Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs.Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically.TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk.This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs. Since 2016, communities across North America have been enduring an overdose epidemic that has been exacerbated by the highly toxic and unregulated illicit drug supply and, more recently, the COVID-19 pandemic . In the In the current era where the unregulated opioid supply is contaminated with several adulterants , there is a need for novel approaches to prevent overdose, including alternatives to first-line opioid agonist therapies . While these medications have been successful for many individuals and continue to be considered the gold standard of treatment among physicians, program retention rates in BC continue to be low . Novel OResearch on injectable OAT is not a new phenomenon . Indeed,There is very limited research on TiOAT specifically, and no known studies have compared liquid hydromorphone to tablet formulations. Amidst an overdose epidemic, TiOAT initially started as a pilot project in 2019 in Vancouver as a harm reduction intervention for individuals with severe opioid use disorder who were actively injecting unregulated opioids , 20, 21.While the overdose epidemic in BC is impacting all jurisdictions across the province, rural and smaller urban communities are disproportionately impacted . For exaIn 2020 and 2021, two programs that provide TiOAT  were launched in two rural and smaller urban settings in BC. These programs exist in Duncan , which is located on Vancouver Island, and in Kamloops , which is located in the province’s interior — a 4 h drive from Vancouver, the province’s largest urban centre. The Kamloops program has two sites whereas the Duncan program has one site. These programs provide TiOAT in clinical settings. Despite the potential promise of these programs in addressing overdose risk and other drug-related harms, to our knowledge no research currently exists on how these programs operate in rural and smaller settings. Therefore, we sought to understand the rural contextual factors that affect TiOAT program access among program participants.We merged qualitative research methodologies – case study and narrative inquiry . Case stParticipants were recruited from three TiOAT program sites across two rural and smaller urban communities. We utilized criteria from BC Ministry of Health in characterizing these communities as rural and smaller urban, which considers population size and proximity to larger population centres and health services in defining rurality . BC Minin = 25; Duncan participants, n = 7).When we started recruiting participants, the Kamloops program had been open since February 2020 whereas the Duncan program had been open since September 2021. Interviews across both sites occurred between October 2021 to April 2022. To be eligible, participants had to be 19 years of age or older, have been enrolled in the local TiOAT program for at least 1-month, and live in Kamloops or Duncan or their surrounding areas. This allowed us to recruit participants that were currently enrolled in the program as well as those who have discontinued enrollment (after utilizing the program for at least 1-month). Posters were displayed in the TiOAT clinical settings and dedicated on-site staff assisted with recruitment and screening. Staff were directed to refer all participants who met inclusion criteria. Given that recruitment occurred in clinics that were integrated among other services, this allowed staff to refer individuals who may be accessing other services  but not the TiOAT clinic, including those who may have discontinued or disengaged from the programs. Interested participants were provided with informed consent forms and signed up for remote interviews. At the time of data collection there were approximately 30 TiOAT recipients in Kamloops and 10 in Duncan and our recruitment numbers reflected these differences  and MM (research coordinator). Due to COVID-19 restrictions, initial interviews were conducted via video communications software and participants were situated in a private offices at the TiOAT clinics. Additional interviews in Kamloops were conducted in-person at a private office and interviewers followed pandemic safety protocols. Qualitative semi-structured open-ended interviews were conducted with participants who were each provided with a $30 cash honorarium . An inten = 7), we were unable to identify any noticeable differences in the experiences across sites during the data analysis process. As a validation measure, and to establish trustworthiness  is about 10 minutes out of town. [Interviewer: How do you get there usually?] Shuttle bus. They provide a free bus. It’s not a good situation, but it’s cheap rent. (K2)Where I was living, it was really close, but now where I’m at now, it’s a little bit harder to get to… it’s kind of out in the middle of nowhere kind of thing and we can only get a ride in twice a day, so it is a little bit harder to access and to get to, and then go back home…There is no bus service out where I live… For us to catch the shuttle, it is either at 9 in the morning or 3 in the afternoon, and that’s it.  Pretty much, yeah. [I: Does that impact your decision if you’re going to come into town or not?] Oh yeah, yeah. (K4)Participants living in supportive housing on the Northshore described the relative ease in accessing the clinic there: I live kinda in the bushed area. If I were to walk it takes probably about an hour and a quarter…I try to receive a ride from [someone] to at least get dropped off into town to walk the rest of the way. (D5)A lack of reliable and frequent transportation was a barrier to TiOAT access for those with housing that was in close geographic proximity to the program sites. No shuttle bus service was reported by participants of the Duncan site, demonstrating even more of an access challenge. For example:The above excerpts demonstrate how proximity and transportation play prominent roles in one’s level of access to TiOAT programs in rural and smaller urban settings.“It works for me. I don’t mind coming every day; it gives me something to do. It’s only a few blocks [away]” (K3). However, the majority of participants described how having to attend the clinic multiple times per day impeded their abilities to do anything else , and how DWI would impact their employment opportunities:The fact that I have to spend the whole day basically at the location ‘cause you got to take it and hang out for 15 minutes and then another 45 minutes down the road you can have some more. Like so it kind of ties you to the building, right? It doesn’t give you much freedom to do anything else…If I was trying to do a construction job or something like that it wouldn’t work out too well, would it? (D3)Similar to other OAT programs in BC, the TiOAT programs across both study sites required participants to attend the clinic multiple times a day for their daily witnessed ingestion (DWI), which was usually supervised by nursing staff. There were mixed feelings among study participants regarding such dosing schedules that required multiple daily visits to the clinic. Some participants spoke about how they liked having a daily routine and that the TiOAT program provided some structure. For example: “From 5 o’clock at night ‘til 9 in the morning you’re SOL [shit out of luck] sort of deal” (K14). While take-away doses  were preferred by many participants, those without them had to rely on using illegal drugs outside of clinical hours: “at least [with carries] I would have stuff instead of using street drugs in the evening” (K18). Only participants at the Duncan site were provided take-away doses in the evening: “they give you carries at the end of the day…they’ll let you leave with 6 tablets” (D3). Some participants in Kamloops reported that carries are only available to those who are able to provide an illicit opioid-negative urine drug sample, which would be challenging for those who procure illicit opioids to address withdrawal outside of clinical hours.In addition to the limits placed on participants via DWI policies, participants from Kamloops specifically reported other challenges with the TiOAT program, as medications were only accessible during the daytime hours of operation: It’s way different. I mean, yeah, the pharmacists were great where we got our methadone from, but they… treated us civilly like they would any other customer and, you know, that’s about as far as it would go. But here, you’re a little closer and interact a lot more, so it’s… I don’t know. We’ve come to call ourselves our TiOAT family. (D1)While participants described the challenges with DWI policies, their experiences in the TiOAT clinical settings were largely positive. Almost all participants described positive therapeutic relationships with clinical staff . These interactions provided them with the ability to have a role in dosing decisions as well as providing linkages to other health and social services , leading to improvements in overall health and wellbeing (as we described elsewhere). The relationship between program participants and clinical staff were describe as creating social and familial bonds. For example:Well the staff here are awesome. Like the staff at this particular pharmacy are amazing, like the pharmacists are all really like good, uh, they deal with some of the people in the world that are judged by humanity, right? They welcome them into their store and you know they have a tab system here so if we haven’t got paid, they let us take like a chocolate bar or pop and you know we can sit and they have a little section of the pharmacy blocked off for TiOAT patients…We can all sit there and chat. It’s really, they’re amazing here. (K1)Pharmacy staff in Kamloops were discussed as going above and beyond their roles in providing TiOAT medications to participants as described in the following excerpt:Well, I always thought drugs was a sociable thing, right? So, when I do get drugs, I like to find somebody to get high with. It has always been that way with me. The [staff] here at the TiOAT program, they all converse when I’m doing my drugs, so it is actually like they’re getting high with us but they’re not doing drugs. That is what it’s kind of like, you know what I mean, it is socializing. (K3)So, I like coming [to the TiOAT clinic] and, you know, seeing everybody I know and you know it’s like Norm walking into the bar at Cheers, you know, everybody knows him and people say hi and yeah, I like the social aspect of it for sure. (D4)Conversing with others was reported as an important cultural element of drug use and how this extended to the TiOAT program via staff and other program recipients led to more positive engagement, as illustrated in the following quotes:Sociability and a sense of community within the