branded materials. Critical site influences included departmental features, local champions, and liaison relationships. Achieving distal reach and fidelity required sequential process and program revisions based on new findings at each site. Conclusions. Beta testing to redesign program elements and modify process steps appears to be a needed and often ignored translational step between efficacy and more widespread dissemination. Few wellness domains are as timely as is achieving a healthy lifestyle. Currently, less than five percent of US adults simultaneously attain the national dietary, physical activity, and body weight objectives . WorksitThe PHLAME  study was an NIH-funded prospective randomized assessment of two worksite health promotion paradigms among firefighters. Despite public perceptions, firefighters are a high-risk group, with an increased prevalence of obesity, hypertension, dyslipidemia, certain malignancies, and chronic musculoskeletal complaints . Their eP < .005), fitness parameters (P < .05) and general well-being (P < .01), and resulted in less weight gain (P < .05). Both also resulted in an immediate reduction in work-related injuries [The original PHLAME study involved two models for worksite wellness: (1) a team-centered, peer-led scripted curriculum and (2) individual counseling using motivational interviewing (MI) techniques, versus (3) a testing and results only control condition . At one-injuries . The team-centered intervention was less expensive than counseling, and that format also is a natural fit for firefighters' work structure, as a shift at a fire station is an existing team. The PHLAME team-centered curriculum is 12, 45-minute peer-led sessions. One shift member uses a Team Leader Manual with explicitly scripted lesson plans, and teammates use corresponding Workbooks. Participants each receive a pocket-sized Guide with expert, firefighter specific content. Each team session is composed of three to six interactive activities, with core components involving nutrition, physical activity, and energy balance. Between session materials are stored in a Team Box, which also stores an accompanying Family Manual and program props .Because of its positive outcomes, NIH funding was continued to implement the team-centered program in other fire departments across the US and to follow the original cohort for durability of change . We sougThe International Association of Fire Fighters (IAFF) is one of the largest AFL-CIO unions; it was an important partner in recruiting PHLAME dissemination sites. The organization arranged for a PHLAME presentation at an annual IAFF Symposium, where we distributed recruitment materials. http://www.phlameprogram.com/).The marketing literature documents the importance of a product branding , and in We received more than 30 inquires from fire departments across the US. Communicating with departments was a time-consuming process; on average, four contacts per site were needed to exchange information and answer questions. Departments were selected based on sustained interest and a verbal commitment to participate. From 15 interested sites, 8 (maximum feasible with our funding) were selected to provide a range in sizes and locations.As with most worksites, fire departments have a hierarchy of decision makers, who differ from the employees ultimately participating in worksite wellness. Once identified as a dissemination department, a second level of communication was required. We visited each department from two to six times, to personally describe the program and meet with the Chief, Wellness Committee, union officials, and other decision makers. Two sites elected not to participate while finalizing plans and were replaced. In those locations, contract negotiations and turnover in key personnel could trump initial administrative and department-wide enthusiasm. “Turbulence” has been used to describe occurrences that adversely affect implementation of drug use prevention curricula , and a sCase studies are a common strategy in education, political science, and business settings . They caOnce the program was adopted and installed, the departments were assessed during follow-up visits using interviews of key informants, such as the wellness coordinator and union head, and focus groups of shift members at fire stations. Purposeful sampling was used to involve at least some members from all work groups initiating the PHLAME team program, along with selected firefighters from work units not participating . The intConversations were recorded, transcribed, and augmented with field notes concerning circumstances and additional observations. The qualitative information was read and coded to identify themes and sorted based on surfacing key issues and shared concepts. Findings were validated by contacting selected respondents and asking them to review a transcript summary and/or notes for accuracy. Compiled qualitative findings for each site were reviewed by at least two investigators, who generated independent case reports, which were then compared for content and implications, and a final case summary prepared for each site . The InsEugene, Oregon was selected as the initial site because of its close proximity and its first-hand awareness of the PHLAME study. The department has approximately 200 employees and 11 stations. Eighteen of 30 potential PHLAME teams had stable membership and were enrolled. Although the department administration and wellness coordinator knew about the program, we overestimated penetration of information to line firefighters. Firefighter participants reported that not knowing more about the program before beginning the team sessions generated suspicion and reactance among coworkers. Reactance or an opposition to actions perceived to threaten behavioral freedoms can cause individuals to adopt a contrary attitude. Most firefighters are male, and because reactance is greater among men than women , our popPHLAME's 12 sessions originally were formatted to be distributed over 12 months, and clusters of weekly sessions were bridged by competitions among team members to maintain a program presence during breaks. However, Eugene teams found it difficult to sustain members' enthusiasm and momentum during the weeks without meetings, and teams often did not resume sessions. Only 3 of 18 Eugene teams completed the majority of sessions, and that finding was in marked contrast to three-quarters of teams completing most sessions in the initial closely monitored PHLAME study . This fiThe Denver South Metro Fire Department (DSMFD) was selected as a mid-western site, comparable in size to the fire department in Eugene, Oregon. It had no health promotion activities or wellness committee, but its wellness officer was a strong local program advocate. We worked with him to distribute program information to all department members, following which he held a general vote of all firefighters about participating. Although the majority voted to participate, rather than mandatory involvement, we advocated maintaining the program as voluntary, both to meet our Human Subjects requirements, and because it is supported as more successful by the human resource literature . Using this strategy, 22 of 30 potential teams began the program, and the majority completed several months of the original 12-month format. Those teams not enrolling generally reported that they felt they already knew the material or the senior officer and/or assigned team leader were not supportive of the program. As in The Sacramento City Fire Department (SCFD) is a large organization