ABR 2012/2014 initiative and the MedPhys Match. This work quantifies these changes and summarizes available reports, surveys, and statistics on education and training.The education and training landscape has been profoundly reshaped by the CAMPEP‐accredited program websites, annual CAMPEP graduate and residency program reports, and surveys on the MedPhys Match and Professional Doctorate degree (DMP).We evaluate data from CAMPEP‐accredited graduate programs rose from 210 to 332, while CAMPEP‐accredited residency positions rose from 60 to 134. We estimate that approximately 60% of graduates of CAMPEP‐accredited graduate programs intend to enter clinical practice, however, only 36% of graduates were successful in acquiring a residency position in 2015. The maximum residency placement percentage for a graduate program is 70%, while the median for all programs is only 22%. Overall residency placement percentage for CAMPEP‐accredited program graduates from 2011–2015 was approximately 38% and 25% for those with a PhD and MS, respectively. The disparity between the number of clinically oriented graduates and available residency positions is perceived as a significant problem by over 70% of MedPhys Match participants responding to a post‐match survey. Approximately 32% of these respondents indicated that prior knowledge of this situation would have changed their decision to pursue graduate education in medical physics.From 2009–2015, the number of graduates from These data reveal a substantial disparity between the number of residency training positions and graduate students interested in these positions, and a substantial variability in residency placement percentage across graduate programs. Comprehensive data regarding current and projected supply and demand within the medical physics workforce are needed for perspective on these numbers. While the long‐term effects of changes in the education and training infrastructure are still unclear, available survey data suggest that these changes could negatively affect potential entrants to the profession. This period of change followed the widespread implementation of specialized, physics‐intensive procedures such as image‐guided radiation therapy and intensity‐modulated radiation therapy, contributing to a demand for medical physics graduates that was much higher than supply.Medical Physics Point/Counterpoint article suggesting that graduation from an accredited graduate or residency program should be a prerequisite for board certification.A proposed solution was published in a 2000 Medical Physics in 2008.In 2008, AAPM Task Group 133 published the report “Alternative Clinical Training Pathways for Medical Physicists.”In contrast to the situation 10 yr ago, the supply of graduates of CAMPEP‐accredited graduate programs is now greater than the clinical demand.The purpose of this work is to summarize the relevant statistics and reports addressing the recent changes in the medical physics education and training landscape and to investigate their effects on various aspects of medical physics education, training and clinical practice. Specifically, we present the current statistics regarding medical physics graduate student matriculation, degree types, graduation rates and demographics of initial placement, with emphasis on residency placement. Additionally, we present these statistics in the form of trends in supply and demand of graduates of CAMPEP‐accredited programs, the state of the conventional residency pathway, and modern alternatives to conventional residency for clinically oriented graduates. We also suggest standardization of data to clearly communicate this information to prospective students interested in the field of medical physics. We hope the data presented here will help elucidate the current and potential future effects of these recent developments on the medical physics education and training infrastructure and on the profession as a whole.2http://www.campep.org/ and http://www.sdampp.org/resources.php. These data are presented in Table Data were acquired from annually released CAMPEP reports on graduatehttps://www.natmatch.com/medphys/aboutstats.html, and the post‐MPM news bulletins published by AAPM,https://www.aapm.org/pubs/newsletter/default.asp. Since roughly 20% of residency positions were filled outside the MPM from 2015‐2016,In Table http://www.campep.org/GraduateProgramSampleDisclosureStatement.pdf as a courtesy, but programs are free to present the data as they choose, which has led to inconsistencies in the way these data are presented. The vast majority of programs binned initial placement of their graduates into residency, industry, advanced degree, and either clinical or academic positions. Placements into research or postdoctoral positions were allocated to “academic” for this report. Those few who were counted as both “academic” and “clinical” were also considered “academic.” CAMPEP recently began providing comprehensive program‐to‐program statistics, collected as survey data for their annual graduate and residency program reports, at http://www.campep.org/PublicDisclosure.asp, though data is currently available for 2016 only.To corroborate and elaborate upon the above data, statistics from each CAMPEP‐accredited graduate and residency program were acquired from every individual program website.http://www.campep.org/ResidencyProgramSampleDisclosureStatement.pdf, and the vast majority of residency programs adhere to this template. Many residency programs also post data on the passing rates of their graduated residents on Part 2 of the ABR Initial Certification exam, but these data was not collected for our study.CAMPEP‐accredited residency programs are similarly required by CAMPEP Residency Standard 2.10As of the date of acquisition of website data, March 31, 2017, several graduate and residency program websites did not have visible links to these statistics on their main pages. A clearly labeled link to the location of program statistics is beneficial for students and evaluators. Eight program webpages did not provide sufficient data for this study: five are so new that they have not posted a graduate, two provided no data on their websites despite being accredited for several years, and one did not bin its residency placements separately from its clinical placements, prohibiting analysis of its data. Admissions, graduation, and graduate placement data from the remaining 44 programs were analyzed.Website data were further used to verify the accuracy of CAMPEP data in the 2015 reporting year, which was chosen because, at the time of data collection, all but three websites had data for this year. The three deficient websites were accounted for by averaging their output from 2010–2014, which accounted for 4% of the 2015 dataset.3Table Figure The number of accredited residency programs has more than doubled in recent years,never placed a resident, the maximum number of graduates is 33. Statistics are generally available beginning only around 2009, even for older programs, so pre‐2009 data from both Table The percentage of graduates from each CAMPEP‐accredited graduate program that placed into a residency program is presented in Table Residency placement percentages were further sorted by whether the graduate program advertises a clinical component on their webpage or online curriculum. The presence of a hands‐on clinical component within a graduate program could be associated with an increase in the placement of graduates into residency positions. We sorted programs by the presence of a clinical component advertised on their websites or in their posted online curriculum, but we found little difference between those with clinical training components and those without. This could be due to the observation that most graduate programs–32 of 44–include a clinical component, including all programs that have not placed a resident since 2010. Data from a recent surveyFrom CAMPEP reports,Not all graduates from CAMPEP‐accredited programs enter residency positions. Indeed, many graduates are not interested in board‐certified clinical practice and do not apply for residency positions. A valuable metric, particularly for clinically oriented applicants to graduate programs, would be the ratio of graduates entering a residency program to the number attempting to do so. We estimate this metric in Section 4.A below, but data are not currently publicly available. Thus, we are limited to evaluating the ratio of graduates entering a residency to the total number of graduates. Four programs do not have any graduates who entered a residency program between 2011 and 2015, and an additional 11 had fewer than 20% of their graduates enter residency programs. Ten programs, however, have over 50% of their graduates entering a residency program— nearly double the average. The residency placement percentage of a program trends downward with more recent CAMPEP accreditation Table . Eight oSome of the programs with very high placement percentages have small numbers of graduates, thus this statistic is difficult to interpret. Within larger programs, for example, those who graduate at least five students per year, from 2011 to 2015, these statistics become more meaningful. Four programs that have graduated at least 25 students over this timeframe have a placement rate above 40%. These four programs filled 91 of the 430 residency positions (21%) from 2011 to 2015. While 46 programs produce MS graduates, as of March 2017,Statistics from the 2015 and 2016 MPM4Whereas these statistics provide a snapshot of the recent changes in the medical physics education and training landscape, further discussion is necessary to put these data into context, to anticipate how they might change in the future, and to determine whether there are potential unintended consequences associated with these changes.4.AFigure One important question surrounding these data is: “how many graduates from CAMPEP‐accredited programs intend to pursue a clinical career?” The 2010 program director survey by CAMPEPWhile we have significantly expanded the residency training infrastructure, creating a total of approximately 117 positions in radiation oncology and 17 in diagnostic imaging as of 2015,Imaging and therapy students face far different realities when attempting to obtain residency positions. Through 2016, website data state that residency programs have graduated a collective 80 residents in imaging, compared to 722 in therapy. This does not account for residency programs in nuclear medicine physics—there were two in 2014.Approximately 98% of residents find employment in the field after graduation from a residency program, though the average time between graduation and employment is unknown. This data point was acquired in June 2017 from residency program websites, which makes it a fluid metric by its very nature. Nevertheless, this appears to indicate that residency trainee production is not higher than clinical demand. One potential unintended consequence of the residency requirement is that, in contrast to the former