In Canada, several community-based, multi-service programs aimed at reaching vulnerable pregnant or parenting women with substance use and complex issues have emerged. These programs offer basic needs and social supports along with perinatal, primary, and mental health care, as well as substance use services. Evaluations of these ‘one-stop’ programs have demonstrated positive outcomes; nevertheless, few published studies have focused on how these programs are structured, on their cross-sectoral partnerships, and on clients’ perceptions of their services.Co-Creating Evidence (CCE) project was a three-year evaluation of eight multi-service programs located in six Canadian jurisdictions. The study used a mixed-methods design involving semi-structured interviews, questionnaires, output data, and de-identified client data. This article focuses on qualitative interviews undertaken with 125 clients during the first round of site visits, supplemented by interview data with program staff and service partners.The Each of the programs in the CCE study employs a multi-service model that both reflects a wrap-around approach to care and is intentionally geared to removing barriers to accessing services. The programs are either operated by a health authority (n = 4) or by a community-based agency (n = 4). The programs’ focus on the social determinants of health, and their provision of primary, prenatal, perinatal and mental health care services is essential; similarly, on-site substance use and trauma/violence related services is pivotal. Further, programs’ support in relation to women’s child welfare issues promotes collaboration, common understanding of expectations, and helps to prevent child/infant removals.The programs involved in the Co-Creating Evidence study have impressively blended social and primary care and prenatal care. Their success in respectfully and flexibly responding to women’s diverse needs, interests and readiness, within a community-based, wraparound service delivery model paves the way for others offering pre- and postnatal programming. Women’s substance use is often intertwined with an array of issues, including physical, emotional, or sexual abuse, intimate partner violence, mental health concerns, child welfare involvement, physical health problems, and challenges related to social determinants of health such as low social support, deep poverty, precarious living conditions and homelessness –6. ReseaSubstance use during pregnancy is associated with risks of harm for both the fetus/infant and the mother; moreover, women’s substance use postnatally is associated with parenting difficulties and increased risk/rates of child removal . At the Multi-service programs offering basic needs and social supports along with perinatal, primary, and mental health care, as well as substance use services are particularly effective for women who are otherwise wary of engaging with the formal systems of care , 20, 21.In Canada, services designed to address the particular health needs of women who use substances and who are pregnant or parenting can operate in two different ways. Since the 1990s, several community-based, multi-service programs aimed at reaching vulnerable pregnant or parenting women with substance use and complex issues have emerged , 17, 18.As another approach, integrated treatment programs for women who are pregnant or parenting and their children have addictions treatment as the entry point and reduced substance use as the focal goal. These programs were designed to overcome the systemic barriers typically associated with more conventional fragmented service delivery structures and similarly offer a range of services that address women’s physical, mental, and social-economic well-being. , 27Evaluations of community-based women-centred, relationship-based, ‘one-stop’ approaches have demonstrated positive outcomes. Findings include increased prenatal visits, improved birth outcomes, reduced substance use, increased support and connection to services, improved health and wellness, improved housing, increased connection and/or custody of infants and children, and reduced isolation , 28–32.At the same time, few published studies have focused on how programs that serve pregnant and parenting women with substance use issues are structured, and limited information is available on the types of cross-sectoral partnerships necessary to support the work of these programs. Similarly, there is a paucity of research on clients’ perceptions of their care at these programs. A small literature exists in the context of integrated treatment programs: two studies in one Canadian province identified the most common networks of partnerships amongst integrated treatment programs and described the categories of services that exist as a result , 26. In While these studies make a valuable contribution to the literature, the authors of this article know of no published studies that have focused specifically on the types of informal, formal or non-traditional partnerships that multi-service community-based agencies rely upon as means to deliver programming and services to highly marginalized women who are pregnant and/or parenting and using substances. Further, the authors know of no research highlighting clients’ perspectives on how they utilize the various services provided by holistic community-based services or how the care and supports they receive make a difference to them and their families.In view of this knowledge gap, additional study of service delivery partnerships as well as clients’ use of and perspectives on the array of supports available through community-based multi-service programs is critical for program development and evaluation of ‘one-stop’ approaches to care for pregnant and parenting women with substance use and other complex concerns. This article aims to begin to address this knowledge gap through discussion of the services, partnerships and client perspectives of the eight Canadian programs involved in the Co-Creating Evidence project.Co-Creating Evidence: National Evaluation of Multi-Service Programs Reaching Women at Risk (CCE) project was a three-year evaluation of eight different holistic programs located in six Canadian jurisdictions, conducted between 2017 and 2020  and possibly socially isolated.Each of the eight programs participating in the CCE study employs a multi-service model that both reflects a wrap-around approach to care and is intentionally geared to removing barriers to accessing services and to providing services identified in the literature as meeting women’s holistic needs. Table The purpose of this article is to describe the array of wraparound services and supports offered by the eight programs participating in the Co-Creating Evidence study, and how the programs organize their services to facilitate access to ‘one-stop’ health and social care. In addition, this article explores how clients utilize these health, housing, food-related, child welfare, parenting, childcare, cultural, trauma-related and substance use services and supports, highlighting clients’ own descriptions of the programming, how they engage with services, and how the supports/services make a difference to them and their children.The article addresses the following research questions:How are the CCE programs’ wraparound services delivered – i.e., through core staff, contracted services and/or program partnerships?How do clients describe their utilization of and involvement with services, and how do the services and programming make a difference?The Co-Creating Evidence study is guided by principles of collaboration , includiThe Co-Creating Evidence study used a mixed-methods design involving semi-structured interviews, questionnaires, focus groups, output/program data, and client intake/outcome ‘snapshot’ data. Data were gathered in two ways: 1) by the project team, who conducted face-to-face, semi-structured interviews, focus groups, and questionnaires with clients, program staff and service partners in spring 2018 and fall 2019; and 2) by the program sites, who collected quantitative output data and client-based data from April 2018 through September 2019.The study received ethics approval from the University of British Columbia Office of Research Ethics (H17-02168), Vancouver Costal Health Authority, Island Health Authority, Fraser Health Authority, and York University. All participants gave written informed consent to take part in the study; all were over age 18 and were competent to give their own consent.This article focuses on data from qualitative interviews undertaken with clients during the first round of site visits between April and July 2018. It is supplemented by interview and focus group data with program staff and the programs’ service partners.Interviews and focus groups with program staff focused on staffs’ and managers’ perspectives on program goals, foundational principles and approaches, program operational issues , program partnerships, and program impacts for clients, families and community partners. Interviews with program partners focused on partners’ perspectives on the partnership and any practice-related and organizational impacts of the partnership, as well as partners’ perspectives on the program’s strengths, challenges, and outcomes. Interviews with clients were conducted using a guided conversation approach that enabled interview participants to speak freely about whatever was most important to them. The client interview guide contained open-ended questions focusing on: the woman’s life situation at the point at which she first engaged with the program and what she hoped to get from her involvement with it; whether and how she utilized the different services and types of programming offered by her program; her satisfaction with the program; and what had been the most significant change for her and/or her family since her involvement with her program. Immediately following the interview, women were invited to complete the Client Questionnaire, which was most often administered verbally by the research team member. Additional information about on-site data collection by the project team is provided elsewhere see , 17)..17]).A total of 125 clients participated in the first round of in-person data collection for the study. In addition, a total of 61 program staff took part in interviews or focus groups at the eight programs; 42 service partners were also interviewed. Based on questionnaire data, all clients who participated in face-to-face interviews and completed the Client Questionnaire identified their gender as female, and more than half (54%) were older than 30 years old. The majority of clients (53%) self-identified their cultural background as Indigenous, followed by European/White (27%) and mixed race (15%), though this varied across programs from 97% at