Individual placement and support (IPS) is an evidence-based practice (EBP) designed to help people with severe mental illness re-enter the labour market. Implementing an IPS program within a new context  to support populations that are complex and multi-barriered presents a set of unique challenges and considerations. This paper provides community-based perspectives that identify implementation strengths and challenges and highlights potential strategies aimed at addressing emergent barriers.n = 15). Using the updated Consolidated Framework for Implementation Research (CFIR) as a guide, we performed deductive thematic analysis to identify key areas impacting IPS implementation.A case study was conducted across three community health centres in British Columbia (BC), Canada, where a novel IPS program was embedded within primary care services. Data collection consisted of open-ended surveys and focus groups with service providers directly involved in program implementation and their associated clinical and managerial support teams (Integration with existing health care systems and primary health care teams and support from leadership across all levels were identified as both key facilitators and barriers to implementation. Facilitators and barriers were identified across all domains, with those within innovation and process most easily addressed. Four cross-cutting themes emerged for promoting more integrated and sustainable program implementation: investing in pre-implementation activities, supporting a dynamic and flexible program, building from community experiences, and developing a system for shared knowledge.Implementing an IPS program embedded within primary health care settings is complex and requires extensive planning and consultation with community-based service providers and decision-makers to achieve full integration. Future practice and policy decisions aimed at supporting employment and well-being should be made in collaboration with communities. Individual placement and support (IPS) is an evidence based practice (EBP) aimed at helping people with severe mental illness obtain mainstream or competitive employment . EBPs arMany EBPs embedded within a health setting fail during initial implementation, sustained implementation, or scaling-up because of implementation challenges . This haKnown implementation challenges exist for health and social initiatives aimed at prevention, promotion, and/or intervention and often span multiple levels or domains, from individual and organizational characteristics to system-wide features. Each factor that holds influence can act as a facilitator towards successful implementation (strength) or a barrier impeding successful implementation , with factors often identified as both  based onKnown implementation challenges for IPS programs are centered around the compatibility and integration of IPS with existing services and systems providing employment support and/or social benefits, collaboration between IPS teams and different partners across mental health services, service provider or organizational resistance to change, and lack of security and funding to ensure sustainability –19. IPS What are the factors influencing IPS implementation within primary health care settings and what actions can address prominent implementation barriers? We explore the perspective of health care and social service providers to better understand community-driven solutions.Our overarching goal is to support the implementation of evidence-based IPS programs integrated into primary health care settings in British Columbia (BC), Canada. Specifically, through this paper we examined the following questions: All components of this study were approved by the University of British Columbia Behavioural Research Ethics Board (BREB) on March 17, 2021 (UBC BREB# H20-02198). Informed consent was received from all study participants.Links to Employment is a supported employment program, operating through the Canadian Mental Health Association BC Division (CMHA BC), aimed at supporting the employment goals of at-risk populations . The program is funded by the BC Ministry of Social Development and Poverty Reduction and based on the IPS model and guided by its eight principles: zero exclusion, competitive employment, mental health integration, benefits counseling, rapid job search, targeted job development, time unlimited, and individualized preferences  had an IPS program in it. So, people know and people see the value.The innovation in this study refers to the The outer setting in this study refers to both the wider health, social, and employment systems that provide programs, services, and supports for individuals across BC and the individual communities in which the IPS program was operationalized.Insecure long-term funding was identified as a barrier that directly and indirectly impacted multiple aspects of program implementation, including staff turnover, health care service provider and organizational buy-in, and program integration into existing local systems of support.We do feel like part of the primary care clinics now but having to qualify our work on whether we will continue or not because of funding, creates a barrier between us, our clinics, and our clients. To able to say we will support our clients through challenges long term, can give [them]the stability to trust us more.Economic and environmental conditions were identified as a barrier impacting community-based engagement and support from local employers, as well as other agencies and organizations providing health or social services. Residual effects from the COVID-19 pandemic have created greater demand for services while capacity and human resources have simultaneously decreased, resulting in many businesses and organizations struggling to maintain current levels of operation.[Our community] does have quite a lot of agencies and programs but I just think everything is so strained and challenged right now due to the current economic climate, the health care system … all of those factors. So that proves to be a big challenge.Some of the challenges have been [around] making the local connections – having an employer that’s open and excited and wants to join the program and really have [that] community-based support.The inner setting in this study refers to the community health centres, which include primary health care services, where the IPS program is available, and the specific IPS program teams directly involved in implementation.Being fully integrated into the system of electronic medical records within the primary care setting was identified as a facilitator towards promoting wider integration and collaborative care across both the program team and their associated health care service providers. An integrated system allowed both teams to independently stay up to date with all aspects of a client’s well-being, whether related to health or employment, allowing client needs to be met more quickly and with less repetition. Where the infrastructure was not in place to allow for a shared system of records, participants identified that it created multiple barriers.Our lack of current integration with primary care is actually causing a barrier to clients because if they had a full network of support and integrated supports, then some of these challenges would be better solved or better supported and would just aid in [the] longevity of employment.Staffing levels were identified as a continuous barrier to implementation. Not being able to find and/or retain highly qualified staff  at each of the three program sites decreased program capacity and slowed program development. Gaps in staffing structure and supervision also limited the support available to the program team in areas such as overall program management and organization administration or reporting , creating additional tasks and responsibilities outside the scope of employment-based service delivery.More training and supervision was needed, especially in the early days of the program.There’s a lot of people in our community that need support and not a lot of resources for people to access at the moment. There’s been scope creep because there’s no support to refer people to in some cases.Participants also reported that staff turnover and capacity within their associated health care teams was a challenge, which often resulted in their clients being disconnected from health services or added to waitlists for health services. This required participants to shift their focus from traditional IPS or employment services to address critical health care needs.Although there was consensus around the importance of working relationships, there was a large disparity in relationship connections across the two levels of the inner setting and across both community sites. Working in collaboration, both through formal and informal pathways, with a health care team, which includes primary care providers, within the community health centre was identified as one of the key strengths supporting program implementation. An existing connection facilitated a more seamless transfer and sharing of clients between health and employment services and reinforced the important role that employment has in shaping an individual’s overall well-being. Additionally, being connected with a clinical team provided added support to clients with higher needs during times of immediate crises and for maintenance of overall health, which allowed program staff to focus more exclusively on employment related goals and work sustainment. Conversely, where there were not strong working relationships, integration was low or absent and IPS teams struggled to secure time with individual clinical staff to discuss shared clients and as a larger team to discuss program structure, referrals, and overall supports.All referral sources should be from integrative health care teams; otherwise, clinical support and supervision is lacking.Across the inner level of the inner setting , relationship connections were consistently identified as a key strength for implementation. Built on shared values and working norms, the strong personal and professional relationships within the program team enabled sharing of difficult tasks, collective brainstorming, and collaborative troubleshooting and outreach. The team-based approach utilizes individual strengths to collectively support the diverse employment goals and well-being needs of clients across all program sites.Many of the guiding IPS principles, notably zero exclusion, time unlimited supports, individual preferences, and integration with mental health , were reFocus[ing] on individualized support has been a great strength. The team has been able to work with clients who have a vast array of preferences and needs to develop goals that align with their desires.This domain highlights the roles and/or characteristics across various groups involved with the IPS program, as well as those that may impact or be impacted by its implementation.In this study, high-level leaders refer to those within the provincial government and/or provincial non-profits that hold decision-making power related to funding allocation and policies for health or social services and service delivery. Mid-level leaders refer to those responsible for making decisions and/or overseeing services at the local community level. Support at each of these levels was considered a vital component in securing buy-in to allow for the program to be operational and sustainable. Challenges at these levels created trickle-down implementation barriers for the IPS team.If we could find the right person in the chain – I know we’ve had meetings with quite high-level health people, and they’re really enthusiastic … and we’ve had meetings with frontline staff, and they’re really enthusiastic. It’s sort of that mid mid-level management.Integration into the clinics was also a long and arduous process that was greatly hindered by lack of communication from upper management.This role refers to all other health care service providers that support the program in various ways. Their support for the program was identified as the key factor for promoting integration between health and employment services, not only for incoming referrals, but also for continued communication and collaborative care. Where program support and buy-in from clinical teams was lacking, program staff struggled to build working relationships and ensure their clients had sufficient access to a range of other health resources.