The Mayer Hashi program resulted in a modest increase in use of long-acting reversible contraceptives and permanent methods in Bangladesh, but less of an increase than in comparison nonprogram districts, which appears to have been the result of weaknesses in the health system environment in the program districts. Addressing system issues to support providers beyond training might have led to better results. The Mayer Hashi program resulted in a modest increase in use of long-acting reversible contraceptives and permanent methods in Bangladesh, but less of an increase than in comparison nonprogram districts, which appears to have been the result of weaknesses in the health system environment in the program districts. Addressing system issues to support providers beyond training might have led to better results. Bangladesh has achieved a low total fertility rate of 2.3. Two-thirds of currently married women of reproductive age (CMWRA) want to limit fertility, and many women achieve their desired fertility before age 30. The incidence of unintended pregnancy and pregnancy termination is high, however. Long-acting reversible contraceptives (LARCs), consisting of the intrauterine device and implant, and permanent methods (PM), including female sterilization and vasectomy, offer several advantages in this situation, but only 8% of CMWRA or 13% of method users use these methods.The Mayer Hashi (MH) program (2009–2013) aimed to improve access to and the quality of LARC/PM services in 21 of the 64 districts in Bangladesh. It was grounded in the SEED (supply–enabling environment–demand) Programming Model. Supply improvements addressed provider knowledge and skills, system strengthening, and logistics. Creating an enabling environment involved holding workshops with local and community leaders, including religious leaders, to encourage them to help promote demand for LARCs and PMs and overcome cultural barriers. Demand promotion encompassed training of providers in counseling, distribution of behavior change communication materials in the community and in facilities, and community mobilization.We selected 6 MH program districts and 3 nonprogram districts to evaluate the program. We used a before–after and intervention–comparison design to measure the changes in key contraceptive behavior outcomes, and we used a difference-in-differences (DID) specification with comparison to the nonprogram districts to capture the impact of the program. In addition to the outcome evaluation, we considered intermediate indicators that measured the processes through which the interventions were expected to affect the use of LARCs and PMs.The use of LARCs/PMs among CMWRA increased between 2010 and 2013 in both program (from 5.3% to 7.5%) and nonprogram (from 5.0% to 8.9%) districts, but the rate of change was higher in the nonprogram districts. Client–provider interaction and exposure to LARCs/PMs were lower in the program than nonprogram districts, and the MH program districts had higher vacancies of key providers than the nonprogram areas, both indications of a more difficult health system environment.The weaknesses in the health system in the MH districts apparently undermined the effectiveness of the program. More attention to system weaknesses, such as additional supportive supervision for providers, might have improved the outcome. Long-acting reversible contraceptives (LARCs) comprise the intrauterine device (IUD) and implants, while permanent methods (PMs) include female sterilization and vasectomy. LARCs offer women and couples who wish to delay, space, or limit childbearing a number of advantages: they are highly effective, require little action on the part of the user, are suitable for a wide range of women, and are cost-effective over the long term.Bangladesh has achieved a low level of fertility  and a contraceptive prevalence rate (CPR) of 62% among currently married women of reproductive age (CMWRA), increasing from about 20% in the early 1980s.Bangladesh has achieved a low total fertility rate of 2.3 and a contraceptive prevalence rate of 62%.However, desire for fertility limitation has increased since the 1990s. For example, in the early 1980s, about half of mothers with 2 children wanted to have additional children.The government of Bangladesh, along with NGOs, have encouraged efforts to increase use of LARCs and PMs to meet the needs of couples for sustained contraception. One example of these efforts is the Mayer Hashi (MH) program, funded by the United States Agency for International Development (USAID) from 2009 to 2013, to increase access to LARCs and PMs and improve the quality of services. We evaluated the impact of this program on use of LARCs and PMs and explored the pathways through which the program aimed to influence use of these methods to interpret the findings of the impact analysis.Both the public and private sector deliver family planning services in Bangladesh. Most of the LARCs and PMs are provided by the public sector, whereas short-acting contraceptives are provided by both the public and private sector. In 2014, 92% of IUD users, 93% of implant users, 85% of vasectomy users, and 69% of female sterilization users obtained their method from the public sector. This compares with 42% of pill users, 61% of injectable users, and 15% of condom users.upazila (subdistrict) health complex at the subdistrict headquarters. The MO–MCH or equivalent personnel also provide LARCs and PMs at other tertiary facilities throughout the country. The upazila family planning officer (UFPO) supervises community family planning activities. NGOs also offer family planning services at the community and facility levels in coordination with the DGFP. All service providers  receive training prior to beginning their jobs.The DGFP delivers family planning services both in communities and health care facilities. Female family welfare assistants (FWAs) are responsible for visiting homes every 2 months to provide information and counseling and to supply pills and condoms.-The Mayer Hashi (MH) program operated in 21 of the 64 districts in Bangladesh during the period 2009–2013.The Mayer Hashi program operated in 21 of the 64 districts in Bangladesh during the period 2009–2013.,The MH interventions were grounded in the SEED (supply-enabling environment-demand) Programming Model.BOX.The Mayer Hashi program was grounded in the SEED Programming Model, which encompasses Supply, Enabling Environment, and Demand interventions.Supply ImprovementEnhancement of knowledge and skills of providers through training and refresher training of:FWAsFWVs MOs–MCH Expansion of services through the DGHS through training of:RMOs and OB/GYNs System strengthening:Orientation of program managers (UFPOs and UHFPOs ) (1-day training on LARCs and PMs)Logistics projection and management :Technical assistance for program managersFacilitation of policy formulation and policy change :LARCs and PMs delivered through the DGHSLARCs and PMs available through the private sectorEnabling EnvironmentAdvocacy:Orientation of community leaders and influential personsDemand CreationCommunity mobilization:Home visits by FWAsCourtyard meetingsCultural programs Advocacy by local leaders and influential personsDistribution of BCC materials :In communitiesAt facilitiesEnhancement of provider skills:Training all providers in interpersonal communicationupazila (subdistrict) family planning officer; UHFPO, upazila health and family planning officer.Abbreviations: BCC, behavior change communication; DGHS; Directorate General of Health Services; FWAs, family welfare assistants; FWVs, family welfare visitors; LARCs, long-acting reversible contraceptives; MOs–MCH; medical officers–maternal and child health; OB/GYNs, obstetrician/gynecologists; PMs, permanent methods; RMOs, resident medical officers; SEED, supply–enabling environment–demand; UFPO, upazilas)—and the program began training private providers on LARCs and PMs.Supply improvement includes enhancement of provider knowledge and skills, systems strengthening, and logistics management. In addition to training DGFP providers and managers, the MH program trained resident medical officers of the Directorate General of Health Services, on LARCs and PMs. The Directorate General of Health Services is an MOHFW agency that provides preventive and curative health services. The MH program trained its resident medical officers to support expansion of LARC and PM services beyond the DGFP. The program also trained obstetrician/gynecologists (OB/GYNs)—the Directorate General of Health Services personnel who provide delivery services including cesarean delivery  materials at the community and facility levels, and community mobilization. The program trained community- and facility-based providers on interpersonal communication techniques in a 1.5-day training session. The primary audience for the interpersonal communication training were the FWAs who counsel clients for LARCs and PMs at the community level, as well as other providers . The providers were given BCC materials (flip charts and leaflets) on LARCs and PMs for client counseling. Leaflets on contraceptive methods were also produced for distribution to current and potential clients. Posters and billboards on LARCs and PMs were produced and displayed in facilities and communities.FWAs organized community mobilization for LARCs and PMs through home visits and courtyard meetings. The primary audience for community mobilization were CMWRA. Street drama and music programs publicized LARCs and PMs, and local leaders and influential persons spoke to communities about LARCs and PMs.The MH team routinely monitored the program by examining quarterly trends in LARC/PM acceptance in the MH intervention districts. However, there was no systematic plan for following up with providers after the training, either by the MH team or by the DGFP, to see how the training affected practice. USAID sponsored a midterm performance evaluation of the MH program that included comparing project achievements with expected results in intervention areas and interviewing stakeholders about program implementation.,We used 2 approaches for the evaluation. To measure the impact of the MH interventions on use of LARCs and PMs, we used a before–after and intervention–comparison design. This design measures the changes in the key contraceptive behavior outcomes in the MH intervention areas relative to those in the comparison areas.To measure impact on use of LARCs/PMs, we used a before–after and intervention–comparison design, and a difference-in-differences (DID) specification.To explore the pathways through which the MH interventions aimed to change contraceptive behaviors, we used an endline-only intervention–comparison design. In this design, we considered a series of intermediate indicators that measure the processes through which we expected the interventions to affect use of LARCs and PMs. This analysis is primarily descriptive.USAID requested the impact evaluation toward the end of the MH program. Therefore, it was not possible to collect pre-program data designed for the impact evaluation. This is a common problem in evaluation in practice. To overcome this problem, we used data from the 2010 Bangladesh Maternal Mortality Survey (BMMS 2010).To form program and comparison samples for the evaluation, we randomly selected 6 (of 21) program districts , and we selected 3 nonprogram districts  to match the program districts in initial LARC and PM prevalence.The baseline data came from the BMMS 2010. The sample size in BMMS 2010 for the 6 program districts was 22,145 CMWRA, and for the 3 nonprogram districts, 9,893 CMWRA . The endupazilas in the 6 program and 3 nonprogram districts were the population of interest for the provider survey. For the DGFP in an upazila, there is 1 MO–MCH and 1 UFPO, both of whom were included in the survey. There are 6 to 8 unions per upazila, and each of the unions has 1 FWV and 6 FWAs. We selected 2 unions at random per upazila. Within the selected union, the lone FWV and 1 randomly selected FWA were interviewed. Providers from the Directorate General of Health Services were also interviewed for each of the upazilas: the resident medical officer and the OB/GYN. The overall response rate of service providers was 77% in the program districts and 82% in the nonprogram districts. The response rates were low for MOs–MCH and OB/GYNs , primarily due to high vacancy rates for these positions. The provider survey included a module on BCC products and materials available at the facilities where the providers were interviewed. Data from providers are available only at endline.Additionally, the endline data collection included a survey of 702 providers in the 9 districts Provider knowledge and reported practice (level of adherence to pre- and post-counseling protocols associated with LARC/PM service provision)○ Pre-procedure counseling during provision of implants○ Post-procedure counseling when providing IUDs○ Post-procedure counseling when providing tubectomy○ Information provided on method side effectsPresence and use of BCC materialsTo assess and contextualize program impact, we performed both bivariate and multivariate analyses. The bivariate analysis compared the indicators of interest between program and nonprogram districts and between 2010 and 2013 (when available). The multivariable analyses involved a regression model designed to assess impact. The foundation of the impact model was a DID regression specification. We implemented this specification through a multinomial logit regression model in which the dependent variable represented the choice of the contraceptive methods by CMWRA. Three categories of choice were considered: (1) no contraception, (2) LARC or PM , or (3) other methods .To implement the DID specification to capture the potential impact of the MH program on increased use of LARCs and PMs or other methods over time, we included dummy terms for whether the district was among the 6 selected for the program as well as a dummy variable indicating whether the observation came from the baseline (BMMS 2010) or follow-up (MH endline survey). We also included an interaction term between these 2 variables, which is crucial. Finally, the specification applied to the multinomial model also included selected independent variables, such as women’s age, education, religion, household wealth quintile, and residential location .We estimated the multinomial model in a fashion that recognizes the 3 sampling design features of the 2 surveys: stratification (both involved a stratified design), clustering, and sampling weights. To generate a unified weighting scheme between the 2 surveys, we normalized together the design selection probabilities for the observations from the 2 surveys. This, combined with the dummy variable indicating the survey (BMMS 2010 or MH endline) from which the observations were drawn, should control for any structural differences between the 2 surveys.Because the multinomial logit is a nonlinear regression model, program impact was captured through an interaction effect obtained from the estimated model. Specifically, program impact on LARC/PM use was:Pr is the predicted probability  of using LARCs/PMs conditional on whether the individual resides in a program area (P=1 if residing in a program area and 0 otherwise), T is an indicator for whether the observation is drawn from the baseline (BMMS 2010) or endline sample, and X are the other characteristics  for which we controlled in the multinomial regression model. Program impact was thus the difference in predicted probabilities over time in program areas minus the same in nonprogram areas. This is in line with the classic DID approach to program impact estimation. The standard error of this program impact measure was obtained via the Delta method for functions of maximum likelihood estimates.where Beyond this causal modeling, all the indicators except for the use of LARCs/PMs and other methods were compared between program and nonprogram districts only at endline. This helped us to understand the intermediate-level variables through which the program can affect LARC/PM use.Bangladesh has regional variations in use of health and family planning services.Most of the Mayer Hashi districts (17 of 21) were in the eastern region of Bangladesh, which tends to have weaker health systems and more conservative values.The LARC and PM use rates in program and nonprogram samples were comparable in 2010 . We also found that these rates were comparable for program and nonprogram districts in 2004 and 2007 for the years when data were available. Women’s age, number of children, and education were comparable in program and nonprogram districts, but the nonprogram areas were more urban and had a smaller non-Muslim population than the selected program districts . The BMMIn the program districts, 63% of each group of providers, MOs–MCH, FWVs, and FWAs, reported that they received training on LARCs and PMs compared with 42% of MOs–MCH, 23% of FWVs, and 15% of FWAs in the nonprogram districts. Among OB/GYNs and resident medical officers, 28% and 5%, respectively, reported receiving training on LARCs and PMs in the program districts compared with none in nonprogram districts.Almost all the MOs–MCH and FWAs reported that they explained to clients the advantages and disadvantages of implants . We alsoP≤.05) and for FWAs, 73% vs. 54% (P≤.05).For IUD clients, in program districts, 74% of FWVs (the only IUD provider) said they provide the follow-up card to the clients, and 54% of FWAs, who accompany the clients for the procedure and play an important role in enhancing the client–provider interaction, said they provide the follow-up card . The folP≤.01) in nonprogram districts than program districts  was (a) generally low in both the program and nonprogram districts and (b) statistically similar in the 2 areas. However, the percentage of providing the follow-up card by FWVs was significantly greater (istricts . ReporteP≤.05).BCC materials were commonly available in the facilities in program districts: 86% to 92% of facilities had billboards, banners, or posters on LARCs/PMs in and around the facilities . Such BCP≤.001) in the program districts than nonprogram districts. The CMWRA also had significantly higher contacts with service providers at facilities in nonprogram districts than in program districts.In 2013, 13% of women interviewed in the household survey reported they were visited by family planning workers in the last 3 months in program districts, compared with 23% in nonprogram districts . The levQuality of care of family planning services can be enhanced if contraceptive clients are told about method side effects, are reminded about follow-up visits, and are told about other method options.In the program districts, 15% of women reported that they read, heard, or saw messages on the IUD in the 3 months before the survey, 22% on implants, 29% on tubectomy, and 17% on NSV . Women iP≤.01). The increase in method use was higher in nonprogram districts than program districts, except for NSV.Use of LARCs/PMs among CMWRA increased between 2010 and 2013 in both program (from 5.3% to 7.5%) and nonprogram (from 5.0% to 8.9%) districts, but the increase was significantly lower in program than nonprogram districts . Table 5Use of LARCs/PMs increased between 2010 and 2013 in both program and nonprogram districts, but the increase was significantly lower in program districts.The CPR increased by 1.6 percentage points (from 54.2% to 55.8%) in 6 program districts and by 3.5 percentage points (from 58.7% to 62.2%) in 3 nonprogram districts. This means that most of the increase in the CPR was due to an increase in use of LARCs/PMs in both areas. P = .14). Thus, we find that the program did not have any significant effect on increasing the probability of CMWRA using LARCs/PMs.As noted previously, MH program districts were predominantly located in the eastern region of Bangladesh which tends to have weaker health systems and more conservative values. To explore the role of health system and regional context on our findings, The primary objective of this evaluation study was to estimate the impact of the Mayer Hashi program on use of LARCs and PMs in the program areas. Additionally, we explored descriptively the intermediate outcomes through which the program aimed to influence use of LARCs and PMs to interpret the findings of the impact analysis. Our findings show that the coverage of service provider training was higher in program than nonprogram districts, but higher training coverage did not necessarily translate into better provider knowledge or reported practice. Service providers in program districts were more aware of policy changes or of new policies than providers in nonprogram districts, but reported practices hardly differed between the 2 types of districts. BCC materials on LARCs and PMs were more commonly found in facilities in program districts than in nonprogram districts, but CMWRA were more likely to recall seeing, hearing, or reading messages on LARCs and PMs in nonprogram districts. The use of LARCs/PMs increased between 2010 and 2013 in both types of districts, but the rate of change was not greater in the program than the nonprogram districts.,upazila (subdistrict) family planning manager who supervises family planning outreach activities, was higher in the program than nonprogram districts.One reason suggested for the underutilization of LARCs/PMs in many low- and middle-income countries is that these methods are more challenging for the health system to deliver than short-acting methods.The lack of impact of the Mayer Hashi interventions on LARC/PM use at the population level could be related to structural constraints associated with program/service readiness.The government monitoring and supervision system is also weak. The ongoing monitoring and supervision of the trained providers was the responsibility of the government of Bangladesh and not in the scope of the Mayer Hashi program, which resulted in weaknesses in support for translation of knowledge and skills acquired in training into behavior change. The providers did not receive any mentoring or supportive supervision, a crucial element of performance improvement. Moreover, LARC/PM service delivery requires carefully designed activities to deal with quality of care, clients’ conservative outlook in the program districts, and many other challenges. The program districts, with poor program readiness and other problems, had an increase in LARC/PM use of 2 percentage points, compared with 4 percentage points in the nonprogram districts. This increase of 2 percentage points is considerable in view of all the challenges in the program districts. CMWRA in program districts reported less contact with the health system than women in nonprogram districts. Family planning workers’ home visits and visits by women to heath facilities for family planning or other care were both higher in the nonprogram districts.Because of the lower desire for fertility limitation and the weaker health systems in the eastern region of Bangladesh, it may be more appropriate to focus on increasing use of short-acting methods in the immediate future.Some interventions were undertaken at the policy level to influence the enabling environment. In particular, policy-level work was successful in expanding provision of LARCs and PMs to include the Directorate General of Health Services and private/NGO providers, and the project began training these providers too. These larger system changes will likely take time to affect the health system environment substantially, however.Because of the generally lower desire for fertility limitation and weaker health systems in the eastern region where the Mayer Hashi districts were largely located, it may be more appropriate to focus on increasing use of short-acting methods in the immediate future. In contrast, the western region has an environment that is likely to be more conducive to LARC/PM promotion because of the higher desire for fertility limitation and higher use of contraception there, and the region’s stronger family planning program infrastructure.The MH team routinely examined quarterly trends in LARC/PM acceptance in the MH districts. These analyses of routine service statistics indicated that LARC/PM use was increasing and that the project was exceeding its objectives.There is a relatively long series of intermediate steps from the project interventions to the outcome of increased LARC/PM use at the population level. The midterm evaluation commissioned by USAID identified some limitations in intermediate steps  from key informant interviews and site visits. The evaluation noted that providers who were trained in postpartum IUD insertion had little