Groin injuries represent a considerable problem in male football, accounting for 4%‐19% of all time‐loss injuries. The Adductor Strengthening Programme is the first groin‐specific prevention program shown to reduce the risk of groin problems. We aimed to use the RE‐AIM framework to examine the players’ experiences with the implementation of the program and player attitude toward groin injury prevention in football. Of the 632 players involved in the trial examining the effect of the Adductor Strengthening Programme, 501 agreed to participate in a survey at the end of the season. Most players thought that footballers are at moderate to high risk for groin injuries (87%) and that there is a need for preventive measures (96%). They also believed that a preventive program with strengthening exercises would reduce the risk of groin injuries (91%). Majority of the players reported using <5 minutes to complete the program (73%), and only 11% wanted additional exercises. However, only 46% reported to have performed the program as recommended, and an even smaller proportion (31%) planned to continue using it as recommended the next season. Our results suggest that footballers believe that prevention of groin injuries is needed. Attitude toward implementation of the Adductor Strengthening Programme was positive, and the single‐exercise approach was considered an important facilitator. However, in future dissemination of the program, the players’ reluctance to maintain the exercise protocol may be a potential barrier to implementation that should be addressed. Until recently, groin‐specific exercise programs aiming to prevent groin injuries have not shown any significant effects.In this study, the compliance with the Adductor Strengthening Programme was higher than what has previously been reported in groin‐specific injury prevention trials.Although better compliance to injury prevention program has demonstrated lower injury rates throughout the season,Thus, the primary aim of this study was to use the RE‐AIM framework to examine the players’ experiences with the implementation of the Adductor Strengthening Programme among male sub‐elite football players. Furthermore, we investigated player attitudes toward groin injury prevention.22.1This survey took place from September to October 2016, as part of a randomized controlled trial (RCT) examining the preventive effect of the Adductor Strengthening Programme on the risk of groin problems in sub‐elite male football players.During the last weeks of the 2016 season, we invited all 34 teams (632 players) enrolled in the RCT to take part in the study. Teams that agreed to participate received a personal visit, where we informed players about the study, and each player was invited to participate. All players enrolled in the RCT were eligible for participation. All players received oral and written information about the purposes and procedures of the project before providing their written consent.This report is prepared according to the STROBE checklist for observational studies.2.2The survey was based on the different dimensions of the RE‐AIM framework2.3Players were asked to complete a paper version of the questionnaire. Players who were injured, ill, or for other reasons did not attend training the day of our personal visit were contacted through e‐mail or phone and asked to complete an online version of the questionnaire using Questback .2.4All returned questionnaires were included in the analysis regardless of missing data. All responses were exported into SPSS Statistics for Windows, version 24.0 (SPSS Inc), and analyzed using descriptive statistics. Player characteristics were obtained from the RCT (at the time of inclusion in February and March 2016).33.1Three of the 34 teams in the RCT declined to participate. In total, 501 (79%) of the players enrolled at baseline were included, 75% from the intervention group (n = 255), and 84% from the control group (n = 246). Of the 501, 408 (81%) responded to the questionnaire during our team visit, while 93 responded to the online version of the questionnaire within 2 weeks. Player characteristics at baseline are shown in Table 3.2Overview of the player responses regarding their attitude toward groin injuries and groin injury prevention is shown in Tables 3.3The questions and responses from players in the intervention group to the questions about the Adductor Strengthening Programme are shown in Tables 3.4Of the players in the control group, 30.5% reported having knowledge about the content of the Adductor Strengthening Programme and 53.3% reported that they had performed the program or other exercises to prevent groin injuries during the season the study took place.4The aim of this study was to examine the players’ experiences with the implementation of the Adductor Strengthening Programme and to investigate their attitudes toward groin injury prevention. The main findings of this survey of Norwegian semi‐professional football players were that most players believed that footballers are at moderate to high risk for groin injuries and that there is a need for groin injury preventive training or other measures. Most players thought that a preventive program with strengthening exercises would reduce the prevalence of groin injuries. Majority of the players reported using <5 minutes to complete the program, and very few wanted additional exercises. On the other hand, <50% of the players reported to have performed the program as much as recommended during the trial, and an even smaller proportion planned to continue using it as prescribed the next season.The recently reported preventive effect of the Adductor Strengthening Programme suggests that dissemination and widespread use in the football community would be beneficial.“less often” to the question “Have you conducted the program with the recommended frequency?” if he has missed just one session. Thus, players may have performed the exercise less often and still have 70% compliance. Although player compliance with the program was somewhat lower than our recommendations, the reported compliance in this trial was much higher than that seen in previous groin‐specific prevention trials.Despite these results, suggesting that reach of the program was successful, the players reported to deviate from the recommended protocol. In the present study, about 45% of the players reported to have performed the program at least as often as prescribed, while data from the RCT documented an average weekly completion of the program of 70%.The single‐exercise approach should be considered as an important facilitator for the successful implementation of the Adductor Strengthening Programme. Only 11% of the players wanted more exercises. They also believed that a program with several exercises, requiring more time to be spent, would decrease their motivation. The majority of the players reported using <5 minutes to complete the program. In other studies reporting on the uptake of the injury prevention exercise programs in football, the length of the program has been emphasized as one important barrier to implementation.A common understanding among the different stakeholders within a club is emphasized as an important premise to succeed with implementation of preventive measures.Interestingly, 31% of the players in the control group reported to have knowledge about and more than 50% to have performed the Adductor Strengthening Programme or other prevention exercises to reduce the risk of groin injuries during the study period. This suggests that there was a crossover effect in the RCT, suggesting that the 41% reduction in risk of groin problems observed may represent an underestimation.From elite level, we know that the main challenges with exercise programs to prevent injury are concerns about muscle soreness and “heavy legs.”4.1There are some methodological limitations that should be kept in mind when interpreting the current results. First, this survey included only perceptions of the players. The RE‐AIM framework is a tool for decision‐makers to assess how interventions are implemented in practice, and their impact at the individual and organizational level. The understanding and perceptions of other stakeholders in the club are not known. Furthermore, this study included only teams from the sub‐elite level; we do not know if teams at other levels of play  or females would have had different perceptions and views.5Players in sub‐elite football teams experience that they are at high risk of sustaining groin injuries and believe that the Adductor Strengthening Programme will be effective in reducing the risk of groin problems, suggesting that there is fertile ground for implementation. The single‐exercise approach was an important facilitator for the successful implementation, and the majority of the players spent <5 minutes to complete the program. However, in future dissemination the players’ reluctant motivation for maintaining the exercise protocol may be considered a potential barrier to implementation that should be addressed.None declared.JH, RB, EGW, and TEA were involved in the design of the study and the data collection. The authors jointly interpreted the data and wrote the paper.This study has been approved by the South‐Eastern Norway Regional Committee for Medical Research Ethics (2015/1922/REK) and the Norwegian Data Inspectorate (45388/3/LT/LR). Click here for additional data file.


Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc.We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions.Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22%  to 48% (95% CI = 47–50%) and program states in Nigeria, from 38% (95% CI = 32–40%) to 55% (95% CI = 51–58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies.Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand. Diarrhea is the second leading cause of infectious deaths in children under-five globally, causing an estimated 526 000 deaths each year, or nearly 1500 childhood deaths each day [th century [ORS was first introduced in the 1970s in Bangladesh by the International Centre for Diarrhoeal Disease Research, Bangladesh  and was championed globally as one of the most important medical advances of the 20 century ,4. Usage century .In 2004, the WHO and UNICEF recommended adjunct therapy with zinc alongside ORS as the primary treatment for childhood diarrhea . In addiBangladesh was the only country to achieve high treatment rates nationally: as of 2014 nearly 80% of children with diarrhea received ORS, and 34% received both ORS and zinc . This waBuilding off the lessons from Bangladesh, POUZN, and other ORS and zinc scale-up efforts, such as the Strengthening Health Outcomes in Private Sector (SHOPS), the Clinton Health Access Initiative (CHAI) began partnerships with donors and governments in 2012 in four high-burden countries – India, Kenya, Nigeria, and Uganda – to take a comprehensive approach to ORS and zinc scale up. These efforts aimed to demonstrate that increased ORS and zinc coverage rates are achievable at scale in other high-burden settings beyond Bangladesh.This paper describes the overall program model and the activities undertaken in each country. The overall goal of the paper is to share program results and lessons learned to inform other countries aiming to scale-up ORS and zinc.The theoretical underpinning of CHAI’s program model was that low demand for ORS and zinc was reinforced by low investment from manufacturers and suppliers, thus creating a “market trap” . ORS andThe program’s theory of change  whether ORS and zinc coverage improved in program areas; (2) whether improvements in ORS and zinc coverage were equally observed among children living in rural areas and poor households; and (3) whether the annual rate of change in ORS and zinc coverage in program areas was greater than that in the surrounding region. Secondary study questions were whether availability of ORS and zinc changed during the program period, whether retail costs of ORS and zinc changed during the program period, and how many deaths were averted during the program period due to changes in ORS and zinc coverage.We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys to evaluate the program model. Population-based household surveys were used to compare the percent of children under-five with diarrhea who received ORS and zinc before and after the program. The public health facility audits were used to check for the availability of ORS and zinc, and private outlet surveys were also used to track the market availability and price of ORS and zinc. We also estimated diarrhea deaths averted due to ORS and zinc coverage changes using Spectrum v5.753 Lives Saved Tool (LiST) . The main paper focuses on results from the household surveys, and the methodology and results of the public facility audits, private outlet surveys, and LiST model are presented in the For household surveys, we identified existing sources, such as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) that collected the necessary indicators prior to the program. In India, Kenya, and Uganda, the District Level Household Survey (DLHS) 2007-08, DHS 2008-09, and DHS 2011, respectively, were used for pre-program estimates of ORS and zinc coverage. In Nigeria, we hired an independent research agency to conduct a state-representative survey in the program states. For endline estimates, we hired independent agencies to conduct population-based household surveys in India, Kenya, and Nigeria. In Uganda, we conducted secondary analyses of the DHS 2016 survey. The sampling and survey methodologies for the program-funded household surveys were designed to be similar to the DHS. The methodology is described in detail elsewhere -33.To compare the rate of change in ORS and zinc coverage in our program areas with the rates of change in the surrounding regions, we also searched for DHS and MICS surveys from countries in Sub-Saharan Africa, Asia, the Middle East, and Eastern Europe. Only countries which had at least two surveys conducted between 2008 and 2016 were included. All surveys included in the analysis are listed in To determine whether ORS and zinc coverage changed in our program areas, we estimated ORS and combined ORS and zinc coverage and corresponding 95% confidence intervals for each survey conducted in our program area while applying the appropriate sampling weights for the respective survey. We consider estimates with non-overlapping confidence intervals to be statistically significant.To determine whether ORS and zinc coverage changes were equally observed among rural and poor households, we estimated ORS and zinc coverage by urban/rural and lowest/highest household wealth quintiles for each survey conducted in our program areas. Definitions of urban and rural areas were defined by the sampling frames used for those respective survey and wealth quintiles were constructed using principle component analysis of household assets -38.We summarized the baseline and endline estimates using unweighted averages across program areas to provide a measure of overall program coverage change. Unweighted averages were also used to summarize baseline and endline coverage levels across program areas by urban/rural areas and wealth. The survey analyses were conducted in Stata 14 .To determine whether coverage changes in program areas were greater than those in the surrounding region, we estimated the rate of change for ORS and zinc coverage in percentage points per year using ordinary least squares method for two periods: a pre-program period between 2008 and 2012 and a program period between 2012 and 2016. Four-year time periods were used as the program periods in the countries were approximately four years. We estimated annual coverage changes between 2008 and 2012 to determine whether pre-program trends were similar between geographies and between 2012 and 2016 to determine whether ORS and zinc coverage changes in program areas were greater during the program period. We first disaggregated the surveys conducted between 2008-12 and 2012-16. Surveys conducted in 2012 were included in both sets. We calculated coverage levels for the years 2008 and 2012 if survey data was not available for those years. These estimates were achieved by calculating the average change in coverage between the two available data points immediately before and after 2008, then applying this linear trend to estimate coverage in 2008 and then again in 2012. Using this method, data points for 2008 and 2012 were calculated for all countries and program areas to fill in these missing points.We then plotted combined ORS and zinc coverage for the year in which the survey was conducted and estimated a best fit line using ordinary least squares. We conducted the analysis separately for the individual program areas, the Sub-Saharan Africa region, and the Asia/Middle East/Eastern Europe region. Countries in Asia, Middle East, and Eastern Europe were grouped together given scarcity of data in the individual regions.For combined ORS and zinc coverage, we found statistically significant coverage changes in all four program areas, and on average, ORS and zinc coverage increased by 23 percentage points. In program states of India, combined ORS and zinc coverage increased from 0% to 19% (95% CI = 18-21%). In Kenya, ORS and zinc coverage increased from 0.2% (95% CI = 0-1%) to 15% (95% CI = 12-19%). In Nigeria program states, combined coverage increased from 4% (95% CI = 3-5%) to 30% (95% CI = 2733%). In Uganda, ORS and zinc coverage increased from 1% (95% CI = 1-2%) to 30% (95% CI = 28-32%).In India and Nigeria, we found a statistically significant increase in ORS coverage for children with diarrhea living in rural areas. In India, ORS coverage in rural areas increased from 20% (95% CI = 19-21%) to 47% (95% CI = 45-49%). In Nigeria, the percent of diarrhea cases living in rural areas receiving ORS increased from 29% (95% CI = 25-34%) to 58% (95% CI = 54-61%). We also found coverage in urban areas in India had increased significantly, though the relative change in rural areas were greater. In India, ORS coverage in rural areas increased by 138% compared to 96% in urban areas. The coverage increase in urban areas of Nigeria was not statistically significant: 43% (95% CI = 34-52%) at baseline and 53% (95% CI = 47-58%) at endline.Among diarrhea cases living in the poorest quintile, we found ORS coverage had significantly increased in India and Nigeria. In India, ORS coverage in the poorest quintile increased by 29 percentage points, from 15% (95% CI = 14-16%) to 44% (95% CI = 42-46%). In Nigeria, the increase was by 31 percentage points, from 18% (95% CI = 21-26%) to 49% (95% CI = 42-57%).We present Bangladesh separately given its unique experience in leading research and implementation of ORS and zinc scale-up. Timor-Leste is also presented separately as the coverage increase over the period of interest is a clear outlier for the region. We find average annual ORS and zinc coverage increases in Bangladesh and Timor-Leste was nearly equal in both periods. Between 2008 and 2012, ORS and zinc coverage increased at a rate of 3.7 and 4.9 percentage points per year respectively, and between 2012 and 2016, the coverage rate increase was 4.6 and 5.1 percentage points per year, respectively. The latest surveys show that combined ORS and zinc coverage in Bangladesh and Timor Leste are 36% and 40%, respectively.In Sub-Saharan Africa, ORS and zinc coverage increased at an average annual rate of 0.1 percentage points per year between 2008 and 2012. Between 2012 and 2016 in Sub-Saharan Africa, the average annual ORS and zinc coverage increased by 2.2 percentage points per year. In Kenya, Uganda, and program states in Nigeria, we found average annual coverage increases of 1.2, 0.2, and 0.5, percentage points per year, respectively, between 2008 and 2012. Between 2012 and 2016, average annual coverage increased by 2.6 percentage points per year in Kenya, 7.1 percentage points per year in Uganda, and 7.2 percentage points per year in program states in Nigeria.Using the LiST model, we estimated 76 090 (sensitivity bounds 60 690-89 140) diarrheal deaths were averted during the program period due to increases in ORS and zinc coverage  can be consistent across countries. Bringing this approach to additional high-burden countries could reach millions more cases and save the lives of hundreds of thousands of more children. Alongside continued scale up of vaccines, improved diarrhea treatment rates could prevent the deaths of more than 500 000 children who die unnecessarily each year from diarrhea-related causes . SummariBox 1Approach: In program states in India, ~ 70% of diarrhea cases seek care, with over 80% in the private sector. Given this, the program focused heavily on changing stocking and dispensing practices of rural medical providers (RMPs). Price was not a major barrier since the price was regulated in the private sector, and ORS and zinc were free in the public sector. To change RMP practices, the program partnered with rural entrepreneurs, who promoted and sold ORS and zinc in their villages, and connected them with quality regional suppliers. This