Eyal and Hurst proposed that locally relevant medical education can offset the prevalence of physician “brain drain” in resource-poor regions of the world, and presented a framework of the ethical and pragmatic benefits and concerns posed by these initiatives. The present study explored the framework’s utility through a case study of the University of Guyana Diploma in Surgery (UGDS) programThe framework’s utility was evaluated using a case study design that included review and analysis of documents and semi-structured interviews with graduates, trainees, faculty members, and policy makers associated with the UGDS program. Data were analyzed from constructivist and interpretivist perspectives, and compared against the benefits and concerns described by Eyal and Hurst.The framework is a useful template for capturing the breadth of experience of locally relevant training in the Guyanese setting. However, the results suggest that delineating the framework factors as either beneficial or concerning may constrict its applicability. The case study design also provided specific insights about the UGDS program, which indicate that the Program has promoted the retention of graduates and a sustainable culture of postgraduate medical education in Guyana.It is suggested that the framework be modified so as to represent the benefits and concerns of locally relevant training along a continuum of advantage. These approaches may help us understand retention within a resource-poor country, but also within particularly remote areas and public health care systems generally. Surgical care is a critical component of effective health care systems. Sadly, there are significant disparities in surgical care worldwide, with enormous deficits in resource-poor countries,To date, the highest impact education programs for increasing surgical capacity have been based on successful partnerships with academic institutions in high-income countries.24Medical education is most effective at promoting retention when it is locally relevant: accountable to the local needs, understanding of the local environment, and empowering of local actors.It is our position that the Eyal & Hurst framework may serve as a useful approach to evaluate global educational programs aimed at improving retention and building local capacity. In this study, the utility of this framework as a tool for evaluating program retention is examined with respect to its utility and comprehensiveness in explaining the context of the University of Guyana Diploma in Surgery (UGDS). This is a postgraduate surgery program in which the Canadian Association of General Surgeons (CAGS) has paired with the University of Guyana to provide a locally relevant program aimed at improving national health outcomes, retaining graduates, and building a sustainable local culture of graduate surgery education in the rural Guyanese context.In conducting a case study examination of the impact of the UGDS Program on the retention of surgical trainees, our intentions were two-fold. First, we were interested in testing the general utility of the Eyal and Hurst’s framework. Thus, we analyzed the resultant data with specific respect to the degree to which it could be accounted for within the framework’s stated factors of benefit and concern. In doing so, we were afforded the opportunity to understand the comprehensiveness and appropriateness of the framework in a specific context. Secondly, the case study approach also served as a form of program evaluation for the UGDS Program, at least with respect to its impact on graduate retention. Thus, we also present a summary of the evaluation findings and recommendations for Program improvement.In order to investigate the utility of the Eyal and Hurst framework, the UGDS participants’ lived experiences were examined by way of in-depth qualitative interviews and document review. This constituted a case study designGuyana is a lower-middle income country in the Latin America and Caribbean region. While communicable diseases present challenges to the health status of the country’s population, the focus of health policy and resource allocation is increasingly shifting towards non-communicable diseases, which account for Guyana’s highest burden of mortality and morbidity. Priority areas include reducing the physiological consequences and mortality associated with accidents, injuries, and violence, and reducing pregnancy related complications,The delivery of health services in Guyana is provided at five levels, accessible through an upward referral system. At the fourth level of the health tier are the four Regional Hospitals, located in the rural towns of Linden, New Amsterdam, West Demerara, and Suddie. These hospitals provide emergency services, routine surgery, dental and diagnostic services, and obstetrical and gynecological care. When complications arise with patients or advanced surgeries are necessary, patients are transferred to the highest level of care – the National Referral Hospital - Georgetown Public Hospital Corporation (GPHC), in Georgetown, the country’s capital and largest urban centre. In contrast to the Regional Hospitals, GPHC provides a larger variety of diagnostic and specialist services. As well, the nature of practice differs in that surgeons at GPHC have a significantly heavier caseload, with more complex and diverse cases.For many years, there were no postgraduate training programs in Guyana. Those interested in practicing surgery left the country for an overseas qualification, with very few returning to Guyana.To foster retention, trainees are provided housing benefits, and graduates of the program have a required return-of-service to the Ministry of Health (4 years). To date, the UGDS program appears to have played a key role reducing the number of emigrating medical professionals - 11 of the program’s 14 resident graduates now practice in Guyana – yet it has not been subjected to formal evaluation. In this regard, a program evaluation of the UGDS’s impact on retention for future professional practice in Guyana and within the program serves as a useful lens for an exploration and critique of Eyal and Hurst’s framework.Purposeful samplingA script for semi-structured interviews was developed to explore the experiences and perspectives that may influence Program participants’ decisions to remain in Guyana; specifically within the public sector. These questions were written with consideration for locally relevant training, and the various incentives and disincentives designed to promote graduate retention and/or mitigate migration. Importantly, in generating these questions, the research team ensured that they were appropriately reflective of the factors of benefit and concern highlighted by Eyal and Hurst (2008) see . The intFaculty and graduate participants were asked to describe their current professional roles, surgical career paths, intended involvement with the program, and strategies for strengthening career paths for future trainees. Specific questions on gender, age, hometown, marital status, family composition, educational attainment, and places in Guyana that the graduates have worked, trained, and lived previously were also incorporated. Interviews were conducted in English, Guyana’s official language. The lead researcher (AP) conducted interviews from June to November 2014. All interviews were audio-recorded and transcribed. Transcripts were checked for accuracy against the recordings.Reflective journals and presentations that were completed as assignments by participant learners following their rural training were reviewed for content pertaining to the framework.We sought to contextualize the data within the framework for locally relevant training. We used a combination of template and inductive analyses,The analysis identified 938 units, 843 of which aligned directly with Eyal and Hurst’s (2008) framework for locally relevant training. Specifically, the analysis confirmed existing categories and the remaining 95 units did not coalesce under a new category or categories that differed from those outlined in the framework. However, certain concepts emerged as subcategories under the main themes. We describe these results below with illustrative excerpts from the dataset.There were 52 units that reflected this factor, indicated overwhelmingly positive views that the UGDS program teaches skills relevant to the Guyanese demographic and low-resource settings. The training program was frequently described as basic, but sufficient for meeting the needs of the community.The program doesn’t teach you… advanced techniques. [It is] Basic surgical training to survive in the community. The routine stuff. Appendicitis, hernias, trauma. The relevance of the training was perceived as extending beyond surgical skills to also encompass understanding of the rural resources and protocols, which may represent an overlooked but very critical component of many locally relevant training models. Learners also commented on their confidence and preparedness for working in a resource-limited setting as a result of the program.It’s not just in this case, the surgical craft but it’s a lot of it is how to deal with the resources you have and how you use those resources. Paperwork. And everything that goes - the protocols in the region. (G03)less relevant for work elsewhere is questionable. As seen in the Guyanese situation, contextually appropriate knowledge is insufficient to stem brain drain.Of the eight graduates interviewed, three had fellowship experience abroad, which demonstrates that the skills acquired may be transferable to other settings. As Eyal and Hurst suggest, contextually appropriate knowledge will make physicians maximally helpful in the regions they work. However, their claim that contextually appropriate knowledge makes graduates’ skills The data coded under this factor (50 units) indicated that there were varying levels of practice-associated burnout among the participants. Participants responded positively, indicating satisfaction with their role, positive working relationships, and feelings of appreciation, but also expressed significant frustration. However, this frustration was not attributed to a lack of preparedness, as is suggested by the framework. Rather, participants acknowledged a sense of frustration being overworked, understaffed, and having a high degree of responsibility.All the responsibility was held on our shoulders and sometimes it can feel overwhelming. (G07)They [the trainees] feel like they are doing most of the work. Review of the data suggests that despite alignment with actual practice, the locally relevant training did not reduce trainee burnout. It is important to consider the immense responsibility that will be placed on individuals that graduate from locally relevant training programs, particularly in regions lacking trained specialists. Thus, the framework should consider the possibility that