The Centers for Disease Control and Prevention (CDC) funded the Colorectal Cancer Screening Demonstration Program in 2005. To assess the feasibility of providing community-based colorectal cancer screening, CDC is conducting a multiple-case study as part of a larger evaluation effort. This article highlights key facilitators and challenges common to the five programs studied during the start-up period.The multiple-case study that includes all five program sites is being conducted during the 3-year program as part of process evaluation efforts. Data collection for program start-up occurred during August 2005 through September 2006. Data include approximately 70 interviews with program staff and stakeholders, document review, and observations. Both case-specific and cross-case analyses were conducted.On the basis of the cross-case analysis, we identified four factors that facilitated program start-up and four factors that challenged program start-up. Facilitating factors included 1) pre-existing program infrastructure, 2) partnerships, 3) clinical expertise, and 4) program champions. Factors challenging program start-up included 1) contracts with endoscopists, 2) resources for treating medical complications of screening and for cancer treatment, 3) administrative barriers, and 4) resource limitations. Additionally, preplanning was critical, allowing programs to efficiently initiate activities once funds became available.The most important facilitator identified was the ability to build on pre-existing infrastructure, which provided experienced staff, partnerships, and provider relationships, as well as aided program integration with other chronic disease programs. Results also suggest that substantial planning and partnership development can begin before funds are secured to implement a colorectal cancer screening program. Colorectal cancer is the third most common cancer among both men and women in the United States . Althougwhat happened ; developing program models, policies, and procedures; enlisting partners; developing data collection and reporting systems; planning client recruitment strategies; and identifying resources for treating complications. A description of individual program models and start-up activities are detailed elsewhere . This maWe conducted a multiple-case study ,5 duringGiven the multiple-case study design, we conducted both case-specific and cross-case analyses ,5,10. ToOn the basis of the cross-case analysis, we identified four factors that facilitated program start-up and four factors that challenged program start-up. Facilitating factors were 1) pre-existing program infrastructure, 2) partnerships, 3) clinical expertise, and 4) program champions. Challenges to program start-up were 1) contracts with endoscopists, 2) resources for treating medical complications and for cancer treatment, 3) administrative barriers, and 4) resource limitations.Pre-existing program infrastructureThe most important facilitator of program start-up was the use of pre-existing health program infrastructure, on which CRCSDP sites built to develop their colorectal cancer screening programs. Sources of infrastructure included the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program, other health initiatives such as prostate cancer screening programs, colorectal cancer screening programs in other parts of the states, previous colorectal cancer screening pilot programs, previous research assessments of colorectal cancer screening capacity, and structures and systems within the grantee institution itself . NBCCEDPThe NBCCEDP was identified as an important framework for program planning in four of the CRCSDP sites by offering structure, systems, and experience. The fifth site did not have experience with the NBCCEDP. The CRCSDP sites typically used components of the NBCCEDP model  and modified them to fit their new model for colorectal cancer screening. For instance, sites used their pre-existing NBCCEDP network of clinical providers to deliver screening services  and make referrals for colonoscopy. The sites also recruited MAB members from the NBCCEDP to establish a new MAB for the CRCSDP, they integrated colorectal cancer-related data management and billing into existing NBCCEDP systems, and they planned to recruit clients for colorectal cancer screening through "in-reach" . One stakeholder working with a provider site said, "When it came time to start policies, procedures, contracts, I think I had a leg up on that because of doing all of that with [NBCCEDP]."PartnershipsPartnerships emerged as another important facilitator of program start-up, yielding benefits including technical support, expertise, and resources. Most important among partners were the Comprehensive Cancer Control (CCC) programs in the states with CRCSDP sites. CCC activities typically are coordinated by the state health department and engage a wide range of stakeholders to develop and implement statewide cancer control plans. In some cases, the CCC programs had planned well in advance of the CRCSDP initiative and provided important support during the start-up period. A unique contribution of the CCC programs involved brokering access to a network of well-established relationships, such as with leading colorectal cancer experts in the state who could be recruited for participation on the MAB. In addition, individual members of the CCC programs were ready to support and advocate for the new colorectal cancer screening programs. One staff member said, "I don't know if we could have had some of the doors open as wide and as quickly if we didn't have the comp cancer program." In addition, CCC groups provided instrumental in-kind staff support and financial resources to the CRCSDP sites.For two of the sites, CCC programs played a central role in applying for CRCSDP funds from CDC. One person noted, "The [colorectal cancer task force of the CCC program] had come up with its own mission statement and vision, so there had been a lot of team building before the writing of the demo grant. It was a good foundation in order for us to move forward." In addition, some of the CCC groups had been awarded competitive funds to host a Dialogue for Action, a day-long event sponsored by the Prevent Cancer Foundation and CDC to increase colorectal cancer screening by convening providers, medical specialists, researchers, and representatives of government and nongovernment agencies. These events had helped to mobilize providers, many of whom were later invited to participate in the CRCSDP.Other key partners included the American Cancer Society (ACS), local universities, and cancer treatment centers . In one Clinical expertiseInterviewees emphasized the value of having clinical expertise available early in the start-up process. Staff members suggested that the CRCSDP was more medically complex than the NBCCEDP, which several program directors also managed. Clinical expertise came primarily from two sources: program staff and members of MABs. Individuals with expertise in the delivery of colorectal cancer screening services assisted in developing program policies, patient flow processes, data collection systems and related forms, treatment plans, and quality assurance measures.One staff member acknowledged the challenges of initiating the CRCSDP without access to in-house staff possessing clinical knowledge:I felt like there needs to be more clinical expertise in the department. Because we didn't have that, we really struggled. . . . [We] had difficulty understanding the various protocols associated with the tests and communicating with physicians and clinicians . . . so I think, would this program start over again, I would say you really need to have a clinical lead with expertise and background in this area.Others believed their staff with clinical training lent credibility to the new program and facilitated communication between the program and its MAB, as well as participating providers. One person said:I think you do need a clinical person. I don't know that it has to be a physician, but I think you at least have to have a nurse to take a look to see that things are making sense. I also think that's true when you're talking with providers in terms of bringing them on board — they need to understand that you really know what you're talking about.Program championsProgram champions were another facilitator of program start-up. Although champions were identified at various levels, the program directors often were viewed as the overall champion during start-up. Their understanding of the whole initiative, their ability to build relationships, and their reputation for past successes led others to want to be involved with the new CRCSDP. One physician on an MAB said, "I've worked with [the program director] previously . . . so she was a major reason for my participating on this project."Champions were identified at other levels of the program as well. In several cases, programs engaged leading gastroenterologists in their state or region to participate in their MAB; these physicians often became champions for the program during the start-up period, offering legitimacy for the CRCSDP in the medical community. One staff member noted, "If other doctors hear that [MAB member] has okay'd something, or that he agrees with it, then they are okay with it because of his reputation and history of involvement with cancer issues."Champions also existed at individual provider sites, negotiating the bureaucracy of their own institutions to facilitate integration of the CRCSDP into their systems and build support for its implementation. One physician, acknowledging this role, remarked, "I see myself as a consultant, a colon and rectal surgeon who knows the problem, who knows what surgeons do, what gastroenterologists do, what patients do, and what hard-headed institutions do who don't want to yield." These champions all exhibited important leadership and commitment toward ensuring the successful start-up of the CRCSDP.Contracts with endoscopistsContracting endoscopists to conduct colonoscopies proved to be a challenge for some sites. Staff and stakeholders identified the following barriers to endoscopists' participation: 1) burdensome government contracting processes; 2) ethical, financial, and liability concerns about the lack of treatment