Currently, whether endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is superior to conventional TBNA (cTBNA) in the diagnosis of mediastinal lymphadenopathy remains controversial. We undertook a meta-analysis of randomized controlled trials (RCTs) to evaluate the diagnostic yield of EBUS-TBNA versus cTBNA in the diagnosis of mediastinal lymphadenopathy, both in benign and malignant etiologies. Computer-based retrieval was performed on PubMed and EMBASE. The quality was evaluated according to the quality assessment of diagnostic accuracy studies-2, and Meta-Disc was adopted to perform meta-analysis. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95 % confidence intervals (CIs) were calculated. The summary receiving operating characteristic curve as well as the areas under curve (AUC) was measured. Four studies with a total of 440 patients met the inclusion criteria. Our results showed that the pooled sensitivity was 0.90 (95 % CI 0.85–0.94) and 0.76 (95 % CI 0.68–0.82), pooled specificity was 0.75 (95 % CI 0.60–0.87) and 0.94 (95 % CI 0.86–0.98), DOR was 75.38 (95 % CI 16.38–346.97) and 108.17 (95 % CI 13.84–845.35), and AUC was 0.9339 and 0.9732 for EBUS-TBNA group and cTBNA group, respectively. Although EBUS-TBNA with a higher sensitivity performs better than cTBNA, there is lack of enough evidence regarding EBUS-TBNA being superior to cTBNA in the diagnosis of mediastinal lymphadenopathy. Considering the limitations of methodology and limited data, further robust RCTs are needed to verify the current findings and investigate the optimal choice in patients receiving TBNA. Mediastinal lymphadenopathy include a variety of benign and malignant conditions, such as lung cancer and sarcoidosis, which are depended on the pathology in terms of the gold standard for diagnosis. Hence bronchoscopy still plays an important role in the diagnosis of mediastinal lymphadenopathy  for eligible trials with the following keywords: “endobronchial ultrasound” and “transbronchial needle aspiration”. Eligible trials limited with randomized controlled trial and written in English were included. Only published trials were included. Bibliographies of all potential studies, including reference lists, citation searches, and relevant systematic reviews, were manually searched.The following selection criteria were included: (1) population: consecutive patients (age > 18 years) with mediastinal lymphadenopathy undergoing TBNA; (2) study design: RCT comparing the diagnostic value of real time EBUS-TBNA versus cTBNA in the detection of mediastinal lymphadenopathy; (3) sufficient data: reported data allowing calculation of the true-positive (TP), false-positive (FP), false-negative (FN) and true negative (TN) values; and (4) reference standard: histopathological and/or cytological analysis, or close radiological and clinical follow up for at least 6 months after TBNA, as the reference standard.All data were extracted from all trials by two independent investigators (LP and BL). The data included first author, publication year, country, number of patients, age and sex of patients, needle type, sedation setting, primary results, and adverse events. Disagreements among authors were settled by discussion or a third investigator (XLC).The quality of RCTs was evaluated according to the quality assessment of diagnostic accuracy studies-2 (QUADAS-2) , region (Asia vs. North America), and patients with diagnosis either sarcoidosis or other thoracic lesions. All meta-analyses were performed using Meta-DiSc 1.4  . A detailed flowchart for the study selection is presented in Fig. The main characteristics of the retrieved RCTs are shown in Table Two authors (LP and BL) agreed on each item of the QUADAS-2. The risk-of-bias analyses suggested that all trials were followed at low risk in terms of patient selection, index test, reference standard, and flow and timing except only one RCT  and 0.76 , specificity was 0.92  and 0.94  for EBUS-TBNA group  to 0.97 , 0.59  to 0.95  for EBUS-TBNA group and cTBNA group, respectively. Moreover, threshold effect analysis showed that their spearman correlation coefficients were respectively 0.949 (P = 0.051) and 0.400 (P = 0.600) for EBUS-TBNA group and cTBNA group, which suggested that no diagnostic threshold effect existed for histological diagnoses, and we believe that the heterogeneity among studies could mainly result from clinical and methodological differences.The overall diagnostic sensitivity was 0.91 , 0.09 (95 % CI 0.01–0.67), and 75.38 (95 % CI 16.38–346.97) for EBUS-TBNA group, respectively. Correspondingly, the pooled PLR, NLR, and DOR were 11.11 (95 % CI 5.16–23.96), 0.11 (95 % CI 0.01–1.47), and 108.17 (95 % CI 13.84–845.35) for cTBNA group, respectively. Additionally, the two SROC were presented in Fig. P < 0.01), and the pooled specificity, DOR and Q* index of cTBNA were obviously higher than those of EBUS-TBNA .Specifically, the Z-test results suggested that the pooled sensitivity of EBUS-TBNA was significantly higher than that of cTBNA , region (Asia vs. North America), and patients with diagnosis either sarcoidosis or other thoracic lesions. Table From Table The current meta-analysis including 4 RCTs was conducted to critically evaluate the diagnostic value of EBUS-TBNA compared with cTBNA in patients with mediastinal lymphadenopathy. The results of our study indicated that both EBUS-TBNA and cTBNA are safe and provide good diagnostic value for patients with mediastinal lymphadenopathy. EBUS-TBNA with a higher sensitivity performs better than cTBNA, however, the pooled specificity, DOR and Q* index of cTBNA were obviously higher than those of EBUS-TBNA.EBUS-TBNA has been a new approach in the estimation of thoracic disease not only in nonmalignant diseases such as sarcoidosis and tuberculosis but also in mediastinal lymphadenopathy, particularly in cases of malignancy (Garwood et al. In the present meta-analysis, we mainly focused on evaluating the diagnostic value across EBUS-TBNA and cTBNA arms during the diagnosis of mediastinal lymphadenopathy, both in benign and malignant etiologies. Our results showed that the pooled sensitivity was 0.90 and 0.76, specificity was 0.75 and 0.94, DOR was 75.38 and 108.17, and AUC was 0.9339 and 0.9732 for EBUS-TBNA group and cTBNA group, respectively. Moreover, the Z-test results suggested that the pooled sensitivity of EBUS-TBNA was considerably higher than that of cTBNA, and the pooled specificity, DOR and Q* index of cTBNA were obviously higher than those of EBUS-TBNA. Based on the above results, we believed that our results could not be used as the basis to choose the operating mode of TBNA for the clinicians, and the choice needs to be followed the principle of individuation. Next, in the present study, sensitivity analyses did not obviously alter the heterogeneity among studies for the pooled sensitivity. The results from subgroup analyses indicated that EBUS-TBNA might be superior to cTBNA in patients from Asia and with diagnosis or suspected of sarcoidosis in terms of the pooled sensitivity. But further studies are needed to investigate these topics. Finally, threshold effect analysis showed that no diagnostic threshold effect existed for histological diagnoses, which indicated that the heterogeneity among studies could be seen as a result of clinical and methodological differences.Additional areas of study are important for future clinical research. Advanced technology and equipment means more expense; therefore, cost-effective analyses are needed. Moreover, further segregation of the diagnostic yield in malignant versus benign disease is needed as it is difficult to delineate which approach is more effective for various patients (Yarmus et al. To be sure, several limitations exist in our study. First, the patients were heterogenous with a mixture of benign and malignant etiologies, and different size a location of the intrathoracic or mediastinal lymph nodes. Second, procedural aspects were also heterogenous, such as the number of aspiration passes, the type of needle, and the type of sedation. Operator experience level is variable which may affect the applicability of our results. Third, four RCTs with a wide variation in sample size were incorporated into our analysis. Overestimation of the diagnostic value is the most likely to occur in smaller than in larger studies. Finally, several unpublished or missing data may increase the risk of bias.In summary, this study suggests that both EBUS-TBNA and cTBNA are safe and provide diagnostic value for mediastinal and hilar adenopathy. Both have advantages and disadvantages. The optimal choice of procedure should be individualized based on availability, patient characteristics and operator experience. Further robustly designed RCTs are needed to better explore the current findings and continue to investigate the most appropriate diagnostic modality.