on‐the‐job training model, residency graduates generally complete their clinical training on a fixed date at the end of the residency training term. With the MPM system now in place and common efforts to make the medical physics residency start date coincide with that of medical residents, the production of newly trained medical physicists will now come mostly in a large annual bolus at the end of each June. Until the market adjusts for this bolus, it may be difficult for residency graduates to obtain their first post‐residency position immediately after completion.The residency placement data per institution presented here must be interpreted with caution as it does not take into account the career objectives of the graduates from that institution. For example, if most of the graduates from a particular program intend to enter non‐clinical careers and therefore do not apply for residency positions, the placement percentage for that program will obviously be relatively low. The percentage of graduates who obtained a residency position out of those who applied for them would be a more appropriate indicator of the success of a program that is striving to place its graduates into board certified clinical practice. Unfortunately, we do not currently have these data. We therefore encourage the collection of these data in the future.4.BThe path to a residency position is now largely facilitated by the MPM. The MPM websiteMany graduate students feel pressured to acquire a PhD to improve their chance of obtaining a residency position.Furthermore, attempting to make the PhD/MPM process fit the traditional MD/match model has consequences that may not yet be fully appreciated. Part of this is due to the fact that the MD degree gives both didactic and clinical training, using the residency for specialty clinical training, whereas the PhD degree gives didactic and research training, using the residency as the source of initial clinical training. Medical school education, unlike PhD education, is a structured process with a clear beginning and end. Since most residency positions begin in July, we are implicitly imposing annual graduation timelines for PhD students that may not be tenable. As a result, residency program directors now must take into consideration the degree completion timeline for PhD candidates who have applied to and/or have been accepted into the residency program. This is not unique to the PhD but is true for any graduate program which has a large and thus potentially variable research timeframe.While about 60% of residency positions from 2009 to 2013 were filled by PhD degree holders,Several editorials by Mills and a reply by Beckham and JacksonThe “alternative pathway” to the profession, as described by TG‐133,4.CGraduates interested in entering clinical practice in medical physics who do not obtain a residency position are faced with either attempting to enter the workforce without board eligibility or finding another job where they can apply their medical physics skills Fig. . The numMany graduates who desire a clinical position and are unable to obtain a residency position perform volunteer clinical work to gain experience. Others are willing to pay for clinical experience. A residency program that charges $31,500 in tuition  was accredited by CAMPEP in October, 2016.We might expect a DMP program to be an attractive option given that it provides guaranteed clinical training and board eligibility since it incorporates the accredited residency training within the degree program. However, the DMP student typically pays tuition for their clinical training, in contrast to the traditional resident who is paid a salary. As a result, the DMP may be perceived as a wise investment for incoming students since it provides accredited residency training experience as required by the ABR, but the DMP may also be seen as a last resort for graduates who cannot obtain a competitive paid residency. The DMP might ultimately be perceived as simply a very expensive way to obtain a residency spot and ABR eligibility. Despite the increased financial burden, it has been suggested that the DMP graduate will reach higher financial status over a 7‐yr plan than other professional doctorates in other fields.Many have been and are currently considering whether the DMP is beneficial to the profession.Nine programs indicated in the 2015 CAMPEP survey that they have created, are in the process of creating, or are considering creating a DMP program. If all of these programs come to fruition and become accredited, we can anticipate approximately 15 additional accredited clinical training positions in radiation oncology and approximately two additional positions in diagnostic imaging. The 2009 SDAMPP survey on the DMP indicated that more respondents felt that the DMP would improve clinical training but degrade both research and the stature/credibility of the profession.The number of graduates from CAMPEP‐accredited graduate programs currently outpaces the number of accredited residency spots by a factor of three. This mismatch continues to be a topic of debate.At present, we may be deterring prospective medical physicists from this career path due to the significant uncertainty about whether they will have an option for board‐certified clinical practice.4.DCAMPEP‐accredited graduate programs are requiredhttp://www.campep.org/PublicDisclosure.asp. Other possible sites are the AAPM student webpage at http://www.aapm.org/students/, which already contains a guide to medical physics education and training for undergraduates,http://www.sdampp.org/resources.php, which has links to all CAMPEP reports to date. In the absence of such a collection, residency applicants have resorted to organizing their own online surveys of their experiences and have created an interactive map based on these informal results, courtesy of the AAPM Student and Trainee Subcommittee.We suggest that the meaning of data tables should be standardized to make these data explicit. This standardization could include, for example, graduates posted represent those graduated in that year, positions with multiple components are counted once by largest fractional time, data are sorted by degree obtained, and the number of graduates who applied for residency is presented alongside the number who entered residency. With such standardization, a collection of all website data could be accurately and robustly displayed on a single webpage sorted by program. CAMPEP recently posted the results of the 2016 graduate program survey publicly at In summary, we, as a profession, should carefully consider the allocation of our training resources. We would be wise to determine approximately how many medical physicists we should be educating and training. Efforts focused on creating an education and training environment that both attracts and cultivates the highest quality trainees will result in the highest quality workforce that will provide the clinical care and create the scientific breakthroughs of the future. We should also allocate research resources toward future researchers–not as a means to improve the chances of graduates to obtain a clinical residency spot, but to drive meaningful scientific advances. We should consider the effects of the current state of medical physics education and training on our future graduate students and trainees. Our students deserve honesty about the current residency and job market and their relative chances of doing what they want to do with a degree from our programs. They also deserve easily accessible information on potential career paths along with data to facilitate their appraisal of the viability of their career plans. Those of us involved in medical physics education and training should carefully consider the recent changes that have taken place and their effects on the future of the profession. We then need purposeful action to drive the education and training landscape to where we would like it to be. We are unlikely to get there by unguided chance.5We present data from publicly available CAMPEP reports, program websites, surveys, and publications to illustrate and to discuss the wide‐ranging changes to the education and training landscape in medical physics over the past decade. Data collected from program webpages correlate well with CAMPEP reports and surveys, though these data could be made more clear and standardized. The rapid proliferation of CAMPEP‐accredited graduate and residency programs, together with the implementation of new requirements for eligibility for board certification, has resulted in significant changes in the education and training pathway. The production rate of accredited graduates increased by over 50% in just 7 yr between 2009 and 2015, and this rate is still increasing, as the 2016 incoming class is the largest ever. While we estimate that approximately 60% of graduates from CAMPEP‐accredited graduate programs would like to enter clinical practice, only approximately 29% obtained a residency between 2011 and 2015. The number of graduates of CAMPEP programs outpaces the number of residency spots by a factor of three, and there is still significant uncertainty in the number of residency positions we need. However, to provide clear data on this in the future, we recommend that survey data requested from graduate programs gather the number of graduates who obtained residency positions and the number who intend to enter board‐certified clinical practice.The residency placement percentage has risen over the past 5 yr, but large differences exist between accredited graduate programs in their placement of graduates into clinical practice, with percentages correlated with program age and independent of the presence of a clinical component. Only approximately one in four graduates of CAMPEP‐accredited MS programs currently obtain a residency position, a fact which is encouraging some students to pursue a PhD to increase their odds to one in three. An alternative solution may be to enter an MS program with better placement statistics. Thirteen programs have residency placement rates greater than 40% from 2011 to 2015. The other current alternative is to pay tuition for clinical training through a DMP program. The long‐term effects of the implementation of the DMP degree on our profession are still unclear, but survey results from those involved in medical physics education and training indicate that additional standardization of this new degree type would be beneficial in demonstrating its utility to the profession. Those same survey respondents overwhelmingly support the need to collect comprehensive data to better evaluate our current education, training, and clinical needs. We have implemented new education pathways, but it is not yet clear how these might affect our training infrastructure. Finally, we have evidence that these uncertainties could influence prospective entrants to the profession and thus the future quality of our applicant pool.The authors have no actual or potential conflicts of interest for the work presented here.


