Genome cohort studies are used to analyze interactions between genetic and environmental factors, providing valuable information for personalized healthcare. Large-scale and long-term cohort studies require a number of specially trained personnel, of whom those involved in obtaining informed consent play a vital role, especially during the initial phase of such studies. The Japanese Society of Human Genetics (JSHG) previously established a certification system for genome medical research coordinators (GMRCs) responsible for obtaining written consent via face-to-face explanation. Meanwhile, in the Tohoku Medical Megabank Organization (ToMMo), GMRCs are expected to play important roles not only in obtaining informed consent and conducting various assessments, but also in communicating with participants throughout the long-term follow-up. Based on the JSHG program, we therefore developed a specific education and training program for ToMMo GMRCs consisting of 17 lectures, one practical training session on the informed consent procedure, and written and interview examinations. Re-education workshops aimed at self-improvement are also carried out following certification. In this study, we evaluated the education and training program in terms of overall understanding, usefulness, and satisfaction using an anonymous questionnaire.An anonymous questionnaire addressing each aspect of the education and training program  was distributed among 152 qualified ToMMo GMRCs. Responses were received from 94 participants (61.8%).There was a significant association between the level of overall understanding of lectures and medical qualification , but not with age or educational background. The level of understanding and overall usefulness were lower in sessions related to genetics and epidemiology than those dealing with ToMMo practices. In the re-education workshops, GMRCs showed a preference for and hoped to learn more about both background knowledge and research progress in the ToMMo.The results of our questionnaire suggest that not all ToMMo GMRCs are able to understand everything during the initial education and training program, especially in terms of genomic medicine. Continuous re-education is therefore vital in improving knowledge, skills and motivation, and preparing GMRCs for a specialist role in community-based personalized healthcare.The online version of this article (10.1186/s12909-019-1725-5) contains supplementary material, which is available to authorized users. The Tohoku Medical Megabank Project (TMM) was launched to support creative reconstruction following the Great East Japan Earthquake in March 2011, providing medical support and carrying out a genome cohort study . Large-sAs part of the TMM project, the ToMMo constructed two cohorts consisting of more than 120,000 participants: the TMM Community-Based Cohort (TMM CommCohort) study, which includes 50,000 adults living in Miyagi prefecture, and the TMM Birth and Three-Generation Cohort (TMM BirThree Cohort) study, which consists of 70,000 family members of pregnant women. Meanwhile, the IMM constructed a TMM CommCohort consisting of more than 30,000 participants. In the ToMMo studies, assessments were conducted as follows: (1) onsite during annual community health examinations in each municipality for recruitment to the TMM CommCohort study, (2) in obstetric clinics and hospitals for the recruitment of pregnant women and their families and recording of clinical data for the TMM BirThree cohort, and (3) in seven Community Support Centers in Miyagi Prefecture for physiological measurements in both studies.Assistants are employed to bridge the gap between participants and researchers, with informed consent (IC) obtained via face-to-face explanation and in a written format according to the Japanese Ethical Guidelines for Human Genome/Gene Analysis Research . Based oWe therefore decided to employ additional assistants living in Miyagi Prefecture to work specifically as ToMMo GMRCs. In addition to the abovementioned roles, these individuals were also expected to be responsible for continuous communication with participants throughout the long-term study, thereby helping maintain a high rate of follow-up Fig. . Close cIndividual studies within large-scale cohort studies and/or biobank projects use different types of personnel to obtain IC and/or conduct assessments. For example, some studies use general practitioners to recruit participants and have research nurses perform the examinations . In otheTo our knowledge, no report has yet documented education programs aimed specifically at assistant staff in cohort and/or biobank projects. However, understanding the effectiveness of these programs is important for training ToMMo GMRCs. In this study, we therefore examined the overall level of understanding, usefulness, and satisfaction of various lectures and training programs via a comprehensive questionnaire survey of qualified ToMMo GMRCs.The education program for ToMMo GMRCs was divided into two parts: initial education and training, and re-education. ToMMo staff who conduct ICP are required to acquire ToMMo GMRC certification via an initial education and training program consisting of 18 sessions and 2 examinations. These initial 18 sessions are composed of 17 1-h lectures and a 2-h practical ICP training sessions  distributed streaming video recordings of each workshop, thereby supporting updates at any time. Through participation in these workshops and related seminars, GMRCs can apply for credits, which lead to the advanced ToMMo GMRC certification and certification renewal, which is required every 5 years.A questionnaire was designed to specifically evaluate the education and training program for ToMMo GMRCs. As shown in Additional file 2-test. The associations between levels of understanding and the usefulness of each lesson were examined using Pearson’s correlation analysis. Lastly, the rate of selection of particular re-education topics was compared with that of all other topics using Fisher’s exact test.All data analyses were performed using SAS Enterprise Guide 7.11 (SAS Institute Inc.). Evaluation of lectures was compared with that of practical training using Fisher’s exact test. Associations between evaluations and the demographic characteristics were examined using logistic regression analysis. The overall understanding of lectures related to basic knowledge of genetics and epidemiology were compared with that of those related to ToMMo GMRC practices using the χTo evaluate the education and training program, 152 qualified ToMMo GMRCs working in the organization as of February 2017 were enrolled in the study. Of these, 94 (61.8%) returned the questionnaire. Demographic characteristics of the respondents are shown in Table p = 0.0009 and p < 0.0001, respectively), with lectures considered harder and more time consuming.The initial education and training program composed of lectures and a practical training session (ICP role-play) was evaluated in terms of the time taken, level of difficulty, confidence gained, and overall satisfaction Table . More thp = 0.016).We subsequently analyzed whether these evaluations were correlated with the demographic characteristics of the ToMMo GMRCs. For this purpose, age, educational background, and medical qualifications were respectively categorized into two groups: < 40 or ≥ 40 years of age, university/graduate school degree or others, and nurse/clinical laboratory technologist or other .Next, the overall level of understanding and the usefulness of each session were examined using a 5-point Likert scale. As shown in Fig. p < 0.0001). These results suggest that ToMMo GMRCs clearly understand topics directly related to their work, but are less knowledgeable on epidemiology, human genetics, and genomic medicine, which form the background to the TMM study.Meanwhile, the rate of usefulness was 70% or more for session Nos. 9, 10, 12, 15, and 18, all of which are related to ToMMo GMRC practices  followed by questions and answers about the ICP in the pre-survey (No. 7) Fig. a. FurtheALDH2 genotyping (No. 19) were also favored. These results suggest that ToMMo GMRCs are interested in learning both about GMRC practices, which are directly useful in their job, and knowledge relevant to the background, results, and perspectives of TMM studies, all of which help with self-improvement. Note that while 60% of participants participated in the re-education program via alternative forms of education such as video conferencing and online workshops, comparisons of online with face-to-face participation revealed that the rate of understanding was nearly the same (about 80%), while the rate of satisfaction was lower with online workshops .Meanwhile, in the small group re-education workshops, lectures on the genetic liability of Mendelian and common diseases (No. 2) and the return of genomic results  (Nos. 8 and 10) were the most selected topics Fig. d. In addLastly, we examined the level of current knowledge among ToMMo GMRCs using a questionnaire quiz consisting of 10 questions conducted on February 2017. The percentage of correct answers is shown in Fig. In this study, we described and evaluated the education and training program developed especially for ToMMo GMRCs. As a result, we found that while the program increases confidence, participants face difficulties understanding basic genomic medicine. Continuous re-education is therefore extremely important in increasing knowledge and skills. To the best of our knowledge, the trial described here is the first example of a systematic educational program specifically for personnel responsible for communicating with participants in a genomic epidemiological study. The findings could therefore be applied to similar human resource training programs in other studies.The education and training program for ToMMo GMRCs was developed to support establishment of large cohorts. In the initial education and training program, lectures not only cover the knowledge required by JSHG GMRCs, but were extended to deliver more extensive knowledge via seven lectures covering topics ranging from epidemiology to human genetics. Furthermore, efforts of the ToMMo were also incorporated into these lectures, such as informational security, de-identification, and bio-banking. Evaluation of the ToMMo GMRC program revealed that participants deem the lectures more difficult and more time consuming than the practical training, suggesting that the lectures were a little too hard and of less overall use in carrying out the ICP. However, we believe that lectures indirectly related to the skills required for the ICP are important in understanding and being able to explain the significance of the TMM project