To increase levels of physical activity (PA), interventions that create or enhance access to places for PA are recommended. Establishing a joint use agreement is one way to increase access to existing PA and recreational facilities. The purpose of this article is to present a case study of In-Motion, a pilot joint use agreement project at one urban high school in Honolulu, Hawaii.Residents of urban Honolulu are underserved by the amount of parkland and recreational facilities available for their use. The Honolulu County Department of Parks and Recreation sought to implement a joint use agreement to use the facilities of one urban high school for a recreational program. The high school selected for the pilot project has a student population primarily from low-income and ethnic minority backgrounds.An assessment of the potential of 7 urban high schools to implement a joint use agreement was conducted to select the pilot site. In-Motion developed and implemented a joint use agreement. PA preferences of students, staff, and community members were assessed to guide recreational program offerings. Various recreational classes were offered free to the school community.Several barriers to implementing the joint use agreement and recreational program were encountered. However, participants were satisfied with the recreational classes they attended and said that the In-Motion program helped them to engage in more PA. Program awareness by high school students and staff was high.In-Motion has successfully modeled a pilot joint use agreement and provided new opportunities for PA to the high school's students, teachers, and staff, and to community residents. Guide to Community Preventive Services recommends interventions that create or enhance access to places for PA combined with informational outreach activities  levels  of at letivities . These itivities . The reculations .Increasing access to safe places and opportunities for PA is particularly important for members of disadvantaged populations. Studies have documented decreased availability of opportunities for PA and of recreational facilities in low socioeconomic status (SES) neighborhoods and neighborhoods with high proportions of ethnic minorities ,8. ReducOne means of increasing access to places for PA is to establish a joint use agreement (JUA). Broadly defined, a JUA is a policy that allows for shared use of facilities among partners. It formally outlines the terms and conditions of use, management, scheduling, maintenance, and liability, as well as the roles and responsibilities of partners . AdvantaThe purpose of this article is to present a case study of In-Motion, a JUA pilot project of the City and County of Honolulu Department of Parks and Recreation (DPR) implemented at Farrington High School (FHS) in Honolulu, Hawaii. In conjunction with developing a JUA, In-Motion offers a recreational PA program to students, staff, and community members, using school facilities both during and after school hours. The mission of In-Motion is to create opportunities for PA that are fun and that promote participants' confidence in their ability to be physically active.In 2002, DPR sought to enter into an intergovernmental JUA with the Hawaii State Department of Education (DOE) to expand recreational activities for the youth and communities of urban Honolulu. Urban Honolulu has a shortage of community-based parkland coupled with a high population density. Compared with other areas of Honolulu County, urban Honolulu is underserved by the amount of DPR-maintained parkland and recreational facilities per capita resident population . The potFHS, the school selected for the pilot JUA project, enrolls one of the largest student populations (over 2500 students) in the state and serves students primarily from lower SES and ethnic minority backgrounds . ImmigraLocated in the Kalihi neighborhood area, the FHS community is composed of over 46,000 residents . In geneDPR received a grant from the Hawaii State Department of Health to implement the pilot JUA project. The grant was the primary source of funding, but additional financial support was provided by DPR and FHS. The project was approved by the University of Hawaii Committee on Human Studies. In-Motion was managed by 2 full-time project staff: a project manager (a DPR employee) and a project coordinator (a contracted employee).In 2004, DPR contracted an independent agency to assess the joint use potential of 7 urban Honolulu high schools . Data onOnce established at FHS, the pilot JUA project was named In-Motion. While the JUA was in development, In-Motion was able to conduct recreational activities. In January 2005, an initial JUA specific to FHS was drafted on the basis of an existing JUA developed in 1971 between DPR and DOE for the use of a baseball field. The JUA required approval from both DPR and DOE agencies, a multistep process involving individuals at different organizational levels. In the final step, the JUA was adopted by the Council of the City and County of Honolulu on June 7, 2006 (Resolution 06-159). Developing and officially approving the JUA took 18 months, and the support of the FHS administration was critical in enabling In-Motion to build its recreational program during this period.To determine which physical activities In-Motion should offer, DPR partnered with the Healthy Hawaii Initiative Evaluation Team (HHIET), composed of researchers from the University of Hawaii, in developing surveys for FHS students, teachers, and staff and for residents of the community. The survey for community residents was translated into Samoan, Chuukese, Vietnamese, Tagalog, and Ilocano. Surveys were distributed in December 2004 to FHS students and staff, parents of FHS students, and community organizations and low-income housing developments in urban Honolulu. Incentives  were given away during a raffle drawing to encourage participation. The surveys sought to determine which physical activities would be most popular, as well as the days and times that would encourage maximum participation in the In-Motion program.Surveys were completed by 1385 FHS students, 112 FHS teachers and staff, and 64 community residents. Approximately 40% of respondents  expressed interest in PA programs at FHS. The most convenient days and times for participation indicated were weekday afternoons, weekday evenings, and Saturdays. Students indicated that they wanted to attend PA classes during their school hours, especially during lunchtime. The most popular activities indicated were volleyball, strength training, and dance.The focus of In-Motion was providing organized recreational classes. Beginning in January 2005, In-Motion provided these classes to students, staff, and community members. Classes were advertised as "free and available to everyone," targeted beginning exercisers, did not have established routines, and were designed to provide a safe and fun environment to exercise. Activities were chosen on the basis of identified priorities, availability of instructors, availability of facilities, availability of existing activities in the community, suggestions from FHS administration, and student feedback. Depending on the number and type of recreational program offerings, approximately 6 to 8 instructors were hired for each program session.Teen classes included hip-hop, salsa, and swing dance; volleyball; learn-to-swim; circuit training; walking; hula; strength training; capoeira ; weight-loss support group; and Physical Fridays . Activities like capoeira, salsa dance, and volleyball were offered during lunchtime when students were free. In-Motion staff organized dance competitions and conducted volleyball tournaments for students. Field trips for off-campus recreational activities  were offered as incentives to students who logged time in the walking program.Adult classes were offered with different target groups in mind. Aerobics, yoga, and group exercise were offered during the early afternoon to target the FHS teachers and staff. Basic body fitness; hip-hop, salsa, and swing dance; and strength training were offered during the early evening to target community members who were on their way home from work. The water exercise class was offered to senior citizens during early weekday mornings. The walking program offered a window of time for any adults in the community to come walk on campus.Recruitment of participants for classes depended on the type of class and its target population. Teenagers were recruited through school publicity , physical education classes, and campus activities such as registration tables, lunchtime activities, social clubs, and performance demonstrations. Recruitment was also conducted at community organizations and middle schools.Adult participants were more difficult to recruit. Through a communications strategy developed by a contracted marketing company, multiple means of disseminating program information were identified. These means included radio-based public service announcements, newspaper advertisements, and flyers distributed throughout the community.Framework for Program Evaluation in Public Health  assumed responsibility for general cleaning and maintenance of the facilities and did not charge DPR any fees for use of facilities.Lack of writing expertise was an initial barrier to creating the JUA, and obtaining approval for the JUA required persistence. Once the document was written, the primary challenge was moving it through several bureaucracies in a timely manner. The JUA passed through many hands before it was heard by the City and County Health and Safety Committee and the full Council. This phase proceeded slowly, because both groups met only monthly. The status of the JUA was checked almost weekly, and without this shepherding, completion would have taken much longer. Although both agencies generally agreed on issues of liability and facility maintenance, reservations over the specific language of the document and delays in passing it among the many decision makers contributed to the lengthy process.Successful program implementation can be attributed to several factors. First, the primary key to success was the trust and effective communication established among key players, including the FHS principal and faculty and DPR project staff. Second, FHS administration, particularly the principal, were accommodating, providing office space on campus, communication systems, storage space for equipment, and administrative assistance. Third, In-Motion consistently adapted the programs in response to participant and instructor feedback. Fourth, In-Motion offered the recreational classes for free, thus eliminating one barrier for low-income families.Overcoming other barriers facing people from low-income and immigrant populations was difficult. For example, some parents did not speak or write in English well enough to complete permission forms, and some family members lacked transportation to FHS.Finding qualified staff available to teach activities during the day for a few hours per week also proved to be difficult; however, In-Motion was able to recruit several skilled instructors who could attract and retain participants. Recruiting teenagers to stay after school was