As chronic cardiac and pulmonary diseases often coexist, there is a need for combined physical home-based rehabilitation programs, specifically addressing older patients with advanced disease stages.The primary aim of this study is to evaluate the completion and adherence rates of an 8-week, home-based exercise program for patients with advanced cardiopulmonary disease. The secondary end points include patient satisfaction; adverse events; and program efficacy in terms of change in functional capacity, level of dyspnea, and health-related quality of life.The participants received a goal-oriented, home-based exercise program, and they used a wrist-worn activity tracker to record their exercise sessions. Activity tracker data were made visible on a digital platform, which was also equipped with several other features such as short instruction videos on how to perform specific exercises. The participants received weekly coaching by a physiotherapist and an occupational therapist through video communication.P=.03). The participants were highly satisfied with the program ; however, of the 9 participants, 4 (44%) experienced technical issues. The Patient-Specific Complaints Instrument scores declined, indicating functional improvement . Other program efficacy metrics showed a trend toward improvement.In all, 10 patients with advanced combined cardiopulmonary disease participated , and 50% (5/10) were men. Of the 10 participants, 9 (90%) completed the 8-week program. Median adherence to the exercise prescription was 75% (IQR 37%-88%), but it declined significantly when the program was divided into 2-week periods (first 2 weeks: 86%, IQR 51%-100%, and final 2 weeks: 57%, IQR 8%-75%; Home-based cardiopulmonary telerehabilitation for patients with severe combined cardiopulmonary disease is feasible in terms of high completion and satisfaction rates. Nevertheless, a decrease in adherence during the program was observed, and some of the participants reported difficulties with the technology, indicating the importance of the integration of behavior change techniques, using appropriate technology.Netherlands Trial Register NL9182; https://www.trialregister.nl/trial/9182 Chronic cardiac and pulmonary diseases often coexist because they share similar risk factors such as older age, cigarette smoking, sedentary lifestyle, and persistent low-grade systemic inflammation . The preExercise-based cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are highly recommended for a wide range of cardiac and respiratory disorders because they result in improvement of exercise capacity and quality of life (QoL) and reduction in hospital admissions related to the disease ,5. DespiTo date, there are 2 major gaps in evidence with respect to cardiac and pulmonary telerehabilitation. First, the studies on cardiac and pulmonary telerehabilitation mainly focus on patients classified as low risk, that is, younger patients, without major comorbidities, in a stable phase of the disease, rather than on the merging group of older and frail patients. These vulnerable patients, however, might benefit most from rehabilitation because of impairment in multiple domains of physical functioning, which lead to recurrent hospital admissions . In factTo address the current gaps in telerehabilitation, this exploratory study was designed to assess the feasibility of a personalized, home-based, goal-oriented exercise program in patients with advanced, combined chronic cardiac and pulmonary diseases. The results of this study will be used to design a future, large clinical trial.This is a single-center feasibility study designed to explore program completion and adherence, as well as possible barriers to adherence, of a novel, personalized, home-based telerehabilitation program for patients with combined advanced chronic cardiac and pulmonary diseases. The secondary end points include patient satisfaction; adverse events; and an exploratory analysis of program efficacy in terms of functional capacity, level of dyspnea, and HRQoL. The results of this study will be used to guide the design of a larger clinical trial. The study was performed at the Máxima Medical Center in Veldhoven, Netherlands. In all, 10 patients diagnosed with a combination of chronic cardiac and pulmonary diseases were included. The eligible patients were randomly selected from a group of patients who were participating in a telemonitoring program for combined chronic cardiac and pulmonary disease because of 1 or more hospital admissions within the past year on account of a cardiac or pulmonary exacerbation or frequent exacerbations treated at the outpatient clinic. The exclusion criteria were neurological, orthopedic, or peripheral vascular conditions preventing the patient from performing exercise; hemodynamic significant valvular disease; and proven cardiac ischemia or heart rhythm disturbances at a low-intensity exercise level. All patients provided written informed consent. The study was approved by the local medical ethical committee of Máxima Medical Center and was conducted in accordance with the declaration of Helsinki. The study was registered in the Netherlands Trial Register (NL9182).Digital Platform and Activity Tracker section). On the basis of the study population, characterized by a high disease severity and the presence of several comorbidities, we acknowledge that program completion and adherence are challenging. Nevertheless, given the fact that the entire program was highly personalized, performed in the patients’ home environment, and supported by fairly easy-to-use technology, we hypothesized that most of the participants would be able to complete the program and that adherence to the exercise prescription would be at least 70%.The primary end points—program completion and