opportunity to apply those skills because postpartum women were not strongly motivated to accept IUDs.,This article reports on an evaluation of a program operating at scale under real-world conditions. Such evaluations face a number of design and implementation challenges that require pragmatic and creative approaches.We did not have baseline data on provider knowledge and behavior or on women’s knowledge of and attitudes toward LARCs and PMs. Therefore, our analysis of the intermediate outcomes through which the program aimed to influence use of LARCs and PMs is limited to a comparison between program and nonprogram districts at endline only and is therefore more descriptive. It is possible that provider knowledge and practice were weaker in program than in nonprogram districts at baseline, and that the interventions brought the providers in the program districts up to the level of those in nonprogram districts. However, the baseline use of LARCs/PMs was the same in program and nonprogram areas, so it does not appear that any baseline differences in provider knowledge and practice were associated with a difference in use of LARCs/PMs. Therefore, while we might be missing some effects of training on the intermediate step of provider knowledge and practice, it is unlikely that this limitation explains the lack of effect of the interventions on LARC/PM use.The DID estimation strategy to evaluate the program effect on LARC/PM use was the strongest evaluation design available to us. The DID model rests on the assumption that the change observed in the nonprogram districts is a proxy for the change that would have been observed in the program districts in the absence of the interventions. It is not possible to test this assumption directly, although trends in LARC/PM use appear to have been similar in program and nonprogram districts between 2004 and 2010. This is a limitation of DID analyses in general, however.,Use of LARCs and PMs is increasing slowly in Bangladesh, but the increase is greater in districts or regions where the health system is stronger or the desire for family limitation is stronger. Provider vacancy is universally a crucial factor in efforts to improve health services. The availability of appropriate, high-quality providers for LARCs and PMs has been a challenge in Bangladesh for many years in spite of its substantial progress in health care.,An immediate solution to these challenges is unlikely; therefore, Bangladesh should seek alternative and/or supplemental avenues to provide high-quality LARC/PM services. The privatization of LARC and PM services is one option. The Bangladesh government has opened up LARC/PM services to the private sector recently, and combined efforts of the public-, private-, and NGO sectors should be encouraged, especially in view of the recent growth of the private sector for family planning and other reproductive and child health services.


Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment.We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006–2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment  to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression.There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty , there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN , general surgery , internal medicine , and finally, emergency medicine . Of those responding, 38.4% stated such questions made them less likely to rank the program.Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly. The residency interview process creates much anxiety among senior medical students and residency programs each year. The National Resident Matching Program (NRMP) was created in 1952, to help medical students navigate the process and in part mitigate some of the high-pressure tactics of recruiting that were common in that era. Prior to the NRMP, students often were forced to accept appointments as early as the second year of medical school, even prior to any clinical clerkship.4The current literature suggests that both applicants and residency program directors feel that the application process retains inherent dishonesty. Applicants feel uncomfortable and forced to lie about ranking a program while program directors distrust the information they receive from applicants.We surveyed applicants in the 2006–2007 NRMP in five specialties: emergency medicine, internal medicine, general surgery, obstetrics and gynecology (OBGYN), and orthopedic Surgery on various topics as part of a larger project understanding the residency match milieu.The survey instrument was developed in conjunction with a survey design and protocol specialist at UC Berkeley, School of Public Health. The instrument was piloted among residents (a population close in age and experience to our survey population) and faculty for clarity. The pilot and revisions were in accordance with survey design methodology to maximize validity and reliability.www.surveymonkey.com) and all data remained anonymous with a custom ID generated by ERAS and securely encrypted. Study participants were informed on the survey that the information would remain confidential and only study investigators would have access to their anonymous responses. The electronic message was sent twice (one week apart) after residency rank lists were submitted by applicants and programs but before match results were known. All data analyzed were received within two weeks of the initial email. We discarded data received after match results were public.We included both categorical and preliminary applicants for medicine and surgery specialties; however, we collapsed them into their respective specialty for analysis. Study participants were recruited through an electronic mail message sent by the Electronic Residency Application Service (ERAS) in February of 2007. ERAS is a centralized service that transmits medical student residency applications to residency program directors. ERAS referred the residency applicants to a public instrument for study enrollment. The instrument was located on a public website . We calculated frequencies for all survey variables. The primary outcome was solicitation of commitment by a residency program. Commitment request was stratified by the covariate variables. We calculated differences using chi square analysis for categorical variables and t-test for univariate variables. Statistical analysis was completed using both STATA  and SAS .The Institutional Review Board at our home institution approved the instrument and protocol prior to distribution.Questionnaires were sent to 11,983 applicants and 7,028 replied, resulting in a response rate of 58.6%. Overall, 1,380 or 19.6% of applicants (1380/7028) were asked for a commitment  to rank a program highly. Of those who were asked for a commitment, 540 (39.1%) were asked by one program, 333 (24.1%) by two programs, 187 (13.6%) by three, and 112 (8.1%) by four.Among those respondents who indicated their specialty, orthopedics had the highest overall prevalence at 28.9% (372/474) followed by OBGYN , general surgery , internal medicine , and finally, emergency medicine  .Women were more likely to be asked for a commitment. Almost 23% of women  were asked for a commitment while only 18.2% of men (612/3358) were solicited. This difference was shown to be statistically significant with p<0.001. There was no statistically significant difference in proportion of applicants asked for commitment by age, race/ethnicity, marital status, number of children, and religious status.Of the applicants asked to provide a commitment, 1,030 (74.6%) felt either uncomfortable or very uncomfortable sharing this information . FurtherAmong those applicants asked for a commitment, OBGYN applicants felt the most uncomfortable – 142 of 179 (79.3%) respondents were either somewhat or very uncomfortable sharing this information. This was followed by orthopedics at 75.5% (102/135), emergency medicine 75% (105/140), internal medicine 74.5% (445/597), and surgery 70.7% (133/188) .When asked if questions of commitment affected their ultimate rank lists, emergency medicine residents stated it would affect them the most. Almost half of emergency medicine residents were less likely to rank a program based on this question . Lower percentages were given by applicants in OBGYN , internal medicine , orthopedics , and surgery  (Table 5).Results of our national survey suggest that residency applicants routinely experience questions of residency commitment. Almost one in five respondents in the surveyed specialties reported facing a direct question asking for a commitment. This is a direct and clear material breach of the MPA set forth by the NRMP. In addition, almost three-quarters of those who received such a question felt somewhat or very uncomfortable answering this question. Applicants also said the effect on their decision to rank a program soliciting a commitment was significant. Over 38% of applicants who received such a request were less likely to rank the program on their rank lists. This information is powerful for residency programs. Knowing that questions on commitment directly lower a program on the applicant’s rank list should encourage program directors to educate their interviewers that such questions are not only a direct violation but can significantly jeopardize recruiting efforts. Program directors could both improve compliance with the MPA and improve their recruiting and retention of highly qualified applicants by taking this information into account.These results may be surprising to medical educators and program directors, but they are not to applicants. Medical student applicants share stories of commitment solicitation during the actual interview as well as post-interview communication between applicants and programs.For program directors, a response might be one of clearly outlining to all interviewers what can and cannot be asked during a residency interview. It is imperative that residency programs have clearly stated policies about post-match contact. One such stance, which might limit the ‘gamesmanship,’ would be that such contact is ‘voluntary and has no bearing on an applicant’s standing.’ It is only once the process becomes more transparent that applicants’ anxiety and unethical behavior on the part of the residency programs can be lessened. The inherent mistrust on both sides has eroded the application process and created an atmosphere where code words and innuendos often lead to disappointment from both sides on Match Day.This study shares limitations inherent in survey-based research projects. Completed potentially months after the interviews, the results were dependent on the memory of respondents. All responses were returned within 2 weeks of electronic mail and therefore, prior to match results being announced.The response rate was 58.6%. The percentage of illegal interview experiences may be artificially increased as respondents who identified illegal or inappropriate questions may be more inclined to return the survey as a means of catharsis.Survey results were based on the applicants’ interpretation of questions rather than actual questions asked. While there is no way to monitor all interviews for commitment questions, asking applicants immediately after the interview season offers a reasonable alternative. This would allow for the applicant to reflect on all of their interviews but may limit exact recall of specific questions.In addition, recall bias may also play a role. An applicant may recall a request for commitment because they remember an uncomfortable interview better than a comfortable experience. This systematic bias might artificially increase the rate of these types of questions.Almost one in five respondents among the five major specialties surveyed were asked to commit to a program during the 2006–2007 residency interview season, often by multiple programs. This is an explicit violation of NRMP match rules. Program directors must realize such questions have a negative impact on their matched applicant list, a finding that may influence them to change their interview practices. Graduate medical education should consider educational outreach and information to both applicants and programs regarding acceptable interview procedures and guidelines. A formal “Interview Code of Conduct” might address a potentially flawed process for selecting future practitioners and medical educators.


