In Canada’s increasing immigrant population, a phenomenon called the “healthy immigrant effect” has arisen in which health declines after four years of settling. Access to healthcare is an important consideration. There is strong evidence that immigrants lack confidence and knowledge for navigating health services. The aim of this study was to develop and pilot test the Accessing Canadian Healthcare for Immigrants: Empowerment, Voice & Enablement (ACHIEVE) program.The study employed an exploratory sequential mixed methods design. A qualitative study was completed. Program content was developed based on a scoping review and refined in a formative evaluation. Then, a pilot test of the program measured participants’ perceived efficacy in improving confidence in healthcare navigation, program satisfaction, and learning in individual sessions.Researchers found significantly higher rates of health navigation and an increase in knowledge about the Canadian health system post-program.Results provide promising evidence that ACHIEVE may improve confidence in healthcare access among immigrants, demonstrating potential for dispersion on a larger scale. Immigrants are a vulnerable population that require special attention with regards to improving their Canadian health literacy. The ACHIEVE program has demonstrated promising results in providing health education to immigrants. Further study is required to determine the program’s effectiveness on a larger scale.Canada, being one of the main immigration destinations in the world, is planning to welcome 350,000 new immigrants in 2021 , obesityThis change in health status years after immigrants settle into a country is not only seen in Canada. Other common destinations for immigrants i.e. US and Australia, are facing a similar problem . In Eurohttp://www.lcclc.org/) [https://kchc.ca/weller-avenue/immigrant-services/) [In Canada, health care is organized provincially and must meet the standards of the Canada Health Act which include: public administration, comprehensiveness, universality, portability and accessibility . Local slc.org/)  and Immirvices/)  can provrvices/) . In Ontarvices/) .In order to have a healthy population, access to health services is essential. Healthcare access can be defined as the ability to navigate health services and communicate effectively with healthcare providers . But immIn Canada, lack of information on how to access or navigate services is also a common barrier experienced by immigrants . In terminteractive and critical [While there are information resources for newcomers , 22, as critical  health lcritical , 25. A rcritical . None ofTherefore, the aims of the study were to develop an evidence-based health education program to address barriers that immigrants may face in accessing healthcare services in Canada; and to pilot test the program in a sample of immigrants. This study was approved for ethics at the Queen’s University Ethics Review Board.This paper describes the development and piloting testing of a healthcare access program named as ‘Accessing Canadian Healthcare for Immigrants: Empowerment, Voice, and Enablement’ (ACHIEVE). An exploratory sequential mixed methods design was employed to address the objectives of the study .First we conducted a qualitative study (Study 1) to identify areas of health literacy missing for Canadian immigrants that would be important for ACHIEVE’s content.Second, we developed the program content (Study 2) in two steps.Step 1: Based on a previously conducted scoping review by the research team  and the Step 2: The content of the program was refined in a formative evaluation through several rounds of consultation with stakeholders/experts to refine the content.Finally we conducted a quantitative pilot study (Study 3) to assess program effectiveness in improving confidence in accessing healthcare services.Due to the variable nature of the immigrant population, in this paper, we will reference immigrants as individuals who had moved from their home country to another country, regardless of year of landing and class of entry  and we uA qualitative study was employed, specifically with an interview process in order to obtain locally pertinent narratives  It was cImmigrants were included if they were 18 years or older, had experience accessing the Canadian health care system, and expressed interest in participating. Participants were required to be fluent in English, meaning that they were able to effectively communicate in English to work and/or study in Canada. Immigrant participants who met the inclusion criteria and whose experiences were predicted to allow for information to be collected from diverse perspectives (maximum variation) were included in the study based on their ethnicity, home country, years of life in Canada, and type of immigration.Healthcare providers were included in the study if they were working in primary care  and had extensive clinical experience working with the immigrant population in the Canadian health care system (at least for 2 years). Out of the six healthcare providers who were recruited to the study, two were native to Canada and the other four were intentionally chosen to be immigrants.Interviews were conducted by occupational therapy students and were on average 45 min. Interviews from both the immigrant participants and healthcare providers were transcribed verbatim and all data was analyzed together. Data analysis was conducted by an occupational therapist under the supervision of the first author, who is also an occupational therapist and has experience with navigating the Canadian healthcare system as a newcomer. Analysis consisted of immersion in the data, substantive coding, comparing, and data sorting . The traThe development of program content was completed in two steps.https://www.ontario.ca/page/ministry-health) aided in providing specific information on the Canadian healthcare system.Based on the scoping review previously conducted by the research team  and qualFurther, content as well as the flow and order of information was reviewed by three English as a Second Language (ESL) teachers ensured appropriate English literacy level (Canadian Language Benchmark Level 3) . In addin = 20) in which verbal feedback was received from both ESL teachers and newcomers. The facilitators of the ACHIEVE program were members of the research team who had first-hand experience as Canadian immigrants as well as had a large involvement in ACHIEVE content creation. An observer who was familiar with the content but was not involve in the content development, took notes during those sessions on timing, as well as questions and issues that arose. After delivery of each class, the program content was revised.During formative evaluation of the program, we refined the ACHIEVE content in two ESL classes  and had an English level of 3 or above which, according to Canadian Language Benchmark standards (CLB) standards, indicates the ability to comprehend short and simple conversation .Immigrant participants were recruited in Kingston, Ontario through two organizations: KEYS Job Centre and Loyola School of Adult and Continuing Education. KEYS offers specialized services to immigrants, including a mentoring program, refugee resettlement services ESL classes. The Loyola School supports the return of former students to the education system and also offers ESL classes. Students who were already attending classes, which corresponded to different CLB proficiency levels, were recruited for the study.The Health Education Impact Questionnaire (heiQ) by Osborne et al. , measureThe second questionnaire entitled “Confidence in Health Access” was created by the research team for this study after an exhaustive literature review and consultation by immigrant experts. The questionnaires are available as an additional file in this manuscript. Questions are based on the ACHIEVE program content with 2–3 questions ranked 0–5 (maximum scores on questionnaires therefore ranging from 10 to 15). Questionnaires were administered at the beginning and end of each weekly session to assess comprehension of course concepts. Face validity of the questionnaire was evaluated by review of the measure by ESL teachers and settlement workers who were familiar with the content of the ACHIEVE program. All reviewers agreed that the questions do measure understanding and confidence that is expected after participation in the program. Their suggestions for simplifying the wording of the questions were implemented before start of the program.Four open ended questions were included in the questionnaire to collect the participants’ general feedback on the participants about what they liked most about the program, what they liked least about the program, what they would add and what they would change from the program.Demographic information was collected once at the beginning of the program to record participant age, type of immigration, family status, and years lived in Canada. Two questionnaires were also used to test the efficacy of the program through participants’ understanding and confidence in healthcare access.t-test using Statistical Package for Social Sciences (SPSS) was calculated to test the effectiveness of the program in improving confidence in accessing Canadian healthcare (p < .05). The heiQ questionnaire was used to measure participant satisfaction in the program using the Program Evaluation Scale. As the data violated assumptions of normality, Wilcoxon Signed Rank tests were calculated to determine the effectiveness of each individual session. The results from the three open ended questions were tabulated.A paired samples This study included 11 immigrants  and 6 HCPs . Immigrant participants originated from a diverse range of countries and varied in the time since immigration. These participants also had a range of employment and marital statuses. All immigrant participants had post-secondary education ranging from trade/vocation school, master’s or doctoral degree, and professional designations. Immigrant participants spoke of accessing the Canadian health care system at different time points depending on their needs at each stage of life. For example, some participants reported medical events such as labour and the birthing process as well as attending the emergency room (ER) after an accident.n = 1), physician specialists (n = 4), and a registered nurse (n = 1), each with a wide range of clinical experience. Of the six HCPs, two were native to Canada and the other four were intentionally chosen as they themselves were immigrants. Time since immigration to Canada for the HCPs ranged from 10 to 28 years.The HCPs included a family doctor  and the flow and order of information were reviewed by expert consultation including immigrants and settlement workers. The content was next reviewed by ESL teachers to ensure appropriate English literacy level for those immigrants with Canadian Language Benchmark Standards of Level 3 or higher.The content was prepared with help from Ministry of Health website information to follow the Ontario healthcare system (n = 20), showed that the 4 subject areas provide a general overview of the CHC, however comments of the program by immigrants showed participants were interested in hearing about specific areas of health literacy in addition to CHC overview. In