Tanzania is a low income, East African country with a severe shortage of human resources for health or health workers. This shortage threatens any gains the country is making in improving maternal health outcomes. This paper describes a partnership between Touch Foundation and NYU Rory Meyers College of Nursing - Global, aimed at improving clinical mentorship and capacity among nurses and midwives at two rural hospitals in the Tanzanian Lake Zone Region. Clinical mentoring capacity building and supportive supervision of staff has been shown to be a facilitator of retaining nurses and would be possible to acquire and implement quickly, even in a context of low resources and limited technology.A case study approach structures this program implementation analysis. The NYU Meyers team conducted a 6-day needs assessment at the two selected hospitals. A SWOT analysis was performed to identify needs and potential areas for improvement. After the assessment, a weeklong training, tailored to each hospitals’ specific needs, was designed and facilitated by two NYU Meyers nursing and midwifery education specialists. The program was created to build on the clinical skills of expert nurse and midwife clinicians and suggested strategies for incorporating mentoring and preceptorship as a means to enhance clinical safety and promote professional communication, problem solving and crisis management.Nineteen participants from both hospitals attended the training. Fourteen of 19 participants completed a post training, open ended questionnaire for a 74% response rate. Fifty-seven percent of participants were able to demonstrate and provide examples of the concepts of mentorship and supervision 4 and 11 months’ post training. Participants indicated that while confidence in skills was not lacking, barriers to quality care lay mostly in understaffing. Implementation also offered multiple insights into contextual factors affecting sustainable program implementation.Three recommendations from this training include: 1) A pre-program assessment should be conducted to ascertain contextual relevance to curriculum development; 2) flexibility and creativity in teaching methods are essential to engage students; and 3) access to participants a priori to program implementation may facilitate a more tailored approach and lead to greater participant engagement. Tanzania is a low income, East African country with an estimated population of 45 million people which faces a severe human resources for health (HRH) or health workforce shortage . The govThe HRH shortage has contributed to a dire state regarding maternal morbidity and mortality in the country. Tanzania is one of seven countries that account for 3–5% of global maternal deaths reported in 2010 . DespiteHealth workers and particularly nurses, who comprise 27.8% of the Tanzanian health workforce, are important to reducing maternal mortality rates. Research has shown a correlation between too few HRH and adverse patient outcomes –11. ReseIn 2013, Vodafone Foundation launched Mobilizing Maternal Health (MMH) in Tanzania, an initiative to reduce maternal mortality. The Touch Foundation  was selected by Vodafone as an implementing partner to reduce maternal morbidity and mortality. The Touch Foundation’s two partner hospitals in MMH target areas and the location sites for training implementation were: Sengerema Designated District Hospital (SDDH) and Shinyanga Regional Referral Hospital (SRRH). While the Touch Foundation was the primary implementing partner for MMH in Tanzania, they lacked the expertise in developing and implementing mentorship and supervision training. Touch partnered with the Global Division of Rory Meyers College of Nursing at New York University College (NYU Meyers) to provide their technical and educational expertise on HRH capacity building.The purpose of this case study is to describe the development and implementation of a mentoring and supervision training program aimed at nurse-midwives, its monitoring and evaluation processes, and recommendations for future training in this area. Traditional mentoring can be defined as a relationship between a less experienced individual (the mentee) and a more experienced individual (the mentor) with the common goal of advancing the psychosocial and professional development of the mentee –16. MentWe use a case study approach to organize our description of the program implementation and evaluation processes. Case studies are an effective method for organizing an analysis where multiple sources of data are needed to capture a phenomenon, but where the context of data collection is less structured and cannot conform to the conditions of other more structured research approaches , 22. In Prior to performing the six day in country needs assessment the principal investigator and remaining members of the NYU Meyers team were in constant communication with Touch Foundation via conference calls and email to organize logistics and expertise on teaching needs that could be anticipated at each hospital. The NYU Meyers team was comprised of four women with extensive international health experience, two PhD prepared nurse scientists with over 20 years’ combined experience in health services research and maternal child health and 2 Master’s prepared nursing PhD students with over 15 years’ experience in midwifery and bedside clinical care experience.IRB and/or ethical approval was deemed exempt by the home institution as it was a descriptive case study and evaluation of an educational training program and did not involve the collection of sensitive information.A strength, weakness, opportunities and threats (SWOT) analysis Table  techniquThe needs assessment was conducted in July 2014 over a six-day period. Once in country, the two assessors met formally with Touch Foundation personnel and provided a layout of the assessment process for the upcoming week. While the initial project sought to implement basic emergency obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care (CEmONC) training, those plans changed due to a new policy mandated from the Ministry of Health and Social Welfare (MOHSW). The new policy specified that MOHSW is the only body that can deliver training for emergency obstetric and newborn services in accordance with the national curriculum. The NYU Meyers team was made aware of the change upon arrival for the needs assessment. Based on the findings from the needs assessment and the critical staffing shortage present at each facility, the team changed the training focus on providing and improving clinical mentorship capacity among the nurses and midwives. The final needs assessment drew from evidence-based approaches to effective maternal child health (MCH) service delivery and organizational evaluations sensitive to the dynamics of nursing personnel working in a low resource, interprofessional clinical setting.To gain an understanding of what was taking place at SDDH and SRRH specific to MCH, the NYU Meyers assessors engaged in conversations with stakeholders which included nursing, midwifery and hospital management, staff, medical directors and district health officials. Informal interviews were held with four key informants at SDDH and eight at SRRH. A semi-structured interview guide was used to elucidate information about the concerns, long term plans and needs of each facility. Team members took notes during the interviews and did not record them. Hospital and unit tours allowed the assessors to observe the realities of nursing and midwifery practice in an effort to generate potential recommendations to help deliver better patient care. Data notebooks with labor and delivery statistics were reviewed for the types of data collected by each hospital. Assessment sheets with delivery statistics were completed within one week by hospital personnel and emailed back to the NYU Meyers team.After conducting the needs assessment, the NYU Meyers team created a curriculum that encapsulated the needs of all stakeholders . The primary goal of the program was to help nurses and midwives to refresh and improve their clinical competence while incorporating principles of mentoring and clinical supervision throughout the training. Importantly, the nursing and midwifery staff determined the priorities for the clinical refresher portion of the program. Some of the clinical content that staff wanted reviewed were complications during labor and delivery such as neo-natal resuscitation and postpartum hemorrhage. The Touch Foundation was provided with drafts of the curriculum for review and feedback prior to implementation.The week-long training was designed and taught by two NYU Meyers nursing and midwifery education specialists. Clinical case studies served as the curriculum framework to discuss how mentorship and clinical teaching could be integrated into an overburdened environment to enhance professionalism and support evidenced based practice. Enhancing mentorship and clinical supervision was a central theme to all learning objectives and exercises. Using methods beyond the traditional didactic method was also key to the week-long training. Methods such as teach back, small group work, demonstrations, role plays, and low technology simulation were actively utilized. While common place in Western settings, these methods were novel to many of the Tanzanian participants. Although the NYU Meyers team tailored the curriculum to meet the needs voiced by our Tanzanian counterparts, we recognized that we were coming from a Westernized perspective and wanted to try and limit the potential for any bias in content delivery and adapt to local learning styles.Sengerema Designated District Hospital. Established in 1959, SDDH is a 318-bed Catholic hospital that offers public services to over 700,000 people in Sengerema district. SDDH joined Touch Foundation’s Treat & Train Network in 2013 and was the first hospital to host Touch Foundation’s external clinical rotations for healthcare students. SDDH attends to over 10,000 births per year and, in 2014, was the first hospital to pilot and implement Vodafone’s MMH program. The training at SDDH occurred in August 2014.Two sites in rural, northern Tanzania participated in the program. Shinyanga Regional Referral Hospital served as the second site. SRRH was built in the 1940s and is a government owned 300-bed hospital serving a catchment area of over 1.5 million people. Shinyanga has been a part of Touch’s Treat & Train Network since 2014 and is now hosting external clinical rotations for healthcare students as well as implementing the MMH program for the Shinyanga District Council. SRRH attends to almost 8000 births per year. The training at SRRH occurred in January 2015.After the needs assessment and discussion with Touch it was decided that the nurses and midwives serving in hospital administration and leadership roles, who also still practiced on the wards, were best suited to select training participants. Participants were purposively recruited for the program.The overall purpose of the training program was to prepare and engage nurses and midwives to nurture and support novice providers and students in delivering optimal care to the women and babies they serve in low resource, high intensity settings. The objectives for the training participants included: 1) defining mentoring and developing an awareness of their preexisting mentoring style; 2) developing an action plan, defining objectives and goals to enhance learning and skills acquisition for novice clinical staff; 3) utilizing essential obstetrical assessment and decision making tools in managing care; and 4) incorporating various teaching techniques to support engaged learning. Core concepts such as communication, interdisciplinary teamwork, trust building and professional leadership in relation to professional development and workforce strengthening were also reinforced. Exploring underlying care values and enhancing respectful maternity care were also subthemes that were intentionally integrated into lesson plans throughout the weeklong training.Each training, one at each site, took place over five days and were four hours per day. In addition, there was up to one hour per day allocated for clinical review of the course content. Table Although the language of instruction in Tanzania is English and each facility assured the NYU Meyers team that the participants could engage in English, all pre-assessment and post questionnaire documents were in both English and Kiswahili. Clinician-champions, exemplar participants, identified by NYU Meyers educators were proficient in both spoken and written English and Kiswahili were also on hand and able to provide translation during classroom instruction. This step helped ensure there would be minimal issues