Natech term is utilizing to describe the technological disasters caused by natural hazards. This study was conducted on the emergency evacuation challenges of residential areas adjacent to a refinery near Tehran based on HThis Research was an applied study at two phases in 2020. In the first phase, a review study was conducted to identify the community's previous experiences on emergency evacuation following Natech events. In the second phase, the challenges of emergency evacuation were analyzed based on the scenario of a possible earthquake and gas release from the refinery.2S gas release in concentration 30 ppm as the result of the earthquake impact on chemical facilities. Emergency evacuation would be inevitable. The existing evacuation places are very unsafe and dangerous due to having open spaces. The nearest suitable evacuation places were found in the north direction for more than 38 % of the exposed population and in the east, west, and south direction for more than 61% of them.Due to the high seismic vulnerability of structures in the area affected Natech risk, the total Resident population in this area would be affected simultaneously by an earthquake and HThe emergency evacuation challenges were discussed in 4 viewpoints, disrupted or interrupted rescue and firefighting operation, unnecessary evacuation, frequent evacuation, and evacuation behavior. The measures such as revising and updating emergency evacuation maps; public informing, training, preparedness; providing protocols and training for operational and therapeutic response teams; and coordination improvement can help resilience increasing to such disasters. The Sendai framework has emphasized the importance of integrated Risk management of all hazards and challenges of such events; too.10 The emergency evacuation of the affected residential areas is the most important measure in these events. Valuable experiences and lessons have been provided about the evacuation challenges from Studying 102 Natech events caused by the release of hazardous materials that led to the evacuation of residential areas in the United States in the period 1990-1990,5 the Izmit earthquake in Turkey in 1999,13 the Great East Japan earthquake and tsunami in 2011.14In recent decades, earthquakes as natural hazards had direct effects both on communities and the chemical industry, especially refineries and petrochemicals, as well caused many Natech events. The term Natech was used for the first time by Schwartz and Meyer to describe technological disasters caused by natural hazards,Due to the experience of previous destructive earthquakes, high population density, and proximity of residential areas to hazardous chemical industries in Tehran, the Natech events risk assessment following the possible earthquake and the toxic substances release, fire, and explosion should be considered in preparedness and emergency response plans. 2S Toxic gas releases from a refinery following a possible earthquake and its impact on the urban community.For this purpose, the present study investigated the emergency evacuation challenges of residential areas in the south of Tehran based on the Natech event scenario of HStudy Design This applied study has been conducted to investigate the challenges of emergency evacuation of the urban community due to the release of toxic gas from a refinery following the scenario of a possible earthquake in 2020.Setting15 Tehran, the capital of Iran, is known as one of the 20 metropolises in the world, as well as one of the 17 metropolises with a population of over 10 million people that is among 3 active faults and in a region with a high relative risk for earthquakes.18 Among the mentioned faults, the North Tehran and North Rey faults are the most important active and inverse ones in the region.17 Examining the documents and seismic records of the faults of the south of Tehran revealed the occurrence of a high number of powerful and destructive earthquakes  in the shahre-Rey that has been associated with many casualties.19Iran is located in the Alpine-Himalayan seismic belt.The refinery under research is located in the south of Tehran, between the northern and southern Rey-Ivanki faults in the north and the Kahrizak-Pishva faults in the south. Tehran has 22 municipality districts. In recent decades, increasing population, urbanization, and the gradual development of residential areas in the north (District 20), northeast (District 20 suburb areas), and west (District 19 suburb areas) have caused the proximity of these areas to the refinery and other chemical industrial facilities.Study steps20 Search terms and keywords were selected by taking the opinions of experts in the disaster management field, and then the search strategy was compiled as follows: After a preliminary search and review of references of key papers, the Web of Science, PubMed, and Scopus databases were used to search and investigate emergency evacuation challenges in the community after the Natech events. The articles, guidelines, books, and conference papers had been published in either Persian or English from 1980 to 2020 and related to industrial disasters and especially chemical disasters after earthquakes. The reason for choosing the beginning of this period was the increasing trend of natural disasters and its various consequences on the communities and the proclamation of the 1980s as the decade of disaster risk reduction by the United Nations.[Natech AND  AND  AND  AND ("Response Capacity" OR Search & Rescue OR Evacuation)]Data Collection Tools and Methods21 was utilized to determine the "End-point distance" of H2S gas release at the ERPG-2 concentration. Rapid-N software supported this guide and to be used to simulate atmospheric gas dispersion. The last version of the National census statistic (2016) was used to extract information about the number of populations and households at-risk for emergency evacuation.22 As well, wherever it was required, we used the latest information on neighborhood population and households to be published by the municipality (2021), emergency evacuation maps.23 And previous studies were used to determine the features of urban districts.26In this study, the "Worst-Case Scenario" in a dense plume of RMP (or the US EPA-1999 Risk Management plan Guide)Natech Event Scenario2S toxic gas into the adjacent area in off-site the facility following an earthquake. Every refinery produces a lot of harmful substances in its process, which is often a liquid state and has the potential to catch fire and explode. The main aim of the present study was the assessment of Natech risk consequences due to the release of toxic gases on the communities around the refinery. Hydrogen sulfide gas had selected by experts, because it is gaseous at atmospheric temperature, heavier than air, and its toxicity,27 quantity, and concentration were such that if released, it was considered a health hazard to surrounding communities.The scenario of the activation of the Ray fault in the south of Tehran with the magnitude: Mw= 7.5  in the modified Mercalli scale) was designated as the consequence analysis criterion for the release of H21 In such conditions, the gas dispersed in all directions from the damaged vessel, which appears circularly on the map. Obviously, as the distance from the vessel increases, the gas concentration would decrease to the side the end-point distance. In a stable atmosphere situation, the exposure of people to gas would become longer and contains serious health effects. In addition, this scenario is consistent with the conditions of Tehran that are faced with frequent and continuous weather stability, especially in the southern parts of the city in some months of the year.The EPA guide described the "worst-case scenario" based on the assumptions including the total quantity of the gaseous released in 10 minutes, dense plume, and urban topography, as well as the meteorological conditions atmospheric stability class F (stable atmosphere) and wind speed of 1.5 meters per second (3.4 miles per hour), the ambient air temperature of 25 C (77 F), and Relative humidity of 50%2S gas at the ERPG-2 concentration with a radius of 6.5 km from the vessel. Natech risk assessment performed by N-Rapid software. The software analyzes the earthquake hazard and faults parameters, types of equipment failure curves, chemical substances physical and chemical properties. In addition, this software supports EPA, and in this Risk Management Plan Guide, toxic gas Endpoint is determined based on ERPG-2 concentration. The H2S data as toxic gas has shown in the following In this regard, 28According to the AIHA (2007), the ERPG-2 value is the maximum concentration in the air below which nearly all individuals can be exposed for up to 1 hour without experiencing or developing irreversible or other serious health effects or symptoms impairing an individual's ability to take protective actions.Natech risk map was placed on Tehran’s map and the urban districts, suburb areas, population, and households affected were determined to emergency evacuation operation. Finally, emergency evacuation capacity was analyzed with emphasis on safe evacuation places and wide and safe evacuation routes in the Natech risk area.Ethical considerationThis study was a part of a doctoral dissertation approved by Shahid Beheshti University of Medical Sciences, Tehran, Iran under the code of IR. SBMU. PHNS.REC.1398.040.Evacuation capacity24 with emphasis on the two parameters of safe evacuation places and safe and wide evacuation routes.The findings of this study have assessed the challenges of emergency evacuation based on the JICA-2004 recommendationEmergency evacuation2S gas release with the ERPG-2 concentration   . EvidencHealth Infrastructure such as other residential buildings would be vulnerable. Even in undamaged structures by the earthquake, the entire staff and patients of these centers must be evacuated due to permeable to the air contaminated with the toxic gas. Results found one-fourth of health infrastructure types and one-third of firefighting stations as disaster responder organizations were at-risk to earthquake and Natech events. In addition, half of the accommodation center and about one-third of the subway station, during the night and day, respectively, as crowd places were at-risk the Natech events. In this study, the subway stations were one of the most dangerous locations for Natech events because hydrogen sulfide is heavier than the air and remains on the ground and inhaled surfaces, and tends to penetrate indoor and enclosed spaces, especially at low-level . In this29 In this situation, the responsible institutions had provided the budget, plans, and execute strategies for providing the equipment necessary to respond to an earthquake and training experienced manpower to perform emergency response operations, including search and rescue, accommodation, emergency evacuation, and periodic practices to increase the skills of their operations teams. While, no budget, plans, and executive measures were considered for evacuation operations in Natech events.Emergency evacuation to the neighboring areas will be inevitable