with 22 stations and 571 firefighters, comparable to Portland, Oregon, which was an original PHLAME study site. Although it had an exercise physiologist on staff, departmental officials expressed a particular interest in the nutrition aspects of PHLAME. The physiologist was a vocal local advocate but not an administrative leader, and he was not supported by an established wellness committee. His role would be better described as an organizational rascal than an opinion leader. The dissemination literature describes rascals as individuals who work behind the scenes and maintain enthusiasm among personnel ultimately implementing the program , 26. Working with a larger organization necessitated a prolonged adoption process and five site visits. Adoption and implementation often have been characterized as a two-stage process . We founMontgomery County, Maryland Fire and Rescue (MCMFR) is a large (39 stations), well-funded department with an established wellness program. Its two wellness officers wanted to add PHLAME to their ongoing health promotion activities. While we recognized the challenges in working with a large department, the potential of the MCMFR Chief as a program champion within national firefighter organizations, lead us to enroll MCMFR. To provide program information, we worked with local staff to develop a site-specific informational DVD, which was delivered to all stations and attached to the department's website. We identified interested work groups and began the program with 15 participating shifts. However, following installation, many MCMFR firefighters were deployed to a national disaster area, which disrupted teams' membership. The only team completing all sessions were fire administration personnel, whose teams remained intact. http://www.iaff.org/hs/well/index.htm).An important aspect of the MCMFR experience was the department's strategic location near the IAFF headquarters in Washington, D.C. As a result, IAFF officials were able to directly observe and experience the PHLAME program. Importantly, they reported that seeing it in action facilitated their continued support, and initial IAFF assistance advanced to program endorsement and inclusion of the PHLAME team program in the IAFF Wellness Directive  received a Federal Emergency Management Administration (FEMA) grant to enhance wellness activities and independently contacted us about implementing the PHLAME team program. Their FEMA grant supported one full-time and two part-time positions for wellness activities. SDFD is a large department with 1133 firefighters. Because of FEMA funding, the department needed to document changes in behavior, and we provided simple anthropometric measures, fitness self-assessments and a validated fruit and vegetable intake screener with online scoring for use as a dietary pre- and postmeasure . SDFD was the first site where, from the outset, we used a paid local liaison to monitor teams' progress. In this setting, the liaison was a San Diego resident, who was not an SDFD employee but had friends in the department and experience with the PHLAME format. She was charged with periodically visiting stations to learn about their experience and provide assistance when needed. Eight of 17 PHLAME teams completed the majority of the sessions, and noncompletion primarily related to scheduling conflicts, such as the team leader being injured and wildfires necessitating deploying firefighters off site. The overall program success was further evidenced by SDFD requesting additional materials and with minimal assistance, initiated the program in a neighboring smaller fire department. The PHLAME program positive outcomes assisted SDFD wellness program's continuation after the FEMA grant ended.The sixth dissemination site was the Indianapolis Fire Department (IFD). IFD is a large department with 34 stations. An individual involved in the city's employee wellness activities spear-headed adopting PHLAME, and we hired that person as the PHLAME liaison. We worked with him and the department's wellness committee to identify a three-month interval with a minimum of conflicts with vacations, training activities, and offsite deployments. Thus, we were able to combine a program champion as our paid liaison and strategic scheduling to maximize PHLAME team member consistency. Using those techniques, three-quarters of teams completed the majority of sessions, which was comparable to the success of the original PHLAME team program.Rogers differentiated technology transfer from diffusion of ideas, with the former needing a directed process, rather that the entropy that guides diffusion . While tFirst, sequential beta testing appeared to be a critical step. Beta testing refers to nonrandomly selected adopters “trying out” a product, reporting on their experience, and using those findings to revise the product, and although the business literature recognizes it as a necessary step in product development , it ofteRecruitment and enrollment are instrumental components for efficacy trials and equally so with dissemination studies. Strategies that appeared to facilitate site enrollment included accessing an existing national organization's communication channels  and desihttp://cancercontrolplanet.cancer.gov/). Although redesign for feasibility may be bargaining away from effectiveness, the original PHLAME mediation results provided guidance about what program aspects were and were not negotiable [As evidenced by the experience in Denver and Indianapolis, midlevel individuals were the most effective change or linkage agents and appeared best able to traverse the boundary between the administration and end users. In general, the PHLAME content remained durable throughout its sequential use. The single feature changed was session scheduling, going from a year long to three-month format. The rationale for the initial duration was the potential of more durable positive outcomes. However, review of the Cancer Control P.L.A.N.E.T. website of evidence-based diet and physical activity programs reveals a range of intervention lengths, many having three months and less duration (gotiable . Our qualitative case study methods have limitations, with the potential for response bias among both participants and those coding and compiling information. To minimize that influence, we attempted to appropriately sample participating and nonparticipating work groups and obtain information from a range of respondents. Case data were reviewed and summarized by more than one investigator, and results compared and discussed. The analytic generalizations concerning program revision may be relevant to others, but readers are cautioned to assess finding applicability for their settings. Worksite health promotion programs with proven efficacy seldom are widely implemented, and less than one percent of health promotion studies are categorized as diffusion research . We beliThis study assessed an evidence-based program's translation among municipal fire departments. Many aspects identified as important in technology transfer were confirmed. Optimal implementation appeared to benefit from face to face recruitment, midlevel advocates, and capacity building among well-informed potential participants. A factor not often mentioned in health promotion dissemination is the need for planned beta testing as a translational step. Its importance was underscored by our findings, and its explicit inclusion would be a useful addition to models of adoption, implementation, and widespread use and enhance the ability of moving science-based programs to service.