related to translation.This section will provide results of both the participant completed assements and the programs' evaluation. In total, 19 nurses and midwives, nine at SDDH and ten at SRRH, participated and completed the trainings. Seventeen were women and two were men. There was a 100% attendance rate for all participants. Clinician-champions, exemplar participants who could help ensure the sustainability of the program, were identified at both sites by training instructors.Prior to the program’s start, participants had completed a self-assessment to measure their clinical competence and barriers to practice in their hospital setting. Overall, participants from SDDH and SRRH self-reported that they were very confident in their clinical skills and their ability to provide competent care to both pregnant women and their newborn babies. Lack of staffing and resources were the two main barriers limiting participants from practicing within their full scope. Poor provider to patient relationships and inadequate staffing, as identified by the participants, emerged as major barriers affecting nurse to patient interactions that involved history taking, encouraging mothers to breastfeed or providing patient updates to family members.Initial, post-training evaluations, completed at the end of each week-long training on site, were positive with participant comments on new knowledge acquired in mentoring, clinical case management, and newborn resuscitation. The initial training evaluation provided anecdotal results from participants who emphasized that they particularly enjoyed “the way the teachers taught us demonstration of newborn resuscitation” and “mentoring.” Participants did emphasize that they wanted an “increase period for training.” The participants at both sites believed the educational climate was conducive to learning, the instructors were prepared and the students felt they were in a comfortable environment to engage and ask questions.After each training, monthly and bimonthly emails were sent to follow-up with participants, elicit their feedback and ascertain their ability to incorporate mentoring principles into their practice. These attempts proved unsuccessful. The team concluded that technological difficulties (access to reliable internet) and a lack of in-country presence post-training implementation were primary factors affecting poor follow-up. A 6-month in-person follow-up with participants at SDDH was scheduled for January 2015, with clinical champions assisting to coordinate the follow-up. Participants were notified in advance, were aware and expressed interest in attending; however, no participants were able to be located or available during the follow-up visit.Having learned from the unsuccessful post-program evaluation attempts from the initial 6-month follow-up, Touch Foundation played a more integral role in assisting with follow-up by distributing and collecting the post questionnaire evaluation forms from providers at each hospital. It was administered in-person by Touch Foundation 11 months after the SDDH training and 4 months after the SRRH training. The post training questionnaire consisted of 11 open ended questions to allow participants to demonstrate: 1) knowledge acquisition and retention about mentoring and supervision after the training; 2) how they have been able to incorporate the training into their daily practice; and 3) recommendations they would make for future trainings.Fourteen out of nineteen participants returned the questionnaires for a 74% response rate. Amongst the respondents, 57% of participants were able to demonstrate proficiency on the concepts of mentorship and supervision, provide examples of action plans on how they could address challenges on their wards and mentor students and novice nurses. In the post questionnaire, participants also highlighted the workforce shortages, lack of professional development for themselves and their co-workers at each site as impediments to their professional practice. Interestingly, 7 out of 14 participants also mentioned language as being a barrier but they did not specify if it was a patient-to-provider or provider-to-provider barrier in terms of language, a finding that needs further exploration.The results from the program and its implementation offer important insights and reminders for organizations seeking to implement similar programs in Tanzania. The lessons may also be applicable to other low income country contexts, but would require further testing as these findings are largely qualitative and not generalizable.Nonetheless, the program was well received by the staff, hospital administration and local government officials at both sites. The staff particularly were enthusiastic, willing to learn, engaged, professional and welcoming. The facilities were very supportive of the program, accommodated the training by providing space and tried to ensure that supplies were provided if needed. This program highlighted the importance of expanding professional development beyond tactile skills and was innovative in that it provided participants with hands on learning experiences, bringing both the tactile and soft skills through this mentorship program. It also provided an opportunity to diversify and expose participants to various teaching styles such as case studies, hands on demonstration and the use of low tech simulation.Despite the positive feedback from participants, there were some implementation barriers identified. For the program instructors, the cultural expectation of payment/compensation from the providers to attend the training proved to be difficult to handle and at times distracting from the lessons taking place. This expectation by staff is not uncommon as it has been found in other studies , 25. In For future similar programs such as this, a pre and posttest should be conducted to assess knowledge gains. Although application in the wards would not be able to be assessed through a pre and posttest there would at least be the opportunity to monitor progress at baseline. In addition, daily feedback would have been sought from participants to re-evaluate and tailor the daily program curriculum instead of an evaluation at the end of the five day course. By the 2nd day of the program, champions would have been identified by instructors and they would have one additional day of mentorship individually with the trainers with continued mentorship one day a month via distance learning with program instructors.After the formal training ends, these identified champions could provide reinforcement trainings every three months on particular modules that need refreshment. These champions could assist with follow-up surveys at each site and be a liaison with the program instructors to provide follow-up with their colleagues about what is working and not working on the wards. The champion mechanism would require buy in from in country partners and each facility would provide this individual with dedicated time away from the bedside and focus on education, follow-up and their continued professional development. At six months, the Champions can administer a second posttest to check on knowledge attainment at that point. With these types of partnerships, in country partners could also serve as a support system to the champions and continue to provide professional development opportunities that they would be expected to bring back to their facilities. In addition, or as an alternative to the pre and posttest evaluation mechanism, there should be consideration for doing a pre and post program implementation focus groups with providers at 3 and 6 months intervals. Integrating this type of follow-up would shed light on the sustainability of the program and potential for long-term effectiveness.While the program was able to demonstrate modest gains in knowledge attainment, a number of limitations with the evaluation data should be noted. NYU Meyers’ limited in country presence after each training was a major hindrance to follow-up with the participants. The sample size was too small for meaningful statistical comparisons and generalizability, but this is common with small scale training programs like this one. In addition, poor internet and electrical power infrastructure contributed to infrequent communication with participants thereby hampering a thorough follow-up to compare pre and post program objectives and goals. More ongoing collaboration with in country stakeholders would have benefited curriculum development but infrastructure limitations hampered that possibility. In addition, the trainings’ dramatic shift from a BEmONC and CEmONC training to a mentoring and supervision training required a rapid restricting and remodeling of expectations, objectives and goals for both Touch Foundation and NYU Meyers.Despite the limitations, the program’s successes were sufficient that the Touch Foundation is exploring expansion into local health centers around each hospital since the original design was structured to be replicable across sites. To facilitate this goal, the NYU Meyers team created a fully decentralized curriculum of shorter modules from the training for expansion to various settings beyond the two original sites. Themes, skills and knowledge covered relate to strengthening the capacity of health care providers to effectively mentor new students and clinicians. On a national level, current efforts between the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children and JHPIEGO, an international non-profit, are also aiming to increase clinical mentoring on a national scale.The common threat to any sustainable HRH capacity building program at both sites is the staffing, recruitment and retention of nursing and midwifery personnel. In resource constrained environments, investing time and energy in newer clinicians can offer much needed support and safety to the patients they care for , 29. BuiOne change that might improve sustainability is that in-country partners or partnering institutions should consider having a line item to include compensation or other perks for providers who participate in program such as this one. If a financial incentive could not be provided, continuing education, cell phone air time, or usb flash drive could be used as incentives. If incentives cannot or will not be provided, participants should be advised well in advance.Finally, partnerships that involve one partner outside of the country where a program will be implemented should have transparency and open communication. For new partnerships, conversations should be had around logistical support for partners while in country to help troubleshoot issues  or provide contacts that could be of assistance. In addition, a liaison or guide at each sight to help trainers or partners get acclimated for at least the first 72 h would be highly desirable. Translators can also be beneficial if the primary language is not spoken by team members from outside of the country. For future programs that will have a needs assessment and program implementation component it is advised that at least one program instructor also conduct the needs assessment as a content expert. If identifying a champion at each site is not viable working with the hospitals to create a full time nurse educator position would be greatly beneficial to continue professional development on site and reinforcing curriculum content.Three recommendations have emerged from the program’s implementation: 1) curriculum development in low resources settings should involve an assessment of the clinical and practical needs of the participants and include their input into the curriculum design and content; 2) flexibility and creativity in teaching methods are essential to engage students; and finally, 3) access to participants a priori to program implementation may facilitate a more tailored approach and lead to greater participant engagement. It is important to note that these recommendations should be taken with caution as country context and partnership goals may vary depending on program objectives. It is important for both partners particularly those vested in the long term to have an in country presence to assist with follow-up communication and responding quickly if things change in country.Health workers’ ability to educate future generations of Tanzanian health care providers must be enhanced and sustained to maximize gains for the women they serve. The shortage of human resources threatens the effectiveness and sustainability of efforts to build capacity among staff. Offering curriculum development and implementation support– through university and non-profit partnerships – may offer a key strategy to filling a need to support nurses and midwives who work under resource-strained conditions.