TiOAT program – among participants, nurses, staff, and pharmacists alike – was a unique experience for participants who had not had these same experiences in other OAT programs.I was in the hospital for ten days and I ended up going through withdrawal because they wouldn’t give me my TiOAT there […] There is something wrong with this hospital…They should actually have the TiOAT program in the hospital. I also tried to get access to methadone at the hospital and they would not give it to me even though I was on a prescription and everything. I ended up going without. (K3)I did end up in the hospital and it’s been horrible. Um, it’s, uh, I go through really bad withdrawal and every time I’ve gone to the hospital I haven’t got to access my TiOAT. Maybe it’s cause I don’t have carries. I don’t know. You think they would have allowed it in the hospital. (K1)Multiple participants described instances when their access to TiOAT medications was interrupted by factors outside of their control. Most notably, participants described issues with dosing continuity when they were in hospital and carceral settings. Participants reported experiencing withdrawal in hospitals due to an inability to access their TiOAT medications. For example:“I could have somebody bring me dope so I could be taken care of one way or another but at least the dillies  are cleaner” (D4).Participants were dismayed by their inability to access TiOAT medications in a hospital setting where access to hydromorphone for patients should not be onerous. An inability to access prescriptions in these settings may lead individuals to access illicit drugs to address their withdrawal symptoms: “I’ve been to jail several times. If I was to get thrown in jail I wouldn’t get – I mean you know I could get methadone probably but I’d never get the Dilaudid and all that” (D6). Another participant who had discontinued participation in the TiOAT program, reported how a lack of OAT options while incarcerated was the main reason for no longer being enrolled in the program:When I went into jail, I got kicked off and they said they were going to continue the TiOAT program in jail and I thought you know what, that’s pretty cool. I didn’t think they’d be giving Dilaudid out in jail…and they didn’t. They ended up cutting me off. And then I just didn’t ever go back on it. (K21)This lack of access to TiOAT medications also occurred in carceral settings, where participants described a lack of options. For example: I was arrested and told the guard that I was a part of this program and if we could call [program staff] to bring me meds. And all I was told was “I’ll talk to the main guard and see what happens.” Nobody came back and by the time I was released, it was too late to get a dose or my carries, so I was screwed for the day. [I: And so what did you do?] I had to take street drugs, otherwise I would have been in pain and puking and all that fun stuff. (D1)Participants also described similar experiences when temporarily in police custody. For example:The above experiences illustrate how a lack of medication continuity across hospital and carceral settings can lead to program discontinuation as well as negative health outcomes .In summary, our findings demonstrate that a variety of factors affect TiOAT program access in Duncan and Kamloops. Proximity and access to transportation, medication dispensing schedules and policies, staff relationships and social interactions, and program interruptions in hospital and custodial settings affected participation in the TiOAT program. Taken together, these findings highlight the experiences among study participants who live in rural and smaller settings and the need for policy and practice changes to improve TiOAT program access.There is very limited research on OAT access in the rural Canadian context and the majority of existing studies rely on medical records and administrative data and are from the province of Ontario . There iSimilar to our findings on DWI policies, research on TiOAT access in Vancouver, BC, also reports DWI as a barrier to program engagement  and simiThat participants described positive therapeutic relationships with TiOAT program staff and clinicians, and how these relationships created familial and social bonds, may demonstrate a strength to the programs in Duncan and Kamloops. These findings illuminate experiences that contrast to the surveillance and stigma experienced by people who use drugs in other healthcare settings –61, as wLastly, in custodial and hospital settings, participants described an inability to access their TiOAT medications, leading to negative health outcomes. Unlike larger urban settings  where hospitals are more adequately equipped with substance use health services, harm reduction programming, and addictions specialists , this isThere are some limitations to this study. This dataset is from baseline interviews and some participants had been enrolled for only 1-month, so there may be other factors over time that we were not able to capture. Follow-up interviews are therefore needed in order to capture any changes over time including additional factors affecting program access. Aside from the take-away doses policy differences across the programs, we were unable to ascertain differences in experiences of access across the sites due to a small number of participants at the Duncan site. Future research should examine differences based on levels of rurality. Also, while we reached a diversity of participants across the two programs in terms of sociodemographic characteristics (see Table To conclude, this was the first study on TiOAT programs in rural and smaller urban settings in Canada. Our findings highlight the unique challenges faced by TiOAT program participants in rural and smaller urban settings in BC. They also demonstrate the beneficial ways in which health services targeted toward people who use drugs can operate by creating an environment free of stigma and with an emphasis on social bonds and belonging. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services.


We also aimed to identify program-related issues from nurse-midwives' comments to improve the program.Breastfeeding is important for preterm mothers and infants. However, evidence-based practice and standardized education remain inadequate. To implement evidence-based practice, continuous education is mandatory for nurse-midwives. We previously implemented our developed education program on early essential milk expression care for preterm mothers among Japanese nurse-midwives. Herein, we aimed We conducted a secondary analysis of our previous data and surveyed the knowledge of 36 nurse-midwives who received a similar face-to-face education program on milk expression care for mothers three months before (Pre-1), just before (Pre-2), just after (Post-1), and three months after (Post-2) the program. We obtained their comments at Post-2 and identified issues for program improvement.The knowledge items, in which the correct answer rates of Post-1 were significantly higher than those of Pre-2, were Verification of the motivation and intent, Benefits of breastfeeding for mothers and infants, Milk volume on the fourth day and at around the second week after birth, Lactogenesis stage 3, Autocrine control, Time between birth and the initiation of milk expression, Early initiation of milk expression, Frequent milk expression, and Duration of pumping. The issues identified were practical training, knowledge retention, and misunderstanding knowledge.Nurse-midwives' unacquired knowledge of milk expression care for preterm mothers was effectively supplemented by the education program. Pre-education knowledge items with low correct answer rates must be strengthened during in-service education. Practical training, knowledge retention, and misunderstanding knowledge can be improved. Preterm birth; Breast milk expression; Obstetric nursing; Knowledge; Education program. We also identified program-related issues based on the nurse-midwives' comments and discussed what needs to be improved in the education program.In the present study, we As a result of the present study, the knowledge items improved by the education program which showed significant differences in the correct answer rates between just before and just after the education program were as follows: Verification of the motivation and intent (Q3), Benefits of breastfeeding for mothers and infants (Q4), Milk volume on the fourth day after birth (Q7), Milk volume at around the second week after birth (Q8), Lactogenesis stage 3 (Q11), Autocrine control (Q12), Time between birth and the initiation of milk expression (Q14), Early initiation of milk expression (Q15), frequent milk expression (Q16), and Duration of pumping (Q17). Therefore, this education program appeared to be effective in helping nurse-midwives acquire these knowledge items.On the other hand, nine knowledge items were not improved by the education program which showed no significant differences in the correct answer rates between just before and just after the education program. As for the underlying reasons, of the nine knowledge items, the nurse-midwives had already most likely acquired knowledge for seven items as the correct answer rates were already 80% or more just before the education program as shown in Regarding Q3 (Verification of the motivation and intent), although the correct answer rate increased significantly between just before and just after the education program brought about by the education program, the rate was much lower than those for the other items as shown in Regarding the previous nurse-midwives' evaluation of the education program, most of them gave positive responses . The comOne nurse-midwife stated that she would forget some of her knowledge because of the lack of opportunities to review the lectures and practice care. Another nurse-midwife mentioned the need for repetitive learning to remember her knowledge. As a proof of this, the changes produced by the education program disappeared three months after the education program for the following items in which the change was obtained just after the education program: Verification of the motivation and intent, Milk volume at around the second week after birth, Lactogenesis stage 3, Autocrine control, and Frequent milk expression. Bowling  showed iIn this education program, one nurse-midwife misunderstood the effective frequency of breast milk expression. With respect to the frequency of milk expression, several criteria were obtained in a literature review article by Tanaka et al. , namely,The present study is an exploratory secondary analysis of data obtained from our educational program in our previous study. It is not a study that was conducted after calculating the sample size to explain the difference in the nurse-midwives' correct answer rates for each knowledge item in the educational program. Therefore, the number of nurse-midwives  was small. In our previous study, the three months time period before and after the educational program was not strictly controlled for each participant, thus the period of three months generally meant ‘about three months’.5The unacquired knowledge of milk expression care for preterm mothers by the nurse-midwives was effectively supplemented by the education program. Additionally, the knowledge items with low correct answer rates before the implementation of the education program must be strengthened in the in-service education of nurse-midwives. Approximately half of the knowledge items acquired by the nurse-midwives was retained even at three months after the education program.practical training, knowledge retention, and misunderstanding of knowledge. These issues can be addressed by the incorporation of practical applications such as simulations and demonstrations, the development of tools that allow nurse-midwives to continuously access knowledge, and the provision of simple and clear explanation about knowledge of milk expression care. These improvements are needed to promote and further increase the utilization of this education program in the future.Based on the comments of the participating nurse-midwives, the issues that can be considered for improvement of the educational program include Rie Tanaka: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.Shigeko Horiuchi: Conceived and designed the experiments; Analyzed and interpreted the data; Wrote the paper.This work was supported by the individual research allowance from Teikyo University.