model increased product margins by reducing supply chain handoffs and created greater flexibility in supply chain. The purchase of products was fully funded by the partners, while the program provided in-kind promotional materials and time-limited operations support. After three and a half years, the partners were fully self-sustaining and continued selling ORS and zinc as part of a broader basket of goods. In addition, CHAI partnered with government on diarrhea “orientation sessions” to educate RMPs on correct treatment. In the public sector, the program worked with state governments to optimize product specifications and packaging in response to consumer research. The program also launched an intensive mass media campaign in years 3 and 4 based on consumer research on most effective messages and channels.Mistakes/Challenges: The approach to consumer demand in years 1-2 focused on interpersonal outreach but shifted to mass media in years 3-4 as cost per contact was lower.Critical Success Factors:Robust consumer research informed program designHigh media penetration even in rural and poor householdsLarge-scale, self-sustaining rural sales force created platform for detailing, better margins, closer stock pointsBox 4Approach: In Uganda, ~ 70% of pediatric diarrhea cases seek care with ~ 45% in public sector and 55% in private sector (DHS 2011). At the start of the program, Uganda had a monopolistic, low-volume, high-price and often subsidized market with only two zinc and two ORS suppliers. To address this, the program provided TA to suppliers to bring new products to market, increasing competition to reduce prices. From these efforts, four low-osmolarity ORS, four dispersible zinc tablets, and two co-packaged products entered the market; average retail price declined ~ 40% to $0.71. The government had a co-pack strategy, and CHAI supported the government nationally and in all 112 districts to ensure volumes procured met public sector demand. In the supply chain, the program promoted zinc/ORS at wholesale distribution points and provided incentives to local distributors hitting availability and price targets (below recommended retail price which was introduced by government in late 2014.) To generate demand, CHAI provided promotional materials to suppliers, and supported professional associations and the MOH to incorporate updated guidelines into all existing CMEs, mentorship, and training platforms. These efforts reached >20K public and private providers. The program also worked through village health teams and community groups  to promote zinc/ORS.Mistakes/Challenges: Initial introduction of the co-pack in the public sector occurred too soon – before affordable co-packs were on the market. This led to an initial co-pack tender that was more expensive than singles. With CHAI support, MOH renegotiated the co-pack tender price once affordable co-packs were available on the market to achieve prices below that of singles.Critical Success Factors:Quantification/forecasting support in all 112 districtsCo-pack strategy and efforts at all points in supply chain to ensure availability and competitive pricingWhile combined ORS and zinc use increased in program areas, coverage remains relatively low: below 30% in each country. Efforts to further improve care-seeking for diarrhea and use of ORS and zinc should be continued. Diarrhea remains a major cause of mortality in these countries, and ORS and zinc are proven cost-effective interventions to reduce mortality in children under five. In Kenya and Uganda, approximately 30% of children with diarrhea still do not seek care and are therefore unlikely to receive ORS and zinc compared to those that seek care. Efforts to improve care-seeking in these countries could have an outsized effect in improving coverage. In India and Nigeria, coverage amongst cases seeking care in the private sector lags behind those in the public sector, and a higher proportion of children with diarrhea seek care in the private sector in these countries. Continuing to engage the private sector and encourage appropriate case management with ORS and zinc could help further gains in India and Nigeria.The program aimed to first ensure consistent availability of affordable, quality ORS and zinc products prior to investing in demand generation. At the start of the program, access to ORS and zinc was limited in Kenya, Nigeria, and Uganda, largely driven by a small number of expensive products on the market. There were no pediatric zinc products available on the market in Nigeria, only one in Kenya, and two in Uganda. The average cost of the full treatment course of ORS and zinc was US$1.67 in Nigeria, US$1.55 in Kenya, and US$1.27 in Uganda  compared to private sector providers (average of 55% for ORS and 33% for zinc). This finding was expected as there are often well-established platforms to reach public sector clinicians as well as more opportunity for management accountability. Other studies have also observed higher ORS coverage among cases seeking care in the public sector compared to private sector . Howeveruse – not just awareness or knowledge. In India, program data revealed that mass media did in fact have penetration with rural households and also influenced coverage increases [To generate demand among caregivers, the program relied on quantitative and qualitative research to not only understand current practices but also what messages and strategies would be most effective in changing behavior. The demand efforts focused on measurable changes in ncreases . In IndiNot unexpectedly, the markets with the highest rates of care-seeking for diarrhea – 89% in India and 76% in Nigeria–also had the greatest coverage increases. India and Nigeria also had the greatest rates of private sector care-seeking (79% of those seeking care in India and 57% in Nigeria). More proximate access to care through an expansive network of private outlets may have contributed to the higher care-seeking rates, and thus higher coverage, in India and Nigeria. This potential advantage is particularly relevant for products like ORS and zinc that can be legally dispensed as over-the-counter products.In all focal geographies, strong government leadership influenced the speed of implementation and the sustainability of results. For example, in Nigeria, the primary program interventions were anchored within Nigeria’s high-profile National Essential Medicines Strategy, and implementation was led by the government and managed through existing technical working groups at national and state levels. These coordinating mechanisms provided ongoing accountability for progress and also facilitated rapid problem solving across government, donors, and nongovernmental organization stakeholders. In Kenya, the central procurement authority issued a strong directive to all 47 county governments to recommend switching to a co-pack, and the Kenyan government also bundled single-units in advance of the co-pack introduction to prepare the system for the switch. These efforts likely helped to accelerate the switch to co-packs and the uptake of the combined treatment.In some markets, broader trends with procurement of essential medicines may have influenced the results of the program as well. For example, in Kenya, procurement authority for the country was devolved from a centralized system to 47 individual counties during the course of the program. Through this period of transition, availability of essential medicines in public sector facilities, including ORS and zinc, was also strained. This broader change in Kenya’s national procurement approach likely contributed to lower gains than expected in the Kenya context .In Uganda, government procurement of ORS had declined in the early part of the program which may have limited improvement in ORS coverage. Between 2011 and 2014, government procurement of ORS had declined by 64%. The decline coincided with the decentralization in the quantification of the Essential Medicine kit from the Central Medical Store to each district and the switch from single ORS sachets to a more expensive co-pack. A household survey conducted by the program at the end of 2014 found ORS coverage had declined from 44% in 2011 to 35% by 2014. By 2016, ORS coverage had increased to 47%.Our evaluation relies on triangulation of multiple data sources, including data collected primarily by the program and secondary data sources such as the DHS. A limitation of this methodology is that the use of multiple sources may affect comparability between data sources. While several efforts were made to adopt the sampling, survey, and implementation methods of the DHS, we had to adjust aspects of the methodology to fit into the available resources. Thus, we cannot rule out that the program household surveys may not be fully comparable to the DHS results. However, we have compared our survey results with other available data sources to validate the estimates obtained in our surveys. In India, we compared our estimates with those found in the National Family Health Survey (NFHS-4), which was conducted approximately a year prior to our surveys, and found similar results. In the NFHS-4, the pooled, weighted ORS coverage for Gujarat, Madhya Pradesh, and Uttar Pradesh was 42% and the combined ORS and zinc coverage was 16%. In CHAI’s endline household survey, we found pooled, weighted ORS coverage of 48% and combined ORS and zinc coverage of 19%. In Nigeria, we compared our estimates with those found in the MICS 2016-17 survey, which was conducted within nine months of our surveys. The pooled, weighted combined ORS and zinc coverage estimate for the eight program states was 25% in the MICS 2016-17 results while we found combined ORS and zinc coverage to be 30%. We did find higher coverage of ORS (55%) than the MICS 2016-17 (40%), which may be due to survey timing, sampling, or how the questions were asked. Our survey was focused exclusively on diarrhea and interviewers carried pictures of local ORS and zinc brands to improve recall, while the MICS survey covers an extensive range of child health and education questions. Going forward however, the DHS and MICS can be utilized to measure whether ORS and zinc coverage has sustained, and ideally increased.Another limitation is that the pre-post evaluation methodology prevents us from estimating the attribution of the coverage changes to the program. Due to the program design which worked with and through the government for sustainability reasons, we do not think it is feasible to fully separate the program efforts directly funded by the program from government activities as these were often done jointly. The changes in coverage are likely a result of the combined efforts of the program, the government, and other partners.We also acknowledge that the authors of this paper were part of the program design and implementation which may introduce inherent bias. Even though several authors were part of the implementing team, we are confident that our study design was rigorous and that an external evaluator would find the same results. We attempted to mitigate the bias by hiring an external research agency to oversee the data collection. As mentioned above, we have also compared our survey results with independent external data sources to validate the survey findings. Furthermore, in Uganda, the program relied entirely on the DHS 2011 and 2016 to evaluate the change in coverage. Fortunately, the program period (2012-2016) neatly aligned with the DHS surveys, thus providing a fully independent source for ORS and zinc coverage changes. The DHS surveys found significant change in combined ORS and zinc coverage from 1% to 30%.Lastly, the lack of routine coverage surveys conducted in other geographic areas limited our ability to draw country comparisons, particularly during the specific program period. In the Asia/Middle East/Eastern Europe region, we were only able to find seven countries with two household surveys conducted between 2008 and 2016. The region may not be fully comparable to the conditions in the Indian program states. The comparison between our African program areas to the rest of Sub-Saharan Africa is also not ideal as Sub-Saharan Africa encompass a very diverse set of socioeconomic and political environments. However, the rates of ORS and zinc increase during the program period are much higher than that prior to the program period. Furthermore, the rate at which combined ORS and zinc coverage increased in Nigeria and Uganda are higher than even that of Bangladesh.Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates and consumer demand.Box 2Approach: In Kenya, ~ 50% of children with diarrhea seek care outside the home, ~ 40% treat in the home, and ~ 10% take no action. Of those seeking care, nearly 2/3 do so in the public sector. Given this, the program approach aimed to change clinical management and dispensing practices in the public sector from ORS alone to both ORS and zinc through a co-pack strategy. In partnership with the MOH, the program also focused on educating mothers on diarrhea prevention and treatment though mass media, ORT corners, and health talks since over 90% of Kenyan mothers attend immunization visits for their child. In addition, the program engaged new, quality suppliers to enter the market by sharing credible demand forecasts, including the MOH’s co-pack approach. CHAI also provided suppliers with in-kind promotional materials for use in detailing visits. Five new co-pack suppliers entered the market, and retail prices declined 55%. In 20 of Kenya’s 47 counties, the program also supported county-level management teams to rollout IMCI in public facilities, including an offsite 5-day training followed by routine CMEs and supportive supervision.Mistakes/Challenges: The greatest challenge in Kenya was the devolution of the health system from one central procurement authority (KEMSA) to 47 different counties in 2014. Forecasting, quantification and ordering became the responsibility of county governments for the first time, causing challenges for consistent stocking of all essential medicines, including ORS and zinc.Critical Success Factors:Active, decisive government leadership at national /county level – high priority & willingness to commit domestic financesStrong private sector suppliers with existing sales teams that responded to market opportunity to meet growing demandCaregivers generally more educated, trust public sectorBox 3Approach: In the 8 program states , ~ 75% of pediatric diarrhea cases seek care, with 25% going to the public sector and 50% to the private sector (DHS 2013). At the start of the program, zinc/ORS prices were high ($1.55 per course), and there was only one quality supplier of low osmolarity ORS and none for pediatric zinc dispersible tablets. The program provided TA to local manufacturers on market intelligence, formulation development, local registration, and cost reduction strategies. From these efforts, 10+ quality products, including six co-packs, were introduced in the market. To target private providers, the program worked with the Pharmacy Council of Nigeria (PCN) and the National Association of Proprietary Patent Medicine Vendors (NAPPMED) to reach >90% of registered PPMVs with peer detailing. To increase rural stocking, zinc/ORS promotional kiosks were placed at wholesale distribution points, and the program partnered with local sub-distributors with significant rural footfall to expand the program’s reach. In the public sector, over 85% of providers were reached through routine training and mentoring. The program also supported the state and national government on forecasting and quantification and on designing and implementing Nigeria’s 2012 National Essential Medicines Scale up Strategy. Consumer demand was driven through facility health talks, female vanguard groups, religious schools and a radio campaign.Mistakes/Challenges: Efforts to incentivize national suppliers to meet rural availability and price targets failed; despite strong buy-in, suppliers lacked expertise in rural markets and the drive to make meaningful investments in novel business models to reach these segments as their existing urban market share bred risk aversion.Critical Success Factors:Strong government leadership at national/state level – high priority and willingness to commit domestic financesStrong PPMV association provided platform for timely and cost-effective message dissemination


Background: Resident physicians’ achievement of professional competencies requires reflective practice skills and faculty coaching. Graduate medical education programs, however, struggle to operationalize these activities.Objective: To (1) describe the process and strategies for implementing an Internal Medicine (IM) resident coaching program that evolved in response to challenges, (2) characterize residents’ professional learning plans (PLPs) and their alignment with EPAs, and, (3) examine key lessons learned.Design: The program began in 2013 and involved all postgraduate years (PGY) residents , and 20 faculty coaches who were all IM trained and practicing in an IM-related specialty. One coach was linked with 3–4 residents for three years. Through 1:1 meetings, resident-coach pairs identified professional challenges (‘disorienting dilemmas’ or ‘worst days’), reviewed successes (‘best days’), and co-created professional learning plans. Typed summaries were requested following meetings. Coaches met monthly for professional development and to discuss program challenges/successes, which informed programmatic improvements; additionally, a survey was distributed after three program years. Data were analyzed using quantitative and qualitative methodologies.Results: Disorienting dilemmas and professional learning plans mapped to all 16 EPAs and four additional themes: work–life balance, career planning, teaching skills, and research/scholarship. The most-frequently mapped topics included: PGY1 – leading and working within interprofessional care teams (EPA 10), research and scholarship, and work–life balance; PGY2 – improving quality of care (EPA 13), demonstrating personal habits of lifelong learning (EPA15), and research and scholarship; PGY3 – lifelong learning (EPA15); career planning was common across all years.Conclusions: Lessons learned included challenges in coordination of observations, identifying disorienting dilemmas, and creating a shared mental model between residents, faculty, and program leadership. The coaching program resulted in professional learning plans aligned with IM EPAs, in addition to other professional development topics. Operationalization of aspects of these results can inform the development of similar programs in residency education. Nearly two decades ago, the Accreditation Council for Graduate Medical Education implemented the Competency-Based Medical Education (CBME) Outcomes Project to better prepare physicians-in-training for practice by focusing on observable activities rather than a less granular, ‘time-based’ framework –3. In coCritical factors that enable the assessment of whether a learner can be entrusted include direct observation, feedback, and reflective practice. ReflectIn 2013, our Department of Medicine and Internal Medicine (IM) Residency Program implemented a coaching program in which residents were paired with a faculty coach for the duration of their training to enhance their professional development. The objectives of this manuscript are to: (1) describe the process and strategies for developing and implementing a longitudinal coaching program that evolved in response to challenges, (2) characterize residents’ professional learning plans (PLPs) and their alignment with IM EPAs, and, (3) examine key lessons learned to guide other residency programs in the development of coaching programs.In 2012, the IM Residency Program at Penn State College of Medicine identified coaching for residents, specifically in achieving entrustment in EPAs, as an improvement area ,29. Led The program’s goal was to enhance residents’ achievement of competence through direct observations by coaches, facilitated reflection-on-action related to disorienting dilemmas, and targeted professional learning plans (PLPs) ,19,28–30All categorical IM residents (n = 60) were matched with one faculty member (n = 20) who coached 3–4 residents across all postgraduate years (PGY1-3). In the first year, only PGY1-2 residents were assigned a coach. In subsequent years, assignments were maintained, and incoming PGY1 residents were paired with a coach during orientation. Programmatic modifications and improvements were informed by monthly, one-hour coach meetings, with discussions focused on challenges and successes. Additionally, strategies to improve and foster self-directed learning were reviewed, as well as mentoring and coaching skills training. Notes were recorded by program leadership . Based upon this process and subsequent changes made in the program over the first three years, we have articulated steps, objectives, a suggested approach, challenges, and strategies for a resident–coach program .10.1080/Each resident–coach pair was expected to meet routinely throughout the year, with the initial goal of meetings approximately every six to eight weeks. Prior to meetings, residents were asked to reflect on their clinical rotations and self-identify improvement areas. ‘Disorienting dilemmas’ and ‘best/worst’ days were used to stimulate this process . InitialThe first aim of this program evaluation was to articulate the process and strategies for developing and implementing a coaching program that could be used by other residency programs. Based upon the process described above, including the survey administered after year three, coaches’ suggestions made during monthly faculty development programming, and several informal discussions between coaching program leadership and IM residency leadership, we made significant programmatic changes over the first three years. We have collaborated and agreed upon the steps, objectives, suggested approach, challenges, and strategies for the resident–coach program that are described in this manuscript.The second aim of this manuscript was the characterization of disorienting dilemmas and PLPs, and their alignment with IM EPAs. We explicitly chose to examine EPAs because our program’s goal at outset was to determine whether our longitudinal mentor-coach model was effective in assisting residents in the development of entrustment. However, anticipating that other meaningful data were addressed in resident–coach interactions and, as suggested by interpretive qualitative research, we also sought to find additional key themes within the transcripts. Thus, aThe third aim was to characterize the key lessons learned, which was inclusive of barriers and facilitators to coach program development. To better inform these lessons, three years after implementation (May 2016), we sent an anonymous electronic survey to residents and coaches with open-ended prompts soliciting perceived challenges and potential improvements . Survey To characterize the disorienting dilemmas and PLPs, we initially examined data from submitted meeting summaries, which included a total of 119 resident–coach meeting summaries. Sixty-five unique residents (81%) submitted at least one summary containing a disorienting dilemma and/or PLP during our review. The frequencies by year included: PGY1 = 51 meeting summaries (160 coding references); PGY2 = 48 summaries (128 coding