burnout may increase with the implementation of locally relevant training, at least until adequate capacity has been built. To assume otherwise is overly naïve.This factor was reflected in 65 data units. Multiple participants commented that graduates are respected and perceived as competent surgeons by their peers and among patients. There was consensus however that the program’s prestige is compromised by the qualification that is ultimately granted. Since the inception of the surgery program in 2006, six other non-surgical postgraduate training programs have been implemented in Guyana that provide a higher qualification . As a result, the prestige of the surgical program has diminished over time.The UGDS program is perceived to be one of the weakest postgrad programs. Not necessarily because of its content. But because of the outcome measure, which is the Diploma. (G02)Importantly, the role of the CAGS influenced the perceived prestige of the program positively.Their [CAGS] visit was helpful both from a technical point of view but more importantly provided credibility for my work. (G01)Positive perceptions of prestige will undoubtedly improve recruitment into the Program and in turn, retention. This is integral for building capacity and program sustainability. However, the results suggest that these impacts may be jeopardized by the view that postgraduate programs that award higher qualifications are more respected.Two trainees interviewed were from a rural hometown, while the others identified Georgetown as their hometown. A total of 192 units were identified within this category. The data were captured under two subcategories: perceptions of rural practice and experiences during rural training.graduates reported that the rural training improved their understanding of the challenges faced in under-resourced areas. As a result, graduates reflected that they are more inclined to practice in the rural setting and indicated a strong desire to “give back” and “make a difference.” However, participants also noted that the Rural Centres referred cases to Georgetown routinely, which was perceived as a limitation to the learning experience:With respect to perceptions of rural practice, So that was a challenge. The patient load [in rural setting] I didn’t believe was sufficient enough for my training experience, to improve at the time that I did it. (G04)Other graduates commented on these attitudes, views and practices as being entrenched, and the subsequent difficulty fostering positive change in these rural areas. A disconnect between the learning objectives of the trainees and the goals and attitudes among those in the Regional Hospitals may impede the potential for capacity building and development through locally relevant training in the regions.With respect to the learning experience during rural training, a recurring theme among graduates, trainees, and faculty was a compromised learning environment, the interaction of limited work availability, a lack of support from rural staff, and resource deficits. Many participants explained that they were less inclined to return to the rural setting as a result.It [the rural experience] was adversely affected by frequent power outages and water shortage plaguing the hospital... (G09)In contrast, several graduates and trainees commented that the rural learning offered a unique opportunity to gain experience practicing surgery independently. The trainees were required to make decisions and lead administrative aspects of surgical care, which were perceived largely as challenging but valuable experience.It [being in rural setting] gave you a chance to be a bit more responsible. With regards to your previous work here [Georgetown Public Hospital Corporation] you always have the consultants and senior people here to fall back on. (G03)built character.”The trainee and graduate respondents also commented that the rural training component contributed to their personal maturation. It was suggested that the experience “The time spent in [the Regional hospital] was challenging but I grew as a person and matured as a surgeon-in-training. (G01)Participants acknowledged the importance of keeping trainees in these rural settings engaged through professional development. Generally, participants considered the public sector a better learning environment than the private sector because of the diversity of cases and the opportunities to engage with other students. Providing opportunities for professional development may help to address these limitations and foster a good learning environment that promotes retention.Overall, the data units in this category suggest that rotations and recruitment from under-resourced regions may both contribute positively and negatively to retention in the rural setting. With respect to Eyal and Hurst’s framework, it may be overly idealistic to assume trainees will be content to remain in the rural setting. It is clear that to many, the rural setting is perceived as a temporary post, rather than a final destination. Assuming individuals may wish to pursue additional training, there is a need for integration with models of locally relevant training. This may involve the development of fellowship programs in surgical subspecialties that are feasible for graduates to pursue following completion of their general surgery training.This theme resonated strongly in the dataset, with 181 units aligning under this factor. Participants reflected that involvement in the program contributed to promotion and the ability to obtain more senior positions .Retention is being driven by the fact that… they have graduated from the program [and] they are being absorbed by higher levels within the hierarchy of service. (F03)Participants agreed that they were frustrated by what they perceived as uncertain career paths and cited the need for more formalized career advancement. Again, several participants explained that the UGDS program grants a Diploma, which is insufficient for those seeking to practice at a higher level, as consultants.You’ve taken them [the trainees] to a certain level then what? So these guys are thinking I want to go ahead. (F01)The participants commented that rural training improves the availability of surgical services, fosters a culture of evidence-based practice, and is ultimately beneficial to the quality of care in the region (42 units). In general, the perception is that basic enhancements in work conditions will play a significant role improving the quality of care irrespective of any changes in the UGDS program. In turn, this will have implications for retention because graduates and trainees prefer to be at the “centre of excellence” and are dissatisfied remaining in a setting where they perceive the quality of care to be sub-standard.The analysis elicited 49 data units related to this factor. Participants acknowledged going elsewhere to pursue further training as a potential option, including study in Jamaica, Trinidad, North America or the United Kingdom. However, participants opted to study in Guyana suggesting it was the more feasible option.Personally, UG was my best option. The other guys from our year that actually went to the University of the West Indies and it’s a little more difficult to get into that program because it’s a paid program – you actually have to pay to get it done. You have to get a job. You have to write their exams to get in. And then they usually take their local people first and if there are spots then they give the foreign people. So I wasn’t really prepared to go through all of that, being re-located and everything. (G07)Participants did not specifically indicate that they felt they were coerced to study in Guyana. For the most part, the program does not deny educational options to learners. Many participants outlined intentions to pursue additional training elsewhere. Freedom of education may be challenged among graduates fulfilling their return of service period, since they may not be permitted to leave the country during this time. Eyal and Hurst also raise a concern that locally relevant training may breach the freedom of occupation by deliberately limiting career options available to the graduates of these programs. This was expressed among several participants who felt that the qualification they received limited their opportunities for career advancement. This was often a key motivation for participants to seek training abroad.There were 12 units coded under this factor. The results suggest that the return-of-service period for graduates of the program were perceived negatively, but only relative to the formal exit restrictions of other postgraduate programs in Guyana. One participant summarized the key concerns with the formal exit restriction:It’s something like, five or seven years of contract, when the program is just two-and-a-half years. And at the end of the program, you just have a Diploma; it’s not a good trade-off. Because there are other programs now, that are four years, and at the end of it you’re given an MMed. And it’s the same exact contract in terms of time. (G08)Lengthy formal exit restrictions may deter prospective learners from joining the program and this may adversely impact capacity building within the program.Participants perceived unequal opportunity relative to graduates of other postgraduate programs (19 units). In particular, the respondents once again pointed to the qualifications granted by other programs as preferential to employers.Because it’s a Diploma program, it’s never complete…You have to compete with other surgeons who have far higher qualifications than you. It doesn’t necessarily mean they can do more than you or that they can do it better. It’s just the way things are. (G07)In this view, one may consider the Diploma qualification as perpetuating unequal opportunities. As well, given that the program only has male graduates thus far, this may represent an area of unequal opportunity, in which women face unique barriers to accessing the training program compared to their male counterparts. Eyal and Hurst claim that unequal opportunities among students may arise due to differences in socioeconomic status. That is, locally relevant training that is subsidized may be the only feasible option for lower income learners, while higher income learners can pursue training abroad. However, this was not reflected in the data.There were 32 units reflecting this theme in the dataset. When asked about the role of Western institutions relative to the UGDS program, participants responded overwhelmingly that the CAGS involvement in Guyana was not hypocritical in this fashion. Participants spoke of the CAGS partnership positively, as collaborative and built on “friendship, respect, and mutual trust.”I think it [the role of CAGS] is supportive. I think we benefit from when faculty comes down, when fellows come down, when junior staff, when they come down they share their