In 2006, the Quebec provincial government committed itself to developing capacity for evidence-based alcohol and other drug screening and brief intervention (SBI) in frontline health-service delivery settings. Two studies were conducted prior to province-wide deployment to inform decision makers as to possible implementation challenges. Study 1 evaluated the efficacy of implementing a model of SBI, adapted from the World Health Organization, in three frontline public health services. Sixty-two clinicians were trained in systematic detection of substance use and brief motivational intervention. Chart review of new admissions (N = 453) prior and following training assessed clinician conformity to SBI guidelines. Forty percent of patients endorsed at least one item on the four-question CAGE-AID . Systematic screening among new admissions peaked at 70% and decreased to pre-training levels seven months after training. However, more than half of all new patients were assessed with validated questionnaires rather than informal questioning. Implementation of motivational interviewing techniques led to modest changes in clinician interventions. A second qualitative study was conducted to document possible organizational barriers to SBI implementation. Interviews were conducted with 24 clinicians and program administrators from frontline services of the six main health regions of Quebec province. Choice of vocabulary used in public policy documents and program material and sequence of delivery of services created confusion among clinicians as to what constituted alcohol and other drug SBI. Many resources developed for other SBI health programs in these frontline services seemed to be transferable to alcohol and drug SBI. Lessons learned were as follows: complexity in the SBI program is inversely related to the subsequent integrity of program deployment; clarity as to what constitutes SBI is paramount; and integration of parallel competencies/related programs could facilitate deployment of alcohol and other drug SBI.


Ceriporiopsis subvermispora. Concentrations of glucose, ammonium tartrate and Polysorbate 80 were varied to establish the optimal composition of liquid media (OLM), where the highest experimentally obtained activities and productivities were 41 U L−1 and 16 U L−1 day−1 for laccase (Lac), and 193 U L−1 and 80 U L−1 day−1 for manganese peroxidase (MnP). Considering culture growth in OLM on various types of immobilization support, the best results were obtained with 1 cm beech wood cubes (BWCM). Enzyme activities in culture filtrate were 152 U L−1 for Lac and 58 U L−1 for MnP, since the chemical composition of this immobilization material induced higher Lac activity. Lower enzyme activities were obtained with polyurethane foam. Culture filtrates of OLM and BWCM were applied for dye decolorization. Remazol Brilliant Blue R (RBBR) was decolorized faster and more efficiently than Copper(II)phthalocyanine (CuP) with BWCM (80% and 60%), since Lac played a crucial role. Decolorization of CuP was initially faster than that of RBBR, due to higher MnP activities in OLM. The extent of decolorization after 14 h was 60% for both dyes.Response surface methodology  was employed to simultaneously optimize enzyme production and productivities of two ligninolytic enzymes produced by  C. subvermispora is a well-known fungus in the bio-pulping and paper industry because it is a selective lignin degrader )max and ([EMnP])max are the highest values of the experimentally obtained maximal Lac and MnP activities ([ELac] and [EMnP] in U L−1) for all settings presented in w is the weighting factor , (d[ELac]/dt)max and (d[EMnP]/dt)max are the highest values of experimentally obtained maximal Lac and MnP production rate (d[ELac]/dt and d[EMnP]/dt in U L−1 day−1) for all settings presented in OFMnP could not be optimized due to the absence of local maxima within reasonable substrate concentration values (the combined measurement and estimation error was too large). Nonetheless, a new Objective Function (OFLac/MnP) for batch experiments was defined as:where ()/productivity (d[ELac]/dt) at the specific glucose (x1) and ammonium tartrate (x2) concentrations at the fixed Polysorbate 80 level , meaning that at lower concentrations both medium components promote enzyme production, whereas an additional increase in concentrations results in an inhibitory effect. The research of C. subvermispora in biotechnological applications revealed the obtained Lac activities around 75 U L−1 and MnP activities around 40 U L−1 after 5 and 14 days of incubation, respectively, in a MPG  medium at 25 °C  on x3, but x3 could have been approximated by linearization. Another feature of interest lies in the fact that the influences of carbon source, nitrogen source, and surfactant seem to be independent, as the interdependence terms  in x1x2 (+)) being the largest of them. The dependences on glucose (x1) and ammonium tartrate (x2) in OFLac) as a function of glucose (x1) and ammonium tartrate (x2) concentrations in y2, d[ELac]/dt). Lac productivity is thus noticeably affected by the inhibitory effect of glucose (x1x1 (−)) and the positive combined glucose/ammonium tartrate effect (x1x2 (+)) (x3) principally affects productivity, as well as activity; the productivity both in the linear (−) and quadratic (+) terms. The overall effect of the surfactant on productivity is the same as that which it asserts on activity, namely negative. Other effects had negligible influence.The maxima in Lac activity/productivity (x2 (+)) . The latw. Parameters  were estimated by nonlinear regression, namely the Levenberg–Marquardt algorithm (10−5 tolerance).The optimization of the quadratic model utilized ensued, where the model parameters were estimated by linear regression. The objective function, constituted from enzyme (Lac and MnP) activity and production rate, was maximized for variable portions of either, OFLac) Lac activity and productivity, and (OFLac/MnP) Lac and MnP activities, which were maximized simultaneously, with variable contributions of Lac activity (w) to the objective function. In the first case one may observe that although the overall objective function OFLac assumes its greatest value (1.17) at w = 0 due to high Lac productivity, Lac activity is greatly decreased . As the contribution to Lac activity in OFLac, w, increases, Lac