to participants. The level of difficulty of the lectures was also significantly correlated with a lack of medical qualifications, suggesting that some lectures, such as the fundamentals of epidemiology and genetics, can be omitted for those with a medical background or qualification and for those with a sufficient level of knowledge as confirmed by a preliminary test. Taken together, the findings of this study suggest that the initial education and training program for ToMMo GMRCs is a unified program applicable across a diverse demographic range, ultimately providing a certain skill level for implementation of the ICP. Moreover, by having an overall understanding of the background and purpose of the TMM, cooperation among ToMMo GMRCs should be possible, thereby increasing overall motivation. For this reason, it is important to compensate for the lack of knowledge, especially in recent advances in genomic medicine, via continuous re-education.The two types of re-education workshops were deemed particularly useful not only in reviewing what was learned in the initial program, but also in keeping participants up to date on any progress in the field. Responses to the questionnaire further suggested that these workshops are also an important opportunity for ToMMo GMRCs to make contact with researchers, thereby increasing motivation. A preference was shown for lectures dealing with the progress in cohort studies and topics related to human genetics and epidemiology, such as the causes of common diseases, thereby supporting what was previously learned but not yet fully understood. Re-education via video conferencing and online resources received a high rate of understanding but a lower rate of satisfaction, suggesting that alternative forms of re-education are of use to only a certain degree. By analyzing completers of a massive open online course (MOOC) recently developed to support online and open access learning opportunities, it was found that having an understanding of participants’ motivation factors, which range from improving knowledge, obtaining certification, and professional advancement, is crucial for the development of MOOCs . ProvidiThere are two limitations of this study. One is selection bias of respondents due to the response rate of only 60%. The other is recall bias as more than 90% of ToMMo GMRCs participated in the initial education and training program in FY 2013 or 2014 Additional file 2:Text 1. Evaluation criteria of the ToMMo GMRC interview examination. (DOCX 19 kb)Additional file 3:Text 2. Questionnaire items used to evaluate the education and training program for ToMMo GMRCs. (DOCX 53 kb)Additional file 4:Table S2. Evaluation of the 17 lectures in the initial education and training program according to the participants’ demographics. (DOCX 25 kb)Additional file 5:Table S3. Evaluation of the practical training session in the initial education and training programs according to participants’ demographics. (DOCX 19 kb)


The School Health and Nutrition (SHN) program is a cost-effective intervention for resource-poor countries. SHN program aims to provide timely support and preventive measures to improve the health of school children, which can be associated with their cognitive development, learning, and academic performance. Stakeholders at different tiers can play significant roles in the program implementation and its success. Their perceptions are equally important to provide information on the factors influencing the implementation process and help to identify the gaps in the process. However, the evidence is scarce on the school health and nutrition policy and program implementation in developing countries. No study has yet explored stakeholders’ perceptions on the SHN program implementation process in low-income countries, including Nepal. Therefore, we conducted a qualitative study to explore (1) the SHN program implementation, (2) its impact, and (3) challenges in Nepal.We conducted a qualitative study through 32 in-depth interviews of the key informants who were actively involved in SHN program implementation in Nepal. The key informants were identified through personal network and snowballing procedure. We adopted a thematic approach for the data analysis.We categorized interview data into three broad themes: (1) SHN program implementation, (2) its impact, and (3) challenges during implementation. Almost all the key informants appreciated the program for its positive impact on students, schools, and communities. The positive impacts included improved students’ health and school environment and enhanced community awareness. However, the key impediments in implementing the program included a lack of coordination between stakeholders, lack of resources, limited training opportunities, and doubts regarding the sustainability of the program.This study provided a deeper understanding of the linkage between the SHN program implementation, impact, and challenges in Nepal. Despite the challenges, all the stakeholders acknowledged that the SHN program had positive impacts on students, schools, and communities. Our findings highlighted that stakeholders from all tiers should coordinate, collaborate, and continue their efforts to effectively implement and expand the program nationwide. Awareness campaigns and advocacy for the program are indispensable to pull more resources from relevant stakeholders. Schools have been a powerful setting to promote health programs , 2. The In 1995, the World Health Organization (WHO) launched the Global School Health Initiative and introduced the concept of Health-Promoting Schools (HPS) , which cHealth-promotion activities have been successfully implemented through the SHN program in resource-rich countries , 5, 11. In Nepal, the Ministry of Health (MOH) and the Ministry of Education (MOE) jointly endorsed the National SHN Strategy in 2006 . Since tTo improve the quality of the SHN program, generating evidence is essential. With this aim, in 2013, we conducted an evaluation study of a 4-year-long SHN project jointly conducted by JICA and Nepal Government in Sindhupalchok and Syangja districts . The proThe evidence is scarce on the SHN program implementation process in resource-limited countries , 12, 19,In this qualitative study, we conducted 32 in-depth interviews with key informants from September to December 2013. We used a stratified purposive sampling technique to choose the study areas , 23 and Table The key informants represented four different levels: (1) central level and (2) aid agencies in Kathmandu valley and (3) district level and (4) schools in Siraha, Sindhupalchok, Syangja, and Kailali districts. At the central level, we included two key informants from the Department of Education, MOE, and three from the Child Health Division, MOH. The central-level key informants were involved in the SHN program development, networking, resource mobilization, and monitoring. From the aid agencies, we recruited one key informant from each of seven different international non-governmental organizations (INGOs), and UN and bilateral organizations. The key informants from the aid agencies were involved in supporting the MOE and MOH to implement the program as well as in monitoring and supervising the programs implemented in the schools. At the district level, four key informants from four District Health Office and four District Education Office were recruited from Siraha, Sindhupalchok, Syangja, and Kailali districts. The district level key informants were involved in planning, coordination, resource mobilization, and monitoring of the SHN program in the schools. From the schools also, we recruited four school principals, four teachers, two local non-governmental organizations (NGO) members, one resource person, and one school management committee member from Siraha, Sindhupalchok, Syangja, and Kailali districts. Key informants from the schools implemented and self-monitored the SHN program in the schools.The first author and a research assistant conducted all the interviews at the key informants’ workplace, some in English and some in Nepali language. Each interview lasted for an average of 1 h and was tape-recorded and transcribed. Notes were also taken while interviewing. At the end of each interview, the interview notes were reviewed with each key informant to validate what he or she intended to convey. After we felt that data saturation was reached, we stopped the data collection procedure . We follWe used a modified interview guide based on the Policy Implementation Assessment Tool for program implementers and other stakeholders, developed by the United States Agency for International Development (USAID) . The intWe conducted a thematic analysis, an inductive approach, using the conceptual framework developed by USAID  to analyIn the compiling phase, the research assistants transcribed the interviews. The first author (RMS) then assigned unique code numbers to all the transcripts from the 32 key informants as P1 to P32 (P refers to participant), verified the transcripts with the tape-recorded conversations and written notes.In the disassembling phase, the first author thoroughly read and reread the transcripts, listened to all the interviews repeatedly, and examined the patterns of interview data. The first author then identified the specific data segments, which were related to study objectives, and gave labels to the data segments to develop preliminary themes, codes, and sub-codes based on the conceptual framework by USAID . The groIn the reassembling phase, we reassembled all the data under the same themes, codes, and sub-codes into different groups. In the interpreting phase, we wrote summaries to interpret the data and discussed important quotations. Three co-authors summarized each transcript, selected quotations, and translated them into English. Finally, in the concluding phase, the first author read the summaries and selected quotations to draw conclusions from the data and discussed them with all co-authors.The Research Ethics Committee of the University of Tokyo and the Nepal Health Research Council (NHRC) approved this study. We obtained written informed consent from all the key informants before the interview. We informed them that their participation was voluntary and they could withdraw from the study at any time. We also assured them of confidentiality and anonymity.We categorized the interview data into three broad themes: (1) SHN program implementation, 2) impact of the SHN program, and (3) challenges during program implementation and suggestions from stakeholders . Table 2 impact oAt the central level, the ministry of education, ministry of health, national planning commission and different aid agencies are