Yoga-based exercise is a promising strategy for promoting healthy ageing, with the potential to reduce falls and increase physical, cognitive and psychological wellbeing. Teleyoga  can deliver yoga programs at scale, potentially reducing costs, increasing convenience, and reaching people who cannot attend studio-based classes. But better understanding of how older people perceive and engage with teleyoga is needed to optimise its design, implementation and promotion.This study built on a previous realist process evaluation of the SAGE yoga trial which is testing the effect of a yoga-based exercise program on falls among 700 community-dwelling people aged 60 + years. In this second phase of evaluation we conducted focus groups with participants who had completed the SAGE program online and with the yoga instructors who were delivering it. We also conducted interviews with participants who had withdrawn from the trial. Six program theories developed in the earlier evaluation provided a framework for data analysis, supplemented by inductive coding and an analytical workshop.Participants described physical and psychological benefits from the SAGE teleyoga program. While noting that teleyoga cannot facilitate hands-on correction or the same quality of observation or interaction as studio classes, participants were highly appreciative of their yoga instructors’ strategies for optimising visibility, instruction, social connection and therapeutic alliance, and for adapting to constrained home environments. Some participants argued that teleyoga was superior to studio classes due to its accessibility and convenience, its lower exposure to potential embarrassment about physical appearance or capabilities, and a reduced sense of peer competition and distraction. Our program theories applied across studio and online modes of delivery.Teleyoga increases accessibility for people in diverse locations and circumstances; it provides a psychologically safer space which combats self-consciousness and unwanted competitiveness; it may enhance embodiment and mindfulness for some; and it has the potential to be offered relatively cheaply at scale which could support free or reduced price classes for people on low incomes and pensions, thereby encouraging a wider population to engage in yoga for healthy ageing and fall prevention.The online version contains supplementary material available at 10.1186/s12906-022-03756-1. Falls present serious problems for individuals and carers, health services and the economy –4. PeoplTeleyoga  is a prHowever, there are barriers to participating in teleyoga. While older people are increasingly engaged with digital technologies —a trend The Successful AGEing (SAGE) yoga trial is a randomised controlled trial testing the effect of a yoga-based exercise program on falls among 700 community-dwelling people aged 60 + years . ParticiThe SAGE yoga program involving 40 weeks of supervised twice-weekly yoga-based exercise, plus goal-setting and unsupervised homework using specially designed yoga resources: videos and a handbook. The intervention is based on the Hatha/Iyengar style of yoga with longer static postures for standing poses designed to maximise balance, stability and leg strength to prevent falls. The program is easily modified to be accessible yet progressively challenging for different ability levels. It is run by experienced yoga instructors who are partners in the trial.A seated yoga relaxation program taught over two group-based workshops and then undertaken individually. This program emphasises seated stretching and does not target standing balance.The primary outcome is rate of falls in the 12 months following randomisation. Secondary outcomes include mental wellbeing, physical activity, health-related quality of life, balance confidence, physical function, pain, goal attainment and sleep quality. An economic analysis is comparing cost-effectiveness and cost-utility. Further details are available elsewhere .Trial participants are recruited via local newspapers, community centres, seniors’ organisations and through social media. Exclusion criteria are: regular participation in yoga within the past 10 years; residence in a hostel or nursing home; presence of a medical condition that precludes exercise; cognitive impairment or limited English language skills.The SAGE program was originally designed to be delivered face-to-face in yoga studios but, following public health responses to the COVID-19 pandemic, classes were moved online. Consequently, participants recruited early in the trial enrolled in studio-based classes but attended a ‘hybrid’ studio/online program, while those recruited later enrolled in and attended an exclusively online program, i.e. teleyoga. The transition to online classes was supported by the introduction of brief 1:1 Zoom meetings between each participant and instructor prior to the program, a WhatsApp group for each class and technology support from the research team. No type or size of device was specified for accessing online classes.Our process evaluation sought to address three research questions:In the SAGE yoga trial, what worked for whom, and under what circumstances?What aided the transition from studio-based to online yoga classes?How were different forms of program delivery valued by participants?We conducted a previous realist evaluation to explain high levels of program adherence indicated in our routine process data and the largely favourable feedback participants gave about the hybrid program. This focused on questions 1 and 2 . In thisIn phase one of the process evaluation we used a realist evaluation methodology to explore what worked for whom in the different program formats offered by the hybrid SAGE program. This is detailed in our methodology paper  but, in The current study sought to (a) further test these program theories with participants who had attended teleyoga classes exclusively (did these theories ‘hold’ or require revision?), and (b) explore participants’ and yoga instructors’ perceptions and experiences of online classes to help us increase.our comparative understanding of how different forms of program delivery were valued by participants, and what conditions best supported positive engagement with teleyoga. We had previously found that the transition from face-to-face classes to online classes was aided by established relationships between participants and instructors, adaptations made by the instructors and participants’ gratitude at being able to access a structured “healthy” program during lockdown. However, post lockdown we continued to see high rates of recruitment and of program adherence over the 12 month teleyoga intervention with positive feedback form data from participants in relation to engagement, satisfaction and impacts on physical and psychological health.For phase two of the process evaluation we had a sample frame of 49 people who had enrolled in teleyoga and completed SAGE exclusively online, and who had given prior permission to be contacted about taking part in qualitative evaluation. We invited 26 of these participants to take part in a focus group, recruiting purposively for maximum variation in age, perceptions of the program  and socioeconomic status across regional and metropolitan areas using postcodes as a proxy. We also sent email invitations to take part in an interview to nine participants who had dropped out of teleyoga classes and withdrawn from the trial but had given permission to be contacted about taking part in an interview. The four yoga instructors who are delivering the SAGE program and are partners in the trial were also invited to take part in a focus group.Two researchers (HG and AH) facilitated three focus groups via videoconferencing software using a semi-structured question guide that focused on reasons for participation in SAGE, experiences of teleyoga and what conditions affected these experiences, and any impacts  by telephone and focused on reasons for participation, experiences of teleyoga, reasons for withdrawal and if anything could have been done to support them to continue with classes Value expectancy (the extent to which people anticipate that benefits will outweigh costs ) was higIt was an age related program.... so [our instructor] was very open to people who had limitations. She could then show them other ways to do what they’d thought they couldn’t do. It was a lot about changing our thinking process. The program design was highly valued for supporting individualised age-appropriate practise, encouraging progression and building physical literacy:I had a knee replacement four years ago and the other knee’s got arthritis in it. To start with I would do the class and then I’d think, “Oh dear, my knees are feeling sore”.… But I just kept thinking, “You know what, the more I do it, the better it’s going to get. It’s because I’m not used to doing this type of exercise”. But it didn’t get any better … then I contacted [our instructor] and said, “Look… my knees are really sore and I’m wondering whether I should pull out of the class.“ So she said, “I will modify the exercises for you” which she did…. and I continued to try it for a few weeks, but it still wasn’t getting any better…. So I thought,.. “I’ve just got to stop this”. However, not everyone who enrolled in SAGE found it beneficial. Some who had withdrawn from the trial described insurmountable injuries or other health problems which they felt the program could not assist with and, in one case, was exacerbating:I may have struggled with Zoom in making sure things were where they should be. Whilst [our yoga instructor] was terrific, and she would correct you, I think a live [studio] class would be better for that than a Zoom class, because they can actually come up and show you, and move you to where you should be. Value expectancy was also affected by the online format: both positively and negatively. The most problematic aspect was reduced visibility, followed by lack of hands-on correction. In phase one of the process evaluation, around half the interviewees who attended the hybrid program felt that online classes were inferior to studio-based classes because their yoga instructor could not observe and correct them effectively over Zoom. This concern was less prominent in the teleyoga participants we spoke to, but a few did speculate that observation and correction in online yoga was poorer:Maybe I’m used to more personal interaction, but …. I just found it, yeah, not satisfying doing it online. I felt I wasn’t getting the personal feedback for me. And I found it a bit isolating…. it didn’t feel real … it felt like pretend. The online format also affected social dynamics. One person who withdrew from the trial explained that teleyoga offered none of the enjoyment she had experienced in the past attending studio classes where there was conversation and laughter with her peers and the instructor:Positive aspects of the online format that increased the perceived value of SAGE are explored in relation to subsequent program theories below.