another challenge, because many had other activities  or preferred to spend time with friends. However, once participants joined In-Motion, their word-of-mouth publicity was a powerful source of program recruitment and was crucial to garnering program awareness.Since project inception, In-Motion has served more than 1000 registered participants and held over 900 class sessions. As of December 2006, surveys were collected from 320 participants (participants from spring 2005 classes and lunchtime activities were not surveyed). More than 90% of participants present on the last day of class completed a survey; however, the overall response rate accounting for all registered participants was only 34%.Most participants were female (66.2%), younger than 18 years (52.8%), Filipino (40.9%), and FHS students (52.2%) . Most paAfter In-Motion recreational classes had been offered for 1 year, surveys were distributed to FHS students, teachers, and staff, and to community members to assess program awareness and impact. A total of 906 students (36% response rate) completed surveys. When asked whether they had heard of In-Motion, 66% (n = 599) of students indicated that they had. Of the students who were aware of In-Motion, 82% (n = 493) also knew that its classes were free and available to the public. Approximately 11% (n = 98) of responding students indicated that they had attended one of In-Motion's classes; however, this proportion is probably higher, because students may not have realized that some classes they attended were affiliated with In-Motion.Of the 260 surveys distributed to teacher and staff mailboxes, 68 (26% response rate) were completed and returned. Of respondents, 99% (n = 67) had heard of In-Motion, and 97% (n = 66) knew that classes were free and available to the public. All 68 respondents agreed that the program had a positive impact on the school and that it was beneficial to students. They reported that the program provided needed opportunities for PA, incurred social benefits , kept students out of trouble, and promoted healthy lifestyles. Approximately 90% (n = 62) said that In-Motion did not create extra work for them, and 99% (n = 67) indicated a desire to continue In-Motion at FHS.A convenience sample of 66 community members completed the survey about In-Motion. Overall, 53% (n = 35) had heard of In-Motion; of those respondents, 83% (n = 29) knew that the classes were free and available to the public. Of the 66 respondents, 14 (21%) had attended one of In-Motion's recreational classes.In-Motion has successfully modeled and implemented a pilot JUA between DPR and DOE. The JUA for FHS can be adapted by other schools to increase opportunities for PA. For DPR, the existing JUA at FHS makes establishing similar partnerships with other schools easier. Recreation staff and school administrators would not only be able to adapt the JUA but would also have their reluctance toward entering into such a relationship allayed by the success of In-Motion. Having a JUA added legitimacy to the project and signaled a higher level of commitment to it. Despite the challenges to implementing a JUA, the agreement helped to overcome barriers — such as safety, insurance costs, and liability concerns — associated with making school facilities available to the public .However, although the JUA formalizes the relationship between DPR and the school and may lead to systemic changes that increase PA, other factors are critical to the short-term success of In-Motion. These factors include the ability of key players  to work well together, respect and trust one another, and be responsive and adaptable to inevitable setbacks. Holding recreational activities during school hours  allowed In-Motion staff to develop relationships with students, which was critical to increasing participation in after-school recreational activities. Furthermore, despite the publicity, attracting participants was mainly accomplished through word-of-mouth. To reach the adult community members, allowing time for word-of-mouth to spread should be expected. Some limitations of our study were the low response rate for some of the surveys and the potential survey response bias that may have occurred if people who liked the program were more likely to participate.DPR is exploring options for continuing In-Motion once the current funding period is completed, including expansion to other schools and community organizations. However, no other schools or communities have chosen to adapt the JUA implemented by In-Motion at FHS. The JUA is a sustainable policy that only requires In-Motion to schedule facility use for future activities at FHS. However, the recreational activities offered by In-Motion depend on external funding, and they will continue only if such funding is secured. In-Motion has provided new opportunities for PA in a safe environment for students, teachers and staff, and community members. The project can serve as a model for other JUA partnerships to increase PA in underserved communities.In-Motion received funding from the Tobacco Settlement Special Fund through a grant from the Healthy Hawaii Initiative, Hawaii State Department of Health. Additional financial support was provided by the City and County of Honolulu DPR and FHS. We acknowledge the work of Nalani Aki, Carol Matsuoka, Ronn Nozoe, Linda Fujihara, Jayson Chun, Joyce Mitsunaga, and PlanPacific, Inc. We thank Principal Catherine Payne and the students, teachers, and staff at FHS, and members of the Kalihi community for their support.


The Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial.Semi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis.The majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data.Participants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program.Current Controlled Trials ISRCTN63355948 DevelThe STAR Program is grounded in a clear theoretical framework, incorpoThe primary objective of the trial is to determine whether clinicians' exposure to the STAR Educational Program results in fewer antibiotics being dispensed to the practice's patients during the year following completion of the intervention. This is to be assessed using routinely gathered data such as Prescribed Audit Reports and Prescribing Catalogues (PARC).Process evaluation of clinical trials serves i) to investigate intervention delivery fidelity, ii) to evaluate the feasibility and efficacy of the program in daily practice, and iii) to identify areas for intervention refinement. The oveThe perspectives of participants are essential to understanding if and how the STAR Program has contributed to behaviour change. A focus on how particular issues are voiced, in combination with the mapping of certain themes or patterns of thought, will provide a representative overview of perceived advantages and disadvantages of the program, as well as identify potential areas for improvement. Moreover, clinicians' perceptions of patient behaviour and attitudes in relation to changes in their own behaviour will give an indication of the efficacy of the program in practice.The STAR Program consists of five core parts, supplemented with an ongoing web forum (part 6), and a booster session (part 7) provided approximately six months after completion of the core program , 10-20 years (M), >20 years since date of qualification (H)), level of antibiotic prescribing in the practice as evident from pre-trial data (ranked high or low according to whether or not practices were in the top 50 percent of prescribing rates), and training completion .Participants were initially approached by letter, they were made aware that the interviews were part of the process evaluation of the trial and that they would be conducted by a member of the STAR team. Not all STAR participants initially approached were able to take part in an interview and so alternatives were approached according to the purposive sampling frame (see Table Interview questions covered three main areas: 1) general information about practice location, time worked in the current practice and level of importance given to the issue of antibiotic resistance before taking part in STAR, 2) effects of the program as perceived by participants after completion of parts one to six, and 3) detailed evaluation of presentation, content, and structure of the actual learning program (see Appendix A). Interviews were conducted by telephone and digitally recorded. They ranged from ten to thirty-six minutes, with an average duration of twenty-five minutes. Data was transcribed verbatim and transcripts coded using NVivo qualitative analysis software. The main coding categories reflected the questions asked during the interview, with deeper level coding focusing on classification of interviewee contributions, as well as positive or negative stance towards topics raised.To ensure validity of categorisation, thirty percent of transcribed interviews were independently examined by two qualitative researchers on the STAR team, disagreements were discussed and consensus regarding content and labelling of coding categories was reached. The data was analysed using thematic content analysis in which outcomes reflect emerging trends in the data as evident from the prevalence of particular categories and the reiteration of particular points of view.The STAR study was approved by the Multi-centre Research Ethics Committee (MREC06/MRE09/31) and all Local Health Boards in Wales.In the selected data extracts, for ease of understanding, verbatim speech has been minimally adjusted and grammatical conventions were adhered to. The following transcription conventions were applied:[word]      text added for clarity(word)      transcriber's guess at unclear speech((word))    transcriber's description of non-speech sounds...             