adherence—were defined as the percentage of participants who completed the 8-week exercise program and the percentage of completed exercise sessions after receiving a prescription, respectively. To assess adherence, the participants were asked to record their exercise sessions with a wrist-worn activity tracker  . This seMoreover, a self-administered, Purpose-Designed Questionnaire (PDQ) was completed by each participant . This quSubjective program efficacy was evaluated through the following 3 questionnaires or rating scales, which were administered at baseline and again at the end of the program:Patient-Specific Complaints (PSC) Instrument. This tool asks the patient to mention 2-3 activities that are difficult to perform because of cardiopulmonary complaints. Each activity is then rated on a scale from 0 (very easy to perform the activity) to 10 (impossible to perform the activity). A mean PSC score is calculated by dividing the total PSC score by the number of chosen activities.Modified Medical Research Council (mMRC) Dyspnea Scale , which mSelf-administered EuroQol 5-Dimension, 5-Level (EQ-5D-5L) Questionnaire, which measures HRQoL and which consists of 5 questions in 5 domains  . Each quThe objective measures to evaluate program efficacy, extracted at baseline and again at the end of the program were as follows:Number of repetitions during the 1-minute sit-to-stand (1-MSTS) test, which is a valid and responsive tool for measuring exercise capacity . The patHandgrip strength as a measure of muscle strength, measured with the Jamar hydraulic hand dynamometer (JLW Instruments) . The patThe exercise program started with a combined intake supervised by both the physiotherapist and occupational therapist at the outpatient physiotherapy clinic of Máxima Medical Center. The intake consisted of an assessment of the daily life activities of each participant and the perceived barriers. On the basis of this interview, 2 to 3 problematic activities were defined that the participant wished to improve. These activities were rated with the PSC Instrument and were translated into patient-specific rehabilitation goals. In addition, the participants were instructed to complete the EQ-5D-5L Questionnaire and the mMRC Dyspnea Scale and to perform the 1-MSTS and handgrip tests.Digital Platform and Activity Tracker section).The 8-week home-based exercise program consisted of a combination of endurance and strength exercise training tailored to the participants’ preferences in exercise modality  and availability of training equipment at home. Exercises for (respiratory) muscle strengthening, breathing techniques, and techniques for mobilization of sputum were provided through instruction videos on the digital platform. The amount, duration, and content of the exercise sessions was determined individually by the physiotherapist. The intensity of the prescribed exercise sessions was guided by the rate of perceived exertion , which was filled in on the digital platform by the participant after a completed exercise session. The exercise sessions were recorded by the participant with a wrist-worn activity tracker  on their satisfaction with the program, and the responses were analyzed after all participants completed the study.An overview of the participant timeline and study measurements is presented in This study used a secure digital platform (Mibida BV). The eligible participants were already using this platform for telemonitoring of their cardiopulmonary disease. For the participants in this study, the platform was equipped with the following additional functionalities:An overview of the executed exercise sessions (recorded with the activity tracker). For each session, the following metrics were visualized: type of exercise, date of the exercise session, starting time of the session, duration of the session, heart rate course, and perceived Borg score. Actual feedback on these sessions was given by the therapists during the weekly videocall sessions.Short instruction films about exercises for (respiratory) muscle strengthening, breathing techniques, and techniques for mobilization of sputum. These films were recorded in advance in collaboration with the physiotherapy department. For each patient, a personalized set of films was selected by the physiotherapist and transferred to the digital platform.An activity diary for 1 or more days to be filled in by the participant, which could be scored afterward by the occupational therapist. These scores, represented as numbers, were discussed during the participants’ video consultations with the occupational therapist.A graphical overview of treatment goals based on the PSC list, with the associated PSC scores. The PSC scores could be filled in periodically by the participant (as was asked by the therapists) to evaluate progress.A videocall module for weekly communication with the therapists.A tab with reports created by the therapists. Tasks and assignments for the upcoming week were summarized here, as well as progress up to that point.Exercise sessions were recorded with a wrist-worn activity tracker . The watch was mainly used for evaluation of adherence, rather than for adjusting exercise prescription based on specific recorded metrics. The exercise recordings were automatically uploaded to the digital platform through the home Wi-Fi network of the patient.P<.05.For this study, we chose a convenience sample of 10 participants, rather than a calculation-based sample size. Nevertheless, we included a very homogeneous group of participants (older adults with a combined cardiopulmonary diagnosis and a recent exacerbation). For this reason, we considered a sample size of 10 patients sufficient to (1) explore whether the approach is feasible to execute on a larger scale and (2) obtain sufficient