Several studies indicate that older age is a risk factor for probable post-traumatic stress disorder (PTSD). However, evidence on the prevalence and risk factors for elderly disaster survivors is limited.Multi-stage stratified sampling was applied in this cross-sectional study. The Revised Version of the Impact of Event Scale (IES-R) was used to evaluate symptoms of PTSD. Chi-squared test was used for univariable analysis of prevalence of probable PTSD by possible determinants. Multivariable logistic regression analysis was utilized to further explore risk factors for PTSD.427 elderly survivors age 60 or older participated. The prevalence of probable PTSD was 40.5, 36.3, and 21.5% according to a cut off score of the IES-R of 33, 35, and 2 points on average across items, respectively. In multivariable logistic regression, elderly survivors with a higher number of diagnosed chronic illnesses were more likely to be screened positive for PTSD and those with a greater number of family members living in the same home were less likely to be classified as having probable PTSD for all cut off scores. Elderly survivors with improved economic status and those with primary school or lower education were more often estimated to have probable PTSD with a cut off score of 35 and 2 points on average.Elderly survivors in a high impact area following a major earthquake are at high risk for developing PTSD. Those who live alone and report pre-existing chronic illness are particularly vulnerable. Post-traumatic stress disorder (PTSD) is the most frequently reported mental disorder following disasters , 2 and wOlder persons are particularly vulnerable to the adverse effects of disasters such as earthquakes. They may be at higher risk because of an accumulation of personal losses, decreased cognitive capacity, chronic illnesses, physical disability, social isolation, poor financial circumstances, limited access to resources, and communication difficulties in using modern technologies . These cn = 101), moderately impacted (n = 153), and mildly impacted (n = 197) at 6 months after the disaster. They reported an overall PTSD prevalence of 32.9% with local prevalence estimates ranging from 56.3% in the severely impacted area to 25.6% in the moderately impacted area. They identified the following risk factors: belonging to an ethnic minority for the severely impacted area; being female and having experienced extreme fear during the earthquake for the moderately impacted area; and having a lower education level, having experienced fear during the earthquake, being religious, and having been injured or trapped for the mildly impacted area. Zhang and colleagues [Previous research on PTSD after the Wenchuan earthquake focused on child and adolescent, community dwelling elderly survivors, and rescue workers. Huang and colleagues  surveyedted n = 17 at 6 molleagues .Prior studies of PTSD prevalence and associated risk factors in the elderly following the Wenchuan earthquake have two limitations. Only one study was conducted about 6 months after the earthquake and sample sizes of elderly survivors from the severely impacted area were relatively small. Studying the prevalence and risk factors for developing PTSD in the elderly following natural disasters is important for several reasons. First, China has a rapidly aging population  with a 2017 estimate of 241 million people (17.3% of the population) age 60 years or older, and projections are that the elderly population will double by 2050. Second, PTSD causes marked suffering in individuals and families. It limits their functional capacity and compromises a community’s ability to recover from disasters , 13.Our study aimed to: 1) estimate the prevalence of PTSD among elderly Wenchuan earthquake survivors in a severely impacted area at 6 months after the earthquake based on a representative sample, and 2) to determine possible risk factors within this population.This was a cross-sectional study conducted 6 months (November 2008) after the earthquake.An 8.0-magnitude earthquake occurred on May 12, 2008 in Wenchuan County of Sichuan Province, China. According to the Ministry of Civil Affairs, 69,227 people were confirmed dead, 374,643 injured, and an additional 17,923 were unaccounted for. Dujiangyan, a county-level prefecture and subdivision of Chengdu, was the fourth most severely impacted area in Sichuan Province. The intensity of the Wenchuan earthquake reached a peak of magnitude 9.0 on the Richter Scale and 3091 people were killed and another 141 were unaccounted for in this area [A multi-stage stratified sampling method was applied. First, two counties were selected at random from Dujiangyan prefecture. Next, two villages were randomly chosen from each of the previously selected counties. Finally, two communities (neighborhoods) were randomly selected within the two villages and all elderly survivors were aproached in these two communities. In the following, elderly persons were approached at central places of the respective communities. Participants were encouraged to recommend other elderly persons living in their community to participate in the study who were then approached by the research team, i.e. employing a snowball method.%.Included were people aged 60 or older who lived in the selected communities, experienced the earthquake, and provided informed consent. Of 497 elderly survivors recruited for this study, 38 participants were excluded because they had difficulties understanding the questions. An additional 32 refused to participate. Thus, 427 participants completed the survey. The response rate was 85.9Two research assistants with master degrees in medical science were trained in the use of the IES-R and communication skills. The importance and purposes of this survey were explained to each participant, and they completed the scale based on the difficulty they experienced from the earthquake during the past 7 days. For those participants, who were unable to complete the questionnaire independently  the research assistants read each question out loud, the participant answered verbally, and the assistants then registered their response on the questionnaire. After completion, data were checked for integrity.The IES-R is commonly applied to evaluate symptoms of PTSD . The scaWhile an optimal cut off has not yet been established, the IES-R is one of two screening instruments for PTSD (the other is the PTSD checklist – civilian version) that have been translated and validated in Chinese. The Chinese version of the IES-R demonstrated good reliability and convergent validity based on its correlation with the General Health Questionnaire-20  and can Demographic variables assessed in this study included age, gender, marital status and educational level. Earthquake exposure related variables comprised: house damage, injuries to self and injury or death of family members (no injury vs. injury vs. death). Post-earthquake variables were change in economic status ; presence of chronic illnesses  hypertension, b) diabetes, c) cerebral infarction, d) cancer, e) angina pectoris, f) asthma, or g) gout); and methods employed by the participants to evaluate their own health  I regularly measure vital signs such as blood pressure, b) I regularly measure my weight, c) I regularly consult online resources and books about health issues, d) regularly visit Traditional Chinese Medicine doctors, and e) regular check ups at the hospital). The latter variable was supposed to indicate whether someone was more or less concerned about their overall health. Based on chronic illnesses reported, we created a sum index for the number of chronic illnesses for further analysis ranging from zero to seven. We also constructed a sum index for the number of methods employed by the study participants to evaluate their own health ranging from zero to five.P <  0.05.Stata (version 14.0) was used for all analyses. Descriptive statistics for the sample are provided. For further analyses, participants were divided into two groups based on their IES-R scores according to different cut off scores . Accordingly, the dependent variable was probable PTSD. Independent variables were age, gender, marital status, education level, house damage, number of people living in the same home, number of chronic illnesses reported , number of methods employed by participants to evaluate their own health . Univariable analyses were based on chi-square tests. Multivariable analysis was based on multiple logistic regression analysis. All variables were included in the multivariable logistic model since we were interested in exploring an overall predictive model, rather than precisely estimating the effects of particular variables. Two-sided testing was used for all tests, and the significance level was set at % (n = 230) were male, 74%(n = 316) were married, and 66.7%(n = 285) had elementary school or a lower level of education. The prevalence of probable PTSD was 40.5, 36.3, and 21.5% with a cut off score of 33, 35, and 2 points on average across items, respectively (Table The mean age of the participants was 70.0 years SD = 7.2) ranging from 60 to 91 years, 53.9 ranging Table The results of the multiple logistic regression analysis with cut off scores of 2 on average, and total scores of 33 and 35 are provided in Table This research focused on the prevalence of PTSD and risk factors among elderly earthquake survivors from a severely impacted area 6 months after the Wenchuan earthquake. The prevalence of probable PTSD was high in this population. Participants with a higher number of self-reported chronic illnesses were more likely and those with a greater number of family members living in the same home were less likely to be screened positive for PTSD according to multivariable analysis, independent of the IES-R cut off score chosen. Elderly survivors with improved economic status and those with lower education level were more likely to be screened positive for PTSD in one of the models only. Differences in prevalence of probable PTSD by employing more methods to evaluate their own health were significant in univariable analysis only.The prevalence of probable PTSD found in this study population when employing IES-R cut off scores of 33 or 35 was higher than the pooled prevalence reported in the meta-analysis on PTSD in earthquake survivors by Dai et al. [Since the prevalence of PTSD tends to decline with increasing time after earthquakes , 