Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa.We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February–March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients’ home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed.We found that clients’ home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother’s advice.These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients’ voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.The online version contains supplementary material available at 10.1186/s12939-020-01377-z. Historically, community health worker (CHW) programs were conceptualized as a way to meet the needs of those who experience marginalization and inequitable access to health care. The 1978 Declaration of Alma-Ata, which formally laid the foundations for countries to initiate and mobilize CHW programs, was based on social justice, health equity, and empowerment of local communities and capacity .Currently, in the context of a global shortage of health care workers, and a rising demand for services, community-based approaches to health service delivery are being re-evaluated as a way to fill this gap . DeployiHowever, while there is a renewed interest in ascertaining how to best engage CHWs to fulfill important roles in health promotion and disease prevention, the roles of CHWs are malleable and not easily-defined in a universal way. In most settings, CHWs are trained lay health workers—who operate either within or in conjunction with, or outside of the formal health (state) system, who are typically members of the communities in which they work, and who are seen as being able to reduce the burden on under-resourced and overstretched health professionals . Part ofThis shift has ostensibly been driven by the needs of health systems, and not necessarily by the people served by CHW programs. There remains little consensus on what the beneficiaries, or clients, of CHW programs actually require and want from programs, as few studies incorporate their perspectives , 11, espThe existing data we have from other clinical settings, and different types of health providers, indicates that relationships are important aspects of clinical encounters in multiple distinct ways. Qualitative research in particular has provided rich data on how clients experience, and respond to, health encounters , 17. A sClients within CHW programs tend to be overlooked in existing research, and we do not know the extent to which they similarly benefit from, and rely on, relationships as a means to support them to achieve better health outcomes . Given tTo build a more comprehensive picture of mechanisms through which CHW programs may bring about change, we need to ask clients themselves about their experiences with and perspectives on their CHWs, as the main interface with the program, and the relationships they maintain. This imperative is reflected in implementation science frameworks such as the Medical Research Council’s guidance on process evaluation for complex interventions . DrawingEthical approval for this study was granted by Stellenbosch University’s Health Research Ethics Committee (N16/05/062). An This study was descriptive in nature and utilized semi-structured qualitative interviews with pregnant women and recently delivered mothers who were clients of the Enable Mentor Mother program, further referred to as Enable. This study was linked to a larger study of the implementation of Enable during its first three years, part of ongoing efforts to strengthen the quality of care delivered to mothers and infants in the region where Enable operates , 26. TheEnable is a home visiting intervention focused on maternal and child health and nutrition; the program has been operating in the O.R. Tambo District since 2016. The program uses the Philani Mentor Mother model, which was originally designed and implemented by Philani Nutrition Project in peri-urban Cape Town . In thisA list of all clients in the Enable program was obtained from program staff. In order to ensure a diverse sample of interviewees, two clients per Mentor Mother were included as a target sample. The first author (CL) purposively sampled clients from each MM’s caseload, while ensuring variation in characteristics by age and number of children. Alternative clients were contacted in cases where a client was uninterested or unavailable.Interviews were conducted between February and March 2018, and were arranged and completed by an isiXhosa-speaking researcher with extensive qualitative interview experience (VN). CL devised a draft interview schedule and met with VN to discuss each question and refine or clarify phrasing where needed. The semi-structured interview schedule was then finalized and used to guide interviews. Topics covered included: client experiences with their own individual Mentor Mother; knowledge gained since enrolling in the program; possible avenues for improving the program; and experiences with the larger health system. Informed, written consent was obtained before interviews began, and all interviews were conducted in participants’ homes and audio-recorded with consent. Both informed consent and the interview itself were conducted in participants’ first language, isiXhosa. Interviews averaged one hour duration each. Rigorous quality control measures were taken to ensure consistency and alignment with core questions. In debriefings following the interviews, CL and VN reviewed interviews, and were satisfied that the target number of participants allowed for saturation. Saturation was assessed by the presence of rich transcripts, with coherent information across interviews, and the understanding that additional information gathering would likely lead to redundancy in the data .Between April and October 2018, an experienced isiXhosa-speaking team reviewed audio recordings, and simultaneously translated and transcribed interview content into English. Specific words or short phrases were left in isiXhosa on a case-by-case basis to preserve meaning, and alternative definitions or explanations were added where appropriate. CL met with the transcription team regularly to discuss progress. A senior member of the transcription team checked 50% of transcripts over the course of the transcription period for quality and accuracy.Thematic analysis was employed, using the methods described by Braun and Clarke , 32. Datn=26) were all female, and on average, 26.9 years of age (SD = 5.77) at the time of the interview. Nearly 60% of participants were enrolled as clients in the first six months of Enable’s implementation. Ten participants were first-time mothers (38.5%), and eight were married (30.8%).Participants . Many codes under preventive care, however, detailed participant responses to and reflections on the MM intervention. As such, these codes were distributed under two overarching themes. These themes included instructive roles  and supportive relationships . Examples are shared in Table In speaking about interactions with their MMs, most clients shared experiences about new information learned, internalized, and accepted, and how this information was relayed (i.e. the mode of instruction). Clients also reflected on the impact of this education—what it meant for their child’s health and their own sense of agency, as well as challenges to enacting this advice.PID13: When she arrives, talking to me, she explains it and asks if I heard what she said.Interviewer: Okay, why it is important for her to ask you if you heard what she was saying?PID13: It is important to me because I have to know it … Because it’s me who agreed to work with her, so I have to know it.In their interviews, clients affirmed that learning new information about their own and their child’s health was a central part of the MM-client interaction. Clients emphasized the skills of their MMs in conveying new instructive information, and ensuring client understanding at regular intervals:In addition to sharing strategies for learning, clients indicated that they felt compelled to satisfy their obligations to the MM-client relationship.PID6: She also acts some other things, I mean she has got many examples … and her examples are clear and corresponding to what she is saying.Not all instruction was described as verbal. Clients highlighted the importance of hands-on activities and examples, saying they learned better when their MM acted something out:PID21: When she emphasizes something, she looks at you directly and says “hey, I’m serious about what I’m telling you, as you always like not to take things not seriously” so that is what I notice with her, and say hey, [my MM] emphasized this thing …When MMs supplemented their instructions and explanations with actions, clients described grasping new knowledge more quickly, and also were able to put it into practice. In certain cases, this also applied to deciding which information was most important. One client spoke about filtering information through cues from her MM:These instructive strategies were often tailored to what a particular client needed to learn, and to ensure uptake of new information and thorough understanding.Beyond sharing experiences and examples of receiving information from their MMs, clients also reflected on the quality of the interaction with their MM as they described the role this information played for them, and the context in which it was delivered. They spoke about perceiving their MMs as trustworthy and being accountable to them, about how they engaged with new health information, and about situations when they faced challenges to taking action in line with their MM’s advice.Speaking about the informational and instructive role of their MMs, clients compared their “current” selves to who, and how, they had been before being enrolled in the Enable program, detailing the process of gaining knowledge and confidence and the importance of having a trusted peer.PID1: As a person, you learn till you die, you see? So there are so many things that I learned. I didn’t know that you have to wash your hands before you touch a baby’s bottle, then wash the bottle and prepare food for the baby, I didn’t know that. Even feeding the child, I thought that you just feed the child … I didn’t know the motive behind it, you see … So after she came and explained to me about breastfeeding, telling me that breastfeeding is very important, even the scale [taking the child’s weight] is very important, telling me that the child must never miss the scale dates [at the clinic], I became alright, I saw myself as a good person and I did things the way she told me to.Another