We describe a pediatric patient who suffered from critical abdominal distention caused by a combination of humidified, high-flow nasal cannula (HHFNC) oxygen therapy and nasal airway.2 of 0.35 was applied. However, severe stridor was observed, then a nasal airway was placed in the left nostril. However, he became restless. Critical abdominal distention was observed. A subsequent chest X-ray revealed that the nasal airway was placed too deeply, and the gastrointestinal air was severely accumulated. Immediately, the nasal airway was removed, and HHFNC flow was reduced to 10 L/min. Frequent suctioning and continuous gastric drainage were required, which achieved gradual improvement of respiratory condition.A 21-month-old boy with a history of chronic lung disease was admitted to the intensive care unit (ICU). Immediately after admission, his airway was established using a tracheal tube and mechanical ventilation was started. Five days after the commencement of mechanical ventilation, finally, his trachea was extubated. Immediately after extubation, HHFNC therapy at 20 L/min with an FiOWe need to recognize that HHFNC therapy is one of the positive pressure ventilation system. Therefore, HHFNC therapy might cause the similar adverse events to noninvasive pressure ventilation. Humidified, high-flow nasal cannula (HHFNC) oxygen therapy has allowed optimal humidification of inspired gas at high flows, which could create a distending pressure-like nasal continuous positive airway pressure (CPAP) . There ith week of gestation and weighed 645 g and had been provided with home oxygen therapy with 3 L/min oxygen administration. His chest computed tomography showed several giant bullae in the bilateral lungs . He was 63 cm in height and weighed 7.9 kg. He was bone on the 242 < 90%) with oxygen administration. Immediately after admission, his airway was established using a cuffed 3.5-mm tracheal tube. Immediately after the beginning of mechanical ventilation, 10-cm H2O positive end-expiratory pressure (PEEP) combined with moderate pressure support (8 cm H2O) was applied.He had been suffering from upper respiratory infection and fever for a couple of days. He gradually developed hypoxia  was applied through nasal cannula .His respiratory status gradually improved. Five days after the commencement of mechanical ventilation, finally, his trachea was extubated. Immediately after extubation, HHFNC therapy at 20 L/min with an FiOHowever, severe stridor because of upper airway obstruction was observed, then a 10-cm-long 3.5-mm hand-made nasal airway  was placed in the left nostril (10 cm depth). It was not confirmed whether or not inserting the tube too deeply because he violently resisted being checked with a laryngoscopy. But, stridor or retractive breathing was not observed. Therefore, HHFNC therapy was restarted with this airway position.2 reduction down to 70%. Critical abdominal distention was observed, and forced gastric drainage was started through a gastric tube. However, the critical situation was not improved. A subsequent chest X-ray revealed that the nasal airway was placed too deeply (Fig. HHFNC was conducted smoothly for a while; however, he became restless and then started agonizing heavily with SpOply Fig. .Fig. 2A Immediately, the nasal airway was removed and HHFNC flow was reduced to 10 L/min. Frequent suctioning and continuous gastric drainage were required, which achieved gradual improvement of respiratory condition. Finally, HHFNC therapy was successfully terminated.2O of positive pressure was generated in our patient at that time. This low level of pressure might unusually force air into the stomach; however, the positive pressure drastically increased with a high nasal prong-to-nares ratio and mouth closed status [It is supposed that the deeply inserted nasal airway caused critical abdominal distention by insufflating the HHFNC flow into the gastrointestinal rather than the respiratory tract. In the early stage before the development of critical abdominal distention, the HHFNC flow might have partially supported his breathing; however, it is likely that the HHFNC flow gradually became ineffective for supporting his breathing because of aerophagia. In addition, his gastroesophageal reflux might have worsened the situation because aerophagia is possibly accelerated by noninvasive positive airway pressure in patients with gastroesophageal reflux . Abdomind status . TherefoIn conclusion, we need to recognize that HHFNC therapy is one of the positive pressure ventilation system. Therefore, HHFNC therapy might cause the similar adverse events to noninvasive pressure ventilation. This time, we would like to underline that critical abdominal overdistention could happen by HHFNC therapy.


This study examined the implementation quality of the Tier 1 Program (Secondary 1 Curriculum) delivered in the second year of the Full Implementation Phase of the Project P.A.T.H.S. . Under the “Co-Walker Scheme”, systematic observation of curriculum units was conducted in 138 schools. Results indicated that the overall level of program adherence was high, with an average of 82.9%. The mean ratings of the program implementation quality were also high. Despite limitations, the findings of this study suggest that the implementation of the Secondary 1 Program (Tier 1 Program) of the Full Implementation Phase was of very high quality. The present findings also provide strong evidence to account for the successful and encouraging outcomes of a major positive youth development program in Hong Kong.


Mobile phones are increasingly being used to deliver health information and health services globally. Mobile health  interventions may be well-suited for minority groups with greater barriers to accessing traditional health services. However, little has been written about the process of culturally adapting interventions for multiple ethnic and cultural minorities within a population.This study describes the process of developing a culturally tailored text message-based maternal health program  for Māori, Pacific, Asian, and South Asian families living in New Zealand. We report on engagement and acceptability of the TextMATCH program.Program data was examined to describe engagement with the program 18 months after implementation. Telephone interviews were conducted with a sample of participants who consented to provide feedback on acceptability and relevance of the program.A total of 1404 participants enrolled in TextMATCH over 18 months, with 18.52% (260) actively opting out at some point (after 0 to 17 months of messages). It was found that 356 (70.9%) of the 502 eligible participants actively switched from the initial pregnancy program to the baby program after delivery. Phone interviews were conducted with 29 participants including 6 who had withdrawn (duration of program from 3 to 16 months). Only 2 participants reported that the program was not useful, with the remainder rating the usefulness of messages positively (average 4.24 out of 5). All participants stated that the messages were relevant, culturally appropriate, and easy to understand. Most were happy with the specific advice and the language options provided.We have demonstrated the importance of an intensive approach to the development of a culturally adapted and tailored mHealth program for multiple different cultural minority groups within our population. Mobile health  is the use of mobile devices, including mobile phones, to deliver health services and information . Due to Adapting effective mHealth programs for multiple minority populations requires attention to relevant cultural characteristics -4,6,9,10Some aspects of cultural adaptation that may improve the sustainability and effectiveness of mHealth include the consideration of users’ health beliefs and health literacy levels in message development ,5, and tThe process of the cultural adaption of mHealth interventions can be broadly categorized into three categories:Translation only: mHealth intervention where content has been translated into the local language or a language nominated by users.Translation and addressing group-specific barriers: the use of a local or nominated language, alongside content tailored to barriers in accessing services or health information which were faced by the cultural group concerned.Translation and sophisticated adaptation: the use of a local or nominated language, alongside more complex adaptation and development processes, involving members of the target group.However, there is a paucity of evidence to support the effectiveness and desirability of cultural adaptation practices in mHealth. In instances where perceptions of culturally adapted mHealth interventions have been described, these perceptions are positive ,6,15-18.One area of mHealth with some published descriptions of cultural adaptation processes is in the field of maternal health. There is growing support for the use of mHealth, including text messaging, in the field of maternal health , particuText4baby in the United States is a free maternal health text message program, which is delivered in English and Spanish, for pregnant women and mothers of babies aged under 1 year. A survey assessed the linguistic appropriateness of the Spanish messages finding that 98.3% of respondents receiving the Spanish messages found the content to be clear and understandable . In addiMobile Alliance for Maternal Action (MAMA) has conducted cultural adaptation of a generic set of MAMA text messages to create new versions including ChatSalud and Mom Connect ,22. In NAlthough these studies have shown the feasibility of cultural adaptation of text messaging programs in maternal health, more evaluation of such interventions is needed to determine their effectiveness .Healthy Babies Healthy Futures, HBHF) targeting the increasing rates of childhood obesity  [In New Zealand, we have developed TextMATCH , an educational and supportive text message program for pregnant, new mothers (of infants aged until 2 years), and other family members. This program was funded by the New Zealand Ministry of Health as part of a broader initiative (e obese) . TargetiTextMATCH was designed to cover three specific areas:improve women’s health during pregnancy and the postnatal period, through promotion of healthy eating and physical activity;promote healthy feeding of babies including encouraging and supporting breastfeeding; andpromote healthy feeding  and physical activity of children at preschool age.TextMATCH, and the broader HBHF initiative it is embedded in, have been developed specifically for Māori , Pacific, Asian, and South Asian families. These are minority groups with particularly high rates of childhood obesity (Māori 19% and Pacific 27%)  or with The development of TextMATCH was guided by our previously developed mHealth Development and Evaluation framework , which pA governance group for the broader HBHF initiative, the Roopu Kaitiaki, provided guidance on the primary focus and scope of the program. This group represented a consortium of community-based providers working with the target audience of the program. The target population was defined as pregnant women and mothers of babies aged under 2 years of Māori, Pacific, Asian, and South Asian ethnic communities within two health districts in Auckland, New Zealand. The target population also included their extended families (whānau in Māori) and anyone else who had influence on the health and wellbeing of the pregnant women, babies, mothers, and their preschool children.The overarching principles agreed wereeducation for those with low health literacy;targeting those who have relatively low involvement with conventional support networks;providing practical tips and suggestions that are relevant to their specific contexts;supporting improvements in health nutrition and uptake of appropriate physical activity;linking pregnant women or mothers of young children and their families to health and community services as early as possible; andusing proven behavior change techniques and theories.Formative work was conducted to inform development of the program including the design, content, and implementation. This included focus groups with the target audience and a review of the literature, guidelines, and publicly available resources.The focus groups aimed to determine how the intended audience engaged with technology, how a technology-based health program could benefit them during pregnancy and the first 2 years of their child’s life, and to understand cultural norms, traditions, and beliefs around technology and maternal health. A total of 4 culture-specific focus groups were conducted with pregnant women, mothers of children aged under 2 years, and their support people. Participants were identified by the community organizations involved in the wider HBHF initiative. All groups were positive about using technology to support people to eat well and