for people diagnosed with cancer, even though the individual programs had identified sources for treatment; 3) capacity limitations among providers; 4) Medicare reimbursement rates being seen as low compared with other insurance sources; 5) data and paperwork requirements for the CRCSDP; 6) overall disruption to the endoscopist's practice in integrating a small number of CRCSDP clients; and 7) concerns about poor compliance  in a low-income client population.One staff member acknowledged that, overall, endoscopists or their institutions might perceive the program to be too burdensome:It's sort of a balancing act . . . even with concerned physicians [gastrointestinal specialists] who are interested and want to do this systematic approach. It may not make sense when you look at it from the business manager's side, or paperwork demands. The [NBCCEDP] program disrupts every aspect of a program from medical people, billing staff, contract people, all of them — our system disrupts their systems. It's not really value added for them; there's no advantage for them.On the basis of their start-up experience, interviewees recognized the need to initiate relationships with endoscopists early on, engaging them in the planning process from the start. One physician suggested, "You need to find somebody  who has the passion to understand the importance of screening and understands that it will cost them time that they may not be paid for, but that it's the right thing to do."Resources for treating medical complications and for cancer treatmentConsistent with the NBCCEDP, CRCSDP funds could not be used to pay for cancer treatment, and CDC required that sites applying to participate in the CRCSDP secure treatment resources as a condition of funding . SimilarSites also faced the practical challenge of requesting no-cost treatment services from local cancer centers and hospitals or considering how best to facilitate clients' applications for emergency Medicaid or other financial assistance. One staff member noted, "[Securing resources is] very 'piecemeal.' . . . We've had problems in our other program where we couldn't get a patient on emergency care, and having to piece together surgery, chemo, pharmacy support, etc., is incredibly difficult." In more rural settings, there were concerns that cancer centers in the largest cities would shoulder the burden for treatment. The lack of treatment resources also deterred some providers from participation in the CRCSDP, given their own ethical concerns, as well as worries about a potential financial burden for their practice or institution.To address this challenge, program staff emphasized the importance of developing partnerships with potential sources of cancer treatment, including cancer centers and hospital-based oncology departments. In several instances, MAB members facilitated these relationships. In addition, staff members suggested the need to identify more than one treatment provider to "share the burden."Administrative barriersAdministrative challenges such as hiring and retaining staff, establishing contracts, and developing and implementing data and billing systems led to delays in the start-up process. In one case, pay scales were blamed for the inability to hire a nurse coordinator and forced the program to alter its program model more than 2 months into the start-up period. In another, staff turnover in a key position left remaining staff to fill the void during a time-consuming hiring process. Contracting proved problematic for several CRCSDP sites, particularly for providers who had not worked with public agencies in the past. One staff member said, "Establishing new contracts with people we've never worked with before is more challenging. The [agency contract] is long and can shock potential contractors." Finally, developing the data management system and integrating it into existing service delivery systems was time consuming and challenging, and in some settings, the reporting requirements were perceived as burdensome. "We're coming to [the providers] saying, 'For our 20 patients, can you give us a paper bill, fill out this special form, use a different appointment system than what you normally do, and by the way, can you also sit on our MAB?' "Resource limitationsThe final challenge to program start-up involved resource limitations. Given expectations that programs would implement screening at 6 months, the CRCSDP sites allocated a substantial portion of their first-year budget to screening costs and made difficult compromises in staffing and other program components. This left some sites relying primarily on existing staff  supported by other program funds and with other responsibilities. One staff person said, "The CCC has basically evolved in supporting the CRC program for the past 2 years. If we hadn't had that ability to move staffing responsibilities around, I'm not sure we would have wanted to start the project." Another staff person emphasized the importance of in-kind contributions: "If CDC gets all this information back and thinks that what we're actually spending to make this program work is what it would actually cost, then they're not in line. . . . I was surprised though with what we were able to accomplish with the funding we got." On the basis of the start-up experience, staff members suggested that financial resources should be obligated to support key coordinating positions for the program.We identified several important facilitators for program start-up, including using pre-existing infrastructure, building partnerships, engaging clinical expertise, and involving strong champions. Of these, the use of pre-existing infrastructure was the most valuable in advancing the start-up of the CRCSDP. Attempts to integrate the CRCSDP with other chronic disease programs such as the NBCCEDP, WISEWOMAN, and other screening programs are consistent with broader calls in public health to move from "silo-funded" categorical programs to a more integrated model . This inResults also suggest that critical planning for colorectal cancer screening and related partnership building had been conducted by sites even before the CDC funding opportunity arose. This work seemed to position the programs to compete successfully for the CRCSDP award and to move more quickly through the start-up period to initiate screening. These results suggest that even for states with minimal or no funding yet available for colorectal cancer screening, important planning and partnership development can be accomplished to prepare for future opportunities. Once funding is secured, such efforts are likely to both shorten the time needed for program start-up and support its success. Furthermore, programs can build partnerships with clinical experts and potentially diminish challenges related to contracting with endoscopists if relationships with these providers can be established early in the planning process and their support enlisted.Champions emerged as important in negotiating the multi-organizational character of the CRCSDP service delivery environment. Given the full continuum of screening and diagnostic services  offered through the CRCSDP, sites developed program models that involve a networked system of agencies or departments, each providing a unique service or services within that continuum . This tyOur findings also highlight concerns about securing resources for treating unanticipated complications of screening and for treating cancer in an uninsured and underinsured population. The NBCCEDP experienced similar challenges before the National Breast and Cervical Cancer Prevention and Treatment Act of 2000 ; those pFinally, results suggest that reliance on staff with competing programmatic responsibilities may further challenge program start-up. Given the intensive effort required to develop the CRCSDP, allocating adequate resources for dedicated staff is important. This may be especially crucial given the clinical complexity of the program, the involvement of multiple provider specialties, and the comprehensive range of services provided .Although these findings represent only five sites, the identified facilitators and challenges to program start-up provide important information for other emerging programs. The facilitators were common across all CRCSDP sites in supporting the start-up of the CRCSDP, and a new program is likely to struggle without attending to each. In contrast, some of the challenges  are more likely to be site-specific, depending on the unique characteristics of the program and its context, and others  may reflect system-level challenges. The formative evaluation conducted through this case study is yielding results that provide information for ongoing program improvement and for more widespread screening efforts in the future. Subsequent reports will provide evaluation findings from the screening implementation phase of the CRCSDP.