[There’s] enthusiasm and support from partner clinics and the recognition of vocational rehabilitation as an important aspect of a person’s overall well-being. Clinicians have always been receptive and appreciative of the work that the team has been doing and are always open to consult with.This role refers to those directly involved with implementing the IPS program and delivering IPS services to clients. Participants reported that the program team’s skills and experience, along with motivation and commitment to supporting clients, were critical components for successful implementation.[There are] strong and diverse team members who are all devoted to serving the demographic we work with.The start to the program required education and courses on IPS, development of resources and program policies, and community networking. The time that it took to do these things were useful to ensure [there was] a solid base for the program to grow from.There were many clients in our program with suicidal ideation. Additional training on this would be extremely necessary. Clients were much more complex and had much more trauma than we were prepared to address.While most participants felt they had the tools and resources to implement the program, some reported inconsistent messaging and conflicting priorities across various levels of leaders and decision makers, including those internal and external to the program/community health centre. For example, during the early phases of implementation there was confusion around program requirements , service expectations , and operational logistics . Some participants also felt that additional training, especially for those without a clinical background, would be beneficial to ensure that complex client needs could be appropriately met.In addition to sharing experiences and discussing the range of factors impacting program implementation, the focus group discussions provided opportunities for collective brainstorming around implementation strategies, suggested actions, and potential program adaptations to strengthen current implementation processes.Participants reported wanting clearer standards, guidelines, and tools for daily operation to increase consistency across messaging and operations and to minimize the time spent on administrative responsibilities. Where possible, participants wanted to reduce documentation and eliminate process redundancy. Participants also suggested developing an information resource that would provide a current list of available health programs, services, and supports within their community to ensure access to the existing network of health services. This type of resource would include local services offered within each community health centre , as well as those available at the provincial level.I had a lot of trouble directing [clients] to a place within primary care. Kind of like if they had addictions issues, directing them to a place where they can be supported – it’s not just the need to integrate, it’s also navigation, help navigating to specific services.Lastly, participants noted that their perspectives and opinions should have greater weight in the decisions made around program practices and policy. Many reporting feeling that routinely incorporating service provider feedback and moving towards a bottom-up leadership structure could benefit program design, ensure ongoing fit with client needs, and support timely solutions to address implementation challenges.Participants suggested additional program-based wraparound supports to help meet the complex and dynamic needs of the program clients. Specific suggestions included adding peer support and opportunities for more community connection, workshops focused on basic life and job skills , and integration of other psychosocial rehabilitation practices aimed at promoting recovery and wellness. Additionally, participants suggested greater integration and use of allied health support. In BC, the allied health workforce consist of multiple regulated health providers such as dieticians, social workers, massage therapists, music therapists, kinesiologists, etc., that provide a range of preventative, diagnostic, technical, and therapeutic health services considered outside the scope of primary health care .Client cases are quite complex and require much more support outside of vocational activities – Clients often require outside referrals and resources to support their day-to-day.Participants identified the need for different program sites to focus on different implementation strategies based on their unique barriers. For sites struggling with referrals and program integration, participants suggested increasing visibility to spread awareness and promote the program. Suggested strategies included developing program advertisements  and securing co-location within a dedicated space. In addition, frequent opportunities to share client outcomes and successes with broader clinical teams would highlight the value of the program to overall client well-being, helping to foster relationship connections across various partners and levels of management, particularly those identified as mid-level leaders.Continuing just to connect as much as possible, to go over to that site – I think that lack of presence is a real contributing factor to the challenges that the team is experiencing.For sites struggling to build community-based employer relationships, participants suggested ongoing resources and educational opportunities for employers to help address stigma in the workplace and to create an inclusive and flexible working environment .Support for employers to know how to hire and accommodate those with multiple barriers.Participants suggested options to build existing staff and team capacity and capability by providing additional resources, training, and supports. In addition, participants felt that the program team should include an occupational therapist at each site and an integrated counsellor at each community health centre dedicated specifically to program clients. This would ensure low-barrier and consistent access to mental health services in addition to primary care services.Participants identified the need for program flexibility as a key component for supporting ongoing implementation. This included extending the scope of services provided beyond traditional IPS to help support clients in other areas of their life that would bolster transferable skills and indirectly increase work readiness. For example, including peer support opportunities for being mentored and/or offering mentorship.A lot of the time that mental health aspect is lacking because a lot of people have become quite isolated and then they actually don’t have that peer connection and that can be a limiting factor, so maybe expanding that peer support.Participants also discussed adapting core IPS principles to better meet the specific needs of their clients. For example, where IPS exclusively promotes competitive employment and discourages the use of sheltered or temporary work placements , particiSome sort of work experience placement that could help with community buy-in with employers, while at the same time, providing clients who maybe don’t have education or experience with real experience [to] you know, help them with some skills. And also provide references and things like that for jobs that they want to do in the future.Implementation barriers are present in all five CFIR domains described above. Barriers within the innovation and process domains were identified as easiest to address; however, there was recognition of the importance of addressing key barriers and/or influential barriers, for example those centered on upstream factors.The aim of this study was to determine community-based perspectives around how different factors influence implementation of an IPS program integrated within primary health care settings and identify cross-domain strategies that might mitigate implementation challenges being experienced. Analysis across domains identified four emergent cross-domain themes or strategies based on service provider experiences: the need to invest more in pre-implementation activities, support a dynamic and flexible program, build from community experiences, and develop a system for shared learnings to support successful implementation. Each cross-cutting strategy or theme is discussed below.Links to Employment program and the potential difference in priorities of employment and primary care services.Although many pre-implementation activities occurred , there were necessary components at this stage that were underdeveloped or incorporated ad hoc during the implementation stage, most critically consistent engagement and buy-in from mid-level leaders. During pre-implementation, all relevant partners and stakeholders should be engaged and share an understanding of the responsibilities and resources required for successful implementation . LeadersIn addition to this, pre-implementation activities should also focus on defining expectations and developing a process for clear communication within and across teams. While these findings are consistent with supporting integration of IPS with mental health services , we emphTo support strict adherence to the IPS model, the eight core principles are further broken down into 25 fidelity items that provide specific guidance around goals for quality improvement across the areas of staffing, organization, and services . FlexibiLinks to Employment program, thereby increasing program support and future sustainability [Poor implementation and implementation challenges contribute to the failure of many complex and expensive innovations embedded within health care settings . A knownnability , 39.Links to Employment program scales to include more sites across the province. A learning health system (LHS), defined as a system where “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience” [The final emergent theme for promoting a more integrated and sustainable program involves developing a system for sharing knowledge that enables multiple programs sites to learn from themselves and their shared network. This is especially important as the erience” , would sThis study provides novel insights into the strengths and challenges associated with implementing an IPS program within a primary health care setting, however, there are study limitations to be noted. First, our sample size was small given the current scope of the program, and we did not have representation from all external health care teams due to conflicting schedules and capacity. We also did not engage decision makers or leadership at every level. Greater representation across all primary health care settings would ensure that unique contextual factors are being sufficiently considered. Second, our study was focused on the perspectives of service providers during the early phases of implementation an EBP. Ongoing research is needed to understand additional facilitators and barriers across different phases of implementation, including during iterative cycles of adaptation and re-design, and towards processes that enable long-term sustainment of service delivery and funding.Links to Employment program provides an example of how employment and primary health care services can complement one another in a real-world setting and the range of factors that should be considered. Further research should move towards building a more participatory process with service providers positioned to guide practice and policy decisions impacting implementation.Our objective was to understand service provider perspectives on the factors that facilitate and impede program implementation within a multi-sector context and identify potential strategies towards more integrated and sustainable service for adult populations with complex health and social needs. The