PEACH™QLD translated the PEACH™ Program, designed to manage overweight/obesity in primary school-aged children, from efficacious RCT and small scale community trial to a larger state-wide program. This paper describes the lessons learnt when upscaling to universal health coverage.The 6-month, family-focussed program was delivered in Queensland, Australia from 2013 to 2016. Its implementation was planned by researchers who developed the program and conducted the RCT, and experienced project managers and practitioners across the health continuum. The intervention targeted parents as the agents of change and was delivered via parent-only group sessions. Concurrently, children attended fun, non-competitive activity sessions. Sessions were delivered by facilitators who received standardised training and were employed by a range of service providers. Participants were referred by health professionals or self-referred in response to extensive promotion and marketing. A pilot phase and a quality improvement framework were planned to respond to emerging challenges.Implementation challenges included engagement of the health system; participant recruitment; and engagement. A total of 1513 children (1216 families) enrolled, with 1122 children (919 families) in the face-to-face program (105 groups in 50 unique venues) and 391 children (297 families) in PEACH™ Online. Self-referral generated 68% of enrolments. Unexpected, concurrent and, far-reaching public health system changes contributed to poor program uptake by the sector  requiring substantial modification of the original implementation plan. Process evaluation during the pilot phase and an ongoing quality improvement framework informed program adaptations that included changing from fortnightly to weekly sessions aligned with school terms, revision of parent materials, modification of eligibility criteria to include healthy weight children and provision of services privately. Comparisons between pilot versus state-wide waves showed comparable prevalence of families not attending any sessions (25% vs 28%) but improved number of sessions attended (median = 5 vs 7) and completion rates (43% vs 56%).Translating programs developed in the research context to enable implementation at scale is complex and presents substantial challenges. Planning must ensure there is flexibility to accommodate and proactively manage the system changes that are inevitable over time.ACTRN12617000315314. This trial was registered retrospectively on 28 February, 2017. There in = 169) conducted in Adelaide and Sydney evaluated a 6-month healthy lifestyle program with and without an additional parenting skills component [P < 0.001) in both groups that was maintained for a further 18 months without further intervention [The Parenting, Eating and Activity for Child Health (PEACH™) Program was developed in Australia at Flinders University in the early 2000s. The PEACH™ RCT  based on a recognisable design that aimed to establish the PEACH™ QLD brand. All materials were required to be approved by the funder. The wide range of marketing and promotional strategies used through the project are summarised in Table Program implementation took a three-phased approach as outlined in Fig. Implementation phases 2 and 3 delivered five iterative waves based on defined time periods  and geographical areas , particularly those related to intellectual property (IP). Due to the geographical and organisational diversity of the sites and venues, occupational health and safety was a major undertaking. Site risk assessments, site inductions, careful selection of venues and documented processes ensured the programs were delivered safely.Eligible participants as identified in the tender were children residing in Queensland, aged 7–13 years and with body mass index (BMI) 85th -95th percentiles (i.e. overweight but not obese) . Based oThe Project Implementation Team’s project dietitian fielded the first contact calls with families to ensure the initial conversation with parents regarding their child’s weight status was positive. These calls were also used to determine eligibility based on parent-reported child height and weight, provide further information on the program, record how families heard about the program and establish the child’s suitability to participate in group-based sessions. Parents who deemed their child unable to attend group activity sessions were still strongly encouraged to enrol and bring their child to the first and last sessions to maximise the collection of pre- and post-evaluation data. Parents completed and signed consent forms, for their own and their child’s participation, at their first session.PEACH™ is a group-based, 6 month family-focussed lifestyle intervention to treat overweight primary school-aged children , 14. TheParent sessions were interactive and each had defined objectives, take home messages and a small homework task. Parents were encouraged to set one or two family specific goals to work on between sessions, and encouraged to use the Planning Ahead Template (PAT) to consider and document the steps for behaviour change. Enrolled families received a 100-page, high quality printed Parent Handbook  and addiDuring implementation, three major review phases were undertaken to address the major challenges of the project see Fig. . The firIn order to analyse project implementation outcomes, and compare planned with actual implementation, project documentation and records were reviewed. During implementation, following each wave, using a cycle of continuous quality improvement, data were analysed against key performance indicators articulated by the funder. Once the project was completed, data were more strategically analysed against reach, adoption and implementation elements of the RE-AIM framework . The ProDescriptive statistics obtained from participant level data were used to examine the characteristics of enrolled children and program engagement data. The sociodemographic characteristics of children enrolled in PEACH™ QLD were compared with those in the eligible population. The population eligible for PEACH™ QLD was described using data from the Child Preventive Health telephone survey 2015–16, an annual cross-sectional survey of Queensland children conducted by the Department of Health. Indicators of participant social disadvantage and accessibility were derived from residential postcode using the SEIFA Index of Relative Socio-Economic Disadvantage (IRSD)  and the Program engagement data, including session attendance and program completion, were obtained from session sign in sheets maintained by parent facilitators. Program completers were defined as those families who attended at least 7 of the available 10 PEACH™ sessions. Data analysis was performed in SPSS 23.0 (IBM Corp) [PEACH™ QLD encountered key reach, adoption and implementation challenges that were underestimated by the Project Implementation Team during initial program planning. These were categorised as (i) engagement of the health system; (ii) recruitment and promotion; and (iii) participant engagement. These challenges were considered at each review phase and responses and strategies are summarised in Table The far-reaching system changes Fig.  at both The culmination of national primary healthcare funding changes and the state move to decentralised HHSs meant a significant loss of health system engagement and capacity to deliver programs such as PEACH™. As a result, the Project Implementation Team relied much more heavily on Other Providers and QUT-Provided groups in order to meet contractual obligations  undertook Options 2 and 3 of the program delivery model  enrolled in the PEACH™ Program. This comprised 1122 children (919 families) enrolled in the face-to-face program and 391 children (297 families) in PEACH™ Online. Data from PEACH™ Online families are not included due to substantial modification of the evaluation framework and format for the online version. One hundred and five (105) face-to-face groups were delivered at 50 unique venues, within 13 of 16 Queensland HHS geographic areas. However, as noted above only five of the sixteen HHS delivered the program in these areas. Of the enrolled children, 48% were boys, 30% and 51% were classified in the bottom two (greatest relative disadvantage) and top two (greatest relative advantage) SEIFA IRSD quintiles, respectively [Self-referral, via the website or toll-free phone number, generated 68% of enrolments with a further 12% of families self-referring after hearing about the program from a health professional. The remaining 20% of enrolments were directly referred by a health professional 14%) or from a hospital waiting list (6%). The importance of self-referral, evident even from the pilot phase, informed the extensive marketing and promotional activities  highlights that sustained implementation requires an acknowledgement of and response to the ongoing state of change in health care systems . This paAlthough the need to prevent and manage childhood obesity is widely acknowledged, responsibility for providing such services in Australia remains unclear. This lack of clarity results in shifting and inconsistent ownership of the delivery of childhood obesity management services as demonstrated in the impact of political changes on the composition of service providers shown in Fig. n = 16) interest in sustained program implementation beyond the project funding period before the implementation trial began, only 5 accepted project funding to directly deliver the program and none delivered groups across all waves. In response, QUT either delivered or subcontracted private healthcare providers to deliver the program thus limiting sustainability beyond the funding term and raising important questions about the role of a university as a service provider.The original tender was conceived in part, in response to clinicians’ concern regarding waiting lists and purported demand for a universal service. Our preferred program delivery model assumed publicly-funded health service providers were well positioned and resourced to deliver the program and ultimately embed it within their usual service. There are well documented examples , 29 wherFor projects delivered at scale, a substantial establishment phase with appropriate funding and milestones is required to enable development of effective governance, stakeholder partnerships, costing models, communication strategies, referral pathways, protocols and ethics approvals and workforce recruitment and training before program delivery commences . The sixPEACH™ QLD applied a horizontal approach  to scaliA key learning was the importance of self-referral and the positive role that schools can play in publicising the program. A disappointingly low proportion of referral from health professionals reinforced our decision to invest heavily in high quality professional marketing of the program. This included development of a suite of high quality, consistently branded promotional materials to engage health professionals, organisations and the community. It remained an ongoing challenge to ensure media stories focussed on positive messages and imagery and avoided blaming and negative stereotyping families, hence it was important to carefully vet all media releases. Where possible, experienced senior project staff handled radio and television interviews. Media training and support of project staff, including facilitators endeavoured to ensure PEACH™ QLD messages were communicated consistently, positively and effectively at the local level. Marketing efforts focussed on a program empowering parents to seek help and support to improve child and family health. It is possible that the campaign had an impact beyond enrolled families in terms of raising community awareness of childhood obesity. While the project did not target eligible children in promotional materials, anecdotal reports from facilitators suggested children influenced family attendance so should be considered in future marketing activities. The interaction between parent and child in the family response to improve child weight status requires further exploration. Any marketing strategies to directly target children will need careful planning to avoid unintended adverse consequences for the children and their families.Our experience suggested recruitment of families was effective when centralised i.e. eligibility, program information and enrolment was managed by the project dietitian as the first point of contact with families; commencement dates, times and locations were confirmed prior to marketing and specified in local publicity; and time between promotion, enrolment and starting groups was minimised, with < 6–8 weeks being optimal. Effective marketing and promotion were critical as the majority of enrolled families self-referred, with promotion through schools being the most effective marketing strategy. This finding is consistent with a study by