representative results to enable us to improve the intervention before upscaling. Descriptive statistics were used to describe the studied population with regard to the baseline characteristics and data on adherence, patient satisfaction, and program efficacy. Because of the small patient population, nonparametric tests were used. The Wilcoxon signed-rank test was used to compare differences in the PSC, mMRC, HRQoL, and 1-MSTS scores, as well as in handgrip strength, before and after the home-based exercise program, and the Friedman test was used to determine whether the change in adherence during the program was significant. Statistical analysis was performed using SPSS software . For the analysis, the significance level was set at The aim was to include 10 patients. Therefore, 13 patients were asked to participate, of whom 3 (23%) declined. Of these 3 patients, 2 (67%) provided reasons for declining to participate: (1) starting an extensive treatment for a comorbid disorder and not wanting to combine it with study participation and (2) feeling insecure about performing exercise that would not be directly supervised.The study participants were included between October 2019 and October 2020, had a median age of 71 (IQR 63-75) years, and 50% (5/10) were men. Additional patient baseline characteristics are presented in Of the 10 participants, 9 (90%) completed the 8-week exercise program, whereas 1 (10%) participant ended the program prematurely because of a hospital admission  shortly after inclusion and inability to restart the program after discharge. The median adherence  over 8 weeks was 75% (IQR 37%-88%), ranging from 20% to 95% .P=.03; When we divided the program into periods of 2 weeks, the median adherence decreased significantly: from 86% (IQR 51%-100%) in the first 2 weeks of the program to 57% (IQR 8%-75%) in the final 2 weeks of the program P=.03; .During the study period, no adverse events occurred that were related to the home-based exercise program. Of the 9 participants who completed the program, in the case of 1 (11%) participant, the study was interrupted for several weeks by a severe pulmonary exacerbation in combination with a COVID-19 infection. This participant successfully restarted the study after recovery.The median total CSQ-8 score was 29 (IQR 26-32), which indicates a high level of satisfaction. The total CSQ-8 score ranged between a minimum of 21 and a maximum of 32. The median total PDQ score was 103 (IQR 92-108), indicating a high level of satisfaction. The total PDQ score ranged between a minimum of 71 and a maximum of 113.The subset of items in the topics provision of information (3 questions) and contact with the therapists (7 questions) were responded to with agree or completely agree by 6 to 9 of the participants, indicating high levels of satisfaction. No participant disagreed with these items. The participants gave the program a median grade of 9.0 (IQR 8.0-9.5), where a grade of 0 represents very bad and 10 represents excellent.The final question of the PDQ is an open one, which gives participants the option to write down comments. Of the 9 participants, 6 (67%) answered this question. The most frequently reported comments were experiencing trouble making a proper video connection with the therapists  and experiencing trouble with recording the exercise sessions with the activity tracker . Of the 9 participants, 4 (44%) answered yes to the question regarding whether they experienced technical issues to a certain extent.P=.01). The mMRC dyspnea score decreased nonsignificantly after completion of the program, from median 3.0 (IQR 2.8-4.0) to median 2.0 . The HRQoL score showed some trends toward improvement; however, no statistically significant changes were observed  to median 5.7 . In addition, no significant differences in handgrip strength were observed, from a median of 30 (IQR 25-34) kg to a median of 30 (IQR 23-33) kg (P=.73).The number of repetitions during the 1-MSTS test showed a nonsignificant increase after completion of the program, from a median of 15 (IQR 12-19) repetitions to a median of 16 (IQR 13-21) repetitions  costs with regard to the deployment of health care professionals and (2) costs with regard to technology . An overview of the intervention costs per participant is presented in This exploratory study showed that home-based cardiopulmonary telerehabilitation for patients with severe combined cardiac and pulmonary disease is feasible in terms of program completion and is associated with high satisfaction rates and functional improvement. However, a decrease in adherence during the program was observed, and some participants reported difficulties with the technology.Our study showed that of the 10 participants, 9 (90%) completed the program, but the median adherence was lower . It should be noted, however, that the actual adherence may have been underestimated because we based our findings solely on the number of recorded sessions with the activity tracker, which was experienced as troublesome by some patients. Other studies evaluating home-based CR in patients with CHF generally showed a high mean adherence but with a wide variation ranging from 54% to 110% . In patiAlthough completion of the telerehabilitation program was high, we observed a decrease in adherence to the prescribed exercise sessions during the study period. A possible explanation for reduced adherence is temporary worsening of cardiopulmonary physical complaints or other coexisting diseases. Although the patients were also participating in a telemonitoring program focused on symptoms and vital signs, an actual integration of telemonitoring and the home-based exercise program was lacking. Ideally, when worsening of physical complaints was detected by telemonitoring, the rehabilitation