involved, while at grass root level district health office and education office, schools, school management committee, child clubs, parents, students unions, health posts etc. are the main stakeholders actively involved." Now, the SHN network is formed and all the stakeholders involved in it have planned and divided their responsibilities. None of the organizations go directly for the implementation of SHN. We all go through SHN network, which has been a good mechanism where we can coordinate." Majority of the participants from the central, aid agencies, and district level mentioned that there is a structural network from top to down, which included Department of Health Services (MOH), Department of Education (MOE), and different aid agencies at the national level, which were involved in program implementation. At the district level and schools, depending upon the local context and area, the key players involved were District Health Office, District Education Office, schools, Village Development Committee, District Development Committee, local NGOs, health posts, Female Community Health Volunteers (FCHVs), youth clubs, and parents. A few participants from the central level stated about the SHN network, which was also formed with stakeholders from different tiers and has been actively involved in implementing SHN programs as a campaign.According to the key informants’ responses from all levels, the major SHN activities could be mainly categorized into four sections, which were based on the four objectives of the SHN strategy . The actMajority of key informants responded that they conducted activities such as general and oral health check-ups, first aid services, deworming, iron supplementation, child club activities, maintaining the SHN register, and providing mid-day meals. These activities aimed to improve students’ use of SHN services.We particularly focused on health examination, oral health check-ups and camps, tooth brushing and hand washing every day, providing mid-day meals, first aid training, providing first aid box to schools, providing training to school teachers and child clubs in the schools." Majority of key informants from all levels mentioned that they conducted activities such as school cleaning programs, access to safe drinking water, improving toilet and hand washing facilities, waste disposal pits in school, construction of classrooms, toilets, etc. They mentioned that the above activities helped to improve the school environment."Students used to defecate openly in the past, but now they have started using toilets. They collect garbage in the garbage box and after it is filled, they burn it." According to the key informants from aid agencies, district level, and schools, they conducted activities such as health education classes, child clubs, and extra-curricular activities to improve students’ health-related knowledge and behaviors. Besides, schoolteachers and child club members were trained to conduct health education sessions on SHN. Awareness programs for parents and community were also conducted.After the SHN program started, there have been many improvements. For example, this program has improved students’ knowledge of health and hygiene practices and keeping the school environment clean, etc. We have seen many positive changes after this program. Some key informants from the central level and aid agencies stated that at the central level, the members of the SHN network and government actively participated in regular meetings to share and discuss the SHN program strategies, activities, and achievements. Some key informants also mentioned that they received support from communities to conduct SHN activities effectively.At the central level, we are the active members of the SHN network. So we are actively participating in the program. Water facility was not available in the schools in Pyuthan district. We had a meeting with parents and teachers and told the parents that we could just give them pipelines. Then, they did all the labor work to set up the pipelines. This is one good example of cooperation between school and community. Based on the key informants’ responses, we categorized the impact of the SHN program into two main parts a) impact on students, and b) impact on school environment and community.Students’ awareness on hygiene and sanitary practices has improved. When I was in Dadheldhura, I visited one of the schools there. When I was looking for a toilet, one of the students from grade 3 showed me the toilet and hand washing soap. The tiffin box program would be one of the success stories and good practices. Parents started sending tiffin to their kids in these tiffin boxes. So this is about the behavior change among students as well as their parents. All the key informants in this study mentioned that the SHN program was successful in improving students’ general knowledge of health and nutrition. Furthermore, the program also brought positive changes in students’ nutritional behaviors, hygiene practices, and life skills. Some participants also appreciated providing tiffin boxes to students, after which many parents started sending tiffin from home in those tiffin boxes.When we conducted the program, we had the baseline and end-line data, which showed a huge reduction in anemia. In the past, there used to be diarrhea epidemics but now there are no such incidents. Physical screening has helped us to identify vision and hearing impairments. We have prevented kids from becoming blind after vision screening and referring them for further treatments. We have also prevented some kids from suffering permanent hearing loss. Many key informants further stated that the program improved students’ health status by reducing problems such as diarrhea, parasitic infections, anemia, blindness, and hearing loss.In the past, students could not understand what they were taught. It’s because their stomach used to be empty. So their focus was more on their empty stomach than on their study. But now all the students bring tiffin. Even if they forget to bring tiffin, their parents bring it to school. So students do not run away from their schools. Their health condition is also getting better. We have qualitative data and reports, which showed students now want to come to school and don’t go back in a break. We have mid-day meal promotion so students come back. For adolescents, we have menstrual hygiene management class, which brings them to school. Many key informants also mentioned that the program improved the attendance, enrolment, and retention rates in schools. They further suggested that improved health has a positive impact on students’ academic performance.Children are changing agents. They are promoting health and hygiene not only in their schools but also in their homes and communities. In the past, proper coordination and communication did not exist between schools and communities, so the communities used to be dirty with open defecation. Even tooth brushing was neglected. After the child club mobilization, the child club members conducted rallies in the villages to generate awareness among the community people. After receiving the messages from the school children, the communities have been empowered. The open defecation decreased and more toilets were built. Later, an open-defecation-free zone was declared in school catchment areas. Parents have also started brushing their teeth! Majority of key informants mentioned that the SHN program brought positive changes in the school environment and community. The cooperation between schools and the community also improved. In some areas, communities were mobilized in SHN activities, leading to community awareness.There are some difficulties with coordination among stakeholders. Horizontal coordination is more difficult than vertical coordination. Most of the organization and ongoing activities come from the health sector. Lower numbers of NGOs or INGOs working in the education sector are involved in SHN program implementation. Though a certain level of coordination exists between the stakeholders, I don’t see that extent of coordination even at the central level, which could generate resources. So I think it is a bit lacking in this part, which can be a challenge for the sustainability of the program Majority of key informants responded that MOH, MOE, and their institutions from the central to local levels were responsible to implement the programs and a certain level of coordination existed between them. However, some of the key informants from the central level and aid agencies mentioned that MOH was more active compared to the MOE. Furthermore, the overall coordination between these two sectors was limited, which therefore led to a lack of planning for the sustainability and scaling up of the program.We conducted the SHN project from Japan International Cooperation Agency's (JICA) support. But we are facing difficulties to expand the program because of financial problems. Human and material resources are insufficient from the central to the district level. We have not been able to fulfill the demands. In our school, we do not have teachers with enough knowledge about health issues. Also, we have not been able to use toilets properly and they are smelly because of lack of water facilities. By using available funds, we can conduct activities that only meet the indicators proposed by our headquarters. We do not and cannot do all the activities of the SHN program. Almost all key informants in this study responded that the allocated funds for the SHN program were not sufficient to implement all the program components and expand it nationwide. Besides, insufficient human resources and physical infrastructures were other major hurdles. Many key informants from the aid agencies agreed that they have limited resources and could conduct only selected programs in some target districts.The training was conducted only once and ended and it was not repeated. I am the focal person for the SHN program. I have worked in the health training department for 7 years but haven’t received any training related to school health yet and I also don’t know about it. All the key informants agreed that training is essential to implement the SHN program effectively. Though the majority of the key informants from the central level and aid agencies stated that they have received different trainings, mixed responses were obtained from the key informants at the district level and schools. Some of them mentioned that they had received the training once, while some were not even aware of such training.As soon as he/she gets some training, he/she will be transferred somewhere else due to either personal interest or organizational changes. Some key informants