Distal radius fracture (DRF) is very common worldwide. In particular, aging countries have numerous patients with DRF, resulting in an urgent need for active preventive measures. As few epidemiological studies have investigated DRF in Japan, we aimed to identify the epidemiological characteristics of patients of all ages with DRF in Japan.This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with DRF from January 1, 2011, to December 31, 2020, at a prefectural hospital in Hokkaido, Japan. We calculated the crude and age-adjusted annual incidences of DRF and described the age-specific incidence, injury characteristics , and 1- and 5-year mortality rates.p = 0.043). The age-specific incidence differed by sex, with peaks at 10–14 years for males and 75–79 years for females. The most common cause of injury was a simple fall in patients > 15 year of age and sports injuries in patients ≤ 15 years of age. DRFs were most frequently sustained outdoors and were more common in the winter season. In patients > 15 years of age, the proportions of AO/OTA fracture types A, B, and C were 78.7% (184/234), 1.7% (4/234), and 19.6% (46/234), respectively, and 29.1% (68/234) of patients received surgical treatment for DRF. The 1- and 5-year mortality rates were 2.8% and 11.9%, respectively.A total of 258 patients with DRF were identified, of which 190 (73.6%) were female and the mean age (standard deviation) was 67.0 (21.5) years. The crude annual incidence of DRF ranged from 158.0 to 272.6 per 100,000 population/year, and the age-adjusted incidence among female patients demonstrated a significant decreasing trend during 2011–2020 (Poisson regression analysis; Our findings were mostly consistent with previous global studies. Although the crude annual incidence of DRF was relatively high because of recent population aging, the age-adjusted annual incidence among female patients showed a significant decreasing trend during this decade. Distal radius fracture (DRF) is one of the most common fractures worldwide. Global studies outside of Japan have reported that the DRF incidence ranges from 100–190 per 100,000 population/year in males and 282–458 per 100,000 population/year in females in the general population . The ageIn Japan, DRF has been the focus of epidemiological studies in three regions –17. ThesThis descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with DRF from January 1, 2011, to December 31, 2020, at a prefectural hospital in Hokkaido, Japan. Patients diagnosed with DRF were identified by searching for the International Classification of Diseases, 10th revision (ICD-10) codes S52.5 and S52.6 in the medical records database; each identified patient was carefully reviewed and their data were retrieved from the medical records. We excluded patients with ipsilateral re-fracture. This study was approved by the Jichi Medical University Clinical Research Ethics Committee . The Ethics Committee waived the need for informed consent because of the retrospective observational nature of the study.Hokkaido is located in the north of Japan Fig. A, and ToDemographic information included patient age and sex. Clinical information included injury data , fracture data , treatments, and mortality data. Injury locations were categorized as indoor  or outdoor . Injury causes were categorized as simple fall, fall from height, traffic accident, crush injury, sports injury, and others. Fracture types were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association (AO/OTA) classification , which iFirst, we calculated the annual incidence of DRF from 2011 to 2020, using population data obtained from the government statistics in Japan . The incA total of 280 patients with DRF were identified. After excluding 20 patients who resided outside Tomamae district and two patients with ipsilateral re-fracture, 258 patients were included in the analysis. There were no patients with simultaneous bilateral fractures and three patients with contralateral DRF injuries at different times in this study period. There were 190 (73.6%) female patients, giving a male-to-female ratio of 1:2.8. The mean (SD) age of the total cohort was 67.0 (21.5) years, ranging from 2 to 99 years; the mean (SD) age was 73.0 (12.9) years for females, and 49.9 (30.4) years for males. Of the 258 patients with DRF, 24 (9.3%) and 175 (67.8%) were ≤ 15 years and ≥ 65 years of age, respectively.p = 0.043), indicating that the incidence of DRF reduced even after adjustment for the impact of population aging. In contrast, the age-adjusted incidence of DRF in males showed no significant trend (p = 0.90)  Fig. . Among tFor the > 15 year group Table , 85.3% oThere were seasonal differences in the incidence of DRF Fig. . The numThe DRF was on the left side in 53% (137/258) of patients and the right in 47% (121/258). Table In patients ≤ 15 years of age, 29.2% (7/24) developed DRF with a concomitant ipsilateral distal ulnar fracture and 71.4% (5/7) had a distal diaphyseal fracture of the ulna. Among patients > 15 years of age with DRF, 36.8% (86/234) had a concomitant ipsilateral distal ulnar fracture, of which 80.2% (69/86) were ulnar styloid fractures. All patients ≤ 15 years of age with a DRF did not receive surgical treatment . In contrast, 29.1% (68/234) of patients > 15 years of age received surgical treatment for DRF.Of the total 258 patients, 92.6% (239/258) were followed up for 1 year after injury, while 2.3% (6/258) died during the 1-year period and 5.0% (13/258) could not be followed up for 1 year. The 1-year mortality rate after DRF injuries was 2.8% (Fig. Using regional population-based data, we identified the following epidemiological characteristics of patients with DRF in Japan. First, the incidence of DRF in our study was similar to that reported in other countries , 9, 11. In our study, the age-adjusted incidence rates of DRF showed a significant decreasing trend over a 10-year period among female patients. The findings of previous studies suggest that this decrease may be due to the establishment of standard osteoporosis treatment for older women, which reduces the incidence of osteoporotic fractures , 9, 24. Our results indicated that the age-specific incidence of DRF was bimodal with peaks in 10–15-year-old males and 70–79-year-old females. These bimodal age patterns in DRF incidence are consistent with the findings of studies conducted in other countries and with a study conducted in Sado City in Japan , 9, 17. Previous studies have reported that the incidences of AO/OTA fracture types A, B, and C range from 54 to 67%, 9% to 14%, and 23% to 32%, respectively , 31. In The present study has some limitations. First, our study had a small sample size compared with previous studies conducted in Japan , 15–17. In conclusion, using regional population-based data, we identified the epidemiological characteristics of patients with DRF. The annual incidence of DRF ranged from 158.0 to 272.6 per 100,000 population/year during 2011–2020. The age-adjusted annual incidence of DRF among female patients showed a significant decreasing trend from 2011 through 2020. Osteoporotic management might have contributed to the declining incidence of DRFs in females. Further research is warranted to investigate the effect of osteoporotic treatment on the incidence of DRFs. The incidence of DRF was bimodal and was highest in teenagers in the male population and in older adults in the female population. This suggests the need for public health measures to prevent sports injuries in young males and to prevent falls in older females.


Effective COVID-19 case investigation and contact tracing (CICT) among refugee, immigrant, and migrant (RIM) communities requires innovative approaches to address linguistic, cultural and community specific preferences. The National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) is a CDC-funded initiative to support state and local health departments with COVID-19 response among RIM communities, including CICT. This note from the field will describe NRC-RIM and initial outcomes and lessons learned, including the use of human-centered design to develop health messaging around COVID-19 CICT; training developed for case investigators, contact tracers, and other public health professionals working with RIM community members; and promising practices and other resources related to COVID-19 CICT among RIM communities that have been implemented by health departments, health systems, or community-based organizations. More than 45 million people living in the United States were born in another country . These iThe National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) was established to develop and disseminate practical resources for health departments and community organizations to use in their work with RIM communities disproportionately affected by COVID-19. Recognizing that some jurisdictions and organizations have had success serving and partnering with RIM communities, NRC-RIM is a venue through which timely and practical information and resources can be shared with those facing challenges. In this note from the field, we describe NRC-RIM activities related to CICT among RIM communities and share outcomes and lessons learned. While NRC-RIM refers to RIM communities collectively, we recognize the significant differences that exist across many RIM communities. Our resources aimed to address common gaps affecting these communities and whenever possible, our work was done in partnership with community members and resources were developed that would allow individual organizations to customize and adapt based on their local needs.NRC-RIM was established in October 2020 at the University of Minnesota with funding from the US Centers for Disease Control and Prevention and the International Organization for Migration . PartnerAn early focus for NRC-RIM was CICT, given known challenges conducting CICT among RIM communities. NRC-RIM and partners reviewed available resources and performed listening sessions and interviews with public health professionals, community members, and healthcare providers. Several key themes emerged, including the importance of community engagement and partnerships to encourage participation and trust in CICT, hiring bilingual and bicultural staff from local communities to serve as CICT professionals and/or using professional interpreters, approaching CICT encounters with an understanding that some RIM communities may have well-founded mistrust of government authorities, supporting CICT professionals with training related to working with RIM communities, developing culturally and linguistically appropriate messaging about CICT, and partnering with local community organizations to provide social services needed during isolation and quarantine. Opportunities were identified to develop new resources, particularly health communications and health education, training, and a toolkit specific to conducting CICT among RIM communities. NRC-RIM activities were determined to be non-human subjects research by the University of Minnesota institutional review board.NRC-RIM reviewed available resources about CICT and identified a dearth of culturally and linguistically appropriate materials, particularly video and audio resources. Existing resources did not feature RIM community members and most resources appeared to have limited community input. NRC-RIM engaged in several CICT health communications and health education efforts to address these gaps.NRC-RIM created a library of publicly available multilingual COVID-19 health communications and health education materials, leveraging collection efforts of the Washington State Department of Social and Health Services Office of Refugee and Immigrant Assistance . NRC-RIMtracer  rather than contact tracing (the act of contact tracing) based on feedback from community members that this approach was less threatening. The videos were released in early 2021 on the NRC-RIM website and NRC-RIM YouTube channel. The videos were also distributed through IRC’s network of local offices via WhatsApp, text message, and email to community leaders.In partnership with the International Rescue Committee (IRC), NRC-RIM developed a series of videos explaining the role of contact tracers. IRC hired a team of bilingual, bicultural content validators from several refugee and immigrant communities. Videos were produced in multiple languages and featured a community member describing the work of a contact tracer to prepare community members if they receive a call from the local public health department. Communities and languages were selected to reflect the largest refugee communities in the United States. IRC worked with community members to develop the script and ensure the language was simple, clear, and addressed potential concerns around receiving a contact tracing call. For example, the