Welsby et al. . Health Despite endeavouring to run the program in small rural communities throughout Queensland, it was often not possible to secure sufficient enrolments to ensure groups were viable. Further, in larger centres, it was also difficult to achieve viable enrolments where programs were run in two consecutive school terms, indicating that careful planning of site locations and adequate spacing of programs across school terms is important. Despite intensive promotional activities our enrolment numbers did not always meet minimum numbers required for group viability in terms of both fixed costs of delivery and group function. In some instances, groups were cancelled or delayed to future terms due to low enrolment numbers. This resulted in disappointment for families who had enrolled and facilitators who were expecting to consolidate their training and run groups. The challenge of enrolment is likely to reflect the well-documented complexity of parental awareness of and readiness to change their child’s weight  rather tReach is a fundamental aspect of implementation at scale . DespiteSuccessful outcomes of childhood weight management programs rely on family engagement . This waEngagement reflects complex interactions at the family level between prior experience, current perceived needs, readiness for change, influence of significant others and feasibility of attending sessions. We considered attendance in PEACH™ QLD a crude surrogate measure of this complexity. The role of other group members, group size and dynamics and facilitator experience, confidence and enthusiasm are also potential factors that may influence attendance. In PEACH™ QLD, the role of facilitators on attendance was underexplored but anecdotally, both parent and child facilitator capability and enthusiasm had an impact on retention. A systematic review by Kelleher et al.  investigSeveral modifications may have enhanced participant engagement beyond pilot phase including changes in format e.g. frequency of sessions from fortnightly to weekly and timing within the school term; shift from healthcare to community-based venue settings; enhancements to program content and materials. As noted above, an inherent challenge is that parents who do not attend any sessions; withdraw formally or otherwise stop attending, do not complete baseline and/or outcome assessment. Hence, there are limited data to enable examination of reasons for poor engagement or the impact of lower attendance (a proxy for intervention dose) on improvements in healthy lifestyle indicators. Parents may stop coming due to a range of factors related to satisfaction and/or logistics. It is also plausible that at some point they feel that the program has met their perceived needs for information and support and they do not need to continue to attend. Characterising how and why families ‘engage’ and meet their perceived needs is complex and to date has received limited attention. Planning, particularly in terms of ethics approval and resource allocation, is required to enable follow up of families who do not attend, to inform development of retention strategies. A practical aspect of poor engagement (never attending/attrition) is the impact on viable group size both in terms of the fixed costs of offering the group at all and group dynamics if the number of families regularly attending drops too low. The initial implementation plan worked on enrolling 15 children per group. This target was rarely met which had a range of resource and operational implications.Balancing strategies to maximise attendance with best practice in childhood obesity management is complex. The PEACH™ Program is consistent with clinical practice guidelines  and evidPEACH™ QLD successfully up-scaled the evidence-based PEACH™ Program by reaching over 1200 families and over 1500 children across Queensland. The cohort was broadly representative of Queensland families with primary school-aged children above the healthy weight range. Contractual enrolment targets were met but recruitment and engagement of families were challenging, although consistent with similar programs. Key learnings for the dissemination of a program at scale include (i) the need to plan and fund adequate lead times to set up governance and operational procedures prior to commencement of program delivery; (ii) the importance of high quality marketing and promotion to support self-referral to the program; (iii) the operational efficiencies of aligning with school terms and engaging schools in promotion; and (iv) the need to ensure process evaluation is structured to provide detailed real-time information on the needs and responses of families, regardless of level of engagement, to inform program modifications within a continuous quality improvement framework. Despite the prevalence of childhood obesity worldwide [The most difficult challenge was engaging the health care sector and ensuring sustainability of the program beyond the funding period. Childhood obesity management is a complex practice and service provision problem. Since completion of the funded project, PEACH™ QLD, is no longer available to Queensland families. PEACH™QLD aligned with multiple government priorities and policies which strongly articulate the need to address childhood overweight and obesity and increase the capacity of health professionals and services within the health sector to do so –42. Desp


Background: In 2008, the Southern California Earthquake Center in collaboration with the U.S. Geological Survey Earthquake Hazards Program launched the first annual Great ShakeOut, the largest earthquake preparedness drill in the history of the United States. Materials and Methods: We collected online survey data from 2052 campaign registrants to assess how people participated, whether audience segments shared behavioral patterns, and whether these segments were associated with five social cognitive factors targeted by the ShakeOut campaign. Results: Participants clustered into four behavioral patterns. The Minimal cluster had low participation in all activities (range: 0–39% participation). The Basic Drill cluster only participated in the drop, cover and hold drill (100% participation). The Community-Oriented cluster, involved in the drill (100%) and other interpersonal activities including attending disaster planning meetings (74%), was positively associated with interpersonal communication (β = 0.169), self-efficacy (β = 0.118), outcome efficacy (β = 0.110), and knowledge about disaster preparedness (β = 0.151). The Interactive and Games cluster, which participated in the drill (79%) and two online earthquake preparedness games (53% and 75%), was positively associated with all five social cognitive factors studied. Conclusions: Our results support audience segmentation approaches to engaging the public, which address the strengths and weaknesses of different segments. Offering games may help “gamers” gain competencies required to prepare for disasters. Targeting the highly active Community-Oriented cluster for leadership roles could help build community resilience by encouraging others to become more involved in disaster planning. We propose that the days of single, national education campaigns without local variation should end. In Southern California, despite the many years of education and campaigns about earthquake preparedness and response, studies continually suggest that people are not fully prepared for disasters nor have they completely processed what actions are most important to take during an earthquake ,2,3. In The public’s lack of overall engagement in preparedness and response activities has provided impetus for more creative and engaging ways to motivate the public to prepare. In response to this demand, the USGS Earthquake Hazards Program collaborated with the Southern California Earthquake Center at the University of Southern California to spearhead the first Great ShakeOut drill. This novel community-based drill incorporates well-known drivers of behavior change. A central component of the drill involved learning through behavioral rehearsal. At the most basic level, participants physically practiced the “drop, cover and hold” actions, while others also rehearsed parts of their worksite’s evacuation, triage, and reunification plans. According to Bandura’s Social Cognitive Theory, rehearsing a behavior improves one’s ability to learn it, as practice allows them to refine the behavior as a skill . RehearsIn addition to the drill, a range of communication initiatives were launched in the months leading up to it to raise public awareness about the drill and earthquake preparedness in general. For instance, there was a dedicated website where participants could access the following items: a narrative booklet, video and audio recording describing a 7.8 earthquake scenario linked to California’s San Andreas fault ,14,15; aIn recent years, there has been a global push for greater community involvement in disaster preparedness efforts in order to build resilience. For instance, the U.S. Federal Emergency Management Agency outlines a strategic framework for implementing “whole community” approaches to engage the public, including understanding the community’s needs, strengthening existing community relationships, and engaging and empowering all parts of the community . The U.SFollowing the launch of the first Great Southern California ShakeOut in 2008, we surveyed those who registered for the campaign about their participation in the drill and other campaign activities. We also collected data on social cognitive factors known to enhance engagement in disaster preparedness that were targeted by the campaign’s best practices, including interpersonal communication, personal responsibility, self-efficacy, outcome efficacy, and knowledge about earthquake preparedness. Using these survey data, the current study aims to assess (1) what types of campaign activities did survey participants enact; (2) whether there are discernable patterns of behavior in which audience segments cluster; and (3) whether these audience segments are associated with the social cognitive factors targeted by the ShakeOut campaign. Previous research supports the value of audience segmentation, as people who share certain behavior patterns and beliefs may benefit from tailored messaging and outreach ,26. By iAn online cross-sectional survey was conducted five months after the launch of the Great Southern California ShakeOut drill among a sample of registered participants to learn about participation in ShakeOut activities and social cognitive factors that may have been influenced by the campaign and drill. We selected and analyzed the survey measures listed below.Demographic and personal characteristics. The following four demographic variables were collected: gender, age, race/ethnicity, and income. We also included a measure of personal experience with a disaster as this is a well-known correlate of participating in disaster preparedness behaviors [ehaviors .ShakeOut participation. Respondents were asked if they participated in eight ShakeOut activities. These activities consisted of (1) participating in the “drop, cover and hold” drill on 13 November at 10 a.m.; (2) practicing a disaster plan; (3) helping others prepare for the ShakeOut; (4) participating in a meeting in their workplace or school about preparing for earthquakes; (5) joining a MySpace ShakeOut group; (6) joining a Facebook ShakeOut group; (7) playing the Beat the Quake game on the ShakeOut Website; and (8) signing up to play AfterShock, which became available after the launch ShakeOut drill.Social cognitive factors. We measured interpersonal communication by asking respondents if they had spoken with family or friends during the past 30 days about earthquakes in general, as well as about their disaster communication plan, earthquake kits, preparing their home for an earthquake, their community disaster plan, and having extra cash on hand. Responses were coded binary . For personal responsibility, respondents ranked the level of importance that they feel personally responsible about being prepared for an earthquake. Responses ranged from 1 (not important) to 5 (extremely important). Self-efficacy was measured by asking respondents three questions about whether they felt capable of preparing for a major earthquake by making the right decisions about (1) water, (2) food, and (3) making a disaster communication plan. Answers ranged from 1 (strongly disagree) to 5 (strongly agree). We assessed outcome efficacy using six questions about how preparing for an earthquake might help if a big earthquake happens. The respondents were asked how much they agreed with the following statements: (1) having a disaster kit may help me; (2) if furniture and appliances are secured, my home may be safer; (3) working with local community may make it easier for my household; (4) storing cash may help my household; (5) calling