The qk gene encodes 3 major alternatively spliced isoforms that contain unique sequence at their C-terminus dictating their cellular localization. QKI-5 is a nuclear isoform, whereas QKI-6 and QKI-7 are cytoplasmic isoforms. The vqk mice harbor an enhancer/promoter deletion that prevents the expression of isoforms QKI-6 and QKI-7 in myelinating cells resulting in a dysmyelination phenotype. It was shown that QKI regulates the differentiation of oligodendrocytes, the myelinating cells of the CNS, however, little is known about the role of the QKI proteins, or RNA binding proteins in PNS myelination.The KIP1 and myelin basic protein (MBP), markers of Schwann cell differentiation. QKI-6 and QKI-7 expressing co-cultures contained myelinated fibers that had directionality and contained significantly thicker myelin, as assessed by electron microscopy. Moreover, QKI-deficient Schwann cells had reduced levels of MBP, p27KIP1 and Krox-20 mRNAs, as assessed by quantitative RT-PCR.To define the role of the QKI proteins in PNS myelination, we ectopically expressed QKI-6 and QKI-7 in primary rat Schwann cell/neuron from dorsal root ganglia cocultures. We show that the QKI isoforms blocked proliferation and promoted Schwann cell differentiation and myelination. In addition, these events were coordinated with elevated proteins levels of p27Our findings suggest that the QKI-6 and QKI-7 RNA binding proteins are positive regulators of PNS myelination and show that the QKI RNA binding proteins play a key role in Schwann cell differentiation and myelination. QKI-5 contains 30 unique amino acids that harbor a nuclear localization signal and thus QKI-5 is nuclear qk promoter deletion observed in vqk mice mainly prevents the expression of QKI-6 and QKI-7 isoforms, hence the balance between the isoforms is lost and QKI-5 is the predominant isoform remaining vqk mice QKI-6 transgenic allele rescues the CNS myelination defects of the vqk mice The KIP1 (cyclin-dependent kinase inhibitor), MBP and Krox-20 mRNAs and these sequences were bound by the QKI proteins in vitro with high affinity using gel-shift assays KIP1 mRNA in vivo and lead to the stabilization of the mRNA half-life in oligodendrocytes The QKI isoforms are members of the KH-type RNA binding protein family that bind specific RNA sequences with high affinity KIP11 has been associated with Krox-20 Schwann cells in the PNS establish close contact with axons and produce myelin, a specialized membraneous structure that permits rapid nerve conduction vqk mouse, axons of sciatic nerves exhibit a separation of intraperiod lines in the myelin sheath, and a variation of Schmidt-Lanterman incisures KIP1 and Krox-20 mRNAs, as assessed by quantitative RT-PCR. These data demonstrate that the QKI-6 and QKI-7 proteins are potent regulators of PNS myelination.In the PNS of the quaking viable mice (vqk) exhibit PNS dysmyelination vqk mice. These observations suggest that QKI-6 and QKI-7 may regulate Schwann cell differentiation in vivo context of glial cells in the proximity of neurons The As the QKI-6 and QKI-7 isoforms are known to promote oligodendrocyte maturation g ratio of 0.734±0.015  that was significantly higher in QKI-6/7 as compared to GFP-transduced co-cultures  was observed , both QKI-6 and QKI-7 isoforms were down-regulated by >80% by QKI-specific siRNA siQKI, . We nextobserved . TogetheKIP1 expression. This is further confirmed by the increased ability of QKI-6 and QKI-7-transduced Schwann cells to produce MBP and myelinate axons of DRGN in primary cultures. Furthermore, in QKI-deficient Schwann cells we observe down-regulation of the level of MBP mRNA as well as other Schwann cell maturation markers, p27KIP1 and Krox-20. Our findings show that both QKI-6 and QKI-7 potentiate Schwann cell myelination, and they exert synergistic effects when combined.In this report we present evidence that the QKI proteins are determinants of Schwann cell differentiation. First we show that the expression of QKI-6 and QKI-7 positively regulates Schwann cell differentiation, as they promote cell cycle arrest by inducing p27vqk mice may be the main cause of the myelination defects seen in the peripheral nerves of these mice.The role of RNA binding proteins or the post-transcriptional events regulating peripheral myelination is unknown fyn and its phosphorylation negatively regulates its association with RNA The QKI proteins are phosphoproteins often referred to as STAR  proteins KIP1and MBP. The differentiation of oligodendrocytes requires their withdrawal from the cell cycle, and the accumulation of p27KIP1 precedes oligodendrocyte differentiation KIP1 null mice, as there were significant increases in QKI-positive; BrdU-positive cells in the subventricular zone compared to wild-type controls KIP1 knockout mice in the optic nerve, consistent with the requirement for p27KIP1 and PNS myelination KIP1 increases after the ectopic expression of QKI-6/7 in oligodendrocytes KIP1 mRNA is stabilized and a QRE is localized within the coding region of p27KIP1 and bound by QKI KIP1 expression. On the contrary, repressing QKI expression using RNA interference resulted in suppression of its target mRNAs including p27KIP1, possibly by rendering the unbound p27KIP1 mRNA susceptible to degradation. These findings suggest that p27KIP1 is a positive marker of PNS myelination and that QKI is upstream of p27KIP1 in both the CNS and PNS.The peripheral myelination induced by the ectopic expression of QKI-6 and QKI-7 coincided with the elevated protein expression of p27KIP1, Krox-20 is another major positive regulator of Schwann cell maturation. The production of Krox-20 mRNA is known to occur within 1 hr of contact with an axon or after growth factor stimulation hence its alternative name early growth factor (Egr2) in vitroqk-deficient mice die at E9.5 and have an open neural tube, thus neuronal and glial cell fate information could not be obtained from these animals KIP1, thus ensuring sufficient transcripts were accumulated in Schwann cells prior to the onset of myelination. If the relationship between Krox-20 and QKI is indeed correct, then human peripheral neuropathies may harbor mutations within the qk gene.In addition to p27KIP1 suggesting that p27KIP1 is a marker of myelinating Schwann cells. Our findings show decreased levels of MBP, p27KIP1 as well as Krox-20 mRNAs in QKI-deficient Schwann cells. Our findings reveal that the QKI proteins are potent inducers of Schwann cell differentiation and strategies to up-regulate or over-express QKI-6 and QKI-7 isoforms may be useful to enhance peripheral nerve myelination.In conclusion, we have shown that the ectopic expression of QKI-6 and QKI-7 isoforms promotes Schwann cell maturation and myelination, as assessed by MBP expression. Interestingly the myelinating Schwann cells contained nuclear p27KIP1  and for β−actin . Goat anti-mouse and goat anti-rabbit secondary antibodies conjugated to Alex546 (Molecular Probe) and Cy5 (Jackson Immunoresearch) were used for double-labeling experiments. Confocal analysis was carried out on a Zeiss microscope. The experimental protocol for preparation of primary cell cultures was approved by the McGill University Animal Care Committee and meets the guidelines of the Canadian Council on Animal Care.Schwann cells/neurons co-cultures were prepared using methods described previously The co-cultures were infected with the indicated adenovirus co-expressing QKI-6 and QKI-7 driven by the TR5 (Tet-Off) promoter and GFP is under the control of the CMV promoter as described previously Adenoviruses treated co-culture were rinsed in PBS, fixed in 2.5% glutaraldehyde in 15mM sodium cacodylate (pH 7.4) for 60 min, and postfixed for 1 hr in 1% osmium tetroxide and embedded for EM. Ultrathin sections were cut with a diamond knife and stained with uranyl acetate and examined by transmission electron microscopy . A myelin layers analysis was conducted on a population of 30 axons by treatment from 3 replicates experimental sets. The g-ratio was calculated by dividing the axonal diameter by the total fiber diameter. The statistical significance of myelin lamellae for each QKI adenoviruses treatment versus the control AdGFP was determined by two-sample t test ANOVA for assumption test and Tukey-Kramer Multiple Comparisons Test for P value of 0.001. InStat3 software (GraphPad Inc.) was used for graph and statistic analysis. (Define G ratio used and its meaning).For analysis of BrdU incorporation using immunofluorescence staining, coculture containing Schwann cells and DRG neurons cells were infected for 24 h with adenoviruses (m.o.i: 50) expressing the different QK isoforms or GFP control. Culture progenitors were given a 16 h pulse with 10 µM of 5-bromo-2′-deoxyuridine (BrdU) and then fixed in 4% paraformaldehyde. Cells were permeabilized with ice cold acetone/methanol (1∶1). After 30 min in 1N HCl and neutralization with sodium borate buffer, cells were incubated with monoclonal anti-BrdU antibody  in PBS + 0.1%Triton + 5% goat serum for 3 hours. A Rabbit anti-mouse Alexa 546 (Molecular Probes) antibody diluted 1∶1000 in PBS; 0.1% Triton was used for detection.CGUACGCGGAAUACUUGA) were prepared according to manufacturer's instructions. 100nM of each siRNA plus 50nM of siGlo indicator (Dharmacon) were delivered to each well of a 24-well plate containing day-21 Schwann cell/DRGN co-cultures using Lipofectamine RNAiMAX. The transfection was repeated once every two days for three times, and cells were harvested on day-28 of culture. Monolayer of C6 rat glioma cells were transfected for 72 hours using conditions above.QKI-specific siGENOME SMARTpool siRNA purchased from Dharmacon (M115062-00-0010), and luciferase specific control siRNA  and reverse transcribed with Super Script II Reverse Transcriptase (Invitrogen). Intron-spanning pre-designed primers purchased from Qiagen were used at concentrations specified by the manufacturer. Quantitative PCR was performed using Quantitect SYBR Green qPCR kit (Qiagen) on Applied Biosystem 7500 real-time PCR system. The relative expression values for each gene of interest normalized to glyceraldehyde-3-phosphate dehydrogenase (GAPDH) were analyzed by ABI SDS software using the comparative CT method.Figure S1QKI encoding adenovirus effectively produces QKI-6 and QKI-7 in Schwann cells (A) Primary Schwann cell/neuron co-cultures were infected for 4 days with control GFP adenovirus (Adv GFP), or the combination adenoviruses encoding myc-tagged QKI-6 or QKI-7 (Adv QKI-6/7). Cultures were lysed, and proteins were immunoblotted for QKI-6 and QKI-7 to reveal the endogenous and the recombinant respective QKI isoforms. Both a short exposure of 10 sec and a longer exposure 10 min is shown. The myc-epitope tag was used to evaluate the relative levels of the each recombinant QKI isoform in infected cultures and Sam68 was used to ensure equal loading. The molecular mass markers are shown on the left in kDa and migration of the myc-epitope tagged QKI (myc-QKI) and the endogenous QKI (QKI) isoforms is shown. (B) The over-expression of recombinant QKI isoforms was quantified by densitometric analysis compared to the endogenous levels in arbitrary units (AU).(2.48 MB TIF)Click here for additional data file.Figure S2Expression of the QKI isoforms in the mouse brains during development. (A) Mouse brains were harvested on embryonic day 17.5, 18.5  and postnatal day 1, 3, 6, 8, 10, 15, 30 (P1–P30), homogenized and lysed. Protein lysates were immunoblotted for QKI-5, QKI-6 and QKI-7 as indicated. β-actin was used to ensure equal loading. (B) The expression levels of each QKI isoform normalized to loading control was quantified by densitometry analysis.(5.48 MB TIF)Click here for additional data file.