video focuses on a contact It is well-understood that health messaging should be linguistically and culturally appropriate and developed in partnership with communities, however creation of materials often centers the perspective of public health professionals rather than the communities. NRC-RIM partnered with IDEO.org, a non-profit design studio specializing in human-centered design (HCD) to co-create campaigns with RIM communities to build awareness and willingness to participate in CICT. HCD is a problem-solving approach that starts with gaining empathy for one’s audience and concludes with solutions tailored to meet their needs. Messaging was created in partnership with a community of farmworkers in Florida, a community of Congolese refugees in Texas and a Hmong community in Minnesota. These communities were engaged to reflect a wide diversity of perspectives. Alongside community leaders and members, IDEO.org facilitated activities to understand concerns, misconceptions, and opportunities regarding COVID-19 and CICT in their respective communities, and co-designed materials that could address specific fears and misconceptions that were culturally relevant and unique to each community. By engaging community leaders, the campaigns could speak authentically to specific concerns held in each community; the language, tone, and visual style was unique and customized; and community members could feel ownership of the materials created. [Insert Table After reviewing publicly available training resources, NRC-RIM held listening sessions with case investigators and contact tracers to inform curriculum development. NRC-RIM found a lack of material addressing skills and knowledge specific to working with RIM communities during COVID-19. Based on these findings, NRC-RIM developed new training modules to address language barriers, and to develop awareness and skills around cultural humility and social-determinants of health.NRC-RIM worked with IRC to develop an interactive, scenario-based module on working with interpreters during CICT. The module covers topics related to techniques for working with interpreters virtually, solutions to challenges faced when working with cases/contacts and interpreters, and methods to improve the quality of an interpreted conversation. IRC created a supplemental glossary of CICT terms in English that was translated into multiple languages for interpreters working with case investigators and contact tracers.Additionally, recognizing that case investigators and contact tracers were undergoing tremendous stress due to working in isolation, encountering cases/contacts during a personal or family health crisis, and the overwhelming demand for their services, NRC-RIM developed a self-care and resilience module and an accompanying training for supervisors. CICT professionals based in Minnesota were engaged to develop the training content, but the training resource was made available to all jurisdictions. The training includes real case investigators and contact tracers discussing their own stories, stressors, and coping mechanisms. An accompanying self-care guide addresses stress, secondary stress, burnout, resilience, and mindfulness, along with resources to cope with stress and promote self-care and well-being. The facilitator’s guide for supervisors provides practical recommendations for conducting listening sessions and suggestions for supporting staff.Through interviews with public health professionals, community leaders, and healthcare providers, NRC-RIM identified many practical strategies, approaches, or programs to improve the effectiveness of CICT among RIM communities. To disseminate findings and amplify local successes, NRC-RIM developed a CICT toolkit intended for health departments across the country. The toolkit contains practical, concise, and instructive materials that health departments can implement. The toolkit contains a collection of practical tips for CICT among RIM communities (e.g. collecting preferred language at testing locations and pre-arranging an interpreter during a case investigation) and checklists of steps health departments can take to organize social services to help community members follow CICT-related public health guidance.The toolkit also contains promising practices from health departments and community-based organizations - strategies, approaches, or programs that have anecdotally shown to have a positive impact in local settings. For example, the use of WhatsApp  to engage RIM communities ahead of a CICT call and support groups for CICT teams in the form of multilingual “virtual coffee hours.” The toolkit also includes guides that illustrate practical steps of implementing new elements to CICT work such as a guide to translating and culturally adapting CICT interview questions about sexual orientation and gender identity.All of the resources described above were made freely available on the NRC-RIM website and were promoted widely through NRC-RIM’s networks. Given that access to the NRC-RIM website is free and does not require users to register for access, detailed metrics regarding which organizations accessed the materials are not available. However, high level metrics regarding utilization are available. CICT-related content on the NRC-RIM website  received over 7,000 web page views with visitors from all 50 states and DC. Table NRC-RIM training modules were hosted on Canvas, an e-learning platform. Access to Canvas is free but requires users to register thus more information is available about users of the training modules. Over 1600 public health professionals representing all 50 states and DC have enrolled in NRC-RIM training modules. According to post module surveys, 73% of participants have demonstrated an increase in knowledge after completing a module and 94% of participants plan to apply the information they learned from the module in their day-to-day work.At the beginning of the pandemic, NRC-RIM sought to enhance and expand on existing CICT programs by centering the perspectives of RIM communities and the case investigators and contact tracers that serve them. CICT will continue to be a core public health tool for COVID-19 response; communities with barriers to vaccination, including some RIM communities, will face greater disparities and will need CICT to prevent and mitigate outbreaks. A strong, culturally and linguistically affirming, CICT response is imperative to ensure that RIM communities receive the support and protection they need to continue to thrive.These practices will have relevance beyond COVID-19. Community engagement, support for public health workers, and replicating the promising practices described here should be foundational elements of the public health response for any public health concern impacting RIM communities. All of the CICT resources developed for COVID-19 remain available on the NRC-RIM website to organizations to use. During the height of the Mpox outbreak in the United States, NRC-RIM worked to re-disseminate the CICT resources for use during Mpox response.NRC-RIM has already leveraged the lessons learned from CICT activities to vaccination-related activities and resources that support engagement, partnerships and collaboration with RIM communities.


Post-natal home visits have been shown to be one of the most effective ways to prevent child maltreatment and reduce risks among children. Unfortunately, these programs tend to be expensive and thus not accessible or practical in many contexts. To address this problem, this paper reviews the literature on home visits conducted shortly after giving birth, considering different types of programs and their outcomes, while focusing on short-term and volunteer-based programs, two approaches that can answer the gap in accessibility. It then introduces a new, innovative, short-term, home visiting program that was developed in Israel. This post-natal program is uniquely structured as volunteer-based to allow it to be culturally informed and inexpensive and therefore accessible to municipalities. The paper describes how experts in the field developed the program and how the volunteers were trained. It elaborates on the protocol for the three defined home visits, each with a specific focus: (1) preventing risks at home, (2) providing parents with emotional support and tools to deal with stress, and (3) connecting them to community resources. We detail the pilot implementation process and some of the challenges that arise. Finally, we describe the design of the evaluation study that is currently collecting data in an Arab town in the north of Israel, with a final discussion on insights gained thus far from the overall process in light of the literature. The prevention of child maltreatment has become a global health priority as its impact on personal development and functioning is profound, long lasting, and even lifelong, with enormous social and economic costs ,2. EarlyTwo possible approaches have the potential to make home visiting intervention more common and accessible, also for systems with limited financial resources. One is to use short-term visiting programs that include only one or two visits by professionals. Growing evidence shows such programs can have an influence on reducing risks among children, lowering rates of investigation for child maltreatment, connecting better to community resources, enhancing parent–child relationships, and improving maternal health ,8. The sThus, the aim of this paper is to review the current general literature on home visiting programs’ effect in the context of child maltreatment and parental wellbeing, as well as more specifically the literature on the effect of universal programs and short-term post-natal programs. This review also refers to the emerging literature on volunteer-based interventions in general and in the context of post-natal programs. Finally, the paper describes a new pilot program that was developed in Israel based on this knowledge. This short-term program was developed to support every family or parent in a municipality shortly after giving birth through three visits of trained volunteers. It has so far been implemented in one Arab municipality in the north of Israel and a follow-up evaluation study recently started. The process of the program development, its implementation, and the challenges it encounters, are explained together with brief details of the planned research.The following literature review briefly describes the vast body of established outcomes for early home visiting interventions and then focuses on universal home visiting programs and short-term post-natal programs. Then, it reviews the second approach for making home visiting programs more accessible via volunteer-based home visiting interventions.Interventions early in the child’s life offer a rare opportunity to influence the developmental pathway and are found to be effective in reducing reports of child maltreatment, preventing the recurrence of such incidents, and in general reducing risk factors . Home viHome visiting programs have been considered a critical type of prevention program in the context of child maltreatment for some decades in the US. In a review of various child maltreatment prevention interventions, home visitation appears as one of the most effective programs . As far Extensive research has been carried out on home visiting intervention over the years. Meta-analyses and extensive reviews show how programs are effective in reducing child maltreatment, both substantiated and self-reported ,11, but Most home visiting programs have focused on targeted populations with different types of high risks. However, there are some advantages to universal implementation . One of It should also be noted that the literature is not conclusive in terms of whether home visiting programs are more effective for a population at greater risk. Some suggest such a program is more effective for the at-risk population in specific domains tested ,26, whilGrowing evidence also shows the dramatic effect of universal home visiting programs on a short-term basis. Durham Connects provided one nurse visit covering basic health topics and connecting the family with local services and was evaluated by a large, randomized, controlled trial study. Generally, the program—later named Family Connects—includes a one-time visit by a nurse to new mothers (up to eight weeks postpartum). During