an additional literary review on specific needs, skills and knowledge on accessing mental health services were identified as there is a presence of depression and anxiety among many immigrants and refugees—often due to migration stress and adjustment issues [The initial formative evaluation, using ESL classes .Of the 46 consenting participants, 20 completed both the pre-test and the post-test heiQ. The primary analysis of pre-post heiQ Health Navigation Scale scores met all assumptions including normality. Scores were summed and a paired samples t-test was conducted to compare health navigation before and after the 7-week long ACHIEVE program. The test demonstrated that post-test scores (M = 17.00) were significantly higher than pre-test scores  = − 3.91, Self-report measures indicating participants’ perceptions of the ACHIEVE program were completed by 22 participants using the heiQ Program Evaluation Scale, with a potential maximum score of 36. As this scale measured participants’ satisfaction in the program, it was only distributed post-session. Descriptive statistics were as follows, M = 32.45, Min = 24.00, Max = 36.00, SD = 3.83.The analysis of weekly comprehension of course concepts using our team’s Confidence in Health Access Questionnaires violated assumptions of normality therefore, medians and Wilcoxon Signed Rank tests were calculated. Pre- and post- test descriptive statistics as well as significance are displayed in Fig. The open-ended questions provided noteworthy self-reports of participants’ perception of the program. When asked what could be changed or what they liked the least in the ACHIEVE program, all participants reported nothing or did not answer the question. When asked what they liked the most, the majority of participants named the mental health sessions. Reports on what could be added to sessions included family health, information on different types of cancers, and nutrition.Overall Results.A complete table of results for the two heiQ scales on Health Navigation and Program Evaluation, in addition to the seven Confidence in Access Questionnaires are available in Table Low health literacy has been associated with poor use of health care services and substandard health outcomes . ImmigraIt should be noted that the ACHIEVE program, in consultation with stakeholders such as immigrants, settlement workers, and ESL teachers, attempted to make the program as inclusive as possible to prevent barriers to receiving this program’s educational information. For example, much of the program attempts to provide diverse cultural examples in addition to having open discussion around comparing and contrasting Western medicine’s cultural expectations with one’s home country. All immigrants and refugees were encouraged to participate in the program regardless of being undocumented. This was done by ensuring individuals could attend the program even if they did not consent to the team using their information as ESL teacher stakeholders outlined this as an issue for individuals who may be undocumented. Further, demographic information such as type of immigration had an option for “prefer not to answer” and participants were encouraged to share ACHIEVE materials with friends and family for knowledge sharing in the greater population. Facilitators also stayed after class for as long as needed to answer any questions for those with lower English comprehension and ESL teachers would also review content outside of class for those who needed extra time. This extra time was provided in an attempt to ensure adequate health care access and health literacy for all participants.Communication in which results showed that this session had a significant increase in learning. This session included symptom tables that participants could refer to in the future as well as provided exercises such as making a doctor’s appointment over the phone. It is of interest to note that no participant named this session as the most helpful. Previous health literacy programs have employed ESL teachers directly to run their programs [In revisiting the goals of the program, better healthcare communication skills and self-advocacy was intended to be address in Session 3: programs , 47 whicprograms  and inclprograms .p > .01).For the goal of knowledge of available resources and self-efficacy in finding resources in the community and social service systems, all sessions included an abundance of resources to meet diverse needs with knowledge of multiple cultures in mind. Further, many activities included navigating specific resources and websites to find health information and services. The Confidence in Health Access questionnaire in session 6 had a question regarding resource access that was also found to be statistically significant,  completed the pre-test and post-test heiQ. In all questionnaires , there was missing data. With such significant missing data, there is potential for bias in the final group of respondents as perhaps this only represents those satisfied enough with the program to provide feedback or those with a higher English language ability. There are a variety of reasons for lack of responses including: privacy, questions not perceived to be applicable to participant, and difficulty comprehending the question. This is the nature of ESL classes as research on these programs has demonstrated problems with program completion for a variety of reasons, especially among those with low- to intermediate-level language skills [Attrition was a significant problem for data collection as many participants would miss classes or leave early for various reasons which prevented us from gathering post-session scores. Of the 46 participants, less than half of the participants (e skills .Secondly, consent and comprehension proved to cause complications among low- to intermediate- level English participants. Earlier trials of ACHIEVE had shown comprehension issues with the consent form and demographic questionnaire, leading the team to remove all “difficult” wording. Even after simplifying the consent form, this document was still observed to be too difficult for some participants to complete. Also, ESL teachers informed the research team that many immigrants, particularly refugees, are hesitant to sign any form of documentation. Further, the potential for undocumented participants or visiting immigrants in the country to participate in ACHIEVE may prevent some from wanting to provide demographic information despite reassurance of confidentiality.An important limitation to acknowledge is that the “Confidence in Health Access” questionnaire was not validated other than considering the face validity as they had been created by the research team to measure pre- and post- learning for each individual session. It is important to practice caution when interpreting the results as it may not be directly measuring learning.Given the limitations, the research team may explore shorter sessions to minimize attrition and study designs like wait-list controls to address potential response biases. Future study designs may also explore including a baseline measure a few weeks prior to commencing ACHIEVE to better monitor the effectiveness of the program. Adding a qualitative study to explore the experience of participants was not possible because of their level of English however it should be noted that this would require the use of third parties such as translators in data collection and analysis in order to accurately capture lived experience in participants’ primary language.This pilot study has demonstrated positive results for the effectiveness of ACHIEVE in improving confidence in healthcare access and increased knowledge in specific areas of CHC. The research team hopes to replicate the results in a larger sample to find reliable success in the program for nationwide implementation. Future directions for ACHIEVE include creating online modules to improve accessibility of the program. The research team may also customize ACHIEVE to accommodate a range of English proficiency levels.Additional file 1. Confidence in Access 1 to 7- short version. Condensed version of Confidence in Access Questionnaires created by the research team. It consists of 7 questionnaires on course content in addition to a pre-program questionnaire and a post-program questionnaire.Additional file 2: Figure S1. Weekly Learning. Depicts the pre- and post- weekly session scores on program content that demonstrates learning in individual sessions.


This study aimed to investigate the association between enhanced recovery after surgery (ERAS) nursing program and stoma-related complications (SRCs) and prognosis in patients with low rectal cancer (LRC) undergoing abdominoperineal resection with sigmoidostomy.LRC patients who underwent elective abdominoperineal resection with sigmoidostomy between May 2016 and May 2019 were retrospectively enrolled. The occurrence of early major or minor SRCs (within postoperative 30 days) was set as the primary end-point. Clinicopathological variables and laboratory tests were compared between patients with or without SRCs. The univariate and multivariate logistic regression analyses were performed to investigate risk factors for SRCs. Hospitalization satisfaction-related and prognosis-related variables were compared between LRC patients with or without ERAS nursing program.A total of 288 patients were enrolled and the incidence of SRCs was 26.7% (77/288). ERAS nursing program was the only independent risk factor for SRCs in LRC patients  by the multivariate logistic regression analysis. Moreover, ERAS nursing program was associated with higher hospitalization satisfaction rate, faster bowel function recovery, better psychological status, and higher quality of life.ERAS nursing program was a protective factor for SRCs and associated with improved prognosis in LRC patients undergoing elective abdominoperineal resection with sigmoidostomy. Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related death worldwide with over 1.8 million new cases and 881,000 cancer-related death in 2018 . As for Enhanced recovery after surgery (ERAS), which was first put forward by Kehlet in the mid-1990s , has shoThis was a single-center retrospective study and it was approved by the Medical Institutional Ethics Committee of our hospital. We retrospectively recruited LRC patients who underwent elective abdominoperineal resection with sigmoidostomy at the Department of General Surgery, Taizhou Peoples’ Hospital between May 2016 and May 2019. Each patient was required to offer the signed informed consent. Inclusion criteria: (a) aged between 18 and 75 years; (b) with a histological diagnosis with LRC ; (c) abdominoperineal resection with sigmoidostomy. Exclusion criteria: (a) with surgical contraindication, e.g. distant metastasis, and severe obstruction; (b) undergoing emergency operations; (c) with malignancies in other systems; (d) with severe hematological, hepatic, kidney disorder, or autoimmune diseases; (e) with preoperative chemotherapy, radiotherapy, or targeted therapy for cancers; (f) with incomplete data. All the patients were under the perioperative management of the same surgical, anesthesia, and nursing team. Protocols of ERAS nursing program were according to the latest Chinese guidelines of ERAS (version 2016 and 2018). In brief, preoperative ERAS program education, personalized nutritional evaluation and support (based on NRS 2002 score), psychological counseling, psychological status evaluation, and improvement (reduce anxiety), no overnight fasting (clear fluids up to 2 h and solid food up to 6 h before the induction of anaesthesia) and carbohydrate loading drinks before the surgery , preoperative bowel preparation (polyethylene glycol electrolyte powder the night before the surgery), venous thromboembolism prevention (based on Caprini score), intraoperative warming (maintain core body temperature ≥ 36 °C), avoidance of routine abdominal drains and nasogastric tubes, encouraged early postoperative mobilization (postoperative day 1), early catheter remove (postoperative day 1), dietary , pain , sleep, and psychology management were recommended. Enrolled patients were followed up for at least three months from the surgical day.The following data were extracted from our database and recorded: (1) demographic variables including age, gender, body mass index (BMI), smoking and drinking habits; (2) clinical baseline variables including serum carcinoembryonic antigen (CEA), American Society of Anesthesiologists (ASA) grade, Charlson Comorbidity Index , nutritiAs described by previous reports, the primary observational end-point was the occurrence of early major or minor SRCs (within postoperative 30 days). In brief, major SRCs included stoma prolapse, parastomal hernia, stricture, fistula, retraction, ischemia, and bleeding. Minor SRCs included skin alterations according to the classification by SACS™ instrument  for assessing peristomal skin lesion .The base area of stoma was measured postoperatively by nurses calculating from the horizontal and vertical size of the stoma base. The pathological TNM stage was identified according to the criteria by the American Joint Committee on Cancer/International Union Against Cancer (7th edition).t-test, and Mann–Whitney U-test as appropriate. The univariate and multivariate logistic regression analyses were performed to investigate risk factors for SRCs. A two-sided P value < 0.05 was considered statistically different.GraphPad Prism 8.0  and SPSS 19.0  were used for data analysis. Data are expressed as number (n) with percentage (%) or mean with standard deviation (SD) as appropriate. Data are analyzed using the Chi-square test, Student’s Three hundred and thirty-three LRC patients who underwent elective abdominoperineal resection with sigmoidostomy were initially enrolled. Forty-five were excluded due to the following reasons  and two hundred and eighty-eight subjects were included in the analysis. The mean age of the cohort was 66.2 years and the majority  were male patients. The total incidence of SRCs was 26.7% (77/288). The clinicopathological characteristics associated with SRCs are shown in Table Table To identify potential risk factors for SRCs, the univariate and multivariate logistic regression analyses were performed. As illustrated in Table Based on the presence of ERAS nursing program, enrolled patients were categorized into two groups (188 with ERAS nursing program and 100 without). The eleven hospitalization satisfaction-related variables were compared between patients with or without ERAS nursing program. As shown in Table The prognosis-related variables between ERAS nursing and non-ERAS nursing program groups are listed in Table To our knowledge, this was the first study to indicate ERAS nursing program as an independent risk factor for SRCs. The operation of stoma formation is commonly performed for patients with malignancy and inflammatory bowel disease (IBD) . Stoma fVarious variables have been identified as independent risk factors for SRCs, including ASA grade , age, ilBased on our results, it appears that ERAS nursing program provided significant benefit to LRC patients undergoing abdominoperineal resection with sigmoidostomy. Our results demonstrated that the ERAS nursing program can be successfully implemented in a single-center municipal hospital. With the adoption of ERAS nursing program, patients were more likely to have better hospitalization satisfaction for the items of comfortableness, communication, emotional support, and participation in nursing. Furthermore, patients who underwent ERAS nursing program had an improved prognosis, which was manifested by earlier gastrointestinal function recovery (shorter time to first exhaust and defecation), shorter LOS, higher SDS and SAS scores, higher QOL (higher GIQLI scores). The decreased narcotic use in the ERAS program partially explains enhanced bowel functional recovery due to the well-known effects of narcotics . PreoperThere are some limitations to this study. First, this is a single-center study with a relatively small sample size. Second, the retrospective nature and long-time inclusion period generate some uncontrollable biases. Third, the involved mechanisms remain unknown. Last, only LRC patients were enrolled and whether our conclusions apply to other stoma operations remain uncertain. Considering ERAS nursing program can reduce postoperative SRCs, improve the hospitalization satisfaction and QOL, it would be generally desirable.In conclusion, ERAS nursing program was a protective factor for SRCs and associated with improved prognosis in LRC patients undergoing elective abdominoperineal resection with sigmoidostomy.


Drosophila imaginal discs that are attached by numerous macrophages. Here we report that changes to the microenvironment of the overgrown tissue are important for recruiting macrophages. First, we describe a correlation between generation of reactive oxygen species (ROS) and damage of the basement membrane (BM) in all neoplastic, but not hyperplastic, models examined. ROS and the stress kinase JNK mediate the accumulation of matrix metalloproteinase 2 (Mmp2), damaging the BM, which recruits macrophages to the tissue. We propose a model where macrophage recruitment to and activation at overgrowing tissue is a multi-step process requiring ROS- and JNK-mediated Mmp2 upregulation and BM damage. These findings have implications for understanding the role of the tumor microenvironment for macrophage activation.Macrophages are a major immune cell type infiltrating tumors and promoting tumor growth and metastasis. To elucidate the mechanism of macrophage recruitment, we utilize an overgrowth tumor model (“undead” model) in larval  Drosophila overgrowth model to show how damaged basement membranes recruit macrophages to undead tissue, via an interdependent effect of reactive oxygen species and matrix metalloproteinase 2.The molecular mechanisms regulating macrophage recruitment to tumors are unclear. Here, the authors use a  They play a role in tumor growth, invasion, angiogenesis, and immunosuppression, thus helping in tumor survival and metastasis1. Often, apoptotic tumor cells release signals that attract circulating monocytes to tumors where they undergo alternative activation to yield M2-polarized TAMs5. The tumor microenvironment also helps in TAM recruitment6, although not much is known about which cells of the microenvironment contribute to this process. While the identities of several key molecular and cellular players in TAM recruitment are well-established, there still remains a need to better understand the dynamic interactions that occur between the tumor and its microenvironment during this complex immune response.Tumor-associated macrophages (TAMs) are one of the major immune cells that infiltrate the tumor and provide an inflammatory environment important for cancer progressionDrosophila melanogaster has become a valuable model system to dissect the fundamental, mechanistic, and conserved aspects of inflammatory responses7. Several studies have reported the presence of macrophages in different Drosophila tumor models13. These macrophages, termed hemocytes, have tumor promoting as well as tumor inhibiting functions, analogous to mammalian macrophages. One such overgrowth-promoting role of hemocytes was recently described for apoptosis-induced proliferation (AiP)14.16. Early work in Drosophila has revealed that the Caspase-9-like initiator caspase Dronc is critical for at least one type of AiP16. To decipher the signaling pathways important for AiP, caspases are activated by expression of the IAP-antagonist hid, but the final step of cell death execution is blocked by co-expression of the effector caspase inhibitor p35, thereby keeping the cells in a permanent apoptotic state that is referred to as “undead”. Because P35 specifically inhibits the activity of effector caspases, Dronc can persistently signal for AiP causing overgrowth of the undead tissue18. If hid and p35 are co-expressed using the ey-Gal4 driver , the undead ey-Gal4-expressing portion of the larval eye imaginal discs  which attract hemocytes leading to activation of the stress kinase JNK Drosophila larval eye-antennal imaginal disc gives rise to the adult eyes and head. It is made up of two juxtaposed epithelial cell layers, the columnar disc proper (DP) and the squamous peripodial epithelium (PE), which face each other apically separated by a lumen while their basal sides are exposed to the hemolymph and are surrounded by a basement membrane (BM)   Fig. 22. Inter25. The BM is important for tissue shape, and provides a mechanical barrier preventing tumor cells from invading into distant tissues27. Major components of the BM are Collagen IVs, Laminins, Perlecan, and Nidogen29. These components are produced and secreted by fat body cells and hemocytes, and incorporated into the BM at imaginal discs and other tissues31. Matrix metalloproteinases (MMPs) are zinc-containing extracellular proteases that are critical for the reorganization of the BM32. The Drosophila genome encodes two MMP genes, Mmp1 and Mmp2. Both MMPs have membrane-tethered and secreted forms35.The BM is a thin-layered polymer of matrix proteins that surrounds the basal side of epithelial tissues including imaginal discs Fig. a25. The Mmp2, and there is a strong accumulation of Mmp2 protein specifically at the basal side of DP cells. Finally, the damaged BM is sufficient for recruiting hemocytes from the circulation to the tissue. These data illustrate the influence of the tumor microenvironment for recruiting and activation of hemocytes to promote tumor growth.Here, we report that the microenvironment of the overgrown undead tissue is important for recruiting and activating hemocytes. The BM of undead imaginal discs is severely damaged. This damage to the BM integrity correlates with generation of ROS and activation of JNK in undead tissue as well as in several neoplastic epithelial tumor models. However, ROS and JNK are not sufficient to cause BM damage in normal tissue. We find that Mmp2, but not Mmp1, is necessary and sufficient for disrupting the BM of undead as well as normal tissue. Both ROS and JNK regulate the expression and activity of 24. Therefore, we examined the integrity of the BM using antibodies that detect the BM components Perlecan and Laminin. In undead ey > hid,p35 discs, the BM is severely disrupted compared to control  discs, which have an intact and uniform BM  in wing imaginal discs. Although the BM in these experiments does not appear to be as smooth as in controls, it is intact