4, we fElderly survivors with more family members living in the same home had a lower prevalence of suspected PTSD in the present study. This result has not been explored in other studies but may reflect the beneficial effects of social support. Higher social support not only allows a greater opportunity to have contact with family members, friends, neighbors and other people, but also to get more resources from the household, community, society and the government. All these factors may help elderly survivors adapt to the changes in the environment caused by earthquakes. Elderly survivors with a high level of social support also tend to use more effective coping strategies than those with a lower level . ElderlyThe result that female participants did not show a higher prevalence of probable PTSD was different from previous research. Chen and colleagues  found anOur finding that elderly earthquake survivors with a greater number of chronic illnesses were more likely to be screened positive for PTSD had not been reported previously. However, it has been demonstrated that the presence of chronic illnesses and the number of chronic illnesses can be associated with PTSD in non-disaster affected populations . AnotherSurprisingly, Improvement in economic status was associated with an increase in suspected PTSD among elderly survivors in this research. This finding differs from prior studies. A meta-analysis of 37 studies with a total of 56,722 participants found that adult survivors with lower socio-economic status were more likely to suffer from PTSD after earthquakes . Lower iA trend for low educational level being associated with a higher prevalence of suspected PTSD among elderly survivors was observed in all models used in this study. This is consistent with previous research from the Wenchuan as well as 1999 Taiwan earthquake. A meta-analysis of predictors for PTSD in adult survivors after Wenchuan earthquake found that low educational level was a predictor of suspected PTSD in 30 of 37 studies that included this predictor . Low eduThere are limitations to our study. First, the data was collected with a self-reported questionnaire that may have biased the results. The IES-R is a screening tool and cannot replace a diagnosis based on a systematic interview by a mental health professional. Second, no formal IES-R cut off score for PTSD has been established for a Chinese population. Accordingly, the prevalence of PTSD may have been over or underestimated. Third, baseline information on physical and mental health conditions in the population before the earthquake was not available so that excess morbidity in terms of PTSD due to the earthquake cannot be correctly determined. Fourth, since a control sample from a mildly or not affected area was not available, it is difficult to draw firm conclusions regarding of the effect of the earthquake on elevated prevalence of PTSD in elderly survivors. Fifth, although the sampling design was a multistage stratified design, we were unable to incorporate the strata into the analyses due to data restrictions. Sixth, as this study was conducted in a very severely impacted disaster area and the sample size was small, results may not be generalized to less severely impacted areas. Seventh, the small sample size may also result in low power to detect effects and imprecision in the estimation of confidence intervals.Our findings suggest that elderly survivors in high impact areas have a high prevalence of PTSD following an earthquake. This is particularly true for those living alone and suffering from chronic medical conditions. Both of these factors will become more prominent over time. The Chinese elderly population grows and takes up a larger portion of the general population and there are fewer young people around to live with them and care for them, in part due to the several decades long one child policy . These t


Introduction: The Accreditation Council of Graduate Medical Education (ACGME) mandates resident scholarship in all residency programs. Resident scholarship requirement continues to be one of the most common citations by the Residency Review Committee (RRC). This study evaluates the impact of a structured roadmap for resident scholarly activity in a single-family medicine residency program.Methods: This retrospective study compares resident scholarship before and after exposure to a structured roadmap for scholarly activity as well as characteristics associated with higher scholarship productivity. The data was analyzed using Statistical Package for Social Sciences  version 16.0. Student’s t-test was used to calculate the statistically significant difference.Results: There were a total of 16 residents who graduated in the first cohort whereas the second cohort consisted of 18 residents. There was a steady increase in resident scholarly activity over time. The number of publications by those who were exposed to a 13-step structured roadmap for scholarly activity was more than twice when compared with the first cohort. Those who pursued a fellowship after residency published three times more than those who did not.Conclusion: Exposure to a structured roadmap for scholarly activity may be associated with higher production of resident scholarly activity. Larger studies comparing national level data from isolated community hospitals and big academic centers are needed for a conclusive argument. Although the availability of resources may increase the likelihood of more scholarship, the establishment of a research culture is more important. Further studies are needed to determine the factors which lead to the establishment of research culture in a residency program. The Accreditation Council of Graduate Medical Education (ACGME) mandates resident scholarship in all residency programs . Since 2National survey from 2011 looked at different factors . AnecdotA family medicine residency program sponsored by a large academic medical center was cited for not having enough scholarly activity in the year 2009. In 2009, a 13-step structured roadmap to finishing at least one scholarly activity by every resident was implemented as the intervention. With this shift, residents also had access to the academic tools and facilities that made formal research pursuits more obtainable. This presented a unique opportunity to study the production of scholarly work before and after through this retrospective analytical study.This is a retrospective study that analyzed the results of two cohorts of residents in a single-family medicine residency program that implemented a structured roadmap for scholarly activity. The residency program retained a similar structure with more than 70% of the core faculty being the same as before. The first cohort was the graduates of the year 2007, 2008, and 2009. These residents completed their training before the implementation of the structured roadmap for scholarly activity. The second cohort, the graduates of the year 2010, 2011, and 2012, finished their residency while the structured roadmap was being implemented. A brief handbook was developed and made available to all residents for ready access to guidelines for scholarly activity. The 13-step structured roadmap is summarized in Table The primary outcome measure was the number of peer-reviewed publications co-authored by the residents. The secondary outcome measures were trends in different types of publications by residents, and characteristics of residents  publishing more than others overtime among both cohorts. Pubmed, Google Scholar, Worldwide Web, Doximity webpages were searched online to collect data on the outcome measures. This study was approved by the institutional IRB Committee from Human Subjects Protection Office as “Not Human Subjects Research”.No sample size was calculated as all residents were included in the studied cohorts. Student’s t-test was used to compare the outcome measures using Statistical Package for Social Sciences  version 16.0.There were a total of 16 residents who graduated in the first cohort whereas the second cohort consisted of 18 residents. Table Although the number of residents in two cohorts was not equal to each other, the distribution of characteristics overall is very comparable in both groups as shown in Table Fellowship post residency increased the likelihood of publishing by three times  while the type of medical school attended and type of practice after graduation did not reach statistical significance. This may mean that future goals affect scholarly productivity more than the past background of medical education.There are several potential limitations to this study including: 1) The use of only peer-reviewed publications as surrogate for resident scholarly activity is a more stringent criteria when many other forms of scholarship which fulfill Glassick criteria are accepted in the graduate medical education as valid forms of scholarly activities. 2) There are many potential confounders to studying the impact of a structured roadmap to scholarly activity with historical cohorts including: a) citation from the RRC at the ACGME served as a drive for the program leadership to work hard to cultivate a culture of scholarship, b) faculty development in scholarly activity was also conducted by the program leadership which would have added to the development of culture of scholarship, c) the GME office from the sponsor tertiary care medical center became increasingly involved in the administration of the program around the same time period which brought more academic resources to the program.Scholarship is central to the work done by clinicians at academic medical centers. Although there is no universally accepted definition of scholarship, Boyer’s definition is widely accepted ,10,11. HIn summary, this study shows that the implementation of a structured roadmap for scholarly activity might be associated with higher production of resident scholarly activity and the development of a culture of scholarship in a program. Since this data is from only a single center which witnessed a transition, larger studies comparing national-level data from isolated community hospitals and big academic centers are needed for a conclusive argument. Although the availability of resources may increase the likelihood of more scholarship, further studies are needed to determine what leads to the establishment of research culture in a residency program than mere availability of resources.


