Mozambique launched its revitalized community health programme in 2010 in response to inequitable coverage and quality of health services. The programme is focused on health promotion and disease prevention, with 20 % of community health workers’ ) time spent on curative services and 80 % on activities promoting health and preventing illness. We set out to conduct a health system and equity analysis, exploring experiences and expectations of APEs, community members and healthcare workers supervising APEs.This exploratory qualitative study captured the perspectives of a range of participants including women caring for children under 5 years (service clients), community leaders, service providers (APEs) and their supervisors. Participants in the Moamba and Manhiça districts, located in Maputo Province (Mozambique), were selected purposively. In total, 29 in-depth interviews and 9 focus group discussions were conducted in the local language and/or Portuguese. A framework approach was used for analysis, assisted by NVivo10 software.Our analysis revealed that health equity is viewed as linked to the quality and coverage of the APE programme. Demand and supply factors interplay to shape health equity. The availability of responsive and appropriate services led to tensions between community expectations for curative services (and APEs’ willingness to perform them) and official policy focusing APE efforts mainly on preventive services and health promotion. The demand for more curative services by community members is a result of having limited access to healthcare services other than those offered by APEs.This study highlights the need to pay attention to the determinants of demand and supply of community interventions in health, to understand the opportunities and challenges of the difficult interface role played by APEs and to create communication among stakeholders in order to build a stronger, more effective and equitable community programme. Since independence in 1975, Mozambique has promoted a health policy based on the principles of broad and equitable access to health services through sustained expansion of the primary healthcare system. This included the introduction of the community health worker programme in 1978 as a strategic solution to existing constraints of limited access to healthcare services by the rural population , 3. HoweCommunity health programmes as a means to accelerating progress towards the Millennium Development Goals (MDGs) have been embraced in many developing countries –9, incluCommunity health programmes have also been seen as a potential way of improving equity of healthcare. In order to ensure equity, any health service must be accessible, acceptable and of equal quality for all , regardlQualitative methods were used for this exploratory study in order to capture the perceptions and perspectives of a range of participants including community members, community leaders, service providers (APEs) and their supervisors . Two disTwo researchers worked together and conducted a total of 29 in-depth interviews (IDIs) with APEs, community leaders and APE managers and 9 focus group discussions (FGDs) with mothers of children under 5 who had used APE services. They held daily debriefing meetings to discuss data collected and to share initial impressions as well as to triangulate and clarify diverse or contradictory findings. Participants were selected purposively to ensure representation based on geographical location, distance to health facilities, gender, age and job experience. Both district supervisors were selected for inclusion and they, in turn, identified health facility supervisors. APEs, both those reporting to the selected supervisors and those who were not, were sampled based on willingness to take part and availability at the time of interviewing. Community leaders and mothers were convenience-sampled with support from APEs and resided within a limited radius of the APE’s work station. Supervisor interviews were held in Portuguese, recorded and transcribed verbatim. The remaining interviews were largely conducted and recorded in the local languages of Ronga and Xi-Changana, requiring translation to Portuguese as they were transcribed. Since the local language is spoken and not written, tools were in Portuguese and their use in the local language required thinking through and consensus by the team. Translations and transcriptions were done by the research team with considerable knowledge of the local language, Portuguese and English. Additionally, during this process, all team members worked together to discuss, clarify and confirm their understanding of the data. In-depth interviews were used with managers, community leaders and APEs to elicit sufficient depth of understanding about the APE programme and the feelings and perceptions of the individuals, allowing sensitive areas to be probed. Meanwhile, FGDs were undertaken with mothers of children under 5 years to use group interaction to generate findings to help understand community norms, common health issues and the need for, access to and use of healthcare services –25.A framework approach was employed for analysis, with emerging themes used to develop a coding framework, based on team consensus . Codes oEthical clearance was obtained from the ethics committee at the Royal Tropical Institute (KIT) in the Netherlands and the Institutional Bioethics Joint-Committee of Maputo Central Hospital and Faculty of Medicine of University Eduardo Mondlane (reference number CIBSFM&HCM07/2013). Administrative approval was obtained from the Maputo Provincial Health Directorate and the District Health Directorates of Manhiça and Moamba. The study implementation adhered to good research practice, including obtaining informed consent of study participants and maintenance of anonymity and confidentiality of all data. To ensure the anonymity of respondent quotations, district and health facility supervisors were grouped into a single category called “APE managers”.We interviewed 18 APEs, 5 APE managers and 6 community leaders, while 67 primary care givers (mostly mothers) of children under 5 years old participated in one of nine FGDs  Another thing that makes me considering it a good program is because the APEs teach us many things in our homes. They teach us how to take care of our homes, water and food in order to not catch diseases.” .In both districts, community respondents agreed that APEs served as a link between communities and health facilities and that the quality of services provided by APEs was good and was helping communities reduce disease by prevention and curative activities. They appreciated APEs’ persistence in promoting community health through basic knowledge and good hygiene practices:“What makes us say their services are of a good quality is that you never see someone going to an APE and not being attended. If you go while you are ill you will get medication and come back better.” .Community members felt that APEs provide effective treatment, responsive to the request for care from community members:“Well, the quality of service is good, [he] may miss one or another aspect because the procedures and health programs are not static, they are dynamic. [APEs] are not in time to keep up … but the work is of quality.” (APE Manager 1).These perceptions about the quality of work carried out by APEs generated confidence and satisfaction among community members. The main community complaints regarding the quality of APEs’ work relate to the low numbers of APEs working in each community and stock-outs of medicines. The first issue was mirrored by APEs as well, who acknowledged long working days with considerable distances to cover, rather than suggesting their workload was too high. Stock-outs of drugs were reported to occur frequently and may be related to the supply system logistics, with new supplies based on a monthly supply kit and stock use reports for malaria tests. The quality of care provided by APEs was acknowledged by most supervisors as well, who argued that despite some constraints, APEs in general provided a good service:“I think it’s good because there are people who appear here as serious[ly ill], I give medicine and [they] improve. Others I give a referral guide (…) but do not go (…) because they have already improved. When I respond to someone’s request and then the person improves, to me that means quality work.” .APEs themselves had positive perceptions regarding the quality of care they provided, as they had not received complaints from the community and received requests to provide more services. People had improved following their treatment, which was recognized by one APE as an indicator of quality:“When I was training I swore I would treat all people in my community without choosing anyone, also because if I do not treat people here in my community it is the same as abandoning my own family…” .Access to healthcare services was addressed to explore the ease or difficulty with which community members have access to the scope of these services and the ease or difficulty for APEs in reaching communities. This can manifest itself in the form of discriminatory practices but also in terms of geographical distances. Regarding equity in access, all participants agreed there was no differentiation or discrimination between members of the community, as this APE explained:Many community members stated that they found APEs more approachable than health facility staff, easier to talk to, less judgemental and more responsive to their needs.