the visit, the nurse assesses six different factors: unmet health needs, maternal and infant nutrition, emotional health, substance use, intimate partner violence, and the physical wellbeing of the mother and infant. After identifying the family needs, nurses provide brief intervention, education, and referrals to community resources. Two weeks after the visit, families receive a follow-up call to document the outcomes of referrals made and to assess the need for additional referrals ,28.The program had a high penetration rate  and fidelity that was empirically assessed using randomized control trials (RCT). Further evaluation after 6 and 12 months showed the intervention group had 50% fewer infant emergency medical care episodes according to hospital records, and fewer hospital overnight stays . The intLong-term effects were also found attributable to Durham Connects. Goodman et al.  tried toFamily Connects programs have been implemented extensively across the US; for example, the Illinois Family Connects  and the Intervention by volunteers is gradually being reported as clearly successful in various types of support interventions. For example, telephone-based peer support was used to prevent post-natal depression . This inVolunteers’ basic operative programs can have possible advantages, especially in the context of home visits for parents. First, one of the main components of success in home visitation programs is the personal relationship with the visitor ,36, someIt is important to note that the average effect of programs using health professionals as providers did not differ significantly from those operated by trained paraprofessionals . In anotSupporting these advantages, participants and volunteers in volunteer-based home visiting programs have generally reported high satisfaction with the program and its effectiveness ,36,40,41Findings that include RCT evaluation are less common , and theIn another RCT evaluation of the Home-Start program, an investigation of a long-term, general friendly support program by volunteers in the Netherlands, a positive change was found in perceived parenting competence, but no effect was found on maternal depression. Parental consistency and observed sensitivity were also found to improve within the intervention group, but no effect was found on other parental measures . In anotLong-term evaluations of Home-Start were also conducted. At the three-year follow-up, the intervention group showed more improvements in responsiveness, affective problem-solving skills of the parents, and less anxiety and emotional problems among the children . At the Finally, another older RCT evaluation showed more conclusive results. The evaluation of the Community Mothers Program in Ireland found that seven years after, the intervention group had a lower risk for accidents requiring hospital visits and were more likely to visit the library weekly; parents were not supportive of corporal punishment, felt they could be proud, were more positive about parenthood, and the children were more likely to be immunized .The findings in the literature show that early home visiting programs are considered effective for reducing risks for children and improving parental wellbeing outcomes. While most of the programs have focused on at-risk target populations, there are some benefits to be considered for providing home visits to the general population on a universal basis. The literature also points out that a short-term post-natal home visiting program can be highly effective in reducing risks for children and promoting wellbeing outcomes for parents. A leading universally based program is Family Connects, which shows long-lasting positive outcomes. Thus, the short-term visiting program shows cost-effective promise. Regarding volunteer-based programs, the literature is less conclusive, and it refers only to long-term programs of “befriending” interventions with no defined structure.Based on the finding of this review, a pilot program was developed in Israel aimed at combining the different advantages found across the programs in the literature in an innovative way. The developed program was planned to be short-term and structured, open to every post-natal mother in the community, based on a service given by trained volunteers.The pilot program, named “Citizen Born”, was developed during the year 2019–2020 by researchers from the Child Poverty and Neglect Center in Tel Hai College, in collaboration with the Haruv Institute and in partnership with the “Beterem—Safe Kids Israel” organization. The pilot program was developed to be a universally based, short-term, early home visiting program based on volunteers. The program focuses on establishing contact and offering community support during the sensitive period after delivery, recognizing that for some families this might be a challenging time that can lead to crises.The two main objectives of the program were: (1) to provide postpartum families with basic knowledge regarding babies’ first months of development and prevention of risks; (2) to improve the relationship of the municipal authority with postpartum families, strengthening parental contact with services in the community according to their needs.During the first three weeks after delivery, families are contacted regarding their participation in the program. Families who agree to participate receive three structured home visits from the volunteers. During the meetings, the volunteer does a short basic assessment of the family’s needs, and emphasizes safety, child development milestones, relationship with the baby, and available local resources for post-natal families. According to the most pressing needs suggested by the family, the volunteer connects them to relevant local services. Two weeks after the third home visit, the volunteer makes a phone call to ensure that the family managed to engage the services in which they were interested, and, if necessary, makes direct contact with the service.The program is based on the principle of respectful, nonjudgmental interaction with families, while emphasizing cultural sensitivity and adaptation. The message conveyed is that parenting is not an easy job for anyone, giving a sense of legitimacy to difficulties and a feeling that they are not alone.A full description is in First visit: personal introduction, awareness of the condition of the baby and the parents, identification of needs, and initial familiarization with services. Main content: (1) Assessing the basic situation of the family after delivery, recognizing possible challenges. (2) Raising awareness of the importance of paying attention to the baby’s mood and temper. (3) Raising awareness of the difficulties that may arise in the face of the baby’s crying and suggesting possible ways to cope with it. (4) Identifying general needs after giving birth, including economic. (5) Checking the family’s familiarity with relevant services in the municipality and referring them to relevant specific services if needed.Second visit: a short visit based on a slightly longer program developed by “Beterem”, focusing on home safety for children. Main content: (1) Identifying parents’ attitudes towards child safety and accident prevention. (2) Empowering and building supervision capabilities. (3) Engaging parents in child safety acts.Third visit: the importance of the parents’ interaction with the baby and the mental state of the parent. Main content: (1) Acknowledging the importance of interaction with the baby and emphasizing how the parent can be more engaged in such activities. (2) Raising awareness of the impact of a parent’s mental state on the baby, and how important it is to seek help if needed. (3) Awareness of the change in the couple’s post-partum relationship and the need for adjustments. (4) Program summary and feedback.The starting point for the development of the program was that we researchers recognized the accumulating evidence in the literature, as shown above, for the impact home visitation programs have on reducing risks among children, even short programs such as Family Connects. In Israel, there is a basic health promotion service, given to newborns and infants by nurses, not based on home visits but rather relying on the parents’ scheduling visits in the nurses’ clinic. When it comes to professional home visits, very few local programs exist, and only on a sporadic basis, mostly intended for families identified as a “high risk” by the welfare agencies. By conducting meetings with relevant agencies in the field we soon realized that home visits by nurses are not relevant to the Israeli context, mainly because there is a very good universal service provided by the health system in which families receive health support in the first two years during family visits to the local clinic. Furthermore, the necessary budget for such a program is very high and irrelevant in the Israeli context, which has seen a decrease in social governmental expenditure in the last two decades . At the Needs survey: To better understand the possibility of such a direction for intervention and to better understand the family’s needs, in the specific context of families in the north of Israel, we conducted a preliminary basic needs mapping survey in Kiryat Shemona, a small town. This survey included 52 participants and identified families’ needs and interest in that kind of service. They thought that entry around the age of one month is relevant, preferably by a female volunteer, and were supportive of the idea that people and even they themselves would be ready to be involved in such program.Developing visits’ content: The next step was to develop the protocols of the visits, based on former research and a discussion with a team of experts, mainly from Haruv Institute, to develop the relevant contents of the program and training. This group included a social work expert with a PhD in child–parent psychotherapy, a clinical psychologist expert in mentalization-based treatment, a developmental psychologist, a public health promotion nurse, a parent support group instructor, and a social worker expert in parent PTSD. A series of meetings with “Beterem” was conducted to incorporate their contribution, mainly during the second visit. “Beterem” has vast experience with home visitation programs in the context of general risks for children at home. Moreover, including a general home safety part in the program would contribute to “normalizing” the program and provide broader coverage of the issue of risks for children at home. After a long process, the program content was finalized in terms of length and depth of content, which is practical for short-term programs.The next step was trying to implement the program in relevant towns in the north of Israel. We reached out to three municipalities to conduct this pilot: a secular Jewish city, a mixed ultra-Orthodox Jewish city, and an Arab city. In a series of meetings with the municipality’s early childhood center and mayors, the program was introduced to them, and they were asked to support it by providing a part-time (25%) coordinator for the program, to recruit suitable volunteers for the program, train them, and later coordinate the program implementation.Aspiring to emphasize universality, we aimed to offer the program to all families from these three municipalities who give birth in the two main hospitals in this northern area. We further planned to conduct evaluation research (its structure will be described later) and thus reached and obtained the approval of the Helsinki Committees of the two hospitals. As part of this process, we developed the study and program recruitment form as well as the study questionnaire in Hebrew and in Arabic.Unfortunately, at the same time the ethical process was carried out, we found out that one municipality could not come up with the budget to support a coordinator for the program. A couple of months later, the second municipality dropped out two weeks before training, as that was when COVID-19 started, and they decided not to move the program online as they did not think their volunteers would be able to manage it. So eventually only one Arab municipality started the program with 20 female volunteers participating in online training supported by Haruv Institute. Their ages varied between 35 to 65. Twelve are Druze, six are Muslim and two are Christian. Ten of them had an