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


Up to a third of global road traffic deaths, and one in five in Mexico, are attributable to alcohol. In 2013, Mexico launched a national sobriety checkpoints program designed to reduce drink-driving in municipalities with high rates of alcohol-related collisions. Our study measured the association between the sobriety checkpoints program and road traffic mortality rates in 106 urban municipalities.We leveraged data from the Salud Urbana en America Latina (SALURBAL), which compiles health and environmental data from cities with over 100,000 residents. Death data from 2005 to 2019  were from official vital statistics. Among 106 Mexican municipalities defined as priority areas for intervention, 54 adopted the program  in 2013, 16 municipalities did so in 2014, 16 in 2015, 10 in 2016, 7 in 2017, and 2 in 2019. We used a difference-in-difference approach with inverse probability weighting adapted to a context where program adoption is staggered over time.There was a 12.3% reduction in road traffic fatalities per 10,000 passenger vehicles in the post-treatment period compared to the pre-treatment period . There was a clear trend of decline in mortality in municipalities that adopted the program (vs. comparison) particularly after year 2 of the program.In this study of 106 municipalities in Mexico, we found a 12.3% reduction in traffic fatalities associated with the adoption of sobriety checkpoints. There was a clear trend indicating that this association increased over time, which is consistent with sustained changes in drink-driving behavior. These findings provide support and insight for efforts to implement and evaluate the impact of sobriety checkpoint policies across Latin America.The online version contains supplementary material available at 10.1186/s40621-022-00407-4. Road traffic injuries are a major public health problem, representing the eighth most common cause of death globally, and the leading cause for children and young people (5–29 years old) , or national breathalyzer program, in partnership with the Pan American Health Organization. , which compiles health and environmental data from all cities with more than 100,000 residents in 11 Latin American countries  containing the list of municipalities that adopted the program and the year of adoption. Unfortunately, data on the number of sobriety checkpoints in each municipality were not available, but municipalities are likely to have several sobriety checkpoints, particularly during weekends and holidays when people are more likely to consume alcohol , as the underlying cause of death with a few exceptions  for municipalities grouped by year of adoption, such that for municipalities that adopted the program in 2013 (n = 54), the pre-treatment period was 2005–2012 and the post-treatment period was 2013–2019. Likewise, for municipalities that adopted the program in 2014 (n = 16), the pre-treatment period was 2005–2013 and the post-treatment period was 2014–2019, and so forth. We also graphically examined covariate balance across municipalities by treatment group.We used a difference-in-difference (DiD) framework with multiple time periods and variations in treatment timing, as proposed by  with the groups that will receive the treatment in subsequent years  at different points in time to estimate group-time specific effects. In this setup, the comparison group for each period changes over time; for example, for the group treated in 2013, the comparison group in 2013 contains all units that were not treated in 2013 . This logic is repeated for all other groups treated subsequently, with the comparison groups containing all units that were not yet treated. To estimate the group-time average treatment effect on the treated (ATTs), we used linear regression models adjusted for pre-treatment covariates combined with inverse probability weighting (IPW). IPWs are based on propensity scores, which are used to create weights that balance treated and comparison groups with respect to the covariates and reduce the likelihood of confounding bias. This combination of IPW in covariate-adjusted models, known as a doubly robust model, is a powerful tool that allows for two opportunities to correctly specify the model without introducing additional bias , and 51 were treated in the subsequent years. Figure 013, and Table The dynamic treatment effect specification for the main model is represented in Fig. In this study examining the effect of sobriety checkpoints on road traffic fatalities per 10,000 passenger vehicles in urban Mexican municipalities, we found that the program was associated with a 12.3% overall reduction in road traffic mortality. Overall, this result supports the hypothesis that sobriety checkpoints are associated with reductions in traffic mortality rates. The dynamic analysis showed that while the program did not have an immediate effect on the outcome, there was a clear trend of decline in road traffic mortality in the treated (vs. comparison) group, particularly after year 2 of the program. Various sensitivity analyses returned consistent results, including a negative control using cancer rates as the outcome.Our results are generally consistent with the literature assessing the effect of sobriety checkpoint programs . Most previous studies evaluating similar programs only followed outcomes for 1–3 years, (Bergen et al. Our study has several advantages compared to previous evaluations of sobriety checkpoints. First, we included a large number of jurisdictions with high rates of road traffic fatalities at baseline that adopted the program over a number of years. We took advantage of this large sample and the staggered adoption of the program across the country to compare jurisdictions that adopted the program with those that would eventually adopt the program. The inclusion of such a comparison group strengthened our study design by reducing the chances of unmeasured confounders, i.e., covariates associated with both the adoption of the program and the outcome. Second, we used a combination of regression adjustment and inverse probability weights, which together improve the plausibility of the conditional parallel trends assumption holding true for municipalities with similar characteristics, e.g., population size and urban development. Third, municipalities were well distributed across the range of values of the covariates, except for a handful of outlier municipalities treated in 2013 that had more than 80% urban built-up. These outlier municipalities could lead to positivity violation, also known as lack of overlap, which means that these observations have no counterfactual in the comparison group (Gelman and Hill Despite the use of a quasi-experimental approach and a comprehensive set of sensitivity analyses, we cannot claim that the reduction in traffic mortality we observed in our study is fully explained by the sobriety checkpoints program. Mexico has made great strides on road safety measures, with state and local governments enacting legislation and strengthening enforcement. However, there is no central database of these policies, and we were not able to account for all potential changes to local policy environments during the study period. In this context, our results regarding the sobriety checkpoints program may be overestimated because they could be the result of the combined effect of sobriety checkpoints and other local policies. Nonetheless, our study findings coincide with prior research on sobriety checkpoints in direction and magnitude, which demonstrate large reductions of road traffic deaths and injuries when checkpoints are implemented and enforced. The lack of available data on the intensity or enforcement of the program across municipalities represents an important limitation of our study. The fact that we did not adjust for these features indicates that our global effect is an average across localities with potentially different levels of intensity or enforcement of the program. In this context, our findings are likely an underestimation of the program’s potential effectiveness if implementation had been homogeneous across locations. We also acknowledge that road traffic mortality is an imperfect proxy for alcohol-related traffic deaths. However, studies indicate that sobriety checkpoints may have a broader effect on road traffic deaths overall by leading to better behavior from drivers in general and improving road safety by removing high-risk drivers from the driver pool. Lastly, vital registration data may be incomplete due to insufficient coverage or ill-defined deaths, although we took steps to mitigate both of these issues (Quistberg et al. In this study of 106 municipalities in Mexico, we found a 12.3% reduction in traffic mortality rate associated with the adoption of sobriety checkpoints. There was a clear trend indicating that this association increased over time, particularly after year 2 of the checkpoint program. These findings provide support for efforts to implement sobriety checkpoint programs in Latin America, and insights for assessing similar initiatives implemented to reduce alcohol-related harms.Additional file 1.. ICD-10 codes excluded in the identification of road traffic deathsAdditional file 2. Descriptive statistics for covariates by treatment group.