Logic models are graphic representations of the relationship between program activities and their intended effects and are used for both program planning and evaluation. Logic models can provide an important foundation for program evaluation by identifying evaluation questions that most appropriately assess program processes and outcomes and by guiding measurement decisions. We demonstrate how logic models can be used to plan program evaluation by describing the adoption of logic modeling by the Washington State Heart Disease and Stroke Prevention Program (WaHDSPP) and by specifying the changes in process and use of logic models since the program's initial funding. Our paper describes how a logic model was used in generating the program evaluation plan for the WaHDSPP, including the identification of evaluation questions and development of indicators to track progress effectively. We describe the use of evaluation results, as well as steps state programs can take to use logic models in program evaluation. The benefits of logic models for program planning and evaluation are evident. As a result, descriptions of logic models are becoming more commonplace in program and evaluation literature, and funding announcements now routinely encourage their development and use. For example, when the Centers for Disease Control and Prevention's (CDC's) Division for Heart Disease and Stroke Prevention (DHDSP) released its 5-year Funding Opportunity Announcement (FOA) for 2007 for state programs to address heart disease and stroke, applicants were required to develop logic models. However, although application requirements now more commonly require logic models, the subsequent use of these models once grants have been awarded may be inconsistent. We describe the Washington State Heart Disease and Stroke Prevention Program's (WaHDSPP's) experience with program logic models and their use in evaluation planning. We also describe how the development and use of program logic models evolved over time. By describing how the WaHDSPP developed its logic model and used it to construct an evaluation plan, we hope to demonstrate the link between development and use. Subsequently, we hope to demonstrate the utility of logic models in public health programs and stimulate the construction of better and more usable evaluation plans.The goal of the WaHDSPP is to build statewide support for programs targeting people who have heart disease or history of stroke, as well as people who are at high risk for developing either condition . The WaHDSPP first received funding from CDC's DHDSP in 2003. From 2003 through 2006, the program was staffed by a full-time program manager and half-time epidemiologist. During this time, the program relied heavily on cross-program staff from the Washington State Department of Health, internal and external partners, and the WaHDSPP advisory council to implement its activities.The Burden of Heart Disease and Stroke in Washington State  of the program, no logic model existed to describe or assist in evaluating the WaHDSPP. Activities conducted by the WaHDSPP were chosen on the basis of their alignment to CDC DHDSP program priorities, the existing program capacity, relationships with internal and external partners, and previous experience. During this time, the WaHDSPP focused on capacity building and needs assessment activities, including developing on State   was developed in Excel , linking evaluation measures to each activity and outcome in the logic model. The 2005–2006 LEP for one activity, the Washington State Collaborative, is shown in Planning for 2006–2007 improved previous years' efforts for several reasons. First, the planning process was a collaborative effort. Second, evaluation and surveillance data, collected as part of the previous years' evaluation efforts, were used in program planning efforts. Given the involvement of internal and external partners in the WaHDSPP, the program staff realized the potential benefits of the partners' input in planning program activities and evaluation efforts. As a result, partners and key stakeholders were invited to participate in the planning retreat for the 2006–2007 continuation application. The involvement of partners and stakeholders responsible for implementing program activities added depth and richness to the discussion. This collaborative process allowed for an in-depth discussion of the barriers to and facilitators of implementing program activities, factors that affect outcome attainment, and future program directions. These discussions were immensely helpful in developing work plans that linked to successful outcomes and that were both feasible and appropriate, given WaHDSPP resources.The WaHDSPP program manager scheduled time during the planning retreat to review surveillance, evaluation, and assessment results from the previous year, ensuring that these data were taken into account in the proposed program activities. Involving partners and stakeholders in this process provided an opportunity to discuss results with people who were the most knowledgeable about the activities, which led to a better understanding of program activities by the entire planning committee and more realistic approaches to program improvement. In addition, being part of the program planning effort increased buy-in and "ownership" of the WaHDSPP. Once work plans were developed, the logic model and the LEP were updated to reflect proposed activities and outcomes. Collaborating on the logic model revisions provided new clarity in the short-, intermediate-, and long-term objectives for both staff and partners, and this clarity facilitated the selection of indicators.The planning retreat for 2007–2008 focused on responding to the FOA released by the DHDSP and included newly hired WaHDSPP staff. As during the previous year, key partners and stakeholders were involved in planning, and evaluation and surveillance data were used to guide planning discussions. One new feature in the planning process involved categorizing proposed activities to align with the spectrum of prevention outlined in the Action Plan. The Action Plan, developed collaboratively by the DHDSP and its national partners, describes a comprehensive approach to addressing heart disease and stroke, from preventing risk factors to preventing recurrent cardiovascular events. The FOA encouraged states to use the Action Plan to guide development of their applications. By comparing proposed activities with the Action Plan, the WaHDSPP was able to identify a gap in its interventions, leading to the development of a new objective for the assessment of rehabilitation capacity.Having additional program staff available to develop work plans for the application enabled partners to collaborate more closely than in years past to revise the logic model. The updated logic model  demonstrDeveloping an Evaluation Plan  outcome of increased public awareness of heart disease and stroke signs and symptoms. This activity is also linked to the intermediate outcomes of increased recognition of symptoms and reduced time between recognition of symptoms and taking action to call 911 and to greater control of risk factors , on the basis of the theory that increased awareness of high blood pressure and high cholesterol levels will lead to improved control of these risk factors.Evaluation planning focused on the stage of development of the activity. Because the African American Awareness and Screening Project was implemented in 2006, evaluation efforts targeted the implementation of the activity and assessment of the outcomes of increased public awareness of signs and symptoms of heart attack and stroke, as well as control of risk factors. Furthermore, the logic model assisted in developing the evaluation questions. By looking at the logic model to determine expected activities and outcomes, WaHDSPP staff were able to develop and prioritize the questions that the evaluation should answer, including the fidelity of the project, the impact of the project, and lessons learned and implemented.The evaluation involves a mixed-methods approach, including both qualitative and quantitative data, and includes 1) the identification of facilitators of and barriers to the project through key stakeholder interviews, 2) a review of quarterly progress reports to evaluate fidelity to the original project plan, and 3) focus group sessions with participating barbers and stylists to evaluate trainings, project implementation, and perceptions about what worked and what did not work. Outcome evaluation will be conducted through review of screening results and follow-up to determine how many screened participants with high blood pressure were treated by a health care provider.Reflecting on the past 6 years of program activity, WaHDSPP staff identified several key lessons that have facilitated the use of programmatic logic models:Logic models have assisted the WaHDSPP in developing its theory of change. By stating the theory of change, the program can better identify intermediate steps — and related indicators — that precede long-term outcomes and identify the incremental steps that precede short-term outcomes, allowing the program to monitor progress in a more proximal manner.The WaHDSPP has used the annual occasion of preparing a continuing application as a time for collective reflection, not only on how to better refine existing activities or develop new ones, but also as a time to critically examine and improve the logic model and evaluation tools.The logic model now categorizes activities and outcomes according to their place in the spectrum of prevention, allowing WaHDSPP staff to visually track the expected impacts resulting from program activities over time and to think more clearly about how achievements in impacts at one stage of prevention may facilitate achievements at another stage by shrinking the size of the vulnerable population .Periodic reflection allows the program to incorporate new knowledge, such as information and resources from the CDC DHDSP, peers, and the literature to enhance evaluation planning.Framework for Program Evaluation in Public Health describes this collaborative approach (Logic modeling is integral to program planning, implementation, and evaluation. The model set forth in CDC's six-step approach .Evaluation and logic model development should be conducted in partnership with program stakeholders, with results feeding directly back into ongoing program planning and progress monitoring. Logic models and evaluation plans are dynamic tools to guide the program in carrying out activities but should always be developed and refined in partnership with activity work plans and the key staff and partners involved in the work.These lessons have been incredibly valuable in informing and improving the direction of the WaHDSPP and demonstrate how logic models are useful in public health program planning and evaluation.


