Home visiting programs focused on improving early childhood environments are commonplace in North America. A goal of many of these programs is to improve the overall health of children, including promotion of age appropriate vaccination. In this study, population-based data are used to examine the effect of a home visiting program on vaccination rates in children.Home visiting program data from Manitoba, Canada were linked to several databases, including a provincial vaccination registry to examine vaccination rates in a cohort of children born between 2003 and 2009. Propensity score weights were used to balance potential confounders between a group of children enrolled in the program  and those who were eligible but not enrolled . Complete and partial vaccination rates for one and two year old children were compared between groups, including stratification into area-level income quintiles.Complete vaccination rates from birth to age 1 and 2 were higher for those enrolled in the Families First program [Average Treatment Effect Risk Ratio (ATE RR) 1.06 (95 % CI 1.03–1.08) and 1.10 (95 % CI 1.05–1.15) respectively]. No significant differences were found between groups having at least one vaccination at age 1 or 2 [ATE RR 1.01 (95 % CI 1.00–1.02) and 1.00 (95 % CI 1.00–1.01) respectively). The interaction between program and income quintiles was not statistically significant suggesting that the program effect did not differ by income quintile.Home visiting programs have the potential to increase vaccination rates for children enrolled, despite limited program content directed towards this end. Evidence-based program enhancements have the potential to increase these rates further, however more research is needed to inform policy makers of optimal approaches in this regard, especially with respect to cost-effectiveness. Vaccinations are one of the greatest public health achievements of the 20th century . HoweverMuch more common in North America are home visiting programs focused on improving outcomes related to cognition, socio-emotional development and maltreatment in children. Evidence for these programs has been well documented on a range of health outcomes –11. TypiThe literature examining this area is mixed. Kendrick et al. conducted a systematic review and meta-analysis of home visiting programs and their effect on vaccination rates and concluded that such programs were not effective at improving vaccination rates  . This stTo address the uncertainty in the literature, we conducted a population-based cohort study to examine the effect of a home visiting program on pediatric vaccination rates and assessed if this relationship differed by socio-economic status. The Families First home visiting program examined in this study provides home visits with the intent of supporting healthy child development, improving parent–child relationships, connecting families with their communities and decreasing child maltreatment . In addiThis study aims to fill a gap in the literature by analyzing a large and representative sample of at-risk children . It also aims to comprehensively address potential confounders by linking multiple databases with Families First home visiting data, thereby providing a large number of covariates to use in the statistical analysis. Programs aimed at improving uptake of interventions can result in overall improvements but also increase inequities ; therefoThe Families First home program was initiated in Manitoba, Canada, in 1999. It was modeled on Hawaii’s Healthy Start program and uses the Growing Great Kids Inc. curriculum , 18. AppThis study was undertaken in Manitoba, a province of approximately 1.2 million people geographically located near the centre of Canada. Residents of Manitoba receive health care services under a universal program of insurance coverage funded by the provincial government, including a program of publicly funded vaccinations for all Manitobans. Data for this study were derived from the PATHS  Data Resource, a unique database developed for the PATHS program of research containing anonymized individual-level data from the Population Health Research Data Repository, which is housed at the Manitoba Centre for Health Policy (MCHP) . The PATThe Manitoba Immunization Monitoring System (MIMS), which is an electronic vaccination registry that captures pediatric and adult vaccinations through a physician billing system for publicly funded vaccinations, as well as vaccinations entered into the system by other health care providers;The Manitoba Health Insurance Registry, which includes demographic information on all residents registered for health care;Employment and Income assistance data;Families First Screen (including the newborn screen and home visiting data);Small Area-level Census data (dissemination area) on employment, education, income and lone-parent status combined in an index of socio-economic status , and useThe PATHS Data Resource comprises population-based individual-level data on the health and social services use for over 99 % of all Manitoba children. The validity of the data included in the PATHS resource has been well documented –23. IndiThis study included children born between January 1, 2003 and December 31, 2009 who had at least three risk factors on the newborn screen, program data, and an actual or imputed parent survey score ≥ 25. Families First program data were collected by public health nurses and the Healthy Child Manitoba Office and included the newborn screen, parent survey, and program implementation data.Figure The outcomes studied were complete vaccinations and at least one vaccination for one- and two-year-old children. The criteria for complete vaccination from birth to age 1 and 2 years can be found in Table Table A considerable amount of the Families First program data were missing (38.8 %) due to parents declining to provide certain information, staff not able to obtain information, coding error and lost records. We used multiple imputation to account for missing data to ensure our cohort was representative of at-risk children in the population.Multiple imputation can provide a valid statistical technique for handling missing data, which accounts for the inherent uncertainty caused by missing values , 26. MulEstimating each child’s propensity score for being enrolled in the Families First Program;Testing the program’s impact on (a) complete vaccination at one year and two years of age and (b) at least one vaccination at one year and two years of age, after adjusting for confounding through application of propensity scores;Stratifying results by income quintiles and testing for effectiveness by income quintile by adding an interaction term to the models; andCalculating Gamma values to estimate findings’ sensitivity to hidden confounding .There were 4 steps to the analyses.Logistic regression was used to estimate propensity scores for all children eligible for the program . The propensity score is the child’s predicted probability of receiving the Families First program given his/her observed characteristics.Three treatment effects were of interest: the average treatment effect (ATE), the average treatment effect on the treated (ATT), and the average treatment effect on the untreated (ATU). The ATE is the effect of the Families First program on vaccination among the entire eligible population. The ATT is the average effect of the program on vaccination among those who actually received the Families First intervention. The ATU is the anticipated effect of the program on vaccination if the comparison group had instead received the Families First program. These concepts are explained in significant detail, elsewhere , 29.The propensity scores were used to create three sets of inverse-probability-of-treatment weights (IPTWs), each set corresponding to the three treatment effects of interest as described above. IPTWs were applied to the models to balance differences between the intervention and comparison groups’ potential confounders; this is one method for adjusting for measured confounding .Standardized differences were calculated prior to and after the weighting procedure for both the Families First group and those who were eligible but not enrolled in the Families First program to assess the effect of the weighting procedure between groups. Standardized differences measure effect sizes between two groups and are independent of the sample size, which makes them valuable in comparing baseline covariates for studies that use propensity scoring . A standGeneralized linear modeling was used to estimate the predicted probability for each vaccination outcome of interest, by exposure-status. Separate models were estimated for each outcome and were used to estimate risk ratios and risk differences. Multiplicative models were used to estimate risk ratios and additive models were used to estimate risk differences . MeasureFinally, we determined whether the effectiveness of the program differed by income quintile by introducing an interaction term (urban income quintile x Families First program) to the models. We examined the interaction term using income quintile as a continuous variable and only considered families living in urban areas for this analysis. The urban income quintile variable was made up of five values, 1 for the lowest income quintile and 5 for the highest. Rural areas were not included because they tend to have more mixing of income groups compared to urban groups, which have more homogenous income groups within a given geographical boundary .With propensity score methods, it is assumed that estimates are not sensitive to unmeasured confounding. We conducted a sensitivity analysis to test this assumption. A gamma value was generated, indicating the strength of unmeasured confounding required to invalidate statistically significant results. In other words, Gamma is the hidden confounding which would make the relationship between Families First and vaccination appear significant when, in fact, it is not significant , 28. A gTable Vaccination outcomes from birth to age one and two can be seen in Table Those who were enrolled in the Families First program were significantly more likely to have complete vaccinations than the comparison group at the age of two . There were no significant differences between the groups for having at least one vaccination from birth to age two .When an interaction term (program x income quintiles) was added to the model for both rural and urban areas, it was not statistically significant. There was no evidence that the program effect differed by income quintile for any of the vaccination outcomes tested.Gamma sensitivity analyses suggested that our results – (a) one year complete vaccination, (b) one year partial vaccination results, (c) two year complete vaccination, and (d) two year partial vaccination – were each likely robust to unmeasured confounding. For each set of results, there would need to be an unmeasured confounder that both (a) perfectly predicted exposure to the Families First program and (b) accounted for over 50 % of the association between the program and these four sets of results, which is very unlikely.Overall, this study found an increase in complete vaccination rates at ages 1 and 2 for those enrolled in the Families First program compared to a similar group who were not enrolled. This difference was not observed for the outcome of having at least one vaccination of each immunogen. A comparison of rates by income quintile did not reveal any significant differences.Several mechanisms can be theorized as to how the Families First program increased vaccination