from the central and aid agencies responded that the lack of trained human resources and turnover of trained staff members were also impediments during program implementation.It is not sustainable. We don’t have enough resources. We have conducted it in two districts but could not expand it to other districts. So if resources are available, we can make it sustainable. Almost half of the key informants from different levels were positive regarding the sustainability of the program, while others were doubtful due to lack of resources.The education sector should be more involved, as the Ministry of Education is also on board. The program will be sustainable if it is integrated into the government system. Aid agencies come and once they are gone, the District Education Office and communities cannot make the program sustainable by themselves. Despite several challenges identified by the stakeholders during the implementation of SHN programs, all of them acknowledged that efforts should be made to make the program sustainable, because of its positive impact on students, schools, and communities. Some of the key informants from the central level and aid agency suggested that MOE should also get actively involved in the program implementation. Besides, a few respondents at the central level mentioned that the program could be sustainable if it is integrated into the government system.In my opinion, the coordination between the stakeholders should also act on pulling up the resources for implementing the program. Child clubs in schools organize Deusi-Bhailo program  during Tihar festival and collect fund. The child clubs also charge membership fees to generate fund, which they use for school health and nutrition program activities Some of the key informants also provided suggestions on resource generations. One of the key informants from the aid agency mentioned that the stakeholders should coordinate well to generate resources. Some key informants from the schools even mentioned that they tried to generate funds from local sources.The training was conducted only once and such training should be conducted repeatedly. We need basic training for all teachers. I don’t think training only one focal teacher is sufficient. Regarding training on SHN program implementation, stakeholders at districts and schools who had received training on SHN program implementation once, suggested that such training should be more frequent and longer and also mentioned that it should be expanded to other parts of the country. They also suggested that all the teachers in the school should be trained.In this study, almost all the key informants appreciated the SHN program implementation in schools and the positive impact it has on students, schools, and communities. The positive impact included improved students’ health and education outcomes, improved school environment, and enhanced community awareness. However, key informants also identified key impediments in implementing the program: there was a lack of coordination between stakeholders, lack of resources, limited training opportunities, and doubts regarding the sustainability of the program.According to many key informants in this study, a broad array of stakeholders was involved from the central level to schools in implementing the SHN programs based on the SHN strategy in the country. MOH and MOE were the lead institutions for implementing the program. Aid agencies were also playing significant roles in implementing programs in different parts of the country. At district level and schools, DOH, DOE, schools, health posts, local NGOs, FCHVs, youth clubs, and parents were actively involved. Understanding the roles of different stakeholders is essential to analyze the implementation process of a program .The majority of key informants mentioned that after the implementation of SHN program in the schools, students had better access to different SHN services, better nutrition, safe drinking water, and hygiene and sanitation facilities. They also acknowledged that the program significantly improved students’ knowledge, awareness, and practices regarding health and hygiene issues. The improved practices included hand washing, using soap while hand washing, and wearing clean school uniforms. Child clubs and extra-curricular activities could have played a significant role in improving students’ health and nutritional knowledge and practices. Similar child club activities are known to help students gain knowledge and learn life skills for their personal development in Nepal . FurtherMany key informants also mentioned that the program had a positive impact on students’ health status, such as reduced diarrheal diseases, worm infestations, and anemia. Students’ better access to SHN services such as deworming, and iron and vitamin A supplementation might have played a significant role in the improved health outcomes. According to a few key informants, physical screening could have also prevented blindness and hearing loss in some students. Our previous study also showed a positive association between the SHN program and students’ better health outcomes . MoreoveFurthermore, this study showed that after implementing the SHN program in schools, more parents sent their kids to school with tiffin and wearing a clean uniform. School children might have played a role as changing agents and generated awareness about nutrition, personal hygiene, and cleanliness at home and in their communities. These findings indicate that SHN program has helped to sensitize parents and community members about child health-related issues and promoting healthy behaviors; therefore, they also benefited from the program. Moreover, parents and community members can also play a significant role in encouraging children to practice healthy behaviors and keep their school environment clean, safe, and healthy . SimilarDespite the positive impact of the SHN program on students, parents, and communities, this study identified several barriers and challenges to implement the program. Some of the key informants from the central and aid agency mentioned that horizontal coordination was lacking between the MOH and MOE. According to the institutional framework of the SHN strategy, the two ministries were the lead institutions to implement the program in Nepal, and aid agencies were the key implementing partners . HoweverFurthermore, most of the key informants identified insufficient funds and lack of material resources as the major hurdles to implement a comprehensive and nationwide SHN program. Many schools did not have sufficient physical infrastructures or facilities to implement the program efficiently. In resource-limited countries, a lack of resources has been a crucial operational barrier to conduct the program , 12, 13.This study further showed that the lack of trained human resources to implement SHN was another key impediment. Although most of the key informants from the central level and aid agencies received and provided training to implement the SHN program, only some key informants from the district level and schools received the training. A few of them were not even aware of such training programs on SHN activities. Besides, only one focal teacher in each school was trained to conduct SHN activities and the students did not have access to the trained health professionals at schools. These findings indicate the dearth of trained human resources to conduct the program effectively. However, capacity building of human resources from the central level to schools is known to be a requisite to improve and sustain the program , 39. A rThis study showed that the sustainability of the SHN program was a challenge because of insufficient material and human resources, and lack of strong leadership. A few of the key informants suggested integrating the program into the government system to make it sustainable. Program sustainability depends on the government’s strong leadership, long-term funds, and trained human resources , 41. DesThe results of this study should be interpreted considering three limitations. First, we collected data from school-level key informants only in the districts where the SHN program was conducted. Therefore, key informants’ responses in this study may not represent stakeholders’ perceptions throughout the country. However, we interviewed key informants from different tiers including the central and district levels, schools, and aid agencies. Second, we did not include parents as key informants in this study though they are important stakeholders in SHN program implementation and their perceptions might have given additional insights. However, they were the least active stakeholders in implementing the program, and thus we have tried to understand their perceptions from school principals and focal teachers, who were communicating with parents on a regular basis. Third, the key informants might have expressed the views that they thought we (investigators) wanted to hear, leading to social desirability bias. However, we conducted interviews in the closed room in their office settings. We also assured them about the confidentiality of the information they provided and the anonymity of their identity. Despite these limitations, this is the first study in Nepal to explore the perceptions of stakeholders from all tiers regarding the SHN program implementation, impact, and challenges.This study provided a deeper understanding of the linkage between the SHN program implementation, impact, and challenges in Nepal. Stakeholders from all tiers identified several operational barriers to implementing and expanding the program throughout the country. The four major challenges identified by the stakeholders were lack of coordination between stakeholders, lack of resources, lack of training opportunities, and low sustainability of the program. Despite these challenges, all the stakeholders acknowledged that the SHN program had positive effects on students, schools, and communities and provided some suggestions to improve the implementation of SHN program in the country.Our study further highlighted that stakeholders from all tiers should coordinate and collaborate adequately to continue their efforts to implement and expand the program nationwide. Furthermore, MOH and MOE should jointly provide strong leadership and recognize their responsibilities to improve students’ health and academic outcomes. Awareness campaigns and advocacy for the program are indispensable to pull more resources from relevant stakeholders. Besides, the government should implement programs to encourage schools to generate resources at the local level and discourage over-dependency on external sources to make the SHN program sustainable.