client spoke about adopting new information to make informed decisions, and why she considered her MM as a credible source of information:PID24: I mean like as a person what you are talking about becomes visible from your facial expression, you see from the face that, “okay, this person knows what she is talking about and she is living it” … She is living with what she is saying, you see … And [you] notice that hey, maybe this thing is good, so you rather try it and [it] helps you after trying it and you see that, no these things that are said by this person are good, so let me follow them and be close to her so that when she talks I do, every time she talks I do what she is saying.would give compliments saying ‘no my child you are listening carefully’ because she teaches those things in a good way. You will never understand someone who came to you with attitude” (PID17). Clients also shared a renewed sense of external accountability, and anticipation, from having a monthly or bimonthly visitor who they respected:PID6: I once had that thing on my previous children … That thing of not going to the clinic. But having that mentality of there is no one who is going to ask me. Now I have that feeling, wishing that she can arrive quickly and also see that the weight of my child increased now, that time there was a scale.For some, this credibility also came with the MM’s approach, as one client described how her MM “These reflections on assessing and internalizing information revealed clients’ abilities to engage with their MMs in an enabling space, which fostered important changes in their own knowledge and practice with their infant.These interactions also enabled clients to recognize their own agency, even when they did not fully follow the MM’s counsel. A young mother spoke about the strength she was able to draw from conversations with her MM:PID2: When I forgot, she reminds me and say “did you do what I told you” and if I didn’t do it I say no I didn’t do it “why you didn’t do it?” so deep inside that thing is encouraging me to continue doing it till I get used to it because it also helps me, at the end it’s me who will be in [trouble]. So by doing that, she is strengthens me because she is the one telling me things.PID25: What was challenging, it was when she asked me to breastfeed for six months but I couldn’t, because I was going back to school and I was going to leave him behind so I was not able to do that … yes, she told me it is good [important] but I couldn’t, and I was like, ‘she will forgive me on this one.’Another client spoke about needing to make a decision about breastfeeding based on her own needs, despite understanding its benefits from her MM:PID22: I don’t fulfil some of the things she teaches me … it is on things that we need to eat [medicines we need to take] when we are not well, so I am unable to reach them because there is no money.By acknowledging her MM’s ability to “forgive” her, this client also described a sense of respect in the relationship, indicating her MM would not condemn her for her decision. Other clients similarly shared challenges to enacting certain advice from their MM due to financial or logistical constraints. Responding to a question about barriers, one client spoke about lacking funds for medicine recommended by her MM:Clients facing these situations might try to enact more feasible options, but continue to face constraints related to poverty.In describing and reflecting on their relationships with their MMs, clients also revealed how the Enable program provided a deeper sense of social support, through the mutual respect, responsiveness, and attentiveness of their MMs. This relationship, built over time, was described as valuable and distinct from other types of relationships.PID24: She is not a person that changes having different faces every day, she remains the same, and she is always humble and I can ask anything that I want to ask from her. She is just a person like that, I can even call her and ask how is this going, what must I do now.Sharing their experiences with MMs, clients iterated that respectful, supportive interactions were essential to their perspective of the program and their MM relationships. They described supportive qualities that their MMs practiced in typical engagement. Consistency and continuity were highly valued:PID5: Since we know her, she is from here, when we have something that we do not understand, we just talk like [MM name], what it is about a certain thing, just like that because we know her. If you can come as another person [from outside the community] maybe we can have things that we are afraid of, but we are not afraid of her.In addition to experiencing support through warm interactions with MMs, clients spoke of knowing a MM through her community embeddedness—reiterating a sense of security, trust, and familiarity that comes with health workers operating in their own communities.PID17: She is diligent to this job but even before she started doing this job she was diligent, she cannot manage to watch someone suffering, even if it’s not her family member, that is her nature … most families here are getting social grants because of her.Where this support was tangible, it further affirmed the role of a MM, showing how she was able to build on existing trust with additional resources.The supportive qualities revered by clients centered on more personal, community-based attributes, facilitating their acceptance of the MM program.Clients also reflected on the importance of having a supportive peer and health paraprofessional in their lives. Many women described a tangible feeling of support that extended beyond what they saw as the purview of the MM; a few women were stricter about drawing boundaries around the role of the MM. These reflections centered on the individual MM’s actions, and did not cover higher-level support from Enable’s supervisors which was also part of the program.One client described a surprise visit from her MM, who arrived on her day off to check on the client’s progress following a health complication:PID11: Hey she once surprised me, she came on a Saturday the time my stitches were damaged, I called her Friday evening and she came, shame, on her off-duty day, she was telling me that “I’m not working but I will come just for your sake”.Interviewer: How did you feel about that, like it was not her day on duty but still when you are in trouble she comes to help you?PID11: It’s kind of...I took her as someone who is dedicated to her work, she does not have that “I’m supposed to be doing my things” and all that, but she can sacrifice her time and do what she [is] supposed to be doing.Our Mentor Mother is very diligent, I love her … it doesn’t matter where she is, if she is at work, she would say after work I will come and listen to what you are calling me for, here at home we like inviting her even if we just sitting we will just call her (PID14).Another client echoed a similar sense of feeling supported outside of typical visits, with a broader household audience absorbing her MM’s advice:These interactions showed a willingness on the part of the MM to work outside the structure of her job, and to put time into fostering positive relationships, even if it meant sacrificing her own time—something that clients felt humbled by.I can say she is more like a parent to my child more than me.” When prompted further, she explained:For particularly vulnerable clients, extended support could act as a lifeline. One young mother who lacked a broader family support system stated, “Because she can advise and I know nothing about a child, saying this is how to take care of a child, telling me about the stages of a child, telling what to feed a child when a child is at which stage and breastfeeding when she was still breastfeeding” (PID2).“Another young mother, who was pursuing her further education away from home without any support from her child’s father, described the emotional support her MM provided:That is what I need, I need somebody, when I cry I feel like there can be someone to give me something positive, as I’m negative and she is always positive” (PID11).“PID26: She would say, ‘never lock yourself with poverty alone here, when you have nothing [to cook] you must phone.’Interviewer: Okay, how does that make you feel, someone saying such things to you?PID26: I feel happy sister, because these days there is no one who can care for you like that.Despite the high level of poverty in the program catchment area, some clients were worse off than their peers because of lack of support, child disability, or living in extremely remote households. One client, who cared for a disabled child completely on her own, shared the extent of her MM’s support:This client and a number of others reflected on times when their MMs provided important assistance when clients were in desperate circumstances—reiterating that this support sometimes took on an instrumental role beyond the emotional and informational roles that MMs played.In a few cases, clients were less inclined to seek additional support from their MMs. These individuals were aware of limitations of MMs’ roles, or seemed to question the extent of MM confidentiality while also being embedded in the same community. One client in particular spoke about the differentiation between official and unofficial “duties”, noting that even if she were to mention specific challenges in passing to her MM, this would not constitute part of the visit. When asked about specific stresses she might discuss, she noted:PID1: She took care for us while we were pregnant and she is still taking care of us as we have children, so I just think those stress issues are just … it’s just a talk after she finished her duties, you see.Interviewer: Okay.PID1: Like telling her that me and my husband we had a problem and I was hurt here and there, so just a talk … It’s not part of her work when I think.PID24: So I would share my problem with you, but since you know me you share it to your loved one, and that one share to another one … So that is what tells me that my problem is my problem, I cannot share it to a Mentor Mother.Even if these conversations took place, this client did not feel her MM was any more able to counsel her on these kinds of challenges than a friend might be. Some clients also felt that there was a limit to the support they could seek from MMs, even if confidentiality was discussed, as they came from the same small, tight-knit community. One client described a hypothetical situation:These perspectives about how MM roles might be limited