The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran’s I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist. The 2015 American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis (RA) provide a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) in combination with conventional disease-modifying antirheumatic drugs (cDMARDs) for patients who fail to meet treatment targets with cDMARDs alone . The addAlthough bDMARDs are an effective and important component of common pathologies such as RA, inequity of bDMARDs access remains a challenge in many communities worldwide . PreviouRural American communities face several challenges in accessing healthcare from reduced facilities due to hospital closures, lower rates of insured status compared to urban areas, and a shortage of both primary care and specialty care physicians -12. PrevIn this study, we aim to conduct a retrospective nationwide analysis of Medicare bDMARD prescription rates and elucidate potential gaps in care. While previous studies have examined racial, economic, and other demographic variations in bDMARD prescription rates for local communities, there is insufficient literature examining national patterns of geographic distribution and community access to bDMARDs ,23. If aTo provide a more robust analysis of nationwide trends in bDMARD access, this study combined multiple public access, county-level databases, including: Medicare Part D prescriber, US Census, Centers for Medicare & Medicaid Services (CMS) Medicare demographics, CMS chronic disease, and the USDA Economic Research Service’s (USDA ERS) databases -27. BecaTo properly compare and sum prescription patterns of the different bDMARDs, it would be improper to directly compare the total number of doses as different medications have different strengths and dosing regimens. Therefore, the total days of coverage prescribed (a base metric recorded in the CMS prescriber dataset) was used as the core metric for tracking bDMARD prescription patterns as it is standardized across all medications. All prescribing variables were scaled to the Medicare Part D populations of their respective county. The bDMARDs rituximab, abatacept, adalimumab, etanercept, infliximab, certolizumab, tocilizumab, and golimumab were tracked both individually and as a whole. The average yearly cost of bDMARDS per county per 10,000 Medicare Part D members was also determined. However, it does not represent the cost to the patient but rather the net cost to Medicare, including ingredient, dispensing, and sales costs. The specialty of the prescriber, the number of different prescribers, and the relative amount of bDMARDS prescribed by each specialty were also calculated for each county as core metrics in understanding who is controlling the bDMARD supply.Centers for Medicare & Medicaid Services' demographic information, including average race, age, and gender breakdowns for each county from 2015-2019, was added along with CMS chronic disease data. Chronic disease data included the prevalence of various chronic diseases and risk factors in the Medicare community including obesity, tobacco use, diabetes, and chronic kidney disease, among others. The USDA ERS 2013 data on the latest RUC designations (a rank from 1 to 9) were used to identify each county on a spectrum from rural (rank > 3) to metro (rank < 3) to urban (rank = 1).The completed dataset was then exported to GeoDa, a geospatial analysis program from the University of Chicago Champaign, to perform network analysis. Each of the 3072 counties was treated as a node in a network with their connections weighted based on the geospatial distance between them. Moran’s I statistic, with a null hypothesis that the bDMARD distributions would be spatially random, was used to identify statistically significant (p < 0.05) clustering across average yearly prescribed days of all bDMARDs per 10,000 Medicare Part D members and across each individual bDMARD. The Moran’s I statistic, specifically the local Moran’s I statistic that was utilized in this analysis, identifies and groups nodes  into five potential categories: Not Significant, High-High, Low-Low, Low-High, and High-Low. Each designation (with the exception of Not Significant) is a combination of two attributes: the first represents a county’s value compared to the average county, and the second represents the average of a county's neighbors compared to the average county. Both values must be statistically significantly (p < 0.05) higher or lower than the overall average for a county to not be placed in the Not Significant group. For example, a High-High designation implies that both the county and the surrounding counties have a significantly higher than national average rate of bDMARD prescription days per 10,000 Medicare Part D members. If both attributes are matching  then these counties are known as spatial clusters and represent hotspots and coldspots, respectively, for the value of interest. If the attributes are not matching  these represent spatial outlier counties, which denote counties that are significantly different from their neighbors. These can represent transition zones and often demarcate shifts from rural to urban counties. The Moran’s I statistic for the average yearly cost of bDMARDS per county per 10,000 Medicare Part D members was used to group all counties into their statistically significant designations which were then exported back to Python where a one-way ANOVA was performed. This ANOVA compared the four groups across the 49 socioeconomic and bDMARD prescription variables to determine what demographics and communities were under- and over-served in access to bDMARDs. Statistical significance in this analysis was defined as p < 0.001.Using Moran’s I for analysis of average county-level bDMARD prescription patterns from 2015 to 2019, we were able to reject the null hypothesis of spatial randomness and found clear disparities in access. Looking first to Figure A paired histogram of the scaled-to-population bDMARD distributions in Figure The ANOVA displayed in Table The majority of existing literature assessing bDMARD access in the US has focused on the geographic barriers facing patients with rheumatic diseases in rural communities -16. Our Much of the statistically significant socioeconomic differences between hotspots and coldspots of bDMARD access are derived from the vast socioeconomic differences between urban/metro and rural counties. Although these correlations may be obvious in describing the rural/urban continuum, they are still more accurate in describing the attributes of the communities most affected by bDMARD disparities. It is interesting to note, however, the presence of an unexpected urban/metropolitan divide, which can be seen with a bullseye-type pattern as seen above in Figure Studies suggest that worldwide, the socioeconomic status of a community and the direct affordability of the medications for patients are the biggest predictors of bDMARD access . Direct The core driving force for the geographic disparities seen across our analysis is not the interplay of poverty and the high monetary cost of bDMARDs but instead the access to a rheumatologist. While rheumatologists only accounted for 1.08% and 0.36% of all specialists who prescribed bDMARDs in hotspot and coldspot areas, respectively, when comparing the percent of bDMARDs that are prescribed by rheumatologists, the proportions are 53.12% and 2.57%. Our interpretation of this finding is that in both hotspot and coldspotmany non-rheumatologists willho will occasionally prescribe the initial dose of medication to patients. But the difference between the high- and low-access areas is that the high-access areas have rheumatologists that manage the majority of patients’ long-term bDMARD care while low-access areas do not. Thus, one explanation for the overall disparity is a lack of access to specialized physicians that are comfortable handling long-term prescriptions of bDMARDS.There are several limitations to the analysis conducted in this study that is important to acknowledge. First, the core of the data is derived from Medicare records, and while they can serve as estimators of trends in the overall population, the Medicare population is not a proportional random sample of the US population. Analysis of Medicare patients does, however, provide valuable information in guiding future policy as this population makes up a substantial portion of federal healthcare spending . Second,Despite its limitations, this study provides a comprehensive county-level statistical geospatial analysis of bDMARD access across the United States. The same study may be replicated using updated data released by the Centers for Medicare & Medicaid Services (CMS) as it becomes available. It will also be of interest to determine whether these inequities in geospatial access across the US are improving or worsening with time if more years of analysis are included. This insight into yet another health disparity facing rural communities and the descriptive mapping of relative bDMARD drug inequities can be used to guide further research such as creating initiatives by the CMS and the US Department of Health and Human Services to promote rural rheumatologic practice and improve access to care in rural areas of the US.


Globally, Indigenous populations have been impacted by colonization. Populations who have endured colonization are at higher risk of developing chronic diseases. Canada’s Truth and Reconciliation Commission emphasizes reducing barriers to participation in physical activity and recommends the creation of culturally relevant and supportive policies and programing. Physical activity is a cornerstone in health promotion and public health to combat chronic diseases; however, in Canada, Indigenous developed physical activity programing is sparse, and those targeting women are non-existent in some regions. Makoyoh'sokoi (The Wolf Trail Program) is an 18-week long, holistic wellness program that was created by and for Indigenous women. Makoyoh'sokoi was developed by communities following extensive consultation and cultural oversight. Makoyoh'sokoi’s core program consists of 12 weeks of weekly physical activity programing and health education, followed by another 6 weeks of weekly health education. Notably, communities have control over the program to modify based on individual needs and challenges. Programs commence and conclude with a ceremony with Elders giving a blessing and opening each other to connection. The goals of Makoyoh'sokoi are to empower women, improve health outcomes, and to implement a sustainable program by training a network of community members in their respective communities to facilitate delivery. Globally, there is a need to recognize the harms and impacts of colonization because of the impact it has had on all aspects of life, including health, traditional roles, culture, socio-economic conditions, access to services, and equity, among others . IndigenWith colonization also came the introduction of patriarchy, disproportionately impacting women who historically played central roles in society and held valuable knowledge on healthy food systems , 5. A 20This program aligns with two Calls to Action of Canada’s Truth and Reconciliation Commission (TRC) report, which aim to counteract the harms of colonization and bring awareness and recognition to Indigenous people . The TRCA review by Rice et al.  of physiMakoyoh’sokoi (Wolf Trail), an 18-week, holistic wellness program for Indigenous women, was developed in the community to fill the gap in programming for adult Indigenous women and to provide evidence for the importance of culturally safe, community-based programs.support Indigenous women to celebrate health and make a difference in our world.We “Support” the creation of a culturally safe and collaborative environment that addresses physical, mental , spiritual, and emotional well-being is central to the Wolf Trail (Makoyoh’sokoi).“Make a Difference” means women who self-activate and support their family, friends, and community. It can come in many different forms, from the prevention of personal ill health to personal growth into positions that may influence the health of others, or to contributing to a supportive healthy community.