academic education , eight had other types of higher education, and two had a high school education.Volunteer training: The training included six meetings. The first meeting focused on introducing the program and its main goals and listening to a lecture by a developmental psychologist on the importance of the first year and family needs after delivery. The second and third sessions focused on supporting a safe environment at home, given by a specialized trainer from “Beterem”. The fourth session included a pediatrician from the child emergency health center from one of the main hospitals in the region, on signs of child abuse and neglect, and a lecture on families’ mental health in the first year by the developmental psychologist. The fifth session focused on home entry and communication skills needed during a visit by an early childhood expert. The last session included representatives of different relevant services for families with babies in the municipality: well-baby clinics, child development services, early childhood centers, and the welfare department and health department. At the end of the training, there was a graduation ceremony in the presence of the mayor and a gift from the municipality.The end of the training marked the beginning of the implementation phase, and the attempt to recruit families from the Arab municipality who gave birth in the relevant hospital. At the hospital during the discharge process, the department secretary reached out to mothers and their partners asking them to participate in the study and possibly also the program, with a promise of some small compensation at the end of the research, and an Arabic-speaking nurse available for more explanation. However, after about two months when no family was recruited, we realized we were experiencing another major challenge. One main reason seems to be that the number of births from this municipality significantly dropped during these months, as we understood most of the women from this town were now giving birth in another smaller hospital in the region. After another month we decided to stop recruitment through the hospital and approach our college ethics committee to recruit families through community services.Recruiting through community services such as community health care clinics, the welfare department, education services, and municipality social networks worked much better, and finally, the program could start. However, unfortunately, the coordinator role was canceled under the reduction of the state budget for the Arab sector, due to a change of government. A new temporary coordinator for the welfare office was assigned to the role, but in a very partial role (about 10%) so the progress was slow. As the volunteers started to conduct the visits, we understood it was necessary to adjust the volunteer’s religion to match the family’s religion (Druze/Christian/Muslim). Furthermore, a request came from the volunteers to enter homes in pairs, saying they felt more competent and comfortable this way, and better able to support the mother.We recently completed the pilot phase and have begun to follow up the program with an evaluation study. Families from the city who gave birth during the preceding month were approached by different services in the city and invited to participate in the study. They were told that the study includes questionnaires for one of the parents to answer at two different points in time, and that the study also includes three home visits by volunteers. Families who gave their consent were randomly assigned to the control group (one-third) and study group (two-thirds), and every third family is in the control group. Both groups are supposed to fill in the first questionnaire when the baby reaches the age of one month. Then the visits should be conducted for the study group between the ages of one to four months. The control group will fill out the second questionnaire when the baby is between three and four months old. The study group will be approached for the initial home visit and follow-up home visits as needed. Upon completing the second questionnaire the families will receive a small gift card (NIS 50). We aim to reach a sample of 100 babies in total  was an Arab town, the materials had to be translated from Hebrew into Arabic followed by a close scrutiny from the local team for any necessary adjustments. Furthermore, the training was conducted in Arabic and with local Arab professionals. However, besides the more technical issues, two further cultural challenges emerged as we progressed with the program. First, as mentioned, we were attempting to provide a universal program, so we planned to recruit families through the hospital, but unfortunately it seemed that families from the town approached by the staff at the hospital were not willing to participate. Of course, this might have been an issue of timing due to COVID-19 uncertainty, but as other programs had successfully approached families at the hospital a short time after giving birth , we suspThe development process of the program was thorough, involving a literature review, the involvement of an interdisciplinary team of experts, and many meetings with the relevant early childhood centers in the field. However, we were unable to predict two unexpected events that had a major effect on the implementation of the program. One was COVID-19, which unfortunately led to the second municipality cancelling their participation in the pilot. The second unexpected change was that by the time we started the program, the main hospital where the women from the town went to give birth changed , and was no longer the one with which we had made contact and for whom we received Helsinki approval (which we chose according to the birth statistics). It is important to take into account that as much as you try to plan ahead there are always changes at the macro and micro levels.A major support was the close connection of one of the authors to officials in the municipality. This especially helped when the program moved from hospital-based recruitment to community-based recruitment, in introducing the program to all the relevant local organizations and reaching out to relevant families. Her involvement helped to keep the early childhood center engaged during the disruptions due to COVID-19, and many other small implementation challenges. We were surprised by who volunteered, having originally thought the dominant profile of volunteers would be retired seniors, not necessarily with a strong educational background. However, most were educated working women, coming from social and educational fields, who felt the program was important. In addition, we were further surprised by the contribution of the program to the volunteers themselves. This reciprocal relationship with the community can be enhanced in the future by a steering committee that can support the program’s implementation and the ongoing connection with the local stakeholders.When we approached the municipalities, we asked them to support the program with a 25% coordination position. While they agreed—and at the beginning, there was a budget for such a coordinator within the early childhood center—after a couple of months the Israeli government changed and that budget was no longer available to the municipality. Then the municipality supported the program with a coordinator who was a social worker in the welfare department, and that brought a lot of complications, as naturally, she was very busy with other aspects of her work. Only lately another arrangement for a coordinator was set, once again within the early childhood center. Thus, it seems that having a more stable designated budget for the program is critical, and while the close connection with the municipality is very important for its implementation, it might be better to have a reliable and independent budget coming from charitable foundations or federal outlay. We also found it important for the image of the program to be less affiliated with the municipal welfare department.As the program was developed by an academically orientated team, the implementation process was intended to incorporate an evaluation study from the very first step. As the interest and priority in the field are naturally different, we encountered issues regarding the implementation of the study, some of which are still being addressed. First, for the program community team and the volunteers, who were very enthusiastic about the program, it was not easy to have a control group, as they had to deliberately not serve families in their own community. To deal with this, we had to explain the purpose of having a control group for the local team and the possible long-time benefits. We also allowed them to offer the program to families in the control group who finished the second questionnaire whose child was younger than four months old (the program content is not relevant for older babies). Furthermore, the need to separate the study team from the program team was complicated for many of the volunteers to understand, as they thought it does not make sense to have another person (from the study team) involved with the family in this complicated time after birth, especially considering cultural and religious sensitivities. Again, we had to explain the rationale, taking into account the complexity of implementing the program in a small, highly interconnected community, where the people all know each other. Finally, another ongoing challenge is fidelity to the program’s protocol by the different volunteers. As more time passes since the training took place, this is becoming more difficult. We currently deal with it by supplying continuous messages emphasizing the importance of following the protocol accompanied by support meetings and follow-up training for the volunteers.While the program tried to address some of the accessibility problems of home visiting programs and manifest its vast strengths, the current program has some limitations. First, at this point, it was only implemented in one town, in a specific context: Arabs, particularly of Druze ethnicity. Implementation in another place would have brought up other issues. The current program still does not have strong budgetary support for its implementation, which raised more complexities in the process. Finally, the study is only in a very early stage, so we are still awaiting the possible long-term effects of the program as described by the literature, and we do not yet know its actual impact.The current manuscript reviewed significant evidence in the literature for the impact a home visiting program can have on preventing risk to children and promoting parents’ wellbeing. It further brought more specific evidence that shows the possible impact short-term programs and volunteer-based programs can have, two possible approaches that can provide a budget-appropriate implementation of post-natal structured home visiting programs. It then presented a program developed intentionally to cover both aspects. While more implementation sites are needed, as well as the longer-term results of the evaluation study, we can already draw some important conclusions regarding the implementation of similar programs based on the process we detailed here.During the program implementation, we found that close attention to cultural aspects is critical, especially in the complex Israeli–Arab and multi-religious contexts. Implementation of a program within a community also demands flexibility to micro and macro changes and developing sustainable close connections with the community. Attending to budgetary issues was also found to be crucial, even for a program that from the outset was developed to be cheap to run.Generally, in terms of the initial recommendations for the implementation of similar programs, we found it valuable to have a close relationship with the community to ensure cultural adaptation and make adjustments when necessary. We also found it important—while trying to keep a certain structure in the program—to attend to the volunteers’ important suggestions, as they may determine the program’s success in practice. As part of this, making sure volunteers have ongoing support and connection with one another also seems to be critical. Finally, we found it is important to establish strong support for the program by different stakeholders both within and outside the community.