activity  first abruptly and then gradually increases towards 1.14, while concurrently Lac productivity  exhibits a rather small decrease, from 1.17 to 1.00. This would imply that, with the exception of very rare cases when the maximal productivity would be attained regardless of the relatively low activity , continuous systems should preferably be operated in conditions of the highest activity and only slightly decreased productivity , or at least in this vicinity. Of course, another aspect to consider is the concentration of medium components at which distinct levels of activity or productivity may be achieved.OFLac/MnP) reveals that it is difficult to obtain high levels of both Lac and MnP, respectively, since for high MnP concentrations (w→0), Lac activity decreases basically to zero. On the other hand, upon obtaining high Lac concentrations , MnP activity may be maintained at an intermediate level .Simultaneously optimizing Lac and MnP activities (OFLac) and Lac and MnP activities (OFLac/MnP) are presented in Examples of initial glucose, ammonium tartrate, and Polysorbate 80 concentrations for the optimal Lac activity and productivity max at CP = 0 g L−1 arise because of the broadly examined range of factors  and Q2 (the latter indicates predicted variability) coefficients, which were 0.875 and 0.872 (R2), and 0.608 and 0.623 (Q2) for Lac activity and productivity, correspondingly. A poorer predictability of the model for MnP activity and productivity may be observed through lower values of R2 and Q2 parameters, which were 0.686 and 0.795 (R2), and 0.339 and 0.468 (Q2) for MnP activity and productivity, correspondingly. The objective function (used in the model), using which we aimed to optimize the production, is indeed extremely useful, but in point of fact implies good predictability of the model . The reported coefficients demonstrate this for Lac activity and productivity, but not for the case of MnP.According to the model there should preferably not be any surfactant in the medium. The implication of the fact that the highest Lac activity and productivity are predicted by the model in the absence of Polysorbate 80 is on the one hand favourable, thus avoiding an additional component in the medium and directly decreases cost; furthermore, this could decrease downstream processing and potential contamination of crude filtrates as well. Nonetheless, verification experiments showed a discrepancy between model and experimental data, implying that the range of Polysorbate 80 concentrations examined may have been too broad. Consequently, a series of experiments was undertaken varying only the surfactant concentration in the region below the lowest concentration of 0.3 g L w = 0.5 , clearlyC. subvermispora cultivation experiments on various immobilization supports using the optimized liquid medium (OLM). Beech wood cubes (BWCM) and pine wood cubes (PWCM) containing natural lignin as inducer and inert polyurethane foam cubes (PUFCM) were used to immobilize the culture growth and to control the immobilization effect in comparison to the combined effect of the other supports that act as carriers as well as inducers. The composition of the liquid media was prepared according to the optimum settings for OFLac/MnP at w = 0.5 obtained from the response surface methodology experiment. In addition, the OLM was used as a reference medium with free mycelium. The results are presented in −1 for MnP and 19 U L−1 for Lac. It is evident that the use of wood supports affected the enzyme activities. Beech wood and pine wood induced higher Lac activities. Maximal values using BWCM and PWCM, achieved after eight days of cultivation, were 150 U L−1 and 135 U L−1, respectively. In contrast, MnP activities using wood supports were lower than the results with only liquid medium OLM, namely 60 U L−1 for BWCM and 20 U L−1 for PWCM. Production of enzymes was the lowest under PUFCM cultivation conditions: MnP activity was only 40 U L−1, while Lac activity was close to zero (2 U L−1). In the literature it was reported that inert materials such as PUF affect fungal growth as an immobilization surface, but alone cannot increase enzyme synthesis [The second phase of the study continued with ynthesis ,20. In cynthesis . Hence, ynthesis . Presentynthesis .C. subvermispora could be used in environmental applications, in the paper industry and also for the decolourization of synthetic dyes [Dichomitus squalens [et al. [D. squalens [C. subvermispora ligninolytic enzyme system show the potential use of this fungus for environmental protection and bioremediation of pollutants. However, in the future during the enzymatic degradation studies, more attention should be paid to the analysis of the products appearing during enzyme degradation.Further, the mixture of ligninolytic enzymes produced by the white rot fungus tic dyes ,4,15,17.squalens . A simil [et al. . The decsqualens . The extCeriporiopsis subvermispora CBS 347.63 was obtained from the CBS culture collection . The strain was maintained on 5% malt extract agar (MEA) at 4 °C as described previously [The fungus strain eviously .v/v) of the mycelial suspension. Glucose, ammonium tartrate and Polysorbate 80 concentrations in the basal culture medium were varied as shown in The mycelial suspension was prepared as previously described by Babič and Pavko . The shaLaccase (Lac) activity was measured by monitoring the oxidation of a 5 mM solution of 2,2′-azino-bis(3-ethylbenzothiozoline-6-sulfonic acid) (ABTS) as the increase in absorbance at 420 nm , and man−1 and 10.0 g L−1 for glucose, 0.1 g L−1 and 2.0 g L−1 for ammonium tartrate, and 0.1 g L−1 and 1.0 g L−1 for Polysorbate 80, the real values being presented in To optimize the medium composition with regard to Lac and MnP activity and their productivity, surface response methodology for enzyme activity and productivity was utilized. Central composite design (CCD)  was used applying full factorial, the inscribed type of design, and no limitations of the maximal block size. Although CCD is a really useful approach for the optimization of enzyme production processes it cannot always be successfully applied using fungi; to overcome this possible problem we repeated in triplicate the experiment of the CCD. Modelling, sensitivity analysis and optimization was performed with Matlab R2011a software. The coded values