for all exposed residents of districts 19 and 20. It will create new challenges for the host region, which had been severely affected by the earthquake and simultaneously had to respond to the needs of people from other areas. Managing emergency evacuation operations, a large number of people and households who are exposed to toxic gas release in the affected area is a challenging issue, especially in a short time.Evacuation routes analysis were shown the obstruction of urban narrow passages in district 20 with the debris of buildings destroyed by the earthquake. The disruption, delay, and slowing in the transportation system would be the serious problems in the emergency evacuation operation process caused by the routes obstruction. It can lead increase in the exposure time to toxic gas in residents, those trapped under the debris, and response teams and lead to more casualties and health effects. Although there are suitable 44 safe evacuation locations for an earthquake in the area, they would be very unsafe and dangerous during the release of toxic gas due to open spaces.The findings showed that the nearest evacuation suitable places to be located in the east direction for near 29% of the exposed population and the east, west, and south direction for more than 61% of them. While for more than 34% of the remained population, the nearest places were located in the north direction that the vulnerability risk of their buildings is very high. The geographical direction of the emergency evacuation due to Natech risk based on population and household has illustrated in Evacuation Capacity Challenge2S gas) must evacuate. The emergency evacuation capacity was investigated based on the two determinants of safe evacuation places and safe and wide evacuation paths. The Research has found that all existing evacuation places and routes are unsafe and dangerous due to their open spaces and blockages paths. Emergency evacuation is a challenging issue in Natech events risk management.29 Despite, numerous studies that have been conducted on emergency evacuation in earthquakes, but few studies were focused on emergency evacuation in multi-hazard risks, especially Natech events risk. Studying Natech events shows that out of 102 evaluated disasters that led to evacuation, only 15% were related to earthquakes, hurricanes, tornadoes, and floods; 35% were due to release in fixed facilities (22% in refineries); 25% were related to the release of natural gases, and finally, 21% were due to the release of petroleum products.5 In this study the challenges of emergency evacuation have been discussed from four dimensions: disrupted and ceased rescue and firefighting operations, unnecessary evacuation, frequent evacuation, and evacuation behavior.29Findings showed the entire exposed population to Natech events risk  to prevent an explosion caused speed issuing evacuation orders.30 The cessation of operations forced the search and rescue teams and people to leave the area for two days while they tried to save the lives of those trapped under the collapsed building.30 On the other hand, the chances of life of trapped survivors under rubble considerably have reduced due to prolonged inhalation of the released toxic gases result of evacuation orders.30 It may remain unclear so forever how many people would have been saved if the search operation had not been canceled.11 In addition, fear and leaving the duty of many firefighters has happened after issuing evacuation orders. Some reasons included lack or low knowledge about the properties of the released hazardous materials and lack of trained and exercised forces to respond to releases of chemical materials following an earthquake at the refinery. Finally, it led to a severe reduction in the firefighting capacity and leaving the fire out of control.12The firefighting and search and rescue operations ceased due to issuing a forced evacuation order, Just a few hours after the occurrence of the Izmit earthquake(1999) and the releases of toxic gases of acrylonitrile, and ammonia from the industries of acrylic fiber production and fertilizer production, respectively.Unnecessary Evacuation 2)12 and 5 km (78 km2), respectively.13 Even the cities more than 10 km away from the release sources evacuated with the population equivalent to tens of thousands of people.13 The unnecessary evacuation has happened because of inadequate communication through informal channels, limited awareness, misunderstanding, the chaos caused by the earthquake.13 For this reason, many people who were exposed to toxic gases for more than 20 hours to informed of the evacuation order by local security forces.13In the Izmit earthquake in Turkey (1999), the evacuation order had issued to an area approximately 100 times larger than the request of the acrylic fiber plant and the refinery to evacuate an area within a radius of 1.2 km , it seems various reasons to issue several evacuation orders. The study found that two-thirds of the studied population evacuated and one-third equivalent to 32% of them had not evacuated. More than 64% of the people were evacuated based on the first evacuation order was issued for the earthquake and tsunami.Evacuation BehaviorIn confronted with the Natech risk, the evacuation behavior of households had studied via several variables such as risk perception, location, time of evacuation order announcement, warning source, demographic variables (age and household size), wind direction, and training. 14 A study on the Greater East Japan Earthquake and Tsunami in 2011 found risk perception variables were a key factor in understanding the evacuation decision-making process.8 The size of the household variable was significantly related to the time of mobilization to evacuate so that the large households had more willing to quicker evacuation than small households, and it showed receiving an evacuation order can be reduced the household's response time to Natech threats.14 Wind direction was an influential factor in the risk understanding and the evacuation response of households to a Natech event.8 The Great East Japan Earthquake and Tsunami in 2011 revealed the lack of experience evacuating and training for the Natech events among the majority of residents.8In the field of Natech risk management, the development of protection strategies largely is depended on the understanding of the evacuation behavior of households faced with such events by emergency managers.14 so that the evacuation probability was 1.22 times higher for each year of aging in Japan.14 The older people were more willing and quicker than young people to evacuate their homes. It originated from personal judgment based on their experiences.14 Wind direction has also been considered as an influential factor in understanding the risk and evacuation response of households to a Natech event.8 The Great East Japan Earthquake and Tsunami in 2011 revealed the lack of experience evacuating and training for the Natech events among the majority of residents.8The age variable also was significantly related to the time of mobilization to evacuate,25In another study has pointed out the importance of emergency evacuation in the first 72 hours after the earthquake; it can play an important role in saving the lives of survivors and reducing their damage, especially to the vulnerable group in the confronted with fire, severe aftershocks, or landslides.29 and all earthquake-safe evacuation sites are highly un-healthy and unsafe to the Natech event.Thus, in the present study, it seems prevention of unnecessary evacuation can be possible via planning for the affected areas and population in determined a radius of 6.5 km area affected by the toxic gas prevention of unnecessary evacuation can be possible. However, it is necessary for preventing frequent evacuations to be considered measures, especially for the evacuated people toward the north areas direction where exposed to widespread vulnerability from the earthquake. The existence of sufficient and safe open space in the east, west, and south direction can prevent the risk of the frequent evacuation of near 61% of the population . On the contrary, the insufficient capacity of northern evacuation sites can be lead to an increased risk of repeated evacuations at 38% of the population (43% of households) with a household size of 3 people . In addition, the evacuation time is limited to more than one hour for the population living in areas affected with EPRG-2 concentration,Planning for the management of Natech events will be inevitable due to the probability of a major earthquake in the metropolis of Tehran, with a history of previous destructive earthquakes, high population density, adjacent to hazardous industries, and increasing of Natech events risk such as the release of toxic substances, fire, and explosion. Both short-term and long-term plans can help to cope with and resilience such events. Some short-term solutions and measures are recommended such as identifying vulnerable industries to natural hazards, identifying areas with a potential risk of Natech events, revising and updating safe routes and locations in the existing emergency evacuation maps in the ex-posed area and adjacent areas. In addition, other recommendations include informing and awareness the people living in the areas exposed to the risk of Natech events, training of appropriate individual and social behaviors when dealing with such disasters and safe and rapid evacuation procedures, development and training of emergency evacuation protocols, and organizational coordination among health personnel, response and firefighting teams, as well educational, accommodation, and underground transportation centers managers. In long term, any measures that can be lead to an increase in the possibility of evacuation and shelter-in-place are recommended such as creating incentive policies and construction regulations to help seismic retrofit of the builders and hazardous industries. Given the relative novelty of Natech risk management and Natech disaster risk reduction management, more research is needed in the emergency evacuation field. It seems to develop Research in the field of all Natech disaster management phases inevitable. The results of the present study can be useful both in understanding the Natech risks following earthquakes and prioritizing measures to addressing the challenges of emergency evacuation and the resilience increasing of surrounding communities.Limitation2S and other toxic gas are operated in the process of several chemical installations, the research team did not have access to their information. Second, considering the disease covid-19 pandemic in the regions of Tehran, it was not possible to access pulmonary and cardiovascular disease statistics individually.This study had two main limitations. At first, the research focused on one installation and one toxic gas. Despite this, in the study area, HAcknowledgementsThis research was a part of a PhD thesis approved by Shahid Beheshti University of Medical Sciences with the ethics code of IR.SBMU.PHNS.REC.1398.040 and supported by the National Iranian Oil Refining and Distribution Company.