text not directly relevant to topic omitted from original transcriptword-       truncated speech; rapid switch to new formulationword         spoken with added emphasisParticipation in the STAR Educational Program was presented as reinforcing already existing knowledge:It has reinforced [my views on prescribing antibiotics] more than anything and perhaps has improved my use of a wait and see policy rather than actively prescribing. I think as a practice we were relatively low prescribers anyway but it was nice to reinforce that and to make sure what we're doing is correct really. (GP142)In particular, locally relevant data was seen as reinforcing the salience of the issue of antibiotic resistance:I think it is easy to get blasé about antibiotic resistance and I think having the study has focused my mind and having local knowledge and the summary of the sort of changes that might come about if you concentrate on it [is] helpful; I think it raises the profile of the whole subject a long way. (GP185)Interviewees also reported greater self-confidence in implementing their prescribing decisions:It has given me a lot more confidence in refusing antibiotics and in fact I have been surprised at how little resistance I've had when I say I won't give something and they say that's good. (GP271)Inevitably, participants varied in the manner in which they expressed this change in awareness and self-confidence, the positive accounts above contrasting with the two more dismissive statements below.In the following excerpt, the interviewer (I) probed the GP about whether participating in STAR influenced his antibiotic prescribing, and the GP seemed quick to point to minimal effect:I: so would you say that [STAR] has changed your actual prescribing behaviour?GP: u::hm just reminded me let's put it that wayI: mhm mhmGP: it has just reminded me of the vigilance and how important it is you know not to prescribe when it is not necessary and things(GP 199)Similarly, in the following example the GP put forward that STAR was only one of the components that characterised already ongoing behaviour modifications:I think ... STAR has come along in a general progressive movement in my prescribing which is going from prescribing obviously more to prescribing gradually less and a gradual education of my patients towards that and I see it more that- it's actually been another impetus along the direction that [I] was already travelling and so ... it has encouraged me in giving the sort of confidence and the backing to continue to move in that sort of direction; it's something we were already doing very much. (GP 229)another impetus', all five data excerpts acknowledge the positive effect of heightened awareness. That there should be individual differences was only to be expected as, after all, the degree to which antibiotic prescribing behaviour needed to be modified varied as well.Whereas the interviewees in the earlier three examples ascribed a clear agency to the STAR Program: 'It has reinforced'; 'it raises the profile'; 'It has given me more confidence' and the last two excerpts relegate STAR to a more secondary position: 'it just reminded me'; 'STAR has come along in  progressive movement'; 'it's been Generally, participants felt that applying the communication skills presented in STAR provided greater insight into patients' wishes and demands, which was then seen to impact directly on future consultation rates and, ultimately, on patients self-managing future episodes:I think [my patients] probably get a better deal out of me actually ... because they get more time which is most of all what they're after and actually I mean I never used to leap on the idea of antibiotics as a way of terminating the consultation quickly before anyway but I think I'm just a little bit more prepared to listen to the patient's experience ... more so than I was ever used to doing. (GP 150)Most clinicians perceived consultations to be lengthened by an average of two to three minutes as a result of implementing the new communication skills. However, again this was generally seen as a positive trade-off to reduce or prevent future consultations:I think it probably does make the consultations a bit longer but not drastically so you know and I would think I feel reasonably confident that we will you know recoup that extra time in the future by people hopefully not re-presenting for antibiotics quite as often. (GP 216)I suppose in the long term they won't come back will they so in a way it's saved you time ... next time perhaps they'll not come in because you get people coming in saying 'I've had a cough for two days' and you think 'well, so what, bugger off', whereas if you'd spend more time on the first consultation explaining to them why you think they don't need them they may not come back, but it's certainly in the short term that it takes more time. (GP 256)Although the type of antibiotics prescribed was not an explicit interview question (see Appendix A), the topic did arise tangentially, as in the following two data extracts:... my perception is that I am using [antibiotics] less often, and I've changed the range of antibiotics that I commonly use. (GP 275)... occasionally I have had a patient who has had severe reactions, for example, when a patient had really bad jaundice after some amoxicillin so it is just a perception from my viewpoint but I seem to see the incidence as far as side effects or bad reactions is less than it was and whether that is related to prescribing more appropriately or less, I don't know. (GP 207)However, as GPs reported increased self-confidence regarding prescribing decisions, to a large extent based on the research evidence provided in the online learning program, the general references to 'more appropriate' prescribing behaviour in the data may well indicate a shift towards narrow spectrum antibiotics prescription in addition to prescribing fewer antibiotics overall.There was little perceived change in the frequency with which specimens were sent to the lab, nor was there a noticeable increase in re-consultation rates, although in this respect, the need to present a united front across the practice was repeatedly mentioned:... colleagues have a few patients who according to criteria were not prescribed at the time but they re-present a week later and their condition is worse therefore I have prescribed. But if they come and there is no change I don't prescribe. I mean you have to reinforce what they were told last time. I think we tried to do that more since the program, not just give in to have a quiet life. (GP207)... we have one mum who brought a child for 3 days on the trot; really struggled with the concept of having no antibiotics and we all, the thing was we could see her coming in the end, ... and we were communicating amongst ourselves to make sure we didn't actually break or crack under the pressure. (GP 161)Finally, two GPs stated that neither their thinking nor their prescribing behaviour was in any way influenced by STAR, although both of them indicated this was because they were already implementing the skills promoted in the STAR Program. As one of them summarised:... it was a revision exercise, I think, ... if you do a study and you say 'oh, I'm already doing that', at least you know that what you are doing is right ... the reason that [participating in STAR] did not change my practice is not because I ignore what was being said, it was because I had already agreed with what was being said. (GP 171)In evaluating the contents of the program, rather than its reported effects, views were sometimes polarised. The presentation of key communication skills was described either in terms of new, useful and exciting, or as old and familiar, though perhaps in need of 'brushing up'. In either instance, however, implementing these skills was acknowledged as leading to better patient care and, ultimately, greater personal satisfaction:I think the communication skills aspect was good, being able to ask patients what they feel about antibiotics and to have a more adult conversation about it ... it sort of encourages you not just to be defensive and [say] 'we don't want to prescribe' but be proactive ... asking the patients what they felt was the benefit of taking antibiotics and what did they think they were going to get out of it .... and sort of telling people it is a self-limiting illness, some of those skills I thought was very good and make it much easier to prescribe the way I'd like to. (GP 229)Respondents viewed the seminar as providing a much-needed 'human touch', although a small number of interviewees, especially those working in single-handed or very small practices, considered it a waste of time and money. Participation in the program seminar was also presented as a unique chance to focus on a particular issue and to increase communication within the practice team:... the trouble is in general practice you don't have time to sit and talk and [it's] usually sort of a business practice meeting we don't often have clinical sort of where we actually discuss and necessarily change or discuss the pros and cons of various things on a regular basis. I'm not saying we don't ever talk about things at all, we communicate quite well, but it's finding the time to do it. (GP 161)Seminar trainer feedback indicated that it proved difficult at times to gather all the trial participants from a particular practice at a particular time, with the absence of practice nurses, who are often in charge of minor illness (telephone) triage, especially commented upon. Overall, however, trainers described the seminar discussions as lively, with participants most eagerly engaged in discussing local resistance rates as correlated with own practice data.The online aspect of the training was generally evaluated positively, with a particular emphasis on its promotion of independent learning and flexibility in accessing the program. However, six out of thirty-three practices experienced  technical difficulties and especially in practices with older computer systems, or for clinicians less comfortable with IT, delays in video streaming and inability to access the program depending on certain computer settings could lead to frustration:talking, I would just as soon have read the text to be honest. (GP 171)... there was a kind of pointlessness about the use of the technology, having video streaming that just made it irritatingly slow to download and it didn't contribute anything, and you'd actually watch a videotape of somebody Finally, some participants found the video material lacking in authenticity:... there was some amusement during the video consultation with the various patients and doctor scenarios because it all seemed to go so beautifully according to plan and the patients never argued and there was lots of time and I thought - we all discussed that and we thought it was rather amusing, we didn't think it was totally realistic. (GP 207)The presentation of up-to-date evidence was generally seen as one of the most useful aspects of the STAR Program. Participants described how they discussed the modified Centor clinical scoring tool for managing sore throat, as well as the prescribing guidelines and evidence summaries with patients during consultations:... you gave us guidelines on- primary care guidelines that have been very useful actually. Again, we've given our nurses copies of those to have a look at when they are seeing patients with minor illnesses. You know, I think no one has given them training in good antibiotic prescribing so I do think they over-prescribe, even though they're very good. I think those guidelines have been quite helpful, in fact we keep them pinned up by the uh, when they're doing nurse triage we keep them pinned up by the phone, so they can refer to those. (GP 248)... the Centor guidelines, the other guidelines, can't remember what they were called now, the ones for the sinusitis and things you know, those I actually have them on my desktop. So what I do is I just put them on if I get someone stroppy ... just put them on and turn the screen and say 'read that, that's the guidelines we've got', because if you've given them an examination and you know they haven't got a temperature and they haven't many chest signs ... On the whole they tend to sort of 'oh okay' then, it's on the screen so it must be true and they see that's it's, you know, it's an official document. (GP 256)As evident from seminar trainer feedback as well as interview data, and in line with the 'computer-says-no' scenario presented in the above data excerpt, STAR participants repeatedly requested antibiotic resistance information leaflets or