rates, directly and indirectly. The vaccination information contained in the program may have influenced parental behavior directly by increasing the likelihood that they would actively seek out vaccination or well-child care from care providers. Public health nurses eligible to give vaccinations are more easily accessed through the home visitor. In addition, there may have also been an indirect effect through the improvement of the social environment in which families exist, including financial or social resources, which removed barriers to vaccination such as a lack of transportation and childcare, thereby facilitating access to preventive health care. Evidence for home visiting programs improving maternal and child social environments has been assessed by the work of Olds and others with findings of positive effects on a range of social outcomes, such as welfare and food stamp use by mothers –11.The magnitude of the improvement in complete vaccination rates for those enrolled in the Families First program (a range of 6–11 %) is consistent with, albeit slightly lower than, other studies examining vaccination rates for home visiting programs . The modContextual factors may also explain the magnitude of increase in vaccination rates. The provision of a publicly funded schedule of vaccinations for all Manitobans may reduce the effect of any one intervention at increasing vaccination rates and could potentially have ‘evened’ the playing field between those enrolled in the program and those not in the program. Most families had some exposure to vaccination as evidenced by the relatively high predicted probabilities for both program and non-program groups for having at least one vaccination. This finding also suggests that families in both groups were not philosophically opposed to vaccination, but rather, faced barriers in achieving a complete record of vaccination.The effect of the Families First program on complete vaccination rates is positive, but may be enhanced with other measures. As discussed previously, home vaccination or home visits promoting vaccination with direct referral to vaccine services could fit well within the scope of current home visiting programs that focus more on cognitive, socio-emotional or child maltreatment outcomes. The large cohort of at-risk families who are directly linked to ongoing public health programming via enrollment in programs such as Families First provides opportunities for incorporating program elements which assess the vaccine status of families and enhance access to vaccination, either during already scheduled home visits or by facilitating referral to specialized vaccination services. This approach may also address cost concerns that have been raised with the high start-up costs of home visiting programs that solely focus on the provision of vaccination. Research is needed to inform policy makers on the best way to integrate these interventions and to further quantify cost-effectiveness in order to successfully improve vaccination coverage rates for children experiencing poverty.Potential limitations of this study exist. Estimating the true effect of the Families First program on vaccination rates rests on having no residual confounding, which can be difficult to address in observational studies. We have taken this into account in our analysis through the use of propensity scoring; however there is a chance that important variables were omitted. Missing values are another limitation of this study, and while imputing these missing values provided a means of addressing this issue, it is no doubt inferior to having real values. This may have resulted in exposure misclassification. Vaccination outcome misclassification was possible through incomplete or inaccurate documentation in the MIMS database by providers.Approximately 20 % of births each year in Manitoba did not receive a screen for risk factors. Many of these children were likely from First Nations communities under federal jurisdiction, somewhat limiting the representativeness of the sample. A provincial rather than a federal organization administers the Families First program.Finally, the effect of the program by income quintile was assessed in the model by using an interaction term, which may not be the optimal approach to assessing this effect. Assessing gaps in program effect for different income quintiles is an area that deserves further research inquiry.Despite these limitations, there are several strengths of the study. A relatively large and representative sample of at-risk children was analyzed compared to previous studies in this field. Another strength was the ability to link several databases, resulting in a large number of variables that could be used in modeling, thereby reducing the probability of confounding. This was further addressed by the use of propensity scoring. Furthermore, the possibility of omitted variable bias was addressed by employing a Gamma sensitivity analysis. Assessing outcomes for both one and two year olds contributed to the assessment of program effects over time.This study reports a moderate increase in complete vaccination rates for one- and two-year old children who were enrolled in the Families First program. The positive effects of the program on complete vaccination rates were seen despite limited program content targeted toward addressing the need for vaccinations. These results suggest a valid method of improving vaccination rates for children experiencing poverty. Program enhancements, such as the addition of home vaccination to program elements, have the potential to increase vaccination rates even further for children enrolled. More research is required to inform policy makers of optimal approaches to improve vaccination rates for children enrolled in home visiting programs.


Mentorship has been noted as critical to medical students adapting to clinical training in the medical workplace. A lack of infrastructure in a mentoring program might deter relationship building between mentors and mentees. This study assessed the effect of a redesigned clinical mentoring program from the perspective of clerks. The objective was to assess the benefits of the redesigned program and identify potential improvements.A redesigned clinical mentoring program was launched in a medical center according to previous theoretical and practical studies on clinical training workplaces, including the elements of mentor qualifications, positive and active enhancers for mentor–mentee relationship building, the timing of mentoring performance evaluation, and financial and professional incentives. A four-wave web survey was conducted, comprising one evaluation of the former mentoring program and three evaluations of the redesigned clinical mentoring program. Sixty-four fifth-year medical students in clerkships who responded to the first wave and to at least two of the three following waves were included in the study. A structured and validated questionnaire encompassing 15 items on mentor performance and the personal characteristics of the clerks was used. Mixed linear models were developed for repeated measurements and to adjust for personal characteristics.The results revealed that the redesigned mentoring program improved the mentors’ performance over time for most evaluated items regarding professional development and personal support provided to the mentees.Our findings serve as an improved framework for the role of the institution and demonstrate how institutional policies, programs, and structures can shape a clinical mentoring program. We recommend the adoption of mentorship schemes for other cohorts of medical students and for different learning and training stages involved in becoming a physician. The history of mentoring programs for medical students and doctors can be traced to at least the 1990s  is a proThe clerkship is a formal learning stage at a workplace in which students learn a broad range of theoretical knowledge and clinical skills in combination with other competencies. Because clerkships can entail extreme stress –12, ChinThe former clinical mentoring program had certain limitations – for example, no regular meeting arrangements existed, mentees hesitated to contact their mentors, mentors were unable to trace their mentees’ performance or provide timely feedback, and insufficient funds were available to mentors for meetings and lunch fees. Moreover, vague mentor role definitions deterred the development of mentoring relationships and contributed to a culture in which the mentoring program was assumed to benefit only the mentees.Some studies have endeavored to identify potential barriers to improving mentoring program design. For example, studies have revealed barriers involving personal factors, such as insufficient confidence or training to be a mentor; relational difficulties, such as juniors not wishing to appear to require help; and structural and institutional barriers, such as insufficient time allocated for mentoring because of competing personal, administrative, and clinical demands , 13–17. In the studied setting, we believe that nearly all mentors had an awareness of their roles; however, we lacked a suitable infrastructure by which a mentor could serve as a ‘functional mentor’ from a medical-education or healthcare organizational perspective. In other words, once the mentor–mentee relationship was established, few answers existed regarding what institutional strategies could be followed to minimize the operational barriers to successful mentorships. Therefore, the medical education authority at the CMUH decided to redesign the clinical mentoring program, particularly to assist clerks formally beginning their clinical experiences.This study assessed the effect of the redesigned clinical mentoring program on mentor performance, from the perspective of the clerks. The objective was to assess the benefits of the redesigned program and identify potential improvements.Healy and Welchert  defined In the former clinical mentoring program, the mentors were senior physicians nominated by the chairs of the clinical departments. The mentor was an additional person assigned to the mentees; each mentor was assigned one to three mentees. The mentors met monthly with their mentees and documented their interactions. Expenses incurred by the mentors for the meetings were reimbursed to a maximum of the equivalent of US$70 per month. The mentors were required to submit reports to the CMUH Department of Education to request further assistance for mentees who experienced difficulties in their clinical duties. The mentors were assigned these obligations without receiving any additional compensation.Some elements of the former clinical mentoring program deserve mention as potential shortfalls. Although the mentors were nominated by their department chair, this did not mean that they were necessarily proficient in mentoring skills; the reasons for nomination could as well have been availability, seniority, or ease of recruitment. Many factors might detract from the benefits of mentoring effectiveness. In addition, because the ratio of mentors to mentees was as low as 1:3, CMUH had to recruit many physicians as mentors, including those with insufficient mentoring skills. Moreover, the limited number of mentees per mentor (three persons) might have reduced peer learning and group sharing. In addition to the mentors having to schedule free time to meet with mentees, the upper-limit reimbursement for mentor–mentee meeting fees (for lunch) might have also implicitly discouraged the mentors and mentees from meeting. Moreover, the absence of compensation