“Here we have the locality 1, 2 and 3, but I hardly ever went to the interior of the neighbourhood 3 because the distance is too far and the access conditions are more difficult, especially when riding a bicycle.” .One of the problems frequently described as influencing access to health services was that of distance, inaccessibility and lack of transportation. Participants referred both to distances within the community, regarding the extent and dispersion of the homes of community members, and to the prohibitive distance to health facilities. Limited transport options and difficulties in accessing households were felt by almost all participants to exert a great influence over the extent to which APEs can visit homes within their catchment areas. Several APEs and mothers of children under 5 mentioned this as a major difficulty:“What hurts me most here is the distance, for example, when the kit arrives at the health unit [facility name], it is a kit that weighs about 20 kg or 18 kg, so I have to walk out of here to go to [facility name]and take the box and walk that whole distance of 20 km with the box on my head to and from, it is not easy…and then even worse when I have to go from house-to-house on the same day or next day.” .The issue of distances was also reported as challenging when collecting new supplies, because APEs must walk long distances while carrying a heavy load on their head:“We also have growth monitoring problems; sometimes the health professionals say that they will come but they don’t appear, so if we had growth monitoring here there would not be a problem. And it is difficult to carry a child to health facilities especially if the child already is more than a year old, so this is what makes hard work to us.” .The community demand for curative and other services not formally seen as part of APEs’ tasks was a common discourse and is in part driven by low coverage and difficulties in gaining access to the health facilities. Mothers and community leaders in both districts emphasized the need for growth monitoring, immunization, maternity care, antenatal care services and an increased range of other (particularly paediatric) curative services provided by APEs. This was due to the current challenges involved with using these services at the health facility due to lack of transportation and money to pay for it. Mothers felt that APEs should offer these services to minimize the cost for clients and reduce distances:“I think it could be very good if the Ministry of Health invested in training APEs in tasks demanded by the community, (now) the APE cannot address some diseases because he doesn’t have training for it”. (APE Manager 2).From the perspective of the community, it was seen as a practical solution to request that the APE receives training to provide a wider range of curative services. The standard APE package was regarded as insufficient by community members, by APEs and by some APE managers, who argued that it cannot address all health issues in the community, as pointed out by one manager:“Sometimes is difficult to me when a community come to me to have a health service and I tell them that this disease I cannot treat. I would like to have more training to avoid this and help much more my community”. .The same view was stressed by APEs, who feel caught between demand and supply:“Many children who come here I have to treat for problems related to diarrhoea, malaria, fever and breathing problems. Sometimes people appear with ‘rheumatism’ problems, especially older people always complain of rheumatism”. .“…I went there yesterday because I did not feel good, my body was aching and I felt headaches. When I arrived he said that was not a problem he could solve…so he gave me paracetamol and told to go to the health facility.” .“Mothers go to Checua only because of the growth monitoring. But our APE says that she doesn’t know and she doesn’t have the equipment for that, so if they could increase her knowledge it would help.” .Regarding the types of care provided by APEs, participants made reference to the treatment of diseases such as diarrhoea, malaria and respiratory infections, while clients with other diseases are referred:“Well, I think what they would need to learn more is about how to apply injections and take blood tests to see what disease the person has. There is no medicine for paralysis, for hypertension, so why not teach them? That is what we think should increase.” .“Yes we would like you to have drugs for asthma and… for all kinds of diseases we have.” .This issue emerged as central in the Manhiça district. It was clear that communities perceive the APEs to be a type of “doctor” and that their health post  represents an extension of health facilities to communities, leading to demand for increased capacities of their “doctor”:“The people from the health facilities told us that we must serve the community and be a link between the community and the health system.” .“Since the time of recruitment and during the training we stress that the aim of the APE program is to work in the community… as well as to serve as a link between the community and health facilities.” (APE Manager 3).The APE programme was widely regarded as a bridge between communities and the health system, and this was described as a formal expectation of the role by APEs and managers but less so by community members:Data from APE interviews as well as interviews with mothers, community leaders and managers reveal that this interface role created a sense of dual responsibility. APEs feel responsible to the health system on the one hand, with its reporting demands in exchange for training and supplies for APEs, and to the community on the other hand, as they were selected and are supported by the community and hence feel an intense loyalty towards them.“The APE is very committed with our health problems and what I most like from him is that he accepts the criticism, when you tell him that this is not right he asks you in which way should he proceed.” .Both community members and the APEs themselves view APEs as “community doctors” with communities taking a direct supervisory role of their “doctors” as described by one community leader:My work must never end for the community. I’ve got to meet the people at the time they arrive and need my help.” .“APEs described feeling caught between expectations and boundaries, as they were selected to serve the communities at all times and to be easily accessible and responsive:Responsiveness to community expectations and supervision thus serve as key factors in the legitimacy and social acceptance of APEs, contrasting with the relative remoteness of guidance and supervision from the health facility and supervisory staff. APEs described agency in the way they construct their roles to satisfy both sides. Some described spending far longer periods of time than formally foreseen on curative tasks when treating individuals, while passing health promotion messages to large groups of people enabled them to meet their 20 % curative and 80 % promotive target. Such co-construction of reporting mechanisms which suit the community demands and health system requirements appeared to satisfy all parties and demonstrates strategic agency by APEs in balancing the expectations of both communities and health systems.Our findings illustrate that APEs are appreciated by communities, who regard them as “community doctors” providing bridges to the health system. However, in the context of resource constraints and a weak health system, they face tensions in their ability to be fully responsive to the needs and priorities of adults and children from remote rural areas with limited or no access to healthcare. Additionally, APEs find themselves caught between community demands for broader curative services while the official policy largely limits their focus to activities related to promotion of health and prevention of diseases. APEs are responsive and accountable to both community and health system officials (supervisors) which between them have contrasting demands and in some cases show agency in co-constructing a middle path acceptable to all.As the APE programme extends the reach of healthcare, it is expected that bringing services closer to the homes of their clients will be more likely to reach the disadvantaged . This exLinking communities and health systems is an explicit role of the APEs in Mozambique and CTC providers elsewhere , 32. To Our study has several limitations. APEs were involved in the selection and recruitment of participants for FGDs with mothers and the IDIs with community leaders; this may have led to bias in these respondents’ answers. APEs tended to select participants living in close proximity to where the discussions were held  and, therefore, also lived closer to the health post and had easier access to the APEs and their services. Rural areas in Mozambique, even in our two districts, are hard to access by bicycles, walking and 4 × 4 vehicles, and this meant that respondents were located no more than a 5- to 6-h drive from the district headquarters. Additionally, respondents selected by APEs may have been those they knew well or with whom they had a good relationship. To overcome this limitation, we focused our questions on the overall programme and not on individual APEs. Additionally, we triangulated information on client experiences across the two districts and included providers’ views. The decision to limit interviews with service users to women with children under 5 was made in view of the focus of the APEs’ programme on children’s health, and this presents a limitation given that many APEs provide curative services to adults as well. The level of education of community members was relatively low and influenced their level of understanding of issues addressed during data collection as well as the need for additional layers of translation, from local languages to Portuguese, with a potential loss of fidelity in transcribing. Both of the data collectors were male. The supervisors and community leaders tended to be male, although overall our respondents were predominantly female and this is likely to have had an impact on their responses and perceptions. Although we did not set out to explore this deliberately, we found very few gender differences in the results, with female/male respondents (APEs and others) having similar views and perspectives. A fuller gender analysis and exploration of the impact of gender on community and APEs’ perceptions of the interface role is required.We conducted a qualitative study in two districts in a southern province in Mozambique in order to explore the interface role of APEs between communities and health systems from multiple perspectives. The findings describe equity improvements in terms of access, acceptability and community perceptions of quality of health service provision. However, findings suggest a disconnect between the needs of the populations and how the APE policy was originally conceptualized. This situation is generated by the differing views of community and policy makers on what is important in terms of curative services. The view that the APE is like a “community doctor”, a lack of health facilities and a lack of transport means that community members often turn to APEs for treatment and APEs try their best to be responsive to this, while still trying to ensure (or constructing a narrative that implies that) they also meet health system expectations to devote 80 % of their time to promotive activities. This study highlights the need to pay attention to the determinants of demand and supply of community interventions in health and to create strong communication among stakeholders to prevent undermining the APE programme.