reflected a sense of caution and care from clients, and highlighted diverse approaches to the client-MM interaction.We explored clients’ experiences of a home visiting program for maternal and child health to gather perspectives on the program, and more specifically, on clients’ relationships with their Mentor Mothers. This analysis helps to identify potential areas for strengthening programming from the perspective of those receiving services directly. It also offers a chance to consider the trade-off between accomplishing tasks and cultivating relationships in similar CHW programs.Overall, client perspectives were positive and reinforced the aims of the Enable program. Clients shared reflections on having an ongoing relationship with their MM, and what this engagement meant for their health and wellbeing. These relationships were central to their experience of Enable, and clients described ways in which these relationships motivated them through a combination of education and encouragement—helping increase their confidence in health-related decision-making. These findings on supportive relationships and enabling encounters map onto existing understandings of how lay health worker interventions activate behavior change –37, as wThese perspectives also raise the question of how, and why, these kinds of relationships and interactions are possible in community health settings. Prior research on CHWs has identified obvious advantages that community members may have in enacting these roles: these relationships can take place outside of clinical hierarchies, with someone from a similar or same community . They maAt the same time, these relationships can also be fraught, as CHWs are tasked with navigating tensions between formal and informal modes of work, and similarly, with projecting a certain image as a professional while also maintaining a degree of relatability . It is eImportantly, not all relationships were described as equally positive. A small subset of clients shared reservations about their MM, related to confidentiality concerns or lack of clarity around the scope of the program. It is also important to note that not all CHWs are equally committed, or receptive to training, and that some CHWs may struggle to build durable, reciprocal relationships with all of their clients . FurtherThese client responses can also be seen as a strength of the program model—enabling clients to exercise agency, challenge advice that does not work for them, and find ways to compromise where possible. This was evident even in data from clients who spoke warmly about their MMs, but who faced additional barriers to adopting different strategies. For some mothers, fully taking on their MM’s advice was more challenging in their specific circumstances, and not always an act of resistance or reluctance. That clients sometimes did not follow their MM’s advice could be seen as contrary to the program’s aims, by stalling progress towards certain health goals. In some cases, this was out of necessity, not choice. However, these modes of engagement are also critical for empowering clients to find their own solutions, especially when evidence-based program goals confront context-related constraints.This analysis adds an important perspective, largely missing from the literature on CHW programs and task-shifting, by incorporating the voices and priorities of clients. Clients’ perspectives provide insight into the kinds of services and interventions they prioritize, and thus offer a way to map these priorities against programmatic goals. For instance, supportive relationships are often seen as a means to achieve intended program outcomes in lay health worker interventions . HoweverThese findings also suggest that even when information and activities are present and prioritized by intervention designers, supportive relationships form an equally important part of these programs, and the ability to draw on existing bonds can make programs more effective. Clients’ characterizations of these relationships, and how they engaged their MMs over time, provides fresh insights into how evidence-based community health programming can and should draw on principles of equity and respect in theorizing how behavior change can happen. Interestingly, clients did not often draw on experiences where Enable’s supervisors intervened to connect them to more tangible resources through additional referrals or connection to government-provided social services. Instead, interviews tended towards a narrower focus on the nature of the MM-client relationship.These findings fill some gaps in concurrent research published by our team, with the Enable program, on MM-client relationships . Our teaRelatedly, this analysis raises interesting questions about fidelity and adherence to the program: as noted above, clients did not always listen to their MMs, nor did MMs always adhere strictly to their job description. While measures of fidelity and adherence are sometimes used to explore the effectiveness of CHW programs, qualitative data may be able to highlight where these defined measures can fall short. Clients were clear that their relationships were able to provide them a sense of agency and collaboration in the routine visits. Less evident, but still present in these findings and in other related interviews, was the flexibility that MMs themselves employed to support clients and build trust—even when these actions occurred outside of the bounds of their job’s expectations . Other rThese data, directly gathered from clients of the Enable program, offer insights into how to tailor specific delivery aspects of this particular program. They also provide lessons for wider-ranging programming and policies surrounding adapted models of community health programs in LMICs, specifically attuned to implementer-client relationships, while acknowledging existing tensions.Firstly, our findings point to implications for training and program delivery. Programs that leverage a more complex range of skills, including counselling skills, in training have been found to produce better quality of care . WorkingSecondly, these findings indicate the need to integrate more regular client feedback through channels that can feed into practice. While MMs typically provide individualized services to different clients based on need and ability, it may also be important for MMs to communicate the scope of their possible role and set boundaries from the time of client enrollment in the program . This prOur study found that clients of a maternal and child health home visiting program formed relationships with their home visitors based on instructive, supportive care. We also found that most clients also felt a sense of agency and confidence from these interactions, even when they were unable or unwilling to fully adhere to health counsel. As community-based health programs are increasingly relied on for increasing access to health care, conscious decisions to solicit the perspectives of clients should be prioritized to maximize the potential of these programs.Additional file 1.


Complex interacting social, economic and historical factors influence the availability and uptake of alcohol and drugs, including among Indigenous communities. Self-harm and suicide as well as homelessness and incarceration, can both precede and result from drug and alcohol use. Rates of self-harm, suicide and incarceration among Aboriginal and Torres Strait Islander people in Australia are among the highest in the world and drug and alcohol treatment programs need to address these underlying complexities. This study examines whether an ‘holistic’ residential drug and alcohol treatment program for adolescents, with over 30% of clients identifying as Aboriginal and Torres Strait Islander, can improve outcomes post-discharge, including reducing self-harm, suicide attempts, arrests and alcohol and drug use. The program addresses substance use, mental health, employment, accommodation, social/community and family life. Program admission and 3 months’ post-discharge data from 2007 to 2016 were analysed.n = 18) who reported suicide attempts in the 3 months prior to admission reported no attempts in the prior 3 months at follow-up. There was also a significant reduction in self-harm with 23 young people out of the 27 who reported self-harm at baseline not reporting self-harm at follow up (85%) and in the proportion of adolescents who reported using cannabis, amphetamines and alcohol, as well as a reduction in the proportion who reported being arrested.From 2007 to 2016, 619 Aboriginal and Torres Strait Islander young people were admitted to the program; 247 stayed in the program for 30 days or more; 89 were successfully followed up three months post-discharge to determine whether there was a significant improvement from baseline using the McNemar’s Test and the Wilcoxon Signed Ranks Test. On admission, 18 people (20%) of the study population reported attempting suicide in the last 3 months and 23 people (30%) reported self-harm. Most had been engaged in the criminal justice system, with 67 people (75%) having been to court and 62 people (70%) arrested one or more times in the past 3 months, with 35 people (41%) in unstable housing, reporting having lived in three or more places in the previous 6 months. At 3 months post-treatment, all (The findings provide support for an ‘holistic’ residential treatment program as an approach to improve health and related outcomes for Aboriginal and Torres Strait Islander young people. In addition to a focus on multiple aspects of a young person’s life in treatment, culturally relevant modes of treatment and support should be a future focus to further strengthen programs when Aboriginal and Torres Strait Islander young people are over-represented in the client group. Complex interacting social, economic and historical factors influence the availability, uptake and use of alcohol and drugs as well as the strategies used to reduce associated risks and harms. Factors, such as homelessness, lower socioeconomic status, incarceration and violence, can both precede and result from drug and alcohol use  with the year 12 retention rate being 55.1% compared to other students (82.9%) AIHW, . EmploymNational health frameworks  approach modified for young people (aged 13–18 years) who have problems with drugs and alcohol (see Participants section). A TC approach utilises the live-in community as a treatment tool and catalyst for change, with emphasis on treating the whole person De Leon, . The proThe program takes a harm minimisation approach, not expecting all