references); PGY3 = 20 summaries (35 coding references). We identified a total of 323 disorienting dilemmas with PLPs mapped across all 16 EPAs, and four additional themes: (1) work–life balance, (2) career planning, (3) teaching skills, and, (4) research/scholarship . Table 2Resident–coach discussions were dynamic and changed throughout the course of residents’ training. During PGY1, most-commonly discussed dilemmas/PLPs aligned with leading and working within interprofessional health-care teams (EPA10), research/scholarship (Theme 4), career planning (Theme 2), and work–life balance (Theme 1). During PGY2, most-commonly discussed dilemmas/PLPs aligned with improving quality of care (EPA13), demonstrating personal habits of lifelong learning (EPA15), research/scholarship (Theme 4), and career planning (Theme 2). During PGY3, most-commonly discussed dilemmas/PLPs aligned with demonstrating professional habits of lifelong learning (EPA15) and career planning (Theme 2). Later in residency, resident–coach discussions shifted away from EPAs towards more traditional mentoring topics, including research, fellowship applications, and professional transition into fellowship/practice. Key lessons learned are derived from surveys completed at the end of year three of the program  and 12 (60%) completing the survey, respectively) and outputs of coach meetings. Three higher-level key lessons learned in the design and implementation of our resident coaching program in an IM residency program were identified by investigators.Our initial plan was to ground relationships in observations performed by coaches, allowing for feedback and subsequent reflection-on-practice. HoweverResidents were occasionally frustrated by the request to identify disorienting dilemmas when they perceived none had occurred. This also became a challenge for coaches, as some meetings were less productive when no challenge was identified and discussed. This prompted several modifications, including encouraging residents to proactively monitor for challenges in real-time, focusing meetings on ”best/worst” days, allowing resident–coach pairs more flexibility in follow-up time intervals, and using the ISMART  mnemonic to establish learning objectives. This alResidents’ ability to self-assess and identify disorienting dilemmas has been and continues to be a significant challenge. Compared to ‘time-in-seat’ education, CBME requires collaboration between resident and coach, with responsibility on the learner to be active in reflecting, assessing, and developing PLPs. ResidenAt the program’s start, residents, coaches, and Clinical Competency Committee (CCC) identified the need to differentiate stakeholder roles, as some viewed the coach as ‘program police,’ seeking to identify struggling residents. Additionally, residents and coaches often had different expectations of the program. We needed to articulate the relationship between the program and CCC, and coach’s role to all stakeholders ,45. DeliIn response to our need to enhance longitudinal relationships between residents and faculty, we implemented a coaching program that supports residents’ professional development. This program was modified over time based on challenges and successes articulated by the residents and coaches. The transition from less granular, ‘time-based’ assessments to Competency-Based Medical Education (CBME) and entrustment requires more direct workplace-based observations of trainees, provision of high-quality feedback, and use of highly reliable assessment tools, all of which require transformation in processes, resources, and faculty expectations ,46–48. OAlthough we identified several successes and benefits to the coaching program, our work highlights several challenges in how faculty coaches could be used in entrustment decision-making. Despite significant investment, we struggled to pragmatically ensure all three components of entrustment – direct observation, feedback, and reflective practice – were fully integrated into the coaching program, with direct observation posing a unique logistic challenge ,50. IdeaRegardless, there is a pressing need to transform clinical learning environments at the systems level to allow for longitudinal faculty coaching to meet these needs. This reSeveral limitations must be considered. Most notably, the number of submitted resident–coach meeting summaries was low, potentially decreasing the reliability of these findings. Theoretically, based on the suggested frequency of resident–coach meetings (approximately seven times/year) and number of residents in our program, we conservatively estimate our data accounts for at least 14% of the resident–coach interactions that occurred during the study. However, informal feedback from the coaches suggests that our data capture a larger proportion of the meetings that took place. Meetings were challenging to schedule . Our data collection was also challenged by the fact that, even after productive resident–coach interactions, residents did not always initiate meeting summaries as requested. An additional limitation to consider is that the single-center implementation suggests modifications would be required for use in other settings. We had 5% departmental FTE support for coaches, which is a substantial input of resources that may not be replicable at other institutions. Lastly, we describe implementation features and do not report the impact on residents’ behaviors or practice. Further study is needed to determine whether this coaching model can lead to changes in the systems or practice environment and whether these changes can be sustained.In conclusion, we designed and implemented a longitudinal coaching program for Internal Medicine residents with the goal of fostering resident abilities in reflective practice to better achieve competency. Future work will need to explore strategies that blend longitudinal resident–coach clinical relationships with coaching processes to allow for residents’ professional development. Future work should also link this coaching work with resident learning outcomes, such as improvements in resident reflection-on-action skills. Ultimately, the strength of any coaching program should be evaluated in the context of how graduating residents practice and how they provide coaching for the next generation of learners.


ARID1A alterations would compromise mismatch repair pathway and increase the number of tumor-infiltrating lymphocytes and PD-L1 expression in some cancers, which would cooperate with immune checkpoint inhibitors (ICIs) treatment. However, a comprehensive analysis of ARID1A alteration frequency and its predictive value for ICI treatment outcome in cancers has not yet been investigated. Hence, we performed this pan-cancer analysis to evaluate the prevalence and predictive value of ARID1A alterations across >40,000 cases in multiple cancer types. We found a high frequency (6.2%) of ARID1A, which were associated with significantly higher tumor mutation burden level across various cancers. Importantly, patients with ARID1A alterations and advanced cancers had the substantially prolonged overall survival in ICI treatment cohort, suggesting it might be used to predict a survival benefit from ICI therapy across multiple cancer types. Notably, ARID1A alterations were correlated with markedly high immune infiltrates in endometrial, stomach and colon cancer. However, patients with ARID1A-mutant renal clear cell carcinoma had dramatically lower CD8+ T cell infiltrations than those without, indicating the association between ARID1A alterations and immune infiltrates was cancer-dependent. Collectively, our findings highlight the important value of ARID1A alterations as pan-cancer predictive biomarkers for ICI treatment. Although immune checkpoint inhibitors (ICIs) targeting programmed cell death protein 1 (PD-1), its ligand (PD-L1), or cytotoxic T lymphocyte antigen-4 (CTLA-4) significantly extend overall survival (OS) in patients with diverse types of cancer, it could benefit only a limited subpopulation of patientsARID1A) is a subunit of the chromatin remodeling complex SWI/SNF, which facilitates access of proteins to DNA. ARID1A is one of the most commonly mutated genes in cancerARID1A loss and impaired ARID1A binding to the mismatch repair (MMR) protein MSH2 similarly reduced MMR and increased mutation frequency and the number of tumor-infiltrating lymphocytes and PD-L1 expression. In mice with ARID1A-deficient ovarian cancer, PD-L1 inhibitor resulted in reduced tumor volume and better survival compared with controlsARID1A alterations and clinical benefit to ICI in some cancers. These findings suggested that ARID1A alteration would not only cooperate with ICI treatment but also have the potential predictive value for ICI therapy. However, a comprehensive analysis of ARID1A alteration frequency and its predictive value for ICI treatment outcome in diverse cancers has not yet been investigated.The AT-rich interaction domain 1A  of ARID1A alterations and significant predictive value for ICIs treatment in >40,000 patients with cancers. We also investigated the association between ARID1A alterations and tumor mutation burden (TMB) level or immune cell infiltrations. The current evidence suggested that ARID1A alterations would yield promising predictive value for ICI treatment across diverse cancers.In this study, we performed this pan-cancer analysis by using online database to systematically characterize the prevalence and predictive value of ARID1A alterations as all kinds of nonsynonymous mutations including missense, frame-shift, splice site, nonstop, nonsense, fusions, deletions and translation start site changes. The frequency of ARID1A alterations in 40167 patients with various cancers was 6.2% . Most of the alterations were missense mutations   = 0.74, 95% confidence interval (CI) 0.64-0.91, P = 0.0026; Figure P < 0.0001; Figure ARID1A alterations were also correlated with longer DFS/PFS  solid tumors  across different cancer typesARID1A deficiency was correlated with significantly higher six immune infiltrates in most of the cancer types, especially CD8+ T cells, including endometrial cancer (Figure ARID1A-mutant renal clear cell carcinoma had dramatically lower CD8+ T cell infiltrations than those without (Figure ARID1A were associated with substantially lower six immune infiltrates in most of the cancer types including endometrial cancer, gastric cancer, colon adenocarcinoma, head and neck cancer, lung squamous cell carcinoma and breast invasive carcinoma (Supplemental To unravel the potential mechanism of the predictive value of r Figure A, stomacr Figure B and colr Figure C. Howevet Figure D. Of notARID1A alterations and the predictive significance of ARID1A alterations for ICI treatment in multiple cancer types. We also observed that ARID1A alterations were associated with significantly higher TMB level. Although ARID1A alterations were correlated with significantly inferior OS in total populations, they were associated with significantly prolonged OS in ICI treatment cohort, suggesting it might be used to predict a survival benefit from ICI therapy across multiple cancer types. Notably, patients with ARID1A alterations were correlated with markedly high immune infiltrates in endometrial, stomach and colon cancer but dramatically lower CD8+ T cell infiltrations in ARID1A-mutant renal clear cell carcinoma, indicating the association between ARID1A alterations and immune infiltrates was cancer-dependent. Collectively, our findings highlight the important value of ARID1A alterations as pan-cancer predictive biomarkers for ICI treatment.To our knowledge, this study firstly reported a high frequency of Supplementary figures and tables.Click here for additional data file.