the Indigenous-focused program in downtown Winnipeg to 0% at the program in rural Nova Scotia. The length of time women had participated in their program varied from less than one month to more than three years. This variation in part is attributable to the policies and funding realities of the individual programs; for example, clients can participate in several programs till their child is school-aged, whereas at other programs, clients end their formal involvement at 6-months or 12-months post-partum.Across the eight CCE programs, the 61 program staff who participated in interviews or a focus group came from diverse professional backgrounds, and included: the manager or coordinator of each program, nurses, physicians, nurse practitioners, midwives, social workers, outreach workers, counsellors, client engagement workers, Elders, Indigenous liaison workers, infant development workers, peer support workers, Aboriginal family support workers, childcare workers, and the executive directors of programs’ sponsoring organizations.For the interviews with clients, program staff and services partners, qualitative data analysis techniques were utilized; NVivo12 software , was utilized to facilitate the analyses. See , 17 for n = 4) or by a community-based agency  (n = 4). Programs operating through a health authority were more likely to include ready access to a wide range of health services on-site, such as: public health nursing; nurse practitioner; physician; specialist addictions and maternity care, obstetrics, and maternal-fetal medicine; psychiatry; or midwifery. Overall this meant that women typically received both regular and specialized medical care that they would otherwise have a difficult time accessing in the community. As described by program staff:The programs participating in the Co-Creating Evidence study are operated (and largely funded) by a health authority  coordinate services for their women and are there to be a bigger participant in the women’s pre- and postnatal care. The biggest strength is to have a close working relationship with the shared goal to support marginalized women with their pregnancy.Through Memorandum of Understandings, another program in the study forged working relationships with a handful of specialized programs for high risk and/or substance using pregnant women, thereby giving its clients access to specialized prenatal care and again making visible women’s unique health care requirements when substance use was also an issue.child welfare services was another important achievement; as noted in Table Seven of the eight programs taking part in the Co-Creating Evidence study actively work with women to address child safety concerns. Having an alliance or partnership with This connection was valuable as it had the potential to positively impact how child welfare services and other service providers viewed a women’s capacity to parent. When government social workers were co-located at the program they could function as a bridge between the program and child protection services, a practice that in the words of social workers could result in everyone having a clearer idea of what was required for the women to achieve their goal of keeping their child:These women have experienced trauma, and the program works with them on planning for reunification. However, given child protection concerns, the plans have to be done in a careful way. Having our social worker at the program helps bridge the gap between us and the women.In addition, government child protection social workers who were involved at a case conferencing or planning level reported that through their relationship with program staff, they became more knowledgeable about the factors influencing women’s lives and therefore could have a more nuanced discussion about options and strategies for keeping children safe:People really listen and seek out the [program’s] staff. We go to them and ask, ”Help me understand what the woman’s experience is.” Staff bring back a broader perspective and understanding around trauma. Our workers are less blaming; they are recognizing that what we are seeing is a result of trauma rather than intentional non-compliance.cultural services and programming. The same was true of housing, which was a major challenge at all program sites. In addition to the three programs that had a direct link to supportive housing, one program had an informal partnership with a supported housing program geared to pregnant women at high risk of experiencing homelessness, and another program offered rental supplements to some clients. Program managers also sought ways to strengthen their on-site services by building or deepening relationships with service providers who had expertise in areas that could benefit the program and clients. As one manager explained:Program managers also sought connections with complementary services and programming in areas other than health care, substance use, and child welfare services. Several programs were able to link their clients to services in the community by means of collaborative working relationships or formal partnerships. Two programs formed close working relationships with local Indigenous agencies so that their clients would have access to relevant We also would like to have more involvement from someone with expertise in children’s behaviours, so that we’d be able to do some educational programming for women about children’s behaviours through the reunification process. We have a meeting with [a community program] about this possibility.In the interviews, clients were asked how they utilized their program’s array of services and supports. Figure By describing their use of their program’s services and programming in their own words, clients could also elaborate on the ways in which they were involved with the services and supports, as well as how the services made a difference to them. A sample of women’s comments is presented in the Figs. Qualitative analyses of clients’ comments regarding how they engaged with services and why they were helpful resulted in several key themes, including:Programs’ focus on the social determinants of health is paramountWrap-around services help ensure women access a wide range of needed primary care, as well as prenatal, postnatal and mental health careOn-site substance use and trauma/violence counselling and support make a pivotal differencePrograms’ support in relation to women’s child welfare issues promotes collaboration, common understanding of expectations, and helps to prevent child/infant removalsPrograms’ developmental lens helps women access key parenting and pediatric services – i.e., services for themselves, for their child(ren), and for the mother-child connectionCultural programming promotes women’s (re)connection to traditional knowledge and teachings, and to holistic and land-based healing practicesBrief discussion of these themes follows.The programs’ use of a social determinants of health lens in understanding women’s needs is a key factor in their ability to engage with women. Food/nutrition-related programming and basic needs support contribute in fundamental ways to the women’s health and to positive birth outcomes, mitigate women’s poverty, and bolster women’s capacity to keep their infant/child(ren) in their care. Many clients also spoke of being drawn to their program because of the meals and other basic needs supports, yet then engaging with program staff and staying on, accessing the program’s array of services. In women’s words:They helped me with basics needs. I couldn’t afford groceries, so I used the Community Cupboard – I used it for groceries for two weeks a month for three months.The food, the doctors. Health care is the best in the city. The services and supports – the staff are kind and non-judgmental.In their comments about the food- and nutrition-related programming, a number of women also expressed their appreciation for their program’s provision of healthy food, which they valued for themselves and their children especially given that nutritious food can be too costly on a limited budget. As well, food-related programming offered opportunities for social connection, peer support and mentoring, and skill development, all of which were linked to wellness and personal development outcomes for women.They gave me food vouchers and the hot meals at drop in groups. We talked about different ways to introduce different kinds of food to children.I get the Food Bank deliveries. I go to the cooking class here. We do potlucks. We all cook and share something. Our big thing here is that it takes a community. We all try to help each other out.Similarly, the programs’ focus on addressing women’s housing needs and assisting them to access safe and stable housing is especially important, given the inter-connections between housing adequacy and child welfare/protection involvement. Many clients reported that having safe and adequate housing was a key precondition for resolving concerns about child(ren)’s safety. Conversely, for some clients, not having safe housing was a factor in their infant’s or child’s removal from their care.They helped me in getting into ‘Moms and babies’ housing. It’s important because it is hard to get into housing that is Ministry-approved, so moms can keep baby with them.