Background/Objectives. This pilot study evaluated the impact of a peer support program on improving multiple sclerosis (MS) related psychological functions  and enhancing quality of life. Methodology. Participants (n = 33) were recruited prospectively and received an 8-week group face-to-face peer support program. Assessments were at baseline (T1), 6 weeks after program (T2), and 12 months after program (T3), using validated questionnaires: Depression Anxiety Stress Scale (DASS), McGill Quality of Life (MQOL), and Brief COPE. Results. Participants' mean age was 52; the majority were female (64%) and married (64%). Median time since MS diagnosis was 16 years. At T2, participants reported improved psychological functioning  0.29, 0.28, and 0.32, resp.) and quality of life  and were less likely to use “self-blame” as a coping mechanism . At T3, the positive improvements in stress  and quality of life were maintained . There were no adverse effects reported.  Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system and one of the most common causes of neurological disability in persons of working age . PersonsThe burden of disease and economic impact of MS upon patients, their caregivers, and on society is substantial. Being diagnosed with a chronic illness, especially one that has no cure or any medical intervention that might stop its progression, is a profound and life-altering event that can result in alterations in physical functioning, loss of control over life circumstances, and subsequent emotional strain . The focPeer support as a resource has been proposed as an effective means for coping with stressful life experiences and for gaining information and support from others who share a common factor, such as a chronic illness , 5. Mutun = 43 articles) incorporating 5 models of peer support  concluded that there was high satisfaction levels with peer support programs, but the evidence of psychosocial benefit was mixed. Peer mentoring for people with spinal cord injury in a pre-post study (n = 37) appeared to enhance self-efficacy beliefs and prevent medical complications [n = 7) studying the effectiveness of a six-week face-to-face peer support program in motor neurone disease suggested a trend towards reduced psychological distress [Despite the popularity of peer support programs, there is limited published data on the effectiveness of peer support programs in chronic disease. A systematic review of peer-support programs for people with cancer   and was approved by the Melbourne Health Human Research and Ethics Committee (HREC 2008.209).A community-based MS group of 101 patients was identified from the RMH MS database (referred to as the RMH from clinics across Victoria). Inclusion criteria included confirmed diagnosis of MS based on McDonald's criteria  as assesAll eligible participants were contacted by mail and invited to participate in the study. Those who replied affirmatively were contacted by telephone by the primary researcher who explained the study further. Once signed consent was obtained, participants were informed that it could take up to 3 months before they receive a peer support program due to operational issues (space and the limited availability of facilitators) resulting in difficulties with accommodating all patients concurrently.This study used a repeat measures design, and each participant was prospectively assessed (face-to-face interviews) at baseline and at 6 weeks and 12 months following completion of the peer support program. Two independent researchers received three half-day training sessions in cognitive and functional ability assessments and completed all assessments. They were observed in a pilot process to confirm achievement of an acceptable standard level. They were not in contact with the treating teams nor shared information about participants or assessments. They received separate and different clinical record forms at each interview and did not have access to medical records, program facilitators, or previous assessments.Data collected included demographic information, measures of depression, anxiety, and stress, QOL, and coping using standardized instruments (see measures). Assessors did not prompt participants but provided rest breaks and assistance to those who have difficulty with completing the questionnaires. All assessments were secured till the time of entry into the database.All participants received an 8-week group face-to-face community-based peer support program called the LifeMoves program. The LifeMoves program is designed to augment a traditional rehabilitation approach   by targeThe senior facilitator facilitated in all groups and provided supervision to other peer facilitators during each session to ensure that facilitation standards were met. All facilitators were volunteers with a neurological condition (either stroke or MS) who had attended a previous LifeMoves program personally. Those who appeared to have good facilitation skills would be selected and encouraged by their facilitators to undergo additional training to become a facilitator themselves. Training involved a 3-hour weekly training program for four weeks, where training was structured to orient the peer to program objectives and the promotion of skills that enable the use of experiential knowledge and the peer's unique understanding of the target population. The training program included information on basic fire safety, roles, boundaries and the importance of confidentiality, basic group rules, how to get the first meeting started, peer relationships and peer support skills, values, beliefs, and attitudes, valuing diversity, communication skills such as active listening, questioning, and summarising, self-care, and integrating experiences and suggestions for resolving questions that may arise during group meetings. All peer facilitators had facilitated in at least one previous LifeMoves program whilst the senior facilitator had been facilitating in such programs for 6 years and was also the coordinator of the program. A priori compliance for session attendance was set at 60% and documented by the facilitator. Participants who attended a minimum of five sessions were classed as “completers.” Adverse effects of the program were recorded and a dedicated phone number was made available to all study participants five working days a week to address any questions or concerns.At the time of recruitment, baseline assessments were completed, which included sociodemographic  and clinical information . The ICF was used as a conceptual basis for choice of outcome measurement. Outcomes were divided into those that described the impact of disease on body structure and function , activity and participation (QOL), and contextual factors (coping mechanisms).Depression Anxiety Stress Scale (DASS) . It is a 21-item instrument, consisting of three 7-item self-report scales that have been designed to measure the negative emotional states of depression, anxiety, and stress. Participants rate the extent to which they experienced each state over the past week on a 4-point Likert rating scale. It has acceptable to excellent internal consistency and concurrent validity. Clinical range, based on normative data, is defined as scores of 16.57 or above for stress, 12.75 or above for anxiety, and 9.26 or above for depression.McGill Quality of Life Questionnaire (MQOL) . It is a valid and reliable 16-item questionnaire, with each question rated from 0  to 10 (extremely). There are five domains, two of which are health related , and three are nonhealth related . For each domain, the score is the mean of the values of the relative items. A total rate is obtained as the mean value of the scores of the five domains. In addition, the participant is asked to indicate his/her self-perceived QOL in the past two days in a single-item scale (MQOL-SIS), rated from 0 (very bad) to 10 (excellent).Brief COPE . This is coping inventory of 14 subscales . Each subscale has two items. It has good reliability and validity and is a brief measure that assesses several responses known to be relevant to effective and ineffective coping.n, %) were conducted on patient demographics and disease characteristics data. The following analyses were conducted on DASS (primary outcome), MQOL, and Brief COPE: given the skewed distribution, analyses were conducted using nonparametric tests (Wilcoxon signed rank tests), comparing the pre- and posttreatment scores, with the baseline score. Effect size statistics (r) were calculated and assessed against Cohen's criteria  [A series of descriptive analyses ( effect) . Statistn = 33) are shown in n = 20, 61%) had also previously received multidisciplinary rehabilitation. A third of participants (n = 10) reported high levels of depression (DASS). Levels of anxiety (DASS) were similarly high with a third reporting moderate-to-severe anxiety.The sociodemographic and disease characteristics of study participants . A further participant was lost to followup at 6 weeks (deceased) and four more at 12-month followup  . There wShort-Term Subjective Outcomes . At the 6-week followup after the end of the 8-week intervention, participants showed statistically significant improvement in psychological functioning . As for QOL, MQOL SIS  was significantly improved at T2  and based on the Brief COPE, participants were less likely to use self-blame as a coping mechanism at T2 . Overall, the participants tended to prefer problem-focused coping strategies to emotion-focused coping strategies. Longer-Term Subjective Outcomes . At the 12-month followup, improvements in stress, as measured by DASS, remained statistically significant , but there were no differences in the other self-reported psychological functioning domains of DASS (anxiety and depression). Improvements in the overall QOL (MQOL SIS) also remained significant . No changes were seen in coping mechanisms based on the Brief COPE.To our knowledge, this is the first positive report of short- and longer-term effectiveness of peer support in the MS population in an Australian community cohort. The findings from this prospective pilot study suggest that peer support programs for MS patients targeting specific behaviour, coping strategies, and self-management techniques improved psychological functioning and QOL. The magnitude of improvement in psychological function peaked at the 6-week post treatment period and was in part maintained at the 12-month review. The participants in this study were similar to those in other studies in terms of age, gender, disease severity, and treatment , 14.The positive effects of peer support programs on psychological function are consistent with reports in other neurological and cancer groups , 12, 19,Other literature has suggested that peer support can have beneficial effects on participants who value camaraderie and comparison . An impoOutcome measurement in MS/peer support research is challenging and varies in different studies , 21. QuaThis study has some potential limitations. Firstly, this is a longitudinal observational study (no control group), which limits the ability to draw casual relationships between the support program and outcomes. However, it was ethically difficult to withhold the intervention since peer support is generally seen as a positive intervention by patients. Secondly, participants were a selective cohort listed on a database (voluntary participation) held at single tertiary institution, which limits generalisability of findings. Specifically, all participants