Large-scale change initiatives stimulating change in several organizational systems in the health and social care sector are challenging both to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in this sector. The purpose of this study was to examine the characteristics of core activities and strategies to facilitate implementation and change of a national program aimed at improving life for the most ill elderly people in Sweden. The program outcomes were also addressed to assess the impact of these strategies.A longitudinal case study design with multiple data collection methods was applied. Archival data (n = 795), interviews with key stakeholders (n = 11) and non-participant observations (n = 23) were analysed using content analysis. Outcome data was obtained from national quality registries.This study presents an approach for implementing a large national change program that is characterized by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time requiring more structure and coordination. The description of activities and strategies show that the program management team engaged a variety of stakeholders and actor groups and accordingly used a palate of different strategies. The main strategies used to influence change in the target organisations were to use regional improvement coaches, regional strategic management teams, national quality registries, financial incentives and annually revised agreements. Interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including elderly people, complemented these strategies. Program outcomes showed steady progress in most of the five target areas, less so for the target of achieving coordinated care.There is no blue-print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention has to be given to the multidimensional strategies that program management need to consider. This multidimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, program content, types of learning and change processes, and the conditions for sustainability. World-wide, national authorities have tried to implement initiatives to improve quality and efficiency in their health and social care systems, with various degree of success e.g. –3. As inMany studies of changes in health and social care deal with relatively small-scale change initiatives involving a few organizations or single strategies e.g. , 11. LarPrevious empirical studies dealing with implementation of LST discuss success factors e.g. , change The driver ‘Planning and infrastructure’ includes vision and aim; carefully developed interventions; solid management; and sufficient resources, both in central administration and in participating organizations. This driver focuses on program organization and the clarity and content of the program. The associated secondary drivers mirror many normative advices from the change and project management literature. Studies have acknowledged the importance to ensure a solid organizational foundation and to assure that appropriate organizational and contextual conditions are in place or are being developed when launching LSTs in healthcare e.g. .Considering individual, group, organizational, and system factors’ include eight secondary drivers: individual and group factors and their dynamics; champions and change agents; leadership roles; capability and capacity development; learning networks; social networks; organizational and system capability; and organizational and system culture. This primary driver reflects the embedded complexity of the health or social care system and emphasizes the need for good system knowledge and actor strategies at multiple system levels. The review also highlights the involvement of several actors and consideration of system factors, for example a study identifying success factors of the Kaiser Permanente’s Performance Improvement System .The identified core activities of the program are organized into three program phases: preparation; initiation and early implementation; and implementation.The main focus during this phase was to explore and obtain stakeholder motivation, engagement and involvement, and to negotiate, decide and initiate the program. The main challenges, as described by the program management, was to get politicians’ and higher decision makers’ acceptance and understanding of the potential role of national quality registries and regional improvement coaches in improving quality of care for the most ill elderly people.The discussions between the Ministry of Health and Social Affairs and SALAR about an agreement to introduce performance based financial incentives were initiated in 2008. The increased transparency of the national comparisons  introduced in 2006, together with new national quality registries targeting care for elderly people had provided insights into the performance of regions, municipalities and private organizations.SALAR suggested that quality registries should be included in the Be-life program agreement and that regional improvement coaches should be used to support the use of registries. A program director with previous experience in quality improvement and coordination of care was recruited in 2009 to form and negotiate the up-coming agreement (signed by both parties in February 2010).The program’s main content, goals and involved actors were negotiated and decided on during this phase. Several fora for communication were initiated. The program structure and approaches to implementation and facilitation were gradually formed, based on assumptions on the importance of interactive learning and a high degree of transparency. Program actions were characterized by a creative trial-error approach. As the management team gradually formed and more actors became involved, vague program strategies were specified and central problem areas identified (e.g. defining measurement strategies). The regional support structure consisting of improvement coaches was put into action. The number and frequency of program activities increased during this phase and implementation in the regions accelerated. Central agreements were annually revised and the first two agreements shared a similar content and scope.Collaboration between the program management team and the Senior Alert and Palliative Registry Sweden were established in regular strategic meetings. Additional meetings with the two dementia registries that were to join the program in 2012 were held, as well as joint meetings with all four registries. A main focus during this phase was providing IT-solutions for easy and open access to the registries’ outcome data.To provide support for the regional improvement coaches in their assignment to locally implement the utilization of quality registries SALAR initiated a national network platform for the improvement coaches. An important aim of the network was to enable sharing of experiences. Eight network meetings were held during 2010 and 2011. In addition, a web-based, interactive project site was launched to facilitate experience-sharing and contacts between meetings.An important aspect of SALAR’s work was to communicate the central program messages to all involved target groups. The program management team presented the program at national conferences, seminars and exhibitions, arranged regional conferences, seminars and educational activities and made numerous visits to regions and took part in many regional and local activities. A senior communication advisor was hired and a communication strategy formulated in 2011. SALAR’s established network of regional health and social care directors was another node used for the launch of and communication about the program.Another important feature during this phase was to monitor the external environment and gain relevant knowledge (and competence) for the program management team. Team members arranged conferences and international study visits to learn about large system change and patient involvement. The program director was a member of the government’s national coordinator team for the care of elderly people. There were ongoing discussions and coordination with the National Board of Health and Welfare and with other governmental assignments in the eldercare area. Efforts were made to monitor the internal SALAR environment to track other relevant programs and projects in order to optimize coordination.The program management team expanded and new members were employed. In spring 2010, a sub-project leader was hired to manage SALAR’s support to the regional improvement coaches. In 2011 an administrator, a communicator, and two more sub-project leaders were recruited.Mentoring support for the program management team played an important role from the start of the program. Long-term support consisted of critical friends . In addition, individuals with specific competences were engaged on short term basis when needed. A reference group of elderly citizens was established. The government commissioned the Swedish Agency for Public Management to perform yearly follow ups and evaluations. Researchers in several universities were asked to follow the program and relate various aspects to scientific areas of interest.In 2012, the implementation process intensified. The agreements for 2012 and 2013 involved approximately four times more funding per year as the previous ones and included three new target areas: dementia, pharmacological treatment and coordinated care. The number and scope of program activities increased, more people and target groups became involved and the external communication multiplied. At the same time, the needs for coordination of program activities increased, and at the end of 2013 more discussions on how to sustain the program were detected.Two dementia care registries were included in the program. During this period, the program management team continued to regularly invite the registries to strategic meetings. They also worked with the registries to coordinate and develop a web portal for easy access to outcome data.The 2012 agreement involved a shift in the improvement coach role, from supporting the mere use of registries towards facilitating improvement efforts based on registries and indicators. This shift influenced the activities within the improvement coaches’ network. Six network meetings were held during the period, along with coaching support via telephone or video conferences when needed. The sub-project ‘Practice Leadership’ launched in February 2012 was designed to inspire, engage and support the regional management levels when planning for and leading the regional work. Motivation was enhanced by the use of real world examples and a focus on the individual elderly person and his/her situation. International experts on large-scale change and improvement were invited to meetings with regional actors. As a part of the Practice Leadership initiative, a national support structure of established county council development centres was initiated with the aim to provide strategic support to the regional strategic management teams.The 2012 agreement was launched at a national conference in January 2012, jointly arranged by SALAR and the Ministry of Health and Social Affairs. The intention was to send a clear message to all regions that the program had a strong backing at national level. Representatives from the program management team and the ministry visited municipalities and county councils together, and took part in various regional and local activities. Three conferences that focused especially on managers and medical advisors in primary care were arranged, addressing the challenge to engage these (and other) groups in primary care. Methods for program communication were further developed during this phase, for example the production of short videos and the use of social media such as Twitter and blogs. Special emphasis was put on presenting good local examples of improvement efforts in digital newsletters, reports and on the Be-Life website.Efforts increased to anchor, monitor and coordinate the program with relevant actors and projects within SALAR  through SALAR’s numerous networks for municipal and county councils. Efforts were also made to create a dialogue with SALAR’s political organisation and to collaborate with the National Board of Health and Welfare on appraisal of the regional results on indicators. The growing complexity of the program and the increasing number of sub-projects contributed to higher demands on program coordination. The program management team participated in 26 national and numerous regional conferences, seminars, educational activities and network meetings. Members of the team attended international conferences and made study visits abroad.A journalist, a web assistant and an expert on pharmaceuticals joined the project management team in February 2012.In order to get support, input and feedback on their work the program management team continued to use mentoring support, with regular meetings with consultants, experts and ‘critical friends’. Annual evaluation reports by the Swedish Agency for Public Management fed back information that was discussed within the team. Feedback meetings were also held with the research group. The reference group of elderly citizens took on a more active role, participating in various activities and meetings describing their views and experiences.One of SALAR’s new responsibilities during this period was to develop a monitoring system for the indicators ‘avoidable inpatient