[Program] staff are helping me to apply for housing. Without housing, I can’t get my baby back.A strong theme in clients’ comments was that having an array of health and social care services under one roof helped to ensure that they got to their various appointments, participated in programming, and were able to address multiple needs at the same time. For example, this client stated:My doctor is at [the program]. The appointments are easier to keep; I’m not being referred to health services in [another community], which is what was happening when I lived in Vancouver. I couldn’t get to the appointments reliably. Now I’m able to, and I’m getting bloodwork done.As a related point, clients expressed appreciation for the trusting relationships they developed with care providers who knew of and were sensitive to their personal histories:I’m still connected with the Nurse Practitioner here. She’s the only heath care provider I’ll see because she knows me and my history.Combining on-site services with transportation and accompaniment by program staff also helped to ensure that clients successfully accessed important health and prenatal/postnatal appointments:I go to the Thursday night classes, and they connected me to my midwife and take me to my appointments.Programs with on-site group-based and/or one-to-one substance use counselling and support, coupled with on-site trauma/violence-related programming made a big difference for women. It is important to reiterate that these are not integrated treatment programs, and women do not come to these programs solely for substance use or trauma-related services. That said, the majority of clients with substance use concerns come to their program in a place of readiness to take steps to reduce or quit their problematic substance use, and they value the groups and individual support they receive:I do one-to-one counselling with [program staff person] who helped me to get clear about relationships and alcohol. I also attended the program’s Recovery Group.I’ve talked with the midwife here. I wouldn’t be still clean and sober if it weren’t for the support here. Sometimes I’m doing well, sometimes not. But I don’t do alcohol and drugs when I’m having a bad day. It’s about maintaining your life.Moreover, clients expressed that the approaches used by program staff  promoted a sense of safety, honesty, trust and community. These approaches were especially important given that so many of the women served by these programs had previously had negative experiences with health and social care systems and hence often avoided them. As these two clients stated:I quit cold turkey from alcohol and drugs when I was five and a half months pregnant with my daughter. I talk to [staff person] about everything, even about my urges to use.I have seen the counsellor a few times. I quit while pregnant. I haven’t been ready to go to a group. It’s the first time I’ve been sober for this long since I was 12 years old. Just having a safe space to go to where no one is drinking really helps, to be in a community that sees me as a mom and not as an alcoholic.In describing their use of their programs’ child welfare related services/supports, many clients expressed deep appreciation for the assistance, accompaniment and advocacy they received from program staff. Many also stated that they believed that the program’s support made a critical difference in enabling them to keep their infant and/or regain their older children to their care. In these clients’ words:[The program’s] social worker made the appointment for me to meet with the Child and Family Services worker. I had to stay clean and sober and get a restraining order against my partner. Because of that, Child and Family Services did not flag me, and I had no issues in the hospital.[The program’s] social worker helped me to meet with [the government’s] child protection workers. She explained to me where they were coming from and she could tell the [government’s] social workers what I was feeling. [The program] staff were always with me, so I was supported and able to go to court for custody.Seven of the eight programs involved in the study offered key pediatric services  and parenting- related programming on-site either by program staff or by a co-located service partner. Moreover, one of the programs, which defined itself as children’s developmental assessment and early intervention program with wrap-around services for women, had a dual-focus model wherein both mother and her infant/child were considered program clients; an eligibility criterion for this program was that women had to have the goal of actively parenting their infant. At the same time, clients participating in nearly all of the Co-Creating Evidence programs voiced their appreciation of their program’s health and developmental services for their infant/child(ren).The children have their immunizations at [the program]. We got a referral to the Infant Development Program to help my daughter with crawling, and my son is getting speech therapy. I do music therapy with my two children on Fridays at [the program].I do groups and have at home visits with the parenting intervention therapist from [the program]. These were the best because they could see me at home and at ease with my children.Five of the eight programs involved in the Co-creating Evidence study engaged an Indigenous Elder or Cultural Liaison who came to the program or was available to clients at least once a week for group-based programming , ceremonies, smudging, one-to-one meetings and/or who connected women with cultural activities in the community  or on the land . Clients expressed their appreciation of the programs offering various opportunities to women to be introduced to or re-engage with culture and traditional ceremonies; similarly, programs having both group-based programming, including activities that could involve the women’s children, and one-to-one time was valued.We do drumming. We’ve made drums. My son loves drumming. We had a baby-welcoming ceremony and smudges.The Elders that they have brought in here are great. I like the baby welcoming ceremony.The current study illustrates that women’s and children’s lives span boundaries and cannot be easily compartmentalized into traditional funding and service delivery structures. Consequently, a multi-sector, multi-service, wrap around programming and partnership approach is essential.When it comes to key activities and services, all programs employ some combination of primary, prenatal, perinatal and mental health care services; moreover, the programs are flexible and evolving, adding and adapting services and supports as women’s and their families’ needs are identified and programming / partnership opportunities emerge, yet adjusting levels of service when funding does not keep pace with costs. Being connected with a range of health care providers paves the way for women to receive multi-dimensional health care and for their children to receive developmental screening and follow-up. How this is operationalized is not as important as the fact that women made a positive attachment with a health care provider, whether that is a nurse, nurse practitioner, physician, maternal care or addictions specialist, midwife, psychiatrist, psychologist or counselor. Women’s engagement with health services in turn results in their children receiving important assessment and pediatric attention. When health services have been offered in-house the connections are more readily facilitated, but it can be seen that programs that relied on off-site providers are also able to effectively help clients to access and engage with services by virtue of the strong relationships between the program and its partners.The ability of the programs to support and strengthen the mother-child connection is an important outcome. Inclusion of child welfare support is thus another key component of the wraparound programs, as it helps women keep their infant and/or regain their children and helps government child protection workers gain a deeper appreciation of women’s capacity to parent, their support needs, and an understanding of how relational, harm reduction and trauma-informed approaches work in practice .An approach designed to meet the wide range of women’s material and social needs and to address barriers to service is similarly fundamental to the programs’ and women’s success. Offering a variety of programming related to food and nutrition was a much-valued means to facilitate and sustain women’s engagement in their program, frequently leading to important peer connections and supports, and becoming an entry point to health and prenatal care. The provision of childcare similarly facilitated clients’ participation in key group-based programming and/or enabled women to access services or attend appointments in the community. For several of the programs in the Co-Creating Evidence study, funding for these types of activities came from community sources such as a local charitable foundation, food bank, non-profit community group, or educational institution. This has the advantage of helping to promote a connection between the programs and their communities that is also reflective of their local context. It also affords program managers leeway in not having to draw down on already stretched core funding while still meeting needs associated with determinants of health.In addition to the wide-ranging array of services/activities, the relational approaches taken by the program staff are also key. Trauma-informed, non-judgmental and non-stigmatizing approaches that recognize the importance of women’s safety, choice, and readiness to set goals and make changes in their lives exemplify ways of successfully engaging women in programs. These approaches are also consistent with the literature, which has demonstrated that a relational and non-judgmental approaches are foundational to constructive change, be that at the individual, institutional or systemic level , 22, 35.Moreover, in keeping with a women-centred approach, women choose what services/programming they access. Services and programming are tailored to known goals, needs and circumstances of pregnant and parenting women who use substances; however, within that evidence-informed framework, women have agency to access what services they feel will work for them, at the pace for which they are ready. This aspect of the services, as illustrated in Fig. This multi-site evaluation study involved eight programs that all volunteered to participate, and the on-site client-related data collection  also employed a volunteer sampling approach. We recognize that that approach could have resulted in bias, in that clients with more involvement in and/or positive views about their program could have been disproportionately inclined to take part in the evaluation study. Nevertheless, as this article focuses on describing the programs’ structure and clients’ perspectives on wraparound programming, we have no reason to believe that clients having less positive perspectives were disinclined to participate in the study. Moreover, the guided conversational approach to interviewing facilitated participants to share their diverse experiences and perspectives.The programs involved in the Co-Creating Evidence study have assiduously blended social, primary, and prenatal care. Although not all programs provide all of the identified services or focus on providing all of the services to the same degree, through a combination of co-location with other services, shared services and staff, and relationships with service partners, they all offer a mix of services and supports. These services are provided either on-site or by connecting women to a wide array of services and support. Indeed, their ability to blend social and health care services is a distinguishing feature of these types of programs. They have cut through barriers that traditionally have seemed insurmountable, to provide context-specific support to pregnant women and new mothers and children that address a very wide range of social and structural determinants of health. Their success in respectfully and flexibly responding to women’s diverse needs, interests and readiness, within a community-based, wraparound service delivery model paves the way for others offering pre and postnatal programming to follow.