individuals to be abstinent post-treatment AIHW, . The goaYoung people are referred to the program from the juvenile justice system, and community  with high levels of trauma, poor mental health, history or arrests and unstable housing  Ethics Committee of NSW (Ref: 1144/15). Approval was also received from the Human Research Ethics Committee (HREC) of the University of New South Wales (UNSW) (Ref: HC13014). An Aboriginal Advisory Committee (AAC) guided the study, with representatives of Aboriginal organisations, researchers, staff and young people who have completed the program. All young people consented to their data being used in research.The study design was a pre/post treatment program follow up study. Data included baseline and three-month follow-up repeated measures for young Aboriginal and Torres Strait Islander people admitted to the program from beginning 2007 to end 2016 who stayed 30 days or more; this is the timeframe used to determine eligibility for 3 months’ post-discharge follow-up by the program. Data were collected over the telephone by program staff using an electronic database to enter responses to the assessment instrument.Drug use measures included current use (yes/no) of the three most common drugs: tobacco, cannabis and amphetamine type stimulants (ATS) , Family Assessment Device (FAD) and Social Functioning Scale (SFS) with IBM SPSS Statistics Version 17 used to analyse the data.To measure statistical significance of ordinal variables, the Wilcoxon Signed Ranks Test was used with a cut off of From 2007 to 2016, 619 Aboriginal and Torres Strait Islander young people were admitted to the program; 247 stayed in the program for 30 days or more; 89 were successfully followed up 3 months post-discharge (36% response rate). Of the 89 followed up, 82 self-identified as Aboriginal (92.1%), three as Torres Strait Islander (3.3%) and four as both Aboriginal and Torres Strait Islander (4.6%).2 (1) = 7.30, p = .007. There were no other differences between males and females. The table also shows males (36%) and females (50%) commonly reported living in three or more places in the past 6 months.As shown in Table n = 30; 51%) compared with young men , . There were otherwise no significant differences between those who were followed up (n = 89) and those who could not be followed up (n = 158) across key variables: arrests in the last 3 months , suicide attempt  or self-harmed in the last 3 months , spending time with family , time with friends who do not do drugs  and number of residences in the past 6 months . There was also no difference between the two groups in scores on the Severity of Dependence scale .Given that only 89 of the original 247 (36.0%) Aboriginal and/or Torres Strait Islander adolescents who stayed in the program for 30 days or more were successfully followed up, it was considered important to compare these 89 people against the 158 (64.0%) who could not be followed up on key study variables. Of the original 247 people, there were 59 young women (23.9%) and 188 young men (76.1%), of which a higher proportion of young women were followed up (n = 247), the number of days in residential treatment ranged from 20 to 120 days. The 89 participants in the study who were able to be followed up spent a significantly greater number of days in PALM  compared with the 158 people who could not be followed up  = − 3.15, p = .002).Among the population of Aboriginal and Torres Strait Islander young people who attended PALM for at least 30 days  are compared against follow-up data for the 89 Aboriginal and Torres Strait Islander adolescents who stayed in the program for 30 days or more and were successfully followed up.p < .001). As shown in Table The proportion of Aboriginal and Torres Strait Islander young people who reported use of ATS, cannabis and tobacco in the last month was compared prior to admission and 3 months’ post-discharge (Table p < .001)   in the number of days young people reported drinking alcohol in the last month  in the number of drugs used prior to admission and 3 months post-discharge, as shown in Table There was a significant overall reduction . Among the young people, the median score decreased for 67, increased for 11 and stayed the same for 2 people  median score prior to admission was 8.00 which significantly decreased to 4.50 at three-month follow-up  and no significant difference in the Social Functioning Scale (SFS) mean score  prior compared to post-discharge.Change in scores on two scales prior to and at 3 months’ post-discharge from the program was analysed Table . There wp = 1.00) (Table p = .052). The majority of young people (66.3%) spent no or little time with friends who did not use drugs at both baseline and at 3 months’ follow-up.There were no significant changes in the reporting of time spent with family before admission and 3 months post-discharge  in the direction of fewer people attempting suicide at follow-up compared with baseline (Table p < .001). Twenty-three young people (out of the 27 who reported self-harming in the 3 months prior to admission) reported no self-harming in the 3 months’ post discharge.There was a significant change between pre-and post-reported suicide attempts by Aboriginal and Torres Strait Islander young people, . However, there was a significant decrease in the proportion who reported being arrested prior to admission and 3 months post-discharge . There were 47% of young people who reported one or more arrests prior to admission, shifting to reporting no arrests 3 months post-discharge. This was a greater proportion than the 4.8% of young people who reported no arrests in the 3 months prior to the program and were arrested during the 3 months post discharge.Aboriginal and Torres Strait Islander young people’s engagement in work or study and arrests in the previous 3 months were compared pre-and post-program (Table This study examined how Aboriginal and Torres Strait Islander young people, following 30 or more days in a ‘mainstream’ residential drug and alcohol treatment program were faring after treatment. The analysis compared data at admission to community follow-up at least 3 months post-discharge. To our knowledge, this is the first study to undertake treatment follow-up measures with this population.This study demonstrates therapeutic communities are an intervention worthy of further examination in relation to preventing self-harm and suicide among Aboriginal and/or Torres Strait Islander people, whose rates are among the highest in the world (Dudgeon et al., Significantly fewer Aboriginal and Torres Strait Islander young people reported using alcohol again since completing the program, with fewer days using alcohol for those who continued to drink. Number of drugs used, and frequency also significantly reduced, and the Severity of Dependence Scale scores significantly improved. These results suggest the program and its components have contributed to reducing drug and alcohol use for at least some of the Aboriginal and Torres Strait Islander young people who participated in the program. Despite a significant reduction in the number using cannabis post treatment compared to baseline, 64% of the sample were still using cannabis at follow up. The reasons for the lack of impact on the use of cannabis among these young people requires further research. The improvements in life circumstances and reductions in related problems surrounding alcohol and drug use, such as arrests were found. It is well-known that Aboriginal and Torres Strait Islander young people are over-represented in youth detention, with a majority in adult prisons having previous periods of incarceration ABS, . The speThere were no significant differences for Aboriginal and Torres Strait Islander young people spending time with friends who did not use drugs or spending a fair or a lot of time with family pre-to post program. A change to peer networks can be important post treatment given the potential influence peer groups can have on young people’s drug and alcohol use (Brown et al., The finding that time spent with family, often seen as an important source of support (Tsey et al., The loss to follow-up in this study is a limitation. Loss to follow-up is an issue in many adolescent drug and alcohol treatment studies Tripodi,  and thisA comparison was made between those who were followed up and those lost to follow up and no differences were found on key socio-demographic measures or among key variables which were the focus of the analysis except that a higher proportion of young women were followed up compared with young men. This is a limitation of the study. Young men are possibly harder to follow up in the community as at baseline young men were significantly more like to be court involved than young women and this difference may persist post treatment for those young men lost to follow up. Additionally, those lost to follow up had a significantly shorter length of stay than those who were followed up.The current study was focussed on those who had a length of stay of 30 days or more given the relationship between length of stay and outcomes (Darke et al., A further limitation is that the measures used were not developed specifically for Aboriginal and Torres Strait Islander young people. The service has used the best available and accepted measures in the field and the psycho-social measures have been validated in a range of studies as detailed in Table Findings of this study provide some support for the capacity of ‘mainstream’ drug and alcohol residential treatment programs to provide positive outcomes for Aboriginal and Torres Strait Islander young people. Culturally-relevant modes of treatment and support are particularly important when Aboriginal and Torres Strait Islander young people are over-represented in the client group compared to in the community population (Gray et al., This study followed up Aboriginal and Torres Strait Islander young people after attending a residential alcohol and drug treatment program in Australia. Given the limited evidence about outcomes among these young people following treatment, this study makes and important contribution to the field. Several significant improvements were found in reduced drug use, arrests, self-harm and reported suicide attempts, although study limitations suggest caution in attributing changes directly to the program. Nonetheless, the study provides some evidence for the effectiveness of a residential treatment program using a Therapeutic Community approach for Aboriginal and Torres Strait Islander young people with problematic drug and alcohol use.