Awareness about hereditary breast cancer and the preventative steps to minimize disease risk is lower in Hispanic/Latina individuals than non-Hispanic White women in the United States. For this reason, we developed a promotor-based hereditary breast cancer education and risk identification program for self-identified Hispanic/Latina women, which included training promotores in basic genetics and hereditary breast cancer. This study explored promotores’ experiences receiving training and participating in virtual practice sessions as well as changes in knowledge about hereditary breast cancer.A total of ten promotores underwent a two-week basic training led by the promotores organization and an eight-hour in person hereditary breast cancer training workshop. Demographic information along with pre- and post-training surveys were completed by ten promotores who participated in the training workshop. Surveys were given to determine changes in knowledge of hereditary breast cancer and genetics. Of the ten promotores, two were selected to lead community education sessions and participated in 6 semi-structured interviews. All interviews and practice sessions were conducted using a virtual platform.The data revealed that after the 8-h workshop and practice sessions, promotores felt confident about their ability to conduct virtual education sessions with the community. Interviews identified key facilitators to success such as a supportive environment, practice presentations, and personal motivation. Learning the online platform was considered the biggest challenge by the promotores, as opposed to learning complex genetics topics.These results provide further evidence supporting promotores’ willingness and ability to provide health education on relatively complex topics. It also offers insight into the challenges of presenting information to vulnerable populations using an online platform and the additional support that is required to ensure a positive outcome.The online version contains supplementary material available at 10.1186/s12905-022-01902-y. Among women of Latin American heritage in the United States (U.S.), invasive breast cancer is the leading cause of cancer death and 3100 deaths are predicted to occur in 2021 , 5. HoweThere are multiple barriers H/L face when accessing health information and care, including health literacy –13. LackStakeholder-informed programs are crucial to addressing barriers to care and disparities in breast cancer outcomes . One proPromotores-led education programs have been shown to increase screening practices among H/L which is why it is important to continue improving the approaches used to train these valuable community educators, particularly when using non-traditional approaches such as virtual training .This study aimed to assess the promotores’ experience participating in ‘Tu Historia Cuenta’ program training and explore their confidence and ability to share accurate HBC knowledge. Due to the complexity of HBC and the lack of online education interventions that consider HBC genetics, it was important to evaluate the promotores’ acceptance and understanding of the materials to improve the program. A similar study performed in South Florida demonstrated that assessing promotores’ knowledge and understanding showed how promotores-led approaches are effective and highlighted ways to improve them . This prThe goal of this study was to evaluate promotores’ ability and confidence to explain important HBC concepts to community members and understand the training experience from the promotores’ perspective. This was designed as a qualitative study to capture the experience of promotores who were recruited to implement the ‘Tu Historia Cuenta’ program. Additionally, it included a short survey to describe promotores’ basic demographics and evaluate pre- and post-workshop training responses for an original cohort of promotores from which the program leaders where recruited.Due to the COVID-19 pandemic, the HBC program moved to an online platform and the promotores performed virtual practice sessions. Qualitative interviews with promotores were conducted before and after each practice session to gain a detailed understanding of promotores’ self-perception of their ability to inform the community about HBC.A community-based promotores organization, partnered with researchers at UCSF to recruit promotores for the “Tu Historia Cuenta” program. Outreach to recruit promotores was focused on individuals who resided in the city of Sacramento and San Francisco as these were the targeted areas for the program. The research team required that recruited promotores had not been exposed to HBC prevention education materials in the past.A group of ten participants underwent a two-week basic training led by the promotores organization and an eight-hour in person HBC training workshop conducted by the research team. The goal of the two-week basic training was to improve the promotores' knowledge and leadership skills. This in-person training included six modules covering topics such as, promotores role, effective communication, conflict resolution, non-formal learning, learning styles, and ethics. Each module was taught in eight-hours for a total of 48 hours during the span of two workweeks. The one day eight-hour HBC training presented the HBC information to the promotores in a simple manner while clarifying any questions the promotores might have had .The program’s budget limited recruitment to four promotores to serve the San Francisco and Sacramento areas. The promotores were chosen based on flexible work schedule, previous community workshop experience, and residence near the area being served. The goal of the hiring process was to select promotores with the greatest potential to positively impact the H/L community. At the start of the program in March 2020, two participants left the project due to COVID-19 related reasons. The qualitative portion of the study is based on the additional training experience of two promotores who were actively preparing for virtual community presentations.Demographic information and pre- and post-training surveys were completed by ten promotores who participated in the HBC training workshop. Surveys given before and after training sessions were administered to determine changes in knowledge of HBC and genetics. Both surveys consisted of the same 16 basic level questions about breast cancer and genetics . PromotoVirtual practice education sessions were conducted during an 8-week period before implementation to allow promotores a space to enhance their HBC presentations before engaging with the community. Each of the participants presented to the research team and colleagues as if they were doing a session with community members. Following the exercise, the promotores were provided feedback to enhance their presentation for the next session. Each promotor led a presentation three times and presentations lasted up to three hours per practice session. Before and after every practice trial, the promotores were interviewed to capture their experience with the HBC material.Semi-structured interviews were conducted via telecommunication  due to the COVID-19 pandemic. Separate guides were developed for pre- and post-session interviews to gather promotores’ perspectives on what concepts within the HBC education program were challenging and self-perceptions of their practice presentation. The two promotores in the study were followed for a period of eight weeks to observe their progress presenting HBC topics . It is not easy. And much less giving a presentation when you have never had a computer in your life.”The promotores found the management of the online platform to be the most challenging aspect of the program when conducting virtual practice education sessions in front of the research team. Individuals explained how their inexperience using Zoom created a challenge during practice sessions. Both promotores expressed greater comfort with face-to-face interaction and felt a lack of preparation to present with the virtual platform. Participant 1 shared her frustrations when asked if she felt that in-person presentations would be easier:She also feared that presentations held virtually would pose a barrier for many community members who do not know how to use online platforms. Both participants experienced similar challenges regarding the online presentations. In their opinion, the largest barrier for success was maneuvering the online system.This qualitative study evaluated the promotores’ comfort and ability to lead HBC education sessions and modify the program for improvement. The increase in post-workshop HBC scores suggested that the HBC training enhanced the promotores’ knowledge concerning HBC and is consistent with our pilot training results . The quaThe promotores expressed a positive experience with the program by highlighting the additional practice to review the HBC content, constructive feedback, and team support. These elements collectively led to a supportive program and should be utilized as a reference when developing future projects. Promotores’ limited background knowledge of HBC did not prevent them from presenting the materials clearly and confidently after appropriate training. Working alongside the researchers provided them with the courage and confidence to continue perfecting their presentations and understanding of HBC. These findings are supported by the robust literature suggesting the efficacy of community-based programs and how successful interventions are attributed to a supportive team –36 This Promotores’ motivation to serve the H/L community and desire to disseminate correct HBC knowledge influenced their success in the program. Although learning the HBC content was found difficult at first, the promotores remained dedicated. Aligned with existing literature, motivation played a key factor in the promotores' success and retention in the HBC program . CurrentThe unexpected transformation of the program into an online-platform provided an opportunity to learn about the challenges associated with implementing virtual learning options for the underserved Spanish-speaking H/L community. Both promotores believed that unfamiliarity with the technological aspect of the virtual sessions posed a great challenge to sharing the HBC information.This key finding provided insight into modification to improve the program, such as additional training with the online applications. Given that COVID-19 has transformed many research interventions into virtual formats, it is essential to consider and address potential barriers. For instance, financial barriers may prevent target populations from accessing high speed internet or a smartphone. When developing novel interventions or adapting pre-existing ones to an online format, additional thought should be put into removing obstacles faced in virtual education.The continuous support from the research team and community organization beyond training and during implementation would be important for promotores as they confront potential logistical barriers or are phased with complex questions that may arise from the community. A plan for ongoing support will ensure the promotores have the resources to share information successfully and facilitate transfer of knowledge to the community.Overall, findings suggest that the interplay between the practice sessions, supportive environment, and motivation to serve the H/L community were key factors in the participant’s confidence and ability to explain HBC content. The project aimed to discover what modifications were needed to improve the fidelity and confidence with which promotores informed the community about HBC. Observing the participants’ progress over an eight-week period allowed researchers to gain insight on the elements of a successful program and areas for improvement. Conducting multiple interviews with promotores was a strength of the study as it provided in-depth data regarding promotores’ perspectives and experiences. Although the sample size was limited, the data can help inform future interventions as well as improve the HBC community-based education program as it continues to expand across California.Additional file 1. Supplementary materials including (S1) pre and post promotores workshop survey, (S2) pre and post promotores virtual training session interview guides, (S3) promotores interviews qualitative analysis code book.