posters that can be displayed in surgery waiting rooms. Interviewees noted that presentation of the research evidence and guidelines in this more generally accessible format could have provided them with an added tool, and they expected it to be part of the overall program.About a fifth of interviewees reported that they did not see the merits of the reflective exercises or recording their own consultations online:I: ... and what did you think was the least usefulGP: I think finding my own cases to put in. I don't know there's plenty of cases you could have found. It was hard to find an interesting one. But in terms of looking at that it didn't really affect what I was doing in any way, it was just a bit time consuming. That was a bit of a chore. (GP152)However, one of these participants, unprompted, addressed his own reservations on this issue, thereby aligning himself with the majority standpoint:... the tasks of recording some of one's own consultations ... I don't know whether recording them had any benefit over simply thinking about them. Obviously recording them takes up a bit more time, but having said that I don't know if I didn't have to record them whether I'd really spend time ((laughs)) thinking about (those cases). It felt frustrating at some level but I'm well aware that that sort of thing does actually improve one's processing of it. (GP216)The core aspects of the STAR Program considered 'most useful' and reported by these sampled participants as responsible for influencing their prescribing most were the research evidence and guidelines provided in the program, and the online communication skills examples, both of which were explicitly mentioned by 12 of the 31 interviewees. Ten interviewees reported that their prescribing behaviour had changed because of the increased overall awareness of the antibiotic resistance issue that results from working through the program as a whole, with four of those singling out the impact of discussing local resistance rates during the STAR seminar.In contrast, there were also respondents who considered the research evidence not directly relevant to their own clinical practice, or found it too difficult to process online. Moreover, the web forum, originally envisaged to become an ongoing learning resource, was dismissed by many as irrelevant, a format participants could not or would not engage with, even if their busy working lives would allow them time to do so.However, it was clear that all interviewed study participants subscribed to the view summarised by GP 207 as follows:... overall I think it's just the being better educated and having therefore more clinical expertise and [the] communication tools to prescribe appropriately, treat appropriately, and therefore give better patient care, which is the bottom line. (GP207)Most of the participants put forward that the STAR Educational Program increased their awareness of the problems of antibiotic resistance as well as how their management of common infections might be improved. GPs recognised the value of enhanced communication skills, both as a means to provide better patient care and as a route to greater professional satisfaction. Using these skills in combination with the up-to-date evidence to exchange information with their patients about the use and the effects of antibiotics was recognised as having both long-term and widespread impact and there was an expressed willingness to invest time and energy in achieving this goal. GPs felt that the STAR Program provided them with the tools to negotiate with patients about antibiotics in the best possible interests not only of individual patients but also, in the long run, the population at large. Besides addressing the issue of antibiotic resistance, applying the communication skills was presented as enhancing doctor-patient rapport. In the practice as a whole, taking part in the STAR Educational Program could lead to a joint focus on straightforward and achievable goals, drawing together practice partners and their associates, including doctors in training. The GPs and Nurse Practitioners felt empowered by their increased insight, even if in some cases this simply meant the confirmation of views already held.Not all aspects of the STAR Program were consistently judged positively. Technical difficulties clearly influenced the appreciation of the online video presentations and contents and presentation of the generally valued research evidence was also criticised. Trawling through patient notes for representative case studies to enter online as part of the STAR core tasks was seen as a time-consuming activity with little practical benefit, while similar views were expressed about participating in the web forum discussions. However, although individual participants may have criticised individual components of the program, overall it was evaluated positively.One of the strengths of this interview study is that it forms only part of the overall STAR trial process evaluation and yet it touches upon aspects of all the other process evaluation components, unifying these potentially disparate elements in the obvious relevance they all bear to how clinicians manage to put the STAR Educational Program into practice. Interviewees made reference to the cost of the seminars or the study as a whole, they commented on seminar content and delivery in a way that overlapped with seminar trainer feedback, they volunteered information about the location and detailed make-up of their practice and how this might influence antibiotic prescribing, and gave insight into when, where and how they accessed the online training. By making all these issues explicit, interviewees illustrated how the combined STAR trial process evaluation components can contribute to providing insights into the efficacy of the learning program and the fidelity of its delivery. In this way the interview study in itself becomes an indicator of the feasibility of a fundamental trial protocol component.GPs' generally heavy workload makes it difficult to reserve time for what are essentially non-core activities such as taking part in research related interviews. To ensure that the widest possible range of opinions could be obtained, the STAR team selected clinicians from each of the thirty-three intervention group practices across the four key sampling domains . However, initial invitations to be interviewed were sometimes declined which meant that alternatives had to be sought. It is another strength of this study that in spite of these practical difficulties, the sampling criteria were just as rigorously applied for second or third interviewee choices. Only three clinicians who originally consented to be interviewed declined to take part after all.A final strength of allowing this group of participants to elaborate on their experiences with STAR is that it not only provided insight into what they considered the most effective aspects of the learning program, but also where they saw areas for improvement. The interview schedule included specific questions inviting talk about positive as well as negative experiences and asked interviewees to elaborate on any additions or changes they might want to make.When using a semi-structured interview format, to a great extent the questions answered are the questions asked. In general, this semi-rigid structuring prevents frequent asides and more individual comments and may prevent topics from arising that could have contributed to greater insight into how effective the learning program may be. This is certainly a limitation, but perhaps a necessary one in an interview in which so many different aspects of a complex learning method need to be addressed.It is clear that in many cases the interviews took place too long after the STAR Program had been finished as some interviewees simply could not remember specific details of program contents or how it was experienced at the time. However, lack of recall only appeared to influence views in one or two instances and did not prevent interviewees from expressing views on their experience as a whole.Another limitation is that not all participants from the intervention group could be interviewed, although the sampling procedure was designed to select interviewees who would best represent the main sampling criteria. However, we are aware that, potentially, this selection process could have introduced bias as there is a possibility that invited participants declined to be interviewed because they felt uncomfortable about expressing any negative views to a member of the STAR team. Moreover, due to the timing of the intervention, it was impossible to obtain the views from clinicians in the control arm of the study who were offered the STAR Educational Program at the end of the study.Participants in the STAR Program reported that the intervention increased their awareness and that they found the up-to-date evidence useful in making decisions about the best treatment for patients, as well as increasing their confidence. Previous studies have used educational approaches with some success to try and reduce inappropriate antibiotic prescribing, althougThese interviews, with their predominantly positive response to the program, illustrate that clinicians find this particular method of Continuing Medical Education (CME) useful, flexible and often enjoyable. The positive feedback regarding the face-to-face element (the seminar) suggests that this was an important part of the learning program. This type of 'blended' approach (e-learning plus face-to-face) may provide a cost-effective way to deliver CME to clinicians. In 1999-2000 in the UK about £1bn was spend on CME. The mosAs is evident from the interview data, working through the STAR Educational Program can lead to a greater awareness of the problem of antibiotic resistance, increased self-confidence, and a change in prescribing behaviour for some. Participants put forward that being better informed and having learned or refreshed specific communication skills contributed to a perceived reduction in antibiotic prescribing and a better understanding of patients' expectations.Apart from some initial technical problems, interviewees did not report any major difficulties in accessing the program or in implementing any of the changes it promotes and, in fact, recommended making STAR available for teaching medical students, for clinicians working in Out of Hours services and for Nurse Practitioners who are often the first point of contact in minor illness cases.Suggestions for improvement include re-thinking the scenarios for the communication skills videos to better reflect real-life consultations, providing patient information leaflets or posters, and more clearly explaining the purpose of the reflective exercises and the case studies that participants are asked to add online. In addition, where possible, the technical platform may be in need of some adjustment to allow smoother transition through the program in cases where people do not have access to high-speed broadband or fast computers.The participants interviewed for this study judged the content of the STAR Program, as well as the delivery methods as timely, necessary and feasible. Based on their experiences in clinical practice, some of the interviewees recommend roll-out of the program not only across a wider geographical area but also across a wider range of medical disciplines and care delivery contexts.The authors declare that they have no competing interests.MJB led the writing of the manuscript, conducted the interviews and was responsible for transcribing and analysing the data. SS served as second data coder and contributed substantially to the discussion section of the paper. CB is the principal investigator on the STAR trial, he commented extensively on earlier versions of the paper. KH, FD, MH and JE also made valuable suggestions for improvement. All authors contributed to, read and approved the final version of the manuscript.