perspective and knowledge and so on. I think the guys who go on these clinical fellowships or observerships, they benefit from being exposed to what it kind of should be like. I don’t think any of them have left because of that exposure. So I don’t think it really contributes [to physician migration]. (F02)In review of the data it seems unlikely that the CAGS involvement contributes to brain drain in the Guyanese context. In this regard, the framework should account for the positive contributions of globally-accountable institutions from high-income countries, which include mentorship, prestige, and shared knowledge.Participants identified faculty members, senior staff, fellow learners, the Institute of Health Science Education, , Georgetown Public Hospital Corporation, the University of Guyana, and the Ministry of Health (Guyana) as key stakeholders in the UGDS program. The data analysis revealed 149 units in which participants spoke of support, or a lack thereof, from these key players. Participants spoke positively about the helpful role faculty and staff played in supporting learners, describing them as “readily available,” “willing to be consulted at any time,” and “encouraging and accessible during times of need.” A resounding theme, however, was the support that the learners themselves provided to the UGDS program. Overall the graduates and trainees indicated a strong willingness and commitment to building capacity as Program educators and leaders in the future.I see myself as wanting to play a pivotal role in advancing the program and continuing what’s already been started. (G02)There is very clear evidence that the UGDS program has the support of its trainees, graduates and faculty members, and that they welcome the opportunity to contribute to improved program capacity.The case study approach yielded important insights about the UGDS program itself, which represent an important secondary outcome of this work. Specifically, the data yielded insights about the influence of Guyana’s surgical training program on the retention of its graduates in the Guyanese health sector as well as within the Program. Overall, the analyses suggest that the Program’s impact is positive in both regards. The majority of the graduates interviewed are currently practicing in Guyana. Importantly, all interviewees stated a strong willingness to engage with the Program as educators and developers of further specialist education in Guyana.In summary, the results imply that the Program’s rural training component raises awareness about the complexities of providing surgical care in under-resourced areas while also providing learners with an opportunity to practice independently and assume leadership positions. In doing so, the Program is effectively preparing learners with the skills and knowledge to function in resource-limited Guyanese settings. This is viewed as influencing retention positively. However, there are also areas where focused efforts may further enhance retention; particularly, in the public sector and rural regions. According to participants, there were a number of influences that may contribute to future decisions to migrate from the Regional Hospitals. These can be best summarized in terms of the learners’ frustrations with both practice and educational experiences in these settings. In particular, a lack of local support, inadequate facilities, and poor organizational attitudes compromised learning and were cited as areas for improvement.Ultimately, one’s choice to leave the Guyana health system altogether, although rare, was most often attributed to a perceived desire for advanced training and qualifications that would support opportunities for career growth. It is recommended that the Program address these perceived areas where possible. For instance, formal exit restrictions may be revised so as to compare with those imposed by other national post-graduate programs. Perhaps most saliently, the ultimate qualification that is granted by the program may be reconsidered. It was a widely held view among students that the diploma distinction leads to unequal job opportunities as compared to other potential degrees .The UGDS Program served as a useful case study for a deeper exploration of Eyal and Hurst’s framework. In this regard, the data demonstrate the framework’s comprehensiveness and utility. Specifically, related themes emerged: improved career options, support for the reform, and the contextual importance of rural training. Nevertheless, the data also indicate the framework could be refined to reflect more accurately the impact of each factor on migration and/or retention. For instance, Eyal and Hurst delineate between the potential benefits and concerns of locally relevant training. However, the study results suggest that the framework factors are better understood along a continuum rather than a dichotomy.The need to consider the framework factors along a continuum from benefit to detriment is apparent when one reviews the data associated with context-relevant skills and alignment with actual practice. However, the need to think of a continuum rather than a dichotomy is clearly illustrated in their claim that involving partner institutions can promote counter-productive recruitment practices. We discovered, to the contrary, that the CAGS’s involvement was perceived to be focused resolutely on building local capacity. This is encouraging for the Canadian partners insofar that it instills confidence that they are contributing to the overall goals of the program. The reciprocity of learning that occurs through such a program together with the personal rewards that accompany this socially accountable practice, demonstrate that the endeavor was largely positive and worthwhile. We understand that our findings do not preclude the possibility that in different circumstances the involvement of partners could be self-serving but we instead point out that such partnerships have the potential to provide benefits. Taken together, our recommendation is that the factors in the Eyal and Hurst framework be revised so that each factor be viewed along a range from beneficial to problematic.The success of this framework in describing the impact of locally relevant training on retention in the Guyanese context leaves us hopeful that it may be similarly useful in other resource-poor regions. In particular, we are optimistic that it can provide insights within each of three types of retention: a resource-poor country, rural/remote areas, and public health systems. By using Eyal and Hurst’s factors to analyze each of these three types of retention, programs will be equipped to leverage training advantages to offset the out-migration of health professionals.The Eyal and Hurst framework may also be relevant for much of the training that is conducted in the Canadian setting, which includes rural or remote areas and regions with a high prevalence of marginalized or culturally-diverse patient populations. For example, a sustained shortage of physicians in Northern Ontario led to the development of the Northern Ontario School of Medicine, which aimed to establish rural-based education that recruits and retains students from the local region.In closing, we recall Hodges’s warning that “the dominance of particular countries or regions is almost certain to lead to the marginalization of priorities, values, content knowledge, and exposure to learning contexts of less dominant countries or regions.”


Mobile health  programs hold great promise for increasing the reach of public health interventions. However, mHealth is a relatively new field of research, presenting unique challenges for researchers. A key challenge is understanding the relative effectiveness and cost of various methods of recruitment to mHealth programs.The objectives of this study were to (1) compare the effectiveness of various methods of recruitment to an mHealth intervention targeting healthy infant feeding practices, and (2) explore factors influencing practitioner referral to the intervention.The Growing healthy study used a quasi-experimental design with an mHealth intervention group and a concurrent nonrandomized comparison group. Eligibility criteria included: expectant parents (>30 weeks of gestation) or parents with an infant <3 months old, ability to read and understand English, own a mobile phone, ≥18 years old, and living in Australia. Recruitment to the mHealth program consisted of: (1) practitioner-led recruitment through Maternal and Child Health nurses, midwives, and nurses in general practice; (2) face-to-face recruitment by researchers; and (3) online recruitment. Participants’ baseline surveys provided information regarding how participants heard about the study, and their sociodemographic details. Costs per participant recruited were calculated by taking into account direct advertising costs and researcher time/travel costs. Practitioner feedback relating to the recruitment process was obtained through a follow-up survey and qualitative interviews.P=.002). Less than half of the practitioners surveyed reported referring to the program often or most of the time. Key barriers to practitioner referral included lack of time, difficulty remembering to refer, staff changes, lack of parental engagement, and practitioner difficulty in accessing the app.A total of 300 participants were recruited to the mHealth intervention. The cost per participant recruited was lowest for online recruitment (AUD $14) and highest for practice nurse recruitment (AUD $586). Just over half of the intervention group  were recruited online over a 22-week period compared to practitioner recruitment  and face-to-face recruitment by researchers . No significant differences were observed in participant sociodemographic characteristics between recruitment methods, with the exception that practitioner/face-to-face recruitment resulted in a higher proportion of first-time parents (68% versus 48%, Online recruitment using parenting-related Facebook pages was the most cost effective and timely method of recruitment to an mHealth intervention targeting parents of young infants. Consideration needs to be given to addressing practitioner barriers to referral, to further explore if this can be a viable method of recruitment. Interventions using mHealth are appealing for a number of reasons: first, a large proportion of the population has access to (and use) apps on their mobile phones; current data indicate that 75% of the world population has access to a mobile phone . A 2012 provider .As a novel use of emerging technology, mHealth is a relatively new field of research with a need for high quality studies to evaluate the effectiveness of mHealth interventions. Conducting mHealth studies presents unique challenges for researchers, one of which is understanding how best to recruit and retain participants , and wheTo date, mHealth studies have used a range of recruitment