exercise during pregnancy and the first 2 years of a baby’s life. Technology preferences differed, with some groups reporting a preference for mobile phone messaging apps , whereas others reported nonconsistent mobile phone ownership and a preference for text messaging  due to limited data access. Other factors of importance for a mHealth program were being free, accessible on all types of mobile phones, and taking into consideration that phones are sometimes shared among family members. Therefore, in order to ensure greatest reach of the intervention, SMS was agreed on as the mode of delivery. Participants felt strongly that there was benefit to the messages being offered to partners or fathers and other family members, in addition to a pregnant woman or mother.Consistent across the groups was a preference for New Zealand-based guidance and references, as there was concern that advice in internationally available apps may differ from that in New Zealand. Differences in terminology were identified, as well as culture-specific foods, practices, traditions, and activities, providing rationale for culturally adapted versions of the program. Preferences for languages varied, with all groups recommending an English option and some Asian participants requesting Simplified Chinese and Korean. In addition, consulted health care providers recommended adding Japanese and Te Reo Maori languages. Women in the Pacific Island and Indian focus groups predominately felt that an SMS intervention would be best in English. This was due to wanting the intervention to be in the language they were likely to be communicating with their lead maternal carers (LMCs) in for consistency, as well as a general preference for texting in English.A review of the current literature, New Zealand guidelines, and resources was undertaken to establish key messages related to nutrition and physical activity for the target population, as well as other relevant areas.Findings from the formative work resulted in the development of key messages for the intervention. The key messages were then adapted into text messages limited to 160 characters. These text messages were sent to a technical advisory group  and revised before being sent to a second panel of experts  for review to ensure factual correctness. Once the key text messages were confirmed, they were then adapted into 4 cultural versions using the feedback from the formative work. These culturally adapted messages were reviewed and adapted further by the 4 cultural community groups in the consortium. Each cultural version was adapted into 2 versions ; one for mothers and the second one for other family members. Where needed, the messages were then translated into other languages  resulting in 16 different versions of the TextMATCH program see , if, at Versions of the program that were delivered in English included greetings and other key words in the appropriate language . The messages were also personally tailored by including the participant’s name, baby’s name, and gender-specific terms for messages after the baby was born . Examples of TextMATCH messages can be seen in The resulting TextMATCH program is individually tailored and available in 16 different cultural versions and 5 languages . A persoThe TextMATCH system is automated following registration. Registration requires manual input of the recipient details for the generation of message schedules. In addition, the system is checked daily for unrecognized incoming messages and these are actioned if needed. The ongoing costs of running the program include the Gateway Company shortcode fees and per text message costs, as well as a maximum of 1 hour of person time per week to check the unrecognized incoming messages and manage issues.TextMATCH went live in August 2014 with people referred to the program by community organizations within two urban health districts in New Zealand. We conducted a study, 18 months post go-live, to assess the engagement and acceptability of the program. The study had two aims:To assess the engagement of participants with the TextMATCH program, including enrollment and disengagement rates.To assess the acceptability of the TextMATCH program, including its cultural appropriateness and relevance, reasons for withdrawal, and to determine ways in which the program could be improved.Engagement data collected by the content management system was extracted on April 7, 2016. All data was kept private and secure to respect the privacy of all intervention participants. Data collected for the first 18 months was used in this analysis. The data for each participant included program number ; month registered; due date month and year; baby birth date and year; whether they switched to the baby program from the pregnancy program; whether they texted “STOP;” their withdrawal date (if applicable); and completion date (if applicable). Descriptive statistics were generated for baseline demographic and clinical characteristics, and measures of engagement with the system. Counts and percentages were reported for categorical variables, along with means and standard deviations for continuous variables.Phone interviews were conducted between January and March 2016. All study documents and procedures were approved by the New Zealand Health and Disability Ethics Committee (15/CEN/210).Participants included those who were registered for the TextMATCH program between August 2014 and August 2015, and who had previously agreed to be contacted about their experience with the program. Potential participants were excluded if it was known that they had experienced a miscarriage; their due date fell during the study period; they only spoke Japanese or Korean, as no interviewer was available for these languages. We also excluded those who withdrew from the program by texting “STOP” after receiving less than 2 weeks of messages, as it was determined that this group would not have received sufficient intervention to provide feedback for this study. To ensure participants with a range of experiences with the program were interviewed, potential participants were split into four categories:those who had received TextMATCH for 6 months or more;those who had received TextMATCH for 3-6 months;those who withdrew from the program by texting “STOP” after receiving a minimum of 2 weeks of messages;those that received TextMATCH during pregnancy but did not self-switch to the baby messages following their baby’s birth.Eligible participants were sent a text message asking if they would be interested in being contacted for an interview. In addition, community providers contacted some eligible participants to invite them to participate, to accommodate those who did not have sufficient credit on their phones to respond, and to ensure adequate numbers. If participants replied “yes,” they were called by the research assistant for the interview. Before commencing with the interview, they read the participant information sheet and consent form, and verbal consent was then obtained. Interviews were conducted in English or Chinese based on participant preference. Following informed consent, the researcher then went through the interview schedule with participants covering the following topics:General feedbackUsefulness of the messagesAppropriateness of the messages, with special attention to the cultural adaptation of messagesPerceived impactsIf withdrew: reasons for withdrawalIf did not self-switch: reasons for not choosing to switch to baby messagesSuggestions for improvementsThe interview data was analyzed and summarized using descriptive quantitative analyses including means, standard deviation and proportions, and qualitative comments analyzed using simple thematic analysis.In the first 18 months of the TextMATCH program, 1404 individuals enrolled and over 98,000 messages were sent by the system. The percentage of participants enrolled in each of the 16 different versions of TextMATCH varied . Even thOf the 1404 individuals who enrolled in TextMATCH, 260 (18.52%) actively discontinued the program by texting the word “STOP.” Discontinuation rates varied between the TextMATCH cultural versions; 14.1% of those registered for the Asian versions of the program (#7-14) texted “STOP,” 15.9% of those registered for South Asian versions (#15 and 16), 19.9% of those registered for Pacific versions (#5 and 6), and 29.2% of those registered for Māori versions (#1-4).For those who texted “STOP,” the average duration of messages received was 3.84 months . Of the 502 individuals who were sent text messages prompting them to switch from the pregnancy version of the program to the baby version, 356 (70.9%) fully completed the three text messages required to switch to the baby program—74.6% of mothers and 59.1% of other family members.A total of 52 people agreed to be contacted for an interview. Of these, 5 declined to participate, 1 was unable to provide consent, and 17 were unable to be contacted. A total of 29 interviews were completed. Of those who participated, 12 (41%) had received TextMATCH for 6 months or longer, 9 (31%) had received TextMATCH for 3-6 months, 6 (21%) had withdrawn from TextMATCH by texting “STOP,” and 2 (7%) had not switched from pregnancy to baby messages.The mean number of months participants had received TextMATCH messages for was found to be 7 months (range 3-16). Those who had stopped the messages or did not switch over (n=8) received on average 6 months (range 3-9) of messages. A summary of the TextMATCH version that the interview participants had received can be seen in All but 2 participants  reported that they found the messages personally useful. For those who found it useful, the mean rating on a scale of 1 (a little useful) to 5 (extremely useful) was 4.24 . All participants responded that the messages were relevant to them, with many commenting that some were more relevant than others . In addition, all study participants reported finding the messages culturally appropriate and easy to understand . Participants provided positive feedback on the personalization of the messages; they enjoyed that the messages included greetings in languages other than English and having their names in the messages.When asked whether they found the specific food practices and activities mentioned in messages appropriate to them, all but three reported that they were . Reasons why food practices and activities were less relevant to participants included that messages referring to meat were not relevant for vegetarians, and that messages referring to dairy products or to prepreparing and freezing meals were not relevant for many Chinese people.Participants were also asked if there were any messages that they found irrelevant or inappropriate with only 6 (21%) reporting that there were. Of these, 3 felt that some proportion of messages did not apply to their own pregnancy or child, but many also commented that they were happy to ignore these. Only one respondent felt that these represented a significant proportion of the program, and said that this was because she had a complicated pregnancy and birth.When asked if they would have preferred the messages to be in a different language, most  responded “no.” One participant would have preferred the messages in Hindi, another in Samoan, and one was happy with her Māori cultural messages in the English language but would have preferred more phrases and words in the Te Reo language. A separate question sought participants’ suggestions about the provision of messages in other languages. Suggested languages included Samoan (n=5), Hindi (n=5), Tongan (n=1), Niuean (n=1), and Spanish (n=1). Some of those suggesting Pacific languages stated that this would be useful to improve their own Pacific language competency rather than assisting people who did not speak English.Participants were asked about the impacts that they felt TextMATCH had on themselves, their family, and their baby see . A commo(when it’s) a stressful time and then you get the message and realize you're not doing too bad.Pacific, motherOver 50% of participants reported that the program had improved both their eating habits  and exercise . Furthermore, all participants reported feeling supported by messages . Those who felt they had not gained knowledge from the program still found it useful because it made them feel more supported. One mother commented:there’s a lot of time in isolation when it’s just you and bubba, it’s quite nice to receive that message.Māori, motherA total of 21 (72%) participants reported improvements to their knowledge and understanding. Some participants felt that the program was ideally suited for first-time parents with less baseline knowledge. However, one user stated that:it’s quite empowering actually just to get that little bit more information you think you know everything after seven children so it’s actually quite cool.Māori, motherA total of 12 (41%) participants reported that