The Human Condition is neither a well-defined nor well-described concept—nevertheless, it is generally agreed that human sexuality is a fundamental and constituent part of it. For most able-bodied persons, accessing and expressing one's sexuality is a (relatively) trouble-free process. However, many disabled persons experience difficulty in accessing their sexuality, while others experience such significant barriers that they are often precluded from sexual citizenship altogether. Recognising the barriers to the sexual citizenship of disabled persons, the concept of a Welfare-Funded Sex Doula Program has been advanced — a program specifically aimed at meeting the various (and often complex) sexual needs of disabled people. Below we show how that program can be justified within at least two different moral frameworks, the capabilities approach and liberal utilitarianism, and consider and repudiate arguments against it. It is generally understood that a ‘life worth living’ should contain not only the basic fundamentals of life such as survival and physical health, but should also include things such as: freedom from persecution, love and sex, liberty, and self-determination. Indeed, it is this very belief that has motivated the development of welfare systems from which many now benefit. These fundamental or basic needs are considered a baseline for the quality of life a government owes to its citizens.all members of a society …the enjoyment of possessions acquired by hard work and good fortune” , p. 487.A simpler  solution, of course, would simply be to suggest that basic needs are those ‘which ensure that we remain in good health’ . Given that sexual citizenship can be positively connected to mental and physical health , 23, 24,The capabilities approach originates in Amartya Sen’s work in economics during the 1970s –28 – thoIn short, the capabilities approach takes ‘means’ and ‘ends,’ and uses them as metrics by which freedoms can be re-framed: thus, societies should focus on ensuring that ‘ends’  are achievable instead of providing ‘means’ (such as public resources and goods). This focus on real or substantiative freedoms provides a new perspective to determine the threshold conditions of justice and human dignity; thusly the capabilities approach both focusses on comparative quality-of-life (QOL) as well as theorising on justice. Yet comparative QOL calculi are not without their difficulties , 31 , which may explain why her formulation has achieved more traction than Sen’s. Her list includes: (1) Life; (2) Bodily Health; (3) Bodily Integrity; (4) Senses, Imagination, and Thought; (5) Emotions; (6) Practical Reason; (7) Affiliation; (8) Other Species; (9) Play; and (10) Control (over one’s environment)—“opportunities for sexual satisfaction” are specifically detailed under (3) Bodily Integrity ” ” , p. 81, de facto claim right to the sexual use of a woman’s body. There are two peculiar and implicit presumptions behind this objection: (1) that doulas can only be female and (2) that only male disabled persons seek sexual citizenship. We shall dismiss (2) because it is obviously false and move to (1). Though the etymology of the word ‘doula’ delineated a female slave, contemporary doulas are of all genders. While it is true that birthing doulas tend to be female, both the Childbirth and Postpartum Professional Association (CAPPA) and DONA International have trained male birthing doulas [The concept of the sex doula program was first introduced at the European Society for Philosophy of Medicine and Healthcare conference in 2018. One feminist worry extended there was that such a program would reinforce patriarchal gender relations and the idea that men have a g doulas ; other dprima facie, plausible and morally compelling” [sui generis [. Such a proposal may seem persuasive, but such experiences must still be generis — that is, of a kind that is debatable . We are sensitive to Srinivasan’s concerns , but believe that simply redacting ‘sexual experiences’ from the list of distributive goods is ‘throwing the baby out with the bath water.’ Once the rights are construed correctly (as we have endeavoured to do above), then the concerns to which Srinivasan alludes seem to dissipate — at least so far as the sex doula program is concerned.Yet the above answer, as Danaher observes, would be to offer a glib response to a serious and pernicious issue , p. 20. pelling” , p. 24; pelling” , p. 24.  generis . Such a  not the same as advancing sexual inclusion rights for all persons (the inclusion of the former is unlikely to result in any misogynistic norm enforcement). Secondly, disabled persons are themselves a vulnerable, oppressed, and discriminated minority — half of whom are women hoping that the provision of sexual support services will help them obtain sexual citizenship, too! This latter point highlights that the rights which are being advanced are not so much ‘male-claim rights’ as they are just ‘rights.’Danaher concludes that ‘Misogyny Objections’ are not enough to undermine the project of greater sexual inclusion, but they do demonstrate how the debate is “fraught with risk and that, if done wrongly, could serve to reinforce a discriminatory and oppressive regime” , p. 25. could be understood as mandated by the CI, if it were seen as a profession which develops one’s own talents so that they better those of an other’s humanity (in much the same way as surgeons use their own bodies and intellect to better the well-being of another).Some Kantians may argue that the selling of sex-related services would violate the Categorical Imperative (CI) — namely by using ‘humanity’ as a mere means. Such a perspective, however, fails to recognise the rational agency of choosing such a career. While it is a legitimate objection to argue that some sex workers are engaged in their occupation non-consensually, sex doulas would be obligated to train for several years in order for them to practice, and their career would, thusly, be a matter of choice and deliberation. Furthermore, working as a sex doula eu zen , would likely be insufficient to subdue such fundamentalist perspectives. As such, we leave such efforts to those who are engaged in that debate and to our future work.Certain theories, such as some natural law theories, may also be resistant to a sex doula program because it could be perceived as going against the human telos as defined by our true nature; similarly, conservative theories might criticise such a program out of fears that its acceptance would result in the fall from decent, upright society into some sort of state-funded Bacchanal cacotopia. However, whatever principles are presented here (and in other works) that promote sexual inclusion with the goal of hierarchical needs, which maintains that no secondary needs should be taken into account until all primary or basic needs are satisfied [prima facie case for welfare-funded sex doulas — accordingly, whatever budgetary dilemma obtains as a result becomes a matter of debate for distributive justice.In terms of economic analysis, it is impossible to avoid the fact that funding a sex doula program would constitute a drain on a state’s coffers and might frustrate some derivative or secondary needs of citizens. This frustration is justified through the LU principle of atisfied ; the CA,atisfied , 28. Ourenough sex for disabled persons. This matter is more tricky to resolve, as what constitutes ‘enough’ is difficult to determine. Not only are there significant cultural perspectives , but whFinally, we think that is it possible for our interlocutor to claim that the problem of sexual inclusion is simply unsolvable because of the complexities involved and because of the perpetual rights debate that ensues. Danaher discusses a similar objection, which he coins a species of the ‘impossibility/impracticality objection.’ He believes that such an objection fails to “scupper the project of fostering greater sexual inclusion,” , p. 25 ain personam, but in cīvītatem—against the state; and through our example of mūnerum medicōrum, we have illustrated how positive claim rights to sexual support services do not (and cannot) violate the negative claim rights of doulas working in the program. We have also established how the sex doula program constitutes a societally enactable policy, consistent within the normative protocol of the capabilities approach, that directly responds to the barriers that cause the sexual exclusion of disabled people and which would ensure that disabled persons function in a way that they currently do not.We have shown above how a sex doula program can be introduced as a part of the greatest need-satisfaction in Häyry’s liberal utilitarianism — and how doing so would help secure a (currently unattainable) “indispensable element of human happiness and well-being”  for disaResponding to criticisms, we concur with Danaher that the broader ‘Misogyny Objection’ demands only that the matter of sexual inclusion must be handled carefully. In addition, we note that concerns over patriarchal rights-claims that generate ‘misogynistic norm enforcement’ are somewhat hyperbolic given that the subject at hand is the sexual citizenship of disabled people. Di Nucci’s ‘sexual rights puzzle’  has been considered and repudiated.Finally, we acknowledge that the above discussion does not constitute an in-depth normative analysis of our proposed program – however, we have sought to provide an overview of how the sexual citizenship of disabled persons could be evaluated and in what areas a sex doula program would need to operate in order to ensure baseline functioning. Our work here seeks only to show that a welfare-funded sex doula program is consistent with (at least) two mainline conceptual frameworks of justice, and we believe that it succeeds in that endeavour.