for the mentors might have implied that the organization did not recognize their efforts.On the basis of the literature for effective mentoring program design, and to address the shortfalls in the former clinical mentoring program, mentoring structures were prioritized in the redesigned clinical mentoring program. In addition to the aforementioned mentoring functions, the redesigned clinical mentoring program included considerations regarding mentor qualifications (recruiting criteria) , positivCMUH is a general hospital with 2,047 beds and 3,722 staff (including 374 visiting physicians and 285 residents). CMUH, an affiliated hospital of China Medical University (CMU), provides various primary, secondary, and tertiary care services in Taiwan. Over the past 5 years, the average monthly volume of outpatients and inpatients was 138,498 and 5,554, respectively. All CMU medical students must complete their clerkship at the CMUH in the fifth year of their 7-year medical degree program. A quantitative survey, including one pre-evaluation and three post-evaluations of the redesigned clinical mentoring program, was conducted among all CMU fifth-year medical students in clerkships from September 2013 to May 2014.One hundred and eighteen medical students were enrolled in the study and provided informed consent. Each clerk was assigned to a mentor at the beginning of his or her clerkship in September 2013, at which time the former mentoring program was still in effect. The first wave of the survey was conducted in early November (T1) to obtain the clerks’ perceptions of the mentoring program without informing them of the upcoming redesigned program. After T1, in mid-November 2013, the redesigned clinical mentoring program was launched. The subsequent three waves of the survey were conducted to evaluate the redesigned mentoring program in December 2013 , February 2014 , and May 2014 . Clerks who responded to the first wave and to at least two of the three following waves were included in the study. In total, the sample comprised 64 clerks and 229 responses. The participants did not differ significantly in age or sex from the clerks not included in the study. Ethical approval was granted by the CMU and CMUH Ethics Committees. All data were collected and analyzed after the cohort was established.α value of 0.97, and from 0.81 to 0.85 for personal support with a Cronbach's α value of 0.85. In addition, the personal characteristics of the clerks, including sex and age were measured. The same items were included in each of the four waves of surveys.This study assessed the effect of the redesigned clinical mentoring program from the perspective of the clerks. The objective was to assess the benefits of the redesigned program and identify potential improvements. The respondents were led by an adjunct section to constrain their opinion of their clinical mentor in the clerkship, who was different from the mentor that they had in school. The 15-item mentorship scale of Scandura and Ragins, which encompasses mentoring functions such as psychosocial support, career development, and role modeling  was adapDescriptive analyses were used to establish the baseline characteristics of the participants. Because the pre- and post-evaluations of the former and redesigned mentoring programs of each participant as cohorts were not independent , did not exhibit unequal variance, and involved an unequal number of repetitions, a linear, mixed-effects model was used , 27. WitIn total 64 clerks, 37 men (58%) and 27 women (42%) with an average age of 23.63 years, completed one evaluation of the former mentoring program (T1) and at least two evaluations of the redesigned clinical mentoring program (T2–T4) during the study period. The T1, T2, T3, and T4 evaluations were completed by 64, 53, 56, and 56 participants, respectively.p<0.05) (p<0.05). The evaluation items regarding the mentors’ special, on-the-job coaching (Item 3), the mentors’ ability to motivate others (Item 7), the mentors’ devotion of additional time and consideration of the mentees’ careers (Item 12), the mentees’ confidence in their mentors (Item 8), and the mentees’ respect of their mentors’ knowledge of the accounting profession (Item 9) did not increase initially after the redesigned clinical mentoring program , but did 6 months after the program was implemented . The mentees’ modeling of their behavior after the mentors (Item 6) and viewing their mentors as friends (Item 10) did not receive progressively improved evaluations over time (p>0.05); however, they were finally rated the highest 6 months after the redesigned program was implemented .In general, from the T1 baseline, evaluations of 13 out of the 15 items improved progressively from T2 to T4, particularly at the final evaluation (T4) (p<0.05) . Regardip<0.05). In addition, the mentees reported socializing more with their mentors (Item 14) 6 months after the program was implemented (T4) (p<0.05).Regarding personal support (Items 13–15), the mentees rated sharing personal problems (Item 13) and dining after work (Item 15) progressively higher over time (p>0.05). In addition, we observed no statistically significant differences in sex or age regarding the mentees’ evaluation of their mentors’ performance (p>0.05).After the implementation of the redesigned program, two items with no improvement were observed. One involved the mentees’ evaluation of how the mentors placed them on critical assignments (Item 2) and the other involved the mentors’ ability to teach others (Item 11); these two items exhibited no statistically significant differences over time . It is questionable whether there would have been an improvement over time regardless of the new program. Although only one wave of evaluation for the former program was conducted, some shortfalls had already been identified by previous mentors and mentees, which was why the medical education authority of CMUH decided to redesign the mentoring program. The clinical mentoring program that we redesigned was based on previous studies that included the elements of mentor qualifications, positive and active enhancers for mentor–mentee relationship building, the timing of mentoring performance evaluation, and financial and professional incentives, which had assumed benefits according to theoretical perspectives in organizational behavior.We determined that, overall, the redesigned program improved mentor performance over time for most of the evaluated items, as rated by the mentees. Although the personal support scores increased significantly (Items 13–15, Some limitations deserve mention. We did not make any direct one-cause-to-one-effect evaluations; rather, we assessed the entire package of redesigned elements as a whole. In addition, the survey instrument used in this study was focused on mentor performance. Future empirical studies can explore other objectives of the clinical mentoring program such as the mentor–mentee relationship in the short and long terms; this relationship might influence clerks’ careers. This study also did not weigh the individual effects of different factors in the redesigned mentoring program, such as whether financial or professional incentives were the key factors behind improved mentor performance. The implications of financial incentives in mentoring programs should be addressed in future studies. Some role models who meet clerks in other settings, such as in extracurricular activities or medical events outside of the workplace, might be viewed as informal mentors and these influences should also be explored. We will promote and publicize this redesigned clinical mentoring model for other stages of medical student training, such as internships and postgraduate physician residencies. Future studies can examine mentor perceptions of the redesigned clinical mentoring program to improve its effectiveness from mentor and job design perspectives.


Purpose: Performance assessments of earthquake medical rapid response teams (EMRRTs), particularly the first responders deployed to the hardest hit areas following major earthquakes, should consider efficient and effective use of resources. This study assesses the daily technical efficiency of EMRRTs in the emergency period immediately following the 2010 Yushu earthquake in China. Methods: Data on EMRRTs were obtained from official daily reports of the general headquarters for Yushu earthquake relief, the emergency office of the National Ministry of Health, and the Health Department of Qinghai Province, for a sample of data on 15 EMRRTs over 62 days. Data envelopment analysis was used to examine the technical efficiency in a constant returns to scale model, a variable returns to scale model, and the scale efficiency of EMRRTs. Tobit regression was applied to analyze the effects of corresponding influencing factors. Results: The average technical efficiency scores under constant returns to scale, variable returns to scale, and the scale efficiency scores of the 62 units of analysis were 77.95%, 89.00%, and 87.47%, respectively. The staff-to-bed ratio was significantly related to global technical efficiency. The date of rescue was significantly related to pure technical efficiency. The type of institution to which an EMRRT belonged and the staff-to-bed ratio were significantly related to scale efficiency. Conclusions: This study provides evidence that supports improvements to EMRRT efficiency and serves as a reference for earthquake emergency medical rapid assistance leaders and teams. China is one of the most earthquake-prone countries in the world and the scale and response speed of China’s medical rescue teams for earthquake relief operations have attracted worldwide attention ,2. On 12Some studies that have assessed the effectiveness of these efforts have found that wasted resources and inefficiency in the process of disaster relief should be issues of concern ,5,6, butData envelopment analysis (DEA) is a linear regression tool used to evaluate the relative effectiveness of types of organizational performance. DEA is particularly appropriate for evaluating the efficiency of health services’ delivery, which typically is a complex and multidimensional process, and it has proven to be an effective and versatile tool for healthcare efficiency measurement. DEA has been effectively employed to evaluate the technical efficiency and productivity of public hospitals , the supThis study used the DEA method to examine the technical efficiency of EMRRTs after the 2010 Yushu earthquake. In addition, Tobit regression analysis was used to analyze the effects of relevant influencing factors. The study’s central goal was to obtain evidence to support improvements to EMRRT efficiency and a reference for emergency medical assistance professionals in earthquake relief.The data were obtained from official daily reports of the general headquarters for Yushu earthquake relief, the emergency office of the National Ministry of Health, and the Health Department of Qinghai Province. During the first two weeks after the Yushu earthquake, the general headquarters of Yushu earthquake relief was the repository for all first-hand institutional rescue data from the hardest hit areas. These data included information on the rescue institutions’ allocations, human resources, workload, and the other information that was recorded in the official daily reports. Supported by the Emergency Response Office at the National Ministry of Health, the emergency medical rescue system of Yushu earthquake relief data were summarized and assessed from October of 2010 through October of 2011. Additional data were collected in a