an out-of-area contact may help me after an earthquake; and (6) having a plan for meeting up with a family may be helpful. Answers ranged from 1 (strongly disagree) to 5 (strongly agree). Finally, knowledge was measured via a 22-item quiz, which asked respondents to choose the correct actions to do in the event of an earthquake. These items were broken up into five sections that asked about what they should do during an earthquake if they were inside a building, outside a building, in bed, or driving, as well as what they should do after the earthquake.The first Great ShakeOut campaign and drill took place in the greater Los Angeles region, which is the second most populous urban area in the United States. It is also one of the most diverse regions in the United States in terms of socioeconomic status, culture, religion, household type, and the economy . Los AngOur goal was to interview as many individuals who registered for the ShakeOut campaign as possible in order to obtain a diverse sample of participants. No a priori power analysis was conducted to calculate sample size. The survey was sent to the full registry of individuals who signed up to participate in the ShakeOut campaign and drill, which was a total of 18,411 people.Invitations to the online survey were emailed on 22 April 2009. The survey design was based on Dillman’s Tailored Design Method  in whichFirst, we ran descriptive statistics for the demographic and ShakeOut participation variables. For gender and race, we calculated percentages within each pre-specified category. To make direct comparisons with Census data statistics, we calculated means for age and income by imputing the mean within each response category . For ShakeOut participation, we calculated the percentages of people participating in each ShakeOut activity.Next, we ran a factor analysis to identify underlying categories of behaviors from the different ShakeOut activities. We used principal component extraction, Varimax rotation and Kaiser Normalization. We used the Scree test to identify the number of factors. Next, we ran a two-step cluster analysis so that we could derive behavioral pattern clusters using the behavior categories identified through factor analysis. With all behaviors included, no clusters emerged, so we removed the factors with less than 5% participation and conducted two-step cluster analysis with the following three input variables: (1) drop, cover and hold; (2) interpersonal behaviors; and, (3) games. We then ran a series of chi-square tests to determine if there were significant variations in the distribution of demographic variables across the various ShakeOut participation clusters.Finally, we ran multiple linear regression models to examine whether demographic variables, personal experience with a disaster, and the ShakeOut behavior clusters were significantly associated with each social cognitive factor . The demographic variables included in the models were gender, age, race/ethnicity, and income. For social cognitive variables, we created composite scales for multi-item variables by calculating the averages across each response. Each of these variables was treated as a continuous dependent variable in each regression model.The study protocol was reviewed and approved by an institutional review board of the University of Southern California. Study: Evaluation of an Earthquake-Preparedness Campaign (UP-08-00347)..The survey was started by 2390 people with 2052 completing the survey (13% response rate)The frequencies for participation in each ShakeOut activity are located in Four clusters emerged from our analysis, which are depicted in Frequency distributions of demographic characteristics for each cluster and the chi-square results are provided in Results from the regression analyses are presented in In comparison to the Minimal cluster, being in the Basic Drill cluster was only significantly associated with greater knowledge about what to do during an earthquake. Belonging to the Community-Oriented cluster was also associated with higher knowledge, as well as enhanced self-efficacy, outcome efficacy, and interpersonal communication. Being in the Interactive and Games cluster was positively associated with all five social cognitive outcomes. However, the strength of the associations was not as strong as those seen for the Community-Oriented cluster, which had particularly high coefficients, especially for interpersonal communication (β = 0.169).The Great Southern California ShakeOut represents an evolution in risk communication and planning efforts to prepare communities for catastrophic disasters. When developing the drill and campaign leading up to it, risk communication was considered within a larger social context and followed a skill-based training approach. The audience was not simply encouraged to plan for an earthquake by having household supplies or a family communication plan, but was also trained to practice specific behaviors in direct response to an earthquake. The main behavior practiced in this exercise was to “drop, cover and hold” when an earthquake occurs. Not surprisingly, the drop, cover and hold drill was the most frequently cited activity among survey respondents. Additionally, the audience was encouraged to connect with others when planning for and participating in the drill. About a third of the participants engaged in interpersonal activities by attending a meeting where preparing for earthquakes was discussed, practiced a disaster plan such as a work evacuation or family reunification plan, and helped to prepare for the ShakeOut drill. Participants also connected with others via media-based interactions offered through the earthquake games and social media groups; however, these activities were less popular than the interpersonal activities. In particular, joining the campaign’s Facebook and MySpace groups was the least cited activity by a substantial margin. Despite social media’s potential to enhance social connectedness , it appeUsing the three most popular campaign behaviors, we were able to cluster the audience segments into distinct behavioral patterns. We found that the majority of respondents fell into the Basic Drill cluster, which participated in the drop, cover and hold drill, but was less interested in the other campaign activities. This segment represents a group that is likely open to a one-time group exercise, but is less engaged in the more involved and interactive campaign activities. In contrast, those who belonged to the Community-Oriented cluster represent a group that is demonstrably active in community planning efforts by also attending meetings, practicing additional plans, and helping others. This group had a greater proportion of Latinos, a demographic group that has previously been shown to respond better to preparedness interventions that utilize discussion-based learning and social networks . The disThis study supports findings from a prior cluster analysis conducted by Adams and Eisenman on a different dataset of Southern California residents . In thatDespite the fact that we surveyed a highly motivated sample that had registered for the ShakeOut drill, 26% of respondents still fell into the Minimal cluster, a group that did not actually participate in the drop, cover and hold drill. While disappointing, this finding was not entirely surprising, as it is well documented in the literature that most individuals do not follow the recommended behaviors for disaster preparedness despite the existence of education and campaigns ,36. ThisThe fourth cluster, Interactive and Games, possessed a unique pattern of behavior. While approximately half of them participated in interpersonal activities, they expressed greater interest in games as a way to get more involved in the campaign beyond the basic drill. Three-quarters of this group played the Beat the Quake game posted on the ShakeOut website and more than half even signed up for the After Shock game before it was made available. The existence of this “gamer” group supports the inclusion of virtual games as an additional interactive platform to engage different population segments. In fact, results from the regression models demonstrate the value of learning and practicing disaster preparedness activities through virtual games. After controlling for demographic characteristics and personal experience with disasters, the Interactive and Games cluster was positively associated with all five social cognitive factors that were targeted by the ShakeOut campaign. If we compare these findings to those for the Basic Drill cluster, which was only positively associated with earthquake knowledge, it appears as though playing games further contributed to interpersonal communication about earthquake preparedness, as well as perceptions of personal responsibility, self-efficacy, and outcome efficacy regarding these behaviors. These results suggest that the act of playing games can promote further discussion of preparedness among family and friends. Practicing preparedness behaviors in a virtual setting where an earthquake is simulated may also enhance feelings about their personal responsibility and ability to prepare for an earthquake, as well as perceptions that these behaviors can successfully protect against the destructive consequences of these disasters.Results from the regression models also demonstrate the benefit of belonging to the Community-Oriented cluster. This group was positively associated with interpersonal communication, self-efficacy, outcome efficacy, and knowledge about earthquake preparedness, which are all factors known to engage the public in disaster preparedness and response ,36,37. IR2 values, indicating that the independent variables did not explain a large proportion of the total variation in the models. The inclusion of additional unmeasured variables may have improved model fit. Finally, our study examined individuals who participated in the first ShakeOut drill that was launched in 2008. While this provides us with insight into who was registered for the first campaign as well as how to improve participation in the Great ShakeOut and other community-based drills, further research is needed to examine how newer changes, such as greater social media presence and the introduction of new interactive games and virtual reality experiences, enhance participation and overall disaster preparedness.Despite our numerous findings, our study is bounded by certain limitations. First, our respondents were a highly self-selected pool among those already registered for the ShakeOut drill. Our results are therefore not generalizable to everyone who participated in the campaign. Self-selection of more engaged participants may have also reduced some of the variation in the outcomes across different segments of the population. Additionally, having the chance to win a $100 gift card as an incentive to participate may have influenced who self-selected to participate in the study and may have led to inappropriate completion of the study questionnaire for the sake of the incentive. Second, while we attempted to encourage survey participation through the $100 incentive, we still had a very low response rate which likely contributed to non-response bias. We thus recognize that our findings are not generalizable to all registrants of the campaign. Third, although our survey intended to capture information about social cognitive characteristics that may have been influenced by participation in the ShakeOut drill and campaign, our data were cross-sectional in nature. While the study design encourages linear temporality by surveying respondents several months after the campaign, the cross-sectional design still only allows us to make inferences on the associations between variables and not causation. Fourth, our multiple regression models had fairly low While the majority of respondents only participated in the drop, cover and hold drill, we identified a more motivated, community-oriented audience segment who we believe should be targeted for leadership roles in order to get others more involved as well as improving social connectedness, which is a key feature of resilience. Additionally, playing online earthquake games contributed to important social cognitive factors for disaster preparedness, including personal responsibility, self-efficacy, and outcome efficacy. We recommend that preparedness drills and programs include more interactive in-person and virtual activities in order to target different segments of the population and enhance overall community resilience. Furthermore, we recommend emergency managers conduct audience segmentation surveys prior to program development and implementation to elucidate who are their distinct audience segments and use these results to provide a panoply of opportunities targeted to the right audience. We believe that the days of single, national education campaigns without local variation should end.