Cycles of incarceration, drug abuse, and poverty undermine ongoing public health efforts to reduce overdose deaths and the spread of infectious disease in vulnerable populations. Jail diversion programs aim to divert low-level drug offenders toward community care resources, avoiding criminal justice costs and disruptions in treatment for HIV, hepatitis C virus (HCV), and drug abuse. We sought to assess the health benefits and cost-effectiveness of a jail diversion program for low-level drug offenders.We developed a microsimulation model, calibrated to King County, Washington, that captured the spread of HIV and HCV infections and incarceration and treatment systems as well as preexisting interventions such as needle and syringe programs and opiate agonist therapy. We considered an adult population of people who inject drugs (PWID), people who use drugs but do not inject (PWUD), men who have sex with men, and lower-risk heterosexuals. We projected discounted lifetime costs and quality-adjusted life years (QALYs) over a 10-year time horizon with and without a jail diversion program and calculated resulting incremental cost-effectiveness ratios (ICERs) from the health system and societal perspectives. We also tracked HIV and HCV infections, overdose deaths, and jail population size.Over 10 years, the program was estimated to reduce HIV and HCV incidence by 3.4% (95% CI 2.7%–4.0%) and 3.3% (95% CI 3.1%–3.4%), respectively, overdose deaths among PWID by 10.0% (95% CI 9.8%–10.8%), and jail population size by 6.3% (95% CI 5.9%–6.7%). When considering healthcare costs only, the program cost $25,500/QALY gained . Including savings from reduced incarceration  improved the ICER to $6,200/QALY gained . Sensitivity analysis indicated that cost-effectiveness depends on diversion program participants accessing community programs such as needle and syringe programs, treatment for substance use disorder, and HIV and HCV treatment, as well as diversion program cost.A limitation of the analysis is data availability, as fewer data are available for diversion programs than for more established interventions aimed at people with substance use disorder. Additionally, like any model of a complex system, our model relies on simplifying assumptions: For example, we simplified pathways in the healthcare and criminal justice systems, modeled an average efficacy for substance use disorder treatment, and did not include costs associated with homelessness, unemployment, and breakdown in family structure.We found that diversion programs for low-level drug offenders are likely to be cost-effective, generating savings in the criminal justice system while only moderately increasing healthcare costs. Such programs can reduce incarceration and its associated costs, and also avert overdose deaths and improve quality of life for PWID, PWUD, and the broader population (through reduced HIV and HCV transmission). Cora Bernard and co-workers investigate the health and societal value of diversion programs for people who misuse drugs. Strategies for people with substance use disorder based on criminalization and aggressive law enforcement have created barriers to harm reduction while having little or no impact on the number of people who use drugs.Diversion programs redirect individuals with low-level drug and prostitution offenses away from the criminal justice system and into community-based services such as treatment for substance use disorder, housing, and mental health care.Our model-based analysis was designed to assess the health benefits and cost-effectiveness of a jail diversion program for low-level drug offenders.We developed a stochastic microsimulation model of adults in King County, Washington that captures sexual and injecting-based risk behaviors and partnerships and tracks the 10-year trajectories of people who inject drugs, people who use drugs but do not inject, and the lower-risk general population, with and without a diversion program.We projected HIV and hepatitis C virus (HCV) incidence, fatal overdoses, jail population size, and lifetime costs and quality-adjusted life years (QALYs) experienced in the population, with and without a diversion program.We estimated that the diversion program would reduce cumulative HIV and HCV incidence, fatal overdoses, and the jailed population, would lead to gains in QALYs, and would be highly cost-effective.A 2016 United Nations AIDS Programme (UNAIDS) report found that the status quo of criminalizing drug abuse is failing from the public safety and public health perspectives. Our study demonstrates that these perspectives can be aligned.Our analysis suggests that diversion programs are likely to substantially reduce spending in the criminal justice system while moderately increasing spending in the healthcare sector and are likely to be highly cost-effective.The spread of infectious disease stemming from drug injection and the global overcrowding of jails and prisons suggest that, more than ever, effective, cost-effective, and innovative approaches are required to address these crises. Diversion programs are one such program. A 2016 United Nations AIDS Programme (UNAIDS) report found that “strategies [for people who inject drugs (PWID)] based on criminalization and aggressive law enforcement have created barriers to harm reduction while having little or no impact on the number of people who use drugs” . Jails aDiversion programs include drug courts, which divert individuals to treatment for substance use disorder with intensive supervision and regular court appearances, and jail diversion programs, which bypass the criminal justice system and focus on a broader array of community services. Drug courts have been shown to reduce state and county government costs , as wellTo quantify these effects and evaluate the effectiveness and cost-effectiveness of a jail diversion program from a public health perspective, we developed a stochastic microsimulation model of adults in King County, Washington. The model captured sexual and injecting-based risk behaviors and partnerships and tracks the 10-year trajectories of PWID, PWUD, and the lower-risk general population, with and without a diversion program. We calculated HIV and HCV infections averted, overdose deaths averted, and change in incarcerated population due to the diversion program. We calculated lifetime discounted costs and quality-adjusted life years (QALYs) from a health system perspective as well as from a societal perspective that includes criminal justice system costs, and we calculated resulting incremental cost-effectiveness ratios (ICERs) for the diversion program compared to no intervention.Our model  stratifiIn King County, 1.7% of the adult population are PWID, 6% are PWUD, and the rest are considered low risk  23–27].–27.23–27We simulated 140,000 individuals in each model run (approximately 10% of King County’s population). The model ran over a 10-year time horizon in weekly time steps. To simulate behavioral and health events, we associated a set of transition probabilities with each individual based on demographic data. Every location , disease status, and risk status in the model was associated with a healthcare cost and, possibly, criminal justice-specific cost as well as a QALY value. An individual’s weekly costs and QALYs were calculated as, respectively, a sum or multiple of all states characterizing that individual at that time. For each scenario (with the diversion program and without), we ran the model 2,500 times. We calculated average values for each outcome over the 2,500 runs as well as the fifth and 95th percentile value.In the model, an individual could commit a misdemeanor or felony . MisdemeHIV or HCV transmission occurred between individuals who had a sexual or injecting partnership. We used a negative binomial distribution to characterize the number of partnerships an individual engages in ,38. PartIndividual, disease, and transmission-route specific probabilities were calculated to determine the chance of infection for every at-risk individual at each time step ,39,40. ICommunity programs in the model included ART for HIV, HCV treatment, treatment for substance use disorder (SUDT), and needle and syringe programs (NSPs). PWID and PWUD were eligible to enroll in SUDT, which broadly included both drug rehabilitation and opioid agonist therapies. SUDT improved quality of life and reduced injection frequency for PWID, thus decreasing both disease transmission and overdose risk ,41,42. TVia SUDT, a small percentage of PWID and PWUD could transition to lower-risk groups  . IndividPrograms such as LEAD seek to connect individuals to housing, employment, and treatment opportunities ,18. ConnIn intervention simulations, a PWID or PWUD committing a misdemeanor was eligible to enroll in the diversion program if not already enrolled; if he did enroll, he was not moved to jail ,56. EnroProgram costs for an individual enrolled in the diversion program were estimated to be $899/month for the first 3 years and $532/month subsequently . All othAt the end of a model run, the costs (in 2016 US dollars) and QALYs associated with every individual at each time step were discounted to the present at 3% annually  and combWe manually calibrated the model to King County epidemiologic targets such as jail and prison populations; HCV and HIV incidence, prevalence, awareness, and treatment; and overdose deaths and HIV-related mortality, both in the population as a whole and in multiple population subgroups. A majority of input parameter values were calculated explicitly from published King County, Washington data or were well established in the literature on disease natural history and other infectious disease models. A subset of parameters had unknown or wide uncertainty intervals; we varied these in our calibration process.For tractability, we took an incremental approach, manually varying subsets of model parameters to stabilize subsets of the model dynamics. We first calibrated parameters related to incarceration dynamics to replicate constant crime rates and jail and prison populations  to high increase in the chance of enrolling (3.0) and high decrease in the chance of quitting (0.25). As expected, when we kept one variable fixed at no change (1.0) and increased the other, the value of the diversion program increased monotonically. However, When the diversion program did not increase an individual’s propensity to