survey of closed-ended questions disseminated by e-mail, post, and in face-to-face interviews.n = 15) during the initial emergency period after the Yushu earthquake. A medical institution is considered technically efficient when it produces the maximum output from a given amount of input or, alternatively, produces a given output with minimum inputs. Thus, when a medical institution is technically efficient, it operates on its production frontier [First, DEA methods were used to assess the daily technical efficiency of each EMRRT  the effects of relevant variables on EMRRT efficiency. This approach was preferred to linear regression (OLS) because DEA efficiency scores are continuous from zero to one where the value of one is positive probability and the probability of obtaining the limiting value of zero is zero.The urgency that characterizes emergency medical rescue during earthquake relief influences the quality of the data recorded in the field by the medical rescue team members, and it often has missing or inconsistent entries. Field data differ from the data collected by health service institutions under normal conditions in that these data problems are intrinsic to the emergency, crisis context of the first days after a disaster.For EMRRTs to be eligible for the study, they had to meet the following criteria. First, they were first responder teams performing triage, first aid, resuscitation, emergency care, and preparations for evacuation during the first five days following the earthquake; Second, they were deployed to the hardest hit areas; Third, they were proximate to other teams. Last, they provided data on all of the variables analyzed in the study. In this study, one day was defined as the unit of analysis. For example, Team X was involved in the rescue task for five days, which provided five days of data from X. Fifteen EMRRTs were deployed to the hardest hit areas and were proximate to each other, and rescue data on 62 of the 75 theoretical days were analyzed.Primary hospitals have 100 or fewer beds, directly provide the local communities with medical care, preventive care, and other integrated services, and are the primary health care institutions.Secondary hospitals have between 101 and 500 beds and are regional hospitals that provide comprehensive healthcare services to multiple communities.Tertiary hospitals have more than 500 beds; provide hospital and other health services at the municipal, regional, provincial, and national levels; and are medical prevention and technology centers with the ability to conduct comprehensive healthcare, teaching, and research activities.Technical efficiency measures the ability of a decision-making unit (DMU) to produce the maximum number of program outputs from a given number of inputs or a minimum input level set at a given number of outputs. In emergency medical rescue efforts in earthquake relief, which are based on a humanitarian spirit and the principle of saving lives, EMRRTs’ primary goal is to speedily rescue as many sick and injured people as possible. Therefore, this study chose the output-oriented mode. In this study, there were 62 DMUs, representing the 62 days of coverage by the 15 EMRRTs in the first five days after the earthquake.Charnes  proposedTherefore, technical efficiency can be decomposed into pure technical efficiency (PTE) and scale efficiency (SE) by modeling both on the same data. If the results were to find the VRS and CRS have different technical efficiency (TE) scores on a given EMRRT, that EMRRT has demonstrated scale inefficiency, which can be calculated by taking the difference between the VRS TE score and the CRS TE score. CRS technical efficiency (CRSTE) is global TE, indicated by the TE scores under the CRS model. The VRS technical efficiency (VRSTE) is PTE, indicated by the TE scores under VRS model. Computing the ratio of CRSTE to VRSTE derives the SE. Scale inefficiency, present when SE < 100%, occurs when the facility (EMRRT) is not operating at its most productive  level . In thisp < 0.05 was the cut-off level of statistical significance.Data Envelopment Analysis Program (DEAP) 2.1 was used to assess the efficiencies of 62 days of data of 15 EMRRTs (62 DMUs). Tobit regression was employed to examine the effects of control variables expected to be associated with the DEA scores using Stata Version 12.0. A value of SD = 5.22), 4.77 (SD = 3.97), and 6.00 (SD = 4.81), respectively. The staff-to-bed ratio and the doctor-to-nurse ratio ranged from 1.38:1 to 3.5:1 and from 0.75:1 to 6.0:1, respectively. The average numbers of injured people that were treated and the average numbers of people treated for non-earthquake medical problems were 41.52 (SD = 36.59) and 21.71 (SD = 18.71), respectively.SD = 0.18), 89.00% (SD = 0.14), and 87.47% (SD = 0.15), respectively. The CRSTE scores of 12 units (19.35%) reached 100%, the VRSTE scores of 24 units (38.71%) reached 100%, and the SE of 21 units (33.87%) reached 100%.p = 0.011) was the only variable that was significantly associated with the CRSTE scores. Regarding VRSTE (PTE), the date (p = 0.012) was significantly associated with correspondent DEA scores. There were two other statistically significant relationships to the SE scores: the type of institution to which an EMRRT belonged (p = 0.007) and the staff-to-bed ratio (p = 0.043).The results of the Tobit analysis found several statistically significant predictors of TE, PTE, and SE scores . The staExtant studies on aspects of medical rescue activities for earthquake relief have yet to assess the efficiency of medical rescue efforts after an earthquake. Moreover, there is a lack of consensus on the definition of efficiency of rescue teams and on how to conduct an objective evaluation. This study is the first to use EMRRTs as DMUs and evaluate the technical efficiency of EMRRTs using the DEA method from the micro perspective. Based on EMRRTs’ primary rescue mission mandate and the input and output variables used in the DEA model of health services in non-emergencies, three inputs and two outputs were identified. The results of the analysis found that 38.71% of the units’ PTE reached 1.0 and the average CRSTE, VRSTE, and SE scores were 77.95%, 89.00%, and 87.47%, respectively. These results are generally consistent with those of previous studies, which found that rescue was swift and effective ,19.Many previous studies have analyzed the changes to total factor productivity over time using the Malmquist productivity index (MPI). MPI measures output changes resulting from the levels of inputs between two points in time. The values indicate the shifts in productivity of each production unit relative to the observed frontier ,20. HoweThe results of the Tobit regression analysis found that an earlier rescue date was associated with higher PTE. In other words, the daily PTE after the earthquake gradually declined over time. Apparently, the so-called golden period for treating sick and injured people corresponds to a so-called golden period of EMRRTs’ PTE. The decline in PTE may be related to increased rescue workload over time and/or increased worker fatigue. The results further suggest that the sooner rescue efforts reach disaster areas, the better is the rescue efficiency, which points to the need to strengthen the rapid response capacities and mobility of EMRRTs ,22.Another important factor to TE was staff-to-bed ratio. In previous studies on health services, staff-to-bed ratio has been a common indicator of a doctor’s workload . This stet al. proposed that small forward teams should be deployed in the early phase of a health disaster response [The Chinese government’s approach to Yushu earthquake relief was to evacuate all of the critically injured people outside the disaster area for treatment ,19,24. Aresponse . One of response ,26.The EMRRTs in the emergency medical rescue efforts after the Yushu earthquake included: (1) 42 medical teams from outside Qinghai Province, mainly from Sichuan, Shaanxi, Gansu, and other neighboring provinces and cities; (2) 27 medical teams from Qinghai Province; and (3) 502 local (Yushu) healthcare personnel who participated in medical rescue efforts. In the present study, no difference was found in EMRRT efficiency among these three types of rescuers. This result is consistent with the response efforts to the Wenchuan earthquake , where s, although primary EMRRTs had higher SE. This result is consistent with the results of previous studies that suggested medical teams should be divided into small groups for rescue work during the emergency rescue period [Among the emergency rescue teams that responded to the Yushu disaster, some were from comprehensive tertiary hospitals that had strong technological advantages and some were from primary hospitals, such as county health centers. In this study, the type of institution to which an EMRRT belonged had no significant effect on the TE or PTE of the EMRRT. However, the type of institution was significantly related to the SE. The results of the telephone interview survey found that, during the emergency rescue period, the primary task of all on-site medical teams was to carry out on-site first-aid treatment and to speedily evacuate the victims after the badly injured people were stabilized. Three days after the earthquake, the number of injured people had been reduced and many patients, with respiratory diseases, digestive diseases, and skin diseases who would be treated at local medical institutions under ordinary circumstances, were being admitted to EMRRTs because the local healthcare centers had been destroyed by the earthquake. Therefore, EMRRTs from tertiary hospitals did not demonstrate significant technological advantages over those from primary hospitals simply because technology was not a factor relevant to treatment. On the other hand, the EMRRTs from primary hospitals (with an average staff of 10.25 workers) had a significantly smaller volume than EMRRTs from tertiary hospitals (with an average staff of 16.93 workers)e period .Last, the results found that the doctor-to-nurse ratio was not significantly related to the TE of EMRRTs. The staff structure of Disaster Medical Assistance Teams in the US is relatively equal across staff positions at 35 doctors, nurses, physician assistants, nurse practitioners, pharmacists, paramedics, and logistics and communications staff ,32. In 2The current study has limitations that are worth noting. In our investigation, most medical rescue records of EMRRTs did not include all of the data on the relevant variables due to the chaotic disaster conditions, resulting in the problem of missing data. As a result, although we investigated many EMRRTs, only 15 of them had complete records and were, therefore, included in the study. The problems related to chaos that yield incomplete or inaccurate reporting need to be addressed, and ways to manage the available data to allow for optimal use without degrading the quality, particularly regarding information about the rescue processes for patients wounded in earthquakes, should be solved in the near future.In conclusion, this study assessed the effectiveness of first responder medical response to the 2010 Yushu, China, earthquake in the first five days after the disaster. It aimed to statistically understand the biggest problems, low rescue efficiency and inefficient resource management, in disaster emergency rescue. The study also addressed the possible influences on effectiveness of other variables , which provides evidence that supports improvements to EMRRT efficiency and a reference for emergency first medical assistance in earthquake relief.