▪ confirm name▪ length of time in the practice▪ rural, urban, valleys practice?antibiotics resistance issue before training: low, medium, high?▪ what level of importance given to ▪ what were your expectations of time commitment before you started? how did this work out in practice? ▪ how did you experience the cooperation with the STAR team? did you communicate directly or via the practice manager?content be improved?(i) How could STAR training be improved?(ii) How could STAR your views on prescribing antibiotics? has it changed your actual prescribing behaviour in any way?▪ has taking part in the program changed ▪ do you think patients have noticed a difference pre-STAR and post-STAR?▪ do you feel that using the skills promoted in the STAR Program affects the length and the nature of the consultation? how?▪ is it possible to estimate (in minutes) the extent of a change in length?▪ what is the perceived impact of taking part in STAR on the practice as a whole? ▪ do you think there are any barriers to implementing the communication skills promoted in STAR?▪ perception of whether patients will use other means to get antibiotics? perception of whether patients will be re-consulting more often▪ what is your ▪ do you use delayed prescribing as a technique for reducing prescribing?▪ if you use delayed prescribing, what is the procedure for delayed prescribing in your practice? ▪ has taking part in the STAR Program had any influence in how often you send a specimen to the lab?▪ general impression▪ is the seminar necessary?▪ length of seminar▪ suitability of venue and trainers▪ seminar contents▪ impact of seminar▪ suggestions for improvement▪ general impression▪ using the software ▪ how useful was the information, both the actual program and the resources provided▪ ratio video - text - reflective exercises?▪ any problems with software?▪ suggestions for improvement?▪ where there any particular 'stumbling blocks'?▪ have you gone back to software since completing the program?▪ was the training provided in the program enough?▪ have you already used the web forum?▪ expectations of web forum?▪ any comments/suggestions for use web forum?▪ are you likely to keep using the web forum in the future?▪ are you aware that literature updates will be available?▪ are you aware that STAR team will keep forum updated with questions arising from latest research?What aspects of the STAR Program were most useful for you?▪ What aspects of the STAR Program were least useful for you?▪ Which aspects of the STAR Program have influenced your prescribing most?▪ What made you decide to participate in the STAR study?▪ The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/11/34/prepub


Evaluations of weight management programs in real-world settings are lacking. The RE-AIM model  was developed to address this deficiency. Our primary objective was to evaluate a 12-week insurance-sponsored weight management intervention by using the RE-AIM model, including short-term and long-term individual outcomes and setting-level implementation factors. Our secondary objective was to critique the RE-AIM model and its revised calculation methods.2 analysis to compare categorical variables and repeated-measures analysis of variance to assess the magnitude of outcome changes over time.We created operational definitions for components of the 5 RE-AIM indices and used standardized effect size values from various statistical procedures to measure multiple components or outcomes within each index. We used χOn the basis of data for 1,952 participants and surveys completed by administrators at 23 sites, RE-AIM indices ranging from 0 to 100 revealed low program reach and adoption , moderate effectiveness (43.8), high implementation (91.4), low to moderate individual maintenance (21.2), and moderate to high site maintenance (77.8). Median (interquartile range) weight loss was 13 lb (6.5-21.4 lb) among participants who completed phase I  and 15 lb (6.1-30.3 lb) among those who completed phase II .This program had a significant, positive effect on participants and has been sustainable but needs to be expanded for more public health benefit. The RE-AIM model provided a useful framework to determine program strengths and weaknesses and to present them to the insurance agency and public health decision makers. Strategic Plan for NIH Obesity Research, the National Institutes of Health Obesity Research Task Force  are eligible for the program, as are overweight members (BMI 25.0-29.9 kg/m2) who also report being treated for hypertension, diabetes, heart disease, metabolic syndrome, or sleep apnea. Participants enroll in the program by calling the insurance agency to be screened for height, weight, and health information and must have written approval from their primary care physician.This study evaluated a weight management program that has been offered since 2004 by a large public employees' insurance agency in West Virginia as a benefit to its members. Obese insured members  resources yielded 352 of these types of facilities in West Virginia. Each approved site is required to designate an administrator to act as liaison with the insurance agency, handle participant contact, coordinate site services, and enter participant data into a database.The insurance agency also screens site providers to ensure the site has adequate safety devices, exercise equipment, and staffing to accommodate high-risk participants. At the time of this study, the insurance agency had approved 31 fitness facilities ("sites") to accept participants: 2 housed in university cardiac rehabilitation/exercise physiology laboratories, 2 in physical therapy facilities, 5 in hospitals, and 22 private wellness/fitness centers. Searches of available print  and onliThe weight management program evaluated in this study is a 1-year benefit, during which weight loss is promoted by using a combination of behavior therapy , individualized site-based exercise programming, and individualized diet therapy. Case management nurses track participant progress on the basis of monthly entry of the following body measurements by the sites into a Web-based database: weight and BMI, systolic and diastolic blood pressure, body fat percentage, waist circumference, and number of site visits. Each site determines its measurement protocols on the basis of available instruments and staff training. Sites are compensated via monthly member copayments and insurance agency payments for the provision of on-site services in 2 phases.Services provided during phase I include 1) access to the exercise site, 2) a 60-minute fitness evaluation and exercise program designed by an exercise physiologist, 3) a 60-minute evaluation and nutrition program designed by a registered dietitian, 4) monthly 30-minute exercise sessions with a personal trainer, and 5) 60-minute follow-up reassessments by the exercise physiologist and registered dietitian at the end of month 3. Participants may be removed from the program if they fail to exercise at the site at least twice per week; turn in food logs periodically; attend appointments with the exercise physiologist, registered dietitian, or personal trainer; or have body measurements taken by site staff monthly. Phase I is considered the "intervention" period for this evaluation. If participants meet the behavioral requirements and lose 12 lb  they may continue to phase II.Phase II spans the remainder of the first year (9 months). This phase is considered the postintervention period for the current evaluation because it is more like a private gym membership than a weight-loss intervention; it provides access to the facility and 1 personal training session per month. Participants are expected to continue exercising at the facility twice per week and have physical measurements and visit data submitted monthly by the sites to maintain the benefit.The insurance agency dictates what services are offered, but not how the services are implemented. The use of relevant weight management guidelines of the American College of Sports Medicine (ACSM)  and the We used archival participant data and site administrator surveys to evaluate the weight management program. The insurance agency granted us access to an online password-protected database containing demographic and physical measurement data of all program participants. The university's institutional review board approved the study for the protection of human participants. We downloaded, verified, de-identified, and imported archival data of all participants into SPSS version 14.0 .To gather site-level program evaluation data, we recruited site administrators by mail, e-mail, and telephone  to compl2 analysis to compare categorical variables and repeated measures analysis of variance (ANOVA) to assess the magnitude of outcome changes over time. In the indices, "positive" effects were reduced by differential or "negative" effects . This index calculation method has resulted in negative values in prior studies . T. TBox).  