therapists should have been informed immediately to adjust the exercise program to the patients’ physical capacity. Indeed, the study by Loeckx et al  showed tAlthough digital technology can serve as a very useful medium to apply behavior change techniques, it should be noted that some of our study participants experienced difficulties using digital technology. Therefore, the technology can also serve as a barrier to achieving behavioral changes. In fact, Tadas et al  found thThe COVID-19 pandemic has added new barriers to participation in center-based CR and PR, namely temporary closure of CR and PR centers, reduced capacity after partial reopening of these centers, and anxiety of patients regarding regular visits to a CR or PR center . This stAlthough the participants in our study were highly satisfied with the home-based exercise program, they were experiencing difficulties in particular with using the wrist-worn activity tracker, which was used to record their exercise sessions. To facilitate the activity tracker’s use, one of its software features was adjusted before the study to enable the participants to start and end training sessions more easily. Moreover, functionalities that were not needed for study purposes were turned off. Nevertheless, some participants still experienced the use of the activity tracker as troublesome, which may have contributed to impaired adherence to the exercise prescription. Therefore, we suggest the use of sensors that patients only need to wear, without the need to perform additional actions. Moreover, automatic transfer of sensor data to a health platform should be provided. In addition, sensors that provide simple metrics (such as step count) and give direct feedback to users have been particularly graded as useful .Program efficacy was assessed using both subjective and objective measures. Although the sample size was too small to evaluate program efficacy with sufficient statistical power, and a control group was lacking, we observed an improvement in the PSC scores. Moreover, a trend toward improvement in the mMRC Dyspnea Scale and HRQoL scores was observed. No clinically relevant changes were observed in the objective measures (1-MSTS and handgrip strength tests). Although several studies on home-based CR and PR showed evidence of improvement in QoL and physical performance, as well as reduction in hospital admissions , this caThis exploratory study aims to optimize the intervention for a larger trial that will assess the effectiveness of home-based rehabilitation in patients with severe combined cardiac and pulmonary disease. On the basis of the findings of this study, we suggest making the following adjustments to optimize the intervention:Integration of telemonitoring strategies and telerehabilitation, that is, creating the ability to adjust exercise prescription in line with fluctuations in symptoms and exercise tolerance.Using prompts to stimulate participants to perform their exercise and also offering rewards after completing an exercise session, for example, through text messages.Use of a sensor that is easy to use, does not need the participant to perform several additional actions, provides metrics that are easy to interpret, and offers direct feedback.A treatment period of 8 weeks was experienced as rather short by the therapists with regard to providing sufficient coaching and education for the participants to achieve their rehabilitation goals. Although a duration of 8 weeks is more often used in rehabilitation programs, a prolonged period of coaching (at least 12 weeks) in this population consisting of patients with complex health conditions might result in higher program efficacy. A step-down approach to contact moments with the therapists might be of added value to be able to extend the program duration without causing an additional financial burden. Moreover, it might stimulate participants to perform their exercise without frequent feedback from the therapists, thereby preparing them for the period after the rehabilitation program has ended.This study included a few limitations. First, the participants were already using the digital platform for telemonitoring purposes. The familiarity with the platform might have resulted in higher satisfaction rates with the home-based exercise program. Of the 10 participants, 1 (10%) was not familiar with the platform before beginning the program; however, this participant also scored high on satisfaction. Moreover, in a future study, home-based telerehabilitation will also be introduced after a period of telemonitoring because of the instability of the diseases.Second, our study only focused on physical activity and not on other lifestyle domains. However, the ability to improve and maintain a certain activity level will also be influenced by other lifestyle behavior domains such as dietary behavior, mental stress, emotional well-being, and sleep quality. These factors were not taken into account in this rehabilitation program.Finally, the results of this trial should be interpreted with caution because of the small number of participants and the lack of a control group. Nevertheless, because this study aims to explore program completion and adherence to, as well as patient satisfaction with, a home-based exercise program to facilitate the design of a future randomized controlled trial, we chose not to include a control group.Home-based telerehabilitation in older patients with combined severe cardiopulmonary disease and multiple other comorbidities is feasible in terms of a high program completion rate and high levels of patient satisfaction. However, a trend toward decline in adherence was observed during the program, which highlights the need for adding technology-based behavior change techniques in future trials.