approaches, including online  and traditional methods of recruitment  . Anotherhard to reach or more at risk groups. More research is needed to understand both the reach and costs of various methods of recruitment to both web-based and mHealth interventions, in order to inform the design of future trials.There is a paucity of research reporting on recruitment to mHealth programs . We wereone-stop shop for evidence-based advice and strategies that are consistent with national guidelines pertaining to infant feeding in the first nine months of life. Participating parents received three push notifications or short message service (SMS) text messages (for those without smartphones) regarding infant feeding and related topics, which were relevant to the age of their infant, for each week of the intervention. Messages were tailored to parents’ feeding mode  with links to more information on the app or website. Further details about the development of the program have been published elsewhere [We have recently developed an mHealth intervention for parents of young infants  that encourages healthy infant feeding practices, with a focus on socioeconomically disadvantaged parents. The program consists of an app and website , providilsewhere . A feasilsewhere  using a The aims of this paper were to (1) compare the recruitment rate, costs, and characteristics of participants recruited using a range of recruitment approaches to an mHealth intervention targeting parents with young infants, and (2) to explore factors influencing practitioner referral to the program. These analyses will provide important new insights into recruitment to mHealth interventions, and further our understanding of utilizing health practitioners for referral to such programs.The methods of this study have been published previously . BrieflyEligibility criteria for participation in the study included: expectant parents (>30 weeks of gestation) or parents/primary care giver with an infant <3 months old, ability to read and understand English, own a mobile phone, ≥18 years old, and living in Australia. Participants were excluded if their infant was born prematurely (before 37 weeks) or had a disability with the potential to impact on infant feeding. Recruitment to the growing healthy program commenced in December, 2014 and continued for a 12-month period. The initial method of recruitment was via practitioner referral and entailed face-to-face recruitment only. However, due to the slow rate of recruitment using these approaches over the initial 6-month recruitment period, online advertising was used in the final six months of recruitment, with the aim of boosting enrolments. Further details of these recruitment methods are described below and outlined in Handing out program brochures at routine appointmentsDisplaying posters in waiting rooms in participating clinics/centers/practicesAsking interested parents to complete an expression of interest form (MCH Services only). Using these forms, parents provided contact details and gave permission for the research team to email information about the study directly to them. This approach was used in response to MCH nurses’ concerns that interested parents with young infants may need a reminder to enrollSending a letter of invitation from the practice  inviting eligible potential participants  to enroll in the programPractitioners were engaged in recruiting parents to the growing healthy program from three primary health care settings: (1) Maternal and Child Health (MCH) nurses (n=87) in two local government areas in Melbourne, Victoria; (2) midwives (n=10) from outpatient antenatal services at a large Melbourne hospital; and (3) practice nurses (n=8) from four general practices in the Illawarra/Shoalhaven Medicare location in New South Wales. Study sites were selected if they had a high relative level of socioeconomic disadvantage in the surrounding communities (based on the Index of Relative Socio-Economic Advantage and Disadvantage ) as wellThe ethics approval for practice nurses in general practice was conditional on the use of passive recruitment strategies only . The use of more active approaches, such as practice nurses providing a brochure to a potential participant, were considered by this committee as potentially coercive due to the existing practitioner-patient relationship. However, ethics committees overseeing the study for MCH nurses and midwives approved both passive and active promotion by practitioners, with the condition that practitioners emphasized that the choice to participate was completely voluntary and would not affect the care provided.Within the MCH Services in Victoria, only practitioners working in the most disadvantaged communities (defined as having an Index of Relative Socio-Economic Advantage and Disadvantage score of less than a 1000 ) were inWithin participating MCH Services in Victoria, a research assistant attended first-time parent groups  in selected low socioeconomic suburbs to inform parents of the growing healthy program. Recruitment involved providing parents with a copy of the program brochure and collecting the names and email addresses of interested parties. These parents were subsequently emailed a web link inviting them to enroll in the program.Online recruitment for the intervention arm commenced in May, 2015 in response to the slow rate of recruitment using practitioner and face-to-face approaches. Online methods involved advertising the program on a range of popular Australian parenting websites and forums, including one advertisement on a parenting website and five Facebook status updates on Facebook pages targeting (and widely followed by) parents of young children. The main factors influencing the choice of website/Facebook pages included: Australian-based groups, groups having a large number of followers, and the advertising costs being within the project budget . Additionally, a capped price (AUD $200) official Facebook advertising package was purchased. This initiative ran for five days and could only be seen by those who were using Facebook on a computer (rather than a mobile device) on the side bar of a Facebook newsfeed. Facebook advertising on mobile devices was not possible because the project did not have a public Facebook page established, which is a requirement for Facebook advertising on mobile devices. In total, online advertisements ran for eight weeks. The snowball effect of social media  continued to promote the app, resulting in recruitment of a substantial number of parents for a number of weeks following the completion of active advertising. A record of the online recruitment processes was kept, including a list of the date and site of each of the online advertisements and the associated costs.Participants enrolled via the program website , which iSeveral pieces of information were collected to calculate the costs for each recruitment method, as outlined in on-costs such as superannuation and leave, and based on salary scales at Deakin University and University of Technology Sydney. The total costs were calculated for each recruitment method and divided by the number of participants recruited using each method, to calculate a cost per enrolled participant for each type of recruitment. Sensitivity analysis was conducted regarding the costs of researcher time.Researcher time consisted mainly of research assistants (AUD $42 per hour), but also involved an administrative assistant (AUD $22 per hour) and a PhD student (AUD $14 per hour). Two research fellows (AUD $59 per hour) led the recruitment of practitioners and were involved in the briefing sessions, along with a senior researcher (AUD $70 per hour). All costs were inclusive of Practitioner referral:in kind as part of practitioners’ routine practice• costs of recruitment materials provided to practitioners, researcher time for attending the briefing session, emails to parents expressing interest, and sending of invitation letters from practices. The costs of the practitioners’ time spent recruiting were not included because this was provided Face-to-face recruitment:• Researcher time for travel and attending first-time parent groups, sending of follow-up emails, and travel costsOnline recruitment:• Researcher time spent searching for, and placing advertisements in, relevant parenting websites and forums, and direct advertising costsNine months after recruitment commenced, all participating practitioners were invited to complete a short five-to-ten minute online survey. The survey asked about how frequently the practitioners referred to the program, the methods used in promoting the program, perspectives on the barriers to referring participants, views about the program content and credibility, and perceptions of the sustainability of continued referral of parents to the program. Practitioners who were invited to complete the survey, but had not yet done so, were sent a reminder email on three separate occasions. Practitioners participating in the survey, along with their service managers, were also invited to participate in individual semi-structured telephone interviews to further explore issues pertaining to referral to the program.Differences in participants’ characteristics (obtained from baseline survey) between recruitment methods were tested using Pearson’s Chi-square test statistics for categorical data, and independent t-tests for normally distributed continuous variables using IBM SPSS Statistic version 22 . RecruitPractitioner survey data were analyzed descriptively using Microsoft Excel. Practitioner interviews were audio recorded (with permission) and transcribed verbatim. Transcripts were analyzed thematically by one author (RL), using NVivo 10  to organThis study was approved by Deakin Human Research Ethics Committee (HREC) (2014_093), University of Technology Sydney HREC  and the Victorian Department of Education and Training.A total of 585 individuals commenced the baseline survey; 171 (29.2%) failed to complete the survey and 32 participants completed it twice (duplicate surveys). A further 82  individuals were considered ineligible (mainly because their baby was older than three months), resulting in 300 enrolled participants (51.3% of those who commenced the baseline survey).Just over 50% of participants (151/300) were recruited online. This approach proved to be the quickest and cheapest method of recruitment, at an average cost of AUD $14 per participant recruited over a 22-week period . Of the Overall, 29.3% of participants (88/300) were recruited by practitioners during a time span of just under one year, with most participants being recruited by MCH nurses (70/88) and few being recruited by practice nurses (16/88) or midwives (2/88). The costs for each participant recruited was AUD $586 for practice nurses, AUD $268 for midwives, and AUD $77 for MCH nurses . In termThere were no significant differences in participant characteristics by recruitment