care’ and ‘readmission within 30 days’ and to coordinate and provide support to the regions’ analytical work in these areas. To support the analysis of measurement results a team that focused on the monitoring system was organized along with a network of regional analysts. A web-based tool for monitoring of patients readmitted to hospital within 30 days and patients discharged from hospitals was developed (in collaboration with Blekinge Institute of Technology), tested and launched in the regions during this period.Ten main strategies to facilitate implementation were derived Figure  based onIn Table Before the program, the Senior Alert registry was virtually unknown among the municipalities. During the first two years the utilization of the registry increased dramatically. There was a similar development among the county councils. In 2010 and 2011, performance bonuses were related to the number of registered risk assessments. From 2012 additional bonuses were granted to municipalities where a risk assessment was performed for a minimum of 90 percent of the elderly people living in special housing units. During the first two years, the average number of registered risk assessments per month increased by over 200 percent each year.At program start the Palliative Registry Sweden was well-known among municipalities and county councils and by the second year, almost all municipalities and all county councils had units participating in the registry. Performance bonuses were paid if the required percentage of all registered deaths in the region was reached. The target levels for performance bonuses were gradually raised each year. The proportions of municipalities and county councils reaching the target levels have fluctuated between 60–79 percent  and 71–89 percent (county councils) over the program period. From 2012, bonuses were also granted based on whether the patient and/or their relatives received verbal information about the imminent death, a key activity in the palliative care process.When the SveDem registry was included in the program in 2012 most patients that were given diagnostic work-ups at specialized dementia care units was being registered, but the coverage within primary care was very low. During the first year in the program, the number of participating primary care units and number of registered diagnostic work-ups increased substantially. There was an even more prominent development regarding the utilization of the registry for Behavioural and Mental Symptoms in Dementia in municipalities, where the number of registered patients increased from 77 to 11 613 between the years 2010 and 2013.All regions reduced their use of the specified medications during 2012, but only two regions (10%) reached the target of a ten percent reduction. To receive performance bonuses in 2013, the regions had to reduce the prescription of the three types of medications for at least four months during the six month long measurement period (April-August 2013), as compared to the same period in 2012. Patient data from registries, based on place of residence , were used and aggregated to county level. All regions managed to reduce prescription of inappropriate medications and anti-inflammatory medications, and two thirds of the regions reached the goal related to medications used to treat psychoses. Variation in results on municipality level is presented in Table In 2012 no region reached the target level of a ten percent reduction in the coordinated care index . A majority of the regions (16 of 21) showed small reductions, less than 2 percent. The two regions with the largest reductions reduced their index levels by 7 and 5 percent respectively. Two other regions increased their coordinated care index by 7 and 9 percent respectively. However, large variations between the regions’ monthly results could be found. In 2013, the criteria were refined and performance bonuses paid to the regions that showed a statistically significant improved monthly value for at least four months, as compared with the same period in 2012, for the two indicators respectively. Ten regions (48%) reached the goal for the indicators ‘avoidable inpatient care’ and another ten the goal of ‘readmission within 30 days’. Three regions (14%) reached the goals for both indicators. Results on national level are presented in Table The Be-Life program involved a massive amount of activities directed at many different groups of actors during its first three years. As reflected in our case description, the program included a mixture of intended and emergent strategies as a large part of the program was built during the process and only some aspects were systematically prepared and planned for at the time for the initiation of the program. The program was organized as a project  with the regional organizations responsible for achieving and sustaining changes and improvements. When a project organization is used to implement policies it is vital to incorporate a complete understanding of the multiple levels of actions needed and the different kinds of variables that can be expected to influence both output and outcome . It is aThe program management provided visions for the future situation for elderly people that pleaded to peoples’ values and life situation and referred to the gap between the current situation and the vision in several areas. The program aims and indicators were primarily related to changes in care procedures and in the elderly person’s situation. Aims for phases in the change process were less articulated, for example how good support structures and procedures should develop over time. The interventions included conventional actions proven successful, but also new rather untested and overarching measures. The program was supported by a solid management structure with strong and charismatic leadership. Through the agreements, the Be-Life program and SALAR were provided with substantial monetary resources for coordinating and supporting the implementation and change process. These results are all in line with the ‘Planning and infrastructure’ driver in Perla et al’s model , which iConsider individual, group, organizational, and system factors’. The program activities and strategies were directed at many different individuals and groups, sometimes inviting several organisational functions, such as higher level managers in multiple areas, to get synergy effects. At national meetings with regional strategic managers various techniques for enhancing learning and interaction were used – in smaller or larger groupings. The regional support structures can also be seen as learning networks, social networks and includes the involvement of local champions and change agents. The many meetings, educational activities, seminars and web sites focused on the aim of building regional capability and capacity. The important role of leadership during change and development was emphasized by the launch of the ‘Practice leadership’ initiative, involving key decision makers in regional organizations. The program management team emphasized values, but organizational culture was not directly confronted, more indirectly approached when cooperation between care providers was addressed. Facilitation of the implementation required dealing with the diversity of sub-systems and their varying capabilities. This required separate meetings, visits and coaching activities in the regions – which were frequently carried out by the program management team. The many activities aimed for the many different actors and stakeholders more or less involved all eight secondary drivers in Perla et al.’s model [Perla et al’s model  also hig’s model . One aspThe pace of change in LSTs is relatively slow as it often is difficult to have a clear plan from the beginning, it demands lots of involvement from many stakeholders and the main attempt of change agents is to minimize resistance , 30. The‘The process of change’ driver in Perla et al’s model [’s model  is the h’s model  did not ’s model , 25. In ’s model . This soWith regard to the third dimension of this driver, mechanisms used for spread, Perla and colleagues  emphasiz‘System for performance measures and evaluation’ in place – driver four in Perla et al.’s model [From the start, the Be-Life program had a ’s model . The nat’s model . Using s’s model .Sizable amounts of money from the state were invested in the Be-Life program, as the regions’ performance was connected to financial incentives. Resources were also used to build regional support structures and to support improvement of registry output and competence in analyses. The application of financial incentives to support changes in healthcare has often targeted micro levels, such as general practitioners, physicians and patients e.g. , 40. In The analysis of outcome data shows a positive development in the use of the quality registries in the areas of preventive, palliative, and dementia care. Results for the indicators on pharmacological treatment were also positive. As could be expected, effects on the system level indicators of coordinated of care were more modest, so far. Based on these results we infer that the Be-Life program during the studied period has had an impact on care for the elderly citizens in line with its goals in all of the five target areas. Results on national level also show that change happened faster in some areas (e.g. preventive care) than in others (e.g. coordinated care). These differences can be related to many factors like pre-existing work with registries, the complexity level of the target area and the number of involved care-giver organisations. More specific investigations are needed to address the program outcomes and the long-term effects on regional level, as well as to understand the mechanisms for more or less successful regional or local implementation.This study is limited to the first four years of the Be-life program leaving one year yet to enhance progress towards the goals. Yet, longitudinal mixed methods studies of LSTs have a potential to expand our understanding of change strategies in complex systems. Such studies can also address the understudied aspects of sustainability and long-term impact . A folloThis case study presents an innovative approach used for implementing a large national change program characterized by an initial flexibility and dynamism regarding content and facilitation strategies, as well as a growing complexity that required increased structuring and coordination as it developed over time. The description of activities and strategies showed that the program management team engaged a variety of stakeholders and accordingly they developed and used a broad array of strategies to facilitate the implementation of the program content. There is no blue-print on how to approach the challenging task of leading large change programs in complex contexts, but our conclusion is that more research and practical focus is needed on the multidimensionality of strategies that program management needs to consider. The strategies used in the Be-Life program depended on the program content, contextual factors, system levels, types of actors and their influences, the program’s progress over time, types of learning and change processes inferred, and the conditions for sustainability. These aspects can give some indications on some of the basic aspects of the strategic multidimensionality needed for achieving LSTs in health and social care.