BCR gene, though less frequently also due to variation in the ABL1 breakpoint. The 3 most common BCR-ABL1 variants are identified by their protein molecular weight as p210 (e13a2 or e14a2), p190 , and p230 (e19a2); alternative breakpoints are extremely rare.1 In myeloproliferative neoplasms, the presence of the Ph chromosome is diagnostic of chronic myeloid leukemia (CML); however, this translocation is also seen in approximately 2% to 3% of children and 20% to 30% of adults with acute lymphoblastic leukemia (ALL).1 In addition, the 2016 World Health Organization (WHO) Classification has recently added a provisional entity of Acute Myeloid Leukemia (AML) with BCR-ABL1, which is an extremely rare AML subtype.2 Tyrosine kinase inhibitors (TKIs) targeting the BCR-ABL1 fusion gene are standard therapeutic agents effective for CML and used in combination with chemotherapy for patients with Ph chromosome positive (Ph+) ALL; however, there is little data regarding the use and efficacy of TKIs in Ph+ AML. We describe, to our knowledge, the first published case of a Ph+ AML patient with a BCR-ABL1 breakpoint at e1a3 who subsequently developed an ABL1 T315I mutation after treatment with dasatinib monotherapy.The Philadelphia (Ph) chromosome is a reciprocal translocation between chromosomes 9q34 and 22q11. The resultant BCR-ABL1 fusion protein can vary in size, primarily based on the specific breakpoint in the 9/L) with 68% blasts, absolute monocytosis (13.4 × 109/L), mild eosinophilia (0.8 × 109/L), and no basophils. The hemoglobin was 9.7 g/dL, and platelet count was 204 × 109/L. Laboratory results from 5 months prior revealed normal blood counts. There was no splenomegaly on exam. A bone marrow (BM) biopsy revealed 78% blasts by manual aspirate differential in a hypercellular (95%) marrow. Flow cytometry of the peripheral blood revealed expression of CD11c, CD13, CD15, CD33, CD34, CD38, CD64, HLA-DR, and TdT with aberrant CD7, consistent with AML. Conventional cytogenetic analysis was positive for t as a sole abnormality in 18 of 22 metaphases. Three additional metaphases represented abnormal tetraploid subclones with 2 copies of the Ph chromosome. An interphase FISH assay with a Vysis BCR/ABL1 Dual Fusion translocation probe  confirmed the presence of BCR-ABL1 in 91% of the cells. A 35-gene next-generation sequencing panel revealed only a nonsense mutation in stromal antigen 2 (STAG2 R1242∗).A 68-year-old male with a history of dementia, coronary artery disease, type 2 diabetes mellitus and pulmonary alveolar proteinosis presented to the Emergency Department with a 2-week history of shortness of breath, malaise and anorexia. At presentation, a complete blood count revealed a marked leukocytosis  studies targeting the canonical BCR-ABL1 p190 (e1a2) and p210 (e13a2 or e14a2) transcripts were performed on RNA extracted from the patient's BM sample. BCR-ABL1 transcripts were not detected in either the p190 (e1a2) or p210 RT-PCR assays. In order to identify an alternative breakpoint, a qualitative RT-PCR assay was performed, which can detect all known fusion BCR-ABL1 fusion transcripts. A variant BCR-ABL1 e1a3 transcript was detected, in which BCR exon 1 is spliced into ABL1 exon 3  57 days after initiating dasatinib therapy. After 3 months on dasatinib therapy, bone marrow biopsy revealed normocellular bone marrow (30%–40%) with trilineage hematopoiesis and 4% blasts indicating a CR. Interphase FISH for BCR-ABL1 fusion remained low positive (3% of 200 cells scored) and flow cytometric minimal residual disease testing revealed 0.04% aberrant myeloblasts. The patient was deemed to be a very high-risk candidate for allogeneic stem cell transplant  due to his comorbidities and declined further work-up.Due to the patient's comorbidities and poor performance status, he was determined not to be a suitable candidate for induction chemotherapy. He was started on dasatinib 140 mg daily (off-label use) for Ph+ AML. The patient achieved a complete hematologic response . After 2 months on ponatinib, bone marrow biopsy revealed normocellular bone marrow with 1% blasts indicating CR. FISH results confirmed BCR-ABL1 in 10% of interphase cells and MRD by flow cytometry was positive at 0.9%. Blood counts remained normal and repeat peripheral blood FISH results after 6 months of ponatinib therapy revealed BCR-ABL1 in 6% of interphase cells revealing ongoing MRD. Unfortunately, this patient developed relapsed AML 8 months after initiating ponatinib. He subsequently received palliative care and died 17 months after initial diagnosis.After 7 months on dasatinib, the patient presented with bilateral pleural effusions and acute kidney injury. Thoracentesis was performed, and 21% blasts were identified in the pleural fluid. Peripheral blood counts remained normal with only rare blasts. Bone marrow biopsy confirmed relapsed AML with 41% blasts by manual aspirate differential. BCR-ABL1 variant transcript. While AML with BCR-ABL1 is rare, it has been described in 0.5% to 3% of cases of AML and is considered adverse-risk by both the European Leukemia Net and National Cancer Center Network Guidelines.5 While it is clinically challenging to distinguish between CML in blast phase and de novo Ph+ AML, the patient meets WHO 2016 criteria for AML with BCR-ABL1 with previously normal blood counts and no basophilia or splenomegaly at diagnosis, which has been associated with a diagnosis of AML with BCR-ABL1 rather than CML-blast crisis.14 The majority of Ph+ AML cases reported in the literature have been associated with the p190 transcript (e1a2), p210 transcript, or co-expression of both transcripts.3 The rare e6a2 transcript has also been described in 5 cases of Ph+ AML and has been associated with particularly aggressive disease.6This is the first published case of Ph+ AML with the e1a3 BCR-ABL1 transcript. The e1a3 transcript has been described in 7 cases of chronic phase CML .14 The median duration of response was only 2.5 months and median overall survival amongst all 16 Ph+ AML patients in that series was 9 months.14 Of note, these patients were all treated prior to the approval of second-generation TKIs. In a later review series of 21 patients with Ph+ AML treated with TKIs, most patients were treated with standard induction chemotherapy with the addition of a TKI and 38% of patients underwent allogeneic SCT15 (Supplementary Table). Of the patients unfit for transplant who received maintenance treatment with TKI alone, 92% achieved CR with median survival of 18.5 months.15 Only 2 patients in this series did not receive standard induction chemotherapy, and both were treated with TKI alone. One patient achieved a CR with single-agent TKI induction and consolidation while the other patient relapsed after allogeneic SCT and died 16 months after diagnosis.15 Resistance mutation data was not reported in these analyses.The efficacy of TKI therapy in combination with chemotherapy for Ph+ ALL has been extensively investigated for over 10 years.BCR-ABL1 with the rare e6a2 transcript, 3 patients underwent allogeneic SCT and achieve sustained response with second-generation TKIs following transplant. The fourth patient had a particularly aggressive course and was refractory to TKIs.6 Therefore, while there appears to be a role for TKIs in AML with BCR-ABL1, further studies are needed to elucidate the optimal agent and dosing strategy, particularly in the setting of patients not suitable for intensive induction chemotherapy.The response to TKIs in the setting of rare transcripts in Ph+ AML has only been reported for the e6a2 transcript. In reported cases of AML with BCR-ABL1 with the rare e1a3 variant. This patient received single agent dasatinib 140 mg daily and achieved MRD+ CR after 3 months of therapy. While this patient relapsed on dasatinib with a T315I mutation, he again achieved CR (with MRD) on ponatinib but subsequently relapsed and unfortunately died of progressive AML. Given the extremely rare incidence of the e1a3 Ph chromosome, it is unclear if TKI therapy is effective for this cohort of patients; nonetheless, limited data available suggests that TKIs may be effective alone or in combination with chemotherapy for AML with BCR-ABL1 (Supplementary Table). Of note, we recommend interpreting this data with caution given the exceedingly positive results, which may be biased by the preferential publication of cases with favorable results. While AML with BCR-ABL1 is a rare entity, given the therapeutic implications, we recommend performing FISH analysis for t in patients in whom routine cytogenetics is not readily assessable or in patients with normal karyotypes with no known driver mutations. An international consortium would be best suited to derive further data and assess different therapeutic strategies in patients with AML with BCR-ABL1. All patients with AML with BCR-ABL1 detected by FISH should have PCR performed to detect the specific BCR-ABL1 transcript affected. If BCR-ABL1 PCR is negative for the most common BCR-ABL1 transcripts  then qualitative analysis for rare fusion transcripts should be performed. Patients with rare BCR-ABL1 fusion variants should be managed similarly to patients with common transcripts, including with TKIs; however, further study is warranted to determine whether specific BCR-ABL1 fusion transcripts may impact duration of TKI response and overall prognosis.In summary, we report the first published case of a patient with AML with JFZ has received honoraria from AbbVie, Agios, Celgene, Daiichi Sankyo, Genentech, Pfizer, and Takeda, has served as a consultant for AsystBio Laboratories, Celgene and Takeda, and has received research funding from AROG, Celgene, Forty Seven, Merck, Takeda, and Tolero Pharmaceuticals.CCC has served as a consultant for Abbvie and Covance, has received honoraria from Abbvie, H3 Biomedicine, LOXO, Octapharma, and Pharmacyclics, and has received institutional research funding from AROG, Gilead, Incyte, LOXO, and H3 Biomedicine.For the remaining authors, no relevant conflicts of interest were declared.