method, with the exception that participants referred to the program by their practitioner, or recruited by researchers face-to-face, were more likely to be first-time parents/primary care givers compared to those recruited online . Approxiagreed or strongly agreed that the growing healthy program was a credible source of information and support for parents on infant feeding, and that there was a need for such programs, less than half of the survey respondents actually referred parents to the program often or most of the time  practitioners completed the online survey to provide feedback on the intervention and the referral process. Four qualitative interviews were subsequently conducted with two MCH nurses (who championed the program in the areas that they worked) and two MCH Service managers in the participating areas. While most practitioners surveyed  the time . The prithe time . A numbeWe had real problems with the app. So for the nurses to feel confident about recruiting people when the app wasn’t working and getting on to the site, was quite difficult…Practitioner 4The survey indicated that a lack of time was the main reason for not referring patients to the app, and this was also discussed in the qualitative interviews:We often get asked to do so many things and we also have quite a number of tasks that we need to achieve under each of the key age and stage visits anyway.Practitioner 2Other barriers included practitioners finding it difficult to remember to refer to the app , and the study enrolment process itself, such as the number of steps involved in accessing the app , and to provide regular reminders to nurses to promote the program. The use of SMS text reminders or a nurse version of the app that provided nurse-specific push notifications was suggested. Managers also discussed the importance of broader endorsement of the program by the MCH Service funding body, for promotion of the program to become standard practice, as well as the engagement of other local health and social services in promoting the app.During the interviews, practitioners made a number of useful suggestions for improving program promotion in the future. These suggestions included engaging parents early , offering the app to parents with babies and toddlers, as well as the use of fridge magnets (instead of paper brochures) to act as ongoing visible reminders for parents to enroll in the program. One interviewee highlighted that vulnerable parents frequently change mobile phones and phone numbers, and that this may be a barrier to parent participation in mHealth programs. Suggestions made to improve practitioner promotion of the program included the integration of promotional materials into the standard To our knowledge, this is the first study to report on recruitment outcomes for an mHealth intervention targeting parents of young infants, and is unique in comparing outcomes of online versus practitioner-led recruitment. We found online recruitment using parenting-related Facebook pages to be a more effective method of recruitment compared to practitioner-led referral that took more than twice as long, and contributed only 29.3% (88/300) to the total sample, at a substantially higher cost than online recruitment. Face-to-face recruitment by researchers recruited less than 10% (22/300) of the sample, was time consuming, and resulted in higher recruitment costs than online recruitment.Our findings suggest that consideration should be given to online recruitment strategies in future mHealth interventions (particularly those targeting parents). In particular, strategies using social media such as parenting-related Facebook pages appear particularly successful. There is growing evidence that parents are high users of social media platforms for parenting information and support -30, and reinvent the wheel on common technological components of recruitment, and natively allows access to a larger population in which recruitment is carried out.A key challenge for mHealth researchers is keeping abreast of the latest online recruitment options. A recent technological development called ResearchKit  may helpclick of a button directly from the online advertisement. The findings from our survey with practitioners also highlighted that very few practitioners actually showed parents the website or app to help promote the program, in contrast to some of our online advertising in which a picture of the app homepage was visible. Over 40% of practitioners surveyed had not downloaded the app or viewed the website, which may reflect a lack of time, interest, technical problems experienced, and possibly the age of the nurses . These s of age ,36.Recruitment rates by practice nurses in this study were very low, and as a result costs per participant recruited were high, partially reflecting the large amount of researcher time involved in recruiting and engaging practices. At the time of the study, primary health care organizations were undergoing a restructuring, making it difficult to engage general practices. As a result, only four practices and eight practice nurses were recruited. Furthermore, ethical requirements prevented nurses from directly promoting the program to parents; instead promotion of the program occurred via direct mail to potentially eligible parents, and displays of the program brochure and poster in clinic waiting areas. In contrast, over 80 MCH nurses were involved in the study, and were able to directly promote the program, resulting in higher yields and reduced costs per participant. The organization of MCH Services also allowed for more time-efficient briefing and engagement with practitioners. There was potentially higher buy-in amongst MCH nurses, given the close alignment of the program with their service goals compared to practice nurses who have a generalist role.Despite our finding that online recruitment was less costly than practitioner-led recruitment, primary health care practitioners are still likely to have an important role to play in promoting and reinforcing mHealth interventions to parents, because parents access these services so frequently. Data from Victoria, Australia suggest that on average parents make 11 visits to general practitioners and 14 visits to MCH nurses in the first year of their child’s life, and most of these visits are unrelated to illness . The finInterestingly, despite practitioner recruitment initially occurring in more disadvantaged areas, there were no significant differences in the measured sociodemographic characteristics between participants recruited online versus those recruited by their practitioner or face-to-face by researchers. There was, however, a higher proportion of first-time parents recruited using practitioner-led and face-to-face recruitment approaches. This finding likely reflects face-to-face recruitment at first-time parent groups and practitioners having greater contact with first-time parents and/or more promotion of the program to these parents. Interestingly, more than half of those who enrolled online were second time parents, suggesting a high demand for the program beyond first-time parents. A number of early obesity prevention interventions -41 have hard to reach or more at risk groups than traditional recruitment approaches [The findings of this study are largely in line with the TXT2BFiT mHealth trial  that tarproaches ,14,21.This study has a number of strengths and weaknesses. The findings of the study are relevant to the recruitment of parents of young infants to mHealth interventions, and cannot be generalized outside of this context. Different research staff were involved in various recruitment strategies . While this factor may influence the interpretation of costings, a sensitivity analysis revealed no difference in costing outcomes when only research assistants were used in the costing calculations. The study relied on self-reports of how participants heard about the study, and this may be subject to recall bias. However, because recruitment via practitioners occurred in specific geographical areas and commenced prior to any online advertising, we were able to cross-reference this data against participant addresses and time of recruitment for clarification in some cases. We were unable to determine if word of mouth recruitment resulted from practitioner or online promotion, and thus participants who said they heard about the study from family or friends were excluded from the costing and comparison of participant characteristics. We did observe a rise in word of mouth recruitment that corresponded with online advertising, suggesting that online recruitment may provide an easy method of referring others .key informants; two of whom were MCH Service managers who were aware of the broader views of MCH nurses in their respective services. The other two participants were practitioner champions for the project in their respective services, and again were aware of some of the broader practitioner views about the program via informal discussions with their colleagues. We have yet to test whether there is any difference in retention or outcomes between the various recruitment strategies, and this issue will be a focus for future analyses.Another limitation of the study was the low response rate to the practitioner survey, and that only four practitioners agreed to be interviewed. This limitation may have resulted in response bias, with those harboring the strongest views about the app (either positive or negative) being more likely to participate. However, the integration of the survey and qualitative findings is a strength, and together provide additional insights into factors influencing practitioner recruitment. The four practitioners that were interviewed can be considered This study provides new insights into the relative effectiveness of various recruitment strategies for a parenting-related mHealth intervention. Our findings suggest that mHealth interventions targeting parents should consider online methods of recruitment through Facebook pages linked to popular parenting websites, and that this tactic is likely to result in researchers meeting their required sample sizes in a shorter timeframe and at a lower cost. Participant characteristics were similar for practitioner-led and online recruitment, with the exception that participants recruited by practitioners were more likely to be first-time parents. While practitioner-led recruitment took longer and recruited fewer participants at a higher cost, this approach should not be dismissed because of the high reach of primary health care practitioners (particularly those working closely with families) and the potential to reinforce program content. Addressing practitioner barriers to referral, including improving access to the mHealth intervention, regular reminders, and integration into routine practice, is likely to be important in enhancing practitioner recruitment to mHealth programs.