“In Our World” reflects our understanding of the interconnectedness of all living creatures and the planet we live on, reflecting Indigenous ways of knowing. We also recognize how rapidly the world is changing and how much more interconnected we have become and will continue to be, recognizing that, when one person’s health changes, it can cascade to impact many others both near and far, and for generations to come. By stating this, we acknowledge how the negative impact of colonization cascaded into intergenerational trauma and severe health inequities for Indigenous peoples.True to the culture of many Indigenous populations, Makoyoh’sokoi is rooted in connection, story, and sharing. After consultation with our communities and advisory group , the spirit of Makoyoh'sokoi (ma-koy-yoh- so-koy) was conveyed by the following vision statement:Makoyoh’sokoi was designed specifically to address the health and wellness needs of Indigenous women. Pilot programming, in partnership with seven communities running ten programs across the Canadian provinces of Alberta and Saskatchewan, demonstrated increased weekly pedometer step counts, increased nutritional awareness (consumption of fruits and vegetables), improved confidence in exercising as a group, and improvements in weight and systolic blood pressure . Most noMakoyoh’sokoi was initially developed in community and expansion was organic, with new sites requesting the program, each with the opportunity to adapt the program to suit their unique needs. Community Leads, individuals with a key role in health promotion within their communities, contributed to the adaptation of the program and the hiring and support of local Program Facilitators. The Program Facilitators administer all aspects of the program, such as hiring fitness instructors, leading the nutrition education, and performing data collection. Together, the Community Leads and Facilitators report back to the participants and their wider community on the outcomes of the program. Additionally, an Advisory Group comprised of Indigenous and non-Indigenous community members and Indigenous Elders oversees the spirit and vision of the program.Community consultation and cultural oversight was integrated throughout Makoyoh’sokoi development and documentation. Following the naming of Makoyoh’sokoi a call was put out to community members for the development of a logo and media that could be used for program documentation. The result of the community call is shown in Fig. Nourish Health and Well-Being Modules© (one for Program Facilitators and one for participants). The operational manual includes administrative information such as budgets, and attendance sheets. The Program Facilitator manual provides an overview of the program and information on how to lead a class including how to organize instructors, connect with community leads and Elders, and experimental learning styles. The Nourish manual includes health and well-being modules that the Program Facilitator delivers to participants , including communities on- and off-reserve. Therefore, although there are core documents and measures that are proposed for each community, a key novelty of the program rests in the ability of the communities to modify the program based on their unique needs.Early program development applied social cognitive theory of behavior change, assuming learning from others and being given opportunity to apply new knowledge in a safe environment would support behavior change . SubsequParticipants are exposed to a variety of physical activity through the course of the program, in part so they can sample and learn what types of activity interests them and gain confidence in their ability to participate. This is done in a safe and culturally relevant environment. They are instructed by individuals that understand their unique needs and social determinants of health. In-between sessions, participants use a step counter and encourage each other , as well are encouraged by the Facilitator, to improve upon their daily steps.Moreover, participants complete health education modules that expose them to health information, a substantial portion of which relate to healthy nutrition and disease prevention, and on occasion to local healthcare providers. Again, supported by the safety of the environment, the group can explore their barriers and facilitators to change openly. Specific healthcare needs can then be indicated, and appropriate resources identified. The goal being to increase activation and the ability to manage one’s own health. It is important to note that childhood trauma, addictions, and mental illness all greatly impact an individual’s ability to make positive behavior changes and through pre-program surveys and engagement by Program Facilitators, individuals with more severe, specific needs may be identified and appropriate referrals made. In each community, the Community Organizational Leads will support the Facilitators to establish a comprehensive resource list of healthcare professionals. Through exposure to local Indigenous Knowledge Keepers and Elders, along with cultural and spiritual elements, participants will gain knowledge of how to access activities to further support their wellness journey.The Makoyoh'sokoi program shows promise as a community-based model for supporting Indigenous women to improve their health. It is grounded in community; increases self-efficacy through opportunity to learn, practice, and share in manageable increments; and increases health literacy through program contents and coordinating healthcare knowledge exchange with other healthcare providers from the community. This is all accomplished in a safe and supportive environment that is therapeutic, enhances connectedness, and fosters collaboration. Lastly, by connecting to aspects of Indigenous culture, participants can be affirmed in their identities and learn more about how connecting to culture may be protective of their health through restored sense of self-worth, sharing, and community support ., 15–30 min sharing circle); (4) an optional urban pole walking session; (5) introduction to local healthcare providers as identified as relevant for the group ; (6) ongoing online support via social media (moderated by the Program Facilitator with weekly contact mid-way between live sessions); and (7) daily pedometer tracking to provide immediate motivational feedback to participants. The 6-week follow-up phase includes: (1) core weekly programming (15–30 min nutrition and wellness education and 30–45 min sharing circle) with an optional informal physical activity component such as a walk or urban poling session run by the Program Facilitator; (2) ongoing Program Facilitator contact to encourage healthy activities, address concerns as needed  and weekly step count recording; (3) continued encouragement and engagement via social media; (4) an end of program celebration with a local Elder.Each Makoyoh'sokoi program is 18 weeks long divided into two blocks, the first of which is intense programming followed by a less intense follow-up phase. Each program aims to recruit 20–25 participants. The initial 12 weeks consist of (1) a pre-program information and orientation session, and data collection; (2) an opening ceremony with a local Elder; (3) core weekly programming . Moreover, dispersed through the nutrition education modules, with a specific focus in Week 5 “Honoring Culture and Traditions” attention is given to traditional foods . This focus on cultural nutrition remains present at celebrations throughout the program with local Indigenous caterers, Program Facilitators, and/or participants preparing local meals to share and connect.Throughout the program, participants complete health education modules in the Nourish manual that support self-reflection, educate on nutrition and disease prevention, and support connection to local healthcare professionals. Again, because of the safety of the environment, the group can explore their barriers and facilitators to behavior change openly without stigma and identify specific needs and appropriate resources to address them with the goal being to increase activity and the ability to manage one’s own health. It is important to note that childhood trauma, addictions, and mental illness all greatly impact an individual’s ability to make positive behavior changes and through pre-program surveys and engagement with Program Facilitators, individuals with more severe, specific needs may be identified and appropriate referrals made. In each community, the Community Leads support the Program Facilitators to establish a comprehensive resource list of healthcare professionals.All measures for the program were approved by the advisory group. Ethics approval for this study was given by the Conjoint Health Research Ethics Board at the University of Calgary. All communities are asked if they have their own ethics processes in place, if so, ethics approval is sought from the local community. If the program is running on a First Nations reservation, then data collection and retention follows (OCAP)® principles of ownership, control, access and possession .Primary and secondary objectives, as well as measurement periods, are summarized in Table The effectiveness of the Makoyoh'sokoi program in improving objective measures of physical activity, health status and patient-reported outcomes will be assessed by comparing measurements made at multiple timepoints.Primary measures include participant activation (PAM™), objectively measured physical activity (pedometer step count), self-reported physical activity , participant mental health status  and overall balance based on Medicine Wheel philosophy.The PAM™ score has been used to assess effectiveness of diabetes prevention programming in Indigenous populations . It is aDaily step counting has been shown to be an enjoyable and pragmatic method for encouraging physical activity and correlates to mortality in the general population; specifically in women , 23. WalThe MHC-SF© has a strengths-based focus and uses three categories . It has previously been used in Indigenous populations and found cultural activities were positively correlated to MHC-SF scoring. What aspects of your mental, spiritual, physical, or emotional health did you come to value through the program? And has becoming more physically active increased your awareness of other aspects of your health?Qualitative Medicine Wheel exercises are to be completed monthly during the program. Participants will be asked to reflect on the question:A peer-researcher will be identified during the second month of each program. The peer-researcher will be trained in the photovoice method. Peer-researchers will meet with participants and educate the participants on how to create a photovoice to answer the question.Secondary measures include health-related fitness measures including cardiorespiratory, muscular, morphological, and metabolic fitness. Social well-being, Quality of Life, nutrition knowledge, and awareness and access to health supportive services will also be measured.Cardiorespiratory fitness will be measured with the one-mile walk test. Muscular fitness will be measured with hand grip dynamometry. Morphological fitness will be measured using bioelectrical impedance (BIA), waist circumference (WC), and body mass index (BMI). Metabolic fitness will be measured through biochemical markers , blood pressure (BP) and heart rate (HR) measurements. Composite scores will be taken indicating presence or absence of metabolic syndrome as well as risk score calculations including the Canadian Diabetes Risk Questionnaire (CANRISK) score.To evaluate social well-being, a question taken from the Canadian Health Measures Survey (CHMS) that measures a sense of belonging to local community will be used. Effect on quality of life will be assessed using the EQ-5D- 5L™.Awareness and access to services  will be measured. Both nutrition knowledge and eating patterns will be assessed, the Healthy Eating Index Score (HEI), as well as the Short HEI will be used to assess the latter, traditional food frequency and intake will also be assessed. The HEI has been adapted to a Canadian context . The higNoting the current mixed methods evaluation and the elements described in our earlier work, applying realist theory, can inform both outcomes and mechanisms. We will also track adaptations made by each unique program in order to assess ecological validity and cultural sensitivity, using a framework adapted from Bernal et al. . ViewingPhysical activity is an important health promotion tool for combatting chronic diseases. Canada’s Truth and Reconciliation Commission emphasizes reducing barriers to participation in physical activity and recommends the creation of culturally relevant and supportive policies and programming. Makoyoh’sokoi is a holistic wellness program, developed and led by Indigenous women to support their health and well-being. The implementation of health and wellness programs that are grounded in Indigenous ways is paramount to fulfilling commitments laid out in the TRC and improving the health and well-being of Indigenous women.The main limitation of our program is that our cultural engagement was restricted to Canadian Indigenous populations, and specifically those located in Alberta and Saskatchewan. It is recommended that communities that want to implement similar programing consult their regional and local Indigenous communities to help modify the program to fit their needs.