attempt to enroll in community programs  per QALY gained. Including savings from reduced incarceration improved the ICER to $6,200  per QALY gained. Additionally, the diversion program reduced the jailed population size and provided significant health benefits, decreasing fatal overdoses among PWID and reducing HIV and HCV incidence. Critically, we found that the effectiveness of a diversion program in connecting participants to community programs such as SUDTs, NSPs, and treatment for HIV and HCV greatly affects cost-effectiveness.As a relatively new initiative, fewer data are available for diversion programs than for other, more established interventions aimed at people with substance use disorder. When we encountered uncertainty for program parameters in our model, we tended toward conservative estimates that would bias us against such a program. For example, we did not include any direct QALY increase associated with diversion program enrollment, despite the fact that such a program would help clients obtain housing and employment, among other benefits . We did Like any model of a complex system, our analysis has limitations. While attempting to capture key aspects of the diversion program, inevitably, we had to simplify pathways in the healthcare and criminal justice systems for tractability. For instance, we did not model the “social contacts” pathway through which individuals can be referred to a diversion program without first being diverted from a crime . As anotParameter uncertainty is always a challenge for public health models. One advantage of modeling a county was that data taken from multiple sources were measuring the same population, enabling us to infer key demographic parameters and check consistency across subgroups. Although there is perhaps more uncertainty and variability in disease natural history parameters, our HIV and HCV models closely reflect published studies ,49,51,61Another challenge in such an analysis is structural uncertainty; that is, understanding how model results depend on the type of model that is used . We usedA 2016 UNAIDS report found that the status quo of criminalizing drug abuse is failing from the public safety and public health perspectives  and is uS1 TextCHEERS, Consolidated Health Economic Evaluation Reporting System.(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Mobile phone apps for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, a fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine the utility of such programs. We adapted messages of the Mobile Alliance for Maternal Action (MAMA) program, which was designed to promote healthy behaviors during pregnancy and a newborn’s first year of life, to the Afghan context. We then piloted and assessed the program in the provinces of Kabul, Herat, Kandahar, and Balkh.The aim of this study was to assess the feasibility and acceptability of the MAMA pilot program, and to examine changes in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow up.We conducted a single-group study with data collected within 10 weeks of enrollment, and data collection was repeated approximately 6 months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mobile health messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes, and health care-seeking practices; and intervention experience and acceptability at follow up. The number of messages received by a given phone number was extracted from the program database. We descriptively analyzed the feasibility and acceptability data and compared the change in MNCH knowledge between baseline and follow-up measures using the McNemar Chi square test.Overall, 895 women were enrolled in the MAMA program. Data from 453/625 women (72.5% of the pretest sample) who received voice (n=302) or text (n=151) messages, and 276/427 men (64.6% of the pretest sample) who received voice (n=185) or text (n=91) messages contributing data at both time points were analyzed. At follow up, 699/729 (95.9%) participants were still enrolled in the MAMA program; voice message and SMS text messaging subscribers received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with the text message subscribers and men; predominant reasons for missed messages were the subscribers being busy with chores or not having their shared phone with them. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226/453 (49.9%) of the female participants reported referring someone else to the program. Most of the participants  believed it was beneficial to include husbands in the program. Joint decision making regarding maternal and child health care increased overall. The proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow up.This assessment indicates that the pilot MAMA program is feasible and acceptable in the Afghan context. Further research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale up. Afghanistan has one of the highest maternal, newborn, and child mortality rates among Asian countries  and faceAmong the factors associated with low uptake of essential maternal, newborn, and child health (MNCH) interventions are illiteracy and lack of education . MaternaWithin Afghanistan, mobile phone ownership and use have expanded markedly in the last decade, creating a potential channel to reach women and their families with health information. In a recent nationally representative survey, 91% of households reported owning a mobile phone . Mobile The Mobile Alliance for Maternal Action (MAMA) program was launched in 2012 as a public-private partnership to scale up an evidence-based mobile health  program that is already being used in two countries . With suIn this study, we assessed a pilot implementation of the MAMA program in four provinces of Afghanistan to determine whether it was feasible and acceptable to Afghan users, and whether users report changes in MNCH attitudes, health decision making, and knowledge of key MNCH concepts. The data from this assessment will guide program refinement, and are intended to improve program use and potential effectiveness at scale up in Afghanistan and adaptation in similar contexts.We conducted a single-group, baseline/follow-up study to assess the feasibility, acceptability, and potential effect of the MAMA program on MNCH knowledge. The MAMA pilot program was implemented in 80 health post catchment areas in the Balkh, Herat, Kabul, Kandahar, and Nangarhar provinces of Afghanistan. Nangarhar province was not included in the program assessment as baseline recruitment was not possible within the study time frame due to insecurity. The selected pilot districts were semiurban or rural and predominantly agrarian. Eligible study participants included pregnant women and their husbands who enrolled in the MAMA program with the help of a community health worker between May and July 2018.The study was reviewed and approved by the FHI 360 Protection of Human Subjects Committee (#1240522-2) and was approved by the Afghanistan Ministry of Public Health (MOPH) Institutional Review Board (protocol #444670) prior to implementation.The MAMA message program relays essential MNCH information to guide actions for pregnant women and families with children under 12 months of age through mobile phones. Educational messages are sent twice weekly and are timed to the stage of pregnancy or age of the newborn. In a report exploring MAMA program implementation experiences in four countries, several factors were noted that may impact feasibility and acceptability . SpecifiFor pilot program implementation, female community health workers were selected from communities with active health posts. Each selected community health worker was trained to recruit and enroll 10 pregnant women and offer enrollment to their husbands, in collaboration with the Provincial Health Directorate and the Basic Package of Health Services implementer. Recruitment was primarily achieved through home visits to prospective clients, although some participants were recruited at locations such as health posts and adult literacy classes. For this pilot program, eligibility for registration was confined to pregnant women and their husbands who lived within the catchment area of the health post of the recruiting community health worker and had access to a functional mobile phone. Potential clients were informed that program staff might call them to confirm message receipt and program functionality. The community health workers ensured that women and men who registered were eligible and provided clients with a choice of written text (SMS) messages or automated recorded voice calls, as well as a choice for time of day to receive the calls or text messages. If the couple shared a phone, the woman was offered these choices, as she was considered the primary subscriber. The first message was timed to the woman’s current week of pregnancy and continued sequentially from that point. Messages encouraged clients to discuss MNCH care with their spouses and families, and promoted healthy practices such as exclusive breastfeeding and seeking health care services, including antenatal care, skilled attendance at delivery, and infant immunization.Monitoring was conducted by HEMAYAT program staff and community health supervisors through three approaches: direct field supervision and mentoring during the community health worker-led registration process; monitoring of the data dashboard incorporated with the MAMA platform reflecting the number of messages sent, received, and nonresponsive numbers; and project staff calls to registered clients to confirm number validity, message receipt, and whether the registered client met the criteria for the pilot registration process. As the first and third approaches were employed early in pilot program implementation, system errors such as some mobile networks not receiving messages were identified and repaired.For baseline data collection, all households that had enrolled in the MAMA program in the four included provinces were approached and program subscribers were recruited to participate in the study no more than 10 weeks after enrolling in the MAMA program. The community health workers who had promoted the program and registered subscribers introduced the data collection team to female subscribers and their husbands or male heads of household. Eligible participants were pregnant women and their husbands subscribing to the pilot program at least 4 weeks earlier and verbally consenting to