in the central composite design matrix were transformed into real values using minimal and maximal concentration values of 1.0 g LA complete description of the process behavior requires a quadratic model :yi is either the maximal Lac activity (i = 1) or its maximal production rate (i = 2) and either the maximal MnP activity (i = 3) or its maximal production rate (i = 4), ai0, aij, ai12, ai13, ai23 and aijj are respectively, the constant term (ai0), linear (aij), mixed  and quadratic (aijj) coefficients for a complete description of the behavior of either the maximal Lac activity (i = 1) or its maximal production rate (i = 2) and either the maximal MnP activity (i = 3) or its maximal production rate (i = 4). The coefficients aij, ai12, ai13, ai23 and aijj correspond to independent variables; specifically, the initial glucose , ammonium tartrate  and Polysorbate 80  concentrations. Both the independent (yi) and dependent (xj) variables were normalized, that is divided by their maximal values, so that they would be within the range of 0–1.where 3 pine (PWCM), beech (BWCM) and polyurethane (PUFCM) cubes for 14 days. The OLM contained 10 g L−1 glucose, 1 g L−1 ammonium tartrate and 0.05 g L−1 Polysorbate 80 in the basal culture medium. In order to prepare the solid support for fungal colonization, PUF cubes were washed three times with hot distilled water to remove all foreign matter and air dried. The cubes were autoclaved in 150 mL of OLM in 250 mL Erlenmeyer flasks. After autoclaving, 50 mL of the medium was removed and the rest of it was inoculated with 5% (v/v) of the mycelium suspension. Aliquots of the culture liquid were collected for determination of extracellular Lac and MnP activities.Immobilized cultures were grown in optimized liquid medium (OLM) on 1 cmmax = 592 nm, and Copper(II)phthalo-cyanine , λmax = 694 nm. Both dyes were purchased from Sigma (USA).Dye decolourization was calculated by comparing the absorbance, measured at the maximum absorbance wavelength for each compound, during the decolorization treatment. The dyes used in this study were Remazol Brilliant Blue R , λin vitro dye decolorization by the crude culture liquid, culture filtrates obtained from cultivation cultures of C. subvermispora in OLM and in BWCM were used. The reaction mixtures consisted of 100 mM Na-tartrate buffer, pH 4.5, 50 mg L−1 dye and 100 μL of crude culture liquid in a final volume of 1 mL. Dye decolorization was measured continuously using a Perkin Elmer spectrophotometer, type Lambda 25 (USA) [For 25 (USA) .C. subvermispora in submerged cultures and their dependence on medium composition can be well described by response surface methodology (RSM) over a broad range of concentrations. For better accuracy, some repetition of the RSM procedure should be performed.In fungal cultures medium optimization should play an important role in the upstream process due to the consequent lowering of process costs. The activity and productivity of ligninolytic enzymes from A two-step strategy, that is, liquid media optimization first and then selection of an appropriate immobilization support to induce the enzyme activities, was successful in increasing Lac activities. It was shown that the methodology of liquid medium optimization can be readily utilized for a wide range of compositions for predicting both ligninolytic enzyme activity and production rate simultaneously and relatively accurately. Therefore, a major advantage of the proposed approach is that it may be usefully applied for systems in which as high activity as possible is desired to avoid downstream separation and purification costs, or for those processes in which maximizing the enzyme production rate is imperative, namely in continuous processes. Balancing these two contributions allows for intermediate regimes in which both the activity and production rate play an important role. Despite the fact that the methodology was applied for a specific medium  its applicability may be extended to other components as well.The natural tendency of filamentous fungi to adhere to surfaces was successfully applied to increase Lac activity in the second step of the study. Naturally an immobilization material with appropriate chemical composition which affects fungal activities and induces enzyme activities should be used for this purpose. This principle, which was used here for enzyme production in batch stationary cultures, is already well recognized for enzyme synthesis in various types of bioreactors with immobilized biomass, for example in packed bed bioreactors, rotating disc bioreactors and biofilm reactors.C. subvermispora can be successfully used for decolorization of synthetic dyes. In addition, they also have good potential for use in other bioremediation and environmental protection applications, as well as in lignin breakdown.It was shown that ligninolytic enzymes, namely manganese peroxidase (MnP) and laccase (Lac), produced by the white rot fungus


To describe HA-BSI secondary to surgical site infections (SSI) in Quebec hospitals.Acute care centers with ≥ 1000 admissions/year were invited to participate voluntarily and declare via a web portal all HA-BSIs secondary to a SSI between 2007 and 2010.The surveillance program also included outpatients and paediatric patients.56 of the 89 eligible centers participated , 64 % of those beds were in teaching hospitals. Of the 7709 episodes of HA-BSIs, 874 (11 %) were secondary to a SSI. Gastrointestinal surgeries were, by far, the leading cause of BSIs (244 – 28%) followed by cardiac surgery (132 – 15%), and orthopaedic surgery (98 – 11%). Implants were present in 25 cases (19%). The majority of SSIs (496 -57%) were organ space infections. S. aureus was the organism most often isolated in 28% (274), followed by E. coli in 13% (130) of patients. Overall, 79% of patients were admitted on a general/specialised ward upon onset, compared to 15% in ICU, and 6% in ambulatory care. The mean time to infection was 21 days with a median of 10 days . 75% of BSIs occurred in teaching hospitals.The Quebec surveillance program for HA-BSIs is a convenient way to survey the most severe SSIs, awaiting the development of a complete SSI surveillance program. Further analyses are needed to better understand the correlation between this targeted program and a complete SSI surveillance program.None declared.