without any gaps, and the Perlecan intensity is comparable to control discs , the BM now shows signs of damage with gaps and holes in the Perlecan labeling, and significant decrease in Perlecan fluorescence  models in ing Fig. , similarext Fig. . Third, ing Fig. . Finallying Fig. . Taken t44. Using the ROS indicator dihydoethidium (DHE), we found that neoplastic RasV12lgl mosaic discs have increased ROS levels  ex vivo, and monitored the effect on the BM. Exposure of discs to H2O2-containing media had no effect on the BM  in ey > hid,p35 discs and monitored the effect on BM integrity. Loss of JNK signaling prevents BM damage and Perlecan labeling is not disrupted  using salEPv-Gal4, as ey-Gal4-induced expression of hepCA causes early larval lethality. However, salEPv > hepCA wing discs, similar to the salEPv > GFP control discs, are not characterized by BM damage  background. srp encodes a GATA-type Zn finger transcription factor required for hemocyte differentiation50. srpneo45 specifically affects hemocyte differentiation51 and dominantly suppresses the overgrowth phenotype of ey > hid,p35 animals14. Despite this suppression, the BM of ey > hid,p35 discs heterozygous for srpneo45 was disrupted with large gaps in Perlecan labeling  are well-known for their remodeling function of the extracellular matrixain Fig. . Mmp2 RNscs Fig. . Howeverscs Fig. .Fig. 4UpBecause of the accumulation of Mmp2 at the basal side of the DP, and because—as shown below—only Mmp2, but not Mmp1, is required for BM damage, we focused on Mmp2 in the following. Excitingly, upon loss of ROS or JNK in undead discs, the increased upregulation and accumulation of Mmp2 at the basal side of the DP is strongly reduced and is similar to control discs Fig. . These d2O2 treatment ex vivo and increased JNK activity, individually or together, are sufficient to upregulate Mmp2. H2O2 treatment of salEPv > GFP control wing discs or hyper-activation of JNK  did not affect Mmp2 levels  gelatin is a polymer-substrate that contains multiple quenched FITC conjugates. Cleavage of DQ-gelatin releases the green FITC fluorescence which can be analyzed in several waysols Fig. . This inp2) Fig.  suggestip2) Fig. .54. While control discs show a uniform, low-level fluorescence across the disc, we noted an increased enzymatic activity through release of fluorescence quenching at undead discs  wing discs Fig. . Likewis BM Fig. . Howeverion Fig. , excludiDrosophila. Our data further suggest that Mmp2 is upregulated in a ROS- and JNK-dependent manner. Mmp2 is responsible for BM damage of imaginal discs and the subsequent recruitment of hemocytes. Intriguingly, BM damage is observed specifically at the basal side of DP in undead discs, while the BM at the PE is unaffected. Consistently, Duox, the NADPH oxidase which synthesizes ROS in undead discs, is localized preferentially at the basal side of DP cells49. We also observed a strong accumulation of Mmp2 protein at the basal side of DP cells in undead discs. Combined, these observations strengthen the view that ROS and Mmp2 interdependently affect the integrity of the BM.In this study, we show a correlation between ROS generation and BM damage not only in the undead AiP model, but also in several neoplastic tumor models in We are proposing the following model to explain the recruitment to and activation of hemocytes at undead and neoplastic eye-antennal imaginal discs.14, to activate JNK in undead cells  in the ex vivo experiments , UAS-p35, UAS-hid, UAS-hepCA, UAS-RasV12, hmlΔnRFP (ref. 63), lgl4 (ref. 64), vps25N55 (ref. 40), hpo42–47 (ref. 65), srpneo45 (ref. 51). UAS-based RNAi and overexpression lines for the following genes were obtained from the Bloomington Drosophila Stock Centre: Mmp1 , Mmp2 , RFP RNAi (mock RNAi) (#67984), UAS-JNKDN (BskDN) (#6409). UAS-Duox RNAi and UAS-hCatS were a kind gift from Won-Jae Lee (ref. 66). The exact genotype of the following stocks isThe following mutant and transgenic stocks were used: ey > p35: ey-Gal4 UAS-p35/CyOy > hid,p35: UAS-hid; ey-Gal4 UAS-p35/CyO,tub-GAL80eeyeful: ey-Gal4 > UAS-delta, GS88A8 UAS-lola and UAS-pipsqueak (ref. 43)ey > hid,p35 stock was crossed to w1118 as control or RNAi and mutant lines, and the offspring was scored for suppression of head capsule overgrowth phenotype. Screening results are presented as percentage of animals with either wild-type or overgrown phenotype.The Gal4/UAS system. Tumor mosaic eye discs were induced using the MARCM technique67 with ey-FLP to generate mosaics with tumor clones marked by GFP38.All crosses were maintained at 25 °C. Except where noted, most crosses were performed using the 68, rabbit anti-Laminin , mouse anti-NimC 69, rabbit anti-Mmp2 70, rabbit anti-cleaved Dcp-1 , rabbit anti-phospho JNK , rat anti-ELAV (1:50), and mouse anti-Mmp1 (1:50) (DSHB). Secondary antibodies were donkey Fab fragments from Jackson ImmunoResearch (used at 1:600 each and incubated at RT for 3 h). Eye-antennal discs were counter-labeled with the nuclear dye DAPI to visualize tissue outline.Imaginal discs were dissected from late 3rd instar larvae in 1× PBS, fixed with 4% paraformaldehyde (PFA) for 30 min at room temperature (RT), washed with 1× PBS with 0.3% Triton X-100, blocked with Normal Donkey Serum, and stained with primary antibodies overnight at 4 °C. The following primary antibodies were used: rabbit anti-Perlecan DHE labeling was performed on unfixed imaginal discs as follows—Imaginal discs were dissected from 3rd instar larvae in fresh Schneider’s medium, incubated in DHE  solution for 5 min, washed three times with PBS, mounted in Vectashield mounting media, and imaged immediately.Images were obtained with a Zeiss LSM 700 confocal microscope, analyzed with Zen 2012 imaging software (Carl Zeiss) and processed with Adobe Photoshop CS6.Samples were processed and analyzed at the University of Massachusetts Medical School Electron Microscopy core facility.2. The dried samples were transferred to aluminum SEM stubs coated with adhesive carbon tape, the edges were painted with silver conductive paste and the SEM stubs were sputter-coated with Au/Pd (80/20). The specimens were then examined using an FEI Quanta 200 FEG MKII scanning electron microscope at 10 kV accelerating voltage.Imaginal discs from 3rd instar larvae were dissected and fixed in 2.5% (v/v) glutaraldehyde in 0.1 M sodium cacodylate buffer (pH 7.2) for 1 h at RT, and then at 4 °C overnight and post-fixed in 1% (w/v) osmium tetroxide for 1 h at RT. The imaginal discs were dehydrated through a graded series of ethanol to 100% and then transferred into porous sample holders and dried at a critical point in liquid COImaginal discs from 3rd instar larvae were dissected and fixed in 2.5% glutaraldehyde in 0.1 M sodium cacodylate buffer pH 7.2 for 1 h at RT and post-fixed with 1% osmium tetroxide for 1 h at RT. Samples were in block stained with a 1% uranyl acetate aqueous solution (w/v) at 6 °C overnight, dehydrated in ethanol, and infiltrated first with two changes of 100% propylene oxide and then with a 50%/50% propylene oxide/SPI-Pon812 resin mixture, and finally polymerized at 68 °C in flat pre-filled embedding molds. The samples were then reoriented, and ultra-thin sections (~70 nm) were placed on copper support grids and contrasted with lead citrate and uranyl acetate. Sections were examined using the CM10 TEM with 100 kV accelerating voltage, and images were captured using a Gatan TEM CCD camera.2O2  solution in Schneider’s medium or fresh Schneider’s medium (control) and incubated for 60 min at 25 °C. Eye discs were washed with PBS and fixed in 4% PFA in PBS for 30 min at RT, followed by immunofluorescence and imaging as described above.Imaginal discs were dissected from 3rd instar larvae in fresh Schneider’s medium. The medium was then replaced with 50 μM HImaginal discs were dissected from 3rd instar larvae from control and undead animals fixed with PFA and stained using anti-NimC antibody and DAPI. Imaginal discs were imaged using confocal microscopy. Total number of hemocytes attached to the discs were counted using multi-point tool in ImageJ software. Activated hemocytes were identified by presence of one or more cellular extensions detected by NimC labeling and counted by the multi-point tool in ImageJ.Mmp2 fluorogenic activity assays were performed using the fluorescein labeled DQ-gelatin, as part of the EnzChek™ Gelatinase/Collagenase Assay Kit (Invitrogen E12055), following manufacturers’ instructions using 25 μg/ml substrate. Imaginal discs were dissected from 3rd instar larvae and lysed with 100 μl of lysis buffer ). Samples were sonicated for 5 min using BioRuptor according to the manufacturer’s protocol , and protein concentrations of supernatants were measured by Bradford Assay. Protein lysates were added directly to the substrate and incubated at 37 °C for different time points, after which the fluorescence intensity was measured on Beckman Coulter DTX 880 microtiter plate reader at 450/8 nm excitation and 535/25 nm emission.54. Mmp2 activity was detected using the fluorescein labeled DQ-gelatin substrate on dissected unfixed imaginal discs. Imaginal discs were dissected from 3rd instar larvae in fresh Schneider’s medium. The medium was then replaced with 10 μg/ml DQ-gelatin substrate in Schneider’s medium and incubated in the dark for 15 min at 29 °C, washed with PBS, mounted in Vectashield mounting media, and imaged immediately.The in situ zymography was performed as previously described with minor modificationsFor gel zymography assays, imaginal disc protein lysates were prepared exactly as described for the fluorogenic assay. Thirty micrograms of protein lysate was resuspended in 2x Novex non-reducing sample buffer and samples were run on Novex 10% Zymogram Plus gel containing 0.1% gelatin (ZY00100BOX). After electrophoresis, gels were incubated with Novex Zymogram Renaturing Buffer and Novex Zymogram Developing Buffer, then stained with SimplyBlue Safestain (LC6060), all according to manufacturer’s instructions (Invitrogen).rp49 expression was used as an internal control for normalization. Three experiments for each genotype were averaged. Sequences for isoform-specific primers are as follows:Total RNA from 20 eye discs was isolated using Trizol (Invitrogen). cDNA was synthesized from 1 μg of RNA with the QuantiTect Reverse Transcription Kit (Qiagen). For RT-PCR analysis, 50 ng of cDNA per reaction was subjected to 40 amplification cycles. Real-time quantification was performed using Power SYBR green PCR Master Mix reagents (Applied Biosystems) on QuantStudio 6 Flex Real-Time PCR System (Applied Biosystems) according to the manufacturer’s instructions. Rp49 forward: CCAGTCGGATCGATATGCTRp49 reverse: ACGTTGTGCACCAGGAACTMmp1 forward: CACCTACAAGAACGGCAAGAMmp1 reverse: CGCTGATTTCCTTAGGGTAGACMmp2 forward: TTACCTCATGCAGTTTGATTATCTMmp2 reverse: CTCCACGTAAGATCCGTTCTGsalEPv-Gal4 domain of wing imaginal discs) was outlined for each disc and mean fluorescence signal intensity was determined. For Perlecan, Laminin, and Mmp2 staining intensity quantification, single sections at basal side of DP and PE were selected and separately measured. For Perlecan and Laminin quantifications, because the BM was only affected at the DP, but not at the PE . Statistical analysis for adult counts was performed using two-tailed Fisher’s exact test. Level of significance are depicted by asterisks in the figures: *p < 0.05; **p < 0.01; ***p < 0.001; ****p < 0.0001.For quantification of confocal images, the ‘Histo’ function of Zen 2012 imaging software (Carl Zeiss) was used. Region of interest (entire eye-antennal imaginal discs or Further information on research design is available in the Supplementary InformationPeer Review FileReporting Summary