A Colon Cancer–Free Zone toolkit was developed for use by Extension Agents to implement the program at worksites in their service communities.Colorectal cancer is the third leading cause of cancer death in the USA, yet is highly preventable and detectable at an early stage through screening. Virginia Cooperative Extension (VCE) implemented a worksite colon cancer awareness program to increase colorectal cancer screening rates and preventive lifestyle behaviors among its employees. The Colon Cancer–Free Zone program is designed using best practice principles of worksite health programs and includes information sessions covering the topics of colorectal cancer, screening guidelines, insurance coverage, and preventive lifestyle behaviors. It is conducted in a campaign format that includes a strategic communication strategy targeting relevant screening barriers and facilitators, peer champions, and incentives. The program was implemented with VCE employees statewide utilizing a web-based system for the information sessions, and resulted in broad participation, a significant increase in screening self-efficacy  contains supplementary material, which is available to authorized users. Colorectal cancer (CRC) is the third leading cause of cancer-related death in the USA among men and women; yet it is highly preventable and detectable through healthy lifestyles and screening , 2. New Interventions aimed at increasing colorectal cancer screening have targeted providers, health care systems, and direct patient education in community-based settings . ApproprThe Cooperative Extension System (CES) is a nationwide education and outreach network established in 1914 that uses research findings emanating from the over 100 state land-grant colleges and universities to equip Americans in rural and urban communities with the knowledge and skills to solve community, farm, and family problems. The CES has been providing evidence-based education in almost every county in the USA for over 100 years . RecentlIn line with the Framework, Virginia Cooperative Extension (VCE) joined a national effort to eliminate colorectal cancer as a public health issue, the National Colorectal Cancer Roundtable (NCCRT) 80% by 2018 initiative, in February 2016 –13. We iWe implemented a two-phase program to increase VCE screening rates and bring CRC prevention awareness to Virginia communities. The Colon Cancer–Free Zone (CCFZ) is designed using best practice principles of worksite health programs including acquiring administration buy-in, developing a strong communication strategy appropriate to the corporate culture, use of peer champions, and provision of relevant incentives for employee participation , 15. It Prior to implementation of the program, top administrative personnel announced that VCE had joined the National 80% by 2018 initiative during the annual VCE Spring conference and encouraged all employees to engage in the CCFZ activities being planned to increase CRC awareness and screening. We distributed a survey previously developed to identify factors associated with CRC use and based on health belief model (HBM) constructs  to VCE pTo encourage VCE employee participation across the state, “Colorectal Cancer Champions” were recruited from employees in each of the 4 state VCE districts. These individuals volunteered as champions and had an interest in the topic due to experience, either personal or among family or friends, with colorectal cancer. They transmitted information about upcoming information sessions, distributed social media messages that were part of the program, and encouraged conversation about colorectal cancer within their district offices. The communication plan was developed using guidance provided by a communications guidebook developed by the NCCRT , informaA program website, Facebook page, and Twitter account were created to facilitate communication. The national key message that colorectal cancer is preventable, treatable, and beatable was repeated in all communication platforms. Facebook posts and tweets were scheduled to be delivered across 6 months, starting 2 weeks prior to the first information session. Motivational messages appropriate for our target audience of unscreened individuals with health insurance were provided through these platforms and included messages addressing control, expectation, trust, and empowerment. Testimonials of colleagues were also posted on the webpage and Facebook page. In addition, a poster announcing the VCE 80% by 2018 program was produced and provided to all 107 county Extension offices for posting.Finally, employees were encouraged to sign a CCFZ “pledge” as a call to action. The pledge was available in both paper format distributed by the Colorectal Cancer Champions and electronically on the website. Signers pledged to get screened for colorectal cancer if they were eligible, to know three simple facts about colorectal cancer provided on the pledge card and to talk to three additional people about colorectal cancer prevention and screening.A validated twenty-eight question health beliefs survey evaluating factors associated with CRC use and demographics of respondents was distributed to the VCE personnel in February 2016 during the in-person annual VCE conference [t tests were conducted on the pre- and post-scores to evaluate change in health beliefs. Spearman’s correlation was performed on data from the post-survey to evaluate the relationship between the number of program activities that an individual participated in and health belief composite scores.The pre- and post-survey evaluated the attitudes of respondents around five health belief categories; self-efficacy (4 questions), benefits of screening (5 questions), barriers to screening (6 questions), susceptibility to colorectal cancer (3 questions), and severity of colorectal cancer (4 questions). Cronbach’s alpha analysis indicated internal consistency among questions within each belief category , so composite scores were calculated for each belief category. To accomplish this, responses to each question were given a number from 1 to 5, with “strongly disagree” as 1 and “strongly agree” as 5. In the case of questions where agreement indicated a health belief associated with negative engagement in colorectal cancer health behaviors, the number ordering was reversed. The average score for questions within each health belief category was calculated to get the composite score. A composite score of ≥ 4 was considered “positive”, while a score of ≤ 3 was considered “negative” to the engagement in health behaviors to prevent colorectal cancer. Paired sample Surveys to evaluate participant’s actions in response to the information sessions were conducted at the beginning of the second, third, and fourth WebEx sessions. The question, “Did you view any of the previous WebEx sessions,” was asked in order to direct those who had participated in a previous WebEx to the follow-up questions about actions taken relevant to that session’s content. Survey questions for each session are provided with the Data on colorectal cancer screening rates was provided by the major state health insurance company, Anthem Blue Cross Blue Shield. Historic claims data for colonoscopy, sigmoidoscopy, fecal occult blood test (FOBT), and fecal immunoassay test were used to evaluate the screening rate of VCE employees insured by Blue Cross Blue Shield in June 2016 before the CCFZ campaign was implemented and in June 2017 after the campaign.Data was also collected on CCFZ information session attendance and colorectal cancer screening pledge signatures.Two hundred and eighty-eight VCE employees (33%) responded to the pre-program colorectal cancer beliefs survey, and 115 (13%) responded to the post-program survey. The lower post-survey response rate was largely due to survey response solicitation being conducted electronically rather than in person in 2017.barriers to screening and severity of colorectal. Post-survey responses showed similar results  indicated a fear of getting colorectal cancer. Additionally, a large majority (86%) felt that they would live longer than 5 years if diagnosed with the disease.The majority of respondents of the first survey indicated positive health beliefs about each of the five belief categories. The questions within each health belief construct showed good internal consistency. Over 20% of respondents had negative responses for the categories of ts Table . A closeBased on the findings of the pre-program survey, the communication plan incorporated messages from the NCCRT communications guidebook into planned Facebook and Twitter posts that were designed to alleviate these specific barriers to screening and provide accurate prognosis information.Although colon cancer is the second-leading cause of cancer death, it is also one of the most preventable with early detection.There are several screening options available, including simple take-home options. Talk to your doctor about getting screened today!Examples:n = 31) of these respondents signed the colorectal cancer pledge, 42% (n = 26) took action to get screened, and 65% (n = 40) talked to someone about colorectal cancer. Over three-quarters of respondents had made changes in their diet to reduce their colorectal cancer risk. The most common dietary change was to increase fruit and vegetable consumption, followed by decreasing red meat intake, and increasing fiber intake. Forty percent of respondents also increased their physical activity. Specific changes in physical activity included beginning to exercise, increased exercise time or intensity of their exercise, and adding strength or flexibility training . Attendees represented 42 of the 107 counties in Virginia, with representation from each of the four Extension Districts. Sixty-two participants in session 2, 3, and 4 indicated that they had attended a previous session. Results from those who had attended a previous session showed that 50%  of respondents were aware that VCE had joined the NCCRT 80% by 2018 initiative. Questions regarding their engagement with the CCFZ program activities indicated that 39% had participated in an information session, 38% viewed the webpage, 36% talked to a colleague, 46% saw the campaign poster, and 50% had signed the colorectal cancer pledge. Only 5% had seen a tweet, and 11% participated in no program activities. Twenty-one participants indicated that they had been screened in the past year. Of these, 12 people responded to the question of whether they got screened due to the 80% by 2018 initiative, 5 (42%) indicated that they had.