Previous research shows that adolescents with autism spectrum disorder (ASD) run several risks in their psychosexual development and that these adolescents can have limited access to reliable information on puberty and sexuality, emphasizing the need for specific guidance of adolescents with ASD in their psychosexual development. Few studies have investigated the effects of psychosexual training programs for adolescents with ASD and to date no randomized controlled trials are available to study the effects of psychosexual interventions for this target group.The randomized controlled trial (RCT) described in this study protocol aims to investigate the effects of the Tackling Teenage Training (TTT) program on the psychosexual development of adolescents with ASD. This parallel clinical trial, conducted in the South-West of the Netherlands, has a simple equal randomization design with an intervention and a waiting-list control condition. Two hundred adolescents and their parents participate in this study. We assess the participants in both conditions using self-report as well as parent-report questionnaires at three time points during 1 year: at baseline (T1), post-treatment (T2), and for follow-up (T3).To our knowledge, the current study is the first that uses a randomized controlled design to study the effects of a psychosexual training program for adolescents with ASD. It has a number of methodological strengths, namely a large sample size, a wide range of functionally relevant outcome measures, the use of multiple informants, and a standardized research and intervention protocol. Also some limitations of the described study are identified, for instance not making a comparison between two treatment conditions, and no use of blinded observational measures to investigate the ecological validity of the research results.NTR2860. Registered on 20 April 2011.Dutch Trial Register  Adolescence is a transition phase in life with physical, emotional as well as social changes that offers several challenges for adolescents with autism spectrum disorder (ASD). People with ASD have impairments in social interaction and communication, and show limited, repetitive and stereotyped patterns of behavior, interests and activities . ASD is The physical changes in adolescence, such as the growth of secondary sex characteristics, can cause insecurity and require the learning of new routines . In Changes in social relations ask for new socio-communicative skills; adolescents become more independent from their parents and intimate friendships are formed . These iGiven the possible risks that adolescents with ASD encounter and their problems with access to reliable information resources, several studies on puberty and sexuality in adolescents with ASD emphasize the need for guidance of these adolescents in their psychosexual development , 14. IntIn the current study we investigate the effects of the TTT program on the psychosexual development of adolescents with ASD. The aims of the study were as follows: to investigate whether the TTT program (1) increases psychosexual knowledge; (2) increases skills needed for friendships and intimate relations (3) increases insight in acceptable and inappropriate sexual behaviors; (4) reduces inappropriate sexual behavior and vulnerability; (5) increases self-esteem, and (6) reduces current concerns and concerns about the future of adolescents with ASD and their parents. We hypothesized that the TTT program is not only able to reduce the difficulties of adolescents with ASD in their psychosexual development, but also to promote a positive and normative psychosexual development in adolescents with ASD.This paper describes the study design, the participants, the content and protocol of the TTT program and the research procedures.n = 100), a large expert mental health care institution in the South-West of The Netherlands that provides specialized care to children and adults with complex psychiatric problems.Participants are recruited among patients of Yulius (n = 50). A large number of adolescents in these settings have a diagnosis of ASD.Participants are recruited among students in schools with segregated settings for special education, in which students with a variety of complex psychiatric problems are educated (n = 50).Adolescents and their parents can apply for the study through open application. Research flyers are distributed through several mental health care centers in the region among adolescents with ASD and their parents and a study website was launched (Participants are 200 adolescents in the age range of 12 to 18 years with a DSM-IV diagnosis of ASD. Recruitment for the study is performed in three ways within a population of adolescents with ASD.Eligibility criteria for participation are 1) a total score of 51 or above on the Social Responsiveness Scale (SRS) , 26, andWritten informed consent is obtained from all adolescents and their parents. This study is approved and guided by the medical ethical commission of the Erasmus Medical Center, Rotterdam (MEC-2013-040).α = 0.05; two-sided) [Sample size for this study was determined in advance by power calculations based on the previous pilot study results (Effect size = 0.70) . In ordeo-sided) , 64 adolThe Tackling Teenage Training (TTT) program is an individual intervention with 18 sessions that cover the following topics: discussing puberty , appearances, first impressions, physical and emotional developments in adolescence, how to become and maintain friends, falling in love and dating, sexuality and sex , pregnancy, setting and respecting boundaries and safe internet use , 24, 28.The training starts and ends with an appointment with the adolescent and the parents, who are weekly informed by mail on the progress of the training by the trainer, via structured contact reports. The contact reports consist of information on the topic of the session  and the take-home assignment of the child, in order to inform parents, but also to stimulate rehearsal of the skills that were taught in the session within the home environment. In addition, particularities  are communicated with parents. The contact reports allow parents to be prepared for any questions or remarks of the adolescent in between sessions and foster an environment in which the adolescent can discuss or practice topics of the TTT program within the home environment and/or broader social environment with guidance of parents to enhance generalization to other contexts outside the setting of the training.All trainers that provide the TTT program in the study have a Bachelor or Master in psychology or social services and experience in working with people with ASD. They have taken the 2 day train-the-trainer course, in which they received information on the psychosexual development in general, possible difficulties in the psychosexual development for adolescents with ASD and they were taught how to provide the training program in a standardized way, with particular suggestions on how it can be customized to the individual needs of the adolescent if necessary. In addition, all trainers participate in interdisciplinary meetings every 3 months, in which questions and case reports can be discussed with other trainers and the developers of the training program. The protocolized manual of the TTT program  is avail, information about the motivation, resistance and openness of the adolescent, and the difficulty of the material for the adolescent, according to the trainer, is registered by the trainer. Motivation of the adolescent is scored by the trainer on a scale from 0 to 10 . The trainer rates how much resistance the adolescent shows and how much information the adolescent shares during the sessions, again on a scale from 0 to 10 . Last, the trainer rates how difficult that particular session is for the adolescent on a scale from 0 to 10 . All session scores are subsequently summed and then averaged to compute an index of overall motivation, resistance, difficulty and openness. During the training, neither the parents nor the adolescent are informed about these scores.For each training sessionFurthermore, after each session the trainer reports to what extend the TTT protocol was followed through standardized short evaluation forms, in order to register adjustments that are made to the TTT protocol. Examples of adjustments are: changing the order of the sessions, spending more time to discuss a theme, or leaving out  texts and questions. In this way, the adherence to the TTT protocol by the trainers can be monitored for each participant and each session.After ending the training, the parents and adolescent fill out an evaluation form with 16 questions, for a more subjective evaluation of the topics the adolescent learned about in the TTT program and how parents and adolescents rate and appreciate the training  on a scale from 0 to 10.Figure Total IQ, verbal IQ (VIQ) and performance IQ (PIQ) are taken from the medical file of the adolescent and are used if the assessment is not older than two years old and if a valid and reliable instrument was used . In cases where no or no recent IQ measurement is available, IQ is assessed using the Wechsler Abbreviated Scale of Intelligence (WASI) . The WASIn the current study we use multi informant questionnaires, both parent-report and self-report. The use of self-report in research with people with ASD is sometimes debated, because of their problems with identifying and describing feelings and emotions of others and themselves . Still, All participating adolescents and their parents fill out questionnaires at three time points during 1 year: at baseline (T1), after inclusion criteria are confirmed; post-treatment (T2), directly after the TTT program (for adolescents in the intervention condition), or after 6 months on the waiting-list (for adolescents in the control condition), and for follow-up (T3), 6 months after the TTT program (for adolescents in the intervention condition), or after 12 months on the waiting-list (for adolescents in the control condition). The adolescents fill out the questionnaires in the company of a research assistant (who is available for questions of the adolescent). The research assistants are blind to the condition of the adolescents. Parents fill out the questionnaires via the internet.n = 100) or the control condition (n = 100). A computerized allocation scheme is used, authorized by an investigator with no involvement in the current research. Adolescents in the intervention condition start the TTT program shortly after the randomization. The adolescents in the control condition are placed on a waiting-list. During the study, adolescents in both conditions can continue other interventions and medications.Simple equal randomization (1:1) takes place at an individual level, after the baseline measurement (T1). Adolescents are randomly assigned to the intervention condition  . Table To investigate whether the TTT program improves knowledge regarding psychosexual themes, a psychosexual knowledge test for adolescents  is adminParents are questioned about the knowledge of their children in the ‘Sexual knowledge of the child according to the parent’ scale of the TTI .The ‘Friendship skills’ scale (self-report and parent-report version) of the TTI is used to measure the ability of the adolescents to make and maintain friendships. The ‘Romantic ability’ scale (self-report version) of the TTI is used to measure the self-perceived romantic relational skills of the adolescents .The Social Responsiveness Scale (SRS)  is used To investigate whether the TTT program increases insight in different sexual behaviors, the ‘Adequate boundaries’ scale (parent-report version)  is used. In addition to this, the flag system (Dutch: het Vlaggensysteem) , is admin = 8 and parent-report version n = 12)  are used. Example items from the parent-report TTI are: “My child touches others where they do not like to be touched”, “My child is able to set his/her boundaries regarding intimate contact”, “Does your child ever masturbate at inappropriate times, in inappropriate ways or places?”