B lymphocytes are important in secreting antibodies that protect against invading pathogens such as viruses, bacteria, parasites, and also in mediating pathogenesis of allergic diseases and autoimmunity. B lymphocytes develop in the bone marrow and contain heavy and light chains, which upon ligation form an immunoglobulin M (IgM) B cell receptor (BCR) expressed on the surface of naïve immature B cells. Naïve B cells expressing either IgM or IgD isotypes are thought to play interchangeable functions in antibody responses to T cell-dependent and T cell-independent antigens. IgM short-lived plasma cells (SLPCs) and antigen-specific IgM memory B cells (MBCs-M) are critical in the first few days of infection, as well as long-term memory induced by vaccination, respectively. At mucosal surfaces, IgM is thought to play a critical part in promoting mucosal tolerance and shaping microbiota together with IgA. In this review, we explore how IgM structure and BCR signaling shapes B cell development, self and non-self-antigen-specific antibody responses, responses to infectious  and non-communicable diseases . We also explore how metabolism could influence other B cell functions such as mucosal tolerance and class switching. Finally, we discuss some of the outstanding critical research questions in both experimental and clinical settings targeting IgM. The turation .Aicda, a gene that encodes for activation-induced deaminase (AID) is highly expressed. AID deaminates cytidine residues in the VDJ and switch regions of the Ig gene, leading to SHM and class switch , IgM shows limited antibody repertoire and reduced affinity despite reasonable mutation rates compared to mammals  and secreted (sIgM), with sIgM being further divided into natural and antigen induced IgM Figure 2vy-chain –62. IgM vy-chain , 64. Simde bonds , 66. Thede bonds , 68. The pathway –71. The  pathway . Secreti pathway . Apart f pathway , 73. Mos pathway .via antibody binding region (Fab), pentameric IgM complexes undergo conformational changes (via binding of the constant (Fc) domain. IgM can bind to several cell surface receptors including complement receptor CR2 and CR3, polymeric Ig receptor (pIgR), Fcα/μR and FcμR on B-cells, epithelium cells, and antigen presenting cells  and occasionally in extrafollicular sites , 47, 53,via MyD88, to induce MZ B cell proliferation and genetic recombination, allowing non-GC class switching  of IgM producing antibodies are typically found in the spleen on the periphery of B cell follicles, displaying little to no SHM Box 1A . Long-liwitching . LLPCs owitching . This powitching , 98, 99.witching . The IgMell help , 57.vs. non-CDR3) and mouse genotype rather than antigen are thought to be key in the persistence (Antigen specific IgM memory B cells (MBCs-M) form a subset of memory B cells that secrete IgM in the spleen, surprisingly also in germ-free mice, albeit with reduced diversity Box 1C , 100. MBsistence . Althougsistence . Comparesistence . It is lsistence . An addisistence . A recensistence . It is l+) fractions in secondary lymphoid organs (SLO) and IgA plasma cells in the gut associated lymphoid tissue (GALT) (MBCs-M acquire high affinity BCRs through SHM upon re-entry of the cells into GCs in an activation-induced deaminase (AID)-dependent process , 100. Eae (GALT) , 92, 100e (GALT) . It may e (GALT) . Whethere (GALT) .H genes with antibacterial activity, suggesting a pre-programmed antibody immune repertoire —SLPCs of IgM producing antibodies are typically found in the spleen on the periphery of B cell follicles, displaying little to no SHM. SLPCs differentiation is governed by the BCL6 and BLIMP-1 transcription factor. SLPC release the early wave of antibodies post-antigen exposure and provide initial protective response prior to emergence of high affinity antibodies.b. Long lived-plasma cells (LLPCs)—LLPCs continuously secrete antibodies at a constant titre. LLPCs also appear to be more stringently selected and appear in late GCs. LLPCs reside in BM, spleen, and gut-associated lymphoid tissues (GALTs).c. Memory B cells IgM (MBCs-M)—MBCs secrete antibodies in response to cognate antigen challenge. MBCs maintain a higher diversity and appear much earlier in GCs. MBCs can be tissue resident or are found recirculating secondary lymphoid organs. MBCs-M display a lower mutation load compared to their CSR counterparts. MBCs-M display large cross-reactivity, particularly against conserved N-glycans of bacteria and retroviruses.+IgD+CD27+) and show clonal relatedness to gut specific MBCs-M, IgM only PCs, and IgA only PCs  and rheumatoid arthritis (RA), IgM and IgG titers are increased and associated with disease pathogenesis. In SLE, IgG autoantibodies directed against double stranded DNA (dsDNA) are thought to be pathogenic, while IgMs anti-dsDNA are thought to be protective . SLE patIn cancer, natural IgMs are associated with recognition and removal of precancerous cells, owing to their ability to recognize self-antigens of carbohydrate patterns and quickly activate the complement . The preAspergillus fumigatus induced allergic asthma  and Bacteroidetes (Bacteroides vulgatus) which are all beneficial  with  burdens Table 1  burdens . Transfe burdens . Granulo burdens . Inducednfection . In thising sIgM .Emerging evidence suggests a localized B cell repertoire in the lamina propria which can influence BM and peritoneal cavity B cell populations . Mono-coNatural IgM antibodies directed against fungal pathogens are important in both complement-dependent and -independent fungal recognition and clearance  and haveCryptococcus neoformans to other organs such as spleen, kidney, and brain when infected intravenously  to avoid host recognition Figure 3ire bats . Antibod. evansi . Type 1 asitemia . Furtherparasite . Complemgression . Mice lagression . Similars of IgM . Interespresence . A recend people . Healthyarsoprol . TLF2-Igtivation .Plasmodium falciparum, a malaria causing parasite (E. coli (O86:B7)  strain and were found to be protective when these mice were infected with different malaria parasites  and T cell-dependent (B220-CD138+) IgM plasma cells  . In humalearance . Childrearasites . Interesarasites . Other nparasite . Similarma cells . These Ima cells . It is pvia classical pathways, leading to viral opsonization and killing  South Africa as well as support by the South African National Research Foundation (NRF) Research Chair initiative (SARChi) and Wellcome Trust CIDRI-Africa (203135Z/16/Z) to FB. SH is supported by NRF Thuthuka Grant (117721), MRC Self-initiated grant.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The growing complexity of the drug development process requires globally recognized professionals who have not only completed the cognitive path of competence, i.e. the specialized post graduate course in Pharmaceutical Medicine, but suggests that these individuals should join a vocational training program in order to consolidate the seven competencies which characterize a competent Pharmaceutical Professional. The Specialist in Medicines Development (SMD) program developed by the IMI project PharmaTrain and further supported by the IMI project IMI-TRAIN can be considered a prototype vocational program. In order to test the SMD value, it was implemented in two countries, Japan and Italy. The preliminary results, after three years of its implementation, are here summarized, and some initial recommendations are offered to all other countries which may consider to establish this program. Professionals with medical and non-medical backgrounds work in the complex environment of medicines development in different functions and are trained on-the-job, leading to an array of competencies across multiple domains . Some ofIn the UK, Switzerland and Ireland a vocational program for physicians has been implemented, leading to a national medical board certification in Pharmaceutical Medicine. But no globally recognized educational path nor structured qualification process is available for physicians in other countries, and for not medically qualified professionals working in medicines development . Indeed,One of the first projects established by the European Public-Private Partnership Innovative Medicines Initiative  was the A pilot implementation of the SMD concept was funded by IMI from 2014 to 2016 as part of the IMI-EMTRAIN ENSO project “IMI-TRAIN” (Grant Agreement number 115015) . This prThe country selected for the SMD pilot implementation was Italy, due to its well established post-graduate education infrastructure in Pharmaceutical Medicine, a relevant pharmaceutical industry, the interest of the Italian Association of Pharmaceutical Medicine (SIMeF) to create such career development opportunities for their members, and the availability of two master courses (Catholic University of Rome and Bicocca University in Milan) which received the recognition of PharmaTrain Centres of Excellence .One of PharmaTrain's consortium partners was IFAPP, the International Federation of Associations of Pharmaceutical Physicians and Pharmaceutical Medicine, and another course recognized as a PharmaTrain Centre of Excellence was the master course in Pharmaceutical Medicine at the University of Osaka. The Japanese Association of Pharmaceutical Medicine (JAPhMed) expressed interest in joining the pilot initiative with their own resources.Experiences made with implementation of the SMD concept in Italy and Japan are here illustrated and commented.In accordance with global PharmaTrain SOPs, a national PharmaTrain Certification Board (nPCB) was established with representatives from JAPhMed, ACRP , and EFPIA , in 2016. Upon initiation of the second year (2017), professors and directors from national universities and national medical centers joined the nPCB, which currently consists of eight members. The nPCB is established and acknowledged by the gPCB to meet the requirements of the local SMD program, according to legal or regulatory requirements, geography and culture. All nPCB members are qualified directors or have a master level, or above, in a life science or medical field, are actively working in or consulting in the area of medicines development science or pharmaceutical medicine, are experienced in at least two speciality domains of the SMD curriculum over a period of not less than 10 years, and are actively undertaking Continuing Professional Development (CPD) in their own area of competence.Under the nPCB, a SEG (SMD Executive Group) was established by the nPCB, to undertake the executive actions of the nPCB to implement, monitor and administrate the SMD program. At present, eight members of the SEG regularly meet and discuss progress of the program and any issue to be discussed at the nPCB meetings, which are held on quarterly basis. In order to align with global directions and to standardize the methods of assessment, a series of SOPs were developed. Forms to report learning activities and their assessment results were also developed for standardized reporting. Since the development of the nPCB and the SEG, the program has been promoted on the JAPhMed website, showing program entry criteria, methods for regular review and assessment of competency by the mentor in the workplace, and the final certification to be granted