The Ottawa Model of Smoking Cessation (OMSC) is a hospital-based smoking cessation program that is expanding across Canada. While the short-term effectiveness of hospital cessation programs has been documented, less is known about long-term sustainability. The purpose of this exploratory study was to understand how hospitals using the OMSC were addressing sustainability and determine if there were critical factors or issues that should be addressed as the program expanded.Six hospitals that differed on OMSC program activities  were intentionally selected, and two key informants per hospital were interviewed using a semi-structured interview guide. Key informants were asked to reflect on the initial decision to implement the OMSC, the current implementation process, and perceived sustainability of the program. Qualitative analysis of the interview transcripts was conducted and themes related to problem definition, stakeholder influence, and program features emerged.Sustainability was operationalized as higher performance of OMSC activities than at baseline. Factors identified in the literature as important for sustainability, such as program design, differences in implementation, organizational characteristics, and the community environment did not explain differences in program sustainability. Instead, key informants identified factors that reflected the interaction between how the health problem was defined by stakeholders, how priorities and concerns were addressed, features of the program itself, and fit within the hospital context and resources as being influential to the sustainability of the program.Applying a sustainability model to a hospital smoking cessation program allowed for an examination of how decisions made during implementation may impact sustainability. Examining these factors during implementation may provide insight into issues affecting program sustainability, and foster development of a sustainability plan. Based on this study, we suggest that sustainability plans should focus on enhancing interactions between the health problem, program features, and stakeholder influence. Hospital care for smoking-related illnesses represents an important part of the healthcare burden. Smokers average more than twice as many hospital days compared to individuals who have never smoked . There iet al. .' (DM 5)Staff behaviour began to change when nicotine replacement therapy (NRT) was made available as unit stock and the DM framed delaying the application of NRT as a medication error and patients smoking as a 'failure to treat their nicotine withdrawal.' (DM 5)Several key informants suggested that framing hospital smoking cessation programs in terms of costs and benefits would influence decisions of the provincial Ministry of Health and Long Term Care to fund hospital cessation programs:'If we take a very aggressive approach to addressing the use of tobacco in patients then we will have cost savings in our hospitals...we will have reduced days of stay, less infections. So I think that the approach, honestly, needs to talk about, obviously it's a wellness thing, and it's important, but hospital administrators are interested in the bottom line. They need to see this as an investment, not an expense. Because if you save two days of stay on the average length of stay, or even one day of stay for every patient who comes in who is a smoker, compared to patients who don't, who have the same procedure, I think that is very powerful data.' (DM 5)Although the four hospitals that implemented the OMSC using unit nurses did so for budgetary reasons, respondents at those hospitals felt that this approach helped embed the program into patient care and fostered sustainability by engaging frontline healthcare workers in the program:'Nurses are used to healthcare teaching, so they see assessing patients' readiness [to quit smoking] as a good fit. It's amazing once they get committed at that point, how I think that's the sustainability component, because they are living and breathing it every day.' (DM 2)A SCC with some dedicated time to counsel patients noted that other nurses had difficulty finding time to counsel patients:'If [the other nurses] know I am coming in, perhaps they won't [deliver the program]; they will leave it for me. Because they don't have the hours dedicated to it, they have to try and fit it into their day and an assessment, the first counselling sessions take about a good 40 minutes or so by the time you are done the paperwork and that is a lot into their already busy day.' (SCC 2)At another hospital, in order to engage nurses in the counselling process, the sessions were modified to take place when nurses are providing other care.Two SCCs mentioned that their expectations about the program changed after seeing the effect it had on patients:'But then when you find that the patient is less irritated, the patient is less restless, if you can provide them with some nicotine replacement and then you get one less problem to deal with, there's a benefit to it.' (SCC 6)'I would say now, my emphasis is more to make them comfortable while they are in the hospital and hopefully they will [quit]. It is still in the long run to make them quit. However, when they are comfortable in the hospital and they see that they can go craving-free for a few days then that sort of gives them the courage to think about quitting or it teaches them that quitting can be an option.' (SCC 2)i.e., individuals who promote the OMSC to hospital staff) to overcome staff resistance and gain acceptance of the model, thus promoting stakeholder engagement in the program. Hospitals strategically chose individuals with high credibility, enthusiasm about the program, and their passion for smoking cessation. One hospital, experiencing resistance from the medical leadership, enlisted a physician champion who 'made presentations and started to order medications for patients, to convince colleagues that it's a safe thing to do' (DM 1).Two of the four hospitals with higher levels of OMSC activity mentioned that they used champions . A hospital with a lower level of OMSC activity found that UOHI's feedback was helpful in providing input into problems they were experiencing:'They would meet with us and look at how our audits were reporting, and looking at what some of our problems were, we were identifying how to improve and it was something that I thought was quite acceptable for new programs. You would troubleshoot as you went along.' (SCC 6)Despite help with specific problems, the two hospitals with lower OMSC activity levels indicated that they did not always feel supported:'Sometimes I don't feel supported. Sometimes I feel badgered. ...I think at this point we're feeling a little overwhelmed by what's before us.' (DM 5)'Whenever there was a decrease in numbers, I'm not sure what supports were there from the Heart Institute, because if there is no sustainability, you are just basically saying, Okay, add this to your workload and although you mentioned great that smoking cessation is important, it is an extra item that we are expecting nurses to remember to do, one, and that they will complete, have the discussion about the IVR afterwards, and follow-up in the community.' (DM 6)When asked if they could envision a time without support from UOHI, many respondents described the role that they felt UOHI could take in sustaining the program. '[UOHI is an] excellent link for us...gives me new research' (SCC 1). 'It is easier to keep a program going if a central institution is involved; it keeps the program on the front burner' (DM 2). Other roles a centralized institution might consider included: offering a mini-refresher course to ensure that everyone knows the newest information available; coordinating various hospital sites to ensure that information is consistent across hospitals; organizing a community of practice teleconference every two to three months between sites so that they could learn from each other; and assisting hospitals with training and resources to manage and process program statistics.Respondents cited the reputation and experience of the OMSC in addressing hospital smoking cessation as a major reason why they decided to implement the OMSC. The ability to demonstrate quit rates appealed to hospitals:'It was already a success in other hospitals. They had really good evidence to support what they were doing, really good numbers [quit rates] showing how successful they had been, so in many ways it seemed like a really good model.' (SCC 2)The best practice statement in the model was also appealing:'It makes it easier for us to try and move the notion forward that not only were we smoke-free property-wide but that we were actually going to try and support patients while in the hospital to achieve that status of not smoking while they were a patient in the hospital.' (DM 5)The baseline survey and other tracking measures were beneficial because they enabled hospitals to see improvement and track their progress, and increased accountability: 'People realize that the program is important because measures are reported to leadership; if they have to report it then they are held accountable' (DM 1). 