Financial incentive programs promote smoking cessation. However, the incentive amount which should be provided—and how this may interact with other program characteristics—is unknown. The objective of this study was to evaluate the influence of the design of incentive programs for smoking cessation on current smokers’ perceptions of programs and willingness to enroll.N = 430). Hypothetical incentive programs were described using five attributes . Participants responded to a series of choice sets comprised of two hypothetical programs. For each set, participants selected their preferred program. They then specified whether they would enroll in their preferred program if it were available. Analyses also considered the effect of participant income on preferences.An online discrete choice experiment was conducted amongst adult current smokers residing in the United Kingdom , enrollment choices did not differ by income.The characteristics of incentive programs influence smokers’ perceptions of programs and willingness to enroll. Higher amounts may encourage greater enrollment rates, but there will likely be a ceiling point beyond which increasing the incentive amount does not meaningfully increase enrollments.There is increasing evidence incentive programs aid smoking cessation. Yet, the variety in previous program designs means how to best structure programs, including optimal incentive amount and the impact of the design on potential enrollment rates, remains unclear. This study suggests enrollments may be highest when incentive amounts are higher, rewards of a consistent amount in cash are provided, and sessions occur once per week in a healthcare setting. Although higher-income participants may desire higher incentive amounts compared to lower-income participants, this may not translate into differences in willingness to enroll. Such work7 supporting the efficaciousness of FI programs has led to an interest in these programs among policymakers and health service providers. However, the designs of previous programs have varied greatly.8 Variations include the FI amount provided, the type of FI , frequency of rewards, and location of implementation . This wide variety in previous designs means how to best structure programs remains unclear. This includes which program design(s) will be most desirable to smokers or result in the highest uptake. Furthermore, despite the evidence for the efficacy of FIs,7 some policymakers and the public remain skeptical about these programs. This Skepticism seems in part due to concerns about the seemingly high costs of FIs.9 Evidence for cost-efficient FIs (without sacrificing efficacy) is thus necessary to both ensure FI programs are well designed, and to address the concerns of potential implementers or users of these programs.Financial incentive (FI) programs have been suggested as a method of addressing these goals. Within these programs, smoking status is monitored over a defined period, with individuals who demonstrate abstinence at various time points provided monetary rewards. Unlike more traditional smoking cessation programs, FI programs provide a salient and immediate reward for abstinence which can increase motivation to initiate quit attempts and, by rewarding behavior, encourage individuals to maintain abstinence. A recent Cochrane review11 This notion is consistent with economic theory suggesting individuals will alter their behavior if the benefits outweigh the costs of change.10 Work in this area includes trials comparing relatively lower to higher FI amounts, typically finding greater abstinence rates for higher FI magnitudes.13 This provides foundational evidence that FI amounts differentially affect behavior. Yet values are commonly selected based on previously used schedules and budget/funding capacity. Hence, there is little evidence to suggest which amounts might most optimally balance effectiveness and value for money , and a paucity of information to address public concerns about the justification for FI amounts. Although reviews—wherein a wider range of values can be considered—could be used to identify optimal amounts, such work only weakly supports an association between higher amounts and greater quit rates; a finding potentially due to the numerous variations in the design and target populations of previous studies.15 Our group has recently explored questions on FI amounts using experimental methods, wherein we observed an increasing quadratic trend in willingness to enroll in hypothetical programs as the FI amount increased.16 This work indicates there may be a ceiling point beyond which further increasing the FI amount fails to result in increased motivation to enroll. Further research is needed to explore the influence of reward amount, including how willingness to enroll may vary by the magnitude of the FI being offered.It has been suggested larger FI amounts will be more effective, based on the idea that FIs operate by increasing the benefits and value of smoking cessation.17 This idea is supported by research on FI programs for weight loss and exercise, which suggest more flexible FI types are associated with increased predicted enrollment in programs due to greater fungibility of the payment.19 The greater the perceived relevance or personal value of an incentive, the more appealing it will be to that individual. Hence individuals may value vouchers at less than their equivalent monetary worth, meaning voucher-based FIs may need to be of a greater value than cash-based FIs to ensure the same utility is afforded.19 In support of these theories, some research20 indicates vouchers are valued at only 80%–90% of their monetary amount.In addition to FI amount, several other program characteristics may impact willingness to enroll. For example, policymakers and healthcare providers have theorized that the type of FI will be important, with smokers potentially preferring cash rewards compared to more inflexible rewards like vouchers or specific items.8 When considering the use of FIs in real-world settings, workplaces may be important implementation locations as employers could finance the incentives themselves, thereby reducing reliance on outside organizations and/or the healthcare system. Plausibly, smokers may prefer workplace programs due to the convenience. Alternatively, smokers may prefer healthcare settings like pharmacies or antenatal clinics as they associate these locations with greater quality or quantities of support. Yet the location preferred by most smokers is unclear.Enrolment rates may similarly be impacted by where a program is located. The settings of previous FI work have varied widely, having included embedding programs into workplaces and a variety of healthcare centers.21 Lower-income smokers may therefore be more likely to enroll for smaller FIs than higher-income smokers, as the amount provides comparatively greater utility.10 However, research supporting this idea is mixed, with some studies22 suggesting no effect of income, while others23 indicate an effect at some timepoints or under some program designs.Recipient characteristics like income level may also influence preferences for program design and willingness to enroll. This is consistent with economic theories including the law of diminishing marginal utility, which suggests the utility of an additional unit of money decreases as the individual’s current wealth increases.24 Discrete choice experiments (DCEs) are a stated preference method that allows consideration of the perceived importance of multiple program attributes , and preferences for the levels of these attributes . Participants make a series of choices between specified options  and by analyzing the pattern of responses across the series of choices, a good indication of what parameters shape individual’s preferences can be determined. This allows the comparison of potential programs in terms of a range of characteristics, including FI amounts, frequency of sessions, and rewards schedules. The use of DCEs has become increasingly common in health economics, with findings used to address policy questions and guide research that could seek to quantify results using revealed preference methods.24 The aim of this study was therefore to use a DCE to explore current smokers’ preferences for common FI program designs, and consider whether preferences varied between income groups.Comparing multiple design aspects of FI programs through methods like randomized controlled trials would be time-consuming and costly. Instead, stated preference methods may be used to compare across multiple design characteristics more efficiently, to narrow the range of design options worth further investigation, and to guide future trials.26 Participants were therefore expected to select the program which provided the greatest expected utility from each choice set. By presenting participants with a series of choices wherein the characteristics of programs varied, the trade-offs between attributes could be assessed and their influence on preferences and potential uptake estimated.25The hypothetical programs within our DCE were described in terms of their attributes  and the levels of the attributes . Programs that differ in the levels of these attributes were paired together to form choice sets, and participants were asked to select which program from each set they most prefer. An example choice set is provided in Participants completed the survey online. Ten choice sets each containing two, 10-week program options were presented one at a time. For each set, participants first selected the program they most preferred. They then indicated whether or not they would enroll in their preferred program if it were available. The participant then moved to the next choice set.27 To test for differences in the perceptions of FI programs between income groups, recruitment was stratified by income. Based on OECD guidelines,28 participants were categorized as low- income , middle- income , or high-income . It was intended to recruit 150 individuals per income group. The sample was not intended to be representative of the broader smoking population. The intended sample size (N = 450) was selected to exceed the minimum sample size recommended by commonly used rule-of-thumb estimates 29 and was consistent with previous health-related DCEs.30Participants were UK residents aged 18 years or older who currently smoked. Current smoking was defined as regular smoking of tobacco products . Education was categorized as low , moderate , or high .31, and completed the study online. Prolific.co is a research dedicated online platform used32 to recruit participants for predominantly psychological, social, and economic studies; see Palan and Schitter33 for an overview. All participants received financial compensation for their time, consistent with Prolific.co’s recommended minimum of £5 per hour. Recruitment and data collection were completed within August 2020. Ethics approval was obtained from the Tasmanian Social Science Human Research and Ethics Committee (H0017964).All participants were recruited from Prolific.co8 and refined through team meetings. Five attributes were included in the final survey: FI amount, FI type, reward schedule, frequency of sessions, and program location ; they were therefore excluded here to reduce the complexity of interpretation. To capture some of the variability in incentive schedules observed within previous trials, the reward schedule was described as either a fixed schedule  or an escalating schedule with reset contingency . The sessions attribute denoted the frequency of sessions: one/fortnight, one/week, two/week, or three/week. All programs lasted a total of 10 weeks. Finally, there were two levels of location , reflecting real-world settings wherein FI programs have previously been implemented.Initial attributes and levels were drawn from a review of literature on previous FI programstion see . Seven F34 was therefore constructed using JMP (version 14)35 and checked for level balance, minimal overlap, and orthogonality. This produced 30 choice sets, which were divided into three blocks comprising of 10 sets per block .Given the number of attributes and levels included, a full factorial design was deemed impractical. A fractional factorial design with zero priors 37 This consisted