To the Editor: Since 2003, highly pathogenic avian influenza (HPAI) H5N1 has shaken the world. In 10 countries, 258 confirmed cases in humans and 154 deaths have been reported  because of the ministry’s cash flow problems (As discussed by the World Bank (The response to the second question, extent of compensation, varies. In Nigeria, farmers are partially compensated for loss of poultry; however, in the United States, farmers who are part of the USDA program are fully compensated for loss of poultry and equipment. Setting the amount of compensation is difficult and can affect the outcome of culling efforts. In Thailand, to take advantage of the program in which compensation was perceived as high, some farmers reportedly moved infected poultry into previously uninfected areas. In Vietnam, where compensation was perceived as low, culling compliance was poor (The last question, who should be compensated, seems straightforward for the United States, where only farmers who participate in the USDA program would be fully compensated. However, H5N1 does not affect only farmers who sign up for such a program. And not all poultry are raised in commercial operations, especially in developing countries. In Thailand, for example, >80% of infected poultry are reportedly raised in backyards (Because each country’s needs and circumstances differ, building a coherent plan for tackling HPAI is difficult. However, each stakeholder should consider compensation as part of an overall package of prevention, preparedness, and response strategies toward controlling and preventing the spread of HPAI. Because H5N1 does not respect international boundaries, donors worldwide should step forward to support the most affected and vulnerable developing countries.


These data suggest that Noc-domains of Noc1p and Noc4p share a common structural backbone in which diverging amino acids play crucial roles in mediating specific regulated interactions. Our analysis allows us to distinguish between different functions of certain domains within Noc4p and contribute to the understanding of how incorporation of Noc4p into ribosomal precursors is coupled to rRNA processing and maturation of the small ribosomal subunit.Noc1p, Noc3p and Noc4p are eukaryotic proteins which play essential roles in yeast ribosome biogenesis and contain a homologous stretch of about 45 aminoacids (Noc-domain) of unknown function. Yeast Noc4p is a component of the small ribosomal subunit (SSU) processome, can be isolated as a stable Noc4p-Nop14p SSU-processome submodule from yeast cells, and is required for nuclear steps of small ribosomal subunit rRNA maturation. We expressed a series of mutated alleles of NOC4 in yeast cells and analysed whether the corresponding protein variants support vegetative growth, interact with Nop14p, and are incorporated into the SSU-processome. The data reveal that the essential C-terminus of Noc4p which contains 237 aminoacids including the Noc-domain represents a protein-protein interaction module. It is required and sufficient for its association with Nop14p and several nuclear precursors of the small ribosomal subunit. The N-terminal Noc4-part seems to be targeted to pre-ribosomes via the C-terminus of Noc4p and plays there an essential role in SSU-processome function. Replacement of the Noc4p-Noc-domain by its homologues Noc1p-counterpart results in a hybrid Noc4p variant which fails to associate with Nop14p and pre-ribosomes. On the other hand, exchange of 6 amino acids in the Noc1-Noc-domain of this hybrid Noc4p protein is sufficient to restore its essential  Saccharomyces cerevisiae the large ribosomal subunit (LSU) contains the 25S, 5.8S and 5S rRNA and 46 r-proteins whereas the small ribosomal subunit (SSU) consists of the 18S rRNA and about 32 r-proteins. Biogenesis of the two eukaryotic ribosomal subunits requires the coordinated action of many proteinaceous factors and small nucleolar RNA (snoRNA) containing ribonucleoprotein particles (RNPs) and proceeds in the nucleolus, nucleoplasm and cytoplasm. Biogenesis factors can be involved in a variety of reactions like rRNA cleavage, other rRNA modifications, RNA folding, assembly of r-proteins, quality control of the nascent ribosome as well as nuclear transport and export to the cytoplasm 2 pre-rRNA containing RNPs to generate pre-60S particles. Several LSU maturation intermediates containing a large number of different non-ribosomal proteins have been characterized in which the rRNA processing events leading to mature 5.8S and 25S rRNA occur Eukaryotic ribosomes consist of four rRNAs and more than 70 ribosomal proteins (r-proteins). In the yeast 2 pre-rRNA levels are reduced Most of the ribosomal biogenesis factors are essential for growth. Among them are the 4 Noc-proteins and Nop14p, each of which is highly conserved in eukaryotic organisms. Heterodimeric Noc-complexes represent a theme with variations involved in both branches of eukaryotic ribosomal subunit maturation. The Noc1p-Noc2p-complex is associated with early pre-60S ribosomes in the nucleolus whereas Noc2p-Noc3p-complex assembles with later emerging pre-60S particles in cis-requirements for incorporation of Noc4p into pre-ribosomes. We analysed a number of deletion and point mutants of NOC4 in vivo and identified thereby distinct domains of Noc4p which are required and sufficient for cellular growth, the association with Nop14p and pre-ribosomes or for the efficient cleavage at early rRNA processing sites. The Noc-domain containing C-terminus of Noc4p mediates protein-protein interactions, since a Nop14p-Noc4p complex lacking the N-terminal part of Noc4p can be formed in an heterologous co-expression system. We found that formation of the Noc4p-Nop14p subcomplex and association with pre-ribosomes were always coupled in all the mutants analysed but that on the other hand Nop14p is not strictly required for the incorporation of Noc4p into pre-ribosomes. Replacement of the Noc4p-Noc-domain by its homologues Noc1p-counterpart resulted in a hybrid Noc4p variant which failed to copurify with Nop14p and pre-ribosomes. Remarkably, exchange of 6 aminoacids within the Noc1-Noc-domain of this hybrid Noc4p protein was sufficient to restore its essential in vivo functions. These data suggest that Noc-domains of Noc1p and Noc4p share a common structural backbone in which diverging amino acids play crucial roles in formation of regulated interactions, an essential characteristic of Noc-domain containing proteins.Here we analyse ToY30 . After partial depletion of wildtype Noc4p through 16 hours growth on glucose containing medium  of NOC4 affects the association of Noc4p with pre-ribosomal components. The All 5 N-terminally truncated variants of Noc4p as well as full length Noc4p, coprecitated 21S and 22S rRNA . After 16 hours shift to glucose-containing medium, we observed accumulation of 35S and 23S pre-rRNAs whereas 20S pre-rRNAs were significantly reduced  direct interaction with Nop14p, or that Noc4p domains which mediate the interaction with Nop14p play additional independent roles in recruitment of Noc4p into pre-ribosomes. To exclude one or the other of these alternatives, we analysed whether Noc4p can associate with pre-ribosomal subunits in the absence of Nop14p. Therefore, we generated strain f Nop14p . AltogetToY489 (pGAL-NOC4) where cellular expression of Noc4p is under the control of the GAL1/10 promoter. When transferred to glucose containing plates, cells expressing Noc4p-Noc1p or Noc4p-Noc3p hybrids stopped growth, while the plasmids coding for yeast Noc4p or for the hybrid of yeast Noc4p and human Noc4p supported cellular growth (The C-terminus of Noc4p contains a stretch of about 45 amino acids (Domain 7 =  “Noc-domain”) which is highly conserved in predicted Noc4p homologues of other eukaryotic species. Remarkably, two other yeast proteins, Noc1p and Noc3p, which are required for LSU maturation r growth . In addir growth . These rWe compared which aminoacids in the Noc-domain of yeast and human Noc4p are conserved or similar but differ from the yeast Noc1p-Noc-domain see . ReplaceThis further strengthens the assumption that Noc-domains found in yeast Noc-proteins share a common structural backbone in which individual amino acids are important for specific functions of Noc proteins, as the formation of protein complexes with Nop14p or Noc2p and the regulated interaction with pre-ribosomal particles.ex vivo affinity purification experiments under stringent high salt conditions was the SSU-processome component Nop14p The experiments shown confirm that Noc4p is part of the SSU-processome, since it 1) copurifies with U3 sno-RNA and 2) is required for SSU maturation . NeverthIn vivo depletion of Nop14p does not completely block association of Noc4p with pre-ribosomal particles (Huntington-elongation-A_-subunit-TOR) repeat proteins articles  indicatiarticles  is requiarticles , Fig. 4.Interestingly, N-terminal truncated Noc4p variants, like full length Noc4p , associaToy30/Noc4 Shuffle was described before Toy489  in strain ProtA-NOC4/ToY31ToY559 , Euroscarf strain Y23846  was transformed with plasmid pToK3 (Ycplac33/NOP14) and the resulting genetic offsprings were analysed by tetrade analysis. A geneticine resistant and 5-FOA sensitive clone was then transformed with plasmid pToK495 (Ycplac111/pGAL-NOP14), it was selected for resulting clones resistant to 5-FOA on galactose containing medium and a TAP-tag coding sequence was integrated at the NOC4 gene locus by homologous recombination according to For cultivation transformation, mating, sporulation, preparation of genomic DNA, and tetrade dissection of yeast, standard protocols were followed 2O. Cells were disrupted by bead beating in ice cold buffer A200 , 1 mM PMSF, 2 mM Benzamidin) on a vibrax for 45 min at 4°C. The lysate was then centrifuged at 15000 g for 10 min and the supernatant was transferred into a new cup. The protein concentration was determined by Bradford. 