'Providing feedback to staff makes them more aware of what is going on; to keep them in the loop and remind them of the processes' (SCC 1). Program results could be used to argue for funding as 'once [you] have outcomes then it becomes more sellable' (DM 2).Hospitals used this performance feedback to make changes to their processes. When two hospitals noticed a decrease in the number of smokers being identified, one began the process to integrate a late-career nurse to provide support to the program, and the other obtained support from UOHI to develop communication tools and conduct additional training sessions. Another hospital, wanting to increase the IVR follow-up enrolment rate, now asks patients about IVR on admission and at discharge because:'Some patients are not ready at the beginning of their stay in the hospital, but once they see how they do within the hospital then sometimes they're more open to trying to stay, to remain smoke-free. So, we would suggest the IVR again, we would ask again at the second time.' (SCC 1)Despite the positive feedback on the measures collected by the OMSC, DMs felt that it is difficult to sustain programs that require data management without dedicated resources. One DM felt that the culture of collecting data for these types of programs has implications for their sustainability because hospitals do not have the infrastructure to collect all of this information, 'It was the reporting that was required, I'm not sure if people knew that up-front, how much reporting was expected or that they would be requested to provide' (DM 6).e.g., technical and privacy).The OMSC program was operating within a social, political, and economic context defined by the organizational setting, community environment, and available resources. Some hospitals were challenged during implementation because collecting data and setting up the IVR component of the program involved the cooperation of different hospital departments , 'When you keep doing the same thing for a long time, you need to spruce it up a bit and talk about it a bit more' (SCC 1).While DMs felt that the OMSC was an important initiative and had advocated for the program's implementation and continuation, they were also cognizant that smoking cessation is only one of many hospital initiatives. To avoid the program becoming forgotten amongst other new and competing initiatives, one SCC remarked that they are trying to incorporate the program into other things that the hospital is doing . At another hospital, the DM reallocated funding in a specialized nursing unit which was not part of the hospital's operating budget to enable the program to continue, but only in that unit.Study respondents identified that resources are necessary for staff education, data management, and to fund a full-time person dedicated to the OMSC. However, opinions differed as to whether assigning an overall champion or employing full-time smoking cessation counsellors would ensure that all patients receive counselling and are informed about the IVR.Key informants remarked that the success of the program would depend on how successful hospitals are including smoking cessation as part of best practices for nurses and other health professionals. One DM suggested that for programs that aim to change behaviours, it is necessary to include these concepts in the educational curriculum of the healthcare providers to increase acceptance of the program by professionals, overcome attitudes of resistance, and to have it looked upon as an acute care health issue. Another respondent suggested that physicians become more involved in smoking cessation by talking to patients about their tobacco use prior to hospital admission.This was an exploratory study to understand how hospitals using the OMSC were addressing sustainability. The OMSC was defined as sustainable if the core smoking cessation activities  were performed at a higher level than when the OMSC was first implemented (baseline). Using this objective measure reduced the likelihood of misclassifying the OMSC as sustainable or not sustainable. It enabled the research team to examine similarities and differences in implementation processes, system supports and resources, and organizational culture that have been suggested to affect sustainability.We did not find any differences in the OMSC's sustainability by hospital unit , management of the IVR follow-up , or length of time since launching the OMSC. However, we did find that hospitals with a SCC with some dedicated time (as little as 10%) to educate and train staff, promote the OMSC (either themselves or by enlisting champions), and ensure that patients are being identified, offered counselling, and follow-up had achieved OMSC activity rates that were higher than baseline. These actions may influence the sustainability of the program by enhancing the interactions between the health issue, stakeholders, and program.Key informants identified that the UOHI training, education, and research updates should be considered a key component to the program's sustainability in a hospital setting. Both SCCs and DMs noted the need for continuous training updates given staff turnover in nursing units. Training and education provide the skills necessary to administer the program, and an opportunity to change stakeholder awareness and attitudes about hospital based cessation programs. Education about the effectiveness of patient follow-up on smoking cessation may impact the hospital's decision to continue with that component of the program.et al. [Hospitals with a sustainable OMSC had designated SCC time for staff education, training, and support, which is consistent with Greenhalgh et al.  who founet al. [e.g., how they influence drivers).Many key informants identified the need for a passionate champion to move the issue forward and to advocate for the OMSC program. Program champions may be needed at various levels within an organization, and their message may need to be tailored to different stakeholder expectations ,18,21. Wet al. [e.g., staff time and actual costs) for some hospitals. Lack of performance feedback and data on cessation rates may jeopardize the sustainability of the hospital based smoking cessation interventions.Blasinsky et al.  examinedKey informants suggested that UOHI could provide support in sustaining a hospital smoking cessation program by creating communities of practice and providing up-to-date research findings and ongoing training. UOHI may also want to consider managing the IVR follow-up and performance feedback system. Future research is needed to determine the type and amount of external support that is beneficial in sustaining hospital participation yet is affordable and feasible for the supporting organization.et al. [et al. [e.g., training, education, communicating results) and the IVR system represent new expenses specific to the OMSC, and hospitals were concerned with funding this supporting infrastructure. Our study was not designed to examine when new programs should become self-funding or whether some functions should be centralized and serve many hospitals. These are important research questions if effective programs like the OMSC are to become routine hospital practice.All key informants felt that dedicated funding was necessary for the sustainability of the OMSC; this is consistent with the review by Greenhalgh et al. , which f [et al.  found coWe distinguished between sustainable and unsustainable smoking cessation