Key strategies of the main ARV procurement program for PEPFAR to reduce supply chain risks include: (1) employing pooled procurement to reduce procurement and shipping costs and to accommodate changing country needs by making stock adjustments at the regional level, and (2) establishing regional distribution centers to facilitate faster turnaround of orders within defined catchment areas. Key strategies of the main ARV procurement program for PEPFAR to reduce supply chain risks include: (1) employing pooled procurement to reduce procurement and shipping costs and to accommodate changing country needs by making stock adjustments at the regional level, and (2) establishing regional distribution centers to facilitate faster turnaround of orders within defined catchment areas. Between September 2005, when the United States Agency for International Development (USAID) awarded the Supply Chain Management System (SCMS) project, and August 2014, the SCMS project delivered over US$1.9 billion in HIV/AIDS commodities, approximately $1.1 billion of which were antiretroviral (ARV) drugs to support the treatment of people with HIV and AIDS. This total sum of ARVs accounted for approximately two-thirds of the ARVs delivered with funding from the US President's Emergency Plan for AIDS Relief (PEPFAR).One of the primary challenges to achieving a reliable, cost-effective, and secure supply chain of HIV/AIDS commodities has been the high cost of commodities. The US Department of Health and Human Services and the US Food and Drug Administration (FDA) made a significant initial response to the issue of cost in May 2004, when they introduced a new initiative to facilitate global ARV manufacturers' access to an expedited product review and inspection process. This tentative approval process to determine the quality of ARVs produced by manufacturers anywhere in the world was designed to increase access to high-quality medications globally. Under this initiative, if products meet the FDA's quality assurance standards, they are eligible for purchase under PEPFAR.between 2005 and 2008 PEPFAR saved over US$323 million by procuring approved generic ARVs instead of equivalent-branded ARVs.As generic products obtained approval for use under PEPFAR, stakeholders began to procure more generic ARVs and fewer branded ones, resulting in rapid and substantial savings to PEPFAR. A 2010 study estimated that Between 2005 and 2008, PEPFAR saved over an estimated US$323 million by procuring approved generic ARVs instead of branded ones.As of September 30, 2013, 6.7 million people were receiving antiretroviral treatment through the PEPFAR program—up fourfold from 1.7 million in 2008.This article describes the practices employed by USAID and the SCMS program to mitigate ARV supply chain risks. From the program's experience in numerous PEPFAR countries, the risks can be grouped into 3 categories of supply, demand, and cost .pooled procurement and the use of regional distribution centers (RDCs) are common strategies across the 3 risk categories, illustrating the interconnectedness of risks. For example, inaccurate forecasting (demand risk) may lead to under-procurement (supply risk), eventually resulting in the need for a costly emergency order (cost risk) to remedy a product stock-out.The program's risk mitigation approaches represent integrated supply chain strategies that take advantage of economies of scale to improve cost and quality. In particular, Production and shipping delays can result in product stock-outs when goods are not delivered according to the supply plan and, hence, are not available for scheduled in-country distribution. These stock-outs can lead to ART interruption for patients if the needed ARV drugs are not consistently available. Country-specific procurements are scheduled according to a multilateral, agreed-upon supply plan, designed to maintain inventory levels across the in-country supply chain.According to SCMS procurement data, between 2007 and 2012, manufacturers of generic ARVs delivered their products on time to the contractually agreed-upon destination  50% to 70% of the time. Orders were considered on time if they arrived at their destination within 14 days of the projected delivery date in the price quote. Of the orders arriving late (greater than 14 days after the projected delivery date), two-thirds were provided within 1 month of the originally agreed-upon delivery date.These 4 strategies are:Multiple-source procurementPooled procurement based on projected demandUse of RDCsFlexible specifications for presentation of ARVs  to facilitate common product use across multiple countriesBased on the best-value approach that is embodied in USAID procurement regulations, ARV procurements are usually awarded concurrently to multiple vendors on a tender-by-tender basis. The benefits of doing so are twofold. First, the risk and consequence of sudden production or delivery failures by a single vendor are mitigated by the completion of orders for the same product by other vendors. Second, it is the opinion of the authors that the participation of multiple vendors leads to an ARV marketplace that is competitive and growing in capacity to supply these products to an increasing number of patients on ART. Starting in 2009, the program began to issue the vast majority of its tenders as multiple-source tenders.Pooling (combining) the procurement for common ARVs across PEPFAR-supported countries based on their supply plans maximizes the availability of these ARVs and reduces procurement and shipping costs for a number of reasons:Economies of scale are attained for manufacturing and shipping.Fewer tenders and orders need to be processed, reducing transactional costs for both the buyer and the manufacturers.Minimum batch volumes imposed by manufacturers before beginning production are reached more rapidly, thus avoiding production delays.The capacity of shipping containers can be maximized fully, particularly when pooled products are shipped to RDCs.Pooled procurement among neighboring countries reduces procurement and shipping costs.The pooled procurement process also allows vendors and recipients to plan ahead strategically. For example, when countries place orders at least 6 months before they need the goods, ocean freight can be used rather than more expensive air freight. Additionally, by pooling procurement, SCMS can negotiate reduced aggregate tendering rates. The program issues approximately 8 planned tenders to the market per year, of large aggregate volumes each time. This process increases the program's negotiating power with vendors, improving the chances of obtaining the best price available, in contrast to an annual tender process, which allows only for a single negotiation. Using a continuous retendering and buying strategy throughout the year also allows the program to take advantage of price declines in the market. Using a continuous retendering strategy throughout the year for large aggregate volumes increases the program's negotiating power and allows it to take advantage of price declines in the market.By combining demand forecasts with procurement history from multiple countries , SCMS can hedge against forecast errors. The combined forecast is shared quarterly with manufacturers, suppliers, other implementing partners, and nongovernmental organizations, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Clinton Health Access Initiative, and the United Nations Children's Fund (UNICEF).To illustrate the cost savings from the pooled procurement model, the authors have prepared the comparison below between the 2013 annual tender process in an East African country and the pooled procurement price in 2013 for two high-volume fixed-dose combination (FDC) ARVs . The pooThe program has established 3 RDCs to provide intermediate warehousing and regional distribution for 11 other PEPFAR-supported countries in sub-Saharan Africa . For exaOne strategy for operating efficient RDCs involves holding common, high-volume generic ARVs in multimarket, pharmaceutical-grade distribution centers to facilitate more rapid turnaround of orders originating within the defined catchment region, reducing delivery time and improving on-time delivery to clients. This model has been used in the private sector as well.Between 2007 and 2012, 90% of orders fulfilled by regional distribution centers were delivered on time compared with only 50%–70% of orders fulfilled directly by vendors.RDCs can also be leveraged to substantially reduce lead time–the time interval between the order and receipt of commodities. Analysis conducted in 2011 showed that partner country programs requesting emergency shipments  received delivery in an average of 28 days from RDCs, out of RDC stock, compared with an average of 72 days directly from manufacturers.Regional distribution centers can be leveraged to substantially reduce lead time.By managing the inventory of ARVs strategically at the RDCs, the program has been able to mitigate many supply and demand risks. Many factors are considered to ensure sufficient RDC stock levels. First, we anticipate demand from countries, which is determined by the ARV supply plans developed by each country as an outcome of ARV commodity forecasts.The program encourages manufacturers to register a common presentation for a given ARV formulation across multiple countries whenever possible, which allows the program to procure and ship a single product to most African countries. In the majority of cases, the single presentation uses labels and inserts printed in both English and French. This common presentation strategy has come to dominate the ARV procurements made by the program; in 2013, 77% of the ARVs procured by the program by volume were of the common presentation with English/French labeling.The authors define demand risks as operational matters at the client, program, or country level that impact the timely and cost-effective processing of ARV orders through the national and donor systems.Producing accurate national demand forecasts is challenging, which can result in orders that may not reflect the country's actual need. On the one hand, under-forecasting can result in product scarcity, increasing the likelihood of stock-outs and creating the need for costly emergency orders. It also substantially increases the use of high-cost air shipping—the normal transportation mode for emergency orders. In contrast, orders placed sufficiently in advance of their desired delivery date can be shipped via ocean, with savings of more than 60% when compared with the cost of air freight. To ensure on-time delivery of the most common fixed-dosed combination and single-dose formulation ARVs shipped via ocean, a minimum lead time of 6 months is needed. This lead time can extend up to 9 months, as supply constraints and demand variations come into play.Conversely, over-forecasting can result in excess stocks that expire before use. This increases costs of storage and handling as well as the cost of properly disposing of the unused product. Additional common challenges to timely, accurate procurement include delays in finalizing and submitting orders and coordination issues between donors and recipients.To mitigate these demand risks, the program has employed a combination of strategies:Regularly updating country forecasts and supply plansRegionally aggregating supply plans for pooled procurement Restocking RDCs based on analysis of likely demand, rather than on firm orders from clientsThe program assists PEPFAR-supported countries in establishing 12–18 month supply plans, which are updated every 3 months and are based on reported product consumption. Delivery quantities for planned shipments can thus be continuously revised to reflect a more accurate picture of demand and to respond to changes in consumption trends, ultimately attempting to avoid both stock-outs and overstocking of commodities.Taking the additional step of aggregating the supply plans of all countries within a region further mitigates supply risks linked to forecasting weaknesses, because adjustments can be made closer to the country program, as opposed to the very beginning of the supply chain. For example, if one country in a region adjusted its supply plans to reflect greater ARV requirements and another country in the same region concurrently experiences reduced demand, the relevant RDC could transfer excess from the latter to meet the increased needs of the former without ever having to order new supplies from manufacturers.The program also uses aggregated supply plans to plan advanced ARV procurements delivered to the RDC in bulk shipments using ocean freight, which saves significant funds. The quantities from these shipments can then be broken down for distribution to countries in the same regions as the RDC. The RDC also allows for flexibility with clients by increasing or reducing delivery quantities of a product to a given country each quarter to align with changes in actual consumption where that data are available. Private-sector companies practice this sort of strategic inventory management by holding a certain amount of stock depending on the forecast and lead time associated with each product or component pieces, enabling the companies to fill orders quickly. Cost risks may generally be divided into risks related to the unit cost of ARVs and risks related to shipping and storage. In short, efforts described above to reduce supply and demand risks through regionally aggregated planning, procurement, and intermediate storage also have a considerable effect on reducing costs throughout the supply chain.,Economies of scale obtained through pooled procurement create the opportunity for cost savings in the ARV supply chain.Pooled procurement provides an opportunity for cost savings through economies of scale.The strategy of the program for transporting ARVs focuses on meeting client country requirements at the lowest possible cost without compromising product integrity. This means balancing the use of ocean and air freight for manufacturer-to-country shipments. Air freight is the best choice when urgency is needed to avoid stock-outs, treatment interruptions, and significant program disruptions; otherwise, optimizing available lead time for orders allows for lower-cost shipment by ocean, which the program seeks whenever possible. In addition, road freight rather than air can be used on key lanes for intra-Africa movements. The program strives to consolidate as many orders as possible into as few shipments as practical, leveraging the process to facilitate lower-cost modes of transport.As shown in Between 2007 and 2011, the project saved an estimated US$34 million by leveraging lower-cost transportation.Through the use of supply chain risk mitigation strategies, particularly by pooling procurement and using regional distribution centers, the program has reduced ARV demand, supply, and cost risks. Among other key impacts, these strategies have resulted in better central-level stock management in PEPFAR-supported countries, improved on-time delivery, and increased cost savings through ocean freight. There are other challenges affecting the in-country ARV supply chain related to human resource capacity, in-country distribution of commodities to treatment sites, reporting and ordering, and storage and infrastructure capacity, which international partners and host countries are addressing collaboratively.