30 µl of IgG-Sepharose (GE) slurry were washed in batch with 15 ml H2O, followed by two times washing with 15 ml buffer A200. 10 mg of whole cell extract was loaded on the beads and incubated for >1 h at 4°C on a turning wheel. Beads were then transferred into a micro column (BioRad) and washed 1×1 ml, 5×2 ml and 1×10 ml with buffer A200. 20% of the beads were used for protein analysis, the rest was used for RNA extraction. Each 200 µg of the whole cell extract were withdrawn for RNA-analysis. Protein A-tagged Noc4p variants and HA-tagged Nop14 were immunodetected after western blotting by an peroxidase anti-peroxidase immunocomplex (Dako Cytomation) (dilution 1∶5000) and monoclonal rat anti HA antibody 3 F10 (Roche Diagnostics) (dilution 1∶10.000).200 ml of cells from of a logarithmically growing culture of a yeast strain containing a ProteinA tagged version of Noc4p were harvested and the cell pellet was washed with 10 ml ice cold HSpodoptera frugiperda insect cells using the Multibac system described previously noc4-dDx carrying an N-terminal Flag-tag were cloned in the acceptor plasmid pFL, whereas NOP14 carrying an N-terminal 6xHis-tag was cloned in the donor plasmid pSPL. The respective PCR products were cloned in the target vectors using restriction enzymes SalI and PstI.Recombinant expression of Noc4p and Nop14p was performed in (-dDx) acceptor plasmids via in vitro Cre-loxP reaction using Cre-recombinase (New England Biolabs). For protein expression, 25×106 insect cells were infected for 48 h, harvested at 136 g for 10 min and lysed in 25 ml lysis buffer  by three freeze-thaw cycles and subsequent sonification.The donor plasmid pSPL-6xHis-NOP14 was fused to the different pFL-Flag-NOC4Flag-tagged Noc4p protein variants were immunoprecipitated using M2-anti-Flag-Agarose (Sigma-Aldrich) and eluted with 0.2 mg/ml Flag-peptide in lysis buffer. Protein levels of 6xHis-Nop14p and Flag-Noc4p variants in the eluates were analyzed by Western blot using INDIA-His-Probe-HRP (Pierce Biotechnology) and a polyclonal rabbit anti-Flag antibody (Sigma).5′TAA TAC GAC TCA CTA TAG GGT GTA TTG AAA CGG TTT TAA TTG TCC3′) and. O378 (5′GTT TTG GCA AGA GCA TGA GAG C). The amplified DNA served as template to produce a digoxigenine labelled RNA probe according to the manufacturer's protocol of the DIG Northern Starter Kit (Roche Diagnostics). For ITS1 detection, blots were hybridized with this probe in 50% formamide, 5X SSC, 0,5% SDS, 5X Denhards solution at 64°C. Detection of the probe was performed with an anti-Dig antibody coupled to alkaline phosphatase, CDP-star chemi-luminescence substrate (Roche Dignostics) and Fuji LAS Reader 3000. U3 snoRNA was detected with 32P 5′ end labelled oligonucleotide O202 (5′ CCA ACT TGT CAG ACT GCC ATT 3′). Hybridisation conditions were 50% formamide, 5X SSC, 0.5% SDS, 5X Denhards solution and 37°C. Radioactive signals were detected by phosphor imaging on the BAS1000 (Fuji).RNAs from total cellular lysates or affinity purified fractions were prepared and analysed as described before Figure S1(0.53 MB DOC)Click here for additional data file.Figure S2(0.25 MB DOC)Click here for additional data file.Table S1(6.45 MB TIF)Click here for additional data file.Table S2(5.46 MB TIF)Click here for additional data file.


Internet-based physical activity (PA) and weight management programs have the potential to improve employees’ health in large occupational health settings. To be successful, the program must engage a wide range of employees, especially those at risk of weight gain or ill health. The aim of the study was to assess the use and nonuse (user attrition) of a Web-based and monitoring device–based PA and weight management program in a range of employees and to determine if engagement with the program was related to the employees’ baseline characteristics or measured outcomes.Longitudinal observational study of a cohort of employees having access to the MiLife Web-based automated behavior change system. Employees were recruited from manufacturing and office sites in the North West and the South of England. Baseline health data were collected, and participants were given devices to monitor their weight and PA via data upload to the website. Website use, PA, and weight data were collected throughout the 12-week program.P< .001). The reduction in weight was largest for employees using the program’s weight loss mode . Mean PA level recorded throughout the program was 173 minutes (SE 12.8) of moderate/high intensity PA per week. Website interaction time was higher and attrition rates were lower  in those individuals with the greatest weight loss. Overall, 12% of employees at the four sites (265/2302) agreed to participate in the program, with 130 men (49%) and 135 women (51%), and of these, 233 went on to start the program. During the program, the dropout rate was 5% (11/233). Of the remaining 222 Web program users, 173 (78%) were using the program at the end of the 12 weeks, with 69% (153/222) continuing after this period. Engagement with the program varied by site but was not significantly different between the office and factory sites. During the first 2 weeks, participants used the website, on average, 6 times per week, suggesting an initial learning period after which the frequency of website log-in was typically 2 visits per week and 7 minutes per visit. Employees who uploaded weight data had a significant reduction in weight (−2.6 kg, SD 3.2,  This Web-based PA and weight management program showed high levels of engagement across a wide range of employees, including overweight or obese workers, shift workers, and those who do not work with computers. Weight loss was observed at both office and manufacturing sites. The use of monitoring devices to capture and send data to the automated Web-based coaching program may have influenced the high levels of engagement observed in this study. When combined with objective monitoring devices for PA and weight, both use of the website and outcomes can be tracked, allowing the online coaching program to become more personalized to the individual. Overweight and obesity are now major causes of preventable health problems across the world. Obesity has serious implications for the individual’s health as well as the population health and economy. A report by the UK National Audit Office (NAO) estimated that, in 1998 alone, the indirect costs of obesity to the UK economy  were around four times greater (£2.1 billion/year) than the direct costs of treatment (£0.5 billion/year) [Health behaviors are personal and complex, and the challenge lies in creating and deploying intervention programs that address this complexity in an engaging, easy to use, and yet effective way. Internet-based interventions serve as a feasible and acceptable delivery method for these programs, thereby providing scale, but evidence suggests that programs must go beyond providing advice and information alone. A review of Internet use for weight loss suggests that successful online programs include a structured approach to modifying energy balance, the use of cognitive-behavioral strategies such as self-monitoring, and individualized feedback and support .Our previous research  also shoFollowing this work with objective PA data collection, we extended the program to include an online weight management module and automated data capture weighing scales. The objective of this study was to assess the level of program engagement of a wide range of employees. A key difference from our previous studies ,5 was thThe study was designed to test the level of engagement with the Web program for employees recruited at 4 work sites in the United Kingdom over a 12-week period and the effects of this on the employees’ health. Work sites were chosen that were geographically and demographically different in order to evaluate if engagement with the program varied by location, baseline demographics, or level of interaction with computers during work hours. Two work sites were in the North West of England and 2 work sites were in the South of England in order to determine the influence of region upon uptake and use of the program. This could be important as, on average, 39% of UK households do not have Internet access. This varies by region, with the highest levels of Internet access observed in the South West and around London, compared to lower levels of access in households in the North West of the country . Additio2), or already taking part in a clinical trial.In order to determine the baseline health profiles and characteristics of all employees who were attracted to the MiLife program, minimal exclusion criteria were applied. The program was offered to adults employed at any of the 4 work sites who had regular Internet and email access or who were willing to access Internet and email via computers installed in communal areas at their workplace. Exclusion criteria were pregnancy, any holiday of more than 2 weeks during the study period without computer access, previous instruction from a health professional not to engage in PA, being severely underweight  at the manufacturing sites. At screening, date of birth, gender, blood pressure (BP), resting heart rate, BMI, and medication were recorded and the Physical Activity Readiness Questionnaire(PAR-Q)  and RoseThe Web program was combined with a Bluetooth-enabled wrist-worn triaxial accelerometer to measure PA and with Bluetooth-enabled weighing scales to record body weight (see Multimedia Appendix). Both devices sent the captured data back to the user’s Web program. The data from these devices were reported back to the individual via their automated coaching Web program, allowing self-monitoring of their PA and body weight and also objective measurement of PA and weight throughout the program. The components of the Web program and the monitoring devices are described in more detail below.Participants recruited to the program were shown, in a brief training session , how to register on the website and how to create their own personal