In addition, these effects are maintained over time. Educating health professionals on ways to care for residents who present behavioral alterations may be one alternative for improving the quality of care that residents receive. Non-pharmacological interventions, besides being individualized and adapted to the needs and experiences of individuals, achieve effects that last longer at low cost. An educational program shows new alternatives to pharmacological intervention, achieving a reduction in behavioral alterations without the costs and effects that psychopharmaceuticals entail.This pilot study aims to analyze the effectiveness of a type of non-pharmacological intervention such as the educating and training of professional caregivers on behavioral alterations and prescription of psychotropic drugs of older adults in nursing homes. One hundred and forty-five people from two nursing homes were randomized to either treatment  or a no-treatment group. Twenty-two professional caregivers in the experimental group received 20 h of a training program. Five data collection points were collected . Intervention consisted of the behavioral alterations and psychopharmacological treatment. The analysis of variance for repeated measures showed significant differences in the time-group interaction for the educational program’s effectiveness in reducing behavior alterations and psycho-pharmaceuticals’ record. The results show that an improvement in the educating and training of professional caregivers can reduce behavioral alterations (F3,407 = 9.29,  The recent events caused by COVID-19 have forced us to rethink many aspects that were previously standardized .One of the most outstanding aspects of this situation is the treatment and needs of people with neurodegenerative diseases. When talking about neurodegenerative diseases, cognitive changes are the most visible and widely studied part of the illness. However, a set of psychological and/or behavioral symptoms stay in the background. These symptoms have greater repercussions because they pose greater changes and suffering in the person’s psychosocial sphere which significantly affects residents and caregivers .Behavioral and psychological symptoms of dementia (BPSD) refer to a heterogeneous set of psychological reactions, psychiatric symptoms, and abnormal behaviors that occur in people with dementia of any ethology and are considered as relevant as cognitive symptoms because their presence is associated with a poorer quality of life for older people with dementia . BPSD inAround 50% to 90% of people with dementia manifest BPSD . These sCurrently, there are guidelines and associations that recommend choosing non-pharmacological treatments to treat these types of symptoms. But in spite of these guidelines, the bad practice of excess psychotropic use still exists in some care homes . These tDyer et al.  highlighThe effectiveness of these training programs is now well supported by the literature .Other options or methodologies are the ones that view BPSD as an expression of unmet needs , bringinIt is important to emphasize the importance of the training of caregivers of institutionalized people because what staff do and the way they do it has a very real impact on the overall quality of life of the residents with dementia . SpecifiImproving and evaluating training to address BPSD should be a priority approach in the treatment of dementia. Recent studies show that few education and training programs for professional caregivers are well evaluated but it is necessary to objectively measure the improvements offered by these programs and make open reports that allow replication . For thin = 82 and the other center did not experience the program—control group, (CG), n = 63. The EG center is a private centre in Spain with a maximum occupancy of 130 places of residence and 40 places of day center. This center has programs that favor person-centered care and has been certified as a center free of physical restraints for more than five years. In parallel, CG was randomly selected in which the educational program had not yet been carried out. The characteristics of the CG center were similar to those of EG. This center also works under the prism of person-centered care and has been free of physical restraints for more than five years.The pilot study’s sample included a total of 145 institutionalized older adults from two nursing homes of the Saleta Care S.L. Group, an organization that leads more than 30 nursing homes in Spain. The educational program was carried out in one of the centers —experimental group, (EG), The inclusion criteria were that the participants of the study had to be already admitted at the time the decision to perform the educational program was done. Participants that left the center for various reasons and could not be monitored during the five evaluations were excluded. Thus, 11 participants were eliminated from our sample because of death during the investigation, and five participants because they left the nursing home or for other reasons. Therefore, in order to evaluate the effects of the program, participants that were to remain at the center for a minimum of two years after the start of the program was a requirement. The absence of BPSD through the Cumming’s Neuropsychiatric Inventory (NPI) scale as criteria for exclusion was not considered because some patients scored low on the scale as the psychotropic drugs regulated their BPSD. Similarly, not only patients diagnosed with dementia were selected, since BPSDs can present as prodromal symptoms of the disease. In a healthy older adult, it may indicate early dementia or be a risk factor for the future development of dementia . What haA quasi-experimental, single-blind design was applied. The nursing homes were randomized to determine where the intervention program would be carried out; the staff could not be blind to the intervention being performed but the patients did not know to which group they belonged. The CG received their usual day-care program; that is, they received the day-care they usually received in the center. Professional participants included 39 caregivers; a total of 22 professional caregivers received the training program (EG) and 19 received their usual day-care program (CG). As an inclusion criterion, participants had to be professionals who completed the program in its entirety and who have been working at the center for at least one year. Furthermore, the professionals who received the training carried out satisfaction and follow-up questionnaires in order to assess their commitment to the implementation of the program as well as to evaluate difficulties.The educational program was made between time one and time two. After this, the organization provided continuous training for all professionals to ensure the training of all workers during the five times evaluated.Regarding the cognitive level and with the idea of providing a brief and standardized analysis of the mental state, and estimate the existence and severity of cognitive deterioration, the Mini-Mental Status Examination (MMSE) was administered in its Spanish version , that coTo assess and evaluate the BPSD, Cumming’s Neuropsychiatric Inventory (NPI)  was usedPsychotropic drugs prescribed at the time of the study were considered and classified into nine categories, as reported by other authors ,33: (1) The prescription of these psychotropic drugs was accounted for without taking into account the amount of the prescription. For example, it was counted as one if one was taking a short-acting benzodiazepine, counted as two if one was taking two short-acting benzodiazepines, or as three if one was taking two short-acting benzodiazepines and one kind of typical neuroleptic. A blind evaluator carried out the evaluations. The tests were administered in a room at the center and lasted approximately 45 min.All participants in the research, institutionalized older adults from nursing homes or their legal guardians and professional caregivers, signed an informed consent about their participation. Data were analyzed in an anonymous and confidential way.To perform the study, five time periods were considered . Time 1 (T1) corresponds to the moment prior to the program, T2 was the post measure and the remaining times  were follow-up measures after the program to analyze the long-term changes.The objective of the educational program for professional caregivers was to train in the non-pharmacological management of BPSD and to implement protocols to promote the rational use of psychotropic drugs. The design of the educational program featured the main theoretical and practical aspects of institutional intervention for the most prevalent behavioral alterations under the model of unmet needs  and aimeThe 20 h educational program was structured into three weekly sessions of four hours each. In addition, attendees were asked for eight hours of work and readings outside the classroom divided into the three weeks. The contents were composed of the theoretical and practical aspects of the correct guidelines to handle the BPSD for institutionalized older adults. —The person-centered approach (session I). Training based on the work of Tom Kitwood .—The behavior-oriented approach (sessions I and II). This approach is based on the importance of the environment and external reinforcements in learning. It is necessary that participants in the course understand that the environment must adapt to each person  as well —The communication approach (session III). This approach aims to raise awareness about how the way of communicating with people with cognitive impairment, including verbal and non-verbal language, has an influence.