[Our instructor] was brilliant … a fabulous tutor…. I was really intrigued how it would work online because there’s this little screen yet you are doing yoga and a lot of it is being in the right alignment and position. But the way it was set up … you could do it with your eyes closed because she knew exactly what you were doing and would just say, “Gloria, straighten, bend, or lift your shoulder”….. So it was really, really positive to have that attention.… She looked after everybody really, really well. Unsurprisingly, excellent instruction was regarded as essential to participants’ engagement with and confidence in online classes. Qualities identified in the previous phase of process evaluation—such as credibility, empathy, encouragement and the ability to safely lead a whole class while simultaneously attending to the needs of individuals—were equally important in the teleyoga program, partly because they addressed some concerns about reduced visibility outlined above:… it was helpful for me to be able to see the instructor up close …. I appreciate that she would stop and ask us to watch her so I could bring my iPad right up close and I could see her clearly. However, excellent teleyoga instruction required some additional specialist skills. Instructors had learnt to be more precise in their directions, using their voice as an instrument more consciously. They would orientate themselves and participants towards the camera, spending more time demonstrating poses and making adjustments to maximise visibility:I’ve got a couple of people who just work between their bed and their wardrobe, so there’s only one position they can be in and it’s up to me to try and get the best out of them…. It’s made me a better teacher, made me adapt. (Instructor 1)Adaptability was a core teaching skill in the SAGE program given that it is designed to support individualised practise, but instructors continued to build on this in the online environment, using resources creatively and modifying poses, for example, so that participants could balance using chairs of different heights or practise in constrained spaces:… because we did the individual interviews … I was able to really zone in … find out their issues and … whatever they’re dealing with. There’s a sense of creating a space of safety, of care, and that whatever their injuries are I make a note. So I say, “Okay, we can work with that”…. that’s vital…. They’ve got to feel safe with me, they’ve got to feel cared for. (Instructor 3)The online platform reduced opportunities for interactivity, making it harder for instructors to connect with participants and demonstrate their commitment to building caring and respectful relationships . However, when the program moved online, SAGE introduced brief 1:1 sessions between instructors and each participant prior to starting classes which were valued highly by participants and instructors for generating rapport and confidence that instructors understood and would be responsive to people’s needs:She noticed when I wasn’t doing it properly … It was good she pointed it out because I was doing a couple of sessions on my own and I thought I was doing it correctly. If I hadn’t had that interaction, I probably would’ve continued on doing it in my own merry little way, not getting the full benefits of it. Participants especially appreciated individualised feedback during classes which assured them they were being observed by the instructor and supported to practise effectively:… being in my own home and with other people in their own home it was a very … friendly atmosphere even though we weren’t together in the same room…. It was a nice feeling that you were with the group, but individual” Although teleyoga classes were not able to promote social connectivity to the same extent as studio classes, participants did enjoy the shared experience and collegiality of practising with a regular group:I quite liked the informal chats before and after the class. There was a nice sense of where people were at and what they were doing, and the teacher would sometimes participate in that as well, which was really nice…. I quite liked that sense of community that was created with that. The friendly atmosphere mentioned in this participant quote was something the instructors worked hard to produce. Strategies included instructor-facilitated pre-class chat sessions, using humour and informal language during the class, and encouraging questions and comments:“I wouldn’t have joined if it wasn’t online” . Free classes increased accessibility which encouraged waverers to give the program a go and to stick with it in the longer term:I was a bit frightened that I wouldn’t be able to do it, but I found that I could. I think if it hadn’t been given to me the way it was – the free, the online, the accessibility – I wouldn’t have done it. … when I saw that it was free of charge, it was an opportunity that I jumped at… If you’re not familiar with yoga, you might need a free-of-charge period to ‘taste and see’ whether it’s for you. Teleyoga offered greater accessibility and convenience than studio-based classes. People were able to attend (with no commuting) from diverse locations and in a wide variety of circumstances, including during COVID-19 lockdowns and other restrictions. For some, this convenience made the difference between enrolling or not, I’m very grateful to SAGE because it has given a dimension to my life that wasn’t there before. The gratitude that participants expressed about the hybrid program was also expressed by those who attended teleyoga program and may have been enhanced by the increased accessibility of classes outlined above, especially during the COVID-19-pandemic:While videoconferencing technology increased accessibility in many ways, it also presented some access challenges. Lack of familiarity with the Zoom platform by many participants and the yoga instructors required considerable support from the SAGE team who offered IT coaching and setup advice, including ‘lurking’ in early classes to step in and provide support when needed.I wondered sometimes if I was actually doing the poses correctly … because I couldn’t always see the whole of her and she couldn’t always see the whole of me…. It was just the setup, I didn’t perhaps have the best setup … Participants used various devices for online classes including phones, tablets and laptops. Surprisingly, smaller screen size did not seem to be a consideration as those who used phones said they were satisfied with this and only two online participants reported difficulty seeing their instructor, “She seemed a little bit distant for some of the poses but… it wasn’t something that particularly disturbed me” . Concerns about restricted lines of sight appeared to be entangled with anxiety about using technology suboptimally rather than screen size:[Our instructor] spent a considerable time getting the setup right for both her and for me, and I think she did it with everybody else…. it made a big difference because I wouldn’t have known where I needed to be …so I had to move around and eventually got it and I was happy with it. This suggests that improved technical proficiency might reduce concerns about line-of-sight. To an extent, this was tackled in the 1:1 pre-program meetings in which instructors gave advice and helped participants to trial the setup they would use in classes:“habit forming” :It gave you a sense of purpose every week to know or twice a week that you would commit to this. And I just organised … my life around that, knowing that on Monday and Wednesdays, I had yoga at whatever time it was, and I miss that. It’s not the same if you just set aside that time yourself and do your own independent practise The four mechanisms identified in this program theory—purposeful structure, momentum, accountability and continuity—were all retained in the teleyoga program which kept the structure of twice-weekly classes over 12 months with progressive challenges. As with the hybrid program, participants found this [what helped was] just that it was a regular thing that you did twice a week, you had to be prepared for it and.…when it started off, I was prepared to just do it sitting on a chair and then I saw the other people not doing it in a chair, I thought “Well, Joyce, get off your chair and do it properly!”…. Yeah I felt guilty if I didn’t attend the class because I knew the teacher was putting herself forward and the rest of the group was too. Similarly, teleyoga participants felt accountable to their instructor and, to an extent, their peers which encouraged attendance and possibly increased determination to make progress:I always feel time pressure when I’m doing it myself…. You negotiate trying to reduce time. Whereas when you’ve got an online class you say, “Okay, I’m just going to focus on this for an hour”…. If it’s a live event, then you’re committing at a particular time with a particular person or group. Participants emphasised the value of synchronous classes rather than pre-recorded videos both in terms of responsive instruction and the sense of commitment to dedicated practise time that live classes generate:…I’ll continue as I’ve got the videos which are amazing because when [the instructor]’s been away or over the Christmas holidays I’m able to do regular yoga in the morning and it makes such a difference to your day…. Because that helps you get your routine. See, I’m a great believer in rhythm and routine in life … with the video it’s really easy to get that rhythm happening. Without it, you think “I can’t be bothered”. However, a few participants used the SAGE homework videos to maintain the program structure over breaks and to sustain yoga practice after the program had finished, thus continuity was enhanced by the greater accessibility of teleyoga but also the availability of tailored resources:I’ve always had an aversion to going to gyms and things like that…. But what we did in yoga … was a positive thing. It wasn’t just dealing with getting my muscles to work better, but it was more holistic like working in the garden where ... it’s almost like the activity is part of something else rather than just being an end in itself. It was really surprisingly calming.