of one additional choice set wherein one program (the dominant option) was more appealing than the other in all ways. Participants were expected to choose the dominant option. Participants then completed the 10 choices sets from their assigned block. Each choice set was viewed one at a time. For each set, participants first selected their preferred program. They then indicated whether or not they would enroll in their preferred program if it were available to them in their local area . These participants were removed from the sample and additional recruitment was undertaken to obtain the prespecified sample size.n = 12) were excluded. Analyses confirmed removing these individuals did not alter the pattern of effects. The final evaluable sample was N = 430.Once data collection was complete, three participants were identified as nontraders , suggesting they had failed to attend to the attributes; these participants were removed from the sample. Additionally, 15 individuals who failed the dominance check  were identified and removed from analyses. We were most interested in how to optimize program designs and willingness to enroll among individuals who would consider using these programs, and reasoned that participants who rejected even very lucrative amounts (£1000) were unlikely to entertain enrolling in real FI programs. Hence, participants who would not enroll in any program  to account for preference heterogeneity among participants. Furthermore, as opposed to standard logistic models, this approach allows consideration of the fact participants respond to multiple independent choice sets. Our study design effectively allowed participants to rank the different hypothetical programs in order of preference. This design and statistical approach allow us to assess the effect of any given program characteristic independent of the other characteristics. For detailed information on these models see Croissantp values indicate the significance of the difference between the estimated value and the mean effect of the attribute. The estimate for the reference (omitted) level is the negative sum of the estimates for the other levels of that attribute.25 An alternative-specific constant for the would not enroll option was included to adjust the attribute coefficients to account for people opting out.40 The final model was used to consider participants’ preferences for program characteristics, and differences between income groups. Significant standard deviations indicate preference heterogeneity. A simpler model without interactions (participant income) was also constructed; this produced very similar results . Other attributes were effects coded and included as random parameters with a normal distribution. With effects coding, the mean effect of all levels of an attribute is zero, and ults see .41 This was calculated using estimates from the final model by dividing the estimated coefficients of the nonmonetary attributes by the negative of the FI amount coefficient. The Krinsky–Robb method was used to calculate confidence intervals.41Marginal willingness to accept indicates the total monetary amount offered throughout the program associated with changes in attribute levels.25 Raw data and r code are available from the University of Tasmania’s data portal (https://dx.doi.org/10.25959/ccv4-4q20).Willingness to enroll was first discussed regarding the frequency at which participants would hypothetically enroll in their preferred program from each choice set. Changes in estimated program uptake across amounts, and secondly across other attributes, were then determined by calculating the choice probabilities using estimates from the model without interactions see .25 Raw d42 However, there were some education level differences, with a higher proportion of our sample having completed a university degree (compared to the broader smoking population). The demographic and smoking characteristics of participants by income group are displayed in the On average, participants were 37.47 years old (SD = 12.27) and approximately 56.51% were female. More than half of participants had made a quit attempt in the past year (62.09%) and intended to quit smoking in the next 6 months (57.67%). The sample was comparable to the broader population of UK smokers regarding age and gender distributions.p = .021 and p = .038, respectively).Model results are summarized in The average FI amount associated with changing attribute levels from the reference level is displayed in n = 199) of participants were willing to enroll in all programs. Conversely, 2.71% of participants (n = 12) would not enroll in any of the presented programs . On average, the proportion of “would enroll” responses across all participants and choice sets was 81.22%, reflecting a very high potential enrollment rate. Based on the model (see p = .680), indicating both groups would be similarly willing to enroll in a program with a specific design. Although there was a trend toward high-income participants being more likely to opt-out than low-income participants, this did not reach significance (p = .052). Low-income participants opted out in 17.04% of choice sets, while high-income participants opted out in 18.28% of choices.Responses to the willingness to enroll questions were first used to provide insight into the general willingness to enroll in FI programs. Overall, 45.02%  across FI amounts are summarized in https://tinyurl.com/dce-financial-incentives for an interactive figure (shiny app)43 displaying variations in estimated uptake for other combinations of program characteristics.Changing from cash to voucher rewards while retaining other attribute levels lowered the predicted uptake, although the size of this difference decreased as the FI amount increased see . Please 40 and for more flexible payments like cash (cf. vouchers)19 have been observed when considering FI programs for behaviors including drug use and exercise. Although workplaces could prove an important implementation location because employers could finance incentives themselves rather than relying on the healthcare system, participants in our study preferred healthcare settings. A slight preference for one session per week over one session per fortnight may be explained by some participants perceiving they would not receive sufficient support if sessions were fortnightly.We here considered how current smokers’ preferences for FI-based smoking cessation programs vary depending on the FI amount and program design. Results suggest that to maximize smokers liking of FI programs and potential enrolment rates, programs could use higher FI amounts, provide rewards of a consistent amount per week in cash, offer sessions once per week, and provide programs in healthcare settings. The observed preferences for the levels of attributes were largely consistent with previous research; preferences for higher FI amounts10 Consistent with this idea, results here suggested middle- and high-income participants preferred slightly higher amounts than low-income smokers. However, differing preferences for FI amounts did not translate into significant differences in predicted enrolment. This is comparable to previous work by our group,16 wherein high-income (cf. low-income) current smokers viewed FI programs as less appealing, but remained equally willing to enroll in programs. These findings add support for the use of FI programs in practice, as it suggests amounts might produce similar enrolment rates across income groups.The FI amount required has been suggested to differ by recipient income, such that lower-income smokers may be motivated by one FI amount, but the amount may need to increase comparatively to income to ensure the same viability.16 the estimated enrolment rates increased across FI amounts. This increase largely followed a concave quadratic trend. While not investigated here, such a quadratic trend will likely contain a peak or ceiling point beyond which the increasing trend levels off. This point may indicate an incentive value beyond which increasing the amount will not meaningfully benefit enrolment rates. This finding is consistent with some previous work40 investigating incentivizing health behaviors other than smoking, and with experimental work by our group wherein current smokers’ perceptions of FI programs increased quadratically with the FI amount, up to a ceiling point.16 Varying other elements of the program design also influenced estimated uptake. However, the magnitude of the differences in estimated uptake produced by varying other design characteristics decreased as the FI amount increased, reaffirming the importance of the amount, and suggesting higher amounts may compensate for less desirable designs.Across choice sets, participants would enroll in their preferred program 81.22% of the time, suggesting a high level of interest and potential willingness to enroll in FI programs for smoking cessation. As was expected based on previous research,44 does suggest DCEs on some health programs can reflect real-world decisions reasonably well. Relatedly, we here measured interest in enrolment as opposed to the effectiveness of amount at achieving outcomes once individuals enroll. This may mean that, for example, while participants here preferred consistent rewards, variable reinforcement and escalating schedules could better promote cessation outcomes.45 Rates of enrolment may similarly differ from rates of engagement with program content, as observed in some46 previous real-world programs. This was not investigable within this study. Hence, although results presented here should still be interpreted with caution, they may be indicative of what smokers would value regarding program design when considering whether to enroll.The method used within this study was a low-cost way of indicating what people may value in FI-based smoking cessation programs. It provides the groundwork for future studies which further investigate the optimal design of programs. Although the choices made within hypothetical scenarios may differ from those made in real settings, some research47 have found lower support for FI use among individuals with lower levels of education, several others49 show no effect of education. Furthermore, reviews23 suggest no differential effects of FIs on cessation outcomes by education level. Relatedly, it is possible demographic characteristics other than income might moderate an individual’s preferences; something future studies may wish to explore. Furthermore, the additional supports used in some previous FI trials  were not considered. The program length was also consistent across all choice options, as varying the length would have increased task complexity. These factors will probably also affect program appraisals and therefore enrolments. Testing in alternative populations and other locations is also necessary, as factors including purchasing power may differ. Using the evidence base provided here, future investigations into the design of programs could consider these additional points, and subsequently test FI levels in real-world conditions.There are some limitations of the work. The included sample was not intended to be representative of the broader smoking population, and indeed had a higher level of educational attainment. However, previous work has shown no clear evidence for the effect of education. For example, while someAdditional methods are needed to encourage smokers to make quit attempts and sustain abstinence. While FI programs can help achieve these goals, clarity around the best program design is necessary to ensure smokers find programs desirable and will enroll, and to facilitate translatability into real-world settings. Our results suggest enrolment rates may be highest when programs use higher FI amounts, provide rewards of a consistent amount in cash, offer sessions once per week, and provide programs in healthcare settings. Although higher-income participants desired slightly higher amounts than lower-income participants, differences in hypothetical willingness to enroll were not significant.https://academic.oup.com/ntr.A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at ntac042_suppl_Supplementary_MaterialClick here for additional data file.ntac042_suppl_Supplementary_Taxonomy_FormClick here for additional data file.