—The emotion-based approach and validation (session III). Training is based on Naomi Feil’s  work on The educational program was divided into three sessions aimed at the training needs for the management of BPSD and the approaches that have been shown to be most effective according to the one review , which aIn order to facilitate the maximum assistance, the educational program was carried out in the work center and scheduled according to each center’s proposed schedule. The sessions were done in one of the centers rooms with a projector and a laptop by an expert psychologist in the field, and an alien to the study, trained in the person-centered approach.p < 0.05. The analyses were carried out with the statistical program SPSS 24 .In regard to the analyses, t-tests were applied for independent samples and the Chi-square test was used to compare the homogeneity of the groups prior to treatment. In order to analyze the effects of the educational program, an analysis of variance of repeated measures with Bonferroni adjustment was carried out, studying both the simple effects and those of the interaction (group x time). The level of statistical significance considered was n = 82), the average age was 87.23 (SD = 6.58) with ages ranging from 70 to 99 years old. CG showed an average of 83.51 (SD = 10.47) with a range of 51 to 101. In relation to gender, EG is composed of 20.7% men and 79.2% women; while CG has 30.2% of men and 69.8% women.In the EG of older adults (n = 22) is composed of 13.6% men and 86.4% women. Their ages ranged from 22 to 61 years with an average of 38.27 years old (SD = 12.98). Regarding their jobs, 59.1% of the professionals were nursing assistants, 9.1% technical team professionals, 4.5% nurses, and 27.3% were professionals from other work areas such as administrative staff and maintenance staff. The CG (n = 19) is composed of 77.4% women and 22.6% men, from 25 to 60 years with an average age of 39.74 (SD = 11.27). A total of 73.3% of the professionals were nursing assistants, 9.3% technical team professionals, 5.1% nurses, and 12.3% were professionals from other work areas such as administrative staff and maintenance staff.The EG of professional caregivers (p = 0.668—and gender—χ2(1) = 1.69; p = 0.193. Significant differences were obtained in regard to cognitive impairment level measured with the MMSE,—t(142) = 2.391, p = 0.018—, with an average score of 19.48 (SD = 9.79) in the EG, and with an average score of 15.25 (SD = 11.33) in the CG. Although it is worth mentioning that both scores are within the moderate impairment scale (score between 20 and 11).Firstly, tests for homogeneity revealed no significant differences between groups in terms of age—87.39 vs. 83.51; t(142) = 1.544; Once homogeneity was analyzed, the program effects were studied. The intention behind this part of the study, related to BPSD, was to know if BPSD had been reduced after the program and if this reduction was maintained over time.p < 0.001, η2 = 0.063). When comparing the scores of the two groups, the existence of significant differences was verified for the first and last time periods as can be seen in The analysis of repeated measures showed a significant effect of the program for the time–group interaction  and an increase that was significant for the CG .Furthermore, a study of the evolution of the BPSD throughout the different time periods was carried out, analysing the groups with and without the program independently. The analysis showed a significant decrease in BPSD for the EG  regarding the use of psychotropic drugs. In addition, and when comparing the scores of both groups, the existence of significant differences in the last three time periods was verified, as can be seen in From the analysis of repeated measures, we observed a significant effect of the program for the time–group interaction  and a significant increase for the CG .Subsequently, a study of the consumption of psychotropic drugs in the different time periods was carried out, analyzing the groups with and without the program independently. The analysis showed a significant decrease of psychotropic drugs for the EC  from different geographical areas in order to increase and generalize the results. The study should be carried out in multiple nursing homes using a cluster randomized trial design. Another important limitation is the availability of a more reliable quantitative measure of drug use. These aspects of the design must be improved in future studies in order to generalize the results of this pilot study.On the other hand, it is important to highlight that the appearance of BPSD and the prescription of psychotropic drugs could be related to a greater cognitive and functional impairment . TherefoIn addition, it would be interesting to include the approach to the emotional sphere, functional status, level of dependence, and physical changes in future interventions. In this sense, it would also have been interesting to add content to the training program that would contemplate the importance of structured, pleasant activities and events, or more social support as already introduced by the STAR project . FinallyThis study has been shown to reduce the prescription of psychotropic drugs in older people living in nursing homes. The use of these treatments is increasing and produces very harmful side effects for older adults. The training and education program for professionals evaluated in this study manages to reduce the appearance of behavioral problems associated with dementia and also reduces the consumption of psychotropic drugs. Moreover, these effects are maintained over time, so that the application of this program can have an impact on the cognitive and functional aspects associated with dementia, and can also help to reduce the costs of this disease and will promote a model of care based on the person-centered approach. This model is very necessary in this situation caused by COVID-19 in nursing homes.


Background: Few studies have reported on the autonomous continuation of Community Health Worker (CHW) activities after external supervision and support have ended.Objective: The study reports CHW activity continuation in Thegon Township, Bago Region, Myanmar, observed after the supervision by the external organization is completed.Method: Following the completion of a child nutrition program in Thegon Township, CHWs were left unsupervised and uninformed of a follow-up at 10, 23, and 40 months from the end of the program survey due to unforeseen circumstances. In a follow-up survey in 2014, data on the activity implementation status from CHWs and activity attendance from caregivers of the target children were collected. Focus group discussions were held with caregivers concerning their information sources on child nutrition and health.Results: On average, CHWs were found to have continued with 2.6 of the four core activities, often with modifications, irrespective of the time since completion of the non-profit-organization-led program. Meanwhile, caregiver attendance decreased over time. Caregivers recognized CHWs as information sources.Discussion: Although unsupervised, CHWs ambitiously continued with their activities, but sorted through and modified them, which may have been unrelated to the local acceptance of the program, as caregiver attendance decreased even as CHWs continued the activities. The observation may highlight the importance of proactive engagement and thus, the autonomy of CHWs in their activity continuation. Increasing attention is being paid to public health program sustainability, although few programs have evaluated their long-term impacts beyond their active engagement –4 as a rPluye summarized that program sustainability matters because the programs' long-term effects are indispensable in relation to individuals' behavioral changes, and thus their ultimate health outcomes . ProgramMoore synthesized a concept of program sustainability, taking into account the differences in sustainability between the individual and program or system levels . Two chiIn low-middle income contexts, the programs can be less sustainable due to financial, infrastructural, and system obstacles , 4. HoweCommunity health workers (CHWs) play various roles in maternal and child health care, especially in middle- and low-income countries –16. VariWhile quality supervision is one incentive that has been found to motivate CHWs , 18, 19,Ozano reported that CHWs in Cambodia had their own ideas about overcoming resource restrictions by modifying their assignments, as well as the skills to do so . Kane meThe study describes an activity continuation of the CHW in Thegon Township, Bago Region, Myanmar, observed after the completion of a child nutrition improvement program implemented by a non-profit organization (NPO).The NPO (Save the Children) conducted a survey months after the Child Nutrition program comprising Infant and Young Child Feeding (IYCF)  and liveThegon Township was a rural agricultural area, and residents were primarily peasant farmers living in poverty. Thirty-four percent of children aged <60 months were stunted, with 8% demonstrating acute wasting . These numbers are consistent with trends in other areas of the country where 35% of children were stunted and 7.9% wasting in 2009–2010 .The NPO had implemented a series of year-long nutrition and livelihood supporting intervention programs in a total of 90 villages divided into three groups , targeting under 60 months children and their mothers, pregnant women. The program aimed to expand the knowledge and practice of IYCF  among thLay, unpaid CHWs specialized in child nutrition-related activities were selected and trained. In each village, the core village members including the village chief, religious leader, and midwives working in the village nominated three male or female CHWs to address nutrition-related activities as “nutrition volunteers,” regardless of the size of the village. The core village members also chose three female CHWs to provide counseling in relation to breastfeeding as “peer counselors.” The NPO designed five core CHW activities based on Growth Monitoring and Promotion (GMP) , 26 as f“Growth Monitoring” : conducted monthly in Group 1 villages, quarterly in other villages, or monthly for undernourished cases“Nutrition Education” seminar for caregivers: conducted monthly“Peer Counseling” for breastfeeding caregivers: conducted monthly; Peer Counseling was introduced after the program ended for Group 1“Cooking Demonstration” for caregivers: conducted monthly in Group 1, and twice a year in Groups 2 and 3“Home Visit” for undernourished children: conducted monthlyThe NPO offered initial training for CHWs for 4 days in Group 1, and 3 days in Group 2 and 3, wherein the midwife from the local health center and the local NPO staff members lectured CHWs on how to implement each activity. During the NPO-led program periods, the CHWs reported to the local midwives each month regarding their activities, such as the topics covered in their nutrition education talks, the numbers of participants, the frequency of the talks, and the results of their home visits. The local midwives provided feedback to the CHWs on the appropriateness of their talk topics and teaching materials.After the completion of the NPO-led program for Group 3, NPO supervision (monitoring and meetings) and refresher training for all CHWs ended. Information on the quality of supervision, the supervisors' training, the refresher training, and CHW retention or replacement during and after the programs is unavailable.Ten, 23, and 40 months after the program ended in 2014, the NPO took advantage of an opportunity to conduct follow-up surveys in all 90 villages aimed at evaluating the lasting effects of the program. The NPO evaluated the situation regarding CHW activities and caregivers' attendance at those activities. The role of the CHWs as an information source for caregivers was also explored through focus group discussions. CHWs were not made aware of the surveys in advance.Face-to-face questionnaire survey was conducted by local NPO staff wherein CHWs in all 90 villages were questioned on the forms and frequency  of the tDone exactly the same way as it was introducedDone with modificationTotally abandoned.They were also asked to choose one of the following options in relation to frequency:Every monthEvery other monthLess than five times per yearZeroOnly once undernourished child is identified (only in case of Home Visit).A face-to-face questionnaire