. Some example items from the self-report TTI are: “I keep contacting someone, even though that person has indicated he/she does not want any contact with me”, “I touch others in places where they do not want to be touched”, and “In general I am good at letting people know what I am comfortable with and what I am not comfortable with”.To investigate whether the TTT program reduces inappropriate sexual behavior and vulnerability, several separate items of the TTI  , 41 at TTo investigate whether the TTT program increases the adolescents’ self-esteem the Self-esteem scale of the Dutch Personality Questionnaire (NPV-2) , 45 is aIn addition, the TTI scales ‘Perceived social competence’ (self-report version) and ‘Self-esteem’ (self-report version) are used to measure changes in the self-esteem of the adolescents .n = 8; self-report version n = 7) about current and future concerns, for instance: “I worry about the vulnerability of my child regarding social relationships in general”, “I worry about my child on the internet”, “I worry if my child will live with a partner” and “I believe it is possible that I will have social relationships in the future” .To investigate whether the TTT program can reduce current concerns and concerns about the future for adolescents with ASD and their parents, we use several questions in the TTI  ASD severity, (2) emotional and behavioral problems, and (3) child and family characteristics on the effectiveness of the Tackling Teenage Training program.The Autism Diagnostic Observation Schedule-2 (ADOS-2) , 47 is aWe expect that emotional and behavioral problems of the adolescents might influence the effects of the Tackling Teenage Training program. Therefore, we use the Child Behavior Checklist (CBCL) , 41 at TDemographic characteristics, such as age, gender, family situation are administered in the baseline measurement (T1).Furthermore, socio-economic status (SES) is determined by income level, educational level of both the mother and the father (or other caregivers), and occupational level of each primary caregiver, using the International Standard Classification for Occupations .Ethnicity is determined by the birth country of both parents. If both parents are born in The Netherlands, the adolescent is categorized as ethnicity ‘Dutch’. If one or both parents are born in another country than the Netherlands, the adolescent is categorized as ethnicity ‘non-Dutch’.In order to determine previous sexual education of the adolescent, the adolescents are asked if they previously received education or training on the subject of friendship, intimacy or sexuality, and if yes, from who they received this education or training . Parents are also asked if their child previously received education or training on the subject of friendship, intimacy or sexuality and if yes, from whom their child received this education or training.Family values and attitudes regarding sexuality are determined with the TTI, with the ‘Openness about intimacy’ scale. Example items in this scale are: “Within our family we discuss sexuality”, “My child takes the initiative to talk about sexuality with me/us” and “I discuss my feelings and/or questions about intimacy/sexuality with my parents” (self-report and parent version) .Differences in baseline characteristics  are examined with independent samples t-tests or chi-square tests. Baseline descriptors that differ significantly are taken into account in following analyses.α = 0.05.To investigate the effectiveness of the TTT program, we explore both within-subject effects (changes within adolescents in both conditions) and between-subject effects (changes between adolescents in the control condition versus the intervention condition). ‘Time’ is the within-subject variable, with three levels: T1 (baseline), T2 (effect), and T3 (follow-up). ‘Condition’ is the between-subject variable, with two levels: intervention condition and control condition. We use several continuous outcome measures: psychosexual knowledge, the scales of the Teen Transition Inventory (TTI), insight in acceptable and inappropriate sexual behaviors, self-esteem, and concerns about the future. And we use several dichotomous outcome measures, such as the separate items of the TTI measuring inappropriate sexual behavior. We correct for multiple testing using Bonferroni correction. Statistical analyses are performed using SPSS 19.0 statistical software (SPSS)  and are In addition to this, we investigate if potential predictors of treatment outcome  influence the effects of the TTT program.For participants in both conditions (the intervention condition and the control condition), we examine the differences between the drop outs and the full participating individuals concerning several descriptors  to investigate whether drop-out is selective or random.The study described in this study protocol is the first randomized controlled trial (RCT) to investigate the effects of a psychosexual training program, the Tackling Teenage Training (TTT) program, for adolescents with autism spectrum disorder (ASD). The current RCT has a number of methodological strengths: The conduction of a first systematic evaluation of the outcome of the TTT program on psychosexual knowledge  in the yIn conclusion, the results of the study described in this study protocol will be a valuable contribution to the growing knowledge of the psychosexual development of people with ASD, and aims to ultimately improve the support adolescents with ASD receive during the challenging life phase of adolescence.Patient recruitment for this study lasted from January 2012 to April 2014 and 210 adolescents and their parents gave permission to participate and were assessed for eligibility. From these, 188 adolescents met the inclusion criteria, completed the baseline measurement (T1), and were randomized. The effect measurement (T2) was completed in November 2014 with data from 168 adolescents and the follow-up measurement (T3) was completed in June 2015 with data from 160 adolescents. All data is currently analyzed.


Members of racial and ethnic minority groups are most likely to experience limited access and poor engagement in addiction treatment. Research has been limited on the role of program capacity and delivery of comprehensive care in improving access and retention among minorities with drug abuse issues. The goal of this study was to examine the extent to which access and retention are enhanced when racial and ethnic minorities receive care from high-capacity addiction health services (AHS) programs and via coordination with mental health and receipt of HIV testing services.This multilevel cross-sectional analysis involved data from 108 programs merged with client data from 2011 for 13,478 adults entering AHS. Multilevel negative binomial regression models were used to test interactions and indirect relationships between program capacity and days to enter treatment (wait time) and days in treatment (retention).Compared to low-capacity programs and non-Latino and non-African American clients, Latinos and African Americans served in high-capacity programs reported shorter wait times to admission, as hypothesized. African Americans also had longer treatment retention in high-capacity programs. Receipt of HIV testing and program coordination of mental health services played an indirect role in the relationship between program capacity and wait time.Program capacity and coordinated services in AHS may reduce disparities in access to care. Implications for supporting low-capacity programs to eliminate the disparity gap in access to care are discussed. Addiction health services (AHS) programs face significant challenges to develop capacity to expand service delivery and enhance engagement of clients in treatment . The AffAmong individuals seeking help for substance abuse issues, waiting to enter treatment is the most commonly cited barrier –9, and tLeadership is essential to fostering change, developing resources, and improving performance , particuRacial and ethnic minorities such as African Americans and Latinos often fare worse than their White counterparts in terms of wait time and retention , 21. EmeCoordination of care can help reduce disparities and improve treatment outcomes . AHS cooThis study used a fully concatenated program and client dataset collected in 2010 and 2011. The sampling procedures for these data have been described in detail elsewhere . All stuDependent variables were wait time and retention. Wait time was measured as the number of days each client reported spending on a waiting list prior to starting treatment. Retention was measured as the number of days between admission and discharge dates as reported by program staff members in the Los Angeles County Participant Reporting System. These measures are widely used in addiction services research and have been previously demonstrated to be predictive of positive treatment outcomes , 11, 27.strongly disagree to 5 = strongly agree), and scores were totaled as recommended. We used the Organizational Readiness for Change Scale to measure program readiness to implement new practices. ORC was measured with 67 items divided into four domains with 18 subscales: motivational readiness ; resources ; staff attributes ; and organizational climate  [strongly disagree to 5 = strongly agree). Items from subscales were added and averaged to create scores for each of the four domains, which in turn were averaged and multiplied by 10 to develop the ORC total mean score; higher scores indicated greater readiness. Item examples and alpha levels are provided for all subscales in Table Our independent variables were program capacity and coordination of services. Measure development is described in detail elsewhere . Program change) , 28. IteTo develop the latent class variable, we relied on latent profile analysis to identify levels of program capacity. Latent profile analysis can incorporate continuous, ordinal, and categorical indicators, in contrast to latent class analysis, which can only accommodate categorical indicators. We determined latent classes that represented different levels of program capacity by considering different solutions for multiple latent profiles . The full procedure is described in a previous study . The funi and j (i ≠ j) are index-specific variables and k designates a specific latent class, such that i in group j, k is the total number of latent classes, and In Equation 1, roviders . To creanever to 5 = always). This measure resulted in bimodal distributions in the never, almost never, and always categories; thus, we transformed it to a dichotomous measure representing high coordination with mental health providers. To measure receipt of HIV testing services during treatment, clients reported at discharge whether they received HIV testing on- or off-site while in treatment.To assess coordination with mental health providers, supervisors rated how frequently their program collaborated with mental health and psychiatric providers to coordinate care for clients with dual disorders  and public funding (8.56 %). We handled missing data using multiple imputation, in which each missing value was replaced with 20 plausible values using the Markov Chain Monte Carlo method . We impup-value specification [We used multilevel negative binomial regression with robust standard errors in Stata for our analyses, using MI ESTIMATE: NBREG with a log link function . The negfication .Descriptive statistics for all variables are shown Table p < .001) and African American  clients entering high-capacity programs had significantly shorter wait times compared to Whites.We found support for Hypothesis 1a, which posited that the relationship between high-capacity AHS programs and client wait time would be moderated by client minority status. Latino  had significantly greater retention in