lived within a 30 km radius due to travel requirements, limiting generalisability to geographically isolated patients . Thirdly, participants in this study were complex in terms of disease severity, symptoms, and psychosocial situations . The likelihood of progressive functional decline, the difficulty in psychological adjustment due to constantly changing disability, and uncertain prognosis created challenges that in turn influenced the type and intensity of the intervention provided. This study, however, neither attempt to control these factors nor control for group effects (such as if a group interacted more positively than another group). The facilitators worked with each participant within a group setting to determine topics for discussion and provide an appropriately tailored peer support program. Lastly, compliance and attendance in sessions were challenging. Because of their MS, a number of patients could not drive resulting in a high reliance on others for transport and hence a relatively high level of attrition. However, most patients who started the program attended a minimum of 60% of the sessions. This suggests that alternate models of peer support that could complement, extend, or even replace face-to-face programs should be further explored. This study was conducted in real-life setting with limited resources and funding. A more rigorous study with a control group, larger MS cohorts in different settings, and single-group-based social support program  would be helpful to establish the generalisability and validity of these results.Multiple sclerosis has profound impact on function and participation. Physical and psychological morbidity in MS is well documented and the effectiveness of multidisciplinary rehabilitation is well supported . However


Residential weight-loss programs aim to help persons with obesity lose weight and maintain a long-term healthy lifestyle. Knowledge is needed on the different actors’ perceptions and experiences from such programs. The aim of this study was to describe how personnel argued for and perceived a residential weight-loss program, to investigate how the participants experienced the program, and to contrast these perspectives.This qualitative study took place in an 18-week residential weight-loss program. Exercise, diet, and personal development were the main components in the program. Data was collected through participant observation and individual and focus group interviews with participants and personnel.Program personnel characterized persons with obesity in specific terms, and these formed the basis of the educational aims, teaching principles, and content of the program. According to personnel, persons with obesity typically had problems acknowledging their own resources, lived unstructured lives, had a distorted relationship to food, experienced a range of social problems and featured a lack of personal insight. Program participants reported enthusiasm about their experiences of exercise and appreciated measures of success with the exercise program. They had, however, very different experiences regarding the usefulness and appropriateness of the parts of the program focused on social and personal development. Some felt that weight loss required an engagement with personal development while others viewed it as unnecessary and inappropriate.The reliance in personnel accounts on particular characteristics of persons with obesity as a rationale for the program might lead to stigmatizing and stereotyping. Program activities focused on social and personal development need to be better understood by participants if they are to be viewed as helpful. To achieve this personnel must carefully consider how these parts of the program are communicated and conducted. Obesity is a growing problem in the Western world Although weight-loss surgery is increasingly used, the combination of exercise, diet, and behaviour therapy in comprehensive weight-loss programs seems to be the most commonly available intervention Soderlund and colleagues Weight-loss programs thus aim to help the participants modify their health behaviors. The main argument for residential programs is to fortify a sustainable long-term lifestyle change. Residential weight-loss programs constitute a rather new approach A residential program differs from out-patient intervention by length and intensity, and in that the participants are removed from their everyday lives. A residential program also offers more time for communication between participants and personnel Very little research has explored different actors’ perceptions of and experiences from weight-loss programs. It has been emphasized that to achieve good results different stakeholders in an intervention should share an understanding of how change is supposed to be implemented and sustained The Regional Ethics Committee for Research in Medicine in Central Norway approved of the study. All participants received oral and written information about the study and signed a written consent form. None of the authors have any contact with or interest in the Danish weight-loss camp outside this research project.This was a qualitative study consisting of on-site participant observation, in-depth semi-structured individual interviews, and focus group interviews. A combination of methods was chosen to ensure data triangulation. Observation was chosen to provide data on real life interaction between participants and personnel and to gain insight into the participants’ immediate reactions to the program. Focus group interviews were conducted to explore the interaction and discussions between participants regarding their experiences and views of the program. Individual interviews were also employed to explore in more depth the ways in which personnel articulated their arguments for and experiences of providing the program, and to delve deeper into the individual experiences of a selected subset of participants.The study formed part of a Norwegian clinical investigation on the effectiveness of different interventions (weight-loss program versus surgery) for persons with obesity. The study was registered in Clinicaltrials.gov with registration number NCT00239850. An effect study from this program is published elsewhere The study took place at a Danish residential weight-loss centre (Ebeltoft kurcenter), which offers an 18-week on-site program. A total of 80 participants were at the centre at the time of the data collection. This study focused on 30 participants who were referred to this program due to taking part in a Norwegian study on the effect of different weight-loss approaches Most of the activities at the centre were organized and conducted in groups. The program consisted of group-based intensive exercise, diet , and an educational program. Structured group exercise and educational sessions took place from Monday to Friday every week. Exercise was compulsory three times per day. Typical exercise activities were badminton, ball games, aerobics, and swimming. In addition, participants were encouraged to be physically active on their own. Program participants were advised to start on an individually suitable exercise level and to focus on the activities that they liked the most.Participants lived together in groups in small houses with sleeping and cooking facilities, and they cooked their own dinners with provided groceries. Breakfast, lunch, and in-between meals were served in a buffet. The different types of food were marked with labels of energy content. The diet contained 55–60% carbohydrates, 15% protein, and less than 30% fat. At the beginning of the program, each participant learned to calculate their energy intake by counting calories and weighing the food. If necessary, diet plans were adjusted individually according to weight measurements during the program.The educational program comprised lessons about nutrition, monitoring of food intake and instruction in behavioral techniques from cognitive therapy. The personal development component included a minimum of two individual conversations with one of the psychotherapists, motivational meetings for all participants, and “family meetings”  to discuss and resolve problems regarding the living arrangements. In addition, mandatory group therapy classes in personal development were held one hour per week. Classes in personal development were led by a psychotherapist. The goals of this component of the program were to gain insight into personal problems and to consider how these problems may be associated with the obesity. The overall aim of the personal development component was to help the participants live a mentally healthy life as an important part of the process of lifestyle change.2 or a BMI over 35 kg/m2 including comorbidities. There were no additional inclusion criteria for the qualitative study.The participants in this qualitative study also participated in a clinical study investigating the effect of different types of weight-loss interventions, including a stay at the residential weight-loss centre The personnel were recruited among the staff at the centre. Since an important aim was to explore the rationale for the choice of program content and structure, key personnel with responsibility for providing the program were recruited to individual interviews.st, 2nd, and 14th weeks of the 18-week program. These weeks were chosen to ensure that the initial expectations and experiences (the first two weeks), as well as the experiences from most of the stay (week 14), were captured. During this period, thematic saturation was reached, and no new experiences, discussions, or perceptions emerged in the last interviews or observation.For the purpose of achieving immersion in the field of inquiry, the first author (UD) took part in the program over the three week period and observed and interviewed personnel and participants. A data collection period was predefined to two periods totaling to three weeks and was conducted during the 1The first author (UD) participated in all activities as an ordinary participant during the three weeks of data collection, that is, she took part in exercise, classes, and social life. The participants were informed before arrival at the weight-loss camp that the researcher would be present during some of the program, and that this was a part of the larger research project. This period of overt participant observation provided an opportunity to observe real life settings and the interaction between personnel and participants. It also provided insights that were used to inform the development of the question guide that was subsequently used in the focus groups and interviews. The observation also involved informal conversations between the researcher and those personnel and participants who did not later participate in interviews. Field notes were written during observation and at the end of every day. Summaries were developed at several points during the three weeks of data collection. Video and audio recording was not used during observation. The field notes were used to record facts about the program and to write reflections during observations and interviews. Field notes were also used as background for focus group interviews and were later compared with the interview transcripts.Those who took part in interviews were asked directly by the first author (UD) and all agreed to participate. A total of 10 Norwegian participants took part in interviews . The age and weight range for these 10 persons were the same