study participation. Following explanation of the assessment, participation was offered, and verbal informed consent was obtained from subscribers interested in study participation by data collectors of the same sex. For follow-up data collection, households were revisited approximately 6 months after the baseline survey.Structured interviews using paper questionnaires were conducted with study participants by trained, sex-matched data collectors fluent in the language(s) predominantly spoken in that province. Translated questionnaires for women and men were field-tested with volunteers from different ethnic groups across implementation sites. The baseline questionnaire included sections detailing household characteristics, the program registration process, and MNCH-related knowledge and attitudes. Interviewers asked program participants about their attitudes toward discussing MNCH and specific practices, household decision making about MNCH care, and their knowledge of several maternal and newborn health issues featured in MAMA messages. We developed the knowledge questions based on content used to measure MNCH knowledge among men and women in assessments and evaluations performed in Afghanistan both within our group and in larger household-level surveys ,27. KnowFeasibility measures included the proportion of female respondents who had to ask permission to register and from whom they asked permission; whether they were asked what time of day they prefer to receive messages and whether they received messages at their preferred time; continued to subscribe and receive messages after 6 months and the number of messages that respondents reported receiving per week on average; and reports of missed messages with stated reasons for missing the MAMA messages. Acceptability measures included the proportion of respondents who reported any and specific benefits to their participation in MAMA; reported that a member of their household listened to or read the messages and who it was ; stated that including their husband or their mother-in-law was beneficial; recommended MAMA use to someone else; and discussed MAMA with other pregnant women or new mothers.Trained male and female data collectors administered the study instruments to consenting participants of the same sex in a private room in the household. The same data collectors conducted interviews at baseline and follow-up sessions; community health workers introduced the data collection team at households during study recruitment and at baseline data collection, consistent with cultural norms. Baseline data were collected in July and August 2018. Follow-up interviews were conducted with the same participants in January and February 2019, using a similar structured questionnaire including the same knowledge and attitude questions and adding questions on exposure to and acceptability of the MAMA program. Additionally, the MAMA mobile platform and database automatically recorded the dates and time of messages that were sent and received. We extracted the overall number of messages received for each participant at follow-up data collection.We used STATA Version 15  to descriptively analyze sociodemographic characteristics, message exposure, and acceptability measures, disaggregated by sex and message type (SMS text or voice message). Results were summarized at baseline and at follow up for attitudes, decision making, and knowledge of MNCH topics. Additionally, we conducted exploratory analyses to examine the change in selected MNCH knowledge measures between baseline and follow up using the McNemar Chi square test for paired data, with a two-sided alpha of .05 and 80% power.The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.Across the four provinces sampled, 895 pregnant women were registered in the MAMA pilot program from May to August 2018. Over two-thirds  of female program participants and 427 husbands who were confirmed subscribers to the program agreed to participate in the study. A total of 499/625 (79.8%) women and 306/427 (71.7%) men completed both baseline and follow-up questionnaires. In some households, more than one woman or man enrolled in the study. However, because telephone numbers were used as the unique identifier to link baseline and follow-up data for participants, if more than one person of the same sex had the same phone number, it was impossible to link the data from the two time points to the correct participant. Thus, due to this uncertainty, we removed records for both participants from the final dataset. Therefore, we present results from 453/625 women (72.5% of the pretest sample) and 276/427 men (64.6% of the pretest sample) with complete baseline and follow-up data, disaggregated by sex.Among both women and men, about two-thirds of participants  opted to receive voice messages and one-third  chose to receive SMS text messages. Sociodemographic and household characteristics of participants indicate that many women did not own a phone and used someone else’s phone to access the program, and most of the participants had primary-level or no education . Over thThe majority  of female participants overall reported that they had to seek the permission of a gatekeeper to enroll in the MAMA program; this gatekeeper was usually the woman’s husband, although in some cases it was the mother-in-law . Some suAfter 6 months of program participation, the automated database confirmed that across groups, 95%-97% of respondents had not cancelled their subscription and were continuing to receive messages . Of the Most women and men cited multiple benefits when asked about perceived program benefits ; gainingWe assessed attitudes toward MNCH, including comfort discussing maternal and newborn care with family members, correct knowledge and acceptance of exclusive breastfeeding and birth spacing, and attitudes about utilizing facility-based care during pregnancy and delivery . The proWith respect to decision making about MNCH care, and when to seek services, reported joint decision making by respondents and their spouses together increased between time points . In geneWe examined differences between baseline and follow up in participants’ MNCH knowledge that overlapped with the MAMA message content. Generally, knowledge was higher for all indicators among women compared to men at both time points . KnowledOur results indicate that the adapted MAMA program was feasible and acceptable to implement in Afghanistan. Consistent with other evidence from Afghanistan, most participants preferred to receive voice calls rather than SMS text messages . Nearly The proliferation of mobile phones is an important development in the Afghan context ,28; howeA recent review found mixed results and insufficient evidence that mHealth interventions improve MNCH outcomes . HoweverAnother unique aspect of this study is the comparison of voice to SMS text message formats regarding participant characteristics, feasibility, and acceptability measures. In several studies conducted in a variety of contexts, voice calls were preferred over SMS text messages ; howeverTwo papers have presented findings from different analyses of the MAMA program in Bangladesh, called Aponjon, which is operated by the nonprofit social enterprise Dnet ,25. The There are several limitations of this study. We acknowledge that the single-group study design precludes attributing changes in knowledge, attitudes, and decision making to the MAMA intervention, and therefore we treat these results as exploratory. The ability to generalize our findings is also limited. Those who opted to subscribe to the MAMA program may differ substantially from those who opted not to subscribe; however, community health workers reported that very few of the women they approached did not subscribe. Additionally, our analyses included only 55% of women who subscribed to the pilot program; therefore, these results may not reflect subscribers as a whole. Participants who could be located and consented to be interviewed at both time points may have had higher engagement and more positive views of the program. Our measurement of MNCH knowledge items reflects participant knowledge at different stages of partial exposure to the program. Because the baseline interview was administered in some cases up to 10 weeks after enrollment and participants were at various stages of pregnancy, some participants were already exposed to some of the knowledge items we assessed at baseline, while others were not. At follow up, participants had similarly varying exposure to newborn care messages. Similarly, due to phone sharing within households, we elected not to assess whether knowledge change was proportionate to the number of messages received. Finally, there may have been confounding effects through exposure to other MNCH information channels during the pilot program. Community health workers at the community level and health care providers are the primary sources of MNCH messages and education in rural Afghanistan, although some households may also receive health information from other community-level volunteers , radio, or television ,32. We aWe found that Afghan women and men welcomed an mHealth MNCH educational program and were largely able to enroll and access weekly voice or text messages with few technological complications, and continued program use from pregnancy through early infancy. Participants reported that they benefited by gaining health knowledge, and many stated that they discussed the messages with their family and peers. Joint decision making between spouses appears to have increased during the intervention period, and including husbands in the program was more often described as beneficial by participants when compared with the discussion of messages with mothers-in-law; both are potential areas for further research in this cultural context. There were improvements in MNCH knowledge measures among both male and female participants; however, given the important limitations of the research that has been conducted on this approach, future research of this and similar programs should be designed to rigorously evaluate the effect of the intervention on MNCH knowledge and health behaviors. Prior to further effectiveness evaluation, we hope that the data from this assessment will be used to secure ongoing and sustained support to allow the MAMA program to be refined and implemented at a greater scale in Afghanistan.