treatment than White clients. However, Latino clients were not associated with greater retention in treatment at a statistically significant level (p > .05).We found partial support for Hypothesis 1b, which stated that the relationship between high-capacity programs and client retention in treatment would be moderated by client minority status. African American clients  and receipt of HIV testing services . We did not find support for Hypothesis 2b regarding the relationship among coordination of care, receipt of HIV testing services, and client retention.We found support for Hypothesis 2a, which posited that program capacity would be indirectly associated with client wait time through coordination of care. Program capacity was indirectly associated with client wait time through both coordination with mental health services . Receipt of HIV testing services was positively associated with wait time . Among control variables, public funding , methadone , and community referrals  were negatively associated with wait time, whereas drug court referral , Medi-Cal eligibility , and homelessness  were positively associated with retention.Two components of program capacity  were negatively associated with wait time, whereas only ORC was associated with higher retention . Race and ethnicity and coordinated mental health and receipt of HIV testing services played an important role in reducing wait time. Path analysis showed that high-capacity programs are associated with lower wait time for all clients through coordination with mental health providers and receipt of HIV testing services. Albeit conjectural, it may be that high-capacity programs situated in communities with large percentages of racial and ethnic minority groups are better able to address specific barriers to treatment and provide more rapid treatment entry by connecting with mental health and HIV testing providers. Programs that understand their community’s service needs may become more responsive to clients’ treatment access needs.Findings also showed that when African American clients entered high-capacity programs, they experienced longer treatment retention than Whites and clients entering low-capacity programs. These results suggest that high-capacity programs are better able to engage African Americans, potentially providing care that aligns better with their needs. Engaging clients in treatment is certainly a complex issue. Although we accounted for client and program factors that play a role in retention, other factors were not included in this study, such as a client’s psychological readiness to engage in treatment and receipt of needed services .However, our latent concept of program capacity allowed us to test a conceptual framework of capacity and follow an efficient methodological approach to compare programs using a multilevel path analysis with complex outcomes (number of days to enter and stay in treatment). This approach is needed to compare programs in a large system of care, such as the AHS system in Los Angeles County, with the purpose of informing system-level interventions. However, understanding the role of different components of program capacity  in wait time and retention is also critical, particularly to inform program-level interventions. Results provided in Table Another important contribution of this paper is its preliminary evidence suggesting that coordination with mental health providers and receipt of HIV testing services enable high-capacity programs to reduce client wait times. High-capacity programs seem to have more resources in terms of infrastructure, workforce training, leadership, and funding. Through their network connections with other providers offering needed services, these high-capacity programs may be able to get clients into treatment faster. However, coordination of specific services, such as mental health treatment or HIV testing, did not play a role in the relationship between program capacity and retention. To address the possibility that our measure of retention did not accurately reflect successful engagement, we conducted post hoc analyses with completion of the treatment episode as the outcome. These results also showed a statistically nonsignificant path through coordination of services in the relationship between program capacity and treatment completion. One explanation for these findings may be that our measurements of mental health coordination at the program level did not allow us to assess whether clients most in need of mental health services actually received these services, thus supporting successful completion of their treatment episode. Ensuring receipt of needed services seems critical in engagement; previous research has demonstrated improved retention based on matching services with client needs . In addiLimitations associated with study data must be considered when interpreting findings. First, although our analysis examined direct and indirect relationships, we did not extend our results to causal or temporal relationships given that our data were cross-sectional. Our path analysis approach was informed by our conceptual framework described in the introduction. Second, program measures were provided by one manager per program and may have been influenced by social desirability bias. We attempted to reduce this bias by completing validity checks with 91 % of the sample during site visits. This procedure is described elsewhere . NonetheResults highlight the importance of measuring program capacity in the rapidly changing service delivery environment in the current health care reform context. Findings may inform system and program interventions. Programs can be distinguished based on their capacity—for example, low-capacity programs can be quickly targeted with system interventions to improve client outcomes throughout the county. As a program-level intervention, it is critical to invest in leadership training, staff readiness for change, and Medi-Cal payment acceptance and reporting capacity to improve the quality of care provided to underserved clients. Although current federal programs sponsored by the Substance Abuse and Mental Health Services Administration on leadership development , evidencThis study was reviewed and approved by the Institutional Review Board of the University of Southern California. The principal investigator, also the corresponding author, has obtained consent to publish from the participants in this study (treatment clients and program staff members).


To assess the prevalence and factors associated with the use of the expanded Brazilian People’s Pharmacy Program among older adults and the reasons for not using it. In this population-based cross-sectional study conducted in the urban area of Pelotas, RS, Southern Brazil, we evaluated 1,305 older adults (aged 60 years or over) who had used medication in the last 15 days. Independent variables were socioeconomic factors, economic status, household income in minimum wages, educational attainment in years of schooling and occupational status. Demographic variables were sex, age, marital status, and self-reported skin color/race. Poisson regression was employed to analyze the factors associated with the use of the program. The prevalence of use was 57.0% whilst the prevalence of knowledge of the program was 87.0%. In individuals aged 80 years or over, use of the program was 41.0%. As to the origin of the prescriptions used by older adults, 46.0% were from the Brazilian Unified Health System. The main reasons for not using the program were: difficulty in getting prescriptions, medication shortage, and ignorance about the medications offered and about the program. Higher age, lower income, presence of chronic diseases, and use of four or more medications were associated with use of the program. It is necessary to expand the knowledge and use of the Brazilian People’s Pharmacy Program, especially among older adults, and to improve the dissemination of its list of medications to users and physicians. Thus it will be possible to reduce spending on long-term medications, which are especially important for this population. People’s Pharmacies, in operation since 2004, dispense 112 medications at cost value, representing a reduction of up to 90.0% of the market value. The PFPB-E, considered an expansion of the PFPB in partnership with private pharmacies and drugstores, was created with the goal of broadening the coverage of pharmaceutical assistance, promoting the integrality of health careSaúde Não Tem Preço  program, the two axes of action began dispensing free medication for asthma, diabetes and hypertensionThe PFPB develops two axes of action: its own network of people’s pharmacies and the ,,Although the program is directed to all age groups, it is especially important for older adults, who tend to have bigger health needs, resulting in increased use of health services and medications,,,As the PFPB is relatively new, studies about it are scarce and give greater emphasis to its own network, which was consolidated first. They are restricted to describing the program in terms of medication availability compared with the public and private sectors and the profile of the population that uses the programConsidering the importance of the universalization of access to medications for population health and the role of the PFPB to expand access, we aimed to assess the prevalence and factors associated with the use of the PFPB-E among older adults and the reasons for not using it.This population-based cross-sectional study was performed with older adults (aged 60 years or over) in the urban area of Pelotas, RS, Southern Brazil. There are approximately 46,099 older adults in the urban area of this city The sample size estimation to study the prevalence of the use of the PFPB-E considered the following parameters: 95% confidence level, 60.0% estimated prevalence, tolerable error of four percentage points, and an increase of 10.0% for losses and refusals. To assess the factors associated with the outcome, the parameters used were: 95% confidence level, 80.0% minimum statistical power, 1:5 ratio between unexposed and exposed, 48.0% estimated prevalence for the unexposed, 1.3 prevalence ratio, an increase of 15.0% for confounding factors, and 1.5 design effect, totaling an estimated sample size of 1,246 older adults.Sample selection was performed in two stages. In the first, the 488 census districts of Pelotas were listed and sorted according to average income, with a random sampling of 133 districts. This strategy ensured the inclusion of several neighborhoods of different economic status. In the second stage, occupied households in the selected districts were counted, estimating about one older adult for every three households. We drew 31 households by district, with the aim of reducing design effects, and sampled approximately 10 households in each selected district, totaling 4,123 households. All people aged 60 years or over in each household were invited to participate in the study. We excluded those living in nursing homes, unable to answer the questionnaire for mental or physical issues, and who lacked a companion or caregiver.The outcome “use of the PFPB” was defined as obtaining at least one medication from the PFPB among older adults who had used any medication in the last 15 days. “Knowledge of the PFPB” was checked by answering yes to the question “Do you know the People’s Pharmacy Program?”When respondents reported not obtaining the medication from the PFPB-E or SUS pharmacies , they were asked if they had tried to. In case of an affirmative answer, they were asked the reasons for failing to get the medication and, in case of a negative answer, why they had not sought the PFPB-E. The packaging or prescription of every medication used was requested to verify the correct names and later classify them by pharmacological groups. To trace the origin of prescriptions, the following question was made: “Who prescribed this medication