as for the total sample. Six personnel participated in individual interviews. All interviews were conducted by the first author (UD).Semi-structured interview guides were employed during focus groups and individual interviews. The guides were used as a memo list to ensure that all the topics were covered in all interviews. The interviewer introduced themes from the interview guide if the participants did not spontaneously talk about them. The participants were also free to talk about issues and topics outside the guide. The main opening question in all interviews was “What are your experiences with taking part in/providing this program?” Additionally, the personnel were asked to describe the content of the program and the rationale for it. Other important topics in interviews with personnel were how personnel attitudes might influence the participants, and how they motivated persons with obesity to change their life-styles.Each interview lasted from 45 to 90 minutes and was audio taped. All interviews were subsequently transcribed verbatim and de-identified. Redundant words and pauses were removed, and local dialect was changed to written Norwegian.st and the 14th weeks of the program. The topics discussed in the first interview were immediate perceptions and experiences with the program: overall setting, exercise, living arrangements, and food. The second interviews focused more on the positive and negative experiences that participants reported of the program.A strategic sample of eight of the participants, three men and five women, were recruited to focus group interviews. The sampling strategy aimed to achieve some variation in experiences, BMI, age and gender. Focus group participants were interviewed two times, in the 1Two female participants were interviewed individually in depth in the first and second weeks of the program. The interviews were conducted to elaborate on specific issues discussed in the focus group interviews. The two participants were selected based on observations of their role in the group of Norwegian participants. During interactions and discussions they had expressed clear views and had provided rich descriptions that offered the potential for meaningful further exploration of key topics in a one-on-one interview. Topics discussed in these interviews included how to make sustainable lifestyle changes, overall approach to weight-loss, and collaboration between the personnel.Six personnel  took part in individual in-depth interviews. These were considered to be key personnel; the director, the administrative executive, and the leaders of the main areas diet, exercise and personal development. The personnel were selected because they strongly influenced the content and form of the program. Five personnel were interviewed during the first and second weeks. In week 14, three of these were interviewed a second time. In addition, one substitute personnel member was added in week 14 since one of the members had a leave of absence. The second interviews were done to elaborate on the topics discussed in the first interview, and to discuss personnel experiences with the current class of participants.Interview transcripts and fields notes were analysed together. The focus of the analysis was to explore the connections between the personnel rationale for the program and the participant experiences of the program. The analysis was inductive and thematically based. The interview transcripts and field notes were read and the main themes generated. The first and fourth author (UD and AS) read all transcripts and made separate analyses. These analyses were subsequently discussed in a group including the third author (BK), and finally with the second author to get a different point of view and to look for alternative interpretations. It was observed that the personnel articulated several recurrent descriptions or characterisations of people with obesity. These perceptions were described by personnel as forming the basis of the rationale for the program, and so perceptions were employed as a coding structure to categorise and interpret the findings. The validity of the results was cross-checked by re-reading the interviews. To illustrate the main themes the most illustrative and comprehensive quotes were chosen. Quotes were translated from Norwegian to English by the first (UD) and second author (MR) and controlled by the fourth author (AS). Quotes from participants used in the result presentation are identified by interview number and gender. Quotes from personnel are not identified to ensure anonymity.A total of 10 participants and six personnel participated in interviews. In addition, observation included 30 participants and approximately 10 personnel.During the analysis of data from interviews and observations, it became clear that there were important differences between how the personnel and participants experienced and perceived the purpose and activities of the weight-loss program. The personnel were very consistent in their perceptions, while the participant experiences and reactions were more diverse. Personnel described very similar rationales for the aims of the program, and for the content and teaching principles used to achieve these aims. Participants had, on the other hand, experiences that ranged from joy and excitement to feeling the program was a struggle and waste of time.During the analysis, the personnel rationale for the program was categorised into five recurrent themes in their characterization of people with obesity: lack of acknowledgement of resources, lack of structure, a distorted relationship to food, social problems, and lack of personal insight. The program was seen to be intended to change these five characterisations, and the program content and teaching principles were selected deliberately in order to achieve these changes. However, interviews and observation both revealed that participants viewed the program content very differently to the personnel. All participants were very enthusiastic about the exercise program and complied with the strict structures and routines involved in the exercise and diet program. The participants were, however, divided on the usefulness of the parts of the program concerning social and personal development. Division was particularly strong on the usefulness and necessity of the personal development classes.In the following section, the five characterisations of participants that personnel believed had to be changed in order for participants to achieve and maintain weight-loss, are discussed in more detail. Quotes that describe participant experiences and reactions to the program content are woven into these sections in order to be contrasted with personnel views. Quotes from personnel and participants are used to illustrate and support the findings.The first characterisation ascribed to participants by personnel was the perceived lack of acknowledgement of their own resources in being physically active and sticking to a diet. This was said to be due mainly to low self-efficacy beliefs and low self-confidence. Personnel emphasised the importance of strengthening participants’ self-confidence by ensuring experiences of success in their efforts to exercise and eat properly during the program. Personnel thus highlighted the importance of compulsory and regular exercise and of setting achievable goals.The participants shall first and foremost get confirmation that they can do a hundred times more than they believe they can. […] It is about transferring the joy of success from one situation to another. (Personnel).Participants confirmed this practice by reporting that even small efforts were praised regularly by personnel, and that personnel also frequently encouraged participants individually during group exercise. This was also confirmed during observation. In the interviews, participants confirmed that personnel supported and respected them. This attitude was described as strengthening their motivation, self-confidence, and sense of self-worth.That is how they [the personnel] build our self-confidence. We are all of a sudden humans again and not just the chubby clown. .When it came to the exercise part of the program participants confirmed personnel claims that success experiences encouraged participants to keep working towards weight-loss. The positive experience of exercise was highlighted both in the observation and interviews from the beginning, and was in fact the most striking finding of the research. The participants were enthusiastic about learning and managing new activities, or activities that they had not engaged in for years or had never tried before. They were also very enthusiastic about improving their physical condition and achieving new goals.My first victory […] was that I managed to ride a bike for 15 kilometres. I think I walked on air for four days after that experience. .th week of the program, participants unanimously agreed that exercise was fun, increased their energy, and instilled in them a desire to be active in the future.This attitude towards exercise remained stable through the program. In the 14The second characterisation that personnel attributed to persons with obesity was that they generally lead unstructured lives. Personnel reported a belief that many things in obese persons’ lives were seen to happen by chance, such as when and what to eat, and what activities to engage in.Our experience is that many obese people are incredibly unstructured and live extremely unstructured lives. Such as keeping appointments and being stringent and sharp in the things you do. (Personnel).According to the personnel, the program schedule had to be very strict. They described that their strictness was important to provide the participants with a daily structure that they could then seek to maintain at home.And those who succeed, those we know maintain their weight-loss… they are those who have a structured life afterwards. Those who eat at fixed times and who get out of bed at approximately the same time each day, and those who know what they want with themselves. (Personnel).This strict structure was evident across all program activities. All participants had to be present at the morning meetings, group exercises, and at six meals every day (at fixed hours). Other activities, like teaching classes and the weekly weighting, were also scheduled. According to the participants, adhering to the structure was an effort they felt they had to do to comply with the program. Although there were several who compared the program to military training and being back at school with very little freedom, both observation and interviews showed that the participants all agreed that a strict schedule was appropriate to initiate lifestyle change.You are supposed to learn some things while you are here. It is like school… subjects are mandatory. And when you know that you have to be ticked off on a list to be registered [by an employee] you show up. There’s no alternative. And if it hadn’t been like that the activity would not have been very great. If you are not there at eight o’clock in the morning they call you and ask: “Where are you?” .The third characterisation articulated by personnel proposed that people with obesity have a distorted relationship to food.Those with a really high BMI have a behaviour that fully can be compared with an alcoholic or a drug addict. They have no control over food. They always have their form of drug lying around in small storages on secret places so