studies  for 2 re studies . Second,c2) for χ2 tests  and the squared curvilinear correlation coefficient  for ANOVA  (Effect size measures (and interpretation) included the squared Cramer phi (φ > .14]) ,19. All The data for 1,952 participants from 31 sites were exported, and administrators from 27 of 31 active sites (87.1% response rate) completed online surveys. Responses from 4 new sites whose participants had not yet completed phase I of the program were excluded from analysis, resulting in 23 completed site administrator surveys. The distribution of most of the participants' measurement data was skewed, and data are presented as median (interquartile range) unless otherwise noted.A total of 60,041 adult members were covered by the insurance agency . By using the state obesity (31%) and overweight (36%) prevalence rates , we estiP < .001, φc2 = .073), and more of them were aged 45-54.9 years and fewer of them were aged 65 years or older , yielding a reach value (R) of 5.4  of 5.4 .P = .001, φc2 = .007), and completion rates tended to rise with age. Participants who completed phase I had significant weight loss , and men lost significantly more weight than women . Differences in weight loss were also revealed among age groups . These components produced an effectiveness value (E) of 43.8 and an individual-level impact ([R * E] / 100) of 2.4 (Phase I outcome changes are presented in ) of 2.4 .adoption value (A) of 8.8  of 91.4 and a setting-level impact ([A * I] / 100) of 8.0  of 8.8 . Site su) of 8.0 .PhII = .ICR457) , shedding 6.7% (2.7%-12.7%) of baseline body weight. Weight loss was similar among phase II completers of different age groups  and between sexes . These values combined to yield an individual maintenance value I(M) of 21.2 (Phase II outcome changes are presented in  = .457) . Excludi of 21.2 .setting maintenance value (MS) of 77.8 and a long-term maintenance value ([I * MSM] / 100) of 16.5 (Four of 18 sites (22%) that had been approved to accept participants at least 1 year before this study had stopped or had been disallowed to continue accepting participants, resulting in a  of 16.5 .We achieved our primary objective of using RE-AIM to evaluate a weight management program. We found moderate program effectiveness and high implementation, suggesting the program has been beneficial for participants and can be implemented in a variety of settings. We found low program reach and adoption, suggesting the program could be improved by recruiting new participants and sites. Recruitment may prove difficult, however, because participants must be highly motivated to enroll in the program, and sites are required to offer services by highly trained personnel often unavailable in rural areas of West Virginia. In the long term, site maintenance was high, but individual maintenance was fairly low, indicating the program is sustainable but the services of phase II may need to be revised to improve participant outcomes. The summary results suggest this weight management program has potential to be expanded for more translation and public health benefit and should be considered a viable model for other public and private insurers.Individual short-term and long-term outcome changes are comparable with those of other behavioral programs and clinical trials. Short-term attrition from this weight management program 23.5%) was slightly higher than is commonly seen in behavioral programs of similar length 10%-15%), though the median weekly weight loss in this program is comparable (1.23 lb vs 1.1 lb) . This pr0%-15%, t% was sliLong-term individual results also compare favorably with other behavioral programs and clinical trials. Participants who completed phase II (n = 348) lost a mean of 20.9 SD, 22.3) lb from baseline, with some recidivism. Slightly more than half of phase II completers 51.5%) maintained phase I weight loss or continued losing weight in phase II. In comparison, approximately 60% to 70% of weight loss is maintained for a year after treatment in other short-term behavioral interventions  providing methods for assessing long-term maintenance at the individual and site levels and 2) addressing 2 methodologic concerns with existing index calculation methods . The revised methods in this study produced positive  methods  would haThe study is limited in a number of ways. Multiple sources of measurement error may have affected the data, including 1) lack of standardized procedures and instruments for measuring health outcomes, 2) missing outcome data, and 3) social desirability of sites when entering participant data and completing survey items. Potential error was addressed in multiple ways. Trained exercise professionals took measurements using accepted professional standards of practice, the insurance agency periodically audited site data, we contacted sites to collect missing data, and all survey recruiting material stressed the informative (not punitive) nature of the study and independence of the investigators from the insurance agency. Measurement error would be more important in a small clinical trial assessing an intervention's efficacy than in this study with its large sample and focus on standardized effect sizes.Numerous questions remain to be answered before the public health effect of this and other weight management programs can be better understood. This program had a significant positive effect on participants and was sustainable, but needs to be expanded. The RE-AIM model provided a framework through which the translation of this program could be evaluated and presented to public health decision makers. In fact, the summary data of this project were presented to the insurance agency and used as evidence for changing the program benefit to address the low reach, adoption, and long-term individual maintenance. We encourage continued study of RE-AIM index calculations and application of the model to evaluate obesity treatment programs. It may be beneficial to add qualitative process data to these outcomes to work toward developing a set of best practices in behavioral weight management ,12. Addi


The qkI gene expresses three major alternatively spliced mRNAs  that encode the QKI-5, QKI-6 and QKI-7 RNA binding proteins that differ in their C-terminal 30 amino acids. The QKI isoforms are known to regulate RNA metabolism within oligodendrocytes, however, little is known about their roles during cellular stress.The In this study, we report an interaction between the QKI-6 isoform and a component of the RNA induced silencing complex (RISC), argonaute 2 (Ago2). We show in glial cells that QKI-6 co-localizes with Ago2 and the myelin basic protein mRNA in cytoplasmic stress granules.Our findings define the QKI isoforms as Ago2-interacting proteins. We also identify the QKI-6 isoform as a new component of stress granules in glial cells. Ago2 is a core component of the RISC complex which regulates gene expression including mRNA degradation and translation repression The QKI RNA binding proteins have recently been shown by photoactivatable-ribonucleoside-enhanced crosslinking and immunoprecipitation (PAR-CLIP) to associate with clusters of non-coding intronic RNAs To identify the regions required for the interaction, QKI-6 and Ago2 truncated proteins were expressed in HEK293 cells followed by co-immunoprecipitation assays. The QKI isoforms harbor a KH domain flanked by the N- (NK) and C- (CK) terminal regions , while ATo investigate whether the QKI isoforms are key accessory proteins of Ago2 in the RISC complex, we reasoned that reduced expression of the QKI isoforms would impair the RNA interference of a luciferase reporter gene. U343 cells were transfected with siRNAs targeting the QKI isoforms, a negative control siRNA targeting GFP or a positive control siRNA targeting Ago2. Twenty-four hours later, the cells were transfected with a luciferase reporter plasmid along with a control siRNA or a luciferase siRNA and luciferase activity was assessed 30 h later. Ago2 knockdown significantly impaired the ability of the luciferase siRNA to function, whereas the knockdown of the QKI isoforms had no effect . These rWe examined whether QKI-5, QKI-6 and QKI-7 co-localize with Ago2 in U343 cells. In the absence of any treatment, Ago2 did not co-localize significantly with any of the QKI isoforms . EndogenAgo2 is known to re-localize to cytoplasmic granules under stress To confirm that QKI-6 and QKI-7 are components of stress granules, we tested under conditions of stress, whether the QKI-6 and QKI-7 isoforms co-localize with the poly A-binding protein (PABP1), a known marker of stress granules in situ hybridization was performed to test whether MBP mRNA co-localize with the QKI-6 isoform during stress. The MBP mRNA is a known QKI target with specific binding sites within its 3′-untranslated region Cellular stress induces rapid shuttling of proteins and RNAs within stress granules In the present study, we show that the cytoplasmic QKI isoforms, QKI-6 and QKI-7, but not nuclear isoform (QKI-5), localize with Ago2, PABP1, and TIA1 within stress granules in the U343 glioblastoma cell line and in primary rat oligodendrocytes. Interestingly, the MBP mRNA, a known QKI RNA target In response to environmental stress, mRNAs are transiently transported to stress granules The QKI RNA binding proteins are involved in various aspects of RNA processing including mRNA stability, mRNA export, and pre-mRNA splicing RNA localization elements are recognized by specific RNA-binding proteins regulating many aspects of RNA metabolism The HEK293 and U343 cell lines were purchased from American Type Culture Collection  and primary oligodendrocyte precursor cells were prepared as described previously 5′-CACCATGGAGCAAAAGCTCATCTCAG-3′ and 5′-CTATGCCTTGTA TAAAACGCTGTTG-3′ for myc-Ago2:1-227; 5′- CACCATGGAGCAAAAGCTCAT CTC AG-3′ and 5′-CTACACAATGTTACAGACCTCCAG-3′ for myc-Ago2:1-334; and 5′-CACCATGGAGCAGAAACTCATCTCTGAAGAGGATCTTGT-3′ and 5′- CTACAGGTGGTACCTGGCCCGGAAG-3′ for myc-Ago2:392-817. The amplified PCR fragments were sub-cloned into the pcDNA™3.1 Directional TOPO® Expression vector (Invitrogen) following the manufacturer's procedure. The GFP-QKI:1–180, GFP-QKI:1–205 were described previously 5′- GCATGAATTCACCAGCCCTTGCGTTTT C-3′ and 5′-TACAAATGTGGTATGGCTGA-3′. The amplified DNA fragment was digested with EcoRI and BamHI and sub-cloned into the vector pEGFP-C1 (Clontech).Anti-Sam68 and anti-QKI-5, -6 and -7 antibodies were purchased from Millipore Inc. Antibodies against β-actin and Flag were purchased from Sigma Inc. The anti-Ago2 antibody was purchased from Novus Biologicals. The Myc-Ago2 pcDNA was kindly provided by Gregory J. Hannon  U343 cells or transfected HEK 293 cells were harvested and lysed in Triton X-100 lysis buffer, as described previously Cells were grown at 30 to 50% confluency and fixed with 4% paraformaldehyde in PBS for 30 min and permeabilized with 0.5% Triton X-100 in PBS for 10 min at room temperature. The permeabilized cells were incubated with primary antibodies in PBS for 2 hr at RT. The cells were washed 3 times with 0.1% Triton X-100 in PBS and incubated with the appropriate fluorescent secondary antibodies (Invitrogen) in PBS for 1 hr (Millipore Inc. 1∶200). Primary antibodies were diluted as follows: anti-QKIs rabbit polyclonal antibodies (1∶200), anti-Ago2 monoclonal antibody , anti-PABP1 rabbit polyclonal antibody , anti-PABP1 mouse monoclonal antibody , anti-TIA1 goat polyclonal antibody , anti-Flag monoclonal antibody  and anti-Myc monoclonal antibody .5′-ATGGCATCACAGAAGAGACC-3′ and 5′- TCTTCCTCCCCAGCTAAATC-3′. The DNA fragment was cloned into pBluescript KS+ vector. Antisense and sense UTP digoxigenin (Roche Applied Science) RNA probes were synthesized with T7 or T3 RNA polymerase in vitro. The in situ hybridization was performed with 5 ng/µl digoxigenin-riboprobe as described A 351 base pair DNA fragment was amplified by PCR using an expression vector for the MBP 14 kDa isoform U343 cells were transfected with control, Ago2 and QKI siRNAs using Lipofectamine™ RNAi Max (Invitrogen). Twenty-four hours after transfection, the cells were co-transfected with pMIR firefly luciferase (FL) reporter (Ambion) plasmid and pRL-TK renilla luciferase (RL) plasmid (Promega) as well as a control or pgl2 siRNA targeting the pMIR firefly luciferase. The FL/RL activities were measured 24 to 30 hr after the second transfection with the Dual-Luciferase® Reporter Assay system (Promega Inc.). In addition, cell extracts prepared and the proteins were separated on SDS polyacrylamide gels followed by immunoblotting. All the siRNAs were purchased from Dhamacon Inc with targeting sequences were: QKI; GGACUUACAGCCAAACAAC, Ago2; UGGACAUCCCCAAAAUUGA and pgl2; CGUACGCGGAAUACUUCGA.