they had family members also receiving the messages. All remarked that it was good for the partners to receive messages, as it put both parents “on the same page” with regard to pregnancy and child care, and many discussed message content. Many mothers also felt that their partners were better able to care for them and the baby as a result of the messages.All participants  reported that they would recommend the TextMATCH program to others. Reasons included that it provides useful information and tips, uses a medium which is very accessible and unobtrusive, provides valuable reminders, and can benefit the whole family. Respondents also mentioned that messages provided valuable support and encouragement and would be especially useful for first time and younger mothers.There were 6 participants (21%) who had texted in “STOP” to withdraw from the program after an average duration of 6 months of messages (range 4-9 months). Four of these participants reported that they withdrew due to not finding the messages very useful or beneficial, one due to a technical issue, and one reported that they had only wanted the messages during pregnancy and so stopped once their baby was born. There were 2 participants (7%) who had not chosen to switch to the baby messages after completing the pregnancy messages. One reported that they had not realized that they had to text back to sign-up for the baby messages, and the other reported that things were hectic after the baby was born and so they forgot to switch.A total of 20 participants provided suggestions for how the program could be improved. Most commonly, participants suggested that the messages could contain more detailed and specific information on the baby’s diet , recipes, and activities . Others thought that bidirectional messages to be able to ask about certain aspects of the program would be useful (n=5). Two participants suggested having extra optional message streams for certain maternal health conditions , areas of interest , or for multiple pregnancies . Other suggestions included information about local events (n=1), the use of other social media like WeChat to enable photo or video messages (n=1), more emotional support for mothers (n=1), changes to the frequency or timing of messages (n=4), and better channels for users to recommend the program to others (n=1).The process of developing TextMATCH with specific cultural, family, and language versions was extensive and resource-intensive. It involved focus groups and testing directly with the target audience. It also involved considerable input from the community groups working with those families. This resulted in what appears to be a rather simple program to the end-user, but which is actually composed of 16 different versions. The system rules ensuring that the correct version is sent to each participant are based on just a small number of questions. The engagement statistics and feedback from participant interviews have indicated that there is value in this process, with positive responses to the personalization and relevance of the culturally tailored messages. Other benefits of our program include the feelings of support reported by all participants, and the inclusion of other family members receiving the messages.Some participants reported that some of the messages were not useful for them, inappropriate or irrelevant. This feedback has been taken into consideration and the program is being improved based on their suggestions. Regardless, all those interviewed, even those reporting it not to be of personal use, reported that they would recommend the program to others. Although the program appears to be well-received and perceived to be of benefit, evaluation of its effectiveness has yet to be undertaken and will be necessary to understand if it is impacting on health outcomes.Feedback from recipients as well as changes in evidence and guidelines mean changes to the content of programs such as TextMATCH need to be made from time to time. In this case, messages are updated using the same process, requiring significant time and input from reviewers before they are loaded into the content management system. This needs to be factored into the ongoing costs of the program.We believe that it is important that mHealth programs target minority and vulnerable populations, who may have difficulty accessing traditional health services due to a variety of reasons. These reasons can include language, cultural differences, geography, travel, work, or roles caring for others. It is also important to consider the technological infrastructure of a setting, and the power dynamics which determine different groups’ access to technologies, and how existing communities and health systems will respond to mHealth ,7,25.It is important that these findings be interpreted in light of the limitations including the small number of participants interviewed, potential sampling bias in those who agreed to an interview, and unequal samples of cultural groups and interview categories. The overall numbers of people using the Korean or Japanese versions of the program at the time of interviewing were not large and interviews could not be offered in these languages, meaning the results cannot be generalized to those receiving TextMATCH messages in those languages. Further investigation is needed into reasons for disengagement in those who had withdrawn from TextMATCH within 2 weeks of signing up as this group was not included in the study and could provide valuable insight into engagement.We have described how mHealth can provide access to health information, motivation, reassurance, and support in simple programs like TextMATCH. It can also link people to existing community programs for appropriate in-person support. It is important that mHealth programs are designed with the involvement of these vulnerable groups in our populations, and that we take the time and extra resources required to ensure that the programs will be relevant and appropriate for the context of their daily lives. This is not simply about translating programs that have been developed for the majority. We have described here an extensive process of developing an intervention with minority populations first. There is no “majority”  version of TextMATCH. This process has begun in collaboration with the community which cares for these families of minority cultural groups and which shares their culture.


Escherichia coli and Pseudomonas aeruginosa, known as E-type colicins and S-type pyocins, respectively, bound to their specific immunity (Im) proteins. First, we report the 3.2 Å structure of the DNase colicin ColE9 in complex with its ultra-high affinity Im protein, Im9. In contrast with Im3, which when bound to the ribonuclease domain of the homologous colicin ColE3 makes contact with the translocation (T) domain of the toxin, we find that Im9 makes no such contact and only interactions with the ColE9 cytotoxic domain are observed. Second, we report small-angle X-ray scattering data for two S-type DNase pyocins, S2 and AP41, into which are fitted recently determined X-ray structures for isolated domains. We find that DNase pyocins and colicins are both highly elongated molecules, even though the order of their constituent domains differs. We discuss the implications of these architectural similarities and differences in the context of the translocation mechanism of protein antibiotics through the cell envelope of Gram-negative bacteria.Protein antibiotics (bacteriocins) are a large and diverse family of multidomain toxins that kill specific Gram-negative bacteria during intraspecies competition for resources. Our understanding of the mechanism of import of such potent toxins has increased significantly in recent years, especially with the reporting of several structures of bacteriocin domains. Less well understood is the structural biochemistry of intact bacteriocins and how these compare across bacterial species. Here, we focus on endonuclease (DNase) bacteriocins that target the genomes of  The three-layered structure of the Gram-negative cell envelope, comprising the outer membrane, inner membrane, and intervening peptidoglycan, is a formidable defensive barrier. Nevertheless, antimicrobial peptides and proteins from competing bacteria can breach these defences. Such competition systems are an integral part of the cohabitation of bacteria in mammalian hosts and are often associated with pathogenesis . Three fEscherichia coli, and pyocins that kill Pseudomonas aeruginosa 0 is the initial concentration of ColE9 and Im9, F is the fluorescence at time t, F0 is the initial fluorescence, and ΔF is the total chance in fluorescence divided by protein concentration. The slower fluorescence quench (200 ms–2 s) was fitted to a single exponential equation.Pre-equilibrium fluorescence measurements were made on an Applied Photophysics SX20 stopped-flow spectrometer, using an excitation wavelength of 280 nm with slit widths of 5 nm, monitoring changes in tryptophan emissions above 320 nm selected with a cut-off filter. The association of ColE9 with Im9 in phosphate-buffered saline (PBS), pH 7.4, was measured under second-order conditions, using equimolar concentrations of each protein (0.35 µM after mixing) at 25 °C as described previously . Four thAnalytical size-exclusion chromatography was used to quantify the release of Im9 from the Y324C, L447C ColE9–Im9 complex in the presence of excess E9 DNase domain. Y324C, L447C ColE9–Im9 (16.4 µM) was incubated with a six-fold molar excess of E9 DNase domain in PBS buffer, pH 7.4, in the presence of protease inhibitor cocktail . After various incubation times between 0 and 156 h, aliquots of the sample were analyzed on a Superdex 200 10/300 GL column (GE) equilibrated in PBS, pH 7.4, allowing resolution of three peaks corresponding to ColE9/ColE9–Im9, E9 DNase·Im9, and free E9 DNase. The area of the E9 DNase·Im9 peak was integrated to quantify the amount of Im9 released as a function of time, with data fitted to a single exponential equation to determine the dissociation rate constant.P1211 with unit cell dimensions a = 94.89, b = 116.05, and c = 150.37 Å. Matthews coefficient . I.J. and L.C.M. were supported by studentships from the Wellcome Trust [093592/Z/10/Z] and [106064/Z/14/2], respectively.


To understand the implementation quality of the Tier 1 Program (Secondary 1 Curriculum) of the Project P.A.T.H.S.  in the full implementation phase, 100 schools were randomly selected to participate in personal and/or telephone interviews regarding the quality of the implementation process of the Tier 1 Program. In the interviews, the participants described the responses of the students to the program, the perceived benefits of the program, the perceived good aspects of the program, and the areas requiring improvement, difficulties encountered in the implementation process, and perceived attributes of the worker-support scheme . Results showed that most workers perceived that the students had positive responses to the program and the program was beneficial to the students. They also identified several good aspects in the program, although negative comments on the program design and difficulties in the implementation process were also recorded. Roughly half of the respondents had positive comments on the “Co-Walker Scheme”. In sum, the respondents generally regarded the program as beneficial to the students and they were satisfied with the Tier 1 Program (Secondary 1 Curriculum) in the full implementation phase, although some implementation difficulties were also expressed.


The Tier 2 Program of the Project P.A.T.H.S.  targets adolescents with greater psychosocial needs, and the related programs were designed and implemented by school social workers. After completion of the Tier 2 Program (Secondary 1 Level), 9,931 participants in 212 schools responded to the Subjective Outcome Evaluation Form (Form C) in order to assess their views of the program, workers, and perceived effectiveness of the program. Based on the consolidated reports submitted by the agencies to the funding body, the research team aggregated the consolidated data to form a “reconstructed” overall profile on the perceptions of the program participants. Four major types of program were identified, including programs based on the adventure-based counseling approach (n = 58), programs concentrating on volunteer training and services (n = 31), programs offering both adventure-based counseling and volunteer training activities (n = 91), and other programs with different foci (n = 32). Results showed that high proportions of the respondents had positive perceptions of the programs and the workers, and over four-fifths of the respondents regarded the program as helpful to them. The present study provides support for the effectiveness of the Tier 2 Program of the Project P.A.T.H.S. in Hong Kong for the Full Implementation Phase.