In the second stage, 10 caregivers assessed acceptability of the platform and answered the System Usability Scale (SUS), which varies from 0 to 100 points. A descriptive analysis of the quantitative data was performed, as well as a thematic analysis on the open questions. All the ethical aspects were respected.In the first stage, nine caregivers/former caregivers assessed the interface of the platform that hosts M = 86.5 ± 11.5).The results of the first stage indicated a user-friendly interface of the system and relevant content of the program, with 55.6 and 77.8% of the participants assigning the maximum grade to these questions, respectively. Of the five possible points, the system’s mean score was 3.7. In Stage 2, 80% of the caregivers rated the program as very useful and 100% would recommend it to other caregivers. Perception of the program’s usability by the SUS scale was excellent (iSupport-BR, considering usability and acceptability of the platform and the program for computers/notebooks, being a pioneer in evaluating it for use in smartphones. Future research studies will have to assess the effects of iSupport-BR on the caregivers’ mental health.This research allowed elaborating the final version of  More than 55 million people have dementia in the world, and a number of projections indicate that there will be nearly 78 million by 2030 and 139 million in 2050 , as well as organizational , socioeconomic (lack of funding and cost of technology) and ethical  . SatisfaA review study on the usability and acceptability of Internet-based interventions developed with caregivers of people who have dementia shows that, for the most part, they are effective, efficient and satisfactory, as well as being considered useful and acceptable by this population . InvolveDevelopment and implementation of supportive interventions that are accessible, acceptable and effective for informal caregivers of people who have dementia is a strategic priority in the Global Action Plan for the Public Health Response to Dementia 2017–2025 . In thisThe initial version of iSupport was developed in English using an encompassing and multicultural approach for transcultural adaptation in several countries, such as Portugal , AustraliSupport-Brasil or iSupport-BR - makes it possible to understand the feasibility of a global and evidence-based resource for use with/by caregivers of people who have dementia in Brazil. The objective of this study was to evaluate usability and acceptability of iSupport-BR, exploring the perceptions of caregivers of people who have dementia about benefits, facilitators and barriers to using the program in a preliminary study.iSupport has the potential to improve universal access to education and support for family members so that they can better deal with socio-emotional issues that arise from interacting with a person who has dementia . In the iSupport-Brasil by caregivers (Stage 2). The procedures adopted were based on the adaptation guide made available by WHO to the licensees. The guide offers standardized advice for translating and culturally adapting iSupport to fit the local target group while guaranteeing that the adapted version is equivalent to the generic one. The usability and acceptability tests allow noticing the users’ interaction with the system  and a subsequent preliminary usability and acceptability evaluation of e system , with diThe content included in the iSupport program culturally adapted to the Brazilian context was incorporated to a digital platform, as described below.Universidade Federal de São Carlos, UFSCar), the University of Brasília  and the Federal University of São Paulo . An Information and Communication Technology company was hired to develop the digital platform. All maintenance tasks and code-related problems were in charge of the company. After testing several options, the Moodle platform was adopted because it is free, with a greater community of developers and users, facilitating its maintenance and continuous and unrestricted use. The platform is in the domain of the UFSCar. The platform’s registration is linked to the Federal Ministry of Health to ensure greater visibility and universal free access by people1. iSupport was originally created to be self-applied. From the home page, registered users can access the program at any time and from any place. A Welcome page, which the users visit before login, presents an overview of the program and asks the person to enroll ; administrators login (for managing the platform content); CRUD  of users of both profiles; CRUD of teaching modules ; visualization of teaching modules; Testing CRUD for teaching validation; and storage of the users’ answers.The platform was filled-in with the content included in iSupport, aiming at the best layout of the content in the system, so that it presents good usability and is accessible . Each usiSupport-Brasil platform is flexible (the user chooses to visit the activities they consider most relevant), personalized , interactive and responsive , scalable (it is possible to insert or remove content instantly and it can be used by an unlimited number of people), secure ; and responsive to the user’s technology .The iSupport-Brasil platform’s interface. Caregivers and/or former caregivers were recruited based on the following eligibility criteria: (a) being 18 years of age or older; (b) identifying themselves as family caregiver or former caregiver of a person who has (or had) dementia in the last 6 months (self-reported diagnosis); and (c) having access to a computer, smartphone, or tablet, with an Internet connection. Recruitment was in charge of the company itself via WhatsApp and email, means through which the individuals were informed about the research objective and stages. From a contact list of the researchers and the company, 15 family caregivers/former caregivers of people who have dementia were invited to evaluate the platform before it was made available to test its usability and acceptability. Six of them refused to participate in the study, totaling a convenience sample comprised by nine participants. After acceptance, to assess functionality of the platform and whether people would be able to use it effectively, a usability test questionnaire was created using the Typeform™ software. The test created by means of Typeform™ allows access through a computer or any mobile device.The interface usability test took place from 11/23/2020 to 12/04/2020 and the objective was to assess the caregivers’ perception on the WhatsApp, YouTube, search in Google, email, Facebook, Instagram, Netflix, Spotify, and Google Agenda).At a first moment, the participants filled out a form with sociodemographic information  and care context . Questions about the use and previous experiences with electronic equipment were also asked, including the following: devices commonly used to access the Internet  and apps used on such equipment  access the content of iSupport-Brasil  simplicity of the system ; (b) appearance of the system ; and (c) usefulness . In the last question, the participants answered which of the five via WhatsApp, when they were informed about the study objective and stages. After accepting to receive more information about the study, the Free and Informed Consent Form was made available through the Google Forms platform for reading, agreement and acceptance. The study participants were 12 caregivers, although only 10 composed the convenience sample and completed all the stages.The researchers recruited caregivers based on the following eligibility criteria: (a) being 18 years of age or older; (b) identifying themselves as the current family caregiver of a person who has been living with dementia for at least 6 months (self-reported diagnosis); and (c) having access to a computer, smartphone, or tablet with Internet access. From a contact list of the researchers, 22 family caregivers of people who have dementia were invited to use and evaluate the platform, of which seven refused to participate and three were no longer caregivers. The participants were recruited •WhatsApp, accessing links [websites], starting and stopping videos) and level of difficulty using electronic equipment .A form with diverse information on sociodemographic  and care context (type of dementia), age of the person who has dementia aspects. Questions about use and previous experience with electronic equipment, including the following: devices used to access the Internet , use of electronic equipment  and questions in relation to the perceptions about the system regarding its complexity, ease, parts of the program that they liked the most/least, navigation, learning, confidence to use (1 = strongly disagree to 5 = strongly agree). The following were considered to assess acceptability: perception of usefulness (from 0 = not very useful to 10 = very useful), recommending the program to other caregivers , reasons that hindered using the program , preference regarding the program’s format , other suggestions and how they organized to use the program (open answer). This questionnaire was developed based on the review study by Ottaviani et al. , in whic•System Usability Scale (SUS): developed by Brooke  and traniSupport-BR program was provided, which the users should employ for a 3-week period. After this period, the caregivers were contacted again to fill in one last electronic form with questions on the individual perception of the system and the SUS scale (both via Google Forms).After signing the Free and Informed Consent Form, the sociodemographic and care form, as well as questions about previous experiences with electronic equipment, were sent to the participants. Subsequently, the link to access and register in the Excel® and the quantitative data were imported into the Statistical Package for Social Sciences (SPSS) statistical software, version 21, for data analysis and presentation. We adopted a qualitative descriptive design and used open-ended questions to collect participants’ general experiences and attitudes