As for other European countries, IBR is a significant cause of financial losses in cattle in Slovakia. The State Veterinary and Food Administration of the Slovak Republic prepared a voluntary IBR control program for cattle farms in 1995, which was implemented in 1996. In subsequent years, 48-119 farms/year enrolled in the voluntary IBR control program. Since the end of 2006, the IBR control program became compulsory by law for all cattle farms in Slovakia. Serology was used to identify infected animals using a conventional ELISA amongst non-vaccinated cattle and a gE specific ELISA in cattle vaccinated with marker vaccine. Eradication is based on culling when the serological prevalence of IBR in a herd is below 15%. When the prevalence is higher than 15%, the culling is combined with the application of a marker vaccine. A radical method where all animals are slaughtered is used with the agreement of the farmer when appropriate, especially for very small herds. Depending upon the selected eradication method, the antibody positive cattle can be gradually replaced in the herds to eliminate financial losses due to the disease. The movement of cattle is under strict control requiring a health certificate issued by the state veterinary authority and the movement must be recorded in the central livestock registry. The next step for herds is monitoring to achieve official IBR-free status. Based on the official figures from The State Veterinary and Food Administration, 60.2% herds were free of IBR in Slovakia in 2020. Bovine herpes virus 1 (BoHV-1) is the causative agent of infectious bovine rhinotracheitis (IBR) and was first reported in dairy cattle in California 70 years ago. IBR was later diagnosed worldwide . BoHV-1 Big differences in seroprevalence and disease incidence were observed worldwide , 7. VeteAs for other European countries, IBR/IPV can be a significant cause of financial loss due to respiratory and reproduction problems in Slovakian cattle. Virus infection has been detected by serology in all regions of Slovakia. However, clinical cases are rarely detected, for example, 14 cases with clinical signs of IBR were observed in 2003.2 The aim of this study is to summarize the basic principles of the IBR control program and its progress in Slovakian cattle farms. We also concentrate on specific problems of farmers in Slovakia with introduction of IBR CP on small and large farms.The State Veterinary and Food Administration (SVFA) of the Slovak Republic has prepared an IBR control program (IBR CP) for cattle farms for all ages of animals in 1995, which was introduced the next year and has been continuously updated.SVFA is the main organization in Slovakia dealing with all veterinary aspects and it is responsible for the IBR CP. There are 40 Regional Veterinary and Food Administration Offices responsible for the organization of the CP at the regional level. Of the four State Veterinary and Food Institutes with diagnostic laboratories, the State Veterinary Institute in Zvolen  is the reference laboratory for IBR. All partners involved in the CP and their responsibilities are summarized in In February 2021, 451,257 cattle were registered in Slovakia. The animals were distributed in small , medium , and large farms . Density of cattle is 0.27 animal/ha of grass area .2. The basic information on the IBR CP presented in this paper was taken from this document.The IBR CP prepared by SVFA was officially approved by the Ministry of Agriculture and Rural Development of the Slovak Republic and is published on its website3 and viral DNA detection with PCR  in samples from non-vaccinated cattle and Ab-gE-ELISA  in samples from cattle vaccinated with a marker vaccine. In rare cases when clinical signs are observed, various methods are used for the detection of BoHV-1, such as Ag-ELISA (accredited in-house method), virus neutralization test,with PCR .The herds involved in the CP have to be serologically screened for BoHV-1 specific antibodies to choose between available methods for IBR eradication on a farm.Depending on the seroprevalence in the herd one of three methods are used in the CP:(a) Elimination method combined with vaccination. This approach is used when the seroprevalence of IBR is over 15%. This threshold indicates more extensive infection requiring vaccination of the herd. Animals are vaccinated by a marker vaccine with a deleted glycoprotein, gE. Vaccination is not compulsory but highly recommended. Animals that are seropositive for the wild-type virus are gradually culled from the herds and replaced with new virus negative animals.(b) Elimination method without vaccination. This method is used when the seroprevalence in the herd is under 15%. Seropositive animals are systematically eliminated from the herds as soon as possible and replaced with healthy serologically negative cattle.(c) A radical method is used in the case of small herds where applying long-term systematic elimination methods is not economically sensible and a better solution for the farmer is the culling of the entire herd.Inactivated and live vaccines against IBR are used in the IBR CP, according to the producers' instructions.®, Czech Republic), the animals are first vaccinated when over 3 months old and revaccinated after 4 weeks. Subsequently revaccination is done after 6-months to maintain immunity. Administration of vaccine is i.m. (Bovilis) or s.c. .In the case of inactivated vaccines  is used, the calves are vaccinated i.n. from 2 weeks to 3 months of age, the second dose being given i.m. at the age of 3-4 months, and subsequent revaccination after 6 months. If Rispoval live vaccine is used , the first dose is administrated i.n. to animals over 2 weeks in age, the second dose i.m., once animals are over 3 months, and then revaccination is after 6 months.When Bovilis live vaccine  surveys on dairy farms continue. Confirmed positive farms must follow the procedures of the CP.Two partners bear the costs of the CP. SVFA pays for the initial screening, monitoring in recovered farms, final tests before ending of the recovery program, and final tests for detection of antibodies in farms recognized as officially IBR-free. The farmers pay for vaccination of animals and serological monitoring during the recovery program and costs of replacement animals.An overview flowchart of IBR CP on the cattle farms in Slovakia is presented in At the start of the voluntary phase, 48 farmers implemented the program in 1996, 119 farmers joined the next year, and this number varied yearly but never reached more than a hundred farmers per year thereafter, until 2004.Significantly more farmers implemented the CP when it became compulsory at the end 2006. Data on results of the IBR control program for the years 2000, 2013, 2019, and 2020 are summarized in Official