Group-based Diabetes Prevention Programs (DPP), aligned with recommendations from the Centers for Disease Control and Prevention, promote clinically significant weight loss and reduce cardio-metabolic risks. Studies have examined implementation of the DPP in community settings, but less is known about its integration in healthcare systems. In 2010, a group-based DPP known as the Group Lifestyle Balance (GLB) was implemented within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying socio-demographics. The regional divisions implemented the program independently, allowing for natural variation in its real-world integration. We leveraged this natural experiment to qualitatively assess the implementation of a DPP in this healthcare system and, especially, its fidelity to the original GLB curriculum and potential heterogeneity in implementation across clinics and regional divisions.Using purposive sampling, we conducted semi-structured interviews with DPP lifestyle coaches. Data were analyzed using mixed-method techniques, guided by an implementation outcomes framework consisting of eight constructs: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability.We conducted 33 interviews at 20 clinics across the three regional administrative divisions. Consistencies in implementation of the program were found across regions in terms of satisfaction with the evidence base (acceptability), referral methods (adoption), eligibility criteria (fidelity), and strategies to increase retention and effectiveness (sustainability). Heterogeneity in implementation across regions were found in all categories, including: the number and frequency of sessions (fidelity); program branding (adoption); lifestyle coach training (adoption), and patient-facing cost (cost). Lifestyle coaches expressed differing attitudes about curriculum content (acceptability) and suitability of educational level (appropriateness). While difficulties with recruitment were common across regions (feasibility), strategies used to address these challenges differed (sustainability).Variation exists in the implementation of the DPP within a large multi-site healthcare system, revealing a dynamic and important tension between retaining fidelity to the original program and tailoring the program to meet the local needs. Moreover, certain challenges across sites may represent opportunities for considering alternative implementation to anticipate these barriers. Further research is needed to explore how differences in implementation domains impact program effectiveness. Little is known about the integration of the Group-based Diabetes Prevention Programs (DPP), aligned with recommendations from the Centers for Disease Control and Prevention, in healthcare systems. We assessed the implementation and local adaptations in structure and design of a DPP within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying socio-demographics.We found instances of both consistency and variation in implementation of the program across three geographic regions, with very different underlying sociodemographic characteristics.The findings of our study expose a dynamic and important tension between the attempt to retain fidelity to the original evidence-based program and the need to tailor the program to meet the local needs of the organization, distinct patient populations, and the clinical context.According to the Centers for Disease Control and Prevention (CDC), around 70% of Americans are overweight or obese, of which 9.5% have diagnosed type 2 diabetes (T2D) . FurtherResearch has shown that lifestyle interventions promoting moderate physical activity and healthy eating habits positively impact long-term weight management and prevention of T2D . The DiaThe CDC established the National Diabetes Prevention Recognition Program (DPRP) to ensure quality and effectiveness of evidence-based DPP translations. CDC guidelines leave much room for variation in the format of program delivery. While the National DPRP provides standards and basic criteria that must be met by all CDC-recognized programs, there is still room for variation allowing for organizations to adapt aspects of the program to a particular setting. There is little information on the implementation of this program and the ways in which it is adapted to meet local needs. Research is needed to understand the extent of this variation in the context of real-world implementation and to explore the balance between the importance of fidelity to the program and the need to tailor the program to specific populations and delivery environments in order to optimize outcomes.In 2010, a group-based DPP known as the Group Lifestyle Balance™ (GLB) program was implemented within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying sociodemographics. The regional divisions implemented the program independently, allowing for natural variation in its real-world integration. The aim of this study was to assess the implementation of a DPP in this healthcare system and, especially, its fidelity to the original GLB curriculum and potential heterogeneity in implementation across clinics and regional divisions. This natural experiment provides a unique opportunity to explore variation in the integration and adaptations of a group-based DPP (hereafter group-DPP). Findings may inform national diabetes prevention guidelines for ensuring both program fidelity while allowing for appropriate local adaptations.This was a qualitative, descriptive study. We conducted semi-structured interviews with DPP lifestyle coaches (LCs). LCs are existing clinical staff who facilitated the face to face program sessions to program participants. They are typically dieticians or nurses who receive additional training in order to facilitate the DPP program. Data were analyzed using mixed-method techniques, guided by an implementation outcomes framework consisting of eight constructs as described below.This study was conducted at Sutter Health, a large multi-specialty healthcare delivery system in northern California. Sutter Health serves approximately 3 million patients per year in more than 100 communities across 5 regional administrative divisions. Sutter Health is a mixed-payer, fee-for-service (FFS) provider organization, which contracts with various commercial payers, as well as the Centers for Medicare and Medicaid Services. Sutter Health’s group-DPP, the GLB program 15, 16), was implemented at a total of 20 clinic sites between 2010 and 2016. The GLB was developed by the University of Pittsburgh , 16, was. The curWe examined the implementation of the program across three geographical distinct regional administrative divisions within a single healthcare system Fig. . We examWe used purposive sampling to identify program LCs within each region and clinic site. Study team members (CN and NKS) first contacted program managers at each region by phone to explain the aim of the study and gather data on the features of the program, number of clinics offering the program, and names and contact information of LCs at each clinic. Then, current and previous program LCs were contacted by email to explain the aim of the study and to schedule semi-structured in-person interviews with them. Interviews were conducted at 20 clinic sites across the three regions between November 2017 and March 2018 by two research associates trained in qualitative research (CN and NKS).Interviews lasted between 30 and 90 min. Interviewers used a semi-structured interview guide including both close-ended and open-ended questions covering the following: 1) LCs’ demographic characteristics; 2) characteristics of program clinic site; 3) eligibility and recruitment of program participants; 4) implementation and characteristics of the program; 5) maintenance and changes made over time; and 6) outcomes of the program. The interview guide was pilot tested and edited accordingly with a LC who previously provided the program at one of the clinic sites. Interviews were audio recorded using encrypted voice recorders and were then transcribed verbatim. In addition, study team members took thorough notes of all the information provided by participants and collected program flyers from each clinic sites. All study activities were reviewed and approved by the healthcare organization’s Institutional Review Board.We utilized multiple methods to ensure the validity and reliability of the results reported below. First, after completing the interviews with LCs, the study team conducted a document review of all the notes taken during the interview as well as information included in the program flyers collected from clinic sites and information provided by site managers to confirm some of the accuracy of the information provided by LCs. Next, responses to close-ended questions included in the interview guide were analyzed quantitatively on STATA 16 using descriptive statistics  and Region 2 (4 sites), and in 2011 at two additional sites (1 site in Region 2 and 1 site in Region 3). Through 2016, 10 more sites implemented GLB. However, between 2011 and 2019, five sites stopped offering the program . Main reported reasons for discontinuing the program was increased patient attrition . LCs across all three regions reported consistent difficulties with recruiting and retaining patients, which affected the sustainability of the program . Nearly 25% of participants have T2D, and 27% of participants are overweight or obese with no other risk factors for diabetes.All regions offered group-based, in-person programs, consist with GLB™; however, variation in program structure were found across regions, including duration of the program, total number and frequency of sessions, and type of curriculum used. In Region 1, the duration of the program was 12 months. It included 12 core sessions provided on a weekly basis for approximately one hour, which is consistent with the GLB™ curriculum. In this region, however, post-core sessions were referred to as a “support group” and were not offered consistently at all sites due to attrition of patients enrolled in the program. The post-core sessions consisted of 9 optional sessions, provided once a month, for one hour each. In Region 3, the program consisted 12 core sessions delivered once per week for 3 months, corresponding to the intensive core phase of the GLB curriculum. In Region 2, the program initially consisted of 12 weekly core sessions; however, it changed in 2014 to a full-year program including 16 core sessions and 9 post core sessions. The 16 core sessions included 13 weekly sessions followed by 3 transitional biweekly sessions. The post-core sessions included 3 transitional sessions offered every other week followed by 6 monthly sessions.All regions utilized the standardized GLB curriculum and content, with some pre-approved modifications included to allow for use among those with diabetes. These minor modifications  were made at the adoption stage and were approved by the University of Pittsburgh. Other micro-variations were observed across sites within Region 2 in terms of additions to the content (e.g. information about vitamins and supplements). LC’s used different types of visual aids to make the information more appealing , strategies used to address these challenges differed (sustainability). Adaptation involves modifications made to the original design of an intervention during the implementation process and can include the adding, removing, or tailoring of information and/or activities from the original program , 34, 35.Studies exploring types of adaptations made to existing evidence-based programs showed that program providers modify programs based on various factors including target population needs , availabWhile many of the issues described are not unique to the health system in question, this was a qualitative study of 33 LCs from a single healthcare system in the western U.S. However, this healthcare delivery system, as a mixed-payer, FFS provider organization, is similar to most other healthcare settings in the nation. Thus, these findings have the potential for broad applicability. Given that the views and perspectives are based on individual responses, other health systems should consider examining program implementation of group-DPP to validate these findings. Further, while it is important to examine the ways in which program implementation was consistent or varies across sites, future research is needed to explore how this these factors may serve as barriers or facilitators to successful implementation of the program. Finally, the program was first implemented nearly a decade ago, which may introduce recall bias. Natural experiments provide an opportunity to study interventions in real-world clinical settings, yet such experiments have several challenges, including non-standardized metrics, inconsistent data collection over time, and incomplete data capture, which has limited our ability to determine the true impact of implementation factors, such as loss of fidelity or low perceived appropriateness, on goal attainment among participants.Healthcare leadership and program implementers must consider building evaluation into the intervention prior to implementation, in order to be able to assess effectiveness and impact of the program. The CDC’s National DPRP provides some incentive for standardized data collection and evaluation, as recognition status is linked to the achievement of several requirements and performance metrics for a given program. More work is needed to support efficient yet robust data collection for program evaluation within healthcare systems.Here we provide an in-depth examination of differences in program implementation and local adaptations in structure and design of group-DPP in a real-world healthcare setting. There were instances of both consistency and variation in implementation of the program across three geographic regions, revealing a dynamic and important tension between the desire to retain fidelity to the original evidence-based program and the need to tailor the program to meet the local needs of the organization, distinct patient populations, and the clinical context. In addition, certain challenges present consistently across sites, in particular, challenges resulting from a reliance on physician referrals as a method of recruitment, and challenges of patient attrition over the course of the year-long program. Identifying the common challenges faced across sites also offers opportunities for considering alternative approaches to implementation to anticipate these potential barriers. Findings may inform national diabetes prevention guidelines, such as the DPRP initiative, for facilitating successful adoption and long-term sustainability of programs. Further research is needed to explore how differences in implementation domains impact program effectiveness.Additional file 1. Participant Socio-demographics and Baseline Characteristics. Bivariate analysis of program participants sociodemographic and baseline characteristics across the three geographic regions.Additional file 2. Active Group-Based Diabetes Prevention Program Sites. Number of clinic sites providing the program, per year (from 2010 until 2019), at each of the three geographic regions.