Sexual and dating violence (SDV) by male youth (≤ 25 years)—including sexual harassment, emotional partner violence, and rape—is a worldwide problem. The goal of this preregistered  systematic review was to map existing SDV prevention programs aimed at male youth, including their characteristics , intended psychosexual outcomes, and empirically demonstrated effectiveness, guided by the principles of the theory of planned behavior (TPB). We conducted searches in six online databases for published, peer-reviewed quantitative effectiveness studies on multi-session, group focused, and interaction based SDV prevention programs for male youth ending March 2022. After screening of 21,156 hits using PRISMA guidelines, 15 studies on 13 different programs, from four continents were included. Narrative analysis showed, first, broad ranges in program intensity , and few program curricula included explicit discussion of relevant aspects of the TPB. Second, programs’ main intended psychosexual outcomes were to change SDV experiences, or related attitudes, or norms. Third, significant effects were found mostly on longer term behaviors and short-term attitudes. Other theoretical proxies of SDV experiences, such as social norms and perceived behavioral control, were sparsely investigated; thus, program effectiveness on these outcomes remains largely unknown. Assessed with the Cochrane Risk of Bias Tool, moderate to serious risk of bias arose in all studies. We present concrete suggestions for program content, such as explicit attention to victimization and masculinity and discuss best practices for evaluation research, including assessments of program integrity, and examining relevant theoretical proxies of SDV. Sexual and dating violence are persistent problems all over the world  health and wellbeing, such as depression, anxiety, sexually transmitted infections, alcohol abuse and problems with fertility  compared to those for undergraduate/college students or adults  by Ajzen . The TPBSeveral other studies have also shown that the specific concepts of the TPB are overrepresented in young men and are indeed linked to SDV perpetration by young men. First, male youth have been found to develop attitudes conductive to SDV. For instance, a recent study on Dutch adolescents showed that especially adolescent boys (but not girls) pick up gender inequitable attitudes when presented by media and peers . The other theme is focused on SDV programs for men with no age specification .Regarding the first theme, dating violence among adolescents, previous systematic reviews  is important, because especially in youth, this behavior may develop into more serious forms, including intimate partner violence, over time  or type of delivery style (group discussions versus a theatre show), resulting in inconclusive results and questions about possible differentiation between programs with different intensity and work forms.The overarching aim of this study is to synthesize the existing scientific knowledge about the characteristics, intended psychosexual outcomes and effectiveness of SDV prevention programs specifically developed for male youth , aimed at the prevention of the broad spectrum of SDV. In doing so, we will describe the effectiveness of these programs regarding SDV experiences, and the theoretical proxies of SDV experiences according to the TPB  behavioral control and intentions). The second aim is to gain insight into the characteristics and quality of the effectiveness studies evaluating these programs, including their design, and investigated outcomes. We focused specifically on group focused, multi-session, and interaction-based programs, as it has been suggested that these ingredients are most often related to effectiveness  or intervening in youth with specific risks to perpetrate SDV . We excluded: Broad sexuality education or masculinity programs that were not specifically aimed at preventing SDV and treatment programs for previous offenders/SDV perpetrators.They had a quantitative design, such as a (cluster) randomized controlled trial (RCT), quasi-experimental design, or pre-posttest evaluation without a control group.They assessed experiences with SDV perpetration and/or victimization, and/or one or more TPB proxies of these experiences, broadly including all SDV-related attitudes, norms, perceived behavioral control  or behavioral intentions. This inclusion criterium did not result in the exclusion of any records see Fig. .They published in peer-reviewed journals in English language .We had selection criteria for both the empirical evaluation studies, as well as the SDV prevention programs that were evaluated in these studies. For the studies, we used four criteria:We included programs that were aimed at male youth . Participants could be school-going, living in youth-care facilities, visiting community centers, or working. Participants could also be youth with mild psychiatric- or behavioral problems.For the evaluated programs in the studies, we used three criteria.(2)Based on previous reviews indicating the following to be the most promising type of program, we included: protocolled programs in which the delivery mode was in person, group focused, and interaction based. This means that the program should have at least one program facilitator and at least two young male participants, who interact with each other and the person who delivered the program.We excluded programs that had one or more mixed-gender sessions, and programs specifically focused on college- or undergraduate students as the effectiveness of these programs has already been evaluated extensively Also based on previous reviews indicating the following to be the most promising type of program we included programs consisting of at least two program sessions.We therefore excluded programs that did not meet these criteria, such as (theater) presentations, film depictions, parent-delivered programs, broad community interventions without a pre-specified program, and fully digital or online interventions.We therefore excluded programs that did not meet this criterium, such as single-session prevention strategies, and programs without a specified number of meetings.We conducted a systematic literature search using PRISMA guidelines  were retrieved and screened for eligibility based on the inclusion and exclusion criteria. Any doubts about the eligibility of full-text articles were discussed among the authors to achieve consensus (k = 23). The full-text articles that met all criteria, were included.The online database searches resulted in 21,156 hits after duplicates were removed. The selection process is depicted in Fig. k = 11 papers to request additional data on program implementation and effectiveness statistics. Two authors responded and provided the requested information. Three authors responded but could not provide the requested information. From one author, no response was received.Relevant data of all selected articles was coded and entered in a structured Excel sheet that was based on the coding scheme used by DeGue et al.  by the fData were coded on program characteristics, characteristics of the included studies, and program implementation, the programs’ intended psychosexual outcomes and effectiveness according to the TPB. The coding scheme is available upon request to the authors.Regarding program characteristics, we coded the program name, program delivery , gender of program facilitators, type of facilitators , the target groups , session length, and number of core sessions, intended psychosexual outcomes, and program content. We also coded program integrity characteristics in terms of dosage , and adherence . It should be noted that dosage and adherence are partly program characteristics and partly study characteristics. For instance, adherence possibly indicates how easy it is to follow the protocol—a program characteristic -, but how much of the program facilitators executed can also depend on other factors such as time of year—a study characteristic.Regarding characteristics of the included effectiveness studies, we coded sample size, retention rate, sample characteristics , study location , site of the program implementation , study design, number of measurements and time between measurements, and type of comparison group .We double-coded all relevant statistical results of all relevant SDV related psychosexual outcomes related according to the TPB. Statistics coded were means and standard deviations, percentages, medians and interquartile distances for behaviors as they were reported in the studies. Moreover, we coded significance of the analyzed differences between experimental- and control groups at post-test and follow-up, or between the pre- and post-test measurement. This was done separately for each outcome from each study.If data for effect size calculation were not readily available in the manuscript, we contacted the authors to retrieve missing data. Some randomized controlled trials (RCTs) or quasi-experimental studies also reported within-person analyses. For comparability across similar studies and because most RCTs and quasi-experimental studies only reported intervention effects , we did not take into account these analyses.To assess the quality of the included studies, we used Elridge et al.  Revised dCohen for pre-posttest designs without a control group , of 13 unique programs from seven countries. For an overview, see Table k = 5), semi-controlled evaluation designs  and non-controlled designs . Eight studies included more than one outcome measurement after the program-period. This was mostly a direct post-test (k = 7) or three months after the end of the program (k = 1) as the first outcome measurement. For the follow-up measurement(s), intervals ranged from three months up to five years after the post-test. The other studies (k = 7) included only one outcome measurement, with intervals ranging from directly (k = 2), 2 to 6 months (k = 4) up to 12 months (k = 1) after the program ended. Hence, the term “pre-posttest study” does not necessarily mean that outcomes were assessed directly post-program. For most (k = 10) studies, the final measurement was at least 3 months after the end of the program.Study designs characteristics are presented in Table N = 8 up to N = 2,006 participants at baseline, but almost all studies had more than 100 participants in the program at the start of the study (k = 13). Retention rates in the intervention groups ranged from 39.9 up to 98.5% at post-test, and 28.2 to 89.6% at follow-up. Of the 14 studies of which we have information about retention at post-test, six had at least a retention rate of 75% at post-test, whereas at follow-up this was the case for k = 4 studies (see Table Study sample sizes ranged from k = 13) and behaviors (k = 11). Less common were intentions (k = 5), perceived behavioral control (k = 2). Social norms were assessed in only one study , India (k = 3), African countries , the Netherlands (k = 2) and Republic of China (k = 1). For the six studies conducted in the USA, samples consisted of mostly black