by the gPCB.To introduce this new program, ten participants were invited for a free submission, six of them from the industry and the other four from academia. Four new trainees and mentors are registered in the second year as fee-paying participants. The SMD program entry criteria require participants to have completed a formal education  in a discipline in life science or healthcare e.g. medical doctors, pharmacists, biologists, chemists, biometricians, certified nurses, as well as to hold a job related to research, development or medical marketing of medicinal products. At present, one trainee was assessed as competent by her mentor and her records were examined by the SEG with a third party review by experts. Having reviewed her assessment records, the nPCB recommended to the gPCB to assign the SMD title. After review by gPCB, this trainee was certified as the first SMD since the development of this international program.The program asks trainees to complete theoretical training  in medicines development in an accredited course covering the entire PharmaTrain Syllabus , with asIn Italy, Regulatory Authorities have addressed, at least in part, the need for structured post-graduate education in Pharmaceutical Medicine for professionals working in this environment. In fact, according to an Italian law dated 2008 , all proThe initial process of the SMD program in Italy was very similar to the steps established by our Japanese colleagues: the main difference is in the nPCB composition. In fact, in order to get more visibility and an independent body, SIMeF opened this Board to several organizations with whom there is a long lasting collaboration. SIMeF identified, among its executives, four senior members for the nPCB, who had the task to support all planned activities. But the nPCB was also composed by the following additional members: one delegate from AIFA , one delegate from each of the two Universities where there is a master in Pharmaceutical Medicine which got the PharmaTrain recognition of Centre of Excellence (Rome Catholic University and Milano Bicocca University), one representative of SIF , one representative of FADOI  and one representative of a patients association. In total, the Italian nPCB is therefore composed of ten members, and the majority of this Board is made of independent professionals.via teleconference. Great efforts were put in place to disseminate the information about the SMD program, and to attract registrations: a very low fee was also enforced , having in mind that most applicants were supposed to pay this fee by themselves. All relevant information about the SMD opportunity was posted on the SIMeF website on a dedicated page; in addition, at every SIMeF seminar, an SMD leaflet was distributed to all participants; finally, in every issue of the SIMeF bimonthly newsletter, an advertisement about the SMD opportunity is published.The first meeting of the nPCB was held in the premises of AIFA, the Italian Drug Agency, in order to give more value to the event, and to underline the independent role of this body: further meetings were and are held every six months, and are mainly arranged Notwithstanding these significant efforts, and also considering the large number of potential applicants holding a master title, two years after the implementation of the SMD program in Italy, we have only four professionals who registered. Three of them are from the same pharmaceutical company, working in the Medical Affairs dept, and their registrations were strongly stimulated by their Medical Director, who greatly appreciated the program's aims and contents. The fourth applicant is a professional holding the master title, who joined the program in order to get a more pragmatic training in Pharmaceutical Medicine.The preparation of the SMD concept started in PharmaTrain in 2013 but was only completed in the IMITRAIN project in 2016, therefore the two pilot experiences of the SMD implementation, in Italy and in Japan, started only 3 years ago. Therefore, it may be too early to draw some conclusions. However, some initial comments may be appropriate, having also in mind that additional National Associations of Pharmaceutical Medicine may be interested to support this program in their countries.Indeed, the basic idea of the vocational SMD program is very appealing: professionals educated theoretically in Pharmaceutical Medicine may gain great competence from the SMD program, because they receive the unique opportunity, while on their job, to gain experience in practice about the full process of drug development, to become familiar with the consequences of decisions made during this path and to have to interact with professionals of several areas, in order to complete their understanding in the seven domains required for being a competent pharmaceutical professional  (see TabThe recognition of the benefits of a candidate's SMD certification to an employer takes time; and also the relevance for attracting high potential professionals by offering the SMD mentoring program in their organization still needs to be fully appreciated. Therefore, National Associations of Pharmaceutical Medicine, universities and industry associations which are promoting this initiative must continue to stimulate professionals, especially the younger ones who have obtained a master title in Pharmaceutical Medicine, to join the SMD program, and to make employers aware of the relevance of these professionals for their organization's success. In the long run this will clearly demonstrate the significant importance of having competent professionals devoted to drug development, in a worldwide environment.Finally, the SMD program is an important additional step to achieve the PharmaTrain vision of modern competence which says “Better trained postgraduate professionals working in medicines development and regulation worldwide produce better medicines”.Introduction, the section about Italy implementation, and conclusions. KI contributed to the idea of the manuscript, and wrote the section about Japan. IK contributed to the idea of the manuscript, and wrote the section about PharmaTrain and IMI roles in SMD preparation.DC conceived the manuscript, and wrote The SMD project was in part funded by grant 115013 from IMI and by grant 115015 from IMI-TRAIN.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Results indicated that the proposed model is superior to the traditional methods for earthquake probability assessment in terms of accuracy. Aside from facilitating the prediction of the pixel values for probability assessment, the proposed model can also help urban-planners and disaster managers make appropriate decisions regarding future plans and earthquake management.Earthquake prediction is a popular topic among earth scientists; however, this task is challenging and exhibits uncertainty therefore, probability assessment is indispensable in the current period. During the last decades, the volume of seismic data has increased exponentially, adding scalability issues to probability assessment models. Several machine learning methods, such as deep learning, have been applied to large-scale images, video, and text processing; however, they have been rarely utilized in earthquake probability assessment. Therefore, the present research leveraged advances in deep learning techniques to generate scalable earthquake probability mapping. To achieve this objective, this research used a convolutional neural network (CNN). Nine indicators, namely, proximity to faults, fault density, lithology with an amplification factor value, slope angle, elevation, magnitude density, epicenter density, distance from the epicenter, and peak ground acceleration (PGA) density, served as inputs. Meanwhile, 0 and 1 were used as outputs corresponding to non-earthquake and earthquake parameters, respectively. The proposed classification model was tested at the country level on datasets gathered to update the probability map for the Indian subcontinent using statistical measures, such as overall accuracy (OA), F1 score, recall, and precision. The OA values of the model based on the training and testing datasets were 96% and 92%, respectively. The proposed model also achieved precision, recall, and F1 score values of 0.88, 0.99, and 0.93, respectively, for the positive (earthquake) class based on the testing dataset. The model predicted two classes and observed very-high (712,375 km Earthquakes are devastating natural disasters that can cause mass destruction and result in the loss of properties and human lives. Therefore, earthquake prevention, prediction and probability monitoring are essential, along with hazard, risk and mitigation preparation. Countries, such as China, Taiwan, Japan, USA and Chile have developed early warning techniques and are highly advanced in earthquake research. However, traditional approaches are not used in the recent hazard assessment or monitoring of earthquakes because these methods are unable to achieve good results ,2. WavefKrinitzsky  calculatParvez and Ram  estimateIn the current study, a convolutional neural network (CNN) model was developed for earthquake probability assessment. To date, no study has been conducted using deep learning and GIS for the earthquake probability assessment. However, this model was implemented for the Indian subcontinent for the first time. The current study aims to update the earthquake probability map of the Indian subcontinent. Some researchers have conducted probabilistic seismic hazard mapping in India. However, they have used traditional methods that exhibit many uncertainties. As the Earth’s internal structure is complicated, therefore traditional models consider some assumptions such as (a) considering segments of a specific fault as one based on uniform seismicity, (b) local attenuation equation to calculate PGA (c) earthquakes occur randomly through time and space. However, these assumptions were not considered in the current study, which could lead to uncertainties on data and accuracy of results. Therefore, mapping the probability of earthquakes and updating old maps are essential. The specific objectives of this study are as follows: (1) to develop a CNN model for prediction of earthquake classification and (2) to develop a probability map based on the CNN prediction of classification results. The model will enable performance accuracy evaluation and loss estimation. The proposed model was tested in India and covered nine probability factors. The estimation result was analyzed by calculating and comparing area and length with those of published old seismic hazard maps.2 [The Himalayas is located in the northern part of the Indian subcontinent, which is seismically dynamic . The stu2 . The mosKolathayar et al.  developeLocal sources refer to the raw data sources in India used in this study. The Geological Survey of India published the seismotectonic atlas , which ihttp://www.pbcgis.com/normalize/). Probability assessment is challenging without selecting appropriate criteria on which the model fully depends upon. To achieve good accuracy in producing a probability map, the most essential and useful steps are selecting important indicators and removing noise and heterogeneity from the data. In this