toward the usability and acceptability of the program. For open questions, thematic content analysis was performed to identify key themes. The analysis was performed by two researchers, ACO and DQM, who, after becoming familiar with the data by reading and re-reading the responses, started to identify the core topics. The themes found were discussed with the entire team in meetings, until reaching a consensus  and to the Secrecy Form, online and n = 9) were women (n = 100%), most were married/in stable relationships (n = 44.4%), with predominance of the age group from 50 to 59 years old (n = 55.6%) and with nine to 12 years or more of schooling (n = 88.8%); among the people with dementia, most were between 80 and 89 years old (n = 66.7%). In stage 2, the sample (n = 10) presented similar characteristics, with predominance of women (n = 90%), married/in stable unions (n = 70%), age group from 50 to 59 years old (n = 50%), with 12 years or more of schooling (n = 80%) and who assisted people living with dementia in the age group from 80 to 89 years old (n = 70%).A descriptive analysis was performed to evaluate the quantitative data. In stage 1, all participants  considered “Module 5 - Dealing with changing behaviors in a person with dementia”, as the most interesting of all modules, followed by module 4 - Providing everyday care  and Module 3 – Caring for me .The assessment showed that the system has a user-friendly interface (55.6% assigned score 5) and relevant content . Of the five possible points, the mean overall score assigned to the system was 3.7. Common difficulties with the interface included the following: finding the “next” button in the activities , suggesting excellent usability. iSupport-BR program to other caregivers and most of them indicated a preference for doing the program in the online format – which is the current format. The following stood out among the barriers that hindered use: 30.0% mentioned lack of time; 20.0% care-related unexpected situations; and 10.0%, difficulty concentrating.Most of the caregivers indicated being very satisfied (60.0%) and considered the program as very useful (80.0%). In general, the caregivers indicated that the program was easy to use and navigate, in addition to being well-integrated, and that most people would be able to learn how to use it. The majority felt confident enough to use the program, with no need to develop new skills, and they would use it frequently (until finishing the lessons they are interested in). All caregivers also answered that they would recommend the The suggestions on how to improve usability refer to the following: (a) visual inconsistencies ; (b) lack of feedback on a lesson; (c) lack of kinship customization code in some lessons; (d) unidentified/unknown icons , (e) non-clickable elements that appear clickable ; (f) lack of back/forward button in the pages; and (g) percentage of some activities that did not show 100% when completed. All these items were improved.iSupport-BR, such as:In general, the participants highlight positive aspects of the content included in I’ve just finished Module 1; in this first module I found that the content was really objective with extra links for more information. It was good!” (Caregiver 3).““I really liked it, I learned a lot as a caregiver myself” (Caregiver 4).“The content is really complete and easy to understand” (Caregiver 8).“I found it really interesting” (Caregiver 9).iSupport-BR, considering time, space and other conditions, most of them indicated doing the lessons in the care intervals, at night before going to bed. They also emphasized limited time availability, as well as a desire to being able to do more activities.When asked how they organized themselves to use “I always did the lessons in the computer, in my room, at the breaks” (Caregiver 1).“The program is perfect. I adapted and reconciled my time and schedules without any problem” (Caregiver 2).“I found it practical to access through the cell phone, I use it more at night when things are calmer” (Caregiver 3).“I did most of the lessons at night, before going to bed” (Caregiver 4).“Little time needed and I used my cell phone to access it” (Caregiver 6).iSupport-BR, such as:Finally, some caregivers made comments to improve usability of I think that the bottoms to answer and send the answers to the questionnaires are very repetitive. In this sense, usability could be more intuitive. In addition to this, a more intuitive organization of my notes, PDF files, the meditation audios and lesson summaries could help bring back specific passages for everyday tasks” (Caregiver 1).““I’d only like that there was a change in the color when you finish a lesson or module” (Caregiver 2).“In the future, having the option of having a handout” (Caregiver 10).iSupport-Brasil, exploring the perceptions, benefits, facilitators and barriers for using the program in the preliminary study. In general, the program was considered acceptable and usable by the family caregivers, presenting excellent usability and satisfaction levels. Regarding the interface, the participants stated that it was easy to use, that the content was easy to understand, and that it fulfilled their expectations, in addition to assisting in the care provided. The usability and acceptability test results showed good outcomes in task performance, satisfaction and program usefulness, with an excellent perception of program usability.Both qualitatively and quantitatively, this study evaluated usability and acceptability of the translated and adapted version of iSupport-Brasil, we noticed the need to implement improvements in the program in terms of style and aesthetics , as well as functional requirements . In the iSupport-Portugal version, some improvement suggestions were also indicated, such as the program’s presentation, functional requirements, format of the content and topics of the classes , suggests that most usability problems are not serious, although they must be solved for a more satisfactory user experience and efficient navigation . For thiThe limited support of a small size of participants from the family and target context can be extended only in part to other limited supports, with the presence of limited resources from the iSupport group that will be quickly contributed to our data. In addition, group compositions vary within other groups, which may contribute to reducing biases, such as the effect of social desirability. Most of the participants in both stages of the study had high schooling (≥12 years) and previous experience in using electronic equipment with the Internet; therefore, the results do not reflect the perceptions of caregivers with lower schooling levels and who probably have less digital literacy , 36. In Our research focused on a restricted and specific cultural and health environment in Brazil, although a diverse group of participants was included in terms of age and care context, only one male participated and one caregiver had four or fewer years of schooling. Schooling is a determining factor for Internet use. The lack of incentives in countries where Internet use by caregivers of people who have dementia is potentially lower; for example, in low- and middle-income countries, it represents an important gap, as almost 70% of the people who have dementia currently live in such countries and their family caregivers are mostly unsupported . HoweverThis study has some limitations that should be considered. Our research focused on a restricted and specific cultural and health environment in Brazil, although a diverse group of participants was included in terms of age and care context, only one male participated and one caregiver had four or fewer years of schooling. Schooling is a determining factor for Internet use. The lack of incentives in countries where Internet use by caregivers of people who have dementia is potentially lower; for example, in low- and middle-income countries, it represents an important gap, as almost 70% of the people who have dementia currently live in such countries and their family caregivers are mostly unsupported . In addiiSupport-BR, as it made it possible to evaluate and improve acceptability and usability of the Brazilian version of this program. It is also hoped that this study can contribute to the well-being of countless people who will benefit from this initiative, meeting the global goals of supporting individuals affected by dementia. This initiative may also support the formulation of technological strategies to help solve other social and health challenges and the implementation of a care policy for caregivers of people who have dementia in Brazil. A future study of the efficacy and effectiveness of iSupport-Brasil will be able to verify to what extent an online platform is able to help this population, promoting their quality of life and mental health.It is hoped that this study will help to enhance the positive effects of The Brazilian version of iSupport was considered acceptable and usable by family caregivers of people who have dementia in the preliminary study, presenting excellent usability and satisfaction levels, and positive subjective perceptions about the program. The caregivers’ impressions reinforce the importance of the participation of possible users in the development of new electronic support programs. Brazil is the first country in Latin America to implement the cross-cultural adaptation of the iSupport program, and was even a pioneer in the use of the program on smartphones, and it can therefore be an example for other countries that are adapting this program or other online interventions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Research Ethics Committee of the Universidade Federal de São Carlos. The patients/participants provided their written informed consent to participate in this study.AO, DM, CF, EB, DO, KC, LC, FS, MZ, AG, and SP conceived, designed, drafted, and revised the manuscript. All authors have read and agreed to the published version of the manuscript.