figures from the SVFA from January 1, 2020 indicate that of 7,245 cattle farms, 3,723 farms (51.4%) were officially IBR-free, 638 farms (8.8%) were declared as IBR-free and 831 farms (11.5%) were in the recovery process. All together 60.2% farms were registered without IBR in Slovakia. However, at the beginning of 2020, 2,053 herds had yet to be tested (28.3%).Many countries in Europe have applied IBR eradication programs based on different strategies , such asBased on positive experiences in other European countries, the farmers in Slovakia also decided to introduce IBR CP in their farms. The basic aim of the CP was formulated as (i) to eradicate IBR/IPV in cattle farms, (ii) to improve the health status of animals, (iii) to decrease the losses in the cattle farm industry, (iv) to prevent eventual restrictions on internal and international trade of live cattle and their food commodities. The control program started as a voluntary project but farmers joined it too slowly. To achieve better progress, SVFA supported by state authorities, decided to change the voluntary program to one that is compulsory by law. This act has drastically changed the situation in control of IBR, leading to an approximately more than 10-fold increase in the number of holdings that joined the program each year. The progress of IBR eradication programs in Europe also indicates that compulsory programs are more effective than voluntary approaches , 14.However, the progress in control of IBR in Slovakia has not been as fast as expected because the initial prediction was to finish the program in 7 years. Here, as in most other Eastern European countries with re-structured economies, the main problem with running the IBR CP is insufficient financial income and support for farmers due to economic problems in the country, especially in the agricultural sector. The costs for running the control program, i.e., price for laboratory investigation, vaccination, replacement of animals are too high for farmers. Despite IBR CP being compulsory and farms receiving customized IBR CPs, the economically weaker farms have problems to follow all the rules of the program.When analyzing the IBR CP in Slovakia we see different motivation of farmers with small and large holdings. Most farms are very small with not more than 10 animals, 90% of them house 1-2 animals only. Production of these farms is focused for individual consumption of food products by the farming family and production of cattle dung. These farmers have no strong motivation to join the CP and bear the program costs. In their experience, when cattle are negative for IBR, the animals remain healthy for a long time as new cattle that might introduce infection are rarely introduced. In infected farms, the replacement of animals is rather slow. Vaccination is not welcomed without visible additional production value. However, despite the slow recovery process, the numbers of infected animals in small farms have diminished due to gradual recovery of commercial farms which are the main source for new animals bought by small farmers.On the other hand, farmers with larger farms are more motivated to join the CP. They expect and usually achieve better health status, higher reproduction indicators and lower numbers of abortions and mortality rate in their herds. Export of animals is an additional incentive for farmers to join the program, but avoidance of restrictions on international trade was less important for those that do not export cattle or their food commodities.It is logical to ask why some farms have been more successful with the CP than others. A critical analysis revealed several factors. The progress with CP depends not only on financial support for the program, which is, of course, very important, but also on education of farmers about animal health, the organization of work on the farm, the coordination of the program by the regional veterinary offices and the local level of veterinary health care for cattle. These factors vary from farm to farm and significantly influence the running of the CP.Education about the CP for small farmers is carried out by private veterinarians who provide advice on the diagnosis and control of IBR (and other diseases), make recommendations on vaccination, and provide details on customized CP options. Farmers with medium and large holdings are better informed about the national CP by the farmer union organization and through the regional veterinary offices and by education from workshops and conferences focused on virus transmission, clinical signs, reproductive problems due to virus infection etc.via contaminated semen , Switzerland, Germany, Province Bolzano and Valle d'Aosta in Italy and on the island of Jersey in the UK.In conclusion, the IBR CP in Slovakia is in progress with specific problems, especially in small farms, where the program runs slowly. Despite the complicated economic situation in the country, which significantly influences the running of the program, the successful recovery of most large holdings provides encouragement that the IBR CP in Slovakia can be finished in a short time.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because results were taken from national IBR control program approved by The State Veterinary and Food Administration of the Slovak Republic. Written informed consent for participation was not obtained from the owners because results of this study are a part of official national IBR control program.RM and JB collected the results of IBR CP. RM and SV wrote the manuscript. JH and LO contributed to the evaluation of results and edited the text of manuscript. All authors read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


While capacity matters, intentional prevention initiatives that seek to promote evidence-based practices are helpful to sites in supporting organizations that might otherwise fail to provide quality programming for youth. This paper addresses a conundrum in prevention science, namely, how to make programming accessible to those who need it with a focus on organizational processes, program quality, and implementation of evidence-based practices.Implementation of evidence-based practices is a critical factor in whether afterschool programs are successful in having a positive impact upon risk reduction and positive youth development. However, important prevention research reveals that contextual and organizational factors can affect implementation (Bradshaw & Pas in School Psychology Review, 40, 530–548,  Increasingly over the past two decades, community-based afterschool programs (ASPs) have been recognized as important contexts in the lives of developing youth. These programs were popularized by the 21st Century (21C) Community Learning Centers, a federal act intended to support working