for you?” .The independent variables were: socioeconomic factors; economic status, classified according to the Brazilian Association of Market Research Companies (ABEP)To describe the sample according to morbidities, the medical diagnosis reported by the respondent was characterized as: diabetes, hypertension, respiratory diseases , rhinitis, glaucoma, Parkinson’s disease, dyslipidemia, and osteoporosis. The need for using long-term medication was assessed by the question “Do you need to take any long-term medication? Consider long-term medication as those you use regularly without a date to stop”. The number of medications used by the older adult in the last 15 days  was also assessed. Social support was considered present if older adults had someone to help with their needs.Thirteen trained interviewers visited the selected households to deliver a study presentation letter explaining it and inviting older adults to participate. After eligible individuals’ acceptance, interviews were scheduled according to their availability. Electronic questionnaires with precoded questions were applied using netbooks.We considered as losses and refusals the interviews not conducted after three attempts, one of those by a study supervisor. Quality control was performed by the field supervisor with 10.0% of respondents selected at random. We used a shorter version of the questionnaire, composed of 19 questions. Correlation was analyzed by the kappa index.Analyses were performed in the Stata 12.1 program. The sample was described in relation to the independent variables, and the prevalence of the outcome “use of the PFPB-E” was estimated with the respective confidence intervals for individuals who had used any medication in the last 15 days. To estimate the prevalence of reasons for not using the program, we utilized a stratified analysis by age.svy command to consider the study design effect. Variables with p > 0.2 not were taken to adjusted analysis. Regression followed a hierarchical model of backward elimination, which comprises three levels. The distal level included demographic and socioeconomic variables; the second level, the presence of morbidities; and the proximal level, knowledge of the PFPB and the number of medications used. Wald tests were used for heterogeneity and linear trend for the categorical variables. Variables with p < 0.2 were maintained in the model to control confounding factors. The significance level of 0.05 was considered.The factors associated with the use of PFPB-E were analyzed by Poisson regression, using the To analyze the prevalence of PFPB-E use and associated factors, the total number of older adults who had used medication in the last 15 days was used as a denominator. To characterize medications , total medications used were the denominator.This study was approved by the Research Ethics Committee of the Faculdade de Medicina of Universidade Federal de Pelotas . All participants signed an informed consent form and were assured of the confidentiality of information given.We interviewed 1,451 older adults. Losses and refusals totaled 21.3% (n = 393), most of them women and aged 60-69 years. Of the interviews, 4.0% were answered by a caregiver or companion. Most older adults (90.5%) had used at least one medication in the last 15 days. Among them, mean age was 70.9 years (SD = 8.2), 64.8% were women, 84.2% were white, 52.4% lived with a partner, and 30.2% had four to seven years of schooling. The predominant occupational status was retired or receiving the social security disability insurance (72.0%), 42.7% had a household income of two to three minimum wages, and 51.8% were part of social class C .About of 93.0% of the older adults reported having someone to help them with their needs. Regarding self-reported health conditions, 25.4% had diabetes, 71.5% hypertension, and 17.3% respiratory diseases .The prevalence of PFPB-E use was 56.8% whilst the prevalence of knowledge of the program was 87.4%. About of 95.0% of the older adults had to take long-term medication, and 54.0% used four or more medications . Of the Among the 1,014 older adults who had not acquired all their medications from the PFPB-E or directly from SUS units, 54.0% had tried obtaining them from the program. The main reasons reported for not having obtained medication from the program were the medication not being in the PFPB-E list (74.0%), difficulty in getting the prescription (17.0%), and medication shortage (13.0%). Among those who did not try to get the medication from the PFPB-E, the main reasons were the medication not being in the PFPB-E list (46.0%), ignorance of which medications were available (39.0%) and no knowledge of the PFPB (29.0%) .Of the people aged 80 years or over who had not obtained all their medications from the PFPB-E or SUS, 42.0% had tried to get the medications from the program. This age group had more difficulty in obtaining the prescription (21.0%) and going to the pharmacy (12.0%) than the 60-79 years group . About 45.0% of them reported lacking knowledge of the program and medications available as a reason not to try obtaining the medication from the PFPB-E. Among older people aged 80 years or over, 16.0% reported difficulty in going to the pharmacy as a reason .Individuals with chronic diseases as diabetes, hypertension, and dyslipidemia used the program 19.0%, 52.0%, and 31.0% more, respectively, than those without these morbidities. Older people who knew the PFPB used it three times more than those who did not, and individuals who took four or more medications used the PFPB-E 40.0% more than those who took only one medication .Of the 5,700 medications used by the older adults, 32.9%  were part of the PFPB-E; of these, 67.6%  were obtained from the program, of which 79.3% (n = 991) free of charge. As to the origin of the prescription used to obtain the medications from the people’s pharmacy, 54.4% were from private or health plan professionals. The most used medications by the PFPB-E, according to pharmacological classification, were antihypertensive drugs (58.3%), antidiabetic drugs (18.7%), and lipid modifying agents (17.5%) .Among the medications used for chronic conditions such as respiratory diseases, diabetes, and hypertension, 41.9%, 85.2%, and 58.9%, respectively, were present in the PFPB-E list (data not shown in tables).The design effect of this study was 1.14, the intra-class correlation coefficient was 0.0099, and the kappa index of the variable “PFPB knowledge” presented good reproducibility (kappa ≥ 0.7).Of the older people who used medications, more than 80.0% knew the PFPB and more than half used it. However, those aged 80 years or over used the program less. This shows that the program is very disseminated, except among the oldest adults. In addition, a significant portion of the older adults with prescriptions from SUS obtained medications from the PFPB-E, even though they are not its priority group.,In a 2008 population-based study in adults aged 20 years or over, knowledge of the PFPB was 32.8%,The main barriers to the use of the program are lack of prescription, medication shortage, and the medication not being part of the program, suggesting difficulty of access to medical appointments and insufficient programming of medication supply and distribution. Although the number of medications offered by the program is great (including the vast majority of treatments for chronic conditions) and the list is revised periodically, it is necessary to assess whether the medications included in the program satisfy properly the treatment needs of the populationWe also noted that difficulty in going to the pharmacy is a major problem for people aged 80 years or over since, in the absence of the patient, a legal representative is required to collect the medication. Although the existence of the program is widely known, there is still a lack of information, especially among people aged 80 years or over. The list of medications offered by the program is the least known aspect by the population.Use of the PFPB-E was greater in the older adults aged less than 80 years. The reduction in the use of the program by people aged 80 years or over might reflect inequality in access to medications since as age increases, older adult tends to be more medicalized. This inequality might be related to inability or difficulty of mobility, which hinders access to medical appointments to renew the prescription and going to the registry to obtain the power of attorney required in case of a legal representative collecting the medication.,,The study was consistent with the findings of Costa et al.,Individuals with partners used the PFPB-E more, which is consistent with the fact that individuals with partners use health services more,,This study shows, consistently with the literature, that the program serves all socioeconomic strata of the populationA 2007 case study including municipalities from the five regions of Brazil suggests that users may have sought the program because of the ready availability of medications and its shorter wait. Centralizing medication purchasing can reduce pharmaceutical assistance costs, but the fact that medications for asthma, diabetes, and hypertension are available free of charge in the PFPB does not exempt state and municipal managers from the continuity of their provision. They should be available in primary health care pharmacies, facilitating the access for SUS usersMedication shortage in the public and private sectors (PFPB-E) implies a greater part of users’ income destined to health expenditure, which is already extremely high. The situation is even more complicated for those who fail to adhere to the treatment for the lack of money to purchase medication, which often worsens their health status,,,,In accordance with previous studiesThe studied sample is representative of the older population residing in urban areas. Losses were not substantially different from the studied population, which reinforces the internal validity. As this study addressed only the PFPB private networks, its results can be generalized to municipalities with these characteristics. To better qualify the outcome characterization, we requested the packaging or prescription of all medications listed by the respondents. The lack of other household surveys concerning the PFPB-E limited the consistency analysis of this study.The results obtained by this population survey expand knowledge regarding the use of the PFPB-E by the older population and of the reasons for not using it. Thus, they contribute to defining policies to qualify the program. People aged 80 years or over present a great need for access to medications and, according to the Brazilian Institute of Geography and Statistics (IBGE), the number of people in this age group increased by 70.0% from 2000 to 2010,Disseminating the list of medications offered by the program both for the population and for physicians is necessary. This knowledge can contribute to increasing the use of the program by older adults and to health professionals, whenever possible, directing the prescription to medications in the list, reducing expenditure on long-term medications, which are especially important for this populationFarmácia Básica (Primary Pharmacy)The PFPB added an enormous cost to pharmaceutical assistance with the currently available medications and the gratuitousness of the most used medications for asthma, diabetes and hypertension. A PFPB medication can cost up to 290.0% more for the Brazilian Ministry of Health than for the It is crucial that local authorities take responsibility for the pharmaceutical assistance of SUS users, promoting access to medication and the effective insertion of pharmaceutical assistance as a health action, especially for those in remote areas, with a medication supply closer to the user. This strategy is crucial to avoid spending on medications and transportation, and even low adherence to treatment in the low-income population.