This issues editorial is an invited commentary authored by John Antolak. It discusses the new CAMPEP‐accredited residency match for medical physicists. This has been a difficult effort and all involved in this effort deserve our thanks and gratitude.Michael D. Mills, PhDEditor‐in‐Chiefth century has to do with medical physics today. When I was asked to write an editorial about the 2015 MedPhys Match (MPM),For those of you who don't identify with the title of this editorial, it is from the lyrics of a song in the 1964 Broadway musical “Fiddler on the Roof”, which was adapted into a successful motion picture in 1971.In my years as a medical physicist, I've witnessed many changes in the medical physics education and training landscape. The need for medical physicists has created a very rewarding (in many ways) profession, and as a result, competition to get into training programs and positions is intense. The American Board of Radiology (ABR) now requires medical physicist students to have CAMPEP‐accredited residency training to complete their board certification process. With the transition to this new requirement, there was a noticeable “food” of candidates getting into the board certification process before the new requirements took hold. I'm not going to debate the merits of the current landscape, but wanted to note that it is now here, and we have to deal with it.Sapareto and et al.Through the efforts of too many people to name, we were able to implement the MPM to create a better recruiting environment for the 2015 recruiting season, and participation in the program is much better than we had hoped. As of late October 2014, we have more than 70 programs participating in the MPM, and more than 140 applicants have registered. The program looks like it will be a success in its first year. In some ways, program directors went out on a limb when signing up this year and I would like to thank all of them for their faith in the system.fast applicant. The applicants who look the best on paper are going to get the first interviews, and hence the offers. I would argue that programs are not necessarily getting the best applicants in this case. From an applicant's perspective, they have little choice. Maybe there would have been a better offer down the road. Going back to my matchmaking analogy, a first love might be the perfect match, but many people have to play the field a little before they find their perfect match (or return to their first love).I would like to use the rest of this editorial to deal with a few nagging questions that some might have regarding how the MPM works and whether it is really better than what we had before. First and foremost, I think that program directors and applicants worry about not being matched and that the previous system might be better in some cases. In prior years, programs would interview a few top candidates and then strike early (making an offer) to lock in the best applicant. More often than not, the applicant would accept — not because they desperately wanted to be part of that residency program, but because they were happy to get a reasonable offer. When programs race each other to find applicants, then applicants will also race each other to apply. It is pretty easy to make the argument that programs are not getting the best applicants, but a good Another common question that comes up when starting up a matching program is what happens to programs and/or applicants if they violate the match agreement. Whenever I hear that question, I always wonder if the person asking the question is thinking about violating the match agreement, but that's just the pessimist voice in my head speaking. The optimistic voice in my head says that the person asking the question is looking for assurance that their decision to follow the match agreement is a good one. National Matching Services (NMS), which is running the 2015 MPM, has indicated that match violations are rare in their experience. If NMS is made aware of any potential match violations, they will pass that information along to the MedPhys Match steering committee, which is a combined committee from SDAMPP and AAPM that is providing guidance to NMS regarding how the MPM should be run and what the terms of the match agreement are. It will be up to this steering committee to investigate any potential match violations and determine what should be done. Potential penalties might include being banned from using MPM for some period of time, reporting the violation to AAPM and/or SDAMPP for consideration or whatever else the committee might think is appropriate. While there are no specific penalties spelled out in the match agreement, the past experience of NMS is that the possibility of violations being dealt with by the sponsoring professional society is usually enough to ensure compliance. In other words, we need to trust that people want to do the right thing.What about residency programs that traditionally take their own graduate students? This was vigorously discussed when setting up the 2015 MPM, and we came to the conclusion that it was in the best interest of the graduate students and residency programs for those residency programs to participate in the MPM. The graduate program uses the promise of a residency position (assuming satisfactory academic performance) as an incentive for graduate student recruitment, and this does not change. The residency program ranks their own graduate students at the top of their list. The graduate students are free to interview elsewhere if they desire, and they may find another residency program that they would prefer. The promise of being ranked highly by their home institution still guarantees a residency position, but because they have the opportunity to interview elsewhere, they might get an even more desirable position. The residency program can interview external candidates at the same time, and if they lose an internal candidate to another residency program, they will have the possibility of immediately filling the position with one of the external applicants.When we first proposed the idea of doing MPM this year, diagnostic physics programs expressed considerable reticence about participating. A misconception in the argument by Sapareto et al.Another argument that is often given against a matching program is that graduate students finish at all times of the year. As many graduate educators will admit, the time that a graduate student spends in the program is often dictated by the demands of the supervisor, who does not want to lose a productive member of the team. This is where graduate program directors need to step in, to end what might be considered taking advantage of the graduate student and of not acting in their best interests.traditional summer start date (approximately July 1). We have opened it up to programs with other start dates , and as long as the program is willing to live within the rules of the match agreement, it is free to participate. The rules have been developed with the assistance of NMS, based on its many years experience running such programs in other professions. The rules may change slightly from year to year under the direction of the AAPM/SDAMPP steering committee; anyone with constructive feedback is invited to contact the author privately to discuss.The last point I would like to address is the notion that it is mandatory for all medical physics residency programs to participate in the MedPhys Match. The way we currently have it structured (subject to change), participation is voluntary and is primarily aimed at those programs that recruit for the In conclusion, I would again like to thank all of the hard‐working individuals who have supported the efforts to get the 2015 MedPhys Match in place. I am convinced that we are now in a better place than we were just a few years ago, and we are definitely making things better for both applicants and programs.John A. Antolak, PhDJACMP Associate Editor


A healthy start predicts better health in later life. Many remote-living Aboriginal and Torres Strait Islander Australian families lack access to consistent, culturally-safe health services. This paper presents a study of implementation of the Baby One Program (BOP). The BOP was designed as a family-centred, Indigenous Healthworker-led, home-visiting model of care focused on promoting family health to give children the best start to life. It was developed by Aboriginal community-controlled Apunipima Cape York Health Council and delivered in Queensland Cape York remote communities. We aimed to determine how the BOP was implemented, enablers, strategies used and formative implementation outcomes.The qualitative approach utilised theoretical and purposive sampling to explore people’s experiences of a program implementation process. Data were generated from semi-structured interviews with four family members enrolled in the BOP and 24 Apunipima staff members. In addition, twenty community members, including two program users, participated in a men’s community focus group. The findings are presented according to themes arising from the data.The BOP was rolled out in nine remote Cape York communities between July 2014 and December 2015 and there was high uptake. Indigenous Healthworkers were supported by midwives and maternal and child health nurses to deliver health education to 161 eligible families. The key to effective implementation of family-centred care appeared to be the relationships formed between health practitioners, especially Indigenous Healthworkers, and families. The data revealed the following themes: challenging environments for new families and valuing cultural ways, resourcing program delivery, working towards a team approach, negotiating the cultural interface, engaging families, exchanging knowledge through ‘yarning’, strengthening the workforce, and seeing health changes in families. Healthworker education and training, and knowledge exchange between Healthworkers, midwives and nurses was critical to program effectiveness. The program continues to grow despite substantial logistic, financial and practical challenges.This study describes an evolving process and explores how health providers connect with families and how the program responds to family and cultural issues. Program development is ongoing; strengthened by more community-level involvement, embedded strategies for ongoing self-evaluation and continuous quality improvements that are responsive to family needs.The online version of this article (10.1186/s12884-018-1711-7) contains supplementary material, which is available to authorized users. A healthy start predicts a healthy life . A childEffective antenatal care can make a critical contribution by addressing health literacy and parenting behaviours, with a focus on nutrition, alcohol and smoking cessation and the benefits of breastfeeding. However, for remote-living Aboriginal Australian and Torres Strait Islander (hereafter Indigenous) families, there are major geographical, environmental, economic, cultural and social challenges. Many families lack ready access to consistent, culturally-safe maternal and child health services, and health promoting educational resources , 4.In some high-income countries, disparities in maternal and child health outcomes of Indigenous populations have motivated development of community-based family-centred healthcare , 6. FamiInternationally, family-centred interventions for Indigenous families have produced positive health outcomes for children, parents and other primary carers, but these can take years to manifest. The Family Spirit intervention delivered by community-based paraprofessionals for North American First Nations families was developed through participatory research over 10 years from 1995 , 9.This study presents a qualitative evaluation of the initial 18 months implementation of an Australian family-centred program for improving child health. The Baby One Program (BOP) was developed by Apunipima Cape York Health Council (hereafter Apunipima) and is delivered in Queensland’s remote Cape York Indigenous communities. The vision of the program is to improve long-term health by ‘giving children the best start to a healthy life’. The aim of this study was, to determine how the BOP was implemented. The key research questions were: (i) What were the