password-protected account. The trainer also demonstrated how to upload weight data from the scales to the PA monitor and how then to upload the weight and PA data from the PA monitor to the computer. Basic computer skills training was provided when necessary and included use of a mouse, computer startup, log-in, and website navigation.The Internet, email, and mobile phone behavior change system was similar to that used in previous studies ,5. An inThe system made recommendations to the user of the mode to follow  based on their baseline weight, height, waist circumference, and stated goals. The major difference between the modes lies in the frequency with which users are encouraged to monitor their energy intake. For weight loss, monitoring energy intake is frequently encouraged; for weight maintenance, monitoring energy intake is encouraged if weight increases; for PA only, monitoring energy intake plays less of a role. The user could follow the recommended mode, choose another mode, or enter a nonactive browse mode with no goal or target setting. Users could also switch between the modes during the 12-week study period. The tools that support each mode are based on best evidence and practice from the literature. For example, in the weight loss mode, the tools were developed based on strategies used within the Diabetes Prevention Program [The design of the Web-based system was founded on key behavior change theories. For example, providing users with information on the typical PA levels of people like themselves is based on Festinger’s (1954) Social Comparison Theory , which aOther studies have shown that asking people to form specific plans (implementation intentions)  about wh While pedometers are low cost, they are typically used to record walking and therefore are less appropriate for 24-hour monitoring of PA. Accelerometer-based devices tend to allow a wider range of movement and for total PA to be recorded -21 in ad2)and indirect calorimetry were measured continuously throughout the activities using a K4b2 portable metabolic gas analyzer with data telemetry  to determine metabolic rate at rest and METs [2. Receiver operator curves for discrimination of intensity categories showed the activity monitor was able to predict light (MET 1.5-2.99), moderate (MET 3-5.99), and vigorous (MET ≥6) intensity activity when worn on either the left wrist  or right wrist . Using this data, cut-points were developed to distinguish moderate intensity and vigorous intensity PA. Further validation of these cut-points in a larger sample is planned with the inclusion of non-lab-based activities such as running and walking outside.We developed a water-resistant, Bluetooth, wrist-worn device that could be worn continuously, including while swimming/bathing. The device contained a miniature triaxial accelerometer unit that produced a signal as the wearer made physical movement, recording all movement up to acceleration levels of 6 g. The acceleration signal was measured and the resultant amplitude integrated. The data were then stored within the PA monitor memory ready for download and analysis. To establish validity of the PA monitor, a lab-based study was conducted in 22 adults . Subjects undertook 10 different semistructured PA conditions: lying down, seated computer work, stacking shelves, washing dishes, sweeping, cleaning windows, and 4 treadmill-based activities . These activities were chosen to represent a range of different physical intensities and metabolic equivalents (METs) and included many tasks that may be undertaken by the participants in their daily living. Oxygen uptake  or above . Data poData from the PA monitor were transmitted via a Bluetooth microprocessor to a personal computer (PC). Bluetooth-enabled personal weighing scales also sent data on the user’s weight to the PA monitor via Bluetooth. Each weight reading was held within the PA monitor with the PA data until transfer to the PC. The PA monitor memory could store many PA and weight readings before needing to upload the data to the PC. All data were sent via the PC to a central secure database managed by an industry standard commercial infrastructure supplier and held in accordance with the UK Data Protection Act and all relevant regulations. The integration of the PA monitor, weighing scales, and PC permitted direct acquisition of data from the wearer via the Internet throughout the study.The primary outcome of the study was the assessment of use of the Web-based and monitoring device–based PA and weight management program in this range of employees and the relationship between program use and the secondary outcome measures. Use of the program is defined by nonusage attrition data (Is the subject continuing to use the program?), as discussed by Eysenbach , and by Sample size was more than 200 employees in order to improve the accuracy of the confidence intervals around the expected level of engagement . Allocation of each subject to a program mode  for data analysis was completed by assessing the number of weeks spent in each mode then allocating the participant to the mode in which he or she had spent the greatest number of weeks. Statistical comparison between the program modes was not undertaken as participants were not randomized to modes and could switch between these modes at any time during the study period.Secondary outcome measures included baseline characteristics , weight , PA level , BP, resting heart rate, and sleep quality and quantity . WeightThe health profile data collected at screening  were aggregated for each site and compared to health risk appraisal (HRA) data collected around 3 months earlier at the same sites. As the HRA had included a greater number of employees (n = 992), this was undertaken to test if the employees participating in the Web program were similar to the larger group of employees on the same site who attended the HRA.At the end of the study, process evaluation questionnaires were sent to managers and occupational health (OH) staff at each site to determine the impact of the study at that site, and feedback questionnaires were sent to all participants. All employees were permitted to keep the hardware and software and, if they wished, could continue to use the program.Analysis of variance (ANOVA) was used for comparison of baseline data  between the sites. Fisher exact test was used to compare the nonusage attrition rates between the sites. The probability of attrition in the first 12 weeks was modeled using multivariate logistic regression with the baseline independent variables  and the dependent outcome variables  with site as a covariate. The association between the total interaction time with the website during the 12 weeks and the baseline independent variables and dependent outcome variables as listed above was modeled using multivariate linear regression, again with site as a covariate. The log of the total interaction time was used to preserve normality assumptions of the model. HRA data were compared with the baseline characteristics of MiLife participants using the Kolmogorov-Smirnov test. Weight change (using LOCF) and BP change at the end of the 12-week study were analyzed using analysis of covariance (ANCOVA), with baseline included as a covariate. Multivariate logistic regression with site, age, and gender as covariates was used to examine the relationship between baseline BP and the probability of attendance at the 12-week BP measure. Data were analyzed using SAS version 9.1 .The study was approved by 2 independent research ethics committees, one in the North West and one in the South of England. All research was conducted in accordance with the Helsinki Declaration .2 (SD 4.8). Ethnicity was also recorded to determine appropriate risk of metabolic disease for a given waist circumference and BMI [Of the 2302 employees at the work sites, 265 (12%) agreed to take part in the program. The numbers for each site and the characteristics of these participants are shown in Of the 265 participants who agreed to take part, 233 started the program ; 32 part                    Pvalues for testing equivalence of the sites: age, P = .009; BMI, P < .001; systolic BP, P = .004; diastolic BP, P = .001; pulse, P < .001), with employees from the factory sites tending to be older and having higher baseline BMI and BP  and higher mean baseline diastolic BP . The difference in BMI between the two populations was most noticeable at the factory sites: the mean BMI for Factory North HRA was 26.6 kg/m2 compared to 29.7 kg/m2for Factory North MiLife , and the mean BMI for Factory South HRA was 26.1 kg/m2, compared to 28.4 kg/m2for Factory South MiLife .We compared the baseline health profiles of the 264 employees participating in the MiLife Web program to HRA data collected previously from a larger group of employees at the same sites . Employees who participated in the Web program were of a similar age as those attending the HRA but had a higher mean baseline BMI . In the remaining 222 subjects, website use remained high, with 78% (173/222) of the participants still using the website at the end of the 12-week study and 69% (153/222) continuing to use the website after the 12 weeks .P< .001). There was no difference in nonusage attrition rates between Factory South and Office North. Logistic regression including the baseline independent variables with site as a covariate showed that nonusage attrition was lower in both Factory North and Factory South as age increased . To illustrate this, 30/58 (52%) of participants 48 years old and under were using the program at 12 weeks, compared to 21/23 (91%) of participants over 48 years old. Inclusion of the dependent outcome variables in this model showed that age was no longer significant but that nonusage attrition was lower in those subjects with a greater weight change over the 12-week period, independent of site .Nonusage attrition data (the proportion of participants who stopped using the program and the proportion who remain) are