study, freely available 30 m resolution digital elevation model (DEM) data was used to generate several layers. The UTM/WGS 1998 reference system was used to map and produce thematic layers. The following thematic layers were derived from several sources: Euclidean distance from normal, strike-slip and thrust faults (including major photo lineaments), fault density, lithology with an amplification factor value, slope angle map, elevation, magnitude density, epicenter distance, depth density, distance from the epicenter, and PGA density [In this study, various thematic layers  were pro density ,40,41,42 density . The proSlope and elevation: Slope and elevation are two main factors used for earthquake potential zoning and earthquake-induced landslide susceptibility mapping . Rough sFault density and distance from fault: Faults are the main source of earthquakes. High fault density denotes the areas with complex tectonics, thus increasing the probability of earthquakes . The comMagnitude, PGA, epicenter density, and distance from epicenter: Likelihood of a particular magnitude, location, depth, and PGA values depend on tectonic condition . EpicentLithology and amplification factor: Ground shaking depends on the amplification factor and rock types . These aThe architecture of CNN for earthquake prediction of classification consists of a sequential model with four convolutional layers, each of which is followed by a dropout and pooling layer. The details of the employed CNN layers are described below and presented in Input layer: Each layer is characterized by a 2D vector. An input sequence of n layers can be presented by concatenating the mathematical structure with multivalued points. The matrix rk input .Convolutional layer: A set of m convolutional filters is attached to this layer, where h is the length.  formula :(1)Ci:=∑The concatenation of all data points in a layer describes the feature vector Pooling layer: The aggregation of the input vectors occurred in a pooling layer, which is the maximum value over a set of non-overlapping intervals. The resulting pooled matrix can be expressed as Hidden layer: A fully connected hidden layer is located at the end of the four convolutional layers. This layer computes the transformation put data .Softmax: A softmax regression layer is connected to the outputs of the previous layer Optimization: The CNN parameters are learned using the Adam optimizer. The validation and parameters with the highest value should be computed and selected, respectively, at a fixed interval.Loss estimation: The loss function is also called the cost function. This function measures the compatibility among output predictions and uses ground truth labels. In this model, a sparse categorical cross-entropy function is implemented as the loss function, which is beneficial for binary classification. However, the mean square error of the continuous values is applied to the regression. One of the hyperparameters is a loss function that can be determined on the basis of the given tasks.a are the weight matrices in the softmax layer for the output classes.Network parameters: The parameters learned during the training are as follows: The parameters of the CNN model were learned through a three-phase procedure: (1) creation of data point embedding; (2) distant supervised phase, wherein the parameters are tuned by training, and; (3) final supervised phase, wherein the training is performed using the supervised training data . In the Accuracy is a simple measure of a classifier’s performance ,37.(4)AThe F1 score is computed from the precision and recall  of each class.The earthquake catalog from USGS was used to estimate PGA based on the attenuation equation provided by Joyner and Boore . The souAccording to Joyner and Boore , PGA cananalysis ,41,42. Tanalysis  is used Three main thematic layers were obtained such as MMI variation, PGA variation, and lithology with an amplification factor map using GIS along with several other layers from the same dataset. Firstly, various attributes of earthquakes were investigated in detail as per the requirement of earthquake probability assessment. Secondly, PGA and MMI were calculated based on the employed attenuation laws and implemented in GIS. PGA density map and intensity variation layers were utilized in earthquake probability mapping and hazard estimation. Several lithological units were extracted from the geological map and assigned amplification factor values to each unit to generate another thematic layer. The detailed information regarding the implementation of the CNN model and attenuation laws to generate the earthquake probability map was described in The detailed methodological flowchart of the employed model is shown in In the first step, a comprehensive earthquake catalog was collected from USGS. Then, several random non-earthquake points were created to train the CNN classifier using GIS. Nine different indicators were used to extract multiple values by points and by keeping earthquake and non-earthquake as the target . In the The spatial layers generated for probability mapping were elevation, slope, lithology with an amplification factor, magnitude density, PGA density, depth density, distance from epicenter, distance from fault, and fault density . TraininMajor earthquake scenarios experienced in the past 200 years in the Indian subcontinent with magnitudes 7.0 to 8.0 and above were also included in the current study. Bi-histogram provides a relationship between magnitude, intensity, and frequency . In totaThe strong quakes that happened in India are the source locations that can produce future events in accordance with active faults. Previous quakes, such as Kutch (Mw = 8.3), Assam (Mw = 8.7), Kangra (Mw = 8.1), Bihar–Nepal (Mw = 8.3), and Assam (Mw = 8.6), are moving closer to the high hazard zones. Training is a major component of the CNN model to achieve an accurate result. Therefore, training and testing accuracies were calculated after the performance evaluation of the proposed CNN framework, reaching 96% and 92%, respectively. The estimated loss from this model was compared against the epochs. The obtained baseline error was 7.95%, and the final accuracy was 92.05%. The confusion matrix  and the The CNN model’s accuracy reached 92.05% for the testing dataset. The probability zones of earthquake-prone areas were mapped for the Indian subcontinent. The probability map was obtained with values varying from 0 (no-earthquake) to 1 (earthquake) , and the2) contributing to active tectonics. The maximum area is within the very-low-probability zone , followed by the low-probability , moderate-probability , high-probability , and very-high-probability  zones. Very-high- to very-low-probability areas comprise approximately 19.8%, 16.43%, 10.53%, 3.87%, and 49.37% of the aforementioned zones, respectively. A two class-based probability map was developed and presented in Approximately 92% of predicted earthquake classes fall within the Himalayan zones (high- to very-high-hazard zones). These probable zones provide a holistic view, which is an integration of several parameters without considering a particular context of the scenario. This finding explains the severity of earthquake hazards that can originate from these regions in the future and provides an alarming view to local and national authorities with respect to necessary preparations for the worst situations with a gradual time course. VS30 values obtained from the topographic gradient. They obtained a PHA at the surface level, wherein the return periods are 475 and 2475 years (presented in contour maps). The validation of results was conducted using a published seismotectonic zonation map and experts’ feedback. Sitharam et al.  reportedVipin et al.  estimateThe associated earthquake probability with peninsular India was evaluated using a CNN model that was described in the implementation section of this paper. While integrating uncertainties associated with various modeling parameters, the most recent knowledge on seismic activity in the Indian subcontinent was applied to estimate probability. Uncertainties related to data that can be linked to a catalog or existing probable factors or other parameters involved in hazard analysis. The discussion part describes the comparison of old probabilistic results and seismic zoning maps with the obtained earthquake probability map. Most traditional techniques are poorly designed for low-magnitude events and do not record seismicity . The objKhattri et al.  developeThe probability assessment was completed on the basis of nine factors . Figure https://law.resource.org/pub/in/bis/S03/is.1893.1.2002.pdf). Therefore, the hazard estimated in this region is higher in contrast with the Indian Standard code. The current study of probability mapping is linked to the hazard map, which is under Zone IV but with low probability. Southern portions, including Tamil Nadu, are under passive margin and exhibit higher ground motion based on the hazard map (Zone III) while presenting low probability in accordance with the obtained map. The western portions of some states, such as Bengal and Orissa, and the western part of Madhya Pradesh, Chhattisgarh, Andhra Pradesh, and Karnataka are estimated as moderate to low probability and low hazard zones on the basis of the seismic zoning map , a large part of the Narmada lineament region spreads up to the northern part of the Godavari graben (ning map . Therefo2) and high  probability areas consist of 19.8% and 16.43% of the aforementioned zones, respectively. The limitation of this study includes the implementation of CNN, which is time- and data-consuming, particularly the training data. This study is limited to earthquake figure probability assessment. The geological and deep learning constraints presented in this research are insufficient for probability mapping. The detailed analysis of factors, including geophysical and precursor studies, could be enhanced to improve the accuracy of the probability assessment. Several assumptions were made and model parameter modification was performed during the entire process, such as the selection of earthquakes with more than 4.5 Mw, distance criteria, including maximum magnitude scenarios, removal of unwanted thematic layers, and the weighting scheme within the CNN model. The earthquake probability map presented in this study is intended to highlight nine influencing parameters that can be changed further with geophysical, geomorphologic, seismic, and field data. The probability map based on CNN can be useful for earthquake hazard and risk mapping, mitigation, land use planning, and other related applications. Understanding the relative importance of the applied factors is crucial for further studies. This study can further support hazard and mitigation strategies and proper planning for critical facilities, including hydropower projects, dams and tunnels, nuclear power plants, and other engineering structures. Source-specific paleoseismic parameters, geodetic considerations, and geophysical parameters can depict micro-level sources in future research. Accurately dealing with associated uncertainties can be another future focus to achieve a good assessment in the field of earthquake probability assessment. More research should be done to improve the seismic probability mapping using state-of-the-art machine learning approaches and advanced artificial intelligence techniques.On the basis of the recent advances in deep learning, a CNN model was proposed to achieve a robust prediction of experienced earthquake events to address the shortcomings of existing methods and develop a probability map for the Indian subcontinent. In the current study, the authors attempted to estimate the probable areas  for future earthquakes. The final probability map achieved an accuracy of 92.05%. Therefore, the proposed model is superior to traditional methods for earthquake probability assessment in terms of accuracy. From the results, very-high (712,375 km