Streptococcus sanguinis mycotic popliteal aneurysm.Mycotic popliteal aneurysms are not a common phenomenon. They can initially be easily confused with other more trivial conditions such as a Baker’s cyst. We present a case of a patient presenting with a progressively worsening leg swelling which was initially misdiagnosed. Only until symptoms rapidly progressed was a popliteal aneurysm diagnosed. To our knowledge this is the only identified case of a Streptococcus sanguinis. Multiple investigations failed to isolate an acute infective source of this infection. The patient recovered promptly with a long course of intravenous antibiotics, being able to mobilize normally.An 81-year-old gentleman presented to the surgical assessment unit with a six-week history of a painful, diffuse swelling in the left popliteal fossa. Initially, when symptoms developed a provisional diagnosis of a Baker’s cyst was made. When the symptoms progressed to involve swelling of the entire lower limb, an ultrasound was arranged. Detailed Imaging revealed a popliteal aneurysm with signs of rupture. Urgent repair was performed, with high suspicion of a mycotic aneurysm intra-operatively. Cultures confirmed this, isolating Streptococcus sanguinis has not been isolated from such an aneurysm until now. The most likely explanation of this case was that the aneurysm was secondary to transient bacteraemia of this organism through the oral cavity, in the absence of any cardiac involvement.Mycotic popliteal aneurysms are not very common and can easily be confused with other benign lesions. The key to diagnosis is the presence of a pulsatile mass and further detailed imaging. This case was unique in that  Streptococcus sanguinis mycotic popliteal aneurysm.Mycotic popliteal aneurysms are not a common phenomenon. They can initially be easily confused with other more trivial conditions such as a Baker’s cyst. We present a case of a patient presenting with a progressively worsening leg swelling which was initially misdiagnosed. Only when symptoms rapidly progressed was a popliteal aneurysm diagnosed. To our knowledge, this is the only identified case of a An 81-year-old gentleman presented acutely to the surgical assessment unit with a painful, diffuse swelling in the left popliteal fossa. The swelling, which was first noticed 6 weeks prior to admission, came on suddenly and was associated with pain and tenderness. Over the following weeks, it had progressed in size and become increasingly painful. The patient had a background history of hypertension, but was not on any regular medication.A provisional diagnosis of a Baker’s cyst had been made by the patient’s primary health care provider and he had subsequently been awaiting an Orthopaedic clinic appointment for this. The swelling continued to increase in size, restricting the range of movement at the knee. The patient subsequently attended the emergency department where a pulsatile popliteal fossa mass was found. The impression was still of a Baker’s cyst and the patient was sent home. In the weeks to follow, the patient struggled to bear weight on the left leg. The 24 hours leading up to his present admission was accompanied by a sudden onset diffuse swelling in the entire left lower leg. An urgent ultrasound was arranged to exclude a deep venous thrombosis which instead revealed a large, 8 cm, popliteal aneurysm in the popliteal fossa, the outer wall of which was not well defined. There was a 5 cm patent channel noted within the centre of this structure with extensive intramural thrombus noted at the periphery. No obvious abdominal aortic aneurysm was seen.On initial surgical evaluation, the patient was haemodynamically stable and apyrexial. The left leg was grossly oedematous from below the knee, with a pulsatile firm tender mass in the popliteal fossa. The pedal pulses were all palpable with good range of movement in the feet; however, there was marked reduction of movement at the knee joint. Initial blood tests including white cell count and C-reactive protein were normal. To get a more detailed image of the aneurysm and arterial tree in the left leg, an urgent magnetic resonance (MR) arteriogram was arranged, which showed a false aneurysm of the popliteal artery measuring 8.8 cm coronally and 7.4 cm axially . ApproxiPer-operatively, the aneurysm was approached posteriorly and the sac dissected. Bleeding was controlled and clamps applied at either end of the aneurysm. The appearance of the aneurysm was very much indicative of a mycotic aneurysm, and a tissue sample was sent to the microbiology laboratory for microscopy and culture. A 5 cm vein graft was used to repair the aneurysm and the wound was closed. After the procedure, a strong flow signal was detected distal to the aneurysm repair. In the days to follow the patient recovered very well and the oedema in the leg slowly started to settle.Streptococcus sanguinis by API 20 Strep (bioMérieux) – a member of the viridans group streptococci. These results were available on the seventh day post-operatively, confirming the suspicion of a mycotic aneurysm. Intravenous benzylpenicillin and flucloxacillin were commenced for 2 weeks, as recommended by the microbiologist.The aneurysm tissue was processed using the local Microbiology Laboratory Standard Operating Procedure for sterile tissues. It was emulsified in sterile saline using sterile glass beads, then plated onto 5% sheep blood (BA), chocolate (CA), CLED and anaerobic (ABA) agar plates and into cooked meat broth (CMB) (bioMérieux), which were incubated in appropriate atmospheres at 37 °C for 48 h (5 days for the anaerobic plate and CMB). The culture on CMB was sub-cultured after 5 days onto BA, CA and ABA, which were then incubated as above. The isolate was identified as trans-oesophageal echocardiogram (TOE) to evaluate his heart further. The patient regularly visited his dentist and had reasonable dental hygiene. In the absence of any focal source of sepsis, a conclusion was made that the mycotic aneurysm was secondary to transient Streptococcus sanguinis bacteraemia through the oral mucosa. The patient continued to show significant improvement in mobility in the weeks to follow.Despite these findings, the patient remained afebrile and serial blood cultures taken all came back negative. As the organism is commonly part of the oral flora, an orthopantomogram and transthoracic echocardiogram (TTE) were requested to exclude infective endocarditis. Both of these tests were inconclusive and the patient subsequently refused to have a Mycotic aneurysms were historically defined as infected aneurysms developing within a previously normal artery secondary to septic embolization due to bacterial endocarditis .Mycotic popliteal artery aneurysms (MPAA) are a rarely described phenomenon and have only been reported approximately 50 times in the English literature. Despite the popliteal artery being the most common peripheral site for aneurysm formation, mycotic aneurysms tend to favour the femoral artery and abdominal aorta , with no particular age predilection and a mean age of onset at 41 years . Whilst Staphylococcus aureus is the most prevalent cause of MPAA followed by Streptococcus viridans and Staphylococcus epidermidis. Other organisms are varied and include Campylobacter jejuni, Escherichia coli, Streptococcus faecalis and Streptococcus pneumoniae, and Tuberculosis and Salmonella spp. (Streptococcus sanguinis to the best of our knowledge. Streptococcus sanguinis is a Gram-positive cocci, a normal colonizer of the oral cavity, and is thought to be protective against dental caries (Reviews of the available literature suggest that, in many cases, blood cultures do not identify a causative organism. However, when the organism has been identified, Unfortunately for clinicians, mycotic popliteal artery aneurysms have a varied and inconsistent presentation. That said, there are some features that one would expect to find in a typical MPAA. Classically, MPAA present as a painful, tender, pulsatile swelling in the popliteal fossa. Some patients will also be pyrexic and often have a primary infective focus such as bacterial endocarditis. As with our case, MPAA can be confused with a Baker’s Cyst and further evaluation is not sought until symptoms of the aneurysm itself, such as claudication, acute ischaemia or digital thromboembolism arise (Laboratory studies typically show raised inflammatory markers and a leukocytosis but this is not present in all patients. Blood cultures, as previously mentioned, are only present in approximately 50% of reported MPAA cases, although this may be explained by pre-diagnosis treatment with antibiotics for the primary infective focus (Once identified, two issues must be addressed: firstly identifying and treating the primary infective source and secondly treating the popliteal aneurysm itself. For the former, this involves assessment of the entire cardiovascular system and often a transoesophageal echocardiogram regardless of the presence of an audible heart murmur. If this is negative it is also worth investigating the adjacent knee joint for the presence of a septic effusion and taking a history for recent trauma or damage to the knee joint. Both of these conditions are treated in the main by at least 2 weeks of intravenous antibiotics followed by 4 weeks of intravenous or oral antibiotics according to clinical response. Septic arthritis also involves arthroscopy or open washout of the knee joint. Treatment of the popliteal aneurysm itself and any complications that have ensued is normally guided by multidisciplinary team management but in the main consists of resection and revascularization. At present, there is no evidence-based consensus on the approach for popliteal aneurysms with both medial and posterior approaches being utilized . The aneOccasionally MPAA, as with all popliteal aneurysms, can result in the need for amputation either as a result of escalation of the primary process itself prior to treatment or failure of the graft. It is likely that these cases are underreported.MPAA and indeed all mycotic aneurysms are much rarer nowadays due to the high index of suspicion for bacterial endocarditis in patients with heart murmurs followed by early and aggressive antibiotic treatment. However, despite their rarity this case report has illustrated new bacteriology in its pathogenesis and also highlighted the pitfalls in diagnosis of the condition.