families, extend school day learning, and provide opportunities for engaging interactions for children with supportive adults and peers  proposes multi-level factors that can impact implementation of evidence-based practices  and program quality ?What are the demographic program and neighborhood characteristics of the types or profiles?Are types of programs and neighborhood contexts associated with variations in implementation of evidence-based practices in ASPs?In sum, afterschool programs have demonstrated positive effects upon youth behavior and achievement, but quality and capacity are likely key. Leadership, staffing models, and leveraging available community resources may be important processes along with more tangible aspects of capacity such as staffing, physical space, and materials. Further, based upon an eco-developmental model and the ISF, we know less about how organizational and neighborhood contexts affect afterschool programs. Afterschool programs are nested in neighborhood contexts that may impact their functioning. As such, our study examines the following research questions:The following methodology describes the sample, measures, and analytical approach to examining these research questions.Data were collected in the context of a cluster randomized control trial of 75 afterschool program sites in a northeastern state including urban, suburban, and rural locales matched by size, socioeconomic status (proportion of children receiving free/reduced lunch), and racial-ethnic distribution and assigned to condition as part of the LEGACY  Together Project. We recruited 92% (N = 75) of the program sites, and many providers N = 12) ran multiple sites (range 2–7). Two programs refused participation due to leadership challenges , and one did not provide data on critical measures. The current study includes the 72 sites (96% participation rate) with both program- and neighborhood-level information. Table 2 ran mulObservational methods were used to characterize afterschool settings  collected data on three measures of program qualityIn addition to observational methods, survey-based methods were used to assess afterschool program capacity. Afterschool program directors received hard copy surveys from data collection staff to return in the mail. The number of surveys received depended on the number of programs each director led. In the Fall, before the intervention program started, directors’ surveys were collected by research staff.Caregiver Interaction Scale  to 4 ; items were reverse coded with higher scores representing higher quality.Research suggests that multiple measures of quality interactions in educational settings should be employed; as such, we used three observational tools. The 26-item Promising Practices Rating Scale . Supportive relationships with adults (SRA) assessed the relationship between afterschool staff and students. Supportive relationships with peers (SRP) assessed the relationship among afterschool students. Level of engagement (LOE) assessed afterschool students’ positive participation in activities.The Youth Program Quality Assessment  to assess effective program management. The director’s perceptions of staff scale consisted of six items to assess innovation readiness. Directors reported on a 4-point scale ranging from 1 (no staff) to 4 . The space scale consisted of 15 items to examine the availability of important physical rooms and facilities on a 4-point scale—1 (not present), 2 (present but not available), 3 (limited) to 4 (adequate). The materials scale examined the availability of important supplies rated on a 4-point scale—1 (not present), 2 (present but not available), 3 (limited) to 4 (adequate). The community linkages scale explored the degree of engagement among the afterschool program, parents, schools, and the broader community. Items focused on the frequency of contact  between the afterschool program and school teachers and frequency of contact  between afterschool program staff and parents. Connections to community organizations ranged from none (1) to five or more (4) that provided support and resources to the afterschool program. Items were averaged for each sub-scale; higher scores indicate greater capacity.Capacity was measured with items created for the study and obtained from surveys of the afterschool program directors (N = 32) in the fall prior to program implementation. Some directors completed multiple surveys , because they managed more than one site; 22 directors completed only one survey. The survey was divided into five sections—scales were created from these sections to measure aspects of capacity. The Afterschool Climate Assessment (ACA) was created for the research project and assessed the extent to which afterschool providers executed evidence-based practices. These practices included having posted rules and expectations, praise and positive reinforcement, concise directions, and active supervision by adults and interaction with children. Independent observers completed the ACA, a binary checklist of 10 dichotomous yes/no items (α = 0.62); a sum of these 10 items ranged from 0 to 1.00, indicating the proportion of implementation. A higher internal consistency reliability was not expected given that ASPs might implement various aspects of the evidence-based practices assessed.The Neighborhood urbanicity was created using the National Center for Educational Statistics metric-centric locale codes  in Mplus 7 to determine if various types of programs were identifiable due to different levels of capacity and program quality. Indicator variables included program director-reported measures of capacity i.e., organizational leadership, staff readiness, resources , community linkages, all at pretest, and program quality , all standardized to facilitate interpretation of the score profiles Table .Robust maximum likelihood estimator (MLR) was used as it was “designed to be robust against misspecification of the likelihood” for latent variable mixture models  and has been found to perform better than other alternative (variants of ML) methods in standard error estimation under small sample sizes and correct specification of the likelihood Muthén, , p. 32. The association between latent profile membership and each of the neighborhood variables was assessed by either chi-squared test for categorical variables  or by one-way ANOVA for continuous variables (diversity and risk factor). To explore whether the effect of neighborhood context on implementation of evidence-based practices varies by program type , a series of auxiliary regression models of the distal outcomes program implementation on neighborhood context were estimated using the manual version of the 3-step BCH  Can we describe different types of programs based on their general capacity  and program