Women in emergency medicine (EM) at all career stages report gender-specific obstacles to satisfaction and advancement. Programs that facilitate longitudinal mentoring, professional development, and networking may ameliorate these barriers.We designed and implemented a program for female residents, faculty, and alumnae from our EM training program to enhance social support, leadership training and professional mentorship opportunities. An anonymous, online survey was sent to participants at the end of the academic year, using a SWOT  format. The survey collected free-text responses designed to evaluate the program.Of 43 invited participants, 32 responded (74.4%). Eight themes emerged from the free-text responses and were grouped by SWOT domain. We identified four themes relating to the “strength” domain: 1) creating a dedicated space; 2) networking community; 3) building solidarity; and 4) providing forward guidance. Responses to the “weaknesses” and “threats” questions were combined due to overlapping codes and resulted in three themes: 5) barriers to participation; 6) the threat of poorly structured events lapsing into negativity; and 7) concerns about external optics. A final theme: 8) expansion of program scope was noted in the “opportunity” domain.This program evaluation of the Women’s Night curriculum demonstrates it was a positive addition to the formal curriculum, providing longitudinal professional development opportunities. Sharing the strengths of the program, along with identified weaknesses, threats, and opportunities for advancement allows other departments to learn from this experience and implement similar models that use existing intellectual and social capital. Gender disparities among emergency physicians (EP) influence compensation, promotion, and wellbeing of female physicians.18Increasingly, EM has been host to national movements raising awareness around gender disparities and promoting new platforms in which to address them.26We set out to design and implement a program for female residents, faculty, and local alumnae from our EM training program to enhance social support, leadership training, and professional mentorship opportunities. Once implemented, we sought to evaluate the first year of our “Women’s Night” initiative using a SWOT  analysis.27We used a six-step approach to curriculum development, starting with the pre-established problem of gender disparities in academic EM and the subsequent need to proactively address those disparities with enhanced professional development as our problem identification/general needs assessment.The Women’s Night program launched in 2016 and comprised six evening events. All female residents, faculty and local alumnae were invited. Female residents were scheduled off from clinical duties, with the exception of those on off-service rotations , whereas faculty could request the night off. This night was part of any given resident’s time off, and participants worked the same number of shifts as non-participants and male residents.Faculty or chief residents hosted the 2–3 hour events in their homes or restaurants, and two female faculty members split the cost of each event. Professional development activities were organized by Women’s Night program leaders. -approved survey to evaluate the program was sent to anyone invited to the events over the prior academic year. Data were collected from June–July 2017 via a REDcap (Research Electronic Data Capture) survey.The study team was comprised of two female attending EPs, two male attending EPs and three female resident EPs. Qualitative content analysis using a consensual qualitative approach was undertaken with a primary coding team  generating initial codes and themes. A secondary audit team  reviewed all original data and thematic structure to evaluate for omissions or oversimplifications.32Forty-eight participants were invited to Women’s Night events, of whom 35 attended one or more events. Five invitees were ineligible because of study involvement. Of the 43 remaining physicians, 32 (74.4%) completed the survey (24 who had attended events and seven who had not). All respondents were female, with 40.6% residents, 37.5% faculty, and 34.4% alumnae. The primary team arrived at an initial 20 codes, resulting in seven themes. Audit team review identified one additional theme resulting in a final framework of eight themes, presented in the dedicated space, networking community, solidarity, and forward guidance. Respondents noted that creating a dedicated space, provided “protected time” to discuss “tough topics specific to women in EM in a non-judgmental atmosphere,” allowed learning “from other women’s experiences,” and fomented dialogue. This space subsequently facilitated networking and community building. Residents particularly mentioned forward guidance noting “women’s night has inspired me to seek female mentees in my next job.” It additionally fostered optimism about careers in academic medicine and made “me more confident as a female provider.” Community-building inside a protected space ultimately resulted in an overarching sense of solidarity among participants who felt the events provided an “opportunity to build each other up,” ultimately helping to “develop plans and approaches moving forward.” This solidarity influenced participant well-being by “validating concerns” and addressing them together.Overarching themes inside the “strengths” category were participation and structure of the events, and one external factor, optics. Scheduling issues and participant engagement were noted as barriers to participation. Limited time off and difficulty of “devoting free time to these events,” which were “another evening away” from family and friends in a career that already requires working nights and weekends. Participants observed that if not well structured, the events could become “redundant” or lapse into negativity and “complaining.” There was concern about enforcing balanced time for social networking and professional development activities so one did not circumscribe the other. Finally, the optics of these events were felt to be a threat with multiple respondents reporting the events were perceived as “girl talk” or “lady’s night” and framed as “special treatment,” running the risk of further ostracizing women. While having a dedicated space was noted as a strength, others noted that one “can’t change the culture or system without including the majority.”Responses to “weakness” and “threats” overlapped and resulted in three themes: two internal factors, Expansion was the primary “opportunity” theme. Some respondents desired greater inclusivity, such as promoting “inter-group dialogue” by including nurses and male physicians at occasional sessions. Increased breadth of topic areas , professional development activities and mentorship were suggested. Expansions into other venues, time frames and scheduling modalities, or ability to bring children to events were recommended as growth opportunities.This evaluation of an applied educational and mentoring model for female EPs found the program was an overall positive experience for both individuals and the local female EP community. The themes above illustrate not only an enhanced feeling of wellness and solidarity as a result of program participation, but also a change in self-perception, confidence, and optimism that have potential to foment long-term change for female physicians. By including alumnae and faculty as core participants along with residents, opportunities for longitudinal professional development and dynamic mentorship pathways emerge.33Despite these successes, tension exists between the strengths, weaknesses, threats, and opportunities. The greatest program strengths were driven by a “safe space” format and solidarity building, yet these strengths are simultaneously viewed as possible weaknesses or threats given the siloed format and the optics of “exclusivity” created by this protected environment. Additionally, the main opportunity noted by respondents was a focus on expansion that runs the risk of inadvertently degrading cited strengths, thus emphasizing the care with which this feedback must be implemented.Although data were collected in our isolated departmental context, we suspect that these challenges are not unique and similar programs could learn from our SWOT analysis to build stronger mentorship programs in their own organizations. To that end, we have included the full three-year curriculum to date . Our proThis single-center study was conducted over one year with a small sample size of mixed career level EPs. The survey format, rather than interview, may have resulted in limited, superficial responses. Additionally, by surveying invited participants, not just those who attended regularly, we lose some depth of analysis of the participant experience but gain insight into the threats and weaknesses faced by the program. Implicit bias from personal values of the study team may have influenced the thematic analysis. To combat this potential bias, we used consensual coding including male study-team members. Finally, “outcome” data related to physician wellness and other experiences of gender in the workplace were not evaluated.This evaluation of the Women’s Night curriculum demonstrates it was a positive addition to the department, providing longitudinal opportunities for professional development. Sharing not only the program strengths, but also identified weaknesses, threats, and opportunities for improvement allows others to learn from this experience and implement similar models.