… You do come with a different mindset than going to the gym or something like that.… it can open another door in your day-to-day living rather than just using it as a sport. It’s just got a different level. It’s the mindfulness…. it’s just how you appreciate your day … so it can be a way of living. The two mechanisms identified in this program theory—mindfulness and embodimentThe mindfulness gave me a peaceful start to my day. I enjoyed knowing that … it was just going to be the teacher talking and me just sitting in the stillness of it all. I yearned for that…. The peace of it. There was a suggestion that mindfulness could be enhanced in teleyoga classes due to the solitude of practice:“mindfulness light”  as classes focused on strength, stretching, flexibility and relaxation rather than deeper meditational techniques. But this was regarded as a feature of the SAGE program design rather than the result of online delivery.A few participants who had previous experience of yoga felt that SAGE delivered I’m a little bit reserved, I don’t know that I would have gone to a studio. I would have felt a bit embarrassed. But this way I didn’t feel embarrassed because I couldn’t see other people looking at me, I just knew it was just the teacher, and that gave me a lot of courage to have a go. One unanticipated finding was that some participants who had signed up for teleyoga said they would not have attended a studio-based class because they felt too self-conscious. So while reduced visibility online was a concern for people who wanted optimal observation and instruction, it was not only a bonus for some others, it was actually a deal-maker:… having done classes in the past in a live [face-to-face] situation rather than online, I did notice that difference that online you’re not comparing yourself to others, and I think that’s actually helpful because you just focus on what you can do and focus on what it is you’re trying to achieve In addition to the benefit of reduced ‘exposure’, some participants explained that limited visibility of their peers made group practise less distracting, reduced feelings of competition and facilitated greater inward attention and embodiment:In our previous process evaluation of the SAGE classes that began in yoga studios then moved online, we reported that many participants found online classes less satisfying and effective compared to studio-based classes. They valued the hybrid program because it enabled them to establish relationships with peers and their instructor while in the studio, and to embed yoga skills that provided a foundation for practising remotely. Thus initial studio-based classes mitigated the impact of decreased interaction, observation and precise correction in online classes . This suIndeed, the teleyoga program retained most of the positive aspects identified in the hybrid program and was actually more appealing to most of the participants in this study. For some, its benefits were a game-changer as it provided access to classes that would have been impossible to attend in person, and offered an environment with reduced exposure to peer scrutiny which attracted participants who would not have attended studio-based classes due to embarrassment. This is a serious yet underdiscussed issue in designing physical activity programs and environments. Body-related anxiety may be especially powerful for younger people , and doeA desire to avoid unfavourable comparison to ideal body types may be one reason why classes designed exclusively for older people were welcomed by our participants. Other reasons identified in our research were that targeted classes are regarded as offering safer, achievable and more effectively tailored exercise with a community of peers. This aligns with studies of older people’s engagement with tailored physical activity programs –68 and mbeing observed, rather than observing, as their primary consideration for safe and effective yoga practice.Screen size did not seem to be a major consideration for SAGE participants in either program format. While this might be expected in the hybrid program where participants were able to observe the instructor and hone poses early on—laying the foundation for later practice—it is more surprising in the online program. This may be in part because of the strategies instructors developed for maximising visibility (including asking participants to set their device to ‘speaker mode’ so the instructor dominated the screen) and improved verbal instruction. It also aligns with participants’ emphasis on It is important to note that in-person yoga programs do not directly translate to online platforms: they demand additional strategies for optimising safety, effectiveness and participant enjoyment. In our trial, these included structural and resourcing changes to the SAGE yoga program, for example, brief one-to-one Zoom meetings before program commencement and technological support from the research team. Considerable adaption to yoga instruction was also required in SAGE, including techniques for building understanding and rapport between participants and instructors. Warmth in how older people are welcomed to physical activity programs, as well as assistance in easing them into this new territory, have both been identified as mechanisms in enhancing engagement . It is vAdditional strategies for support and engagement might include providing participants with a setup ‘tip sheet’, being explicit about the challenges older people have faced since the pandemic began and advocating self-care, building in feedback mechanisms to inform instructors’ continual learning, and incorporating empowerment-focused coaching techniques in the one-to-one meetings which engage participants in solution-focused planning to address any potential barriers to program adherence –75. A foOur iterative process evaluation is a strength as it builds on rigorous program theory development using realist methods to understand the impact of different mediums on program implementation and engagement . PurposiTeleyoga cannot facilitate hands-on correction or the same quality of observation or interaction as studio-based yoga classes, but there are manageable strategies for optimising visibility, instruction, social connection and therapeutic alliance, and for adapting to constrained home environments, which satisfied most of our participants. Teleyoga increases accessibility , opening it up to people in diverse locations and circumstances; it provides a psychologically safer space which combats self-consciousness and unwanted competitiveness; it may enhance embodiment and mindfulness for some; and it has the potential to be offered relatively cheaply at scale which could support free or reduced price classes for people on low incomes and pensions, thereby encouraging a wider population to try yoga and maintain their practise. While some of our process evaluation participants preferred studio classes, most firmly agreed that teleyoga was much better than no yoga at all. Therefore, in terms of scalable costs, reach, acceptability and sustainability – teleyoga may be the way forward both for fall prevention and for general health and wellbeing.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3


Severe Acute Malnutrition (SAM) is a serious public health problem in many low- and middle-income countries (LMICs). Therapeutic programs are often considered the most effective solution to this problem. However, multiple social and structural factors challenge the social inclusion, sustainability, and effectiveness of such programs. In this article, we aim to explore how poor and remote households face structural inequities and social exclusion in accessing nutrition-specific programs in Pakistan. The study specifically highlights significant reasons for the low coverage of the Community Management of Acute Malnutrition (CMAM) program in one of the most marginalized districts of south Punjab. Qualitative data are collected using in-depth interviews and FGDs with mothers and health and nutrition officials. The study reveals that mothers’ access to the program is restricted by multiple structural, logistical, social, and behavioral causes. At the district level, certain populations are served, while illiterate, and poor mothers with lower cultural capital from rural and remote areas are neglected. The lack of funding for nutrition causes the deprioritization of nutrition by the health bureaucracy. The subsequent work burden on Lady Health Workers (LHWs) and the lack of proper training of field staff impact the screening of SAM cases. Moreover, medical corruption in the distribution of therapeutic food, long distances, traveling or staying difficulties, the lack of social capital, and the stigmatization of mothers are other prominent difficulties. The study concludes that nutrition governance in Pakistan must address these critical challenges so that optimal therapeutic coverage can be achieved. Worldwide, nearly 20 million children suffer because of SAM. Every year, half of the global childhood mortality is caused by malnutrition and one-third of these deaths are caused by SAM alone . South APrevious evidence around the globe shows that supplementary programs have reduced moderate and severe acute malnutrition in children ,9,10,11.In Pakistan, a nutrition-specific CMAM therapeutic program was set up in Southern Punjab’s poverty-stricken and flood-affected districts to deal with SAM. Under the CMAM program, moderate as well as noncomplicated SAM cases are treated with Ready-to-Use Therapeutic Food (RUTF), whereas complicated SAM children are referred first to the nutrition Stabilization Center (SC) by LHWs. Once complicated SAM cases become stabilized by using specialized medical milk 75/100, they can use RUTF. Ingredients in RUTF depend on the local acceptability availability and cost, but a standard RUTF is made up of milk powder, peanut butter, vegetable oil, vitamins, minerals, and sugar. The advantage of the product is its long shelf-life without refrigeration, but its demerit is its import as it is not prepared locally.A sufferer’s experience is a social product shaped by structural violence, which may be defined as violence “built into the  structure and shows up as unequal power and consequently as unequal life chances”  p. 171)117]  with key officials of the District Health Authority were conducted face to face by the principal author who has experience in public health nutrition and knowledge of medical