Globalization results in a rapidly diversifying population, increased inequities, and more complex health problems affecting populations. This forces medical schools to integrate global health (GH) into the training of health-care professionals from curriculum development to practical learning activities, here and abroad.The approach aims at enriching existing programs in GH competencies in an interdisciplinary context. The goal is to ensure that all health-science students develop a certain level of GH competency. The main actions are the mobilization of key stakeholders, the development of a competency framework (CF) to perform gap analysis, tool formalization, and monitoring and evaluation activities. Subsequent to scoping review and stakeholder consultations, ten principles are identified and used to guide the enrichment process.Actual outputs cover a broad scope, from key decision-makers’ support and endorsement to the formalization of tools and the consolidation and creation of activities such as service-learning activities, rotations among underserved populations, and training for international rotations.While this unique approach is proving to be a major challenge, the preliminary results are well worth the effort. The project’s tangible impacts on health-sciences teaching, the GH competence of graduates, and care delivery are topics of interest for future investigation. Local, national, and international news provide us daily reminders that we live in a globalized world with increased interaction and integration of human, societal, and economic activities around the world and among countries.6Educational institutions for health-care professionals are consequently called upon to integrate GH issues into their programs.11Academic institutions are under external pressure to move in this direction. In addition, many students are showing growing interest in GH and want to be better equipped to care for the most vulnerable individuals,14Health-sciences programs are often asked to add new curriculum items or content.Over the last four years, the Université de Sherbrooke’s Faculty of Medicine and Health Sciences (FMHS) has committed itself to overcoming these challenges. Herein, we share FMHS’s vision and actions for an interdisciplinary and integrated approach to enriching health-sciences programs in GH. It particularly focuses on underlying principles, project implementation processes, and our preliminary results.The foundation for this work lies with the FMHS strategic plan to develop social accountability and competencies in GH for future health professionals.project goal is to ensure that all health-care professionals are committed to GH, socially responsible, and more competent at serving vulnerable or excluded populations.The main objectives are to enrich the four existing programs  in GH competencies in an interdisciplinary context to ensure that all health-sciences students develop a level of GH competency adequate for addressing the challenges of practicing in a globalizing world. The logic model framework (LMF) illustrated in The The project consists of developing and implementing GH competency in existing programs. Given its nature, no ethical approval was required for this project.A scoping literature review of GH issues in health and health-sciences education programs over the last ten years was conducted. Broad consultations were also performed to round out our thinking and further develop the characteristics of the educational approach and to ensure broader acceptance. Key practitioners in the field , students interested in GH, leaders of health-professional education programs, and educational specialists were consulted during roundtable discussions. All were asked about students to be targeted; vision of GH education and training to be developed at our school; existing activities and resources; program coverage of issues such as diversity, social determinants of health, and vulnerable and underserved populations; and suggestions on how to integrate GH into programs; etc. Educational and organizational principles were progressively confirmed. Box 1The main focus is on enriching existing learning activities rather than adding to the curriculum, while supporting new initiatives, when needed.GH competencies are closely linked to and complement the exit competencies of each program.The educational interventions are simultaneously and conjointly implemented in the FHMS’s four health-professional programs: medicine, nursing, physiotherapy, and occupational therapy.All students in the targeted programs develop a basic level of GH competencies (mandatory basic profile) through access to core GH training.Advanced training activities are available for interested students to develop competencies at a higher level (advanced profile).GH education must reflect GH’S local and international issues.The exit purposes and competencies are common to all four programs but adapted to each discipline.The methods to ensure implementation are adapted to the specific realities and contexts of each program and are flexible enough to be customized as needed. They include both theoretical and practical activities in large or small groups, service-learning activities, clinical rotations, etc. They occur throughout the four-year programs.Collaboration between disciplines is fostered through interdisciplinary educational activities.Learning activities are of increasing complexity from the first to fourth year (stepladder approach).Coordinating this project covering four (4) programs and more than 1,650 students represents a major organizational challenge, due, in part, to the number of stakeholders involved. coordinating committee, ensuring overall project coordination, has four members (the authors of this paper) with complementary expertise and competencies: a professor with major GH expertise in practice and education, a senior professor with extensive administrative knowledge of the FMHS’s inner political workings, an occupational therapist with clinical and research experience, and a professional project coordinator. This committee meets for a full day on a bimonthly basis with the objectives of ensuring a comprehensive vision of GH training within the FMHS, supporting programs in implementing GH enrichment, advocating for GH education and the enrichment project, obtaining the required resources, and confirming and supporting partnerships. Program directors appointed one faculty member involved in their programs and committed to GH to act as GH theme leaders (TLs) for the program. Together with the coordinating committee, these individuals form the extended committee which also includes a student representative from each program, a medical-education expert, a program-evaluation expert, clinical-rotation coordinators, and the MD-program faculty member responsible for ensuring consideration is taken of Quebec’s First Nations and Inuit peoples. While opinions vary on including Indigenous people in GH, we feel it is important to consult someone knowledgeable about the historical and contextual aspects related to First Nations and not to focus solely on their health problems. This is invaluable in providing an appropriate context for clinical scenarios and avoiding stereotyping.A extended committee meets for three hours four times a year in a context of interdisciplinary collaboration. It acts as an intermediary between the coordinating committee, programs, and students, while providing the coordinating committee with suggestions on enhancing programs.Program directors attend the committee’s meetings for consultation at strategic times or when their engagement as leaders is important in implementing project actions. The The Université de Sherbrooke, the FMSH, and the Office of International Relations provide engagement and support in the form of financial and human resources. A sustainability plan is in place to ensure continuous funding, support from FMHS stakeholders as well as commitment from program directors and education leaders.An internal communication plan targeting FMSH deans, program directors, teachers, and students helps bring all stakeholders on board and get them to buy in. The TLs are highly instrumental in creating crucial bridges with their respective programs. As project ambassadors, they provide influential leadership in adopting the project’s goal and objectives and adapting actions to their specific needs and characteristics. Adaptability and flexibility are proven key success factors.The targeted programs use the GH competency framework—developed and generally accepted at Sherbrooke FMHS and adapted to CanMEDS rolesCollaborative work and consultation with experts resulted in the development, adoption, and uptake of various tools within our faculty. These tools facilitate communication and ensure the consistency of the work with and within each program.Since faculty development is essential, a plan was developed and adapted to teacher needs, which are twofold: increase teacher GH competency (most teachers) and increase teacher capacity to optimally sustain student GH competency development .Educational and program-evaluation specialists assist in developing evaluation and monitoring plans so that project processes and implementation can be monitored on an ongoing basis. Monitoring consists of regular reports, action documentation, and qualitative consultations with TLs, program directors, and students.Box 2An operational definition adapted to our learning environment.A competency framework that describes in detail the key elements and interdisciplinary learning targets (targeted competencies) using commonly agreed-upon terminology. Inspiration for this framework came from CanMEDS roles,A comprehensive vision of the FMHS GH training continuum covering undergraduate medical education and other undergraduate programs, residency programs, graduate programs, continuing education, and faculty development.A dedicated and continually updated collaborative intranet site accessible to the whole FMHS community. It serves as the central depository of all documents and communications regarding project developments and includes a reference library of articles, related sites, and available GH resources.A faculty-development program designed to reach all concerned teachers and build collective GH competency within the FMHS.aA field of study, research, and practice that transcends boundaries aimed at improving health and equity in health care for every individual worldwide. This takes into account the global burden of health problems; social and economic determinants; complementarily of the individual and population approaches; impacts related to the mobility of populations and individuals; problems associated with the health and well-being of travelers  and migrants; vulnerable populations; communities with limited resources; environmental concerns and the impact of climate change on health; concepts of marginality, exclusion, poverty, and vulnerability; and political, economic, social, national, and international issues that affect health.FMHS GH operational definition: bframework for improving patient care by enhancing physician training. Developed by the Royal College in the 1990s, its main purpose is to define the necessary competencies for all areas of medical practice and provide a comprehensive foundation for medical education and practice in Canada.CanMEDS: Through regular project updates, the FMHS dean, academic vice-deans, and program directors support the project and endorse its guiding principles. Participation in meetings and implementation of GH-enriched educational activities demonstrate that teachers are engaged and motivated to modify their teaching and educational activities. Adopting a student-centered approach — getting students involved in the process