Salmonella enterica serovar Typhi (S. Typhi) is the causative agent of typhoid fever in humans. Because mice are not permissive to S. Typhi infection, we employed a murine model of typhoid using S. enterica serovar Typhimurium expressing the Vi polysaccharide (ViPS) of S. Typhi (S. Typhimurium strain Typhi RC60) to evaluate the role of natural IgM in pathogenesis. We found that natural mouse IgM binds to S. and S. Typhimurium. The severity of S. Typhimurium infection in mice is dependent on presence of the natural resistance-associated macrophage protein 1 (Nramp1) allele; therefore, we infected mice deficient in secreted form of IgM (sIgM) on either a Nramp1-resistant (129S) or -susceptible (C57BL/6J) background. We found that the lack of natural IgM results in a significantly increased susceptibility and an exaggerated liver pathology regardless of the route of infection or the Nramp1 allele. Reconstitution of sIgM−/− mice with normal mouse serum or purified polyclonal IgM restored the resistance to that of sIgM+/+ mice. Furthermore, immunization of sIgM−/− mice with heat-killed S. Typhi induced a significantly reduced anti-ViPS IgG and complement-dependent bactericidal activity against S. Typhi in vitro, compared with that of sIgM+/+ mice. These findings indicate that natural IgM is an important factor in reducing the typhoid severity and inducing an optimal anti-ViPS IgG response to vaccination.Circulating IgM present in the body prior to any apparent Ag exposure is referred to as natural IgM. Natural IgM provides protective immunity against a variety of pathogens.  Salmonella enterica serovar Typhi (S. Typhi) is the causative agent of typhoid fever in humans. Global estimates reported by the Centers for Disease Control and Prevention indicate that 21.6 million cases of typhoid fever occur each year resulting in 226,000 deaths , a natural pathogen of mice causing a “typhoid-like” systemic disease in mice, became the most widely used bacterium to understand pathogenesis and immunity in inbred mice . Organs of the mononuclear phagocytic system, such as liver and spleen, are the major sites of replication of S. Typhimurium during infection in mice   . Humans S strain . S. TyphS. Typhi . HoweverS. Typhi , 19. To S. Typhi  introducin TH170 , roles fin TH170 , evadingin TH170 , 23, andin TH170  were ideepE gene . This st in mice . Using t in vivo , 27.−/− mice have a 2- to 3-fold increase in basal levels of natural IgM  with S. Typhimurium RC60 and the impact of natural IgM on the anti-ViPS IgG response to immunization.Circulating IgM present in the body prior to any apparent Ag exposure is referred to as natural IgM –30. Natuural IgM . Using Anfection . A strikype mice . We hypoype mice . This fi tissues . In the −/−) have been previously described (−/− mice used are on a 129Sv (129Sv.sIgM−/−) or C57BL/6J (B6.sIgM−/−) background. Control wild-type  and  mice were purchased from The Jackson Laboratory . The sIgM genotype/phenotype is confirmed either by PCR or IgM ELISA . The purified PCR product was then sequenced using the primer 5′-CCCCCATCTATGTTATCACCC-3′  that expresses the S. Typhi genes necessary for ViPS synthesis, export, and regulation as in S. Typhi (600 of ~1.0 in Luria–Bertani (LB) broth with 10 mM NaCl. The expression of ViPS was assessed by a slide agglutination test using a commercial Vi mAb reagent . Bacteria were washed twice in Dulbecco’s PBS (DPBS), and 100 μl of DPBS containing 3 × 104 CFU was injected i.p. or i.v. At 3 d postinfection liver and spleen were collected, and the tissues were processed using a Minilys tissue homogenizer . The bacterial burdens in the liver and spleen homogenates, as well as blood collected into anticoagulant, were determined by plating serial 10-fold dilutions on LB agar plates followed by counting CFU , and total, necrotic, and infiltration areas composed of lymphocytes and other mononuclear cells in the entire specimen were quantified using Aperio ImageScope software (Leica Biosystems) , 26.+/+ or 129Sv.sIgM−/−) were injected i.p. with 150 μl of sterile-filtered serum obtained from naive 129S1/SvImJ, 129Sv.sIgM−/− mice or 200 μl of PBS containing 200 μg of purified polyclonal IgM purchased from Rockland Immunochemicals . The commercial IgM preparation was purified from normal serum and contains 0.1% azide and 0.5 M NaCl and 0.1 M Tris . Therefore, the IgM preparation was dialyzed against PBS (1000 ml) twice in a 10,000 Da molecular mass cutoff Slide-ALyzer MINI dialysis device (Thermo Fisher Scientific). Because IgM has the shortest half-life among all of the Ab isotypes  mAbs in 200 μl of PBS  or PBS alone. As previously reported, this treatment results in neutrophil depletion for 4 d .8 CFU of heat-killed S. Typhi strain Ty2 (grown in LB broth containing 10 mM NaCl) in 100 μl of DPBS  and cell-free supernatant was used. The dilutions, 1:25 for IgG and 1:50 for IgM, were chosen after evaluating various serum dilutions within the linear range by ELISA. Bound IgM or IgG was measured using HRP-conjugated goat anti-mouse IgM or IgG . Because ViPS-specific mouse IgM and IgG reference standards are not available, and the ViPS-specific Abs in mice are likely to be of oligoclonal nature with varying affinities, the Ag-specific Ab levels in the current study were interpreted as nanogram per microliter “equivalents” using normal mouse serum IgM or IgG standards .ViPS-specific IgM and IgG in the blood were measured by coating 96-well microtiter plates  with 2 μg/ml ViPS purified from te C6524  in DPBS 600 of 0.5 at 37°C) of S. Typhi strain Ty2 were prepared in LB broth with 10 mM NaCl. Bacterial cells were washed in DPBS, and the bacterial cell density was adjusted to 2.5–5.0 × 104 CFU/ml in DPBS. The expression of ViPS was assessed by a slide agglutination test using a commercial Vi mAb reagent . Serum samples were heat-inactivated by incubating at 56°C for 30 min prior to use in the assay. Ten microliters of S. Typhi strain Ty2 in DPBS (250–500 CFU) was added to each well of a round-bottom polypropylene 96-well plate containing 50 μl of heat-inactivated serum in serial dilutions, 12.5 μl of baby rabbit complement , and 27.5 μl of DPBS. Triplicate samples of each dilution were incubated for 120 min at 37°C with gentle rocking, and 10 μl of this mixture were plated on LB agar plates for counting CFU. Serum bactericidal Ab titers are defined as the reciprocal of the highest dilution that produced 50% killing in relationship to control wells containing complement, but no mouse serum. Naive mouse serum served as a negative control, and serum from either mice immunized with heat-killed Escherichia coli strain W3110 expressing pDC5 plasmid, which contains the genes necessary for the synthesis and export of ViPS  served as two independent positive controls.A serum bactericidal assay was performed as previously described . In brie of ViPS , or S. TS. Typhimurium strains IR715 and RC60 and S. Typhi strain Ty2 were grown in LB broth. Overnight bacterial cultures were washed twice in PBS, then resuspended in 25% normal mouse serum (from C57BL/6 mice) in PBS to achieve a final concentration 1 × 109 CFU/ml. After a 1-h incubation at room temperature, the bacterial cells were washed three times in PBS by centrifugation . Bound serum proteins were eluted by resuspending the bacterial pellet in 100 μl of 0.1 M glycine-HCl for 30 min. Following centrifugation , 80-μl supernatants were collected and neutralized with 20 μl of 1 M Tris-HCl buffer (pH 8.0). Two microliters of these samples was mixed with 48 μl of Laemmli buffer containing 2-ME and boiled for 10 min. Five microliters of the samples was subjected to SDS-PAGE and Western blot analyses. After electrotransfer, the polyvinylidene difluoride membranes (Merck Millipore) were blocked for 1 h in 2% BSA in PBS containing 0.25% Tween 20. The blots were probed either with HRP-conjugated goat anti-mouse IgM Ab or with HRP-conjugated goat anti-mouse IgG Ab . After a 1-h incubation, the blots were washed with PBS containing 0.25% Tween 20, developed using Super-Signal West Dura substrate , and images were obtained on an imager, Protein Simple FluorChemR .Data presented throughout depict pooled data from at least two independent experiments. Statistics were performed using the Prism 5 software program , and the statistical tests are indicated in the figure legends.S. Typhi and S. Typhimurium, we performed a mouse IgM binding assay using serum obtained from naive C57BL6/J mice. This assay is identical to the one developed for human IgM binding to Salmonella, except we used mouse serum instead of human serum  or mice deficient in sIgM (129S.sIgM−/−) with S. Typhimurium strain RC60 either i.v. or i.p. Compared with 129S.sIgM+/+ mice, the 129S.sIgM−/− mice had a significantly increased bacterial burden in the blood, liver, and spleen regardless of the route of infection  with S. Typhimurium strain RC60. As previously shown for the S. Typhimurium strain SL1344  reconstitution when we transferred 200 μg of purified IgM ..−/− miceS. Typhi and S. Typhimurium (S. Typhimurium RC60 by natural IgM is independent of the classical pathway of complement activation.Natural IgM controls the early phases of viral and bacterial infections . Naturalhimurium . Althoughimurium . For theS. Typhimurium and generates immune complexes (S. Typhi and S. Typhimurium (S. Typhimurium RC60 in vivo. Humans and mice express two distinct Fc receptors specific to IgM, namely Fcα/μR and FcμR (S. Typhi immunization was significantly impaired in the absence of natural IgM (Certain ViPS-conjugated vaccines do not induce optimal anti-ViPS IgG responses in typhoid disease–endemic areas , and it omplexes . In supphimurium . In addiand FcμR . Fcα/μR and FcμR . In contural IgM . FurtherSup Fig 1 and Fig 2