survey was also conducted in all 90 villages by local NPO staff wherein caregivers were questioned on their IYCF-related knowledge and practices and their prior attendance (“Never attended” or “Attended”) at IYCF-related CHW activities. All of the primary caregivers with children aged under 24 months, as well as 40% of those primary caregivers with children aged 24–59 months who were randomly selected based on the number of children of the same age group registered in each village were invited to participate in the questionnaire survey. Considering the local cultural context, female caregivers were regarded as the primary caregiver regardless of whether they were the children's mothers, and verbal consent was obtained prior to the surveys.One-to-two-hour Focus Group Discussions (FGD) were held in public places in six randomly selected villages (two from each Group). The village CHWs invited five or six caregivers with children aged <60 months or pregnant women to participate in the focus groups and discuss their information sources regarding IYCF and child health. Written consent was obtained prior to data collection, including recording. The ages of the participants, number and ages of children, and months of gestation in the case of pregnant women were obtained prior to the discussions.The discussions were facilitated by a Burmese medical doctor who was a staff member of the NPO, accompanied by another staff member who recorded proceedings, and two note-takers from the local NPO office. The conversations were recorded to help the note-takers fill in any parts of the conversations they had missed and to confirm their understanding of what was said. The discussion topic was “How information on baby/child care is transferred,” and the facilitator paraphrased their questions in an arbitrary manner to stimulate conversation, based on the following concepts:How does the information cascade between generations?Is there communication with other experienced mothers?Who provides information to the caregivers?How do the caregivers obtain information?After the facilitator translated the original notes from Burmese into English, two non-Burmese NPO staff members, the facilitator, and the two note-takers reviewed the meaning of each response after considering the local context.The CHW activities were classified as “Same” if they had not changed, “Discontinued” if they had been abandoned, and “Modified” in all other cases. We define that an activity was considered to have been “maintained” unless the CHW advised that the activity had been totally abandoned, and the CHW “activity continuation” as the number of conducted activities (with the form described as “Same” or “Modified”) for all five activities except for the Home Visit, which designed solely for undernourished children. We divided the villages into two groups according to their level of CHW “activity continuation” (≤2 or ≥3) based on the numbers of activity continuation and calculated the elapsed time from the end of the program.Time-dependent trends in CHW activity continuation (≤2 or ≥3) and caregiver attendance (“Never Attended” or “Attended”) were examined using the Cochran–Armitage test. The notes from the FGDs were reviewed and categorized according to information sources.Responses were obtained from CHWs in all 90 villages. Most villages had been able to maintain at least two activities, although one village had discontinued all activities . Among tA median of 14  primary caregivers from each village responded, with an overall response rate of 90.9%. The majority  responded that they had attended CHW activities by the time of the survey, but attendance rates decreased significantly with time .In the focus groups, a total of 35 caregivers or pregnant women, with a median age of 30 (range 18–44) years old, and a median child number of 1 (range 0–5), participated. Ten of them were pregnant, and seven were in their first pregnancies. Although, in all six villages, expansion of the discussion by the participants themselves was extremely difficult, they provided their various information sources, as follows:CHW activity: Growth Monitoring, Nutrition Education, and Cooking Demonstration.Other sources: campaign events by other organizations, health care professionals , casual conversation , and media (magazines/radio).In the surveyed villages, CHWs had maintained their activities for up to 40 months after the end of the NPO-led program. They had sorted through and modified some activities once the NPO-led program ended, continuing with the activities thereafter with little change and several activity patterns: “continuity with modification” for cases of Nutrition Education and Peer Counseling, “relatively high continuity without modification” in Growth Monitoring, and “total discontinuation” in Cooking Demonstration. Such activity patterns may reflect the proactive ingenuity of CHWs, which can be a factor to promote program sustainability , 23, ratWhile more than half of the caregivers had participated in CHW activities, their attendance rates decreased over time, which contrasts with CHW activity continuation. If the decreased attendance had resulted from diminished local acceptance  , then thHow the CHW valued and modified their activities, the local needs or awareness, or activities attended by the individual caregivers were unfortunately not investigated. The lack of this important information considerably limits any further discussion about the underlying reasons for CHW activity continuation. Other limitations include recall bias and social desirability bias in the questionnaire responses and FGDs. Considering the irregularity in activity instructions , training opportunities, and activity targets, the amount of time elapsed from completion of the NPO-led program may also indicate differences in program quality or in the villages themselves, rather than serving as a simple time passage. In addition, changes in activity frequency, and activity quality were not analyzed. The program should be evaluated further according to recipient level health outcomes  .Even with these limitations, we still believe the CHW activity continuation observed in Thegon Township is worth presenting, as it may have been due to the proactive engagement of CHWs in the absence of supervision, and was potentially unlinked to the level of local acceptance, suggesting the importance of CHW autonomy  in theirt-oguma@jichi.ac.jp.The data analyzed in this study was obtained from Save the Children Japan. Requests to access the datasets should be directed to Taeko Oguma, https://www.facebook.com/Thegon-child-nutrition-2007488195945235/*with limited accessible areas). The NPO also obtained ethical approval from the Ministry of Health and Sports, the Republic of the Union of Myanmar (Letter No. 116/Ethics 2015).This study was approved by the Ethics Committee of the Faculty of Medicine of the University of Tokyo (No. 110617). All the participants gave consent in the follow-up survey, also the NPO offered the participants an opportunity to opt-out before providing the anonymized data to the University of Tokyo through a social networking service (TO analyzed the data and wrote the initial draft. EW and TM critically reviewed and revised the manuscript. YF contributed to data interpretation and editing. All authors approved the final version.TO participated in the NPO survey as a paid consultant in 2014. YF had worked as a paid employee during and after the NPO activity and the follow-up survey. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Mind, Exercise, Nutrition … Do it! (MEND) childhood obesity intervention was implemented in British Columbia (B.C.), Canada from April 2013 to June 2017. The study objective was: a) to describe and explore program reach, attendance, satisfaction, acceptability, fidelity, and facilitators and challenges during scale-up and implementation of MEND in B.C. while b) monitoring program effectiveness in improving children’s body mass index (BMI) z-score, waist circumference, dietary and physical activity behaviours, and psychological well-being.This prospective, pragmatic implementation evaluation (Hybrid Type 3 design) recruited families with children and adolescents aged 7–13 with a BMI ≥ 85th percentile for age and sex. The 10-week MEND B.C. program was delivered in 27 sites, throughout all five B.C. health regions  over 4 years. Families attended two weekly in-person group sessions aimed to increase physical activity and promote healthy eating. BMI z-score and waist circumference were measured at baseline and follow-up. Dietary and physical activity behaviours and psychological well-being were measured using validated questionnaires. A mixed-method approach was used to collect and analyze the data.d = − 0.13), nutrition behaviours (d = 0.64), physical activity levels (d = 0.30), hours of screen time per week (d = − 0.38) and emotional distress (d = − 0.21). Challenges to continued program implementation included: recruitment, resource requirement for implementation, and the need to tailor the program locally to be more flexible and culturally relevant.One hundred thirty-six MEND B.C. programs were delivered over 4 years. The program reached 987 eligible participants. 755 (76.5%) children and adolescents completed the program. The average program attendance was 81.5%. Parents reported the program content was easy to understand, culturally suitable, respectful of family’s financial situation, and provided adequate information to build a healthy lifestyle. Children achieved significant positive changes across all four evaluation years in BMI z-score (The program reached a broad demographic of children and adolescents in B.C. Families were highly satisfied with the program delivery. MEND. B.C. at scale was effective across all four evaluation years in improving BMI z-score, lifestyle behaviours and psychological well-being among children. Future interventions need to explore strategies to enhance program delivery flexibility. The prevalence of obesity has tripled in the last 15 years in Canada . ObesityFamily-based lifestyle interventions, such as MEND, are one of the principal approaches for achieving long-term weight control in children . InternaIn order to achieve population-wide health improvement, these family-based childhood obesity intervention programs need to be ‘scaled-up’; extending the program reach . ScalingThe MEND B.C. scale-up and implementation project was a prospective, pragmatic implementation evaluation that used a Hybrid Type 3 evaluation design . This tyChildren and adolescents were eligible to participate if they were between 7 and 13 years old, with a BMI ≥ 85th percentile for age and sex and had no contraindications for participating in physical activity or group sessions. MEND B.C. was a self-referral program. At least one parent or caregiver had to attend the sessions. Families were excluded if medical clearance was needed and not obtained for the child to participate in physical activity. Provincial and local recruitment strategies included advertisements in schools, community and recreation centers, libraries, general practitioners, pediatricians, local media, social media, word of mouth, and self-referrals. Each MEND B.C. program had the capacity to accommodate up to 15 families per program