participants (k = 3), participants of mixed racial composition (k = 2) or white American participants (k = 1). In most other countries, the population consisted of (mainly) the local majority (k = 7), and for two studies, the composition of the sample was not mentioned. The mean age of the studies’ samples ranged between 10 and 23.5 years. Participants were on average between 10 and 13 years (k = 4), 15 and 16 years old (k = 6) or 18 and 23.5 years (k = 5). In k = 14 out of 15 studies, participants’ individual maximum age was 24 years. In one study , the individual age range was wider  but skewed to the right, resulting in an estimated sample mean age of 23.8 years. Finally, what type of SDV was addressed by the programs as described in the studies, and its definition and operationalization (if any), is presented in Table The context of the included studies is presented in Table p = 7), one in a suburban area and the rest of the studies were conducted in rural areas (p = 3) or in multiple areas (p = 3). For one program this was unknown. About half of the programs were implemented at schools (p = 7). Other sites were in the community (p = 5), at the workplace (p = 1), or in a care setting .The characteristics of the 13 included programs are presented in Table p = 6) the main intended psychosexual outcome was to prevent SDV behaviors along with the attitudes of social norms conductive to SDV. For four programs, the main psychosexual outcome was changing attitudes related to SDV (p = 2), or changing attitudes and promoting SDV bystander behaviors (p = 2). Finally, for two programs the intended psychosexual outcomes were norms (p = 1) or norms and skills necessary for SDV prevention (p = 1).In about half the programs (p = 3); (2) living situation , (3) culture , or (4) activity/employment status   age ;  living sp = 5), see Table p = 3), or people who received some training in the program manual but were not professionals in SDV prevention, such as teachers or coaches (p = 3). Two programs were delivered by a combination of a professional , and someone who may have received some training to implement the program , simultaneously (p = 2). When the gender of the facilitator was mentioned, they were most often male (p = 8) and for one program, a female (co-)trainer could also facilitate the program. Notably, for the other five programs, facilitator gender was not reported.Program facilitators were most often professionals  consisted of less than or around 10 sessions. In terms of intensity , programs ranged from less than 2 up to 96 h. In terms of frequency, most programs had weekly sessions. Session length could range from 10 to 15 min, up to 3 h per session.Programs consisted of a broad range of sessions (varying from four to 48 sessions), see Table p = 4), facilitators were more active than participants, as they presented the program mostly in the form of interactive presentations or lectures. In the other programs, participants were most active .Most programs included various work forms , and also actively involved the participants, see Table p = 12 programs. For most programs (p = 9), but not all, sexuality was mentioned as a program topic. For one program (Program H), the authors mentioned that leaving sexuality out of the program was a deliberate choice due to the young target group of about 10 years . Information about the dosage (k = 5) and/or adherence (k = 4) was available either directly from the papers (k = 4), or upon request via personal communication with the authors (k = 2), or not, despite several reminders to send the requested information (k = 3). The reported dosage ranged from 33.7 up to 98.8%, and the reported adherence ranged from 54 up to 99.5%.About half of the studies reported information on program integrity during the study  were significant (18 at post-test and 19 at follow-up). All significant effects were in the hypothesized direction. Measurement intervals at post-test ranged from directly—12 months after the program had ended. For the follow-up, this was 3 months up to 5 years after the posttest. Hence, the studies represented a broad range of short-term and longer-term effects , significant effects on at least one assessed outcome were found, only one program showed no significant effects whatsoever. At post-test (directly up to 12 months after the program ended), most effect sizes were (very) small (61.1%). At follow-up (3 months–5 years after the post-test), most significant effects were also (very) small (63.1%), but another 31.6% were large/huge. A summary of the proportion of significant effects (post-test and follow-up) per TPB-factor are presented in Fig. For almost all programs p = 1, signifik = 11; 52 effect sizes; see Fig. Almost all included studies assessed behavioral outcomes  were significant. Regarding bystander behaviors, seven effects (38.9%) were significant. For SDV perpetration, all significant effects were (very) small. For bystander behaviors, effects were larger. Concluding, more evidence for effectiveness on behavior was found at follow-up (65%) than at direct post-test. Most significant effects were (very) small.Six studies investigated intentions  were significant. Regarding gender equitable attitudes, 18 effect sizes were included. Seven of the effect sizes were significant (39%) The effects were mostly small. Two effect sizes were reported for attitudes as one composite outcome, and these showed very large effects at post-test and follow-up. Concluding, more evidence for effectiveness was found for changing gender equitable attitudes than attitudes towards SDV. For both categories, effects were mostly small, and most effects were found at post-test.k = 1; see Fig. d = 0.46. While the effect had a p-value of p = 0.03, the authors of this paper did not consider this a significant result, as they corrected for multiple testing using α = 0.005.Social norms (friends’ acceptance of SDV) were assessed in one study . Examples of outcomes that were assessed regarding this concept are outcome expectancies of persuading a partner into having sex . The second concern was lack of blinding in all studies, as participants may therefore have responded differently. The third was incompleteness of outcome data: attrition might have been related to the true outcome which possibly leads to overestimating effects, or missing data were not properly addressed (k = 3 were judged as high risk). It should be mentioned that bias due to attrition does not necessarily lower quality of a study but may nevertheless present a risk of bias in the estimation of effects.The risk of bias assessment is included in Table k = 8 non-randomized studies, k = 5 studies were judged as moderate, and k = 3 as serious risk, arising from problems on three main domains . The second was measurement of the outcome, as self-report in combination with knowledge of intervention status may have biased participants’ answers (k = 4 were judged as moderate and k = 2 as serious risk). The third domain was incomplete outcome data, relating to problems with adhering to reporting standards or selective outcome reporting, which was often not possible to assess because of lack of pre-registration (k = 2 were judged as moderate and k = 2 judged as serious risk). In sum, the assessment of effectiveness of the studies included in this review was based on five RCTs and eight non-randomized studies, all with moderate to serious risk of bias.Regarding the Sexual and dating violence (SDV) among youth is a worldwide problem, and male youth are specifically at risk of perpetrating SDV. We systematically reviewed 15 studies, from seven countries, evaluating 13 different programs to get insight into the form and content, intended psychosexual outcomes, and effectiveness of SDV prevention programs for male youth. Specifically, we looked at programs targeting theory-based underlying risk factors for SDV such as attitudes, social norms, (perceived) behavioral control  and intentions , whereas in higher-income countries (USA and the Netherlands), programs were often implemented at schools and facilitators were typically professionals or teachers. Moreover, facilitators were mostly male, but the facilitator’s gender was often not clear. Currently the possible effect of facilitator gender on program effectiveness remains therefore unknown. Second, duration and intensity differed widely. However, unlike other reviews  accounted for most significant effects . It should be noted that most of these significant effects were (very) small . However, even small effects on behavior can make meaningful differences, depending on the severity of the behaviors prevented by a program, and its cost-efficiency and scalability  were generally a bit older . However, most of the studies on these programs also included larger samples and/or had better fit between the intended and assessed outcomes. Moreover, some of these programs  had relatively many program sessions . This makes it difficult to say much about what caused the found effects. Regarding other program—or study characteristics, we did not find any clear patterns.From this systematic review, we have three suggestions for future practice in SDV prevention for male youth. First, developers of these programs should take into account the theoretically relevant factors related to SDV behaviors, and in the program curricula more attention should be paid to evidence-based topics such as attitudes regarding masculinity, and skills necessary for (perceived) behavioral control . Second, online SDV is increasingly on the rise. Examples of online SDV are online grooming, a sequence of behaviors employed by an offender in order to make the victim less resistant to sexual abuse  and attitudes (short-term), and whether these programs are also effective on the other relevant theoretical proxies of SDV, such as social norms and (perceived) behavioral control, remains largely unclear. Critics may argue that the overall relatively small effects beg the question to what extent these programs can be considered meaningfully effective, and when implementing such programs permits the substantive investment in terms of time and money. However, we would like to oppose that most importantly, there is still a lot of work to be done before such a conclusion can be validly drawn. Based on our evaluation of this body of literature, we have presented concrete suggestions for research and practice, and urge these fields to continue to collaborate toward continued program evaluation and further program development, using detailed descriptions of the programs and the evaluation designs. The formulation of relevant guidelines and effective program ingredients is an inherently iterative process, informed by theoretical perspectives and empirical insights, which are dynamic and subject to continuous change in youths’ social worlds. To conclude, investing in research and knowledge on effective early prevention of SDV across countries, and moreover, reducing the prevalence of SDV among youth worldwide, is of vital importance for both individual wellbeing and public health.