presented in                     Log-in data are shown in                     P< .001). To illustrate the magnitude of this slope (mean log duration 2.472), each additional kilogram of weight loss was approximately equivalent to an extra hour of program use over the 12-week period. Gender was also associated with total interaction time over the 12 weeks, with women spending, on average, 200 more minutes interacting with the Web program over the 12-week period (P= .002).During the first 2 weeks of the study, participants were spending more time on the website per log-in compared to the subsequent weeks , 211 (93%) uploaded weight data that could be used to determine weight change during the study period using the LOCF. The mean weight change in this group was −2.6 kg , indicating that employees with a higher starting BMI, on average, had greater weight loss during the study period. Mean weight loss was higher in those employees who spent most of the 12-week period in the weight loss mode . No statistical comparison was conducted between modes since subjects could switch modes during the study period. There was no significant difference in weight change between the sites, but there was a significant inverse association between baseline BMI and the amount of weight lost over the 12-week period  of moderate or above PA per week.At all sites, weight loss was the most popular mode. Of the 228 website users (including those who withdrew during the 12-week study), 138 (61%) spent the most time in weight loss mode, 46 (20%) spent the most time in weight maintenance mode, 39 (17%) spent the most time in the PA only mode, and 4 (2%) spent the most time in the nonactive browse mode of monitoring without goal and target setting.At the start of the program, each participant was asked to select one or more goals that he or she would most want from a list on the website. Research has shown that people with a strongly desirable goal are more likely to enact their intentions to perform a health behavior . The lis                    At the 12-week BP assessment, some employees at each site were lost to follow-up . Logistic regression with site, age, and gender as covariates showed that participants with a higher baseline BP were more likely to attend the follow-up (P= .047).The high level of participants lost to follow-up was possibly influenced by the proximity of these measures to the Christmas holiday period. As a result, data have been aggregated for all employees who returned for a 12-week BP measure . The mean baseline BP in this group was 129/86 mmHg , and the mean 12-week BP was 128/80 mmHg . There was a significant reduction in diastolic BP .P = .004). This was particularly evident in the following PSQI components: self-assessed overall sleep quality (P < .001), hours of actual sleep achieved (P = .01), ease of both maintaining attention and/or enthusiasm for everyday tasks (P = .006).Data from the Pittsburgh Sleep Quality Index (PSQI) questionnaire collected at baseline and 12 weeks (n = 93 completed) suggested an increase in sleep quality overall, corresponding to a decrease in the global PSQI score (Data collected from the exit questionnaires (n = 130) showed that 101 employees (78%) found the website very easy to use, with the most useful tools listed as those providing PA analysis, planning, and information. Many employees liked wearing the PA monitor and found that having it on served as a constant reminder to keep to the program. The site was seen as informative, motivating, and helpful. The PA and weight charts were thought particularly helpful as they enabled participants to monitor their progress and played an important role in providing feedback and motivation. The low response rate  to the exit questionnaire may have been influenced by the proximity to the holiday period.The OH staff at the work sites who responded to the survey (n = 6) agreed that “the study had been a supportive program in the company objective”of vitalizing employee health. Several of the OH staff commented that the study had been a positive initiative that participants had found enjoyable and rewarding and which should be encouraged. Employee participation in the program resulted in some extra work for OH staff in answering participants queries, although OH staff were generally happy with the resources they had received from the study team to support participants.Feedback from managers at the work sites (n = 6) was overall very positive, and managers received positive feedback from participants. Managers noted that the study appeared to have been beneficial in the workplace, and participation may even have led to increased job satisfaction in some instances. Managers were also in agreement that they would encourage future staff participation in the Web program and would recommend participation in the program to other sites.The study was designed to test the level of Web program engagement over a 12-week period for a wide range of employees recruited at four work sites in the United Kingdom. Work sites were chosen that were geographically and demographically different in order to evaluate if engagement and outcomes varied by location, baseline demographic and health measures, or level of interaction with computers during work hours.This study showed that a Web-based PA and weight management program designed to include components known to be effective  was appA key difference in this study compared with our previous studies ,5 was thAlso, rather than an RCT, the current study was conducted in a more naturalistic setting in which a branded commercial program (MiLife) was offered to employees as a benefit in collaboration with their company’s OH professionals. One limitation of this approach was the lack of a control group. Subsequent use of the program in an employee wellness setting may provide the opportunity to test engagement with the program against alternative weight management and PA initiatives available to those employees. This would build on the insights generated in this research by using an RCT efficacy design and allowing a full intent-to-treat and per protocol statistical analysis.Employees who participated in the Web program had a higher average diastolic BP and BMI compared to employees previously taking part in an HRA at the same site. This was most noticeable at the factory sites. This does not mean that the Web program enrolled all high-risk individuals, as not all employees take part in HRAs , but it 2). Both programs were Web-based PA and weight management programs, although it is unclear if the difference in the user profiles was due to differences in the programs or to the populations targeted by the interventions. The Dutch Web-based program did conclude that obese people were more likely to participate in Web-based programs, possibly because of the non-stigmatizing way of addressing body weight through the Internet.Further comparison of the baseline demographic data in this adult employee population with the profiles of participants using a Dutch Web-based health promotion program available to the Dutch general public at no cost  suggestsNonusage attrition rates were much lower with MiLife than with other Web-based eHealth interventions that have reported this data -33. ThisRecent reviews including more than 50 studies of Internet-based programs for PA and dietary behavior change ,41 showeNorman et al  highlighReinforcement and positive feedback are also an important part of the program, and the PA and weight graphs and charts were the most liked part of the program by users. Where positive feedback is not received for effort, users may be less likely to engage with the program. In a pedometer-based walking program, those users who did not receive positive feedback for all of their effort were 5 times more likely to fail to wear the pedometer compared with a group for whom total effort was recognized .Therefore, in this program, the use of simple monitoring devices to continuously record PA data and weight data combined with automated data upload to the website and positive feedback may have had a number of effects. It is likely that this approach influenced the high levels of data capture, the utilization and engagement rates observed, and also the likelihood of achieving the behavior change. The combination of monitoring devices with a Web-based program is not without challenges, and we did experience some initial hardware reliability issues. This was anticipated to an extent, and part of the study design was to test the robustness of the hardware in such a large group of subjects. While replacement devices were issued to any employee experiencing technical problems, feedback from the exit questionnaires indicated that hardware problems did influence the user experience for some participants. However, Web program use remained high in these employees.Analysis of the mean interaction time with the website suggests that there was a learning period in the first few weeks, with users spending more time on the website, finding the tools, and navigating the site. Typically by the fourth week of the program, subjects were interacting with the website for 10-20 minutes per week, and the total time spent on the website over the 12 weeks was associated with the amount of weight lost.The time spent on the website per week is similar to our previously reported work , in whicThis study suggests that the MiLife Web-based program designed to support PA and weight management and utilizing simple monitoring devices for weight and PA can be successfully deployed in both office and manufacturing sites. The program received positive feedback from both OH staff and managers at each site. Most importantly, the program appealed to and engaged those employees who would most benefit from changes in PA and weight management, with many employees enjoying the experience, improving their health parameters, and returning to follow a second 3-month program with no financial incentive.