Prevent It! Uniquely, the primary goal of this program was to change the behavior of participants, as well as to increase knowledge about CSA and positive attitudes toward it. A comprehensive review shows no previous similar approach. The program includes a detailed manual to allow standardized administration by trained facilitators, as well as multiple video segments from CSA survivors and professionals. A total of 23 program workshops were run, with 366 adults participating. Of these, 312 (85%) agreed to take part in the study. All completed baseline ratings prior to the program and 195 (63% of study sample) completed follow-up assessments at 3-months. There were no significant differences between the demographic make-up of the baseline group and the follow-up group. Assessments included demographic data, knowledge, attitudes, and several measures of behavior (our primary outcome variable). Behavioral questions asked individuals to select behaviors used in the previous 3-months from a list of options. Questions also included asking “how many times in the previous 3-months” have you “talked about healthy sexual development or Child sexual abuse (CSA) with a child you know”; “suspected a child was sexually abused”; “taken steps to protect a child”; or “reported suspected sexual abuse to police or child welfare”? The majority of attendees were women, with the commonest age group being between 30 and 39 years old. Approximately 33% had experienced CSA themselves. At 3-month follow-up there were highly statistically significant improvements in several aspects of behavior and knowledge, and attitudes regarding CSA. For example, the number of subjects actively looking for evidence of CSA increased from 46% at baseline to 81% at follow-up, while the number of subjects who actively took steps to protect children increased from 25% at baseline to 48% at follow-up. For general public adults, this is the first program designed using the current evidence base for effective training in CSA examining longer-term outcomes and the first to focus on actual behavioral outcomes. The results suggest it is highly effective and support its widespread use.Here we describe the development of an evidence-based education program for adults about childhood sexual abuse (CSA), called  Child sexual abuse (CSA) is common . In the current publication we describe the current research background, the theoretical background, methodology of development of the program, and the first study into it's effectiveness. In particular, we examined the extent to which a classroom-based CSA prevention program for adults can change participant's longer-term behaviors, as well as attitudes and knowledge.There is great variety in the types of prevention programs that exists, their target groups, the methods, and their specific contexts  to address this issue. We also evaluated the program, with our primary outcome measure focusing on behavior changes over a 3-month period.Adult-targeted CSA education programs use a variety of formats to teach adults about CSA. One randomized controlled study measured attitudes, knowledge, and behavioral intentions after being exposed to media-based CSA materials founding a significant increase in knowledge scores after exposure but no significant change in attitude  in CSA education with a wide group of individuals. These included members of the Police Services involved with all aspects of CSA, psychologists working in the field of CSA, charities involved in training, and with sexual assault centers. Because our main outcome goal for the program was behavior change, it was important to structure the program utilizing methodology previously demonstrated to maximize likelihood of subsequent behavioral changes. Although some studies have shown changes in behavior pre-contemplation, adults are not yet considering the behavior change in question, while in (2) contemplation, the person considers change but has not yet decided to make the change. In (3) preparation, the person prepares for, and plans for, making the change and in (4) action, the individual starts making the change. Finally, in (5) maintenance, the change has is made and is continued over a longer period of time. The program was therefore designed to facilitate the movement of participants through each subsequent stage, and to assist them to reach the action (stage 4) and maintenance (stage 5) phases of change.The TTM approach to understanding behavior change combines all components into a single cohesive theory  Kolb, . The ELCProgram content was determined after the detailed consultation process, combined with regular communication and contact with the range of stakeholders and also with experienced trainers. A detailed “program guide” was developed, including the rationale for each section, presented in an easy to understand format written for a general audience. It provides all necessary background information for the program content and approach. The program guide is an 80-page document and was made available to program staff.A briefer “information book” was also developed for all program participants, derived directly from the program guide, to be used by all participants during the program, and subsequently by them as reference material. During the program, facilitators directed participants to the relevant sections of the information books to engage in exercises throughout the program, and used this to guide participants through the exercises.The program includes a significant video component, with the group facilitator showing video segments throughout the program. The facilitator introduces each section before showing it, and after viewing each segment, there was a guided exercise aimed to increase personal and critical reflection on the material. Video sections include overall narration, interviews with experts in the area, survivors of sexual abuse, and professionals who work in related fields.The survivor interviews provide personal accounts of sexual abuse as well some of the impact of CSA on them in both the shorter-term and longer-term. These interviews helped to highlight the personal toll of CSA and remind participants that CSA significantly impacts of range of different people in multiple ways. In order to reduce the potential for harm to people that might regret their decision to tell their story in the educational video format, only CSA survivors who were already publicly sharing their stories were approached to be involved. All survivors were told in advance about the types of questions they would be asked in the interview, and were told that they were in control of the question answering process. They did not need to answer all the questions if they did not want to, and they were reminded that they could change their mind and decide not to participate at any point in time during the video production phase or subsequently.Professionals working in fields related to sexual abuse were also interviewed. Effort was taken to have a wide range of professional voices represented. Interviews featured in the film, in addition to CSA victims, include a psychologist and Traumatologist, an experienced police detective involved in many cases of CSA, a defense attorney, and a psychiatrist.The facilitator guide explained what was expected from the facilitator at each point in the program workshop, with information grouped around several themes. Table Prevent It! program at changing adult participant's behaviors 3-months after the training session , as well as improving attitudes toward CSA and knowledge about this. A priori hypotheses were that participants who took the workshop would: (1) decrease adherence to problematic myths about CSA (referred to as negative attitudes), (2) increase accurate knowledge about CSA, and (3) increase their use of individual and organizational prevention behaviors to reduce risk of CSA and identify this early. One explicit long-term goal, not studied in the current program, was that this program will help with early identification, and appropriate interventions, of CSA when it occurs. We hope to explore this issue in subsequent research.The target group was adults who interact with children, including caregivers, teachers, coaches for sports and recreation activities, youth group leaders, and religious leaders. This study evaluated the effectiveness of the We wanted to measure the effectiveness of the program based on the population that it will be serving. To do this, we used a convenience sample of adults who registered to take educational programs with a charity that provides this (Little Warriors).Study participants were recruited from people that enrolled to take the program. While registering for the program, each person was informed in general terms about the study, and asked if he/she could be contacted with more information. Individuals who agreed to find out more were provided with information and the informed consent form. If they agreed to take part they were then given a unique user number, and information about how to use this to access the secure on-line site where information was collected at baseline. The only required inclusion criteria, other than agreeing to take part in the training session and study, was that they were aged 18 or older. There were no additional exclusion criteria for this study.There were a total of 23 program workshops, involving 366 participants, carried out during the final 3-months of 2014 in 14 communities in Western Canada. The individual who facilitated the vast majority of groups had no previous expertise in this, and no background in medicine or allied professions, to allow some approximation toward the anticipated outcomes when given by other similar individuals. Groups who participated in program workshops included those offered to the general public (14), child/youth serving organizations (5), community groups (2), a mother's group (1), and a group of individuals attending a conference regarding youth issues (1).Prevent It! program would increase behaviors to reduce children's vulnerability to CSA.Participants were given pre-test (baseline) measurements to assess attitudes, knowledge, and behaviors related to CSA during the 7-days prior to the program workshop. Three months after their participation in the program workshop they were asked to complete follow-up questionnaires. Each participant's post-test results were compared to baseline results to assess the amount of change that occurred. The main hypothesis being tested was that, at 3-months post-training, participation in the During the 7-days prior the program workshops, participants completed baseline questionnaires via the secure online site. Participants then took part in the 3-h program workshop. Three months after completion of the program, study participants were contacted and asked to complete the follow-up questionnaire online. This process involved contact (via phone or email—at the choice of the participant). A maximum of three attempts were made for each individual who did not complete the follow-up questionnaire.Participants were asked to self-report their gender, age, highest education level completed, level of previous CSA training received, and if they had experienced any type CSA themselves during their childhood. Before being asked about their own experience of sexual abuse, each participant was reminded of the confidentiality of their responses and of the reason for collecting the information. Participants were able to skip demographic details if they chose.The sample consisted of 312 adults who took the program and completed the informed consent and pre-test questionnaire. Of