Earthquake-induced deaths vary greatly between individual years and exhibit no significant trend. The Qinghai-Tibet seismic zone is the area with the highest frequency of earthquake disasters and the largest accumulated DELs, whereas the North China seismic zone is associated with the highest number of deaths. Among the 722 earthquake disasters, nearly 99.0% of deaths and 95.0% of DELs are attributable to 1.8% and 3.9% of the earthquake disasters, respectively. Approximately 54.2% of recorded earthquake disasters have earthquake magnitude (Ms) values between 5.0 and 5.9, while earthquake disasters with Ms greater than or equal to 7.0 account for 88.5% of DELs and 98.8% of deaths. On average, earthquake-induced DELs and deaths increase nonlinearly with increasing Ms per earthquake. DELs have a positive correlation with deaths and casualties on a logarithmic scale. This study further discusses that during different stages of socioeconomic development, changes in both exposure and vulnerability may be the major factors leading to change differences in earthquake-induced socioeconomic consequences. This study is a beneficial supplement to the global earthquake database and is useful for calibrating global or regional empirical loss models.Understanding the spatiotemporal pattern of historical earthquake disasters and resultant socioeconomic consequences is essential for designing effective disaster risk reduction measures. Based on historical earthquake disaster records, this study compiles a Chinese earthquake disaster catalog (CH-CAT) that includes records of 722 earthquake disasters that occurred during 1950–2017 in the mainland of China. This catalog includes more complete data records than other existing global earthquake databases for China as a whole. Statistical results demonstrate that the number of earthquake disasters and the resultant direct economic losses (DELs) exhibit significant increasing trends ( Ms) of 8.25 in Shaanxi was the deadliest earthquake on record; it killed approximately 0.8 million people [China is located at the intersection of the Circum-Pacific and Mediterranean seismic belts. Within this earthquake-prone area, earthquakes in the mainland of China account for approximately one-quarter to one-third of the world’s earthquakes . The disn people . The 197n people . The 200n people , amountiwww.emdat.be) [www.ngdc.noaa.gov) [www.munichre.com) [www.iisee.kenken.go.jp). These earthquake disaster databases have provided a good foundation for analyzing global or national earthquake disaster characteristics [There are several global and regional earthquake disaster databases that include earthquake-induced damage records for China, such as the Emergency Events Database (EM-DAT) (mdat.be) ,6, Signioaa.gov) , NatCatShre.com) , the PAGhre.com) ,10,11, aeristics ,17,18,19eristics ,21,22. Teristics ,24,25. Teristics ,27,28. UChina has experienced frequent earthquakes since ancient times, and many researchers have studied earthquake disaster characteristics over the past several decades . Dong etThus, our aims are to map how historical earthquakes and their socioeconomic consequences have changed in space and time and to analyze the statistical characteristics of DELs and deaths. For this purpose, first, this study compiled a Chinese earthquake disaster catalog (CH-CAT) during 1950–2017 based on data from China Earthquake Administration (CEA). Then, we mapped the trends and distributions of historical earthquake disasters, DELs, and deaths. Lastly, we analyzed relationships among earthquake magnitude, DELs, and deaths. These results can help us to develop an empirical loss model and to design effective disaster reduction strategies across China.(1)www.csi.ac.cn), which is maintained by the CEA. It provides information about the date, time, latitude, longitude, Ms, depth of hypocenter, and location of earthquakes that have occurred in China since 780 B.C. The comprehensive seismic parameter catalog provides a reference list to avoid omitting earthquake disaster records.Seismic information was acquired from the China Seismic Information database ((2)www.cea.gov.cn). Earthquakes that occurred in Taiwan, Hong Kong, and Macao were excluded from this study due to a lack of statistical loss data.Records of earthquake-induced damage during the period 1950–2017 across 31 provinces in the mainland of China were collected from published books as well as online and relevant references provided by the CEA . DELs ca(3)www.stats.gov.cn).Socioeconomic statistic data  data) were collected from the National Bureau of Statistics of China .Among the 722 earthquake disaster records, 443 (61.4%) earthquakes were associated with DEL reports, and the other 289 disasters caused at least some form(s) of casualties bars in a. Notablp < 0.01, M-K trend test), but with fluctuations, in the annual total number of earthquake disasters in China during 1950–2017 (p < 0.10) during 1986–2017 (Ms ≤ 5.9 (p < 0.01) and 6.0 ≤ Ms ≤ 6.9 (p < 0.10) during 1950–2017. Among the 722 earthquake disasters, 54.2% of them had magnitudes of 5.0 ≤ Ms ≤ 5.9, and earthquakes with magnitudes of 4.0 ≤ Ms ≤ 4.9 and 6.0 ≤ Ms ≤ 6.9 each accounted for approximately one-fifth of the recorded earthquake disasters. As seen in 950–2017 b; for ex986–2017 b. Regardp < 0.05), while similar increasing trends in the Qinghai-Tibet (p = 0.88), Northeast China (p = 0.65), and South China (p = 0.22) seismic zones were not significant. Furthermore, the North China seismic zone exhibits a weak downward trend (p = 0.23). . a. Ms equal to or greater than 8.0 occurred in Xinjiang (one event), Sichuan (one event), and Tibet (three events). Although Yunnan Province experienced the most earthquake disasters, the maximum Ms was 7.8 during 1950–2017.At the province level, earthquake disasters affected almost all provinces in China during the period 1950–2017. The number of earthquake disasters in the provinces of Yunnan (158), Xinjiang (123), and Sichuan (106) accounted for 53.6% of the total number of earthquake disasters. Additionally, nearly half of the provinces experienced more than ten earthquake disasters. Earthquakes with The magnitude distribution of the 722 earthquake disasters is close to a normal distribution a. In totMs 8.0 Wenchuan earthquake caused the greatest DELs . Additionally, the DELs also show a significant increasing trend during 1990–2017 (p < 0.01). The frequency of earthquake disasters with severe DELs has increased since 2008. For example, there was only one year in which the DELs were greater than 20 billion CNY before 2008, while there were five years in which the DELs were greater than 20 billion CNY after 2008. The total DELs in the period 2008–2017 were approximately 7.8 times higher than those in the period 1950–2007. By earthquake magnitude, the decadal average DELs per earthquake event with magnitudes of Ms < 5.0, 5.0 ≤ Ms ≤ 5.9 and 6.0 ≤ Ms ≤ 6.9 showed significant upward trends (p < 0.01); a similar trend was observed for Ms ≥ 7.0 but was not statistically significant (p = 0.13)  d.The total number of deaths due to earthquake disasters varied greatly between individual years and were often concentrated around large-scale events b. More dp < 0.05)  b. In con < 0.05) c. At the < 0.05) b. Ms ≤ 4.9, 5.0 ≤ Ms ≤ 5.9, 6.0 ≤ Ms ≤ 6.9, 7.0 ≤ Ms ≤ 7.9, and 8.0 ≤ Ms ≤ 8.9 are 1.0, 2.0, 7.0, 