SchistosomaICT IgG-IgM for screening urinary schistosomiasis in Nigeria.Schistosomiasis is a blood fluke parasitic illness affecting human lives in rural endemic areas. This study evaluated the performance of SchistosomaICT IgG-IgM were used for analysis. SchistosomaICT IgG-IgM used 2 mL of each serum for serological examination. Then, 3 mL of each preserved serum was sent to LDBIO Diagnostics, France for re-examination with Schistosoma ICT IgG-IgM and confirmation with SCHISTO Western blot (WB) IgG. The performance of the index tests was determined using sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and positive likelihood ratio (PLR). The Youden index (YI) and diagnostic accuracy (DA) were used to determine the accuracy of each test. The statistical significance was at p-value ≤0.05.Three hundred and seventy four (374) urine samples were examined. Reagent strips, urine filtration and Schistosoma ICT IgG-IgM had a good Cohen’s kappa index (κ=0.68), good Youden index (YI=0.58) and good diagnostic accuracy (DA=0.78).The test had a sensitivity of 94.9%, specificity of 63.9%, positive predictive value of 72.4%, negative predictive value of 92.6%, and positive likelihood ratio of 2.62. SchistosomaICT IgG-IgM has proven to be the best technique for the screening of urinary schistosomiasis in Nigeria. Schistosoma sp which are trematode worms. The disease is an acute and chronic illness affecting humans living in rural areas. It has been estimated that 240 million people are infected around the world and about 90% of them are found in sub-Saharan Africa ..SchistosThe usual laboratory examination of schistosomiasis in health centers of rural and urban areas was based on reagent strips , 9]. Ur. Ur9]. USchistosomaICT IgG-IgM was developed recently as a rapid and qualitative test. This study evaluated the first screening performance of SchistosomaICT IgG-IgM in Nigeria 6 months after its commercial availability. This research compared SchistosomaICT IgG-IgM to reagent strips and filtration usually used on the field.The study was conducted in Takum Local Government Area (LGA) located at latitude 07° 15′N and longitude 09° 59′E of Taraba State, Northeast, Nigeria. It is bordered to the South by the Republic of Cameroon, to the West by Ussa LGA, to the North by Donga LGA and to the East by Katsina-Ala LGA, Benue State. The Local Government Area is sub-divided into 10 wards among which seven wards were selected. The selection was based on the presence of functional Primary Health Care Centers, where inhabitants were referred to for treatment. The areas were all drained by substantial rivers from which inhabitants depend on for their daily home activities. The wards selected were Barki-Lissa, Birama, Chanchanji, Kashimbila, Manya, Malumshe, and Sufa .The climate of the area is tropical with vegetation characterized by a typical guinea savannah interspersed with gallery forest. There are two distinct seasons: the rainy season, which starts from mid-March to mid-October and the dry season from mid-October to mid-March. The annual rainfall ranges between 1,200 – 2,000 mm. The average temperature is between 24 and 32 °C with a peak at 37 °C in March and April.The area is inhabited by civil servants, agricultural business people and peasant farmers. The Local Government is an area of intense agricultural and fishing activities.Schistosoma ICT IgG-IgM on the field. Urine filtration, microhaematuria and proteinuria were used as index tests. Serological samples were sent to LDBIO Diagnostics, Lyon, France for re-examination with Schistosoma ICT IgG-IgM and confirmation with SCHISTO II Western blot (WB) IgG.The research was a prospective study for the use of Prior to the commencement of the study, ethical permission was obtained from the Directorate of Health, Takum LGA (TLG/PHC/403) and shown to the Ethical Committee of Federal Medical Center, Jalingo, Taraba State.jukun”, a local language in the area. The inhabitants of each ward were informed to gather at their local chief premise for interaction a day before collection of urine and stool samples. Each local inhabitant was informed to convene respectively to his functional Primary Health Care ward for collection of samples. Adults, children and their parents or guardians to be enrolled were verbally interviewed in their tribal language ‘jukun’. Participants conveniently followed the instructions before sampling.The local chief of each community ward was contacted and briefed about the significance of the study three days ahead of sampling. The oral expression with the participants to collect their urine and blood for examination was in “P=50% is the estimated prevalence of urinary schistosomiasis. D=1, reflects the design effect of the simple random sampling used for enrollment of subjects. E2=0.0025, precision . Z=1.96, for two tails.The sample size of the subjects was calculated by the formula:Four hundred and twenty (420) individuals were enrolled for the study. Sixty (60) individuals were randomly sampled in each of the seven wards. Participants that were ill and had urinary illness within 2 weeks were excluded. Women on menstruation were also excluded from the study. Each subject who refused to give 5 mL of blood to prepare plasma was equally excluded. Subjects that also refused to give 10 mL of urine for filtration technique were disengaged. Some individuals refused to participate because of their cultural beliefs on the use of their blood and urine. Participants that fulfilled all the criteria to give their blood and urine samples were included in the study. Participants that were diagnosed of urinary schistosomiasis were treated immediately with Praziquantel.Schistosoma ICT IgG-IgM was used for sera. Anonymous and coded duplicates of sera used on the field were sent to LDBIO Diagnostics, Lyon, France for re-examination with Schistosoma ICT IgG-IgM. SCHISTO II WB IgG was used for confirmatory diagnostic decision of sera collected.Subjects and parents of the children were informed on different examination methods. The urine filtration and reagent strips were used for urine samples while Kato-Katz  was used for faecal examination. Reagent strips  were used for determination of microhaematuria (Ery/μL) and proteinuria (mg/dL). Microhaematuria was determined as: 0=negative, Ca.10=+, Ca.50=++ and Ca.100=+++. Proteinuria was measured as: 0=negative, Ca.30=+, Ca.100=++ and Ca.500=+++Filtration is a field technique for urinary schistosomiasis. A 10 mL syringe, swinney polypropylene filter holder (13 mm diameter) and polycarbonate membrane filters (12.0 μm porosity)  were used during urine filtration. Urine samples were reported as: 0 eggs/10 mL of urine (not infected), 1–49 eggs/10 mL of urine (lightly infected) and >50 eggs/10 mL of urine (heavily infected) using WHO standard .Faecal sample examination was conducted using the Kato-Katz and faecal concentration techniques. The infection was classified as <100 epg (low parasitic load), 100–399 epg (medium parasitic load) and >400 epg (high parasitic load) .Schistosoma ICT IgG-IgM is a newly developed rapid and qualitative test. It is based on immune-chromatography technology detecting simultaneously IgG and IgM. A 10 mL of blood sample was collected from each subject. Then 5 mL of serum was prepared from each blood sample. Each Schistosoma ICT IgG-IgM used 30 μL of each prepared serum for schistosomiasis examination. The cassette assay determined the positive, negative and invalid tests between 20 and 30 min. The test procedure was described as follows: 30 μL of serum and an eluent were firstly dispensed in the sample well of each assay. The test became positive when a red test band “T” appeared. It was rather negative when a control blue band “C” appeared. The test was invalid when there was no appearance of “T” or “C” bands. The details for use of Schistosoma ICT IgG-IgM are found in the instructions . P. PSchistDespite the common use of microhaematuria and proteinuria as reagent strips for screening, previous studies recorded unsatisfactory results , 18]. T. T18]. TSchistosoma ICT IgG-IgM had a good sensitivity, fairly good specificity and fairly good positive likelihood ratio. This happened due to good reading of the cassettes used by researchers who assisted the laboratory technicians. The assessment of Schistosoma ICT IgG-IgM in Nigeria has been found as a potential and fast screening test for rural endemic areas. The immunology of examined individuals might have also contributed to the false negative and false positive results obtained. An improvement to the development of other immunological new tests is needed to have a very good specificity.Proteinuria had an average sensitivity while microhaematuria had the least. The low and average sensitivities of those tests showed their inability for efficient report of urinary schistosomiasis in endemic areas. Those sensitivities were equally observed in Central Region of Ghana . The higSchistosoma ICT IgG-IgM determined schistosomiasis in infected individuals. This guarantees the prescription of Praziquantel drug to treat schistosomiasis in infected individuals. Such individuals will acquire enough protective antibodies for almost two years against future infection . C. CSchistnfection  reportedSchistosoma ICT IgG-IgM had reasonably good positive and high negative predictive values. Eventually, it had a good Cohen’s kappa, fairly good Youden Index and best diagnostic accuracy. Schistosoma ICT IgG-IgM was the easiest and most efficient test kit in screening schistosomiasis in endemic areas of sub-Saharan Africa.Schistosoma ICT IgG-IgM was expensive for sub-Saharan African countries. The financial cost needs to be curtailed by the company for those countries. This will help such countries to acquire the test kits for fast screening. It will equally help to implement treatment to ill individuals in endemic areas. Most rural inhabitants in sub-Saharan Africa are poor and could not afford such test kits at that expensive amount. The poverty of such population is ineffable. The various companies around the world should manufacture and sell at affordable price.Economically, Schistosoma ICT IgG-IgM was the preparation of plasma or serum. Inhabitants disagreed with the test as they observed the laboratory technicians collecting blood for plasma or serum. The rural inhabitants had contrary minds because of their indigenous practices. Secondly, the immune-chromatography technology test kit was expensive.The first limitation of Schistosoma ICT IgG-IgM was a suitable and good diagnosis test in screening urinary schistosomiasis in sub-Saharan Africa. Schistosoma ICT IgG-IgM had the best sensitivity, fairly good specificity and fairly good positive likelihood ratio. The test kit had a fairly good Youden index and better diagnosis accuracy. It is recommended that the manufacturer LDBIO Diagnostics, Lyon, France and other companies develop similar tests that could use blood directly instead of serum.Supplementary MaterialClick here for additional data file.