interventions by using a measurable definition of sustainability based on hospitals' performance of the OMSC intervention relative to baseline. This facilitated investigation of similarities and differences between hospitals to examine components of the OMSC and how they were being sustained. It was also possible to examine factors that have been associated with sustainability in the literature that emerged from our analysis.et al. [Although we interviewed only two key informants per hospital, each provided similar responses to the interview questions and held similar perceptions of OMSC sustainability, organizational culture, and the value of performance feedback. Both within, and between hospitals, similar factors were identified that can affect sustainability, such as problem definition, role of program drivers, use of champions, and performance feedback. This similarity provides some validation of the study findings, and is consistent with the interactional model proposed by Gruen et al. .The exploratory nature of this study and the small number of hospitals and key informants interviewed means our findings cannot be generalized beyond those interviewed. Generalization was not the purpose of our study; rather, we sought an understanding of how hospitals were approaching sustainability. A larger study with more hospitals  may lead to different conclusions. However, consistent themes emerged from this analysis that provides direction for further research.Hospitals were selected based on UOHI records of performance, availability, and willingness to participate. We collected only limited information on the organizational characteristics of participating hospitals that could affect sustainability, particularly if competing priorities, infrastructure, or procedures directly affect sustainability. It was interesting to hear from DMs that smoking cessation is perceived to be more of a public health intervention than an acute care treatment. This needs further exploration because hospitals do implement cessation interventions when defined as a hospital problem.As in all studies, there is the potential for a social desirability bias. Because the interviewer was not a member of the UOHI, respondents may have felt more at ease to discuss any concerns with the OMSC. The focus on understanding and open-ended nature of the interview likely reduced any concerns about an evaluative purpose of the study.The OMSC is an effective smoking cessation intervention for the hospital setting that can reduce the prevalence of smoking in the population. Success of the program is dependent upon the ability of hospitals to sustain the program in the clinical setting over time, despite competing priorities. Understanding DMs' priorities and frame of reference and showing how the intervention meets the needs of various stakeholders may impact the willingness of these drivers to prioritize the program. Using program champions, incorporating relevant performance feedback, conducting ongoing education, training, and promotion, designating a hospital based coordinator role, and demonstrating program effectiveness emerged as important factors for sustainability of the OMSC. Hospitals in this study also identified the need for centralized roles such as research updates, shared learning and potentially program monitoring and performance feedback.et al.'s [In order to impact a program's sustainability it is necessary to understand the factors involved in continuing the program and to develop an approach to address any concerns . This iset al.'s  model isRDR has received a speaker's honoraria from Pfizer, Inc. All other authors have stated no competing interests.SC (Lead Investigator) and KP  were responsible for the design, conduct, analysis, and interpretation of this exploratory sustainability study of the Ottawa Model of Smoking Cessation. Both participated equally in writing this manuscript. KAM is responsible for overseeing implementation of the OMSC in Ontario hospitals. She facilitated the evaluation process, provided feedback on data interpretation and findings, and contributed to the manuscript sections on the Ottawa Model. RR participated in the design of the study and provided critical feedback to both the evaluation report and manuscript. RDR is the principal investigator of the OMSC implementation and dissemination study. He participated in the design of this study, reviewed findings and contributed to the manuscript preparation and revision. All authors have read and approved the final manuscript.Interview Guide. Questions used to gain an understanding of the sustainability of the OMSC.Click here for fileAspects of program delivery. Overview of how different hospitals implemented the OMSC.Click here for file


On 9 April 2013 at 11:52 UTC , a Mw 6.2 earthquake occurred at the depth of 20 Km in Dashti district in south-west Iran’s Bushehr province. The macroseismic epicenter was located nearby the city of Shonbeh. During one month after the earthquake, a total of 282 aftershocks hit the epicentral region, mostly at the east and north sides. They ranged from 2.5 to 5.7 on the Richter scale. Seventy aftershocks (24.9%) were M4.0-4.9 and eight (2.8%) were M5.0-5.7. Aftershocks are potentially able to do additional damage. In Bushehr earthquake, a M5.4 aftershock on 10 April in Chahgah village caused at least four injuries and destruction of several buildings that had been already damaged by the main shock. Knowledge about the aftershock induced damages provides opportunities for timely risk communication with the affected people and for long term community education. This will hopefully increase the community awareness and minimize the risk of further loss of lives.  On 9 April 2013 at 11:52 UTC , a Mw 6.2 earthquake occurred at the depth of 20 Km in Dashti district in south-west Iran’s Bushehr province According to the International Institute of Earthquake Engineering and Seismology based in Tehran, during one month following the earthquake, a total of 282 aftershocks hit the epicentral region Distribution of aftershocks’ magnitude on the RS was as follow: 33 M<3.0 11.7%), 171 M3.0-3.9 (60.6%), 70 M4.0-4.9 (24.9%) and 8 M5.0-5.7 (2.8%). Among the 78 aftershocks with M ≥4.0, four aftershocks (5.2%) occurred at the depth of ≤10 Km, 63 (80.8%) at the depth of 11-39 Km, seven (8.9%) at the depth of 40-50 Km, three (3.9%) at the depth of 50-100 Km and one aftershock (1.2%) at the depth of 102 Km 1.7%, 171By definition, aftershocks are earthquakes that follow the largest shock of an earthquake sequence The aftershocks are potentially able to do additional damage In Bushehr earthquake, a M5.4 aftershock on 10 April in Chahgah village caused at least four injuries and destruction of several buildings that had been already damaged by the main shock on 9 April, according to the Director of Iran’s National Disaster Management Organization Lack of a consolidated reporting system on consequences of aftershocks is a challenge as we have also observed in other major earthquakes in Iran, like Bam (2003), Zarand (2005) and Lorestan (2006) earthquakes. This limited our knowledge about the aftershocks induced damages which is necessary for timely risk communication with the affected people and for a long term community education. Because people entering damaged buildings are at risk should an aftershock occur, we believe that this information must be developed and shared with Iranian community to increase their awareness and minimize the risk of further loss of lives.The authors have declared that no competing interests exist.Ali Ardalan MD, PhD. Tehran University of Medical Sciences. Harvard Humanitarian Initiative. Email: ardalan@hsph.harvard.edu


The published figure legend is as follows: (WRONG)Figures 1–10. Blacometeorus sinicus Chai & Chen, sp. n. ♀, holotype. 1 antenna 2 head, frontal view 3 head, dorsal view 4 mesonotum, dorsal aspect 5 propodeum and metasomal tergite I–II, dorsal aspect 6 fore wing 7 hind wing 8 body, lateral view 9 hind leg 10 hind tarsus.The CORRECT one is as follows:Figures 1–10. Blacometeorus sinicus Chai & Chen, sp. n. ♀, holotype. 1, head, dorsal view 2 head, frontal view 3 antenna 4 body, lateral view 5 hind leg 6 hind tarsus 7 fore wing 8 hind wing 9 mesonotum, dorsal aspect 10 propodeum and metasomal tergite I–II, dorsal aspect.