early on and regularly consulting them — keeps us aware of their needs. Four student members on the extended committee provide learner perspectives.Below is a brief list of the tools developed as a result of the committees’ work.Based on the gap analysis between the actual and targeted coverage of GH aspects (as described in the GH competency framework), programs review their learning activities to close the gap and meet the objectives set. Here are few examples of newly developed or consolidated initiatives:Seizing the opportunity: major curriculum renewal of the MD program. Various ways of incorporating GH concepts into new educational activities are progressively implemented.Société, culture et occupation,”Occupational-therapy program: development and implementation of “Implementation of service-learning activities targeting vulnerable populations in the community; required participation for all first- and second-year medical students. The competency framework is used to develop these activities in order to enhance cultural humility and community engagement.Clinical rotations for occupational-therapy students in daycares and community schools in low-resource settings.Optimization of pre-departure training available to all students going on international rotations to include GH key elements developed through this project. Now offered to students on rotations in GH contexts in local communities.Development of comprehensive revision of all issues  to support students before, during, and after international and local GH rotations, based on Besette 2016 scoping review.21Throughout the years, project leaders have implemented the communication plan by maximizing internal and external national/international dissemination activities. These actions ensure continuous clarification and exchange of ideas with other experts, on-going development of team expertise, partnerships with other medical schools and experts in the field, and scholarship.unexpected results, such as the gradual transformation of health-professional education programs from a silo approach to a culture of collaboration. The work in developing the common competency framework is bringing together the various disciplines to share their professional perspectives. The extended-committee meetings offer unique occasions for program directors and faculty members to work together on a common project and openly share several initiatives in their respective programs.The project has revealed 2016–2018 Strategic Plan, the FMHS commits to enrich its programs so as to model, promote, and seek social accountability and to ensure GH-skill training for all future health-care professionals.The project convinced FMHS leadership to deepen its engagement for GH. In its The pace of enrichment varies according to the program and campus location see . SpecifiA project of this magnitude cannot be implemented without challenges. Efficient governance through constant communication with all stakeholders is necessary to support programs through the implementation process, alleviate the resistance related to curriculum overload, and assist in identifying existing GH activities often not explicitly described in the curriculum.The relationship of trust among stakeholders and the team buying into common goals mitigated some of these challenges by proactively resolving issues. Our organizational structure is based on strong leadership, intertwined responsibilities, connectivity among different levels, and efficient collaboration.22Over the next three years, we intend to continue to support the gradual implementation of key GH elements within programs, clearly establish the optional advanced GH profile and provide means for student recognition, deploy faculty-development activities, and establish the GH connection from undergraduate programs to residency programs, master’s programs, and doctoral programs as well as in continuing-education activities. One of the most important aspects will be studying the project’s impact on student learning and student development of GH competencies.The project of enriching existing health-professional educational programs in GH competencies within an interdisciplinary context is a major undertaking. Nevertheless, the preliminary results are well worth the effort invested.It might have been simpler to target a single program without considering an overall vision or consistency. Targeting the four programs yielded healthy discussions and unexpected benefits. Sharing led to mobilization and eventually to emulation. Involving stakeholders early on in developing the vision has proven effective in bringing people on board. Working closely with various programs is more demanding than simply bringing together GH experts, but it significantly increases buy-in and consequently speeds up implementation.Taking our time, consulting stakeholders, and respecting paces is both wise and advantageous. Developing a common competency framework while allowing room for program readiness leads to its quick adoption. Sharing a common language and working collaboratively has positive impacts.Having a determined, well-supported team convinced of the project’s importance is fundamental because the time and resources required to implement a project of this scale must not be underestimated.So far, this project meets our ambitious original objectives. It establishes a vision and sets a framework that prepares students to become competent health-care professionals equipped to meet the challenges brought about by globalization. A qualitative study is currently being planned to determine the right paradigm to truly evaluate the impact on student learning and GH competencies. The project’s tangible impacts on health-sciences teaching, the GH competencies of graduates, and care delivery are topics of interest for future investigation.


A third of the world rabies burden is in India. The Sikkim Anti-Rabies and Animal Health (SARAH) program is the first state-wide rabies program in India and demonstrates a successful One Health model of dog-mediated rabies elimination. The SARAH program was created in 2006 as a collaboration between the Government of Sikkim and international non-government organizations—Vets Beyond Borders and Fondation Brigitte Bardot. Activities are directed to canine rabies vaccination, humane dog population control, community education, and treatment of sick and injured animals. In 2005, there were 0.74 human rabies deaths per 100,000 (4 deaths) within Sikkim, and from 2006 to 2015, there were no human rabies deaths. In 2016, two human rabies deaths were reported near the West Bengal border region. From 2005 to 2010, the incidence of animal rabies is unknown; from 2010 to 2016, eight cases of animal rabies were reported. Major challenges for the program are continued commitment to rabies control in the face of 0 to low human rabies incidence and the risk of rabies incursions. Effective intersectoral communication between Health, Veterinary, Forestry, and Police officers is essential to enable rapid response to animal bite incidents and possible rabies incursions. An integrated One Health approach needs to be maintained with enhanced active rabies surveillance. Other states must establish similar programs if India is ever to achieve a goal of eliminating dog-mediated human rabies. Globally, the incidence of human rabies deaths transmitted from dogs is estimated at 59,000 people, and a third of the world rabies burden is in India , 2. In IThe SARAH program was created as a collaboration between the Government of Sikkim, Australian non-government organization (NGO)—Vets Beyond Borders (VBB), and French NGO—Fondation Brigitte Bardot (FBB) in response to the public of Sikkim requesting that mass shooting of street dogs cease and a more humane method of controlling the dogs be implemented. In 2005, human rabies incidence in Sikkim was 0.74 deaths per 100,000 persons, totaling 4 human deaths  canine rabies vaccination is needed for control of human rabies, (2) surgical desexing will reduce dog roaming and fighting, and hence the risk of rabies, (3) canine rabies vaccination and sterilization are provided free of charge, (4) sterilization will reduce the number of unwanted puppies, and (5) if your dog is unvaccinated and bites a person, you may be held responsible by the Panchayat  and the affected person for the cost of PEP for the affected person. PEP is available free from public hospitals, but if it is unavailable at the hospital, it must be purchased from a private medical store. In the last 2 years, Panchayats have placed the onus of financial responsibility for PEP on the owners of unvaccinated dogs.The SARAH program has developed over 10 years with capacity building and government commitment from a small NGO-managed program relying substantially on international volunteers to a state-wide government program, providing a One Health model of sustainable dog-mediated rabies elimination.Initially, Program administration, veterinary volunteers, and training were delivered through VBB with a VBB Program manager present in Sikkim and 2–3 international volunteers assisting with the work throughout the year. FBB provided funding on a matching grant arrangement with the Government of Sikkim with the expectation that after 3 years the project would be taken over by the government. Government provided facilities for clinics and public education, accommodation for volunteers, and local staff for the project. A SARAH clinic was established for surgical sterilization, rabies vaccination, and treatment of sick and injured street dogs; mobile units enabled the Program to be extended to rural regions.Initial and subsequent training activities had a strong emphasis on animal welfare and have been critical for community acceptance of the Program and cost control. Extensive training of local veterinarians in veterinary surgery and medicine, and local staff in animal handling and dog catching occurred through the formal VBB VetTrain© program. Volunteers provided mentoring, on-the-job training, and train-the-trainer programs to local staff. Important elements for community support for the Program were the adoption of humane catching methods, which cause minimal distress to animals and demonstrate a recognition of animal sentience and the significance of dogs in the community, good surgical outcomes with a low rate of surgical complications (<0.003%), rapid return of dogs to their home territory , and commitment to treat all sick/injured street dogs.In 2009, the Program became a Division of the Department of Animal Husbandry. VBB volunteers continued to participate, but VBB had a reduced role in Program administration; FBB provided reducing financial support Table .Multisectoral cooperation is essential for sustained rabies elimination , accordiThe second decision was to implement an annual state-wide rabies vaccination campaign each September with World Rabies Day activities incorporated . Critically, the implementation of state-wide rabies vaccination extended the Program to the rural regions of Sikkim. Canine rabies vaccine is provided free of charge; annual rabies vaccination of pet dogs is compulsory under state legislation. House-to-house vaccination was needed initially, but central vaccination posts are now feasible in most villages. A catch-vaccinate-release-resight program is undertaken for street dogs with marking of vaccinated dogs with paint. An annual dog census is correlated with village council knowledge of dog numbers facilitating 70% vaccination coverage to be achieved in East Sikkim –22. VaccA distemper outbreak occurred in 2012 resulting in the death of thousands of dogs and community fear that distemper was caused by rabies vaccine. Extensive community education was undertaken to ensure participation in subsequent rabies vaccination