they always know that they are close to the food and they become insecure if it is not in the house. (Personnel)According to the personnel, most persons with obesity were addicted to food and would have to live with an eating disorder for the rest of their lives. The program was designed to give the participants the practical experience of eating like a standard weight person and, through that, to change their relationship towards food.I tell the participants that they all have a normal weight person inside. They shall hold on to this person and from now on leave the decisions to the standard weight person. […] This is not a treatment; it is four months of practice in living as a standard weight person. (Personnel).In the beginning of the program, it was observed that participants talked a lot about how to manage the new diet chart, frequency of eating and the amount of food, and the result of their latest weighing. Although there was a consensus among participants about the necessity of managing new eating habits, the experience of enthusiasm and success were less apparent in discussions about diet than about the exercise program. The participants expressed the belief that changing eating habits and adhering to the diet regime was laborious. At the end of the program this was, however, a theme the participants talked less about. When asked, the participants said that following a diet plan had become an automatic behaviour.In the beginning I was strictly adhering to the written diet chart, but now I have noticed that I am composing the diet based on my energy target. .The fourth characterisation of people with obesity highlighted by personnel was a belief that they often have poor social skills. Personnel expressed that persons with obesity often had felt like an outsider and therefore had adopted unfavourable approaches to handle this. Examples of approaches mentioned by the personnel were taking on the comedian role, social isolation, avoiding conflict, and not recognizing or acknowledging their own needs. The housing structure during the program, in which people share apartments and house work and cooking takes place in groups, was deliberately chosen to give the participants practice in socializing with other people.Quite a few experience social isolation. So groups are a way to get out of isolation and learn to associate with others. (Personnel).The main approach to managing conflict between participants was in line with this focus on social training. Personnel facilitated problem-solving techniques by asking participants what they believed they could do themselves. According to the personnel, this was intended to assist participants with focusing their skills and abilities.If two persons share a flat and have different habits… If one of them stays up at night to watch TV and the other person wants to sleep but can’t. Then one is forced to say: “Do you know what, I need to sleep. Could you be so kind as to turn off the TV?” […] Then there are two people learning. One is the person who gets the message and the other is the person giving the message. They both learn how it is to enter a conflict. (Personnel).The participants had different experiences with the social development component of the program. Some participants described that living closely together was a very positive experience and that they had made friends for life. Others described it as challenging and difficult, and said that they hardly talked with the other participants in their group.They have strong emphasis on the mental part, and it is very important… and I feel that I have come a long way […] and at the same time… I don’t want to participate so much because… well, there is a lot of gossip here. And if you open up with sensitive stuff you cannot be sure whether it is on every corner afterwards. So I have… I told them [the personnel] that this was my decision, and it was fine. This part of the program should have been different. I don’t think all will benefit from it. .The fifth characterisation described by personnel asserted that persons with obesity lack insight into their personal problems. Personnel expressed the belief that lifestyle change require a development in personal insight, and that participants have to reflect on their own behaviour to achieve this. Therefore, the program included classes in personal development. During these group classes, participants were urged to identify underlying factors that may have influenced their obesity problem, such as family relations, working conditions, or economic contexts. The personnel believed such personal development was crucial to enable participants to implement and maintain lifestyle changes.It is important that they become aware of what in their life makes a difference in being obese or not. They have some enemies out there and some accomplices […] Not only persons… it might also be their work. But to get control over them you first have to be conscious of what they are. (Personnel).The participants were clearly divided in their perceptions of the usefulness of the personal development program and views on whether personal development classes should be compulsory. Some strongly disagreed, while others shared personnel views about the importance of personal development. Some participants even asked for more individual sessions with the psychotherapists.I think we get tools to gain self-insight and retrieve things we have forgotten… also things that you might not want to touch. […] And suddenly […] you have changed as a person. And you experience things and perceive things quite differently and you get a different outlook in life. .Other participants saw losing weight, not as a matter of personal development and psychological factors, but rather as a matter of changing bad habits - to eat less and exercise more. These participants were more likely to avoid or refuse to engage in the process of identifying any underlying factors, either by not attending the personal development classes, or by not participating in the discussions during class.It is about the personal [development] part… I cannot benefit from it. I will never open up in that room and talk among the others. I will not do that. .According to the personnel, those who withdrew from classes or discussions were the persons most in need of attending. Personnel expressed the belief that they were prepared for the type of conflicts that arose, e.g., participants not showing up to classes due to feeling alienated from the content. Personnel explanations of this type of reaction drew on their understandings of some of the potential mechanisms underlying obesity, such as having an eating disorder or a lack of self-insight.There are some who do not want to attend our classes. There are some who do anything to avoid them. But they are mandatory. And this is because sometimes you have to hear things more than once before it sticks […]. Those who do not bother to attend the lessons are often those who need it the most. (Personnel).Personnel perceptions of persons with obesity as persons in need of insight and personal development were noticed by the participants. Some of the participants expressed the view that these generalised characterisations were demeaning, and explained that this could make them feel misunderstood and not treated as individuals.…they talk to us like we are all the same. […] As if we are flawed. […] And as if we all have the same problems.” .According to the participants, the best part of the program was the strict and intensive exercise regime, which was overwhelmingly embraced. Here, the participants and personnel also interacted without any noteworthy conflicts. The participants were very enthusiastic, and the major reason for this was in accordance with the personnel rationale for the program: the experience of success. Experiencing success to strengthen self-confidence and self-efficacy is a well-known approach The rationale of the program was explained and justified in personnel accounts by articulating a series of claims about the most common characteristics of persons with obesity. The personnel viewed this population as typically resourceful, even if people with obesity didn’t always find this easy to acknowledge themselves, and also lacking in structure, social skills, and personal insight. It was a clear finding that the stereotyping helped the personnel build a joint understanding among themselves regarding both the objectives of and activities in the program. Stereotypes also seemed to help the personnel to remain focused and firm during the program. There are some similarities between the personnel views and the negative attitudes and stigmas that persons with obesity are likely to experience both in society and among health care professionals Personnel attitudes observed in the present study might be in conflict with the ideal of building a relationship of trust and acceptance According to the personnel in this study, characteristics of persons with obesity were also described as the reasons for being obese, and changing these characteristics was described as a potential way towards a healthier lifestyle. Some studies have shown that persons with obesity agree that determination, commitment, and discipline are necessary to change diet and exercise Most agree that making changes in exercise and diet is essential to losing weight. The idea that personal development is important to achieve and maintain weight-loss is less well recognised or understood. Claiming that a person with obesity has to change internal factors such as self-knowledge and self-acceptance is also a more sensitive topic than claiming that more exercise and healthy food is necessary to lose weight. Yet personnel argued consistently that personal development was especially important to maintaining lifestyle changes long-term. Studies have also confirmed that knowledge about how to eat healthy is not always sufficient to be able to change eating behaviours long-term It could also be important to discuss the criteria of success in weight-loss programs. While successful obesity treatment can be related to absolute weight-loss, another main focus could be to reduce the risk of cardiovascular and metabolic diseases The strength of this study is that it is the first to explore and contrast personnel and participant perspectives in a residential weight-loss program that has been reported to be successful The interviews partially revealed situations that were not observed, and in our judgement, we achieved a good overview of the main picture through quite extensive observation and long interviews. However, this study only collected data from a limited group of participants in this program. Although the personnel confirmed that the participants taking part in this study did not differ substantially from other groups, the results could have been different if a different group was studied.Personnel characterisation of persons with obesity as a rationale for the design and delivery of a weight-loss program could lead to stigmatizing and discrimination, and thereby less adherence to the program. Participants embraced and adapted to the exercise part of the program. However, the personnel claim that social training and personal development is necessary to lose weight and to maintain weight was not supported by all participants. The social and personal development part of the program is therefore likely to be the most challenging and controversial part of residential weight-loss programs.