108.5, and 3300.0 persons, respectively. Similarly, the corresponding median numbers of DELs  are 12.9, 36.3, 154.8, 678.7, and 5182.0 million CNY, respectively. The median number of DELs for 7.0 ≤ Ms ≤ 7.9 is approximately 18.7 times higher than that for 5.0 ≤ Ms ≤ 5.9. In addition, earthquake disasters with magnitudes of 5.0 ≤ Ms ≤ 5.9 caused only 3.4% of the accumulated DELs and 0.2% of the accumulated deaths during 1950–2017. In contrast, 88.5% of DELs and 98.8% of deaths were caused by earthquakes with magnitudes greater than or equal to 7.0.Earthquake-induced DELs and deaths increase steadily with increasing earthquake magnitude, on the denary logarithmic scale . The medMost earthquakes are associated with relatively low losses, and only a few earthquakes cause enormous losses. Among the 189 earthquake disasters that caused death, half of them resulted in less than four deaths, and only 4.8% of earthquake disasters resulted in more than one thousand deaths a. Most eMs 1950 Chayu earthquake caused 3300 deaths and ranks fifth on the list of the 10 deadliest earthquake disasters . Furthermore, the criteria for defining an earthquake disaster event also vary. For example, in the case of the 2008 Wenchuan earthquake and its aftershocks, we found that there were eight damage records in PAGER-CAT but only one record in CH-CAT. This discrepancy may be the reason why the total number of earthquake disasters in PAGER-CAT is higher than that in CH-CAT in certain years .In addition to missing records, differences in the criteria used in these databases are another important reason for differences among the datasets. For example, for a disaster to be entered into EM-DAT, it must fulfill at least one of the following criteria: (1) ten or more people were reportedly killed; (2) one hundred (100) or more people were reportedly affected; (3) a state of emergency was declared; or (4) a call for international assistance was issued  and a decreasing trend of average annual deaths (p < 0.13), but the latter did not pass the significance test. An earthquake disaster is closely related to hazards, exposure, and vulnerability, and its severity depends on natural features and on socioeconomic development. The consequences of an earthquake disaster can change due to changes in exposure and vulnerability during different stages of economic development . In earlCurrently, rapid economic development as well as population growth corresponds to increased exposure to earthquakes. The total GDP located in the most seismically hazardous areas reached 6.2 trillion CNY in the year 2010, with an average annual rate of increase of 11.3% over two decades . The popHowever, the vulnerability of residents and the economy has decreased due to growing investments in risk reduction . With inEarthquake disasters are important natural hazard-induced disasters in China. Along with the recent socioeconomic development and population growth, both the exposure and the vulnerability of disaster-bearing bodies have changed dramatically. Earthquake disasters and their impacts on human society have attracted the attention of the international community. However, because our ability to predict earthquakes is currently limited due to the large uncertainties associated with earthquake forecasts, the government is under great pressure. Coupling earthquake forecasting/prediction with disaster-reduction measures may become a future priority . In thisIt is important to customize disaster-reduction measures based on geographic differences and the different characteristics of earthquake disaster areas. For the regions regarded as seismically inactive and those that are frequently affected by earthquakes but have experienced little financial loss, more attention should be paid to investing in buildings to reduce the vulnerabilities of properties and residents. The Qinghai-Tibet, Tianshan, and North China seismic zones suffer from frequent earthquake disasters. Sichuan and Hebei Provinces represent the high-cost areas in this region and are places where large earthquake disasters have occurred. These factors usually correspond to greater exposure. Therefore, in addition to implementing engineering measures, it is important to reduce risk by educating and training the public , making earthquake insurance available, and implementing other measures. The Chinese government has been developing earthquake emergency rescue capabilities since the start of the 21st century. The Chinese rescue team has played important roles in rescue and relief actions at home and abroad . After t(1)Ms of 5.0 ≤ Ms ≤ 5.9. However, earthquake-induced damage was mostly produced by large earthquakes. The 10 costliest earthquake disasters accounted for 90.6% of the total DELs, and the 10 deadliest earthquake disasters accounted for 98.5% of the total deaths from all earthquake disasters. By province, Yunnan Province experienced the highest number of earthquake disasters, Sichuan Province experienced the greatest DELs, and Hebei Province experienced the most deaths.Earthquake disasters caused approximately 1.393 trillion CNY (223.7 billion US$ in 2015) in DELs and 352,282 deaths during 1950–2017 in China. Among the 722 earthquake disasters, half of the earthquake disasters had (2)p < 0.01) but were subject to disaster impacts reporting quality over time. By earthquake magnitude, the decadal average DELs per event show t increasing trends with time (p < 0.01) for Ms < 5.0, 5.0 ≤ Ms ≤ 5.9, and 6.0 ≤ Ms ≤ 6.9. By seismic zone, the Qinghai-Tibet seismic zone was the area with the highest frequency of earthquakes and the largest DELs, and the North China seismic zone was the area with the highest number of deaths. The decadal accumulated DELs of the earthquake disasters in Tianshan, Qinghai-Tibet, Northeast, and South China seismic zone showed increasing trends with time (p < 0.05). The number and DELs of earthquake disasters exhibited increasing trends with time ((3)Ms per earthquake. Most earthquake were associated with relatively low losses, whereas a few large earthquakes caused enormous losses. Among the 722 earthquake disasters in CH-CAT, only 26.5% resulted in deaths, and among these earthquakes, half resulted in fewer than four deaths. Furthermore, most earthquake disasters resulted in DELs between one million to one billion CNY. Moreover, on the logarithmic scale, earthquake-induced DELs had a positive correlation with deaths and casualties. Statistically, earthquake-induced DELs and deaths increased nonlinearly with increasing This study compiled an earthquake disaster catalog for China (CH-CAT) that includes 722 earthquake-induced disaster events from 1950–2017; CH-CAT is a more complete earthquake disaster catalog than the existing global datasets. Based on the data from CH-CAT, the statistical socioeconomic consequences are as follows:Overall, changes in earthquake disaster frequency and resultant DELs suggest that earthquakes will exert greater impacts on society, especially when facing increasing exposure. The spatiotemporal characteristics of earthquake-induced socioeconomic impacts discussed above provide a good foundation for customizing disaster-reduction measures based on geographic differences, while the earthquake-induced damage and its relationship with hazard also provide a basis for calibrating loss estimation models.