ρ = 0.029, N = 40). This increase strengthened when only those who indicated they had engaged in some way in the activities of the initiative were included in the analysis . There was no significant change in the other categories.The analysis of mean change in health belief category composite scores among those who completed both the pre-and post-health beliefs survey showed that there was a significant increase in self-efficacy  was directly correlated with the HBM categories of self-efficacy, perceived benefits of screening, and inversely correlated with perceived barriers to screening. Higher scores for the latter category indicate a negative impact on engagement in healthy behaviors related to CRC prevention Table .Table 3CThe screening rate of VCE employees increased from 52.7 on June 2016 to 73.3% on June 2017.The reduction of colorectal cancer incidence and mortality is a national priority . EvidencWe demonstrated the successful implementation of a worksite colorectal cancer awareness program, the Colon Cancer–Free Zone (CCFZ), with Virginia Cooperative Extension (VCE). The program resulted in a 20% increase in employee colorectal cancer screening rates and changes in dietary and physical activity behaviors that are shown to reduce colorectal cancer risk. The CCFZ is a multicomponent program that combines various strategies to increase knowledge, dispel misinformation, improve self-efficacy, and remove barriers to action. The key strategies of the program include accessible information sessions provided by recognized experts, relevant repeated messages transmitted through multiple media platforms, a call to action via a colorectal cancer pledge, peer champions and testimonials, and visible administration support.Due to the nature and size of the state Cooperative Extension service, most of the program activities were conducted virtually. The initial announcement of the CCFZ program was done by the administration during the annual VCE in person conference, and employees in county Extension offices were encouraged by the peer champions to attend the virtual information sessions together. Although the majority of individuals viewed the information sessions alone, fourteen county Extension offices attended one or more of the sessions in a group. The participation rate in the web-based sessions was approximately 9.3% . This does not capture the total number of employees who were impacted by the CCFZ program in some way, however. Ninety percent of the 115 employees that responded to the post-program survey indicated they were aware of the CCFZ campaign, and over a third had seen information on the webpage, talked to a colleague about colorectal cancer, or seen the information poster. Half had responded to the call to sign the CCFZ pledge. Of all of the program strategies, Twitter appeared to be the least effective, with only 5% of survey respondents indicating they had seen a tweet. Of significance, the number of program strategies that a person was exposed to was directly associated with greater self-efficacy, a higher perception of the benefits of screening, and decreased barriers to screening.Valuable information was gathered from the peer champions about their role in the program during informal interviews and a post-program survey. All of the champions were satisfied with the frequency and clarity of information they received from the program organizers and transmitted this information to colleagues in their district through email and announcements during district meetings. They confirmed that using multiple media platforms to transmit messages was necessary to reach more people and acknowledged that Twitter was the least effective as it is not commonly used by themselves or their colleagues. Key recommendations from the champions to increase program effectiveness were to have more peer champions, ensure support of program activities by administrators in the local Extension offices, and to encourage friendly competition between Extension locations by publicizing program participation by office location.Subsequent to the completion of the Colon Cancer–Free Zone within VCE, the program was adapted for use by Cooperative Extension Agents at worksites in their service communities. The timeframe of the program was shortened to a two- to four-week period, and information sessions were condensed to two sessions. Key elements of the program were retained, however, including the campaign atmosphere of the program, recommendation of demonstrated buy-in by worksite administration, a relevant communication plan, peer support, participation incentives, and a call to action. A toolkit with implementation guides, templates, and communication guides has been developed and was introduced to Cooperative Extension agents. Agent program uptake, implementation, and outcomes are being evaluated.ESM 1(DOCX 16 kb)ESM 2(DOCX 178 kb)


BackgroundCardiopulmonary arrest is an uncommon event in pediatric patients. Additionally, physicians-in-training see far fewer cardiopulmonary arrest events. Therefore, they have limited confidence in their resuscitation skills. Mock code training with active participation and debriefing may be an effective tool to fill this gap in experience. The aims of the study were to assess the impact of a mock code simulation program on patient outcome for children with cardiopulmonary arrest in a tertiary pediatric academic center and provide evidence that code simulations can improve the quality of cardiopulmonary resuscitation (CPR).MethodsThis was a retrospective cohort study conducted in a tertiary academic center. This study had two phases: Phase 1 before the mock code simulation program began (pre-intervention) and Phase 2 after the mock code program began (post-intervention). The data were collected from pediatric patients with cardiopulmonary arrest during the study period who met the inclusion criteria, and variables included the survival rate at hospital discharge, CPR initiation time, time to the first dose of epinephrine, and the adherence rate to American Heart Association (AHA) guidelines.ResultsA total of 13 patients in the pre-intervention period and 19 patients in the post-intervention period were included. The results showed a significant improvement in team performance represented by a decrease in CPR initiation time post-intervention and improvement in AHA adherence; however, the results did not show a significant difference in the survival rate or mortality within 28 days of the cardiopulmonary arrest event between the pre- and post-intervention groups.ConclusionsMock code simulation was a helpful tool to enhance team performance and improve the quality of cardiac resuscitation and cardiac arrest recognition, while its impact on the survival rate was not significant in our study. Cardiopulmonary arrest is considered to be an uncommon event in pediatric patients and requires timely and high-quality cardiopulmonary resuscitation (CPR) to improve outcomes ,2. PhysiA mock code, which is defined as a simulation exercise with a mannequin/human patient simulator that has no respiratory effort and/or no carotid pulse, helps to encourage interprofessional teams to collaborate and improve their teamwork and fast response skills ,10. ThesMoreover, conducting good debriefing after the simulation sessions and sustaining the program over time are other important elements that help to ensure a successful program and achieve better patient outcomes ,8,14-17.There are various approaches to resuscitation training. In situ simulation training holds the training session in a realistic environment and offers the opportunity to identify issues with the existing code processes, such as equipment availability, location, and functionality ,18-20. SDespite the educational model used in the mock code training program, the goal is to optimize the survival rate. Many of these programs found a strong correlation between the survival rate and high numbers of mock codes ,26-28. TFew studies have assessed the impact of mock code simulations on pediatric patient survival. Overall, it appears that this kind of simulation-based training had a significant positive effect on performance in a cardiac arrest situation ,12,13,15Our study aimed to assess the impact of a mock code simulation program on the resuscitation practice of resuscitation team, and patient outcome for children with cardiopulmonary arrest events in a tertiary pediatric academic center.Simulation program design and participantsThe mock code simulation program at King Abdullah Specialized Children Hospital, Riyadh, was established in 2015. This institution is the largest pediatric tertiary care medical center under the Ministry of National Guard - Health Affairs in Saudi Arabia. The hospital’s inpatient bed capacity is about 225, with the 25-bed pediatric intensive care unit (PICU) and nine specialized inpatient pediatric wards in which code simulation sessions have been