The pediatric surgery residency program is new in Saudi Arabia. As with any new program, residents experience a degree of fear and anxiety about their future in the program. The aim of this study is to examine residents’ satisfaction with the program.This study included an online survey examining residents’ satisfaction. It consisted of demographic, financial, personality, program-specific, and burnout assessment questions. All questions were multiple-choice items.Descriptive statistical data are presented as frequency distributions and percentages. Cross-tabulations and chi-square tests were used at the bivariate level of analysis to compare subgroups and identify factors of satisfaction. Binary logistics regression was used at the multivariate level of analysis to compute the odds ratio of significant variables.Thirty-one out of 32 residents responded to the survey. The multivariate logistic regression showed that current year of residency, current relationship status and personality statistically affected the satisfaction of residents. Senior residents, i.e., residents who had spent four years or more in the program, were 40 times more likely to be satisfied than were residents in their first year; residents who were married were more than eight times more likely to be satisfied than were residents who were single; and residents who were neutral or who agreed that they were very indecisive were 8% less likely to be satisfied than were those who reported being decisive. Gender was statistically significant, such that males were more satisfied than females were.Although the pediatric surgery residency program is new, this survey has shown that there is generally a high rate of satisfaction. Satisfaction was also observed more in senior residents. Further studies should be conducted in the future when residents graduate from the program. Residency training programs are diverse in regard to many aspects, such as structure, workload, expectations, and experience. Some publications have examined residents’ satisfaction and well-being in particular programs –3. The pDifferent tools of assessment, formative and summative, are used based on the curriculum. These tools are logbook for surgical procedures, end of year written exam, structured oral exam, objective structured practical exam (OSPE), first part written exam, and final written and clinical exams.www.scfhs.org.sa.The program is considered highly competitive in the Saudi Commission for Health Specialties matching system and is one of the top five programs since it started. More details of the program are available as a supplement and can be accessed at The residents are relatively young which makes them vulnerable to burnout and with any new program, residents experience a degree of fear and anxiety about their future in the program . The aimThis study was approved by the Institutional Review Board. Project No. E-20-5007 and a written consent was obtained from the study participants. In April 2020, a voluntary online google documents survey was electronically distributed to all the residents in the training program using the list of registration at the Saudi Commission for Health Specialties for pediatric surgery program, Saudi Arabia. The online-based survey consisted of 15 demographic, financial, and personality questions, 20 program-specific questions, and 22 burnout assessment questions. All questions are multiple-choice items. The full survey is available as a supplement.The data processing and analysis were performed using the Statistical Package for Social Sciences (SPSS) . Descriptive statistical data are presented as frequency distributions and percentages. Cross-tabulations and chi-square tests were used at the bivariate level of analysis to compare subgroups and identify factors of satisfaction. Binary logistics regression was used at the multivariate level of analysis to compute the odds ratio of significant variables.Satisfaction was measured by asking residents to select responses on a scale on which dissatisfaction is indicated if they chose “disagree” or “strongly disagree” and satisfaction if they chose “neutral”, “agree”, or “strongly agree”.n = 22) showed that the items have an accepted measure of internal consistency and can be used to generate a construct. Some questions were reversed to ensure that the responses from the questions were directional. The questions were thereafter compiled together. Respondents who had scores below 60 on the scale were categorized as satisfied, while respondents with scores above 60 on the scale were categorized as not satisfied.For burnout questions, a dichotomous variable representing the satisfaction of residents was generated using all 22 items on the scale provided by the survey. A reliability test using Cronbach’s alpha was conducted to measure the internal consistency of the items or questions. A Cronbach’s alpha of 0.70  responded to the survey. Twenty-eight residents were approximately equally distributed by postgraduate year (PGY), from PGY-1 to PGY-4. Only three residents were in PGY-5. Nineteen females and 12 males were aged between 25 and 30 years. Most of the residents were single (64.5%). Half of the residents took care of other people similarly to how they would take care of their parents. Of those who took care of others, 4 (26.7%) provided financial help, such that they sent money regularly to their parents; 3 (20%) took care of their parents’ social needs, such as accompanying them to their appointments or social events; and 8 (53.3%) took care of both the financial and social needs of their parents. Most of the residents believed that their monthly salary was sufficient for basic requirements.2 = 9.83, p < .05). Residents who had spent 4 years or more in the program were satisfied more than were residents in their first year. Similarly, there was a significant association between gender and the satisfaction of residents  = 4.29, p < .05) and between current relationship status and the satisfaction  = 6.23, p < .05). The percentages of respondents who were satisfied or not did not differ significantly across all other variables  = 7.89, p < .05). Satisfaction did not differ among those with other personality types  respondents were satisfied, while 15 (48.4%) respondents were not satisfied.p < .05); residents who were married were more than eight times more likely to be satisfied than were residents who were single ; and residents who were neutral or who considered themselves to be very indecisive were 8% less likely to be satisfied than were residents who reported being decisive . Gender was statistically significant, such that males were more satisfied than females were (Table The multivariate logistic regression to determine the factors affecting the satisfaction of residents showed that their current year of residency, current relationship status, personality statistically, and gender affect their satisfaction. Senior residents, i.e., residents who had spent 4 years or more in the program, were 40 times more likely to be satisfied than were residents in their first year (O.R. = 40.160, The pediatric surgery training program is new in Saudi Arabia. With any new program, anxiety and many other concerns may arise regarding the program and the future of the gradates. We conducted this survey 4 years after the beginning of the program to examine and explore residents’ satisfaction with the program. Resident satisfaction is an important performance metric for surgery programs. Low satisfaction can lead to resident attrition . IncreasFrom the survey, there was a significant association between current year of residency and the satisfaction of residents, where satisfaction improved significantly when they became seniors. The more senior the resident, the more satisfied they were. Senior residents, i.e., residents who had spent 4 years or more in the program, were 40 times more likely to be satisfied than were residents in their first year. This finding could be explained by the fact that residents learned more as they progressed through the program, or may be due to the many rotations they have to go through during their more junior years, which may in turn affect their satisfaction.There was a significant association between gender and the satisfaction of residents, and there was a statistically significant association between current relationship status and satisfaction. Single female residents were less satisfied with the program than were males or married residents.Demographic and socioeconomic factors have been reported as reasons for dissatisfaction in the literature , but in Most of the residents were satisfied with the program structure, faculty, and different rotations. All of the residents except one would choose the same pediatric surgery training program if they had the chance.The survey contained 22 questions about burnout. Although most residents were satisfied with the program in general, half of them were dissatisfied when answering burnout questions. Burnout is experienced as emotional exhaustion or depersonalization , 10. A rTraining program satisfaction surveys may guide to implement interventions that improve satisfaction and reduce burnout . Using rThis survey had some limitations. Although the response rate was 96.8%, the total number of residents was small. In addition, the survey might have produced different results if it had been distributed after a few years, when some residents had graduated from the program.Although the pediatric surgery residency program is new, this survey has shown that there is generally a high rate of satisfaction. Satisfaction was also observed more in senior residents. Further studies should be conducted in the future when residents graduate from the program.