IgM is an important and long-lived component of anti-malarial immunity in humans and blocks infection of red blood cells. Plasmodium falciparum infection and is prominent during malaria in children and adults with lifetime exposure, together with IgG. Unexpectedly, IgM persisted for extended periods of time; we found no difference in decay of merozoite-specific IgM over time compared to that of IgG. IgM blocked merozoite invasion of red blood cells in a complement-dependent manner. IgM was also associated with significantly reduced risk of clinical malaria in a longitudinal cohort of children. These findings suggest that merozoite-specific IgM is an important functional and long-lived antibody response targeting blood-stage malaria parasites that contributes to malaria immunity.Most studies on human immunity to malaria have focused on the roles of immunoglobulin G (IgG), whereas the roles of IgM remain undefined. Analyzing multiple human cohorts to assess the dynamics of malaria-specific IgM during experimentally induced and naturally acquired malaria, we identified IgM activity against blood-stage parasites. We found that merozoite-specific IgM appears rapidly in  Plasmodium falciparum, where vaccines aim to prevent merozoite invasion of red blood cells (RBCs) . Further, IgM was a long-lived response in the absence of reinfection. To provide a mechanistic link to immunity, we demonstrate that IgM can inhibit merozoite invasion of RBCs and blood-stage replication by the fixation and activation of complement on the surface of merozoites. IgM to the merozoite surface increased with age and was associated with protection in a longitudinal cohort of naturally exposed children. Our data suggest that IgM responses, alongside IgG, are important contributors to naturally-acquired immunity against malaria.Here, we define the acquisition, maintenance, and decay of merozoite-specific IgM during P. falciparum and treated when blood parasite levels reached 20,000  parasites/ml . Children also had slightly higher magnitude of IgM to the merozoite surface (P = 0.04) but not to MSP2 during clinical malaria . The higher IgM in children was not apparent following treatment . In avidity assays among a subset of samples, the avidity of IgG was higher than that of IgM . We tested serum samples for specific IgM to intact merozoites and recombinant MSP2. We also measured cytophilic IgG subclass responses, IgG1 and IgG3, that are associated with protection from malaria (t of IgM  and appeP = 0.16). IgM and IgG responses were weakly correlated . There was no change in IgM or IgG prevalence rates between October 2003 and October 2004 (P = 0.83), but there was a significant decline in IgG magnitudes between October 2003 and May 2004  at three time points during a period of rapidly declining malaria transmission intensity . At the time of clinical malaria, both IgG and IgM were detected . In the We recently demonstrated that a key functional mechanism of merozoite-specific IgG is complement fixation . There wTo further support the role of complement in IgM inhibitory activity, we demonstrated that IgM could fix and activate complement on intact merozoites and MSP2. Levels of C1q , and downstream components C3b and C5b-C9 (which form the membrane attack complex in the cell surface to mediate lysis), were quantified. Both IgM and IgG fractions effectively fixed C1q, leading to the formation of C3b and C5b-C9 on the surface of the merozoite and on recombinant MSP2 . On intaP < 0.0001); median OD, 0.94 versus 0.2 (P < 0.0001); fig. S5, B and C]. The proportion or magnitude of C1q-fixing antibodies was not different between adults and children during clinical malaria . Levels of C1q-fixing antibodies significantly correlated with IgM responses . There was also a strong correlation between IgG1 and IgG3 with C1q, reflecting a substantial contribution of these IgG subclass in mediating C1q fixation  from a longitudinal cohort in a moderate-to-high malaria transmission region of PNG . IgM andChildren with high levels of IgM at enrolment were associated with a 53%  reduction in the risk of clinical malaria (fever plus >5000 parasites/μl) compared to children with low levels of IgM after adjusting for confounders (age and location of residence) . For comN = 190) were classified as either protected from clinical malaria  or susceptible to clinical malaria ; children with no recorded infections were excluded to ensure that only children who were exposed were included in the analysis. Children who were protected had significantly higher levels of IgM than susceptible children  and 28 days (IgG3) . Participants were treated with anti-malarial drugs at day 7 or 8 of infection. Blood samples from 60 volunteers (from 10 independent cohorts) were collected before infection (day 0), at peak infection (day 7 or 8), and 14 or 15 and 28 to 36 days after inoculation; in analysis, these time points are grouped as days 0, 7, 14, and 30. Plasma was collected from lithium heparin whole-blood samples according to standard procedures, snap frozen in dry ice, and stored at −70°C. All studies were registered with the Australian and New Zealand Clinical Trial Registration scheme. Participants were healthy males and females between 18 and 55 years with no prior exposures to malaria or residence in malaria-endemic regions. Two groups of participants were tested. The first group  were drawn from clinical trials nos. NCT02867059, NCT02783833, NCT02431637, and NCT02431650. The second group , tested only on days 0 and 30, was drawn from clinical trial nos. NCT02453581, ACTRN12613001040752, and ACTRN12613000565741.For participants in controlled human malaria infection, inoculum preparation, volunteer recruitment, infection, monitoring, and treatment were performed as previously described . Sera were collected within a week of presentation and at one or two additional time points following treatment (30 to 90 days and > 90 days).P. falciparum parasitemia was assessed among all children by light microscopy of blood smears. Throughout the cohort period, active malaria case detection was performed weekly; children who were febrile (temperature of ≥37.5°C) or had a recent history of fever or illness had a blood smear performed. For the purpose of this study, we assessed antibody responses during the period of minimal malaria transmission, only in children (n = 50) who were sampled at all three time points that corresponded to the decline in malaria prevalence , who were aparasitemic at all time points and intervals, and who were previously positive for antibodies to merozoite antigens at October 2003 , where biannual malaria transmission occurs (May to July and November to December). This cohort composed of approximately 300 children aged 0.5 to 10 years who were followed for 3 years from May 2002 to October 2004. Venous blood was collected in May and October from each year. At each time point, the presence of P. falciparum malaria from Sabah, Malaysia, plasma samples were collected from participants in prospective comparative studies of Plasmodium knowlesi, P. falciparum, and Plasmodium vivax malaria, including at three district hospital sites  , and available sera samples were analyzed.For patients with clinical P. falciparum malaria was defined as a fever and P. falciparum parasitemia of >5000 parasites/μl.For the longitudinal study of PNG children, plasma samples were obtained at enrolment from a prospective treatment reinfection cohort of 206 children aged 5 to 14 years (median = 9.3) in Madang, PNG (n = 20) or from Australian residents supplied from Australian Red Cross blood bank (n = 15) were used for to generate IgG and IgM serum fractions. Antibodies were purified from pooled plasma via ammonium sulfate precipitation. Plasma was diluted to 20% in 0.9% NaCl (w/v), and saturated ammonium sulfate solution was added to a final concentration of 50% and incubated on ice for 30 min. Precipitate was pelleted at 10,000g and washed once with 50% ammonium sulfate solution before being resuspended in phosphate-buffered saline (PBS). Samples were dialyzed in PBS in dialysis tubing of 14-kDa molecular weight cutoff.Pooled plasma from individuals from Sabah who had a recent malaria infection (IgG and IgM fractions were separated by the 5-ml NAb Protein G Spin Column (Thermo Fisher Scientific) as per the manufacturer’s instructions. Ammonium sulfate–precipitated antibodies were incubated with columns for 10 min to bind IgG. Unbound supernatants, depleted of IgG but containing IgM, were collected; this IgG-depleted fraction is referred to as “IgM fraction” for clarity of reading. IgG was eluted from column with elution buffer and then dialyzed in PBS in dialysis tubing. To improve IgG depletion, IgM fraction was passed over the NAb Protein G Spin Column a second time before use in assays. To assess purity, fractions were run by SDS–polyacrylamide gel electrophoresis 4 to 20% polyacrylamide gel (Bio-Rad) in reducing sample buffer along with ChromPure IgM and IgG standards. Gels were visualized with Coomassie