Lymphatic filariasis (LF) is a mosquito-borne parasitic infection that causes lymphedema, elephantiasis, and hydrocele. Haiti is one of only four countries left in the Americas where transmission of lymphatic filariasis still occurs. The National Program to Eliminate LF (NPELF) was started in Haiti in 2000, and by 2005 a population of 1.6 million people in 24 communes, including the majority of high-prevalence communes, was targeted at least once for mass drug administration (MDA). An interruption in external funding at the end of 2005 paralyzed the program, but with new donor support the NPELF was able to scale up to achieve full geographic coverage, reaching more than 8 million people in 2012. The LF program in Haiti has faced many challenges, including political crises, hurricanes, a devastating earthquake, and a deadly cholera outbreak in the earthquake's aftermath. Despite these challenges, the NPELF and partners have persisted, and now the program is integrated with soil-transmitted helminth (STH) control, is national in scope, and provides appropriate supportive care for persons suffering from LF morbidity. Haiti serves as a model for successful program implementation in countries affected by political and social challenges and natural disasters.Culex quinquefasciatus mosquitoes that transmit LF in Haiti are adapted to breed in conditions in which the environment has been degraded, a description which applies to much of Haiti's countryside, but increasingly so in urban and peri-urban locales as well as in the areas affected by the aftermath of the earthquake early in 2010.Lymphatic filariasis (LF) is a mosquito-borne parasitic infection that is best known for causing elephantiasis and hydrocele, conditions that prevent affected persons from living full and productive lives and may isolate them from family and community Significant progress has been made in the effort to develop a national LF program in Haiti, thanks to the highly motivated staff of the Ministry of Public Health and the Population (MSPP) and partners and critical funding support from the Bill & Melinda Gates Foundation, the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), CBM, the Inter-American Development Bank (IDB), the Abbott Foundation, PepsiCo, the Frank Eck Family Foundation, and other private donors. This manuscript will review Haiti's remarkable success in overcoming a host of challenges in the ongoing effort to eliminate LF, support persons disabled by LF, and control neglected tropical diseases (NTDs).Culex and LF transmission into previously LF-free areas, population migration, or some combination of all of these.Studies to characterize the epidemiology of LF in Haiti were carried out in the 1970s and 1980s by Dr. Christian Raccurt and colleagues Following the completion of mapping, the MSPP established the National Program to Eliminate LF (NPELF) with three goals: (1) to interrupt transmission, (2) to reduce the suffering of persons with clinical and chronic manifestations of LF, and (3) to encourage positive health behaviors. During the first years of the NPELF, the main focus of the program was to interrupt transmission. To achieve this, communes were categorized according to their endemicity level as defined by the CFA surveys into high (≥10%), moderate (5%–9.9%), low (0.1–4.9%), and nonendemic communes . TreatmeMDA in Haiti first started in Léogâne under the umbrella of a CDC-funded demonstration project with diethylcarbamazine (DEC) and albendazole in 2000 The approach used in most of the communes included a number of training sessions prior to each activity. Training for community leaders was conducted to sensitize and educate them about LF, including how to organize the MDA. Training sessions on health communication were organized in each community and focused on main messages related to LF treatment, transmission, and prevention, as well as the clinical manifestations of LF. Training was followed by an intense social mobilization campaign using available media including banners, posters, audio spots on local radio stations, and messages delivered by megaphones to inform and encourage the population to participate in the MDA During 2000–2002, only the commune of Léogâne was treated . In 2003, the NPELF and IMA World Health each targeted four new communes with a population of 492,000. In subsequent years, the partners added communes as shown in Haiti has faced many challenges that have affected the scaling up of the program. A political crisis enveloped Haiti beginning in 2003 that escalated into violence in 2004, with kidnappings and carjackings becoming commonplace in Port-au-Prince. In that period, one staff driver of the NPELF was shot and a principal administrator for the Hopital Ste. Croix program was killed by the random violence that seized Port-au-Prince, Gonaives, and other cities. However, even with the political unrest and violence spreading over the country in 2004 and 2005, the NPELF and partners continued MDAs. This persistence reflected the expressed desire of the treated communities and program staff to keep the program going. Despite the commitment of the NPELF, an interruption in external funding at the end of 2005 halted the program. Although the political situation was eventually stabilized by the introduction of a United Nations peacekeeping force, the social unrest and violence accelerated a longstanding pattern of outmigration among skilled health and other workers: the so-called “brain drain.” The impact of the interruption in funding on transmission was assessed in Léogâne; both microfilaremia and antigenemia prevalence increased, demonstrating that a single year of missed MDA can set the program back by up to two years in high-transmission settings like Léogâne Extensive advocacy efforts were needed to convince donors that the LF program in Haiti was providing health benefits and that it could succeed. With the funding stream restored in late 2006, the program was able to return to the level of geographic coverage attained in 2005. In addition, a new award from RTI/USAID also resulted from the increasing interest of the international donor community in the integration of delivery of preventive chemotherapy for NTDs. Both LF and intestinal helminth infections represent public health concerns across Haiti With a more stable funding base, the NPELF developed plans to cover the entire country with MDA, with the exceptions of the metropolitan area of Port-au-Prince, again due to resource constraints, and the island of La Tortue, where two rounds of MDA have apparently interrupted transmission . Even as the program scaled up, natural disasters continued to present challenges. Four hurricanes hit Haiti in rapid succession in 2008, leading to widespread flooding and delays in implementing MDA in Gonaives and elsewhere. The 2010 earthquake coincided with one of the regularly scheduled meetings of NTD partners in Haiti. A staff member for one of the partners died in the collapse of his home, and several others were trapped in the wreckage of the meeting venue. The earthquake caused massive destruction in Port-au-Prince and throughout the West Department, killing more than 300,000 people and displacing more than a million more. On the heels of the earthquake's devastation, a cholera outbreak started in the center of the country during October 2010 and spread nationwide within a little over a month By February 2012, MDA was completed in the final six communes comprising the metropolitan area, bringing the total number of people treated nationwide to 8.1 million  and 2. DThe realization of full national coverage fulfilled the first step toward successful elimination of LF from Haiti , but intIn principle, DEC-fortified salt represents an alternative approach that can facilitate elimination of LF Recent developments within the salt project raise the prospect of a significant increase in the production and distribution of co-fortified salt, including the establishment of a three-year technical services agreement with Cargill Salt, an upgrade in the salt production facility to allow production of 3,000 metric tons per year, and development of a National Salt Strategy to regulate food-grade, fortified salt. All of these steps will facilitate a transition to processed food-grade salt, with the potential to greatly assist the sales and marketing of DEC-fortified salt.C. quinquefasciatus, the vector of LF, is thought to be less affected by LLIN than Anopheles spp., it is likely that such a program may, nonetheless, reduce human-mosquito vector contact and contribute to interruption of LF transmission. Other vector control methods, including source reduction and the use of polystyrene beads to interfere with larval development, have not been widely implemented in Haiti, primarily for cost and practicality considerations.Another possible way to accelerate the elimination of LF could be through the use of insecticide-impregnated materials distributed to control and eventually eliminate malaria from Hispaniola Though targeting LF morbidity was originally described as the second pillar of the global program to eliminate LF, establishing strong systems for providing care for patients with morbidity due to LF has been a challenge for many countries Surgery using appropriate technique is necessary to provide a long-term solution for patients with hydrocele. A training program was established at Hôpital Ste. Croix to provide experience in the surgery technique pioneered by Professor Joaquim Noroes in Recife, Brazil, and recommended by WHO, in which the entire tunica vaginalis is excised The MSPP in Haiti is determined to interrupt LF transmission and control intestinal helminths using MDA in combination with other approaches. Despite a host of challenges, the LF program stands as an exceptional public health success in Haiti. MDA is popular both with MSPP and communities because of the significant public health benefits that it delivers. Even in settings that are characterized by political and civil strife and natural disasters, MDA can continue to provide a platform for delivery of health services to impoverished communities. The appeal of this message extends beyond Haiti to other countries facing crushing poverty and civil strife. LF and other NTD programs represent an inviting opportunity to engage communities that frequently lack organized public health activities and to provide them with significant public health benefits. Haiti is prepared to meet the technical challenges that need to be addressed to end transmission of LF, to extend care to all those already affected by this disease, and to extend these successes to other public health problems facing the country.