Endoscopic therapy for inflammatory bowel diseases (IBD) or IBD surgery-associated complications or namely interventional IBD has become the main treatment modality for Crohn’s disease, bridging medical and surgical treatments. Currently, the main applications of interventional IBD are (i) strictures; (ii) fistulas and abscesses; (iii) bleeding lesions, bezoars, foreign bodies, and polyps; (iv) post-operative complications such as acute and chronic anastomotic leaks; and (v) colitis-associated neoplasia. The endoscopic treatment modalities include balloon dilation, stricturotomy, strictureplasty, fistulotomy, incision and drainage (of fistula and abscess), sinusotomy, septectomy, banding ligation, clipping, polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The field of interventional IBD is evolving with a better understanding of the underlying disease process, advances in endoscopic technology, and interest and proper training of next-generation IBD interventionalists. Crohn’s disease (CD) is a primary phenotype of inflammatory bowel disease (IBD). The majority of patients with CD eventually develop strictures, fistulas, and abscesses, and some of them may develop colitis-associated neoplasia (CAN) , 2. CD iThe main management strategies for CD are medical, endoscopic, and surgical treatment. While medical therapy plays a key role in the treatment of B1 disease and inflammatory components of B2 or B3 disease, and perianal disease, endoscopic and surgical therapy are the main treatment modalities for structural or neoplastic complications. The inflammatory component of strictures may benefit from medical therapy, particularly biologics . PatientSurgical interventions including bowel resection with anastomosis and stricturoplasty are discussed in a separate article in this issue. In the review, indications and basic techniques of interventional IBD are discussed.A stricture is defined as the narrowing of the intestinal lumen. On histology, intramural stricture consists of fibroblasts, collagens, intervening acute or chronic inflammatory cells, hypertrophy of muscle fibers, and neuronal hyperplasia . In addiIntramural strictures are categorized into inflammatory, fibrostenotic, and mixed types, by endoscopy, histology, and cross-sectional imaging. Strictures can further be classified into: (i) primary vs anastomotic; (ii) single vs multiple; (iii) short vs long with a cut-off length of 4–5 cm; (iv) benign vs malignant; (v) ulcerated vs non-ulcerated; (vi) stricture with or without prestenotic dilation; and (vii) simple or complex (e.g. those with associated fistulas or abscesses) .The main endoscopic treatment modalities for strictures are endoscopic balloon dilation (EBD), endoscopic stricturotomy (ESt), endoscopic strictureplasty (ESTx), and endoscopic stenting. Most short (<4–5 cm) primary or anastomotic strictures in CD are amenable to endoscopic therapy. The consensus guidelines suggested the use of an immediate passage of endoscope after treatment as technical success and surgery-free survival as long-outcome . The maiA common pathway of phenotypic evolution in small bowel CD is characterized by chronic transmural inflammation, stricture with gradual prestenotic luminal dilation, and formation of fistula proximal to strictured bowel lumen. Classical examples are ileocecal fistula with a stricture at the ileocecal valve , ileosigThe disease course of fibrostenotic and perianal CD is different from the small bowel counterparts. Often we encounter perianal fistulae and abscesses with tight anal strictures at the anorectal ring, just proximal to the origin of the perianal fistula .EBD has been applied to strictures at any location of the gastrointestinal (GI) tract and is increasingly used in the treatment of primary and anastomotic strictures in CD . PerformTechnical success and long-term outcomes of EBD have been extensively studied with small and large case series. It is estimated that the technical success of EBD in the treatment of primary or anastomotic strictures of CD is ∼85%–95% and two-thirds of patients were about to avoid surgery during the follow-up periods . En. En26]. de novo CD process is not recommended. However, placement of a drainage catheter or stent can be attempted via an anastomotic fistula-associated abdominal or pelvic abscess if transcutaneous drainage via interventional radiology is not feasible.Incision and drainage, and endoscopy-guided seton placement can be performed in CD-associated perianal fistulas and abscesses in CD . TransluEndoscopic closure of bowel wall defects is a routine clinical practice in gastroenterology. Commonly used tools are through-the-scope clips (TTSC), over-the-scope clips (OTSC), and suturing devices. Some endoscopists have been tempted to use OTSC to close the primary orifice of Crohn’s fistula . The maiPatients with CD can have lumen-blocking materials or lesions in the presence or absence of intramural strictures . IntramuPost-operative complications in CD are common. The common complications are anastomotic bleeding, anastomotic strictures, and acute or chronic anastomotic leaks . The endBleeding from anastomosis can occur anytime post-operatively, although it is not common or is under-recognized . PurportProlonged (>3 days) post-operative ileus after bowel resection surgery in CD is common . The proIn post-operative CD, common locations of anastomotic strictures following bowel resection and anastomosis and strictureplasty are the ileocolonic anastomosis, ileorectal anastomosis, enteroenteric anastomosis, and the inlet or outlet of the strictureplasty site. Anastomotic strictures usually develop over time. It is believed that most anastomotic inflammation results from underlying CD, rather than surgical ischemia, based on a histopathological study . WhetherAnastomotic strictures in CD can safely be treated with EBD, ESt, or ESTx  and 7 1, 38–40. Patients who have ileostomy or colostomy for refractory CD commonly develop complications at the stoma or area around the stoma. Among them, strictures at the skin and fascia level can be appreciated by a careful ileostomy or colonoscopy via the stoma. These strictures can also be treated with EBD or ESt . In addiPatients with CD having bowel resection are more at risk for the development of anastomotic leaks than those without IBD. The reported risk factors include use of corticosteroids , 43, smoThe endoscopic treatment modalities for acute anastomotic leaks include vacuum pressure therapy, endoscopic TTSC or OTSC, fibrin glue injection, and stenting . Acute fAcute anastomotic leaks usually lead to adjacent abscesses or sepses. Endoscopic drainage with a stent or catheter may be attempted if surgical or radiological drainage is not feasible.Chronic anastomotic leaks commonly present with fistulas, sinuses, or chronic abscess cavities. Endoscopic treatment strategies for chronic anastomotic leaks are different from those for acute anastomotic leaks. Preferred definitive endoscopic therapy modalities of chronic anastomotic leaks are fistulotomy  or sinusEndoscopic clipping may be performed as an alternative. Pre-clipping tissue debridement with cytology brush or argon plasma coagulation is required to enhance the efficacy of endoscopic closure with TTSC or OTSC .Patients with persistent or chronic inflammation of the large bowel from IBD are at risk for the development of CAN . PatientCAN in CD can have endoscopic presentations, such as polypoid, raised, flat, or decompressed lesions, similar to those in UC. In addition, CAN may present with colonic strictures. As in CAN in UC , discretEndoscopic excisional therapy of strictures with neoplasia is not recommended. Rather, bowel resection is warranted. The role of endoscopic treatment of neoplastic lesions of glandular or squamous source in perianal or anorectal CD has not been investigated. Topical injection to perianal fistulas in CD with stem cells or stromal cells has extensively been studied and in some parts of the world cell therapy has been a part of routine clinical practice , 78. It The evolving field of interventional IBD currently covers endoscopic treatment of strictures; fistulas and abscesses; lumen-blocking bezoars, foreign bodies, or inflammatory polyps, and bleeding; IBD surgery-associated complications; and CAN . The maiNone.