these, 209 individuals (67%) also completed the 3-month follow-up questionnaire. However, of these a total of 12 questionnaires were not usable due to incomplete identifying information, while one individual with the same identifying information completed the questionnaire twice and both versions were therefore excluded. Thus the final study sample consisted of 195 individuals (63%) for whom there was study data, although some individuals did not complete every section as specified below. Demographic details for the 3 month follow-up group are shown in Table It is important to note that we have baseline demographic data on 312 individuals, but detailed follow-up data only 195 individuals. However, a Wilcoxon signed-rank test showed no statistically significant demographic differences between these groups.Child Abuse Myth Scale , r = 0.30 (medium effect), r = 0.50 (large effect). Statistical significance was defined as p < 0.05. Spearman's correlation was used to determine associations between demographic variables and dependent variables. Missing values due to lack of response to individual questions were excluded from analysis.We used the Wilcoxon signed rank test to determine within-subject statistically significant change from baseline measurements to post-test measurements, given that the Wilcoxon test is appropriate for use with non-parametric data and related groups. Note that we did not apply a Bonferroni correction for multiple comparisons since, while a Bonferroni correction can be useful for reducing the risk of Type I errors in multiple comparisons, it also creates a loss of power to detect changes that are present making its usefulness disputed in studies such as the current one Keppel, . Effect ” Field, . Effect ” Field,  guidelinZ = 7.463, p < 0.001 . Results of a Wilcoxon signed-rank test found a highly statistically significant change between the median at baseline and 3-month follow-up, A total of 186 study participants completed both baseline and 3-month follow-up questionnaires in this section of the behavioral questionnaire. Results of a Wilcoxon signed-rank test found no statistically significant changes between the median at baseline and 3-month follow-up  took part in the program, and therefore the impact of this program on men is less certain. This is a problem that is common in studies in this area (i.e., Rheingold et al., Nonetheless, despite the positive findings from the present study, there are some methodological matters that should be considered as potential limitations. Firstly, we utilized a within-subject design comparing baseline to 3-month follow-up, with studies suggesting that attitudes and behavioral intentions are persistent over time (Deblinger et al., Prevent It! program is highly effective, and strongly support it's more widespread use.In conclusion, the purpose of this study was to determine the effectiveness of a CSA prevention program. Previous research has demonstrated the ability of programs such as this to change knowledge and increase participant's likelihood of using preventative behaviors. This is the first study to measure general public adult's self-reported use of preventative behaviors. Compared to baseline, at the 3-month follow up, participants who took the program were talking about CSA and healthy sexual development twice as much, were using twice as many individual action strategies, and were utilizing three times as many organizational strategies. Knowledge and positive attitude also increased significantly. The results suggest that the PS and EM designed and performed all aspects of the study.Prevent It! program. The other author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.Previously, PS has been a non-paid volunteer on the Governance Board of Little Warriors. Neither author has any financial interest in the


However, it will be argued here that Tomasello overlooked important findings in the mechanisms of evolution as well as in the cognition and socialisation of great apes, making his theory stand on arguable foundations. By understating the social skills of other hominids and simplifying the relation between culture and theory of mind, the importance of other cognitive abilities in this debate is often forgotten.Although Tomasello’s book has now been published some 16 years ago, this review was motivated by the recrudescence of social and cultural arguments based on the comparison between humans and great apes. From education e.g.,  to socioTomasello’s experiments on nonhuman primates and young children led him to the conclusion that if all hominids can understand the other as an intentional agent, only humans can share intentionality . If greaTomasello’s starting point is that evolution, on a short period of time that is two million years, could only produce one main difference – that his book aims to find – between Homo sapiens and the other hominids, especially if we consider that we share around 99% of our DNA with Bonobos, our closest relatives. However, three objections can already be made. First, evolution can be accelerated by processes such as niche construction  or groupIn order to determine this unique difference between humans and other primates, Tomasello compares how children and great apes react to different cognitive tasks involving socialisation and intentionality. That is, apes and children are faced with a seemingly incompetent experimenter and are required, to “successfully” pass the experiment, to read the intentions of the researcher and to help him in his (rather simple) task. And, here, the conclusion is clear: if children start extremely early on – around 6 months – to enthusiastically help the experimenter, apes do so only when rewarded with food. Thus, humans have a predisposition towards socialisation that allows them to share intentionality. Why, then, can apes in captivity and under certain other conditions understand intentions and yet are not very willing to do so? The effects of enculturation are often pointed to in this case, and it has been argued either that treating apes as intentional agents may lead them to see others as being so as well , 2004, oFirst, displaying the same ability does not necessarily mean that it is possible through the same processes and it is indispensable to look at how the ability evolves during ontogeny . HoweverTomasello’s final assumption is that the necessary and only condition for the apparition of cultural evolution is the emergence of theory of mind, as they both depend on socialisation. This theory, with little modifications, is widely shared in psychology e.g., , the useThis points towards an alternative explanation of our differences with great apes. Indeed, if most of the experiments on great apes tend to demonstrate how skillful they are, little attention is given to how long it takes the experimenters to make them achieve a task (see ii with the aggressiveness of apes in the same situation (To conclude, Tomasello’s work provides extremely interesting data and stimulating hypotheses. However, although his book is well argued and raises some valuable points, other important findings and theories that have been overlooked cast a shadow on a key part of his argument. It cannot be denied that socialisation is a cornerstone of the evolution of our species. Comparing how eager children brought up in isolation are to communicate ii with tituation  leaves l


Despite the existing evidence of a long lasting effect of disaster related experiences on physical and psychological health, few studies have evaluated long-term quality of life (QOL) outcomes of disaster survivors and the factors associated with such outcomes.23 years after the 1988 Spitak earthquake in Armenia, the associations of demographic characteristics, trauma exposure and psychosocial variables on QOL were explored among a cohort of 725 exposed individuals. The EQ-5D-5 L instrument was applied to measure QOL of participants. Multivariate linear and ordinal logistic regressions were applied to evaluate the determinants of QOL and its underlying five domains .Older age, current depression, post-traumatic stress disorder and anxiety symptoms were negatively associated with QOL. Additionally, those with severe losses  had significantly poorer QOL outcomes, with higher odds of mobility difficulties , self-care difficulties , and mood problems . However, those with severe earthquake related losses who received financial/material aid reported less self-care difficulties  usual activity difficulties , and mood problems . Finally, each unit increase in current social support score was found to be significantly associated with a better QOL outcome and better self-reported outcomes across all underlying domains of QOL.These findings suggest that earthquake related loss and concurrent psychopathology symptoms can have adverse impact on the QOL of survivors. They also indicate that well-targeted post-disaster financial/material aid and social support should be considered as means for improving the long-term QOL outcomes of disaster survivors. Research have shown that disasters have adverse impacts on short-term physical and mental health of survivors, negatively affecting their quality of life.However, studies evaluating long-term impact of disasters on quality of life of survivors are limited.What is already known on this subject?The current study followed earthquake survivors over two decades and found that the impact of disaster related loss on QOL can extend to the third decade after the disaster.The findings suggested that intervening variables such as concurrent physical illnesses and mental illnesses are negatively associated with QOL measures after two decades.Post-earthquake financial aid to those with severe loss was positively associated with QOL even two decades after the disaster.What this study adds?Health consequences of natural disasters, particularly earthquakes, are a major public health concern. There is a large body of evidence on the short-term as well as growing evidence on the long-term mental and physical health impact of earthquakes -4. HowevEarthquake-related experiences may also influence QOL in the long-term. Few studies have explored the associations between earthquake related material loss, level of post-earthquake social support and the QOL and found that social support was positively associated with QOL measures ,8,9. In Our own studies from the 1988 earthquake in Armenia have shown that earthquake exposure, related material loss, and social and financial support were associated with post-earthquake-psychopathology ,11. OtheOn December 7, 1988, the Spitak earthquake, with a magnitude of 6.9 on the Richter scale, struck the northern part of Armenia, resulting in extreme destruction, homelessness , serious injuries , and deaths . Our study aimed to explore the associations between earthquake-exposure experiences, psychopathology and socio-demographic characteristics of survivors, and long-term QOL measures, 23 years after the Spitak earthquake.The study population consisted of the employees of the Ministry of Health (MOH) of the Soviet Republic of Armenia living in the earthquake region and their family members. Their data were identified from the national payroll office. A total of 32,743 individuals were located, assented to participate and were included in the baseline cohort of the study (phase I) . After the completion of phase I, a geographically stratified sub-sample of the original baseline cohort, consisting of 1773 adults, was selected to be involved in the three follow-up phases conducted from 1991 to 2012 . This stratified sub-sample included a