staining.Total concentrations of IgM and IgG in each fraction were quantified with ELISA against ChromPure human IgM and IgG standards (Jackson ImmunoResearch). Standards and IgM- and IgG-purified fractions were coated in serial dilutions in 96-well flat bottom MaxiSorp plates (Nunc) at 4°C overnight in coating buffer (0.1 M sodium carbonate and 0.1 M sodium bicarbonate). Plates were washed in PBS-Tween 0.05% three times and blocked with 1% casein in PBS for 2 hours at 37°C, and IgG and IgM were detected with goat anti-human IgG horseradish peroxidase  and sheep anti-human IgM HRP . Binding was detected with TMB  substrate (Sigma-Aldrich), and reaction was stopped using 1 M HCl. The optical density was read at 450 nm.P. falciparum D10-PfGPF isolates . Cultures were incubated in candle jars at 37°C. Parasite cultures were synchronized with heparin (Sigma-Aldrich) and used for merozoite isolation and invasion assays as described . Merozoite lysis assays were performed as previously described (+) merozoites were stained with ethidum bromide and incubated with normal sera and IgG and IgM fractions, and the counts of GFP+ merozoites were measured by flow cytometry.5 merozoites/ml) or 50 μl of recombinant antigen (0.5 μg/ml) in PBS overnight at 4°C.To assess levels of antibody isotypes targeting merozoites, ELISA was performed following a standard procedure. Ninety-six–well flat bottom MaxiSorp plates (Nunc) were coated with 50 μl of merozoites (2.5 × 10Escherichia coli) (E. coli as previously described (E. coli), a gift from Ross Coppel at Monash University, Melbourne, Victoria, Australia (E.coli as previously described (E.coli as previously described (www.cbs.dtu.dk/services/NetNGlyc/) leading to modification at six amino acid residues to prevent potential glycosylation. The PfAMA1 protein sequence was used to generate a DNA sequence that was codon-optimized for mammalian expression and then synthesized (GeneArt). The synthetic genes were supplied in a Puc vector and then cloned into pcDNA 3.1+ using Xho 1 and Bam H1 restriction sites. The final plasmid was quantified and used to transfect HEK293F FreeStyle cells (Thermo Fisher Scientific) cultured and transfected following the manufacturer’s protocols. Expressed protein was purified by nickel resin columns (Life Technologies) and washed with 20 mM imidazole/PBS (Sigma-Aldrich), and bound proteins were eluted in several 1-ml fractions in 500 mM imidazole/PBS. Protein size and purity were confirmed by SDS-PAGE. For all ELISAs, plates were washed three times with PBS-Tween 0.05% and blocked with 200 μl of 1% casein (Sigma-Aldrich) in PBS for 2 hours at 37°C. Serum samples (1:250 dilution) or purified IgG or IgM fractions were incubated in 0.1% casein in PBS for 2 hours at room temperature. For detection of antibody isotypes and subclasses, antibody binding was detected with the following antibodies: anti-human IgM (clone HP6083), anti-human IgG1 (clone HP6069), anti-human IgG3  from Invitrogen detected with goat polyclonal anti-mouse IgG HRP conjugate , or goat polyclonal anti-human IgG HRP conjugate  for 1 hour at room temperature. For detection of complement-fixing antibodies, following incubation with sera or IgG/IgM fraction samples, plates were incubated with 10% normal sera or purified C1q as a complement source. C1q fixation was detected with rabbit anti-C1q antibodies (Dako) and anti-rabbit HRP (Bio-Rad). C3b and membrane attack complex formation was detected with anti-human iC3b or anti-human SC5b-9 (Quidel) and anti-mouse IgG HRP (Merck Millipore). To assess affinity of IgM and IgG, standard ELISAs were performed with the addition of a dissociation step of increasing concentrations of ammonium thiocynate (in PBS) incubated for 20 min at room temperature following incubation with serum samples. TMB substrate (Sigma-Aldrich) was added for 1 hour at room temperature, and the reaction was stopped using 1 M HCl. The OD was read at 450 nm. For ELISA using isolated merozoites, washes were done with PBS without Tween to prevent parasite lysis. Standardization of the assays was achieved using positive control plasma pools on each plate. Background values (wells with no plasma) were subtracted from all values of other wells, and positivity was determined as the means + 3SDs of the OD from naïve plasma samples  included in each assay or for the PNG children longitudinal (Mugil) cohort as the upper 95% CI of naïve plasma samples.For ELISAs, the following antigens were used: MSP1-42 (42-kDa fragment of MSP1), a gift from C. Long at the National Institutes of Health . IgM and IgG were also compared between children who were protected  or who were susceptible  during follow up. Logistical regression analysis of protected and susceptible outcomes was adjusted for age and location of residence. This analysis only considered children who had at least one infection during follow-up to ensure that analysis included only children who were exposed to infection.Analysis of the association of IgM/IgG with protection in cohort study was performed with Stata/SE 12.0. Differences in IgM/IgG between groups were assessed by Wilcoxon rank sum tests. For assessment of associations between IgM/IgG and protection, subjects were stratified into three equal-sized tertile groups according to low (including those classified as “negative”), medium, or high IgM and IgG responders, as determined by OD values for each sample. This method allows for a dose-response relationship to be examined while maintaining sufficient numbers of participants in each group to maximize statistical power. Tertile groups were compared for risk of clinical malaria (fever and >5000 parasites/μl) or high-density parasitemia (>5000 parasites/μl) with the Cox proportional hazards model and Kaplan-Meier survival analysis, taking into account the first malaria episode only. Age and location of residence were included in adjusted analysis as these factors were previously identified as potential confounders (U test was used to compare responses between different populations (acute versus control) and for invasion inhibition assays. Spearman’s rank correlation coefficient was used to assess correlations between antibody responses and C1q fixation. To assess the relationship between C1q and IgM and IgG subclasses in Sabah individuals, ELISA OD data were transformed into arbitrary units, relative to the highest responder in the cohort.All other statistical analyses were performed in GraphPad Prism. Wilcoxon matched-pairs signed-rank test was used for comparisons of responses between acute (day 0) and convalescent time points (days 7 and 28) in matched samples. Mann-Whitney Written informed consent was obtained from all participants or, in the case of children <18 years of age, from their parents or guardians before inclusion in studies. Ethics approval for the use of human samples in the relevant studies was obtained from the Alfred Human Research and Ethics Committee for the Burnet Institute ; the Ethics Committee of the Kenya Medical Research Institute (SSC1131); the Medical Research Advisory Committee of Papua New Guinea (MRAC 98.03); the Medical Research and Ethics Committee, Ministry of Health, Malaysia (NMRR 10 754 6684); the Human Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC 10/1431); the Human Research Ethics Committee Melbourne Health (2004.038); and the Human Research and Ethics Committee of the QIMR-Berghofer Institute of Medical Research (P1479).


Older people living in congregate environments are obvious beneficiaries of supportive services. The potential for prevention is clear, particularly among low-income elders living in subsidized housing; it is this group that is at high risk for significant healthcare and other costs, and it is this group that suffers considerably from a fragmented healthcare system. Policymakers have long seen the advantages of reaching this population, but most existing housing with services programs have focused more on social than health-related supports. The Right Care, Right Place, Right Time initiative (R3) was launched in July 2017 to demonstrate the value of supportive services to seniors living independently in affordable housing in the Greater Boston area, while reducing health care costs. The R3 program consists of two on-site wellness teams, including a wellness nurse and wellness coordinator. Each team is responsible for about 200 participants across two housing sites. The R3 evaluation included both quantitative and qualitative components. The quantitative component entails pre/post comparison as well as a control group analysis, focusing on various health and health utilization outcomes. The qualitative component includes key informant interviews examining program development and implementation and focus groups capturing the resident experience. The purpose of this symposium is for evaluation team members to report on the experiences of program participants, administrators/staff, housing managers/staff, and community partners with the R3 program, and to assess program impact. Edward Miller