enablers and strategies used in implementing the BOP? and (ii) What were the formative implementation outcomes?2, about the landmass of England. The population is approximately 18,000, 60% of whom are Indigenous Australians  know that they have a safe place to talk, because I build that relationship” (IHW). Mothers are essential partners in the BOP, but a relationship with the whole family was viewed as important. “The way that it should be done is about building relationships with those families and maintaining them over the 1000 days” (R-S). Some believed program implementation could be more responsive by valuing and validating decision-making capacities of family members. “It should be more family led…” (R-S). An Indigenous Healthworker believed the program was achieving this. “It just lays it all out well for them to be able to take control of their health and their baby’s [health]…it is important for [families] to have…control over their own health.”From the data, the key to effective program implementation was the relationships formed between health practitioners and families. Program development and quality improvement was contingent on responsiveness to family needs. Staff members identified the need for respect, empathy and positive language: challenging environments for new families and valuing cultural ways.In the process of evaluating context in the implementation of the BOP two key factors were identified from the data: “You don’t get any other support from your families.” The other commented “Well, I don’t have much family. That’s why I’m making family.”The conventional view, that people in Cape York Aboriginal communities have close family and kinship ties, implies that the responsibility of caring for children is shared between parents, grandparents, uncles and aunties. However, two of the three mothers interviewed stated that they did not always have family support in caring for their infants. One said: Involvement from the start [will create] acknowledgement of family members…If [fathers are] involved, support will continue. Involve the man more.” (Men at focus group). An Indigenous Healthworker agreed “…the father’s got to be a part of that thing from day one…it’s like you want to be with your wife, your newborn, you’ve got to be a part of this child from the beginning”.Family members believed that the mother’s evacuation to Cairns at 36 weeks, without her immediate family, assumes that her other children will be cared for by her partner and/or extended family members. Men noted that exclusion of the father at the birth of his child could establish a pattern of the absent father; they advocated: ““I’m tired because we are in the middle of everything, and it’s really noisy, and there’s just parties here, parties there, and it’s like really loud and straight through us. I don’t know how [baby] coped with it all” and, “…it’s hard, it’s pretty noisy, but you’ve got to cope with it.”Household overcrowding challenges some families. Mothers reported that living situations can be distressing.“Everything can be a bit too much … you’ve been out of community [in Cairns] for 4-6 weeks, depending on whether you gave birth on your due date…the stresses of being a new mum again.” (IHW).A need to provide support for new mothers is clearly recognised by Indigenous Healthworkers.“you can see that families really need it, especially first time mums.”Another Healthworker said “I think it’s shared roles…nutrition is not all mums’ business. And the stuff around the bathing. This is where we challenge fellas. It might be taboo for you to bath babies, but it’s not taboo for you to get the bath ready…A lot of fathers want to be involved, but they just don’t know how.” (R-S).Because many traditional roles of men (as hunters and providers) have changed, fathers are often expected to take on roles and tasks within the family that were once the domain of women. One health practitioner observed:“I think part of building healthy children is strengthening culture. It’s also a reflection time for the mother too, she is reflecting on her culture too, she is passing it on to baby.” (P-S).An Indigenous staff member reflected, “educates the whole family, so it’s in the household and you are giving the information to the mother and her brothers and sisters or her aunty or grandma or who will be there looking after that baby.” She continued, “it’s really good because you use your normal body language and eye language and you can do it in a more culturally appropriate way for your community.”An Indigenous Healthworker confirmed the importance of a family-centred approach in the BOP. She said the program, resourcing program delivery, working towards a team approach and negotiating the cultural interface.Three key enablers of BOP implementation were identified from the data: The BOP is funded by the Commonwealth and Queensland governments. The initiative is regarded as a flagship program of Apunipima, however resource limitations across the organisation have meant amendments to program support, including plans for expanded employment. Full implementation of the program across all 11 Apunipima communities remained to be achieved at the time of data collection.“…it’s a really great concept, but in other ways there’s a lot of pressure on people to do it now and have results now…” (R-S). The time commitment for Healthworkers was particularly high during the first year of the program because families are enrolled at their first antenatal visit and early scheduled visits are close together. The projected ideal caseload is 25 families but one Indigenous Healthworker reflected, “In [community name] about 16 or 17 and that is ante and post-natal, and in Cairns there is about 12 on the list.” A community-based Indigenous Healthworker said “…we definitely need more Healthworkers on the ground”.Staff workloads are often high and there are substantial service delivery expectations. Healthworkers are responsible for clinical service in addition to health promotion work,The program included one full-time position to provide ‘on-the-ground’ training and support to BOP Healthworkers across nine communities. Field support was regarded as an important adjunct to formal BOP Healthworker training. Managers and Healthworkers urged the need for allocation of more resources to heathworker support, however, the high cost of bringing staff together over long distances for formal training blocks resulted in a reduction from quarterly to bi-annual face-to-face training workshops.The BOP arose from Apunipima’s strategic decision to realign maternal and child health into a family-centred, Healthworker-led service.“…literally dumped…on the Healthworkers, implement it, and own it” (P-S), an Indigenous Healthworker said “from the time that I first started, Healthworkers have a real good influence on how the [program] is delivered and how the education…is given to communities.”There was divided opinion about involvement of Healthworkers in development of the program. Whilst one staff member believed that the BOP manual was “they didn't want the RNs [Registered Nurses] involved.” (R-S). An Indigenous Healthworker said there was a “big divide between a Healthworker and nurses…even though we don’t have a university degree, we have all this other knowledge that probably can’t be written on paper.”The focus on Healthworker leadership meant that some nurses and midwives felt excluded. A health practitioner said it seemed like, “We know that it is Healthworker-led…If the Healthworker is struggling and wants assistance, then yeah, they can ask and we can do that…” (R-S).A quality improvement approach and new ideas resulted in evolution of the program’s structure and content. Indigenous Healthworkers and midwives reported that their work roles became more clearly defined. A health practitioner commented:“When a new Healthworker comes on, the midwife is part of that learning journey, so even though it’s…being led by the Healthworker through the cultural expertise, and the midwife as the expert in the clinical…we are walking together.” (P-S).A manager acknowledged early confusion over professional roles and reported the steps made to address the concern. “It is an opportunity for us to learn from each other without having to reinvent the wheel…someone within the group may have a suggestion that might knock our socks off and make a real improvement to how we do things.” (P-S).BOP implementation has provided an opportunity for knowledge exchange between Indigenous Healthworkers and other health practitioners. A comment by one Apunipima staff member exemplified openness to hearing new ideas,“I think because the program is in its infancy. There is a lot of room for improvement and there are areas that need to be worked on to ensure that.” (IHW).Some identified the future challenges of the program and delivery of its full potential. Apunipima values a strong Indigenous workforce as the way to build culturally-safe relationships with community members and connect them to health care resources.If you're going in to a…clinic and you feel scared because your child is sick…people use big words that you're not used to... And if you have the Healthworker that you actually really trust, has been seeing you in your home, knows you, has been knowing you for about a year, and you can look to her and you can say ‘what are they talking about?’” (P-S).“Ideally, Indigenous Healthworkers can translate and explain Western medical concepts in language more easily understood by family members.“…when it is a community person, sometimes they might not be able to speak to or have a lot to do with one side of community” and“…you'll find that sometimes in the communities, the female Healthworker may not be allowed culturally to speak to that male or father.” (P-S). To address these cultural needs, roles are negotiated across program staff members.However, because Indigenous Healthworkers live in the community and are often family members, they may face cultural barriers when working across gender, or kinship relationships. engaging families, exchanging knowledge through yarning and strengthening the workforce.Three key strategies of BOP implementation were identified from the data: “…to me the engagement part is the most important part. You get that right, everything else is just going to come in” (R-S) and “[as] a first time mum…you need to build a relationship with the team that is going to be there for you right through…your pregnancy and then through the upbringing of your child.” (P-S).Initial engagement through the BOP provided a foundation for effective ongoing relationships. A health practitioner explained, “…we use broken English to explain things. I find the BOP gives you more options to talk about what is actually going on with people’s lives, not only the child, but the mum and the dad.” (IHW). Baby baskets delivered by Healthworkers during family visits are used to engage with families. Most expressed appreciation for the baskets, and found the contents helpful. One mother said, “The baskets are good, it’s helpful, and I’ve never had anything like that before...” Another mother said that she did not previously have what she needed for the baby, “I didn’t have enough chance to get much for the baby when I was down in Cairns [for birth]. It was too much…I couldn’t leave my one year old…”Communication style was cited as important. “Yes, [home visiting] it’s helpful, it saves me going all the way up [to the clinic]...because sometimes I don’t have the time to go.” Other families prefer to meet the Healthworker outside their house. One Indigenous Healthworker explained, “We can have it [home visit] outside on the veranda. I wait for them to tell me where they want it to happen…”. When families “are more comfortable, they are more likely to open up to you. I find with the BOP that people are inviting us in.” (IHW).It is convenient for some families to be visited at home, especially parents with small children. One mother said, Yes, I rather stick to one.”Family members noted that knowledge exchange through the program was helpful. One mother agreed that she was able to talk about issues that concerned her and understood the response provided. Indigenous Healthworkers reported that yarning about health and wellbeing topics is best done in the context of