anthropology. Secondly, a Focus Group Discussion (FGD) with LHWs was conducted in a healthcare facility by the two qualitative researchers (F.A. and S.Z.). In the group discussion, 10 participants were maximally allowed to take part. Participants of this discussion were inquired about the major difficulties, barriers, and challenges that hampered therapeutic coverage at the district level. Finally, healthcare providers helped to identify and communicate with mothers having SAM children. The mothers of malnourished children were identified by the Nutrition Assistants appointed at SCs and LHWs involved in the CMAM program. To seek consent to take part in this research, 30 mothers were informed about the nature of the study. However, consent could be agreed upon by 20 mothers. We chose the respondents’ places deliberately so that they felt safe and comfortable. Audio recorders were not used, owing to locals’ comfortability and cultural sensitivity. In-Depth Interviews (IDI) were in a flexible format, ranging from one to two hours. All interviews were conducted face-to-face in the local language (Seraiki). The open-ended in-depth interviews continued until experiences and essences were repeated, and until information saturation was achieved through 10 mothers . The majWithout delays, researchers translated verbatim all the qualitative data obtained from group discussions, semi-structured interviews, and field notes from the local language to the English language. Then, we reviewed all the raw data available and labeled all sentences and text into different colors and codes to find out the common meanings. After this, we grouped similar codes to create broader categories. Next, we had to cross-verify the narratives and remove the inconsistencies, vagueness, and discrepancies. Lastly, codes and categories were analyzed and different themes that affected therapeutic coverage were identified using inductive research methods. In total, seven prominent subthemes subsequently emerged from the whole exploratory qualitative data. In the end, all conspicuous challenges, barriers, and difficulties were subsequently assembled into five leading themes: (1) politico-economic or financial, (2) administrative and planning, (3) logistical, (4) social or cultural capital, and (5) behavioral or interactive see .The ethical approval for this study was acquired from the advanced study and research board (AS&RB) of Quaid-e-Azam University Islamabad in its 307th meeting held on 20 October 2016. The board committed to approving the endorsements of the Dean of the Faculty of Social Sciences to accept the current qualitative and ethnographic research in the Department of Anthropology. In addition to this, the Department of Health District Rajanpur also approved the study protocols and tools. All the participants were thoroughly informed about the nature and purpose of this study before taking their formal consent to be part of this exploratory qualitative research. As the majority of mothers were illiterate, oral consent was provided according to their wish and comfortability. After taking informed verbal consent from all study participants, we promised to ensure their anonymity, privacy, and confidentiality.Our overall qualitative findings revealed the emergence of multiple financial, administrative, logistical, and behavioral difficulties that challenged the CMAM therapeutic program for the treatment of severely malnourished children in the Southern Punjab region of Pakistan.Health priorities at the micro-level are influenced by macro-level incentives. Funding for different national or provincial health or nutrition programs determines the focus of health staff.The national Polio Eradication Program, being the most favorite program, was prioritized by the health bureaucracy. The health department used most of its energy in this program and deprioritized others. “Although the nutrition program has been functional for many years, the staff isn’t free to run this at the district level. The health office gives importance to their routine matters and does not let this kind of vertical program be implemented in full scale and strength”. LHWs coordinate between the community and health department; therefore, they were involved in almost every program, whether provincial or national. They frequently complained that they faced extra work pressure and burden, particularly from the Polio eradication program. Their primary duty was to cover and coordinate with more than two thousand pregnant and lactating females in their concerned outreach areas. Over-involvement reduced their concentration in their original work about child and mother work. The over-involvement of LHWs de-prioritized nutrition activities by the health department. “LHWs are involved in other programs, especially Polio. After working three to five days in the Polio campaign, one LHW would not go into the field because she is already tired. Similarly, in Measles, LHW is fully engaged for 12 days and becomes so fatigued and rarely visits the field for some days, and demands rest. When the department asks working overly and extensively, how she can fill the high gaps created in the nutrition program. This pressure is regular; Polio and other activities are unfinishable”. “Funding availability in the Polio eradication program was the leading cause of why the health department Punjab always engaged LHWs for only this at the stake of another important program because their funding was low or none. It was owing to this fact that LHWs always wandered for Polio drops and skipped nutritional screening and education”. In Southern Punjab, several LHW posts were vacant according to reports of the district health information system. Out of a total of 900, only 650 LHW seats were filled, which showed that the covered-up population in the district was 44%. LHWs felt dissatisfaction with the lower salary packages and other allowances. Logistical and cultural hurdles, along with extra workload, jointly restricted their will and motivation. On many occasions, many of them took this duty as no more than a formality just because they could not merely refuse orders from the department. As a result, they ignored visiting assigned households regularly due to low salaries and poor economic incentives. Many LHWs were not well trained in anthropometric measurements of mothers and children for screening purposes. Unfortunately, these LHWs in the least developed areas were not appointed or even remained absent. Many of these LHWs reported that their performance was perfect, and they tried to justify their role. They always report that everything was going well. One official remarked:“LHWs are called almost every week, sometimes for meetings, sometimes for training, or sometimes for another task. She has to maintain and carry multiple registers. I mean, it’s a serious matter that needs to be seen and fixed. The patients from remote rural and tribal areas are missed; SAM cases are from remote areas, where there is a water problem, and access is limited. So cases mostly come from rural areas”. The training of field staff, screening, referral of SAM cases, and distribution of therapeutic food are compromised due to the weak administration of the program.In 2008, the Government of Punjab recruited Health and Nutrition Supervisors at the BHU level to screen and train the community on common health diseases and nutritional issues. However, many of the remote BHUs missed them as there was no infrastructure. Since their creation, they have barely taken part in any significant nutrition intervention in the district. Their role in CMAM was never acknowledged until recently when the multisectoral nutrition center (MNSC) at the provincial level anticipated their future participation in the province of Punjab in a report in 2017. They were not fully trained on nutritional issues and, hence, lacked relevant knowledge about the causes and treatment of malnutrition. It was reported that an international organization (Micronutrient Initiatives (MI)) had trained them on the importance of micronutrient iodine for mothers and children. Therefore, these supervisors were mostly assigned monitoring duties for Polio, EPI, and dengue prevention programs instead of nutrition. However, they were properly trained on malnutrition for the first time in 2017 after 9 years of recruitment, which showed the lack of coordination and failure of the precise job description. This also showed a weak commitment to combatting malnutrition, lack of vision, and relevant policy failures. The staff appointed at remote health units rarely performed duties because of insecure environments, a lack of monitoring mechanisms, dilapidated hospital buildings, damaged roads, and a lack of transport facilities. These isolated areas are those where more attention is needed. Most recently, new district coordinators were recruited by the multisector nutrition center who also need training on nutrition issues.“There are gaps….as the district coordinator of the malnutrition addressing committee has only one or two meetings with the Deputy Commissioner of the district. Also, MSNC established by the Planning and Development Commission of Punjab province has recruited district coordinators, but they are new and have no significant work to do. Nutrition supervisors are also not so trained and involved, nor can they help measure and refer malnutrition cases, but their involvement is limited to the polio program. Although all these have been appointed, they have no work to do, except work on special weeks. Recently, we called nutrition supervisors on nutrition week. They were assigned to distribute multi-nutrient sachets in their schools as area in-charges, but they are not really in much coordination”. Intrahospital or staff interpersonal politics at the Basic Health Units (BHUs) level emerged as one of the most significant reasons behind the weak referral of SAM cases to the SC at District Headquarters Hospital (DHQ). It was remarked that:“The cases which reach DHQ without a referral are admitted right away, but SAM referral is constrained and slow, especially, people from remote rural areas are in great need because of the weak and poor referral system to the Stabilization Centre. Every month LAMA (who quit treatment) cases are increasing; 4–5 SAM cases are admitted daily, totaling approximately 120–150 in one month. Most of these cases are located at the basic health unit (BHU) level. For the treatment of SAM, it is very difficult to screen a child with a complication from the field by these LHWs through Mid Upper Arm Circumference (MUAC). LHW refers these SAM cases to Lady Health Visitor (LHV) who has to verify MUAC and complications, and forward complicated SAM cases to DHQ by an “1134 ambulance service”. After the anthropometric screening, LHWs generally referred malnourished mothers and children to BHUs and Rural Health Centers. However, many mothers were kept waiting unnecessarily by Lady Health Supervisors (LHSs) appointed at BHUs. Many poor and illiterate mothers left health units because they felt they were being ignored, unattended, and devalued by these LHSs. “LHW and LHV are often at odds with each other. Sometimes LHS dislikes an LHW, who insists on checking children immediately. Every LHW expects that she has hardly convinced and referred parents of SAM case to BHU, so now LHS should give priority so that it could be further referred to Stabilization Centre at DHQ. LHS asks LHW to ‘wait outside’ and does not attend to the case even after hours. This is how SAM cases leave hope for treatment and run away, and this is why referral of severely malnourished children with complications is minimum. However, a child specialist and nutrition staff, specified for this work only, are readily available at SC; therefore, SAM cases are measured and admitted without trouble. However, people from only nearby areas can reach directly to SC, but cases from remote areas have to be ignored”. The presence of formula milk companies inside hospitals and the sale of not-for-sale RUTF were two significant factors. Although banned theoretically, representatives of the multinational formula milk were reported to move freely in the SC, BHUs, and RHCs for advertising and selling formula milk to the poor parents of severely SAM children. “Soon after recovering from complicated SAM, mothers were motivated to try their products. The company trains its agent to remain alert and keep an eye on every person monitoring and conducting research. They are well trained in rapport building with medical staff and patients’ attendants for convincing them to use their products after the advertisement. Nobody ever restricted such active advertisement and sale”. Therapeutic food was reported to be sold out at the hands of some LHWs. These packets of therapeutic food are not for sale. It was informed by community members that the Plumpy-Nuts were being sold out at some places at the price of PKR 20–30 per sachet by a few LHWs. A mother indicated: “I requested our LHW to give some food but she refused. I threatened one such LHW who used to sell it by saying, ‘give some sachets for my son, or else I would complain against you that you sell off the therapeutic food illegally.’ Never were any actions taken against such complaints by the concerned authorities”. “The distribution of therapeutic food is not altogether transparent and fair. Health staff often prefer and prioritize their relatives and close ones first whenever the task of providing therapeutic food is given to them”. Relationships with those who control power, access to information, and interpersonal skills necessary to communicate are essential requirements for becoming beneficiaries of development programs.When asked whether the field staff visited your area or household and what were the impacts of therapeutic food, most respondents agreed that the milk provided at the stabilization center and RUTF had a good impact on the sick child. The majority of the enrolled mothers in CMAM showed that their children were recovering gradually. In their opinion, the specialized medical milk (75/100) and RUTF brought a positive impact on their severely malnourished children. When asked how mothers came to know about the treatment of severely malnourished children at stabilization centers or CMAM, most parents revealed that they were referred by the medical community or people from urban centers told them about this program and suggested visiting the nutrition Stabilization Centre at DHQ to obtain special milk (75/100) for malnourished babies. “Doctors, LHWs, and active community members helped to refer us to the CMAM program and SC, for therapeutic 75 milk for the severely malnourished baby”. “LHWs visited our area and told us to bring milk from CMAM staff; vaccinators also visit and inform us about the program”. “LHWs do not visit our area, but vaccinators do once a year so we sometimes bring our children to the hospital for immunization and sometimes not. People from the city informed us about this program; they suggested us to visit Stabilization Centre because milk [75/100] was being distributed there”. Only a few parents reached the SC without any referral, which implies how different local forms of social capital or relationships helped mainly urban or peri-urban families to become beneficiaries and isolate and seclude the majority of the most deserving remote, rural, illiterate, and lower-income families with lower social capital. “We, the females, are carrying this unfortunate child without any help from other family members. I am a mother, how can I leave him alone in this condition, only my heart knows how much disturbed I am. No one can realize the state of my heart; I cannot see my child suffer. I am in profound psychological distress. When will my child feel normal and healthy, I don’t know. I have tried my best to make him healthy and nourished. We have wandered everywhere, here and there, to find if someone could suggest a better way. Recently a person from our neighborhood informed us about this program, I requested my mother to test this place [Stabilization Center] too”. Treatment of complicated SAM children requires their mothers and other caregivers to stay at the SC for some days until the child is stabilized and can come to the simple RUTF stage. However, most mothers complained they had to leave medical advice due to logistical hurdles.The poorest of the poor mostly live in risky, far remote, and underdeveloped areas. Geography is one of the central causes of inequities in health and nutrition. Results showed that distance emerged as a substantial barrier to coverage and access to health and nutrition programs. Logistical problems emerged as the most significant reasons for low access. The bad transportation, long travel times, damaged roads, and long distances to the site were the major determinants of little coverage. Females are less empowered in these settings due to the lowest access to healthcare facilities and literacy and employment opportunities. One mother stated, “We are tired and we still have to travel”. The mother informed that they reached the stabilization center after much difficulty and running errands:“The [Nutrition stabilization] center is very far from our village, and it took hours to get there. We had to catch several types of transport; the first motorcycle from our community to another town, then an auto-rickshaw to the main highway. After it, we had to catch a bus from the road to reach the district bus stand. From the bus stand to the hospital, we had to hire an auto again. After wandering here and there madly in the hospital building, we reached the stabilization center by asking for addresses with the help of so many people. We got tired when we arrived here, and we still have to travel, we’ll have to go back home as it is not allowed to stay without permission”. Many mothers insisted on the hospital staff that they wanted to treat the complicated SAM children at home. SC staff had objections to this idea because the condition of the severely malnourished children was unstable, and they were required to stay until the children became stable in the center. The Punjab government previously claimed to set up SCs at the sub-district level, but activities at the SCs were being limited at the district level, and at any time, the program may come to an end. UNICEF in Pakistan has recently intended to study the bottlenecks in the CMAM program. This indicates that these programs are still under the control of UN agencies and the government lacks ownership.“Convincing parents about the treatment at SC is a very complex task. Mental preparation of family and parents is essential for this because a mother or someone from the family has to stay for at least four days. They have to prepare their basket or bag”. The other strong reason for low therapeutic coverage was the loss of income if the mother and father were to stay at the SC receiving the treatment for only one severely malnourished child and ignoring the rest of their children. This made them indifferent to complete treatment. Therefore, most grandmothers had to stay at the SC. Mothers could not stay longer, because no one could take care of the rest of the children at home. During crop season, poor rural mothers could rarely afford to give proper time for treatment and health-seeking. Some domestic servants also complained about working hours. As they could not escape from their duty, they delayed check-ups and treatments of complicated SAM children. If mothers had to stay, they had to bring all of their kids along with them to the SC at the district headquarters hospital. As children were unaware of cross-infections at the sites, they were playing in the hospital’s wards, touching the floor with their hands, and eating foods there without handwashing.Another critical factor of low coverage of the therapeutic program in rural and Southern districts of Punjab province in Pakistan involves the elements of stigma, respect, and dignity.Many poor parents felt stigmatized and complained of being unattended at the hands of the hospital and nutrition staff. Illiterate people with low socioeconomic status had low confidence to communicate with hospital staff and feared being insulted by the doctor and staff. The behavior of the staff was not supportive. Sometimes staff felt irritated by the poor’s dirty clothes. CMAM staff was often reported to have been rude to mothers of severely malnourished children. you are always here to get this milk”. Once, a female nutrition staff member threw the packets of formula milk 75 toward a mother in a very disgusting mood and said angrily, “hold this packet and get out”. In another instance, when a poor mother brought her child to the stabilization center for the treatment of SAM, the on-duty staff responded “take your dirty luggage from here; it smells stinky”. Multiple times, mothers indicated taunts and offensive remarks and the mothers felt ashamed of this embarrassing situation. For example, on one occasion, a nutrition assistant at the SC vocalized to a mother, “Complaints about not being attended to by low-income parents were much more common. Mothers explained how the staff at the nutrition stabilization center was indifferent, careless, and rude.