Various actions have been taken during the last decade to increase the number of organs from deceased donors available for transplantation in Switzerland. This study provides an overview on key figures of the Swiss deceased organ donation and transplant activity between 2008 and 2017. In addition, it puts the evolution of the Swiss donation program’s efficiency in relation to the situation in the neighboring countries.This study is an analysis of prospective registry data, covering the period from 1 January 2008 to 31 December 2017. It includes all actual deceased organ donors (ADD) in Switzerland. Donor data were extracted from the Swiss Organ Allocation System. The “donor conversion index” (DCI) methodology and data was used for the comparison of donation program efficiency in Switzerland, Germany, Austria, Italy and France.n = 1814), 24% livers (n = 903), 12% lungs (n = 445), 9% hearts (n = 352) and 7% pancreata or pancreatic islets (n = 249). The donation program efficiency assessment showed an increase of the Swiss DCI from 1.6% in 2008 to 2.7% in 2017 (+ 69%). The most prominent efficiency growth was observed between 2012 and 2017. Even though Swiss donation efficiency increased during the study period, it remained below the DCI of the French and Austrian donation programs.During the study period there were 1116 ADD in Switzerland. The number of ADD per year increased from 91 in 2008 to 145 in 2017 (+ 59%). The reintroduction of the donation after cardiocirculatory death (DCD) program in 2011 resulted in the growth of annual percentages of DCD donors, reaching a maximum of 27% in 2017. The total number of organs transplanted from ADD was 3763 (3.4 ± 1.5 transplants per donor on average). Of these, 48% were kidneys (Swiss donation activity and efficiency grew during the last decade. The increased donation efficiency suggests that measures implemented so far were effective. The lower efficiency of the Swiss donation program, compared to the French and Austrian programs, may likely be explained by the lower consent rate in Switzerland. This issue should be addressed in order to achieve the goal of more organs available for transplantation. Various actions have been taken during the last decade to improve the situation of deceased organ donation in Switzerland. Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, and its Comité National du Don d’Organes (CNDO) have implemented a broad range of measures to increase the number of organs available for transplantation in Switzerland. In late 2011, the donation after cardiocirculatory death (DCD) program was reintroduced following an initiative by Swisstransplant . In addiIn the framework of the national action plan “More Organs for Transplantation”, launched in 2013 by the Federal Office of Public Health (FOPH) and the cantons, Swisstransplant and the CNDO were commissioned to develop and implement further measures to advance deceased organ donation in Switzerland . These mThe aim of this study was twofold: First, to give an overview on key figures of the Swiss deceased organ donation and transplant activity between 2008 and 2017. Second, to compare the evolution of the donation efficiency of the Swiss donation program to that of the neighboring countries: Germany, Austria, Italy and France. Finally, we discuss the current situation of organ donation and transplantation in Switzerland in the context of future challenges.This study is an analysis of prospective registry data. It covers the period from 1 January 2008 to 31 December 2017 and includes all deceased organ donors in Switzerland. Patient data of all actual DBD donors and DCD (since 1 September 2011) donors were extracted from the Swiss Organ Allocation System (SOAS). Demographic data from the Federal Statistical Office was used for the calculation of the donation rate per million of population (pmp), based on the permanent resident population as of 1 January of each year (data available until 2016) [The primary outcome of the study was the number of actual deceased donors (ADD) and basic donor characteristics per year. Per definition, an ADD is a consenting, eligible organ donor in whom an operative incision has been made with the intent of organ recovery for the purpose of transplantation . The secThe international comparison of deceased donation program efficiency is based on the “donor conversion index” (DCI) methodology and data . The DCIDonor data for the year 2017 were retrieved from the websites of Eurotransplant  and Centro Nazionale Trapianti  , 19. Then = 39) of ADD (n = 145) in 2017.During the 10-year study period, there were 1116 ADD. The total number of ADD per year increased from 91 in 2008 to 145 in 2017 (+ 59%). While there was an overall increase, inter-annual donation figures showed some variance during the study period (Table n = 473) and 58% males (n = 643). The mean donor age showed only minor variance during the 10 years analyzed, with an overall mean donor age of 53 ± 18.2 years.Patient characteristics of ADD in Switzerland between 2008 and 2017 are given in Table Table The overall average number of transplants enabled per DBD donor was 3.5 ± 1.5, and 2.2 ± 1.1 grafts transplanted per DCD donor. The mean number of transplants per DBD donor showed some inter-annual variance, with slightly higher rates at the beginning of the evaluation period. In DCD donors, the transplant rate per donor increased until 2013 and showed a downward trend thereafter.n = 3541) of transplants resulted from DBD donors, and 6% (n = 222) from DCD donors. Of all grafts transplanted (n = 3763), 48% were kidneys (n = 1814), 24% livers (n = 903), 12% lungs (n = 445), 9% hearts (n = 352), and 7% pancreata or pancreatic islets (n = 249). (The percentages per organ type shown in the table represent the graft utilization rate.).The total number of hearts, lungs, livers, kidneys, and pancreata or pancreatic islets transplanted during the study period was 3763 from all ADD. Figures not included in the table show that 94%  during the study period was lower than in Italy, France and Austria which had annual donation rates > 20 pmp , and > 23 pmp (France) in each year between 2008 and 2015 [Patient characteristics of Swiss donors during the decade preceding our study period showed a marked increase in the mean age of donors . In our As DCD may be considered as supplementary to DBD, the reintroduction of the Swiss DCD program has successfully contributed to the increase of the number of organs available for transplantation , 33. As The improved efficiency of the Swiss donation program suggests that the measures implemented were effective. A considerable proportion of the DCI increase, however, was due to the reintroduction of DCD. The DBD efficiency also increased over time, but less pronouncedly. Due to the relatively small absolute number of donors per year in small countries, annual DCI variations may occur (such as in 2016 in Switzerland or the see-sawing of the Austrian DCI). Yet, the evolution of the Swiss DCI shows a clear trend of increasing donation efficiency since 2012.When considering possible reasons for differences in DCI between the countries, the consent rate (proportion of patients and/or families consenting to organ donation) is one factor that has a major impact on the DCI. Even though there is no internationally standardized way to report consent rates, published data show important differences between countries , 46, 47.In comparison with the neighboring countries and as discussed above, the performance of the Swiss organ donation and transplant program can be considered equal or slightly better, as the average number of transplants enabled per donor is similar to figures in Germany and Austria, and higher than in France and Italy. The relatively high number of transplants per donor contributes substantially to the overall performance of the Swiss donation program as it ensures an optimized use of the limited donor pool.One factor that clearly has a negative impact on the donation activity and efficiency in Switzerland is the low consent rate which is in contrast to the largely positive attitude towards organ donation and transplantation among the Swiss population –51. UndeAction areas of the action plan included the training of healthcare professionals, the implementation of standardized processes and quality management, as well as optimizing structures and allocating resources in the hospitals , 58. SwiThe training of health care professionals has been standardized and integrated in a newly created blended learning program, established in 2015. The blended learning program consists of ten e-learning modules, and two face-to-face courses . Since its introduction, roughly one thousand health care professionals have been enrolled in the program. Hospital staff in charge with tasks related to organ donation  are required to complete the program and pass the final exam within two years.As an additional measure and since mid-2016, earmarked funds are being allocated to the local organ and tissue donation coordinators. The allocation of earmarked funds has been a crucial step in the optimization of the donation process. First, because these funds recompense defined percentages of coordinators’ working time. Second and related, it is bound to enhanced accountability concerning the specific tasks of the coordinators. All hospitals with an accredited intensive care unit are contractually obliged to designate a local organ and tissue donation coordinator. To ensure a 24/7 donation coordination, the hospitals are clustered into donation networks, with each network having an on-call service for donation coordination.The optimization of structures and processes included, among others, the involvement of accident and emergency departments as well as paramedics, and the ongoing training of staff. While the action plan mainly focused on optimizing the prerequisites for donation, one should bear in mind that there are other areas where there may be additional potential for improvement. For example, in donor management, procurement and ex-vivo conditioning –62, or iFinally, an evaluation of the performance of the Swiss organ donation and transplant program should take into account that its ultimate goal is to enable a maximum of transplants with a successful outcome. Outcome data for transplant recipients in Switzerland are generally similar or slightly better than the results reported in large international registries –69. In vOur study has several strengths and limitations. We consider it the main strength that it provides key figures on the evolution of the Swiss organ donation and transplant program during the last decade. These data, in combination with the assessment of the donation efficiency, should allow the reader to gain a general overview on the performance of the Swiss organ donation program. It also provides the context for a comparison with the performance of the donation programs in the neighboring countries.Limitations of the DCI include that the mortality from the selected causes allows only for an approximation of the potential, and that international mortality data was only available until 2015 (for a detailed discussion of the DCI’s limitations see ). The 20Even though the Swiss donation activity and efficiency have been substantially improved during the last decade, it remains below the French and Austrian donation rates and DCI. This may be explained, at least in part, to the considerably lower consent rate in Switzerland. The increased donation efficiency in Switzerland suggests that the measures implemented so far  have been effective. In view of the fact that the consent rate has been roughly stable at a low level, the Swiss intensive care units were able to increase the performance considerably in terms of donor detection and referral. The most important factor that negatively impacts the donation activity and efficiency is the high percentage of family refusals. This issue needs to be addressed in order to achieve the goal of more organs available for transplantation.


Correction to: BMC Public Healthhttp://dx.doi.org/10.1186/s12889-019-7144-zIt was highlighted that the original article  containeThe Publisher apologizes to the authors and readers for the inconvenience caused by the typesetting mistake.Incorrect title:Formative research for the design of a scalable mobile health program water, sanitation, and hygiene: CHoBI7 mobile health program.Correct title:Formative research for the design of a scalable water, sanitation, and hygiene mobile health program: CHoBI7 mobile health program.Incorrect Table Correct Table