delivery cycle. Families may not repeat the program.Stakeholders included MEND B.C. program delivery teams, which consisted of a programmer, theory leader, exercise leader and program assistant. In some cases, one individual performed more than one role e.g., a programmer who also served as a theory leader. Program-wide stakeholders included Childhood Obesity Foundation, provincial level delivery partners (British Columbia Recreation and Parks Association [BCRPA] and YMCA of Greater Vancouver), B.C. health authority regions  and localhost agencies that delivered MEND B.C. such as YMCA and BCRPA member recreation centres.https://healthyweightpartnership.org/). The Childhood Obesity Foundation was funded by the Province of B.C. and licensed by HWP to establish, manage and deliver MEND in B.C. The Childhood Healthy Weights Intervention Initiative was considered to be a Demonstration Project in Year 1 (April 2013 to June 2014). At the end of the Demonstration phase responsibility for MEND operations and delivery was transferred to the Provincial Health Services Authority (PHSA) and implemented under the leadership of the Childhood Obesity Foundation in partnership with the Province of B.C.MEND was originally developed and extensively evaluated in the United Kingdom (U.K.) –7 and suMEND B.C. was offered for free to eligible families and delivered by trained leaders with recreation and health backgrounds. The programs ran for 10 weeks and were delivered throughout B.C. by local teams out of venues such as recreation centres. MEND included two weekly in-person group sessions  that occurred on weekday evenings and weekends. Improving family’s knowledge, attitudes, social support and self-efficacy was the aim of the sessions. Sessions promoted behaviour change focusing on increasing physical activity, reducing sedentary behaviours and promoting healthy eating and used practical and engaging activities to deliver information. After program completion, participating families were given free three-month passes to their local recreation centres. Families were also given two-year access to “MEND World”, an online resource for maintaining and creating new healthy lifestyle changes after finishing the program.The MEND B.C. scale-up could be described as a guided expansion of the same program to variety of different sties  . The scaProgram staff used feedback surveys at baseline to document the number of families enrolled, their demographic characteristics, and how families heard about MEND. Program staff also tracked the strategies used to promote programs in their communities, and the number of documented inquiries received that translated to enrollment.The program staff used a weekly survey to track the number of sessions each family attended and reasons for missing classes and dropping out. Drop-out was defined as a child who has attended < 5 of the 20 sessions inclusively. Attendance was calculated excluding children classified as drop-outs.Weekly MEND sessions were assessed for delivery fidelity. At each site, the program staff indicated whether they were able to (yes/no) deliver all the required program content at each session from 2013 to 2016 (years 1 to 3). From 2016 to 2017 (year 4), the program staff used a five-point Likert scale to evaluate the quality of delivery  .Parents completed anonymous feedback surveys  following the program to evaluate the following areas of program acceptability: whether the information given in the sessions was easy to understand, culturally suitable, respectful of the family’s financial situation, and adequate to build a healthy lifestyle.Parents and children completed anonymous feedback surveys to assess whether they enjoyed attending the weekly sessions and learned about healthy living. Program satisfaction was measured using a five-point Likert scale . Opened-ended questions were used to identify particular aspects of the program that the families enjoyed.The implementation facilitators and challenges were identified from stakeholder interviews , leader feedback surveys (July 2014 through March 2017), document review (from July 2016 through March 2017), and participant feedback surveys (July 2014 through March 2017).Change in children’s BMI z-score  following the 10-week program . Waist cd . All quantitative data were analyzed using STATA version 13 .A mixed-method approach was used to analyze the data. Descriptive statistics were used to summarize responses to the survey items to evaluate program reach, attendance, acceptability and satisfaction. Per-protocol analysis using paired t-tests compared mean changes in children’s BMI z-score, waist circumference, dietary and physical activity behaviours, and psychological well-being pre and post the MEND intervention. Effect sizes for each outcome variable were calculated using Cohen’s Open-ended questions from feedback surveys and stakeholder interviews were qualitatively analyzed for common themes. We used a framework analysis approach to analyze the content . First, Recruitment activities led to a total of 987 eligible children and adolescents (7–13 years of age) participating in MEND B.C. over the 4 years. Most of the participants heard about MEND B.C. from posters and flyers  and referrals  were the most common source of recruitment. Other sources of recruitment included word of mouth , Internet , social media .Targeted recruitment activities were evaluated in-depth from September 2016 to January 2017 (during year 4). During this period, MEND B.C. information was delivered through 8900 engagements in the health sector, 2400 engagements in the physical activity and sport practitioner sector and 3500 engagements in the education sector.n = 52), schedule conflicts (n = 42), loss of interest or did not respond to follow-up calls or emails (n = 59). The participants recruited came from diverse educational, ethnic and socioeconomic backgrounds. Overall, the sample consisted of 48% male and 52% female  registered in a MEND B.C. program. Reasons for not registering in MEND B.C. included 1) not meeting the inclusion criteria n = 5, schedulSeven hundred fifty-five (76.5%) participants completed the program. The average program attendance was 81.5%. The reasons for families not continuing the program include: not the right time for the family (19.3%), other priorities (11.7%), sickness (10.3%), change in family circumstance (10.3%), not the right program (4.8%), program too intensive (4.1%) Time not convenient (4.1%), and too difficult to get to (3.4%).The program staff rated whether they were able to deliver all the required program content at each session from 2013 to 2016 (years 1 to 3). The proportion of the sessions where all program content was delivered during year 1 (April 2014–June 2015), year 2 (July 2015–June 2016) and year 3 (July 2015–June 2016) were 93, 95 and 95%, respectively. During year 4 (June 2016–July 2017), when program staff used a Likert scale to evaluate the quality of delivery (1 = very poor to 5 = very good) 78% of all the lessons delivered were rated 4 or above and 21% had a rating of 3, with only 1% having a rating of 2.Six hundred seventy-six parents completed the program acceptability survey over the 4-year assessment period. Program acceptability results are presented in Table Six hundred seventy-six parents and 708 children and adolescents completed the program satisfaction survey. Program satisfaction results are presented in Table The facilitators and challenges to implementing the program identified by stakeholders, program staff, and participants are summarized in Table d = 0.64), physical activity (d = 0.40), hours of screen time per week (d = − 0.38) and emotional distress (d = − 0.21). Cardiovascular fitness, measured by recovery heart rate, significantly improved in year two (d = − 0.22) and year four(d = − 0.23).The effectiveness of MEND in changing anthropometric, lifestyle behaviour and psychological outcomes are shown in Table This study aimed to evaluate the implementation and scale-up of MEND in B.C., Canada. Scale-up of family-based childhood obesity intervention programs is likely a key component of strategies to combat the upward trends in childhood obesity . MEND B.Scaling up efficacious interventions into real-world settings is critical to prevent delays in community access to effective health services . The metOur recruitment strategies enabled our team to reach families that were characteristic of British Columbian families. According to a recent census of all B.C. families with children at home, 27% were single-parent families , which wThe effectiveness of the MEND B.C. scale-up trial in improving BMI z-score and lifestyle behaviours were similar to the previous MEND studies –9, 30. IThe overall family-based approach used with MEND was perceived as positive by those families that participated. However, after 4 years provincial stakeholders suggested that several important program challenges needed to be addressed in order for them to sustain delivery of the program. First, they identified a need to address the disconnect among stakeholders as to whether the program should be treated as a targeted intervention program for overweight or obese children or a more inclusive community-based family healthy living program without BMI restrictions (>85th percentile). With the BMI criteria in place, program staff and partners faced challenges around what language to use when speaking with parents about their child’s weight. This contributed to recruitment challenges. Second, that future programs needed to incorporate cultural and determinants of health lenses in order to enhance program relevance to population subgroups such as Indigenous families and those experiencing the impacts of poverty; and reduce deterrents for these subgroups participating (e.g. moving beyond free programming). Third, stakeholders wanted greater local program delivery flexibility and had concerns about the resources needed to run the program.With the advancement in Internet-enabled digital devices  and improved access to the Internet, there is emerging evidence these innovative digital technologies can help deliver population-based chronic disease prevention programs without overtaxing health-care resources –35. FutuThere were several limitations to this study. First, as a Type Three hybrid design the primary focus was on evaluating implementation with a secondary objective of monitoring program outcomes , thus thMEND B.C. was successfully scaled-up and implemented in B.C., Canada from 2013 to 2017. The scale-up initiative was founded on cross-sectoral partnerships and reached communities and families across British Columbia; with 987 overweight (18%) and obese (82%) children and adolescents (7–13 years of age) and their families provided with extensive lifestyle intervention support. MEND. B.C. ‘at scale’ remained effective in improving BMI z-score, lifestyle behaviours and psychological well-being among children. Families were highly satisfied with the program delivery and found the program met their needs. However, recruitment was challenging over all 4 years of implementation. In addition, the resource requirement for implementation and the need to tailor the program locally to be more flexible and culturally relevant for B.C. were challenges to continued program implementation.