conducted.Pediatric Simulation Training and Education Program (PediSTEP) is a multidisciplinary simulation program and offers different types of simulation programs such as high-fidelity and low-fidelity simulation, interprofessional simulation, and in situ mock code simulation.This in situ mock code simulation is held two to three times per month, at random time and place. It is announced as real code, allowing us to offer the training opportunity for team members in their real settings and work environment. The pediatric cardiac arrest team is composed of a pediatric resident as a team leader, pediatric ward nurses as first responders, pediatric intensive care nurse, respiratory therapist, pharmacist, and pediatric ward charge nurse.Multiple scenarios have been designed, including different types of common arrhythmias with structured debriefing sessions that focus on CPR and resuscitation skills. A low-fidelity mannequin is used for this purpose, while other instruments used, such as defibrillators, oxygen, medications, suction machines, and resuscitation carts, are from actual ward settings.Design, setting, and populationsThis was a cohort retrospective study conducted at King Abdullah Specialized Children Hospital at King Abdulaziz Medical City in Riyadh, Saudi Arabia.This study had two phases: Phase 1 before the mock code simulation program began (pre-intervention), between 1 June 2015 and 31 May 2016, and Phase 2 after the mock code program began (post-intervention), between 1 January 2017 and 31 December 2018; a six-month implementation period was excluded.Ethics approval for the study was sought from our local Institutional Review Board (IRB) at King Abdullah International Medical Research Center prior to data collection, and as this was an observational retrospective study and no identifiers were collected, the IRB considered the study exempt from the need for informed consent.All records of pediatric cardiopulmonary arrest occurring in the study periods have been reviewed. All patients aged one month to 14 years with cardiopulmonary arrest events that occurred in PICU or in the ER were excluded, as the settings of these two areas are different.Outcomes and measurementsThe primary aim of this study is to evaluate the impact of the mock code simulation program on team performance by assessing the CPR initiation time and time to the first dose of epinephrine.The secondary aims were to evaluate the adherence of the code team to the American Heart Association (AHA) guidelines and to determine the impact of the mock code simulation program on the survival rate of pediatric patients with cardiopulmonary arrest at hospital discharge. AHA adherence has been reviewed through CPR records and CPR Committee reports.Statistical analysisCategorical variables collected were sex, admission location of cardiopulmonary arrest, specialty of the most responsible physician, the days when the CPR occurred , timing of CPR , admission diagnosis, and comorbidities. The results are summarized as frequencies and corresponding p-values. Continuous variables age, weight, height, length of stay in the ward, time taken for the team leader to arrive, time to initiate CPR, duration of CPR, time taken to administer epinephrine, epinephrine doses, PICU stay duration, and length of stay in ward were compared between the pre- and post-intervention phases by using the Wilcoxon rank-sum test. The results are summarized as the means, standard deviations, and corresponding p-values. Odds ratios (ORs) were calculated for patient outcomes between pre- and post-intervention phases. The results are reported as ORs and corresponding 95% confidence intervals. AHA guidelines were compared between the pre- and post-intervention phases by using Fisher’s exact test. Significance was declared using a p-value less than 0.05. Analysis was carried out using SAS version 9.3 .The study sample was collected from the pre-mock code simulation phases. Between 1 June 2015 and 31 May 2016, 15 participants were excluded because they were not a real code or seizure. In the post-mock simulation program period (between 1 January 2017 and 31 December 2018) there were 23 participants, and four of them were excluded due to the same reasons. The pre- and post-intervention groups were similar overall (Table The results showed a significant decrease in CPR initiation time by 22 seconds (p=0.031); however, no significant changes were noticed in the length of stay either in the hospital or in the PICU  and electrical therapy for shockable rhythm (p=0.007), while the results for other elements did not significantly change between the pre- and post-intervention phases Table .Overall, the results in this study showed a significant improvement in team performance represented by a decrease in CPR initiation time after the mock code simulation program, in both the CRP initiation time analysis and the AHA adherence analysis, as both revealed faster CPR initiation, which may reflect that cardiac arrest recognition improved after the mock code simulation program, and the first responders initiated chest compression earlier. Other studies reported the same results related to the CPR initiation time, which was part of the team dynamics improvement in some of them ,25,29. IThe mock code simulation program can enhance overall CPR performance by improving cardiac arrest recognition and CPR initiation time and increasing adherence to AHA guidelines. These results suggest advantages of the mock simulation program in terms of team performance, while its impact on survival rate is not clear in this small sample. Thus, future research with a larger study sample size might show a significant relation between the mock code simulation program and survival.


As an attendee at various national and international conferences during the formative years of IVF in the early 1980’s, I distinctly remember how difficult it was to hear a myriad of laboratory and clinical techniques being described and to have any possibility of discerning which were best practices for IVF success. I concluded that the only way to be successful was to copy every aspect of the process from a successful program. I therefore took a sabbatical in Melbourne Australia with Alan Trounson and his clinical team at Monash, while also observing another successful program across town at The Royal Women’s Hospital with Alex Lopata. That experience convinced me of the critical role of a top quality IVF laboratory and allowed me to establish a highly successful IVF program on my return to UCLA (A few years later as President of the Society for Assisted Reproductive Technology (SART), I helped to set up a program with the College of American Pathologists (CAP) for accreditation of embryo laboratories in the U.S. and served as the first commissioner. However, the CAP model focused on quality control aimed at assuring accurate and reproducible test results, whereas the successful outcome of an IVF laboratory is a healthy baby. In the absence of any widely accepted best practices I realized that the most we could do was to develop an accreditation program emphasizing quality control. As just one example, a quality laboratory must have written procedures and an accreditation visit must verify that those procedures are being followed. rd year directing this University of California course, now on Coronado Island in San Diego in conjunction with the University of California San Diego. It currently attracts over 400 attendees, the majority of whom are from other countries (www.davidmeldrummd.com - click on “Coronado Island”).Recognizing the limitations of existing clinical conferences and the laboratory accreditation process, I realized that the best way to improve IVF results was to set up a postgraduate course with lectures on every aspect of IVF-ET by recognized authorities having good outcomes. Due to the world pandemic, July 18-21, 2021 will be be our 33The practice committee of ASRM has assumed the ultimate task in this process by beginning to publish best practices, as recently illustrated with their publication on embryo transfer  that there are about a hundred things one has to get right to have a highly successful IVF program. Onsite visits are not something I have chosen to spend my time on since then, but I found it very satisfying.The most important factor is the insight of individual program directors and their fellow physicians to accept their limitations and to be sufficiently motivated to spend the time to learn. Time out of the office to attend a course such as ours and time to read the journals can easily take second place to other demands of busy lives. They also might convince themselves that they have more difficult patients or use other excuses to explain away their lower results. Over the years I have had many experienced physicians attend our course looking for any improvements they can glean. It has been particularly satisfying to have had physicians from Melbourne, where I was first launched into the field. IVF practitioners should not be too proud to ask for help or to be seen at a course learning. IVF is a very “tough nut to crack”.Patient education is the most potent force to stimulate programs with suboptimal results to improve. SART membership gives some reassurance. It is not awarded to a programs without agreeing to have their laboratories certified and to publish their results subject to an on-site audit. Hopefully all other international societies will require the same. Couples seeking IVF care must carefully assess the qualifications and results of physicians and programs under consideration. The field of IVF has been more strictly regulated than most others, but consumers must do their homework, which information technology makes easier than ever.