a relationship. The preference for having the same Healthworker through a woman’s pregnancy and post-natal period was noted by one mother, ““The workers based in the community, they…were just like no, I don’t feel comfortable with talking about this” (R-S). However, a senior Indigenous Healthworker, when asked if there were any health promotion topics she felt she couldn’t raise with families, said “No, I’m quite confident”.The BOP manual summarises the content of yarning topics in order to support consistent delivery across Cape York communities. Some Healthworkers discuss the topics in a prescribed order, while others use them according to the needs of the family. Some were reluctant to talk about sensitive topics such as family violence or sexually transmitted infections. “I use the iPad if the lady is real quiet and doesn't talk much…so I just use the visual so she doesn't have to say anything.” Another staff member said, “…it [the video] took the pressure off raising and having those conversations…even to raise that topic.” (P-S).Sensitive yarning topics were developed and presented via educational videos. A Healthworker said, “said ‘you know I’ve never really had education like this before’” and “…some of the ladies that we do education around, they kind of nod their head and say ‘oh we didn’t know that’.”One Indigenous Healthworker believed that the yarning topics made a positive difference. She reported that a mother “…the capacity of Healthworkers is different, so some will need more support and maybe just reminding.” (P-S). Continuing investment in Healthworker support and training has been regarded as critical to the ongoing successful delivery of the program.Apunipima’s strategies to strengthen program workforce included training and supporting Healthworkers with a commitment to recruiting new positions from Cape York communities. A health practitioner observed, I just believe you need to work together for this to succeed.” A health practitioner agreed “…it would be a really good program where male Healthworkers were working with the fathers through pregnancy, for a thousand days [and] could become very much involved.” (P-S).There was also an opportunity to promote coordination between the BOP Healthworkers and the Apunipima Men’s Health Team. An Indigenous Healthworker said, “seeing health changes in families.Early formative outcomes identified from the data of BOP implementation were related to “People will come up to me in community and say that they (don't) smoke any more, or I’ll hear good feedback from other family members” (IHW). A mother reported her achievement in giving up smoking and drinking, “…both of us used to be bad at smoking and drinking…but we just gave it up.”The program promoted good health through behaviours such as quitting smoking and reducing consumption of alcohol. “With help of the Baby One Program and the support network of the midwives and the Healthworkers, we’ve actually stopped a lot of that happening. Because we say to Child Safety, ‘oh no, they’re engaged in this parenting program, this is a parenting visiting program, this is what we do every fortnight.’ I tell them ‘we'll come and see this girl.’ So there’s been lots of good outcomes like that.” (IHW).Healthworkers reported a reduced risk of families engaging with the Department of Child Safety because of the support provided by the BOP.a lot more” than for her previous children, and that she liked the Healthworker visits and involvement of the midwives.Family members also reported feeling more comfortable at their local clinic, visiting the clinic more often and better engagement with clinic staff. A mother noted that she saw the Healthworker ““There is the capability of this program to be a source of pride for Cape York Healthworkers and Apunipima, and that relates to obviously their having a positive impact on the families that they’re supporting and delivering health care to…and that’s the bottom line.” (P-S).A program support staff member concluded that,The BOP was developed by health practitioners and Healthworkers in Apunipima’s family health team. As is common with many health promotion programs, it was based on evidence from previous program evaluations –18 in adThe study confirmed that the central factor in program implementation is the quality of the relationship developed between health practitioners, especially Healthworkers, and families. Family members are encouraged to participate in decisions, ask questions and voice their opinions and concerns. Such relationships value and support family autonomy . RelatinThe BOP’s family-centred approach focuses on health promotion according to the principles of choice, participation and self-determination . ApunipiPast colonisation and assimilation policies have greatly disrupted traditional Indigenous Australian cultures. For many Cape York families, disadvantage is characterised by high levels of unemployment, food insecurity, poor housing, limited education opportunities and geographical remoteness. It is within such environments that Apunipima staff strive to meet the considerable logistical demands of delivering the BOP using ways that value and respect local cultural beliefs and practices. And here, health systems could certainly do more to promote family unity. While family and kinship ties are fundamental to Indigenous societies and underpin delivery of key maternal and child health services, it cannot be assumed that everyone has immediate family support at critical moments in their lives . GovernmThe management and facilitation of such a program must evolve in response to changing circumstances and an embedded quality improvement system is an essential component. Internationally, program leadership by well-trained Indigenous Healthworkers has proven to be effective , 9, 25. There were limitations in this study. They included difficulties in recruiting family members for interviews, and scarceness of research resources that precluded necessary travel to remote communities. Opportunities to recruit BOP families were restricted to the time when expectant mothers were transferred to Cairns to await childbirth. Apunipima staff who had existing relationships with families interviewed family members. These staff were not all experienced interviewers, however, we believe this strategy optimised participant safety and enabled efficient use of scarce resources. Given the study focus on program implementation, the combination of data from family members and other participants was considered sufficient for data saturation.A further limitation of this study was that, on this occasion, the grounded theory approach for development of the theoretical model was not supported by Apunipima staff as an accurate representation of their experience. The focus of interview questions was across an 18-month developmental period in a rapidly changing practice environment, and the theoretical model was perceived not to reflect current practice. Apunipima staff members were unclear about how the model could be used to inform further practice improvements. According to Glaser , grounde.Recommendations from the study fell into four categories. Under the first category, ‘community consultation and program promotion’, the recommendations were: 1. Ensure that participating communities are engaged in comprehensive and ongoing consultation. Care should be taken to include community members, particularly Elders, local councils and health action teams, and 2. Raise community awareness of the program using the tenets of social marketing and principles of program branding in a four-step process (i) Planning and strategy development (ii) Create and test concepts, messages and materials (iii) Implementation (iv) Assess effectiveness and make refinements. In the second category, ‘responsive health services’, the recommendation stated that health services should be responsive to family needs; for example, more could be done to promote family unity by supporting fathers and other children to travel with the mother for the birth of a new family member. In the third category, ‘professional development’, recommendations were: 1. Continue essential up-skilling, education and field support for Healthworkers, midwives and maternal and child health nurses, and 2. Support and encourage knowledge exchange between Healthworkers, midwives and maternal and child health nurses. New program staff should receive complete orientation that highlights this critical aspect of the program. The final category included recommendations concerning formal processes for ongoing program evaluation. They were: 1. Identify appropriate health outcome indicators, data collection methods and obtain formal ethical approvals and informed consent from families for continuous monitoring of program effectiveness and 2. Develop and embed program evaluation components to measure family satisfaction with service provision at identified time points across family engagement with the program. The substance of such recommendations may be transferrable to other maternal and child health innovations designed for Aboriginal and Torres Strait Islander familiesThe development and implementation of the BOP has presented substantial logistic, financial and practical challenges. In contrast to international Indigenous family-centred interventions which have taken a decade to develop , this reStrengthening family health and wellbeing in remote Indigenous communities is a complex task. This paper describes a model of care designed as a Healthworker-led, family-centred program that has been implemented in very remote Aboriginal communities of Cape York. The program engaged 161 families over an initial 18-month period and continues to grow, engaging more families as women present for their first antenatal check. This research found that the relationships formed between health practitioners and families, and program responsiveness to family health and cultural needs in challenging environments were key to successful implementation. This is maintained by regular Healthworker contact with families aligned with antenatal and child health checks, where Baby Baskets are delivered and ‘yarning’ topics explored. Even though the BOP implementation has presented substantial challenges, it continues to evolve. Healthworker education and training, and knowledge exchange between Healthworkers, midwives and nurses was seen as critical for strengthening the workforce, a team approach and seeing positive health changes in families due to program effectiveness. This is where resources must be gainfully invested for long-term success. Ongoing evaluation of the program, including built-in collection of health outcome indicators, should drive improvements in service delivery and better outcomes for Cape York children and families. The goal is a healthy start to a healthy life.Additional file 1:‘Aboriginal & Torres Strait Islander Health Workers’. BOP Evaluation interview guide. (DOCX 20 kb)Additional file 2:'Managers and Clinical and Allied Health Staff'. BOP Evaluation interview guide. (DOCX 21 kb)Additional file 3: 'Mums and family members'. BOP Evaluation intervew/focus groups guide. (DOCX 18 kb)


The Tier 1 Program of the Project P.A.T.H.S.  is a curricula-based positive youth development program. In the experimental implementation phase, 52 schools participated in the program. Based on subjective outcome evaluation data collected from the program participants (Form A) and program implementers (Form B) in each school, the program implementers were invited to write down five conclusions based on an integration of the evaluation findings (N = 52). The conclusions stated in the 52 evaluation reports were further analyzed via secondary data analyses in this paper. Results showed that most of the conclusions concerning perceptions of the Tier 1 Program, instructors, and effectiveness of the programs were positive in nature. There were also conclusions reflecting the respondents’ appreciation of the program. Finally, responses on the difficulties encountered and suggestions for improvements were observed. In conjunction with the previous evaluation findings, the present study suggests that the Tier 1 Program was well received by the stakeholders and the program was beneficial to the development of the program participants.