I provide a review and critique of meta-analyses and systematic reviews of school-based smoking prevention programs that focus on long-term effects. Several of these reviews conclude that the effects of school-based smoking prevention programs are small and find no evidence that they have significant long-term effects. I find that these reviews all have methodological problems limiting their conclusions. These include severe limiting of the studies included because of performance bias, student attrition, non-reporting of ICCs, inappropriate classification of intervention approach, and inclusion of programs that had no short-term effects. The more-inclusive meta-analyses suggest that school-based smoking prevention programs can have significant and practical effects in both the short- and the long-term. Findings suggest that school-based smoking prevention programs can have significant long-term effects if they: 1) are interactive social influences or social skills programs; that 2) involve 15 or more sessions, including some up to at least ninth grade; that 3) produce substantial short-term effects. The effects do decay over time if the interventions are stopped or withdrawn, but this is true of any kind of intervention. Researchers and others have developed many school-based tobacco prevention programs over the past 30 years. Early approaches to smoking prevention went through several phases: informational, affective/motivational and psychosocial. Thompson , in a reOver a dozen reviews of approaches to tobacco control or substance abuse prevention published since the early 1990's have included school-based smoking prevention within their realm ,13-27. SDuring this same period there were many reviews ,28-37 anHowever, findings in the field are sometimes confusing to practitioners and policy makers because some early or short psychosocial programs reported promising short-term effects that did not last -48. In aI now provide a critical review of findings from prior meta-analyses and reviews. In an accompanying paper  I will pMy objective is to provide a critical review of past reviews to determine whether or not school-based smoking prevention can be effective. Meta-analyses of school-based prevention programs have used various criteria and so have varied in scope, from focusing only on the quality of eleven evaluations (and not their outcomes) , to inclprograms that used interactive learning strategies and involved same- or similar-age peers as leaders or facilitators were most effective. Tobler and colleagues found that smoking prevention programs produced an average effect size of 0.16, with "interactive" programs producing a significantly larger effect size than non-interactive programs (0.17 versus 0.05) [Nan Tobler  summarizus 0.05) . Tobler us 0.05)  also fouHwang and colleagues  estimateHwang and colleagues  also estHwang et al.  found thschool plus community programs produce about double the effect when the type of school program is held constant.Regarding setting, Hwang et al  found thRooney and Murray's  meta-anaThomas and Perera  completeThese are rather rigid criteria, and even many high-quality studies of school-based programs cannot meet them all, partly because many of the criteria are outside the control of researchers and partly because of editorial decisions by journals. For example, performance bias is likely in any school-based effectiveness trial, where regular school teachers or other providers deliver the program, compared with an efficacy trial, in which research staff deliver the intervention. However, this kind of bias is likely to lead to an underestimation rather than an overestimation of program efficacy, although potentially a true estimate of effectiveness under real-world conditions. The second kind of performance bias, contamination of the control group has become more likely historically, at least in most developed countries, as more and more schools already have some form of smoking prevention program, often derived from the same theoretical principles as the program being evaluated. Again, however, such bias is likely to lead to an underestimation of program effectiveness .studies should not automatically be penalized based on levels of student attrition. On the other hand, if one or more schools drops out of a study, that would be a great cause for concern.Attrition is an issue that was more of a problem when the field considered the student as the unit of analysis. Now that we (correctly) take the school to be the unit of analysis (as well as of random assignment and program delivery), the amount of attrition at the individual student level is less of an issue (as long as it is similar across conditions in both magnitude and type). In addition, attrition is likely to be high in schools with high turnover, the very schools many studies have deliberately selected for their studies because students in these schools are at highest risk for smoking. Non-differential attrition may reduce external validity  of study results but not the internal validity (bias). Although attrition should be assessed and any differential attrition reported , Another consideration is that journals often will not publish all of the details of studies. For example, they often do not care to know whether randomization was concealed or not. They usually do not require that ICCs be reported, and only a few researchers have reported them. Analytical approaches have changed over time as statisticians have developed the methods to handle clustered data. Thomas and Perera determined statistical significance from their own analysis of odds ratios – the odds of baseline never smokers starting to smoke by posttest in the intervention group compared to the control group. When ICCs were not reported, they assumed an ICC of .097, the average found in a limited set of older studies . This apAnother criterion that might be overly strict is requiring at least one assessment at least 6 months beyond the end of the intervention. As interventions have become more comprehensive and longer-lasting, it is becoming more difficult to meet this standard. For example, many programs include some type of follow-up sessions during high school. It is not clear that a study should be excluded from consideration in a review because the last posttest was less than 6 months after the last session, albeit at the end of high school, when the bulk of the intervention may have occurred several years earlier.It leads to the omission from consideration of many important studies, at least just as many of which may be biased to an underestimate of effect size as are biased to an overestimate of effect size. The overwhelming focus on methods is also at the expense of an informed focus on the interventions. A better approach would be thorough meta-analyses that provide analyses of the effects of methodological issues as well as programmatic ones .Regarding program types, Thomas and Perera assigned studies to the groups of information-only, social competence , social influences , combined social competence/influences , and multimodal . Some of the assignments are questionable. One glaring question, for example, concerns why most of Gilbert Botvin's studies of Life Skills Training were assigned to the combined social influences/competence category, yet one was assigned to the social influences group. A study by Ausems and colleagues  and anotThe only outcome reported by Thomas and Perera was the prevalence of smoking among pretest never smokers. They did not include other possible outcomes, such as changes in the proportion of ever, weekly or monthly smokers. This also unnecessarily limited the studies that were considered.Within all of the above constraints, Thomas and Perera concluded that:1. There is little evidence that information alone is effective (only one study in this category met their inclusion criteria).2. Nine  of 13 studies of social influences that met their criteria demonstrated effects and 4 did not.3. The most rigorous and long-lasting test (65 lessons over 8 years) of a social influences program (Hutchinson) was not effective (see further discussion of this study below).4. There was limited evidence for the effectiveness of social competence programs (only two studies met criteria for inclusion).5. Of only 3 high-quality studies of the combination of social competence and social influences, only one showed a significant effect and one showed a significant effect only for the health-educator led condition (but not the "self-instruction" condition).6. Three of the 4 studies of multimodal approaches that met standards for inclusion produced positive effects (characterized in the text as providing limited evidence of effectiveness).7. There is little evidence of the long-term effectiveness of smoking prevention programs.The conclusions reached in this review are overly restrictive for several reasons. First, as pointed out above, too many studies were eliminated from consideration for suspicions of bias that are unreasonably strict. Second, evaluations of DARE, a program that is known to be ineffective from several RCTs and two prior meta-analyses were included with the social influences group. Although DARE is partly based on the social influence approach, it is clearly a very poor example of it (see further discussion below). Third, the focus on the Hutchinson study is unwarranted – it is an example of a preoccupation with methods leading to misleading conclusions – as detailed information about the intervention or data on the short-term effects of the program have never been reported (see further discussion below). There is no way to judge whether or not it was a good example of the social influences approach or another watered-down approach like the DARE program.As noted above, Thomas and Perera concluded that there is little evidence of the long-term effectiveness of smoking