Emerging evidence shows that homelessness continues to be a chronic public health problem throughout Canada. The Bridge Healing Program has been proposed in Edmonton, Alberta, as a novel approach to combat homelessness by using hospital emergency departments (ED) as a gateway to temporary housing. Building on the ideas of Tiny Villages, the Bridge Healing Program provides residents with immediate temporary housing before transitioning them to permanent homes. This paper aims to understand effective strategies that underlie the Tiny Villages concept by analyzing six case studies and applying the lessons learned to improving the Bridge Healing Program. After looking at six Tiny Villages, we identified four common elements of many successful Tiny Villages. These include a strong community, public support, funding with few restrictions, and affordable housing options post-graduation. The Bridge Healing Program emphasizes such key elements by having a strong team, numerous services, and connections to permanent housing. Furthermore, the Bridge Healing Program is unique in its ability to reduce repeat ED visits, lengths of stay in the ED, and healthcare costs. Overall, the Bridge Healing Program exhibits many traits associated with successful Tiny Villages and has the potential to address a gap in our current healthcare system. A report from 2016 estimated that 235,000 Canadians experience homelessness every year, indicating that homelessness continues to be an ongoing problem in Canada  housing developments and increases in neighbourhood crime”, and that inviting police and emphasizing security should be a priority in public meetings.No link between affordable housing and decreased property values have been found.Arguments that affordable housing will strain infrastructure , can be valid or a mask for discriminatory opposition. Such concerns can be addressed by the fact that the project must meet community planning and engineering requirements, and higher density in housing overall requires less infrastructure building by the city.Education and public engagement is key to reducing stigma around affordable housing, including effective, tailored, and robust communication platforms such as fact sheets, website, newsletters, presentations, etc.Project planning should include “developer, people and agencies that would benefit from the project” from an early stage, and selection of the neighborhood for the project should be carefully considered including potential surveys about public reaction to such a project.Effective monitoring strategies should be set up to gauge the success of public engagement and to establish the long-term value of projects to the neighborhood, with the potential to sway public opinions post-project.Given that there is extensive evidence of NIMBYism for tiny home projects around the world and even in Alberta, measures tackling NIMBYism have to be addressed for any future projects. In a Canadian literature review on NIMBY by Alberta Centre for Child, Family and Community Research, the review establishes frameworks to address NIMBYism for affordable housing. Their conclusions include the fact that :“NumerouOverall, Tiny Home developments have historically encountered NIMBYism. While the reasons for NIMBYism are multifaceted, accounting for NIMBYism is key to a project’s success . CurrentConsideration of the intersections between race and homelessness has not been thoroughly examined in many cases of Tiny Homes. Of the cases examined, four of these studies do not have data on the percentage of non-white individuals in their program , nor do they outline programs that address any plan to create specific resources for homeless individuals of a systematically oppressed racial background. Dignity Village denotes that of non-white individuals present in their program, 1% are Black, and 3% are Indigenous . This maWhen considering Edmonton’s makeup of homeless individuals, Indigenous people are vastly overrepresented, making up 48% of the total population ,63. ThisIn our evaluation of the proposed Bridge Healing Project, it does not include sufficient programming that specifically addresses the specific needs that Indigenous or other Non-White homeless individuals require. This represents a major flaw that needs to be addressed in the future.In addition to combatting general homelessness, what is unique about the Bridge Healing Program is its potential to have a positive impact on public health by reducing repeat visits to the ED, decreasing length of stays, and reducing hospital costs. The data on the correlation between deteriorating health and homelessness has become increasingly clear over the years. A report studying 1165 homeless Torontonians found that homeless residents substantially use hospital services at a higher rate compared to control groups  with an average 9.1 ambulance encounters, and 2.0 ED visits per homeless person per year . These EThese problems are a major contributor to increased healthcare costs ,73. In fAs of August 2020, there are no formal plans to determine how the Edmonton Bridge Healing Program will be evaluated but it has been proposed among team workers that one of the Capstone teams will be responsible. This team hopes to conduct updates and surveys (similar to KWV and Dignity Village) wherein they track how many people use the Program, the average length of time, and costs, and the team will also interview residents to determine user satisfaction ,37. AnotThrough our research, we have identified some key parameters that have been shown to be good indicators of an affordable housing program’s relative success ,79,80. TFirst proposed in 2009, “The Ten Year Plan to End Homelessness” was an Edmonton initiative intended to eradicate homelessness in the city by 2019 . Based oOne of the major reasons for this failure was the lack of funding that the program received, which consequently led to a shortage of affordable homes . The iniWith regards to the Edmonton Bridge Healing Program, we see that this new proposal aligns with the goals of the city. Both subscribe heavily to a housing-first initiative and the Edmonton Bridge Healing Program will serve as a means of outreach to obtain affordable homes. Furthermore, when the city conducted a survey of 1600 community members, they found that increased affordable housing units with supports  were one of their highest priorities. As the Edmonton Bridge Healing Program intends to provide support to all graduates even after graduates begin independently living, it appears that this new program also meets the demands of the public.After reviewing the case studies of the six Tiny Villages, their experiences point to a net benefit for homeless people in Canada. The villages are all unique and adapted to fit the specific needs and circumstances of the local environments and policies.A Collaborative community wherein residents can work with staff to better the village as a whole. Case studies have shown that this fosters a sense of equity among community members and can be a defining feature of the project.Public support or at the very minimum, strategies that improve public awareness and public relations on the benefit of Tiny Villages for the homeless.Adequate funding for all housing and services costs.The availability of affordable permanent or semi-permanent housing for residents upon graduation from Tiny Villages programs.From the information we gathered, we built an initial  model for those seeking to design a Tiny Village. We conclude that an ideal model should have the following elements:Applying these lessons to the Edmonton Bridge Healing Program, we conclude that the project has competently collaborated with local organizations to provide temporary housing, occupational opportunities, and health services to the homeless. Efforts to secure funding to maintain and expand the program are sought through outreach to investors, social and capital marketing and eventually through support from health care organizations and the public health system.The program also anticipates relatively short stay times for residents compared to examples in the case studies, but this might be offset by the increasing amount of time spent by the program in helping find affordable housing for their residents. While this project has not encountered community opposition yet, the project should start making attempts to educate the public more about the initiative and be prepared to address potential hostilities as the project moves forward. One limitation of the Bridge Healing program is their current lack of consideration regarding ethnicities and race, despite Indigenous homelessness being greatly over-represented in Edmonton. Although there is a lack of data on how race/culture play in the Tiny Home projects we looked at, race/culture are important factors that affect inclusion and success of individuals in more traditional housing models/projects. In turn, the Bridge Healing Program should acknowledge and be aware that race/culture may have an impact on the project going forward. Even considering these limitations, the successful deployment of Tiny Villages to temporarily house homeless residents has the potential to effectively reduce the number of repeat ED visits from homeless residents seeking shelter and, consequently, to help diminish healthcare costs and alleviate ED overcrowding while also helping to combat homelessness in Canada.