quality ; (2) what are the demographic program and neighborhood characteristics of the types or profiles; and (3) are program types and neighborhood contexts associated with the implementation of evidence-based practices? This section describes the findings of our latent profile analyses.capacity but demonstrated the lowest observed program quality . We termed this, the “Have Some” profile in terms of their scores on capacity. The third profile had high scores on both director-reported capacity scores and observed quality which we referred to as the “Haves.”Model fit statistics for 2- to 4-class solutions are given in Table df = 4, p = 0.07; Fisher-Freeman-Halton exact test value = 8.46, p = 0.052). The program profiles did not differ significantly in percentages of different race and ethnicity categories (except % Asian Pacific Islander) or eligibility for free/reduced lunch , but evidenced some lower to moderate level of program quality and relatively higher implementation of evidence-based practices. In this profile, implementation was better in the locales with more neighborhood risk (Table capacity but was lowest in quality and implementation. As expected, the “Haves” were programs with high capacity, higher quality, and implementation of evidenced-based practices. The “Haves” spanned urban and suburban areas, serving sizeable proportions of Black and Brown children with a mean of more than half of their children being eligible for free/reduced lunch, an indicator of SES. Implementation was higher among the Haves when sites were more diverse in terms of race-ethnicity (Table more neighborhood risk was present. Having resources does not appear to be a suitable substitute for the importance of intentional programmatic and social processes that help youth to feel they belong in supportive, engaging community-based afterschool programs.We found that the “Haves-Nots” were low in terms of director-reported sk Table . The “Haty Table . Interesand, with greater quality, excelled relative to the other sites in implementation, speaking to the added value of fostering program capacity. The programs that had capacity and quality implemented well in sites rich in racial-ethnic diversity (Table This study offers some mixed support of the benefit of capacity, instead prioritizing the role of program quality and implementing evidence-based practices. However, as explicated by the ISF, programs that were well-resourced in terms of capacity ty Table . Returnity Table  in whichty Table .These findings should be understood in the context of the strengths and limitations of our sample and measures. Though the participating programs represented a range of children in terms of racial-ethnic and social backgrounds and to some extent geographic locales, the data emanates primarily from a northeastern state and needs replication with a sample with increased range in terms of free-reduced lunch status and neighborhood risk. The average percentage of free/reduced lunch served was 52%, and many programs were characterized as suburban than urban or rural. However, the definition of “suburban” is quite encompassing and varies greatly in terms of the children served in terms of SES and race-ethnicity. The programs in our study represented White, Black/African-American, and to a much lesser extent Latinx and Asian-American youth. Though we worked hard to identify sites including youth diverse in their racial-ethnic backgrounds, other prevention scientists have conducted work focused on Latinx youth in afterschool (Riggs & Greenberg, In summary, in terms of afterschool, this study contributes to understanding the important role of capacity and implementation of evidence-based practices for quality youth programming. Whereas previous research has suggested and likely is quite true that risk and need can offer barriers to quality, we found that some youth-serving programs can compensate for a lack of resources with a press for higher quality programming; though it is true, that having both is preferable. Interestingly, the staff serving diverse children in terms of race-ethnicity and SES were more experienced and likely possessed the motivation to make a difference for their children. With aspects of “readiness,” i.e., leadership, program structure, this study indicates that geography and diversity need not fatalistically predetermine the success of innovative and intentional program leaders. This research explores how to foster best practices among the young people who need them in terms of their self-regulation, socio-emotional development, and achievement. This is a positive sign for prevention science indicating that efforts to build capacity, and help “the ready and willing” can be fruitful. Further, it is possible that when there is readiness at a higher level of management, it could lead to leadership that builds a cadre of staff who are excited for innovation-specific capacity, to benefit the children they serve. We trust this work begins to offer hope for equitable, innovative practices that help to foster positive youth development across diverse racial-ethnic, socio-economic, and geographic contexts.


Japan has faced numerous issues in the last twenty years with its mandatory long-term care (LTC) insurance program. This LTC insurance program obviously affected older adults’ informal support exchanges, reducing support from family and the community, which became more valuable, subjectively. Furthermore, changes in support have impacted older adults’ subjective well-being and children’s perceived care motivation. Additionally, a mandatory uniform system challenges the issue of tolerance of diversity, meaning how non-traditional families’ opinions be involved LTC situations. This symposium discusses unexpected shifting issues in Japan in the implementation of a public LTC program with a focus on older adults’ support exchanges. The first paper examines the long-term impacts of formal and informal support by examining the effects of implementing formal services. The second paper assesses a community’s role in relation to family in the presence of a public LTC program. The third paper examines the subjective impacts of older parents, who provided support to adult children and their reciprocal expectations of receiving LTC. The fourth paper, on the other hand, articulates reciprocal impacts on sons’ care motivation, which has become more important, since the introduction of the LTC program reinforced men’s participation in LTC. Finally, the fifth paper clarifies how a public uniform program accommodates informal support from non-traditional families when the program premises the presence of family in advanced care planning. Our findings have long-term implications for aging societies in relation to formal and informal support exchanges.