prevention programs. Other recent reviews also raised questions about the long-term (high school or beyond) effects of school-based smoking prevention programs.Wiehe et al. [e et al.  conductee et al. ,61 that,e et al. . ClearlyOf the studies reviewed by Wiehe et al., only the Life Skills Training (LST) program, which is an interactive program of 15 sessions in 7th grade, 10 in 9th grade, and 5 in 10th grade that incorporates the social influences approach as well as other general personal and social skills, was effective at long-term follow-up. Wiehe et al. concluded that "there is little evidence to suggest that existing programs produce medium-term decreases in smoking prevalence (page 168)." In an editorial comment, Glantz and Mandel  misleadiGlantz and Mandel suggest that all aspects of smoking education should be integrated into regular core curriculum classes. This approach has not been shown to be effective. Furthermore, it is not likely to happen in the near future because of the current demands on schools, nor is it likely to be effective because one would expect much less adherence to the program components if the program was delivered by multiple teachers.Skara and Sussman [ Sussman  reviewedIndeed, meta-analyses can obscure some kinds of information, particularly when there are wide variations between the types of interventions being reviewed. Meta-analyses make more sense in medicine, where the effects of the same drug or procedure can be estimated from multiple trials. In a field like school-based smoking prevention, one is often comparing different kinds of programs with differing formats, theoretical orientations, targeted behaviors, and targeted populations and age groups. Furthermore, different programs were developed by different researchers or practitioners with different theoretical or philosophical orientations (sometimes even when they claim to be the same), and implemented by different providers who, themselves, have different training and readiness for the work. There are also large differences among studies in research design and the measurement of smoking behavior. It really takes someone who is intimately familiar with a body of research and program development to conduct the most useful kind of in-depth review of a field like smoking prevention, where different programmers and programs have different training, theoretical bases and degree of understanding of children, youth and their families and other social settings, such as peer groups, schools and communities.Despite the above short-comings, the meta-analyses by Tobler and Hwang provide clear directions on what types of programs are most effective. On the basis of a systematic review of reviews and individual studies of mediators, boosters, peer- versus adult-led, community components, Pim Cuijpers  develope1. Interactive delivery methods2. The use of the social influence model (defined more broadly than by Hwang – see below)3. Including components on norms, commitment not to use, and intentions not to use4. Adding community components5. Including the use of peer leaders rather than relying totally on adult providers6. Including training and practice in the use of refusal and other life skillsIn addition, meta-analyses have established that programs that have more sessions, and that continue for multiple years are more effective.Many smoking prevention programs and activities that have received lots of attention are not effective, especially in the long term, when evaluated fully. Examples include one-time visiting speakers, other one-day special events, poster competitions, lotteries, etc. A high-profile example in the literature is the "No Smoking Class" competition, first established in Finland, where it has been carried out annually since 1989 , and expThe effects of an intervention should be measured immediately or shortly after the program, and then the long-term measurement should serve to assess how permanent the effect is, or how quickly it decays.The Hutchinson project  is another ineffective program, the evaluation of which has received lots of attention because it was of high quality and long term. The project was designed to be a multiyear (grades 3–10) social influences tobacco prevention program. A large randomized trial (20 school groups per condition) produced no significant effects at the end of grade 12 or 2 years later . These fCertainly, one cannot use the Peterson et al. results to conclude that the social influences approach to smoking prevention is ineffective in the long-term deterrence of smoking among youth, as these authors did. These results must be interpreted in the context of the many other studies of the social influences approach in the literature ,70.The DARE (Drug Awareness and Resistance Education) Program was developed by the Los Angeles Police Department (LAPD) and the Los Angeles Unified School District (LAUSD) in the early 1980s. They essentially took the two variants of Project SMART (Self Management and Resistance Training) that were being tested with grade 7 students in LAUSD schools at the time , combineAlthough early nonrandomized studies suggested that DARE sometimes had small effects for elementary school students, multiple randomized trials ,73-77 an. Physicians or medical student volunteers go into 4th and 5th grade classrooms and provide one interactive 45-minute session that focuses on the short-term, image-based consequences of tobacco use. This is preceded by a lesson provided by the regular classroom teacher to teach students that, contrary to their perception, tobacco users are in the minority. The guest session is followed by a poster contest. A quasi-experimental evaluation suggests that this program produces short-term changes in knowledge [ accessed January 18, 2008).Many health education programs are promoted as being effective even without good evaluation data. One smoking prevention program in this category is the "Tar Wars" program for elementary students operated by the American Academy of Family Physicians nowledge . Despitenowledge , includiAnother program that has been promoted as being an effective prevention program, but that had no long-term effects on smoking, is the Michigan Health Education Model. It consists of 30 lessons taught during grades 5–8, some of which include resistance skills training. Although it produced an 82% relative improvement (RI) in ever smoking at the end of the program ,81, no s accessed January 18 2007). The University of Colorado provides a comparative matrix  accessed January 19, 2007). For one list of lists see  accessed January 18 2007). The University of Colorado provides a comparative matrix . The stated purpose of these lists and guides is to help decision makers, at both the federal and local levels, choose programs that are supported by the best available evidence ["Evidence-based practice" and other related terms have become common terms and standards in the U.S. and other countries in recent years. Multiple agencies have reviewed evaluation studies of substance abuse prevention programs and produced lists of "scientifically proven" or "evidence-based" programs , by different providers , in different settings . A clear example of this is the European Smoking prevention Framework Approach (ESFA) . The ESFThe details of the ESFA programs varied considerably across countries. Such variations may have accounted for the differences in outcomes, and prior research may be informative. For example, some studies have found programs to be ineffective (or even harmful) when delivered by regular classroom teachers ,91. The Programs with replicated findings are more likely than programs for which there is no prior evaluation to be effective in different settings, but only if those replications showed effectiveness in many different types of students, providers and settings in evaluations by different investigators. The program with the most replications is Life Skills Training (to be reviewed below), but most of these have been conducted by the program's developer in the U.S, with replications in Spain and Europe.Gandhi et al  found thCultural sensitivity is believed to be important in public health  and for In a study in ethnically diverse schools  in Southern California, Johnson and colleagues ,120 company community or country adopting a program will need to evaluate it rigorously to determine its effectiveness in the new setting or culture.The kinds of results reported above suggest great caution is needed when implementing programs with different ethnic groups or in different cultures. On the one hand, some programs seem to be equally effective with many different groups but, on the other hand, some studies suggest that making programs culturally relevant might be very important. Clearly, we need more research on this issue. In the mean time, In summary, findings from various reviews and meta-analyses suggest that school-based smoking prevention programs can have significant long-term effects if they:(1) are interactive social influences or social skills programs that(2) involve 15 or more sessions, including some up to at least ninth grade, that(3) produce substantial short-term effects.However, it is not easy to adopt and adapt a program for use in contexts different from those in which it was tested, especially in other cultures and countries, and great care must be taken to implement with integrity and monitor implementation and outcomes. These findings also suggest that many more programs that have reported short-term effects might also have medium- and long-term effects if they were evaluated. Unfortunately, long-term studies are relatively rare, mostly due to lack of funding. In the accompanying paper I provide a review of selected school-based smoking prevention programs that have the promise of long-term effectiveness.The author declares that they have no competing interests.