Many community-dwelling older adults experience limitations in  activities of daily living, resulting in the need for homecare services. Whereas services should ideally aim at maintaining independence, homecare staff often take over activities, thereby undermining older adults’ self-care skills and jeopardizing their ability to continue living at home. Reablement is an innovative care approach aimed at optimizing independence. The reablement training program ‘Stay Active at Home’ for homecare staff was designed to support the implementation of reablement in the delivery of homecare services. This study evaluated the implementation, mechanisms of impact and context of the program.n = 23) and program trainers (n = 4).We conducted a process evaluation alongside a 12-month cluster randomized controlled trial, using an embedded mixed-methods design. One hundred fifty-four homecare staff members  from five working areas received the program. Data on the implementation , possible mechanisms of impact  and context were collected using logbooks, registration forms, checklists, log data and focus group interviews with homecare staff . Registered 26 September 2017.ClinicalTrials.gov (Identifier The online version contains supplementary material available at 10.1186/s12877-020-01936-7. Due to the ageing of the population, many high-income countries nowadays stimulate an ‘ageing-in-place’ policy to enable older adults to live independently at home for as long as possible , 2. ConsInnovative care approaches may support homecare staff in implementing the ‘doing with’ approach in daily homecare practice. This fits well with the holistic and person-centered philosophy of reablement . ReablemThe Dutch reablement training program ‘Stay Active at Home’ was recently designed to integrate reablement in the delivery of homecare services , 16. TheClinicalTrials.gov (Identifier NCT03293303).This process evaluation was conducted alongside a 12-month cluster randomized controlled trial (cRCT) in the Dutch homecare setting. For logistical reasons, the program’s implementation and evaluation occurred in two waves; the first wave started in October 2017, the second in January 2018. We used an embedded mixed-methods design in which quantitative data were embedded within a mainly qualitative methodology –23. DetaThe healthcare organization involved has divided its region into seven working areas that are sub-divided into small-scale self-directed nursing teams, with on average 11 teams per working area (range 3–28). Each team consists of baccalaureate-educated registered nurses, vocationally-trained registered nurses, (certified) nurse assistants and nurse aides. The team is jointly responsible for providing personal care ; nursing care  is provided by registered nurses only. One of the nurses on the team, the district nurse, has a more supervising and coordinating role. In addition, each working area includes a group of domestic workers who provide domestic support . They are not registered and do not need a formal domestic qualification. In this article, we used the term ‘nursing team members’ when referring to nurses, nurse assistants and nurse aides; the term ‘homecare staff’ was used when referring to nursing team members and domestic workers simultaneously.The healthcare organization appointed ten nursing teams from five working areas (two teams per area), which were pre-stratified based on area and randomized into the intervention or control group, together with their clients and, if applicable, clients’ domestic workers. The current article focused on homecare staff in the intervention group, as they directly engaged in the program. Nursing team members were eligible to participate in the program if they worked in one of the intervention group nursing teams at the start of the study . Domestisecondary intervention delivery pathways) through equipping homecare staff with knowledge, attitude, skills and social and organizational support from colleagues and team managers to implement reablement in daily homecare practice (primary intervention delivery pathways). The program’s implementation process is outlined in Fig. The ‘Stay Active at Home’ reablement training program aims to improve the independence of homecare clients , bi-(monthly) team meetings (60 min each) over a 6-month period, and a booster session at 9 months (120 min). Although meetings were largely similar for all staff members, distinct trajectories were designed for nursing team members and for domestic workers. The joint kick-off meeting for all staff members of the same working area provided background information on why a re-orientation of homecare was needed. Each team meeting then addressed a skill to facilitate the implementation of reablement in practice: 1) motivating clients, 2) increasing clients’ engagement in daily and physical activities, 3) implementing goal setting and action planning, 4) involving the social network of clients, and 5) assessing clients’ capabilities. Domestic workers received fewer meetings than nursing team members due to a lower annual time-budget for training activities in the Netherlands. Practical assignments were distributed at the end of each meeting to practice skills in-between the meetings. As part of the assignments, nursing team members also received a booklet with practice exercises and an ecomap . Additionally, all staff members received 20 weekly newsletters by email during the first 6 months of the program. In terms of procedures, all team meetings started with discussing the practical assignment, followed by a presentation about the addressed skill, and a skills training including one or more interactive teaching methods. In the joint booster session, homecare staff practiced conversational skills in role-plays with professional actors. Team managers were also invited to the program meetings; they also received the weekly newsletters. An overview of the program is outlined in Fig. 0 min, biThe program meetings were organized in the working areas in which the homecare staff was located. Two program trainers were present per meeting; they received a program manual and a 2-h training by one of the researchers before the program started, and short preparatory sessions before every program meeting. Homecare staff received an information letter and a program overview prior to the training, and presentation handouts, practical assignments and other supporting materials during every meeting. If staff members were unable to attend a meeting, we send them the materials by email. Additionally, we had regular contact with district nurses and team managers in-between the meetings to reflect on homecare staff's program engagement and, if applicable, to further tailor the program to staff's needs and wishes.We collected both quantitative and qualitative data from homecare staff and program trainers to assess different research questions, in which the quantitative data provided a supportive role to the qualitative data , 24.Background characteristics  were assessed through a baseline questionnaire during the first program meeting.We collected information on the process domains implementation, mechanisms of impact and context of the MRC framework , see TabReach was defined as the extent to which the intended audience came into contact with the program. A project logbook was consulted to assess the number of staff members who refused, dropped-out or completed the program; reasons for refusals and dropouts were also assessed.Dose was defined as the quantity of the program that was delivered by program trainers and received by homecare staff. Registration forms and checklists were completed prior to every program meeting to record homecare staff's number of program meetings attended and practical assignments completed. Log data from the software program LaPosta  monitored homecare staff's compliance towards consulting the weekly newsletters.Fidelity was defined as the extent to which the program was implemented as planned. The project logbook was consulted to assess whether the program was conducted according to the protocol. Adaptations that were made to the program to achieve better contextual fit  were also assessed. In addition, focus group interviews were conducted with homecare staff and program trainers after the implementation period of the program to gain insight into their degree of engagement in the program and with applying the program in practice. In total, five focus groups were performed: one with a subsample of nursing team members (November 2018), one with a subsample of domestic workers (November 2018), two with district nurses to interview all of them (December 2018), and one with the program trainers (August 2019). Subsamples were selected through quota sampling in a two-step selection process by one researcher (author THR). First, homecare staff who attended at least half of the program meetings were selected. Second, two nursing team members and two domestic workers per working area were invited by email, taking age, gender and years of work experience into account, to capture a wide range of perspectives [pectives ; when a November 018, one Acceptability was defined as the extent to which homecare staff and program trainers were satisfied with the program. Their opinion about the program, including their most/ least appreciated program aspects, and experiences with using the program in practice were assessed by focus groups interviews as described above.Mechanisms of impact were defined as mechanisms through which the program may produce change. Based on previous research, these mechanisms were assumed to be homecare staff's knowledge, attitude and skills about reablement, and social and organizational support from colleagues and team managers [managers , 15, 17.Context was defined as factors external to the program that may have influenced the program’s implementation. A project logbook was used to assess contextual factors. Additionally, the focus group interviews provided insight into factors that may have facilitated or impeded the application of the program in practice. In addition, suggestions for change were assessed to further improve the program or facilitate its implementation.Quantitative data were used to asses reach and dose, and were analyzed using descriptive statistics in SPSS Statistics for Windows version 25.0 . Qualitative data were used to assess the remaining process domains and indicators, and were analyzed using a directed qualitative content approach in ATLAS.ti version 