campaigns and encourage owners to vaccinate dogs for distemper.A One Health Intersectoral Rabies Committee was established in 2012 to transcend sectoral boundaries, comprised of Departments of Health, Animal Husbandry, Forestry, Urban Housing & Development, Police, and Army. The tasks of the committee were to prepare a proposal for rabies to be a notifiable disease in Sikkim, formulate procedures for restrictions of cross-border dog movement, formulate procedures for dog registration, work with the National Centre for Disease Control to establish a State Surveillance Laboratory for rabies control, develop a surveillance system for achieving rabies, and improve garbage control. A major achievement was rabies becoming a notifiable disease in Sikkim in 2014 for animals and humans . GarbageBoth human and canine rabies were controlled in Sikkim during 2006–2015. Complacency developed about rabies as the perception of disease risk was low. The Health Department stopped stocking PEP and rabies immunoglobulin (RIG), and the need for rabies surveillance and development of laboratory capacity was given low priority. This occurred in the face of complex ecological interactions including wildlife habitat disruption associated with road construction, socioeconomic change, and a migratory workforce located in Sikkim who bring unvaccinated dogs with them and are on the fringe of Sikkim civil society.In December 2014, two people and a number of dogs were bitten by a jackal in a village close to the West Bengal border. Dog brain samples were sent interstate for testing, but the results were inconclusive. In February 2016, there were reports of a jackal attacking cows near the West Bengal border. Two cows tested positive for rabies Table : inadequRabies vaccination of dogs is the cornerstone of rabies control , 26. TheDog population management is important for the Program goals of improved animal welfare , 29 and Intersectoral coordination and communication, essential for rabies control , 19, is Education on animal welfare and the obligation to care and value dogs has been associated with increased community participation and support for the Program. There is a temptation to assume that the animal welfare emphasis of the Program will only work in Sikkim where animal sentience is accepted and the complex relationship between people and dogs is acknowledged in festivals such as Tihar . It has been suggested that the important role of dogs in Hinduism may be an impediment for successful program adoption , but in Recent suspect rabies cases highlighted the need for formal and regular intersectoral communication at community level, the need for improved epidemiological data, for enhanced active surveillance related to animal bites, training for appropriate medical response to suspect rabies dog bite, the logistical difficulties in getting both human and animal samples from Sikkim to a laboratory for confirmation of rabies, and the ongoing risk of rabies incursion and sylvatic rabies.The seasonal pattern of the recent rabies outbreaks occurring at the border during winter when food sources are scarce suggests rabies incursions into Sikkim, rather than ongoing circulation of rabies within Sikkim. An effective surveillance system with tracing back of suspect animals is needed to confirm this hypothesis , 38. IncThe SARAH program is a State Government supported program and lacks the international resources available to national programs. Effort is being directed at establishing low cost enhanced active rabies surveillance . The RapThe Sikkim Government, together with SARAH partner NGO—VBB and FBB, has made a considerable investment to eliminate dog-mediated rabies. The recent re-emergence of rabies in Sikkim highlights the imperative of an integrated One Health approach to increase the sensitivity of rabies surveillance and to ensure interruption of rabies transmission. The SARAH program is a model of rabies control in a predominantly rural environment with limited resources. It is also an example of the challenges encountered in maintaining rabies control in a landlocked state. Other Indian states must establish similar programs if India is ever to achieve a goal of eliminating dog-mediated human rabies.HB has been involved in the SARAH program since 2006. HB and AB researched, designed, and wrote this paper. TB has been local coordinator for the program since inception and provided expert and local knowledge about the paper subject.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Insight into user adherence to Web-based intervention programs and into its relationship to intervention effect is needed.The objective of this study was to examine use of a Web-based self-help intervention program, the Chinese version of My Trauma Recovery (CMTR), among Chinese traumatized individuals, and to investigate the relationship between program use and user characteristics before the intervention and change in outcomes after the intervention and at 3-months’ follow-up.The sample consisted of 56 urban survivors of different trauma types and 90 rural survivors of the 2008 Sichuan earthquake, who used the CMTR in 1 month on their own or guided by volunteers in a counseling center. Predictors were demographics , health problems , psychological factors (coping self-efficacy), and social factors . Program use was assessed by general program usage  and program adherence . Outcome measures were the Posttraumatic Diagnostic Scale (PDS), Symptom Checklist 90-Depression (SCL-D), Trauma Coping Self-Efficacy scale (CSE), Crisis Support Scale (CSS), and Social Functioning Impairment questionnaire (SFI) adopted from the CMTR.1,144=40.50, P<.001) and visited more program modules in 1 month  than urban participants. (2) Predictors and program use: total number of visiting days was correlated with CSS at pretest , and total number of completed webpages was associated with SFI at pretest . Number of webpages completed in modules was correlated with all demographic, disease severity, psychological, and social factors at pretest. (3) Program use and outcomes change: in general, use of the triggers and self-talk modules showed a consistent positive association with improvement in PDS, SCL-D, SFI, and CSE. The relaxation module was associated with positive change in PDS, but with negative change in CSS and SFI. The professional help module was associated with positive change in SCL-D, but its use on the first day was associated with negative change in CSS and CSE. The unhelpful coping module was associated with negative change in SFI. The mastery tools module showed a consistent association with negative change in PDS and SCL-D.(1) Program use: rural participants had a larger total number of visiting days  and social factors  should be considered when delivering Web-based interventions, particularly in collectivist cultures. Specific program adherence indicators , rather than general program usage indicators , should be developed to examine the effectiveness of various program modules or elements.Australian New Zealand Clinical Trials Registry: ACTRN12611000951954; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=343399 (Archived by WebCite at http://www.webcitation.org/6G7WyNODk) In recent years, the Internet has been adopted as a valuable tool to deliver physical and mental health services to large populations . ResearcThe relationship between user exposure to intervention programs and the effect of Web-based interventions can be complicated  and may To improve Web-based interventions for target groups with various physical and mental health problems, previous studies have investigated potential predictors of program use, with mixed findings. One group of predictors is user characteristics, including (1) demographic variables, such as age, sex, education, marital status, and socioeconomic status ,11, (2) Based on these findings, this study investigated the role of demographics, health problems, and psychological and social factors in Chinese traumatized persons’ use of a Web-based self-guided intervention program, the Chinese version of My Trauma Recovery (CMTR). The program showed preliminary short-term treatment effects on PTSD and depressive symptoms in a randomized controlled trial in 2 Chinese populations . The triNote that, although it has been argued that Web-based interventions are potentially beneficial for rural residents to receive mental health help, because they have little access to face-to-face mental health resources , few empIn sum, this study aimed to investigate (1) how urban and rural participants used the CMTR program, including general program usage and program adherence, (2) how program use was related to demographics , health problems , psychological factors , and social factors  before the intervention, and (3) how program use was associated with change in outcomes after the treatment and at 3-months’ follow-up.The CMTR program was translated, with minimal cultural adaptation of pictures, audio and video segments, and professional hotlines, from the English My Trauma Recovery program (previously referred to as Journey to Trauma Recovery), which aims to improve trauma recovery by increasing individual coping self-efficacy and coping skills . CMTR coF1,88=4.23, P=.04), but no significant differences in the Posttraumatic Diagnostic Scale (PDS), Symptom Checklist 90-Depression (SCL-D), Social Functioning Impairment questionnaire (SFI), or Trauma Coping Self-Efficacy scale (CSE)  at pretest.We used a sample of 56 urban and 90 rural participants, which was part of the sample  reported earlier . SpecifiUrban and rural participants used the program in some different way. The urban participants had experienced a variety of traumatic events , reported at least two PTSD symptoms in a trauma screening questionnaire, and had sufficient Internet access time (≥360 minutes in 4 weeks). They had Internet access at home or work and thus decided themselves when, where, and how often to visit the program during the 1-month treatment period. Research assistants did not contact them or give reminders until posttest. The rural participants were survivors of the 2008 earthquake in Beichuan county in Sichuan province, and reported at least two PTSD symptoms in the trauma screening questionnaire. Due to lack of personal Internet access, they used the program 5 times (at least 30 minutes per time) in a counseling center’s computer room. Some participants used the program more than 5 times because they broke off one or more intervention sessions for personal reasons and then made them up later. Note that research assistants provided support for all urban and rural participants only for technical problems with CMTR. When participants asked for support with their distress or the program content, research assistants first evaluated the participants’ needs and, if these were not acute, sent the participants a brief reply that CMTR was a self-help program and they would get further support, if needed, after the follow-up test. Otherwise, the research assistants would interrupt the session for other treatment, which did not happen in this study.This scale includes 17 PTSD symptom items assessing the frequency of trauma-related symptoms in the past month on a 4-point scale  . The intWe used the 13-item depression subscale of the Symptom Checklist-90  to measuWe adopted 4 questions from the My Trauma Recovery program to examine individual functional impairment after trauma experiences. An example question is “To what extent have your reactions to what has happened reduced your ability to complete your normal responsibilities ?” Participants answered the questions on a 5-point scale . The internal consistency of the questionnaire in this study was alpha=.88.This 7-item scale measures received practical support, received