higher proportion of individuals from the severely impaired areas to better assess the association of exposure with the outcomes of interest.Up to phase III, the follow-up information was successfully obtained for 97% of the initial population . For theA wide range of previously (1990–1992) collected socio-demographic characteristics, including age, gender, and education, was updated during phase IV (2012). Additionally, during the same phase, information on self-reported socio-economic status (SES) of participants was obtained.Data on earthquake exposure, including earthquake-related injuries of respondents and deaths among respondent’s family members, were collected during phase I (1990–1992) and verified during phase III (1992–1994). During phase I (1990–1992), in addition to the information on the earthquake related loss , data was obtained on the financial/material aid received post-earthquake. Earthquake related material loss was divided into three levels of none to minimum loss, moderate loss, and severe loss. Exposures to life time stressful and traumatic events, including natural disasters, violence, life threatening accidents, sudden unexpected death of a loved one, participation in war, and any other horrifying or life threatening event were collected during phase IV (2012). The number of exposures were summed into a continuous variable (range 1–7). Data on participant’s smoking and drinking habits were obtained in phase IV (2012). Drinking two or more portions of alcohol on four or more days per week was considered as alcohol abuse.During phase IV (2012), detailed self-report of physical health was obtained. The health questionnaire included current cardiovascular diseases, respiratory diseases, diabetes, arthritis, migraine, allergic diseases, and digestive tract diseases. The total number of physical illnesses was used for analyses (range 0–15).not at all to extremely (1–5) with a summative score ranging from 17 to 85. A cut-off of 52 or above on the PCL-C was used to distinguish possible PTSD cases from non-cases. Anxiety symptoms were assessed by using the 10 item Symptom Checklist 90-Revised [During phase II (1991) of this study, the participants underwent screening for depression, anxiety, and PTSD symptoms, using instruments based on the DSM-III-R diagnostic criteria . Elabora-Revised . This sc-Revised  consisti-Revised .Self-perceived family/friend related social support score ranging from 0 to 28  was generated from the responses to seven questions administered at phase IV (2012).mobility, self-care, usual activity, pain/discomfort and anxiety/depression. Each question had a 5-level ordinal response scale indicating the level/frequency of difficulties experienced in each domain. The instrument provides a health index (a population specific-weighted index) [The official Armenian translation of the EQ-5d-5 L was used to assess QOL . This isd index) , which id index) .The study protocols for the phases I, II and III were approved by the Institutional Review Board (IRB) of Johns Hopkins School of Hygiene and Public Health, and for the phase IV by the IRB of the American University of Armenia. During all phases, the interviews were conducted only after describing the study, its objectives, potential risks and benefits and after obtaining informed oral consent to participate.We used STATA 12.0 to conduct statistical analyses. For each scale - depression (CES-D), anxiety (SCL-90-R) and PTSD (PCL-C), cases with three or less missing values on a scale were maintained in the analysis with the missing values replaced by average value of answered items on that scale, while the cases with more than three missing values on a scale were excluded from the analysis.mobility, self-care, usual activity, pain/discomfort, and anxiety/depression.We employed a bivariate linear regression analysis to investigate the association between the QOL score  and psychosocial factors, as well as earthquake related experiences, including earthquake related material loss and post-earthquake support. We applied multivariate linear regression analysis to evaluate the true association of variables of interest with QOL while controlling for potentially confounding factors, including all variables with a p-value of less than 0.25 in the bivariate analyses. We initially considered an interaction term between post-earthquake financial/material aid (two-level) and earthquake related material loss (three-level), however, as the effect of material loss among those with none to minimum loss and moderate loss were statistically similar, they were collapsed into a single category resulting into a two-level material loss variable. Finally, after assuring that the data met the parallel-lines model assumptions, ordinal regression was applied to evaluate the association between variables of interest  and the five domains of QOL instrument: Table Table Table For the entire sample, post-earthquake financial and material help was not associated with QOL. However, there was a statistically significant positive association between post-earthquake financial/material aid and QOL among those individuals with severe earthquake related material loss Table .anxiety/depression domain, but expanded over the other domains. For instance, having PTSD symptoms increased the odds of reporting difficulties in self-care (1.83), and usual activity (2.36) domains. Likewise, depression was significantly associated with the same two domains, and additionally with pain/discomfort. Those with anxiety symptoms had two times higher odds of experiencing pain/discomfort as compared to those without anxiety. The higher number of physical illnesses was also associated with worse outcomes across all domains. The negative impact of severe earthquake related material loss was significant for the mobility, self-care, and anxiety/depression domains. Although financial/material aid was not positively associated with any of the QOL domains, a statistically significant interaction term was found; those with severe earthquake related material loss who received financial/material aid had statistically significantly better outcome in self-care, usual activity, and anxiety/depression domains. Social support was found to be a statistically significant protective factor across the five domains of QOL.Table To our knowledge, this is the first epidemiologic follow-up study that has measured the association between socio-demographic, earthquake exposure, physical health, and psychopathological variables and QOL among survivors two decades after a major disaster. The data collection was done in four different study phases, and for some important factors data was repeatedly collected in various study phases, which minimized potential recall biases and reporting errors. Despite the fact that two decades had passed since the baseline study phase, we were able to track 80% of the initial group of 1773.The study had some limitations. The collected data were all self-reported, which may be subject to recall bias, nevertheless, considering the lack of a comprehensive medical records and the limited resources, this was the only feasible method to use. However, considering that the baseline population was made of Ministry of Health employees including a large proportion of health professionals with better access to health services, we expected better self-reporting of morbidity and medical outcome data than the general population in our cohort. Another limitation is the lack of QOL measures in earlier study phases. Such data would have given us the opportunity to study the association of earthquake related factors with the change of QOL over time.anxiety/depression domain. Those with current depression had significantly higher odds of having poor outcomes in all domains of QOL. Current anxiety was also related to higher rates of experiencing pain/discomfort and difficulties with mobility. These results are consistent with findings of other studies , showing adverse effects of anxiety, depression and other mental conditions on QOL [mobility, usual activity, and pain/discomfort may lead to increased utilization of healthcare services and decreased job performance and productivity. Such problems can have a negative impact on social activities and family relationships.The multivariate regression analyses indicated that symptoms of concurrent psychopathology were negatively associated with QOL (even though symptoms of baseline psychopathology measured in phase II were not independently associated with QOL). The associations of current depression and anxiety with QOL were not limited to the s on QOL -23. The anxiety/depression domain. This is consistent with prior findings indicating a strong correlation between PTSD, depression, and anxiety [anxiety/depression domain. Those with PTSD symptoms above the cutoff level applied also reported difficulties in performing usual activities, which is in line with both DSM-IV criteria for PTSD [Consistent with other research ,24-26, c anxiety ,28. PTSDfor PTSD  and othefor PTSD ,31 showiThe cross sectional measurements of current psychopathology symptoms and QOL outcomes limit us in making conclusions regarding the direction of such associations. The association of psychopathology with QOL scores may be a bidirectional relation whereby QOL and mental health are modified by the effect on one another. A similar alternative causation between health and SES has been previously described by Adler and colleagues . LongituThe lack of association between baseline psychopathology (phase II) and QOL and the existence of an association between concurrent psychopathology and QOL suggests that intervening variables rather than psychopathology that occurred decades earlier impacts current QOL. For example, the number of physical illnesses was one of the possible intervening variables strongly associated with all domains of QOL.Even two decades after the disaster, the earthquake related material losses were negatively associated with survivors’ current QOL. Earlier studies, based on phases I and II data, have shown that those with severe earthquake related material loss had higher rates of depression and PTSD, and that post-earthquake financial support did not show an immediate impact on psychopathology ,11. Howeself-care, usual activity, and anxiety/depression domains among those who experienced severe earthquake related material loss compared to those who had similar level of loss but did not receive any aid and support. These findings suggest that financial/material aid should be prioritized to those who have suffered serious losses. And those with serious losses have to be prioritized.Even though post-earthquake financial/material aid had no effect on the QOL among the whole sample, it had significant positive effect on overall QOL and specifically on its Social support was another factor positively associated with overall QOL and all the domains of it. The observed positive effect of social support on QOL extends findings of shorter term studies conducted among earthquake survivors in China and Taiwan ,8,33.This study highlights the negative impact of mental and physical morbidity on QOL. More importantly, the findings demonstrate the necessity of close monitoring of earthquake survivors, specifically those with severe earthquake related material losses. The present findings indicate that financial/material aid provided soon after a disaster to those with severe material losses would be beneficial intervention with regard to their QOL. Finally, provision of social support and enhancement of existing social networks may benefit the QOL of survivors.