8.4 . Interviews were transcribed verbatim and coded using a coding scheme developed prior to the analysis based on the process domains and indicators. As the analysis proceeded, additional codes were generated by marking relevant sections, phrases or sentences. Two researchers (authors THR and RGMV) independently coded one-third of the transcripts. Author THR coded the remaining transcripts. Subsequently, the two researchers independently established categories by grouping codes. Any differences in coding or categorizing were discussed until consensus was reached. In a final phase, one researcher (author SFM) verified the categories and made minor adjustments in the allocation of the categories to the process domains and indicators in consultation with authors THR and RGMV. A detailed description of the findings supported with literal quotes from the focus group interviews, which were translated to English by a professional translator, are reported.Different strategies were adopted to ensure the trustworthiness of the findings regarding credibility, dependability, confirmability and transferability . Credibin = 154) agreed to participate in the program . Table The selected working areas included 67 nursing team members and 102 domestic workers, who delivered care to 354 clients. Most of them .The project logbook showed no major deviations from the protocol. Program trainers felt sufficiently prepared to provide the program meetings and covered all components of the program meetings . Only the time spent on the different components varied due to the teams’ different needs; nevertheless, the skills presentation often took up most of the time.We frequently used PowerPoint presentations (during the program), and people may or may not be learning from those. In the healthcare organization, on the other hand, we would normally use more interactive methods. I think that is a little more effective. (program trainer 1).According to the homecare staff and program trainers interviewed, there was variation in the extent to which staff members engaged during program meetings. The program trainers assumed that the large training groups, on average 14.3 ± 5.1 staff members at team meetings and 25.5 ± 9.1 at the kick-off/ booster session, undermined homecare staff's active participation. Furthermore, they surmised that staff members did not always actively participate because the meetings predominantly focused on explaining rather than practicing skills.One minor adaptation was made to the program’s implementation. Due to variation in homecare staff's program engagement, the district nurses and team managers were asked to emphasize the importance of participating in the program to their teams by mail, or during team meetings not related to the program. No changes were made to the program itself. Nevertheless, program trainers were able to share more examples from practice after the first wave of trainings due to the shared experiences during this wave.They (the actors) stayed in their role while I was thinking about how to respond. That was pretty intense. But I did get a taste of what it would be like in real life, and I also learned from the way others responded. (domestic worker 4).Staff members were generally satisfied with the program. They particularly valued the program’s practical elements . According to many staff members, the role-plays provided insight into how to encourage clients in practice and helped to reflect on their own behavior. Some domestic workers felt out of their comfort zone, though, as the professional actors always remained in their role, challenging them to react verbally and behaviorally.(I liked) the booklet with the practice exercises, because if I am telling clients that they should be keeping physically active, now at least I can show them what kind of exercises will help them. (nurse assistant 4)Most nursing team members also appreciated the booklet with practice exercises, which contained comprehensible examples of how to remain active at an older age. This supported them to motivate clients to participate in daily and physical activities. According to some staff members, the practical assignments in general helped to practice skills in an accessible manner, and to reflect on one’s own actions so as to engage in a process of continuous learning. Others, though, considered the assignments a burden, due to an experienced lack of time or because they were not used to putting things down on paper.I especially liked the newsletters with the tips, which also provide some explanation and background information. Some of our team members even showed the newsletters to their people (clients). It helped them to explain to clients why it is good to stay physically active, because it is quite difficult to explain something like that. (district nurse 3).Many staff members also considered that the newsletters were useful reminders with valuable information about the benefits of remaining physically active and practical tips on how to motivate clients towards performing activities for themselves. This supported staff members in conversations with clients about stimulating independence.Some district nurses, though, felt that their colleagues read fewer newsletters towards the end of the program due to their high frequency (once per week).There now is a lot of interaction (with colleagues), and that encourages people to ask each other questions, like: ‘Oh I saw you with that client, so how would you approach this?’. (nurse assistant 5).Most staff members also appreciated the program’s team approach, as this allowed them to get to know each other and to exchange experiences about what clients can still do themselves and how to approach them in the best way. Many staff members indicated that they would like to interact even more with colleagues both during and outside the program, so as to learn from each other’s working practices.Everyone had to set goals and design action plans for their own clients. I noticed that most of the nurses could do that quite well, but some of the others found it harder (nurse assistants and nurse aides). They were not sure how to describe some of the things they do. They know what they are doing in practice, but they do not always know how to describe that properly. (district nurse 3).Staff members' opinions were divided regarding whether the program fitted with their daily practice. District nurses and program trainers indicated that the program fitted the roles and tasks of staff members; however, some district nurses considered the meeting on goal setting and action planning possibly too difficult for nurse assistants and nurse aides. Consequently, one district nurse did the assignment on goal setting and action planning together with the team to support them.Many nursing team members indicated that they were already familiar with most of the program content due to a previous short training on self-management.Opinions were also divided regarding the program’s duration. Most staff members appreciated the program’s gradual structure, allowing them to implement changes step-by-step by alternating between learning, experimenting, and reflecting. Some nursing team members, though, considered the team meetings of 1 h too short to practice skills and some domestic workers considered the 2 months in-between the team meetings too long to remain continuously aware of the program while providing homecare services.If there is a client who needs to be showered twice a week, then you would also help them to get dressed afterwards. But for the rest of the week, they would be doing that by themselves, so I do not actually need to help them to do that. So sometimes it is just about thinking differently. (nurse assistant 4).According to many staff members, their knowledge regarding reablement improved because of the program; they mentioned several benefits for older adults  and for themselves . They also mentioned tips on alternative ways of providing care  and other strategies to improve clients’ activity levels . This knowledge raised awareness among staff members, which helped to change their way of thinking towards encouraging independence among homecare clients.In the past, the work was really about taking care of people and basically doing everything for them. That is how I learned to do it from the start. And that makes it hard to think about your work in a different way. (nurse aide 1).The program trainers, though, found that some staff members considered certain parts of the program as complex ; they therefore expected that not all program content led to increased knowledge of staff members. Most district nurses, on the other hand, indicated that the knowledge to encourage clients towards independence was generally present, but that homecare staff sometimes considered it challenging to integrate this knowledge into their working practices.When I go to visit a client, and I find them standing by the door waiting to tell me that they have cleaned out their cupboard on their own – that is what makes it really worthwhile! They look so proud of themselves and that is motivating because we have really achieved something. (domestic worker 6).He feels more involved now. Before, he used to think he could not do anything for himself anymore, but now he is happy that he is able to do things independently. He does not have to bother other people anymore. (domestic worker 1).Most staff members experienced positive changes in their attitude towards reablement due to the program. Reasons frequently mentioned for this were successes that they gained regarding encouraging clients to perform activities themselves again, and the impact that this had on clients’ view about themselves.Some staff members were still doubtful about reablement, though, for instance, due to negative outcome expectations of reablement , a preference for or habit of taking over activities, or a short-term vision of care where it is faster to take over tasks.Team meetings 1 and 2: Many staff members now used the different communication strategies that were part of the program more consciously in practice, such as motivating and complimenting clients, being firm, negotiating and joking. They also shared more tips with clients on how to engage in daily and physical activities.Now I talk more to the clients about their health - and for example, when I tell them about the 10% decrease in muscle mass, that really gets them thinking. I had never thought about mentioning that, but it really opens their eyes. (domestic worker 6).The program trainers, however, indicated that homecare staff's conversational skills varied considerably; they therefore assumed that conversations might not always have been conducted in the correct manner.Team meeting 3: Most district nurses spent more attention on reablement during the needs assessment with newly referred clients because of the program. They also formulated client-centered goals more specifically to clarify to their colleagues which activities (not) to take over.I learned to set more specific goals. In the past, I would often formulate goals like ‘performing ADL’, or ‘showering or washing at the washbasin’, but things are not always clear then. It does not say, for instance, that he (the client) should try to wash his upper body himself. (district nurse 4).Most domestic workers often did not work with goals and action plans, but sometimes made verbal agreements with clients.Team meeting 4: Many district nurses spoke more frequently with the social network of clients than before the program, for instance, about clients’ resistance to change. Some other nursing team members also had more contact with the social network.We had one lady who was slowly able to start doing more things for herself again, but her son used to stop her all the time. He would say: ‘(Staff member X) will be here soon, so leave that for her to do.’ I told him that if she can do things for herself, she really should be doing them because that is much better for her. (nurse assistant 3).Some district nurses, however, indicated that not everyone was equipped for such conversations, especially when the social network unnecessarily took over activities and resisted the change. The domestic workers rarely had substantive contact with the social network of clients.Team meeting 5: Many staff members assessed clients’ capabilities more often because of the program; they looked more consciously at what clients could still do themselves, and better defined to clients what they could expect from them.In the past, when I had a new client, I would just arrive at the agreed time and start working right away. But now I arrive 10 to 15 min early and I use that time to talk (to the client) about what they are still able to do and what I can do for them. Then they know what they can expect from me and what I will expect from them, and I can refer back to that. (domestic worker 4).The district nurses, though, indicated that the extent to which homecare staff succeeded in this varied. They also got the impression that some staff members considered the assessment of capabilities the responsibility of the district nurse; they therefore expected that staff members did not always consciously look at what clients could still do themselves.In the past, we would just do the household chores, and the nurses would get on with their own work. But since the program, we have started talking more. Now it feels more like a joint effort. (domestic worker 7).Most district nurses indicated that the program led to greater support and cooperation within the team. They spoke more frequently with their team about how to implement reablement in practice; they also set goals more often in consultation with the team to create a shared responsibility in the care provided. Consequently, most nursing team members started to report more extensively on these goals, thereby gaining more insight into each other’s working routines. If someone on the team deviated from agreements made in the team, they were called to account by colleagues, thereby reducing differences in their working practices. Most domestic workers had little contact with their colleagues outside the program, although some did have more contact with nursing team members than before.My team found it (the support of the team manager) very positive. The interest, the compliments, and the personal attention - they appreciated that. (district nurse 1).According to the staff members interviewed, the extent to which team managers attended program meetings and supported homecare staff towards implementing reablement in practice, varied. Most domestic workers and some district nurses valued the presence and support of team managers during program meetings and meetings not related to the program. Many staff members also felt free to consult the team manager in challenging situations. Nevertheless, some domestic workers considered it challenging to express themselves when the team manager was present at the program meetings or to approach the team manager when they encountered problems.What I see is that our team still makes the most progress with new clients who need care. They (the staff) actively focus on engaging them (newly referred clients). (district nurse 4)Homecare staff mentioned several contextual factors that facilitated the program’s implementation. First, the use of digital care plans provided nursing team members with better insight into goals that were set with clients, which made them more inclined to report on them. Besides, care plans were accessible to the clients’ social network, allowing them to monitor the care process . Second, the healthcare organization’s lump sum funding system (meaning that the organization receives a fixed amount of money per client irrespective of the amount of care delivered) ensured that staff members were less time-bound when providing care. Lastly, newly referred clients could be more easily encouraged, since they did not experience the old system of care provision in which activities were often taken over.Time pressure - for me that is one of the biggest challenges. You have a busy day, and you know that people need to receive care at a particular time, so very quickly you’re inclined to just say ‘let me do that for you’ (the clients). (nurse aide 2).Homecare staff also mentioned some contextual barriers. First, resistance to change from clients or their social network impeded staff members in implementing reablement. Reasons frequently mentioned for this were older adults feeling too old or too weak, feeling entitled to care, being afraid of losing care, or having unrealistic expectations about homecare that were created by other stakeholders . Second, nursing team members still struggled to encourage clients in complex care situations. Lastly, particularly nursing team members indicated that time pressure and staff shortages could lead to taking over activities.Homecare staff and program trainers had some suggestions to improve the program and facilitate its practice implementation. To improve homecare staff's attendance rates and program engagement, staff members suggested to make the training mandatory and program trainers suggested smaller training groups and more interactive teaching methods. To improve homecare staff's knowledge, attitude, skills, social and organizational support, staff members suggested to include training on-the-job, practical assignments on a team level and more role-plays. Program trainers suggested to further tailor the program to homecare staff's needs and wishes to better support them during the process of behavior change. Additionally, they suggested to first train team managers and district nurses about how to support staff in implementing reablement before training staff members. To reduce resistance to change, homecare staff and program trainers suggested providing information on reablement to clients, their social network, and to other relevant stakeholders.This comprehensive process evaluation provided insight into the implementation, mechanisms of impact and context of the reablement training program ‘Stay Active at Home’ program that was implemented in the daily practice of Dutch homecare for older adults. The program was largely implemented as intended. Homecare staff's compliance with attending the program meetings was reasonably good; however, the extent to which staff members conducted the practical assignments and consulted the weekly newsletters varied. They experienced positive changes in their knowledge about and attitude towards reablement, learned new skills or further developed already existing skills to encourage clients towards independence, and perceived social and organizational support from colleagues and team managers to implement reablement in practice. Contextual factors that potentially facilitated the implementation were digital care plans, the organizations’ funding model (lump sum funding instead of fee-per-hour) and newly referred clients. Potential barriers were resistance to change, complex care situations, and time pressure and staff shortages.To understand how the program may have produced a change in homecare staff's behavior, it is essential to unravel its mechanisms of impact . Based oreceptiveness may have influenced staff members' program compliance. Domestic workers were more compliant with attending the program meetings than nursing team members, possibly because they receive little training in the Netherlands, thereby making them more eager to participate. Another explanation may be that mainly nursing team members suffered from time restraints and staff shortages. A lack of understanding may have limited staff members in internalizing reablement. Some program parts were experienced as difficult and some found it challenging to integrate the program knowledge into practice, which is in line with other research [willingness to adopt reablement may have been impeded by a preference for or habit of taking over activities or by negative outcome expectations of reablement. This indicates that staff members were likely in different stages of behavior change and that the program possibly did not always meet their needs and wishes to successfully move to the next stage [ability to change may have been impeded by a variety of other behavioral factors , contextual factors , or by a combination thereof. Nevertheless, by implementing ‘Stay Active at Home’ in Dutch homecare practice, we have been able to take the first steps in changing homecare staff's behavior from taking over activities of older adults towards encouraging older adults to perform activities for themselves.Although most staff members held a positive opinion about reablement, it was sometimes difficult to change their behavior. This is in line with other studies confirming that working with reablement can be challenging , 9, 10. research ; this imxt stage , 32. StaFuture program implementation may benefit from minor adaptations. First, further tailoring the program to homecare staff's needs and wishes may likely improve their engagement in the program and with delivering the program in daily practice. In doing so, it might be valuable to take into account differences in educational backgrounds and experiences, so that the program is explained in a comprehensible manner to all staff members involved . In addiThis study has several strengths. Using the MRC framework provided a profound understanding of the program and its implementation, and gave indications for mechanisms of impact and contextual factors that may influence the intended behavior change . FurtherThe reablement training program ‘Stay Active at Home’ program was feasible to implement in Dutch homecare and was perceived as useful in daily practice. The program seemed to have a positive impact on homecare staff's knowledge, attitude, skills, social and organizational support to implement reablement. However, integrating reablement in homecare staff's working practices remained challenging due to personal and contextual factors. This study contributes to the growing body of evidence that shifting homecare services from ‘doing for’ towards ‘doing with’ older adults involves a major paradigm shift for homecare staff. Future program implementation may benefit from minor program adaptations and a more stimulating work environment.Additional file 1. Interview guide for focus group interviews with homecare staff (n = 23).Additional file 2. Interview guide for focus group interview with program trainers (n = 4).