sympathy, being able to find someone to talk to about the traumatic experience, and overall satisfaction with received social support after trauma . ExampleThis 10-item scale is a short version of the Coping Self-Efficacy Scale for Trauma . It measAfter the first log-in, most participants left CMTR without logging out and then visited the program without logging in next time. It was thus difficult to calculate the number of log-ins or the amount of time spent on CMTR. Thus, we counted as 1 day when a participant visited the program within one 24-hour day. The maximum could be 30 days during the 1-month treatment period.We tracked how many CMTR webpages participants completed during the 1-month treatment period. Because participants were encouraged to use the program as many times as they wanted, webpages were counted repeatedly when repeated use occurred. Thus, the total number of webpages completed could be larger than the number of webpages contained in CMTR.The maximum could be 7 modules in this study; that is, 6 recovery modules and the mastery tools module. Note that participants could have visited 1 module but not have completed all the webpages in the module.We calculated the proportion of each module completed during the treatment period. The number of webpages completed could be larger than the actual total number of webpages in each module due to repeated use.We tracked how many modules participants visited on different days through the treatment course. The maximum could be 7 modules.We tracked the proportion of each module that was completed on the first day. The number of webpages completed in each module could be larger than the actual total number of webpages due to repeated use.We analyzed the data using IBM SPSS version 22 (IBM Corporation). Chi-square analysis tested urban and rural subsample differences in demographic characteristics. We used 1-way ANOVA to test subsample differences in the pretest scores on PDS, SCL-D, SFI, CSS, and CSE, and in program use indicators. We conducted 1-way ANOVA and correlation analyses to explore the relationship between program use and demographics, health problems, psychological factors, and social factors at pretest. Finally, we conducted linear regression analysis for PDS, SCL-D, SFI, CSS, and CSE posttreatment incremental difference scores . In the linear regression analysis, we entered trauma duration and 6 dummy variables as independent variables in the first block  and the indicators of program use in the second block (enter method). Similarly, we conducted linear regression analysis for PDS, SCL-D, SFI, CSS, and CSE 3-month follow-up incremental difference scores .F1,144=40.50, P<.001). Urban and rural participants did not differ in the total number of CMTR webpages completed .On average, the total number of days visiting CMTR was 3.50  among urban participants, of whom 80% (45/56) visited the modules for ≤4 days. The total number of days was 5.51  among rural participants, of whom 87% (78/90) used the modules for 5 or 6 days. The subsample difference reached significance .On average, the number of modules visited was 4.63 (SD 2.17) for urban participants and 5.48 (SD 0.66) for rural participants see . Chi-squAs P>.12). As for the number of completed webpages in each module, the urban participants aged 26–40 years completed significantly more webpages in the mastery tools module than those aged 16–25 years . Among rural participants, female participants visited more webpages in the professional help module than did male participants , and married participants visited more webpages in the relaxation module . In addition, correlation analysis showed no significant relationship between trauma duration and the 3 program use indicators in each subsample.A 1-way ANOVA among urban and rural participants revealed no significant sex, age, education, marital status, and family income differences in the total number of visiting days or the total number of CMTR webpages completed , professional help , and self-talk  modules was associated with score reductions in the PDS and SCL-D. However, use of the mastery tools module in 1 month was unexpectedly associated with score increases in PDS and SCL-D.In addition, use of the triggers (in 1 month) and self-talk (on the first day) modules was associated with score increases in CSE, but use of the professional help module on the first day was associated with a score reduction in CSE.As for social variables, use of the triggers (on the first day) and self-talk  modules was associated with score reductions in SFI. However, use of the relaxation (in 1 month) and unhelpful coping  modules was associated with score increases in SFI. Also, use of the relaxation  and professional help (on the first day) modules was associated with score reductions in CSS.The urban and rural participants used the CMTR program for 1 month in different ways and showed different patterns of program use. In general, the rural participants used the program for more days, visited more modules, and completed more webpages in most modules than the urban participants in 1 month. However, the rural participants may actually have been passive users compared with the urban participants. First, they completed a much smaller proportion of the mastery tools module, which contains all of the tools and skills exercises. Second, while the urban participants quickly decreased the number of modules they visited from the second day, which is consistent with previous findings , the rurIt is important to note that the relatively passive program use among rural participants might have been due to their lack of Internet use experience  rather than lack of motivation. The data revealed that the rural participants completed a larger proportion of the professional help module on the first day, as well as during the treatment period, which may indicate a motivation to receive interventions. If this is the case, future studies could effectively increase the program use in rural populations by improving their Internet use skills before applying interventions.The total number of visiting days and completed webpages showed a positive association only with social factors. That is, users with higher social support and social functioning impairment tended to use the program more. As for the number of webpages completed in the modules, demographic, disease severity, and psychological and social factors all showed some significant correlations. Consistent with previous findings , the urbPTSD symptoms and depression before treatment were positively related to module use, particularly to that on the first day. This suggests that disease severity has a motivational role in program use, which is consistent with previous findings . MoreoveWhile social functioning impairment was positively related to module use, similar to disease severity variables, our findings on the other social factor  were more complex. Social support at pretest was positively associated with the total number of days visiting CMTR, but negatively related to the use of most modules, except for the professional help module, which introduces what happens in face-to-face professional counseling. These findings indicated that, on the one hand, individuals with less social support might be less interested in seeking face-to-face professional help, and be motivated to use Web-based intervention programs. On the other hand, more social support might provide resources for individuals to insist on using a self-help intervention program.The motivational role and resource role of social support were also reported in previous studies . For exaFinally, participants’ coping self-efficacy was negatively related to the use of the self-talk module on the first day, but positively related to use of the mastery tools module in 1 month. Thus, coping self-efficacy might also play a motivational role in pushing individuals to use the program content, and resources could be offered for individuals particularly to complete interactive tasks , providing further support for the role of self-efficacy in improving Web-based intervention program use ,13.Among the 7 modules that we examined in this study, the self-talk and triggers modules showed a consistent association with improvement in 4 outcomes . The relaxation module was associated with positive change in PTSD symptoms, but with negative change in 2 social variables . The professional help module was associated with a positive change in depression, but its use on the first day was related to a negative change in coping self-efficacy and social support. The unhelpful coping module showed an association with negative change in social functioning impairment. The mastery tools module use in 1 month showed a consistent association with a negative change in disease severity variables .These findings provide a better understanding of how the CMTR program worked to help the participants in dealing with their PTSD symptoms and depression after trauma . They alMoreover, it is surprising that the CMTR modules seem to have had much less of an effect in improving users’ social support and social functioning impairment. Given that individuals turn to the Internet for social support, as well as for health information, the perceived low effectiveness in social support improvement may also cause user dropout and low adherence to Web-based intervention programs . It is tFirst, this study had limitation in sampling. Due to the small size and self-selected sample, our findings cannot be generalized to populations from hospitals or outpatient clinics. Future studies need to examine CMTR program use in a larger representative sample. In particular, attention should be paid to the difference in Web-based intervention program use between urban and rural users. As a potential target group of Web-based interventions, rural residents may benefit from  guided self-help interventions, although lack of Internet use experience could hinder their full use of these interventions. Future research should investigate more directly the impact of this group’s other characteristics  on their program use and explore effective methods to improve their program use in a practical way, such as offering short-term computer training before interventions.A second limitation was a lack of control over the impact of program factors  on module use. Such an impact might be complex. For example, the self-talk, social support, and unhelpful coping modules all contain a relatively large number of webpages , but the (urban) participants used them in very different ways. Thus, more specific indicators should be adopted to assess the active use of these program elements rather than passive exposure to the general program.Finally, the findings on first-day and 1-month program use have implications for further research. Finding out user and program characteristics that promote initial program use and continuous program use will be helpful. Understanding the quicker and slower effectiveness of various program elements would also be helpful.


The Tier 1 Program of the Project P.A.T.H.S.  is a curricular-based program that attempts to promote positive youth development in Hong Kong. In the second year of the Full Implementation Phase, 20 experimental schools  and 23 control schools  participated in a randomized group trial. Analyses based on linear mixed models via SPSS showed that participants in the experimental schools displayed better positive youth development than did participants in the control schools based on different indicators derived from the Chinese Positive Youth Development Scale. Differences between experimental and control participants were also found when students who joined the Tier 1 Program and perceived the program to be beneficial were employed as participants of the experimental schools.