“We would wait all day and night, but no person attended a little. The sick child used to cry all night as they would give our child nothing to eat and drink. We were worried when the doctor and staff would pay attention to our child. Leaving such treatment [of indifference and disgust] would be better than just wasting time [in wait] here”. “My husband said to SC staff ‘my child is hungry, and you pay no attention. I do not want to leave my sick child as hungry all night.’ Nurses complained about my husband to the head doctor, who called him and insulted him. My husband got disheartened and finally decided to quit the treatment at this center”. This study discovered mothers’ interactions with the biomedical treatment and therapeutic system of the CMAM program and nutrition stabilization center. It specifically explored how poor, illiterate, and rural women were often incapable of navigating the therapeutic coverage and politics with institutions. These difficulties were perilous for many women, mainly from remote and secluded areas, who were illiterate and lacked the required minimum cultural assets and social skills to negotiate the complex and unfamiliar setting . Women’sFamilies, who had some links within local power circles , received better chances of coverage. To combat the problem of malnutrition, the government needed to change priorities. At the primary level, deprioritization of the “nutrition program” in comparison with the “Polio eradication program” resulted because of heavy international funding for the latter. This suggests that the government must increase funds for nutrition . FurtherThe poor rely on traditional treatment methods because of their low income. Stigmatization and the trust deficit of the poor in government departments are strong indicators of low biomedical service utilization along with expensive and uncontrolled private clinicians’ prevalence that need urgent policy decisions. This study showed that the medical staff did not care much about the marginalized victims of social stigma and ignored the poor’s feelings . The futEvidence showed that nearly half of the population in several rural districts was not covered by LHW, especially in the most remote and the poorest areas ,38. UNICSome respondents revealed that therapeutic food was being sold off by LHWs, and representatives of formula milk producers were free to move into hospital settings. There is evidence that formula milk companies ignore the laws and continue marketing their products inappropriately . The litMany poor, illiterate, and rural mothers indicated that they faced rude behavior and stigma in medical settings. In a study in the Kenyan context, analogous shame, stigma, and discomfort at health clinics related to malnutrition and fear of mistreatment at the hands of the biomedical staff were noted as the most significant barriers to treatment for childhood acute malnutrition , which pOur findings showed that mothers faced logistical difficulties. Evidence in Guatemala similarly showed that poor women suffered from running errands . SimilarThis article monitors mothers’ interactions while accessing the nutrition-specific CMAM program. In doing so, it proposes that a “politics of neglect” is at play in these programs in neglecting the social body and poorer sections of society in the program’s target areas. These interventions do not consider processes of power and exploitation and ignore the complex and unequal social relations. The narratives showed how the poor often faced structural inequities and social exclusion due to a lack of social or cultural capital. Evidence showed that the poorest of the poor and low-caste families with the lowest social capital in Punjab were excluded from the cash transfers program (nutrition-sensitive program) at the will of local political leaders . Some ofAccording to Bourdieu , culturaIn addition, CMAM is a short-term curative measure, especially in emergency contexts. Not aligned well with local socio-cultural realities, the short-term global technical solution in the form of RUTFs and CMAM was implemented “under neoliberal governments and facilitated an increasingly inequitable economy with minimal state involvement in an increasingly individualistic social environment”.  (p. 16).The CMAM program in Southern Pakistan encounters multiple social, economic, and structural obstacles. First, funding in nutrition as compared with other programs deprioritizes officials’ interest in nutrition and involves LHWs in other multiple tasks that increase their work burden and divert their attention from maternal-child health and nutrition. In addition, the corruption in food distribution and the unethical sale of RUTF by LHWs are reported, which need strict monitoring and fair dispensation. The normalization of social exclusion has roots in politico-economic and structural inequalities. The study includes the following recommendations: prioritizing more funding for nutrition; proper training of field staff; improving screening skills and referral of SAM cases; providing traveling incentives to needy, illiterate, and rural mothers; devolving the child stabilization service at the micro (UC/BHU) level; distributing RUTF fairly by LHWs; treating parents politely. Finally, vacant LHWs’ seats in remote rural areas demand urgent allocation.


Furthermore, there was a significant reduction in diarrheal prevalence for all participants (adults and children)  0.35, 95% CI: 0.14–0.85) and for children under 5 years of age  during the 3-month program. (d) Conclusions: These findings demonstrate that the CHoBI7 Cholera Rapid Response Program is effective in lowering diarrhea prevalence and increasing handwashing with soap for a population at high risk of cholera.(a) Objective: To build an evidence base on effective water, sanitation, and hygiene interventions to reduce diarrheal diseases in cholera hotspots, we developed the CHoBI7 Cholera Rapid Response Program. (b) Methods: Once a cholera patient  is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot (households within 20 m of a cholera patient) through both in-person visits during the first week and bi-weekly WASH mobile messages for the 3-month program period. A randomized controlled trial of the CHoBI7 Cholera Rapid Response Program was conducted with 284 participants in 15 cholera hotspots around cholera patients in urban Dhaka, Bangladesh. This program was compared to the standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured observation of handwashing with soap and diarrhea surveillance was conducted monthly. (c) Findings: Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints (overall 54% in the CHoBI7 arm vs. 23% in the standard arm,  Globally, 2.9 million cholera cases and 95,000 cholera deaths are estimated to occur annually in cholera-endemic countries. In Bangladesh alone, there are estimated to be over 160,000 cholera cases and 5000 deaths each year ,4. PreviIndividuals living in close proximity to cholera patients are at an increased risk of subsequent cholera infections ,10,11. TThe standard of care in Bangladesh for cholera patients at the time of discharge from the health facility is to give these patients oral rehydration solution (ORS) for rehydration. There is no standard of care for the family members of cholera patients despite them being at >100 times higher risk of developing cholera infections than the general population during the one-week period after the index patient seeks care at a health facility ,12,13. TTo evaluate the efficacy of the targeted CHoBI7 WASH intervention in reducing cholera infections among household members of cholera patients during their 7-day high-risk period, we conducted a randomized controlled trial (RCT) of CHoBI7 from 2013 to 2014. We compared the CHoBI7 WASH intervention to the standard recommendation given in Bangladesh to diarrhea patients at discharge on ORS use. Delivery of the CHoBI7 intervention to cholera patient households resulted in a 47% reduction in overall cholera infections and a significant reduction in symptomatic cholera during the 7-day high-risk period for subsequent cholera infections .To expand the evidence base on CHoBI7 further to those residing in cholera hotspots around cholera patients, in the present study, we developed the CHoBI7 Cholera Rapid Response Program. For this program, when a cholera patient confirmed by bacterial culture is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot where the patient resides (areas within 20 m of cholera patient households) through both in-person visits during the 7-day high-risk period and bi-weekly WASH mobile messages for the 3-month program period. In this study, we conducted an RCT of the CHoBI7 Cholera Rapid Response Program to evaluate the efficacy of this intervention in reducing diarrheal diseases and increasing handwashing with soap and water treatment behaviors.Vibrio cholerae was one of the enteric pathogens assessed by bacterial culture through this diarrheal surveillance system. The cluster RCT compared the standard recommendation given in Bangladesh to diarrhea patients at discharge from health facility staff on ORS use for rehydration (standard message arm) to the CHoBI7 Cholera Rapid Response Program. The trial is registered at ClinicalTrials.gov (NCT04816552).The CHoBI7 Cholera Rapid Response Program RCT was a two-arm cluster RCT conducted in urban Dhaka, Bangladesh, from 22 March 2021 to 28 November 2021, where a cholera hotspot was a ring of 20 m around the residence of a cholera patient. All eligible households meeting our study eligibility criteria were enrolled. A 20-m ring was selected to include households at the highest risk for subsequent cholera infections . CholeraThis study did not include the public in the design, or conduct, reporting, or dissemination plans. Patients and those living in cholera hotspots contributed to intervention design through in-depth interviews conducted during formative research reported elsewhere .All study procedures were approved by the research Ethical Review Committee of International Centre for Diarrhoeal Disease Research, Bangladesh , Dhaka, and the Institutional Review Board of The Johns Hopkins Bloomberg School of Public Health . All study participants provided informed consent. Adult participants (>18 years of age) signed an informed consent and/or parental consent form, and children 12–17 years of age signed an assent form. If a study participant could not read, the consent form was read to him or her, and the participant was then asked to document his or her consent with an X in the presence of a witness. All evaluation and intervention team members received intensive training when the study began and then quarterly refresher trainings to reduce the likelihood of bias in intervention and evaluation activity delivery.In order to be eligible for the trial, households had to: (1) not have running water inside their home (mostly slum areas of Dhaka); (2) report ownership of an active mobile phone in their possession on the day of enrollment; and (3) have a child under five years of age in their household . The study biostatistician (JP) assigned randomization using the software R version 3.3.0. JP did not have involvement in data collection activities for the trial. Block randomization of cholera hotspots was performed based on a randomly permuted block of size 2 prior to the start of the RCT using a random number generator. The study arm assignment was revealed to the study coordinator by the study biostatistician. Blinding was not possible because the intervention had visible components. To minimize bias, we used two separate teams for intervention and evaluation activities. Both the standard recommendation and CHoBI7 Cholera Rapid Response Program arms received the standard recommendation given in Bangladesh to diarrhea patients at discharge from health facility staff on ORS use for rehydration using a pamphlet produced by the government of Bangladesh. The CHoBI7 Cholera Rapid Response Program was developed through a theory-based approach informed by the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) and the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) Model ,17. A deThe CHoBI7 Cholera Rapid Response Program has three components for intervention delivery: (1) in-person visits (two home visits and one community session); (2) a cholera prevention package; and (3) weekly mHealth messages for 3 months. The two home visits and one community session  are delivered by health promoters during the 7-day high-risk period after the cholera patient is identified in a cholera hotspot, within 48–72 h of cholera patient identification at the health facility. In-person intervention visits included the delivery of a flipbook explaining cholera transmission pathways through narratives of stories of actual families and modules explaining the importance of and how to properly wash hands with soap and water, how to treat drinking water using chlorine tablets and boiling, and how to safely store drinking water. The cholera prevention package provided to each household contains the following items: a 7-day supply of chlorine tablets for water treatment, a soapy water bottle containing water and detergent powder , a handwashing station, and a water vessel with a lid and tap to ensure safe water storage. WASH mHealth messages, including voice, interactive voice response (IVR), and text messages, are sent bi-weekly for 3 months. These mobile messages are sent by study staff using the web-based VIAMO mobile platform to all phone numbers provided by study households. Two characters deliver the CHoBI7 mHealth messages: Dr. Chobi and Aklima . Dr. ChoDiarrhea was defined as at least three or more loose stools over a 24-h period in the preceding week. Clinical surveillance for diarrhea was performed at baseline enrollment and monthly thereafter until the 3-month time point for all enrolled household members through in-person visits by evaluation research assistants. For children under 12 years of age, diarrhea was assessed through caregiver reports. In order to observe handwashing behaviors, 5-h structured observation was conducted in households from 7:30 a.m. to 12:30 p.m. at 1 week and 1 and 3 months after enrollment. Handwashing with soap was recorded at food- and stool-related events. To assess the presence of soapy water on the household compound (promoted as part of the intervention activities) and the presence of free available chlorine in household stored drinking water (a measure of household water treatment practices), unannounced spot checks were performed in all households at 1 week and 1 and 3 months after enrollment.Primary outcomes were: (1) individuals handwashing with soap at food- and stool-related events during 5-h structured observation (a measure of handwashing compliance)  at week 1 and 1 and 3 months after enrollment; and (2) presence of chlorine > 0.2 mg/L in household stored drinking water at week 1 and 1 and 3 months after enrollment. (Secondary outcomes were: (1) the prevalence of diarrhea among all age groups and children under 5 years over the 3-month study period based on monthly clinical surveillance; (2) presence of soapy water on the household compound at week 1 and 1 and 3 months after enrollment.Our original sample size was 300 households from 60 cholera hotspots; however, due to the ongoing COVID-19 pandemic stopping study activities due to lockdowns in 2021, we only achieved recruitment of 73 households from 15 cholera hotspots. This power calculation for the primary outcome is described in Between March and November 2021, we randomly allocated 7 cholera hotspots to the CHoBI7 Cholera Rapid Response Program arm and 8 cholera hotspots to the standard message arm  with a total of 284 participants from 73 households . Eight pCompared to the standard message arm, all age groups combined (children and adults) had significantly lower 3-month diarrhea prevalence in the CHoBI7 Cholera Rapid Response Program arm : 0.14–0.85])  vs. 4% (CHoBI7 arm)). Children <5 years of age also had significantly lower diarrhea prevalence in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm (PR: 0.27 [95% CI: 0.09–0.87])  . Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints  . CHoBI7 Cholera Rapid Response Program arm households also had significantly higher free available chlorine >0.2 mg/L in stored drinking water at Week 1  compared to the standard message arm, however not at Month 1  (after the 7-day supply of chlorine tablets was completed). Neither study arm had chlorine present > 0.2 mg/L in stored drinking water at the 3-month follow-up.Compared to the standard message arm, where no households had a soapy water bottle present on the household compound, the CHoBI7 Cholera Rapid Response Program arm had 97% (33/34) households at Week 1, 92% (24/26) of households at Month 1, and 91% (21/23) of households at Month 3 with a soapy water bottle present during unannounced spot checks on the household compound . This finding suggests that there are not large differences in WASH behaviors with the delivery of CHoBI7 between these two different populations at high risk of diarrheal diseases. This was surprising given that one would suspect higher WASH behaviors in households where a family member had severe diarrhea compared to those that have only a neighboring household with severe diarrhea. Future mixed method studies that explore the psychosocial factors driving WASH behaviors among these two populations in parallel are needed to understand further the reason for this finding. Rapid delivery of cholera response programs after a cholera patient is identified in an area is crucial to the success of program implementation. A previous study in Haiti found that cholera rapid response teams that were delivered quicker could reduce the number of suspected cholera cases and shorten the outbreak duration . HoweverIn the present study, we focused on households within 20 m of cholera patients. There is substantial variability in the cluster size for the delivery of cholera rapid response programs . In DRC,Vibrio cholerae in the stool of participants living in cholera hotspots. We have an ongoing separate randomized controlled trial that will evaluate the impact of the CHoBI7 program on reducing cholera for those living in cholera hotspots nearby cholera patients.This study has some limitations. First, our sample size was much smaller than planned because of lockdowns in 2021 due to the ongoing COVID-19 pandemic. Nevertheless, the CHoBI7 Cholera Rapid Response Program was found to be effective in reducing diarrhea and WASH behaviors even with this much smaller than expected sample size. Second, we conducted our study in an urban setting which limits the generalizability of our findings to rural settings. Third, we did not measure This study has several strengths. First is defining cholera hotspots as locations where a bacterial culture-confirmed cholera patient resided within 20 m, building on previous studies that define cholera hotspots based on suspected cholera cases. Second, our clinical surveillance included both adults and children, building on previous cholera studies that excluded diarrhea for children under 5 years of age. Third is performing structured observation of handwashing with soap and unannounced spot checks of chlorine concentrations and soapy water bottles at multiple timepoints, which allowed us to observe these WASH behaviors prospectively over time.The CHoBI7 Cholera Rapid Response Program significantly lowered diarrhea and increased handwashing with soap and water treatment behaviors over our 3-month study period. These promising findings suggest that delivering the CHoBI7 Cholera Rapid Response Program to households in cholera hotspots in urban Bangladesh can serve as an effective approach to increase WASH behaviors and reduce diarrheal diseases among this high-risk population. Future studies are needed that investigate the impact of this program on cholera transmission in this setting.


Gerofit, an evidence-based supervised exercise and health promotion program for older Veterans, has demonstrated success with its best practice model through the improved health, physical function, and well-being of participants. In 2017, Cincinnati VA Medical Center (CVAMC) launched an innovative approach to address the staffing needs of this wellness program by utilizing a Physical Therapy (PT) resident model for Gerofit group supervision/functional testing. As licensed PTs, residents engage in year-long advanced training in geriatrics across a variety of settings. They encounter adults who have unhealthy behaviors , and demonstrate the knowledge/skills to reduce risk factors, prevent/treat chronic disease, prescribe physical activity/exercise, perform interventions consistent with the biopsychosocial paradigm, design/deliver individualized exercise prescriptions, and lead telehealth group exercises classes for Veterans. This presentation will explore how PT residents are in an ideal position to promote health/wellness in the Gerofit Program.


Infection is a significant factor adversely affecting the health of nursing home (NH) residents, potentially even leading to death. Therefore, educating NH staff to think critically is necessary to prevent and control infection. In this study, we developed an electronic problem-based learning (e-PBL) program using the Network-Based Instructional System Design model to enhance South Korean NH staff’s critical thinking competencies; subsequently, its effectiveness was evaluated. This study utilized a quasi-experimental nonequivalent pretest–post-test design. The participants (n = 54) were randomly allocated into an experimental group (n = 28) and a control group (n = 26). The results indicate that the e-PBL program significantly improved the critical thinking disposition in the experimental group compared with in the control group. Frail residents in high-density nursing homes (NHs) are at high risk of infectious diseases ,2. Such In NH settings, the early detection and prevention of infections is paramount, while in acute medical settings the focus lies on treatment . RecogniCritical thinking refers to an individual’s competence in applying higher-order cognitive skills and his/her disposition to deliberate on a logical course of action for solving new problems . Chang ePBL is known as an effective educational strategy that can improve critical thinking in many healthcare disciplines ,15. PBL-PBL is a new learning paradigm that emerged in the mid-1960s . It was The teacher develops problems based on unstructured situations and presents them as assignments to students. The teacher also guides students in collecting and exploring learning materials to help them solve these tasks. The PBL process structured in eight steps are as follows: (1) arousing students’ doubts about problems, (2) prior to studying problems, (3) raising questions, (4) defining the scope of knowledge, (5) proposing an information acquisition plan, (6) conducting research, (7) sharing information and (8) concluding . In thisThis study’s research process was divided into the educational program’s development and the evaluation of its effects.This study followed the Network-Based Instructional System Design model to develop the educational program . The modIn Step 1, the characteristics of the learners and the educational contents were identified by analyzing learners’ needs and conducting a literature review. To analyze learners’ needs, in-depth interviews were conducted with nine practitioners in NHs. The average age of the participants was 48.25 ± 11.76 years. All of the participants had used the e-learning training program before. Each individual’s work experience was varied, with an average of 5.44 ± 2.50 years. Eight registered nurses and one nurse assistant participated in the interviews, which lasted 60 min. Semi-structured questions regarding infection control education goals and contents, educational media, and training time were used. The findings of the in-depth interview are as follows. The goals and contents in NHs focus on early detection and prevention rather than on the treatment of infections. Furthermore, e-learning has been confirmed as a suitable educational medium due to the nature of the intervention during the COVID-19 pandemic and the nursing staff’s workloads. Regarding training time, it was decided that 2–3 h was an appropriate duration. The literature review showed that PBL is a suitable educational method for improving nurses’ judgment for early detection and prevention of infection . The praThe program was designed considering the educational goals and contents identified in the analysis stage, the educational medium, and the training time. Text and multimedia materials suitable for the learning topic were collected and composed in PowerPoint. The PBL contents were constructed based on various infection control cases collected from the in-depth interviews to enhance the suitability of the problem scenario. For communication between learners and educators, technical support was established via instant messaging, chatbot.The first author (Y-R.) created a storyboard based on the educational content confirmed at the design stage and then discussed it with the e-learning program producer to develop the program. The program contents were finalized by modifying and supplementing the educational contents through discussion between one professor of nursing and two doctors of nursing. The program was developed to be optimized in the Chrome environment as a software tool. The expanded educational program was pilot-tested over two weeks.Participants joined guided meetings in which they were trained on how to use the program and the related procedures, and the necessary guide materials were provided. The education program was made available to NH staff through a website for two weeks, beginning 30 December 2021. The research team responded to the learners’ questions regarding the use of the program and learning contents through a chatbot and checked the web page for errors.The critical thinking of NH staff was evaluated to judge the effectiveness of the e-PBL education program. Granting that the PBL education improves learner’s critical thinking abilities in clarifying, understanding, and analyzing problems and making inference for creative solutions, evaluating critical thinking means measuring a long-term meaningful improvement of education ,27. The A nonequivalent control group pretest–post-test design was used . We compThis study was conducted with 54 NH staff working in Seoul and Gyeonggi Province in South Korea. The selection criteria were as follows: currently working and providing direct nursing care as nurses, care workers, or nursing assistants in NHs. To assess the effects of the education program, individuals who had difficulties using computers were excluded from this study. Using G*Power 3.1.9.4 software, it was determined that for an effect size of 0.80, significance level of 0.05, and power of 0.80, a sample size of 52 would be appropriate . A totalThe Critical Thinking Disposition Tool developed by Yoon was used to assess the participants’ critical thinking . The scaIntellectual eagerness/curiosity: Having a desire to learn and an attitude to search for answers to problems and to pose new problems.Prudence: Withholding judgment and pursuing results accurately until valid and sufficient evidence is obtained.Self-confidence: Believing in one’s reasoning process and drawing valid conclusions through critical thinking.Systematicity: Not deviating from the core of the problem being discussed, exploring it systematically and in an orderly manner, and maintaining logical consistency until reaching a conclusion.Intellectual fairness: Fairly evaluating one’s own and others’ opinions while seeking the truth with an open mind.Healthy skepticism: Simultaneously acknowledging and questioning generally accepted facts.Objectivity: Drawing conclusions based on valid evidence and taking a position when evidence and reasons are sufficient.To measure the participants’ satisfaction with the program contents, we used a 5-point Likert scale (1 = absolutely not satisfied to 5 = absolutely satisfied).t-test were performed to confirm respondents’ differences in critical thinking disposition before and after the program. All analyses were validated at a significance level of 0.05.IBM SPSS version 25.0 software was used to analyze the data. Descriptive statistics and a two-sample Ethical approval was obtained from the institutional review board of the first author’s university (KUIRB-2021-0057-01). Written informed consent was obtained from all participants.The e-PBL-based infection control education program developed in this study was designed to solve problematic situations related to infection control in NH settings through a step-by-step learning process. p < 0.001). However, among the subcategories of healthy skepticism , intellectual eagerness/curiosity , and intellectual fairness , there was no statistically significant difference between the two groups. However, for self-confidence , systematicity  prudence , and objectivity , we identified a statistically significant difference between the two groups (There was a statistically significant difference between the two groups, with a difference of 0.15 ± 0.14 points in the pre- and post-scores for the 27 questions in the critical thinking disposition of the experimental group and 0.04 ± 0.07 in the control group (t = −5.006, o groups .In high-density NHs, where residents are vulnerable to various infectious diseases, including COVID-19, it is crucial to improve the staff’s competency to prevent and care for them. This study developed and evaluated an educational program for improving the critical thinking disposition of NH staff to improve their infection control capabilities.The key contribution of this study is the development of an effective educational program to improve the critical thinking disposition of NH staff for the early detection of infection signs and symptoms of NH residents. The goal of the educational program developed in this study was to improve NH staff’s capability for the early detection of infection signs and symptoms in NH residents. Early detection is the most important factor for resident care in NHs ,32 becauWeb-based education has become commonplace in various educational fields, especially after the COVID-19 pandemic ,35. FurtThe findings confirmed that the critical thinking of NH staff improved significantly after using the e-PBL-based education program. In the existing literature, PBL has been widely used as an educational method to stimulate critical thinking; however, prior studies’ findings are inconsistent. Some studies have shown that PBL improves critical thinking ,40, whilIn this study, an e-PBL-based educational program significantly improved the total scores measuring the critical thinking disposition. This indicates that the education program is effective at improving the NH staff’s critical thinking involved in incorporating their knowledge and residents’ sign and symptoms of infection to determine possible solutions ,27. HoweBoth groups exhibited no statistically significant difference in intellectual eagerness/curiosity. This is because extroverted learners have been reported to have high intellectual eagerness/curiosity and introverted learners to possess high prudence . AlthougOne limitation of this study was that the participants interviewed were a convenience sample; however, all participants were qualified staff in NHs with more than 5 years of working experience who could practice infection control for residents. Furthermore, we could not measure changes in critical thinking disposition over time. It is therefore necessary to confirm the program’s long-term effects via studies with longer durations.The purpose of this study was to suggest an effective way to improve infection management by enhancing the critical thinking and problem-solving ability of NH staff rather than to immediately reduce the infection rate; therefore, we did not measure the exact change in the incidence of residents’ infections. It will be possible to conduct a study that targets a reduction in the incidence of infection in NHs over a lengthy period of time through other research designs in the future.The developed e-PBL-based educational program sheds light on the new direction of NH education. A chatbot-assisted interactive web program can be employed to help NH staff improve their critical thinking disposition to solve infectious problems. Unlike conventional education, which is constrained by time and space, this online education could generate more effective outcomes and increase learners’ satisfaction. The program could be adapted to include nursing problems other than infection control, expanding on the ways NH staff could by instructed in competent practices for resident care.Pandemics such as COVID-19 pose a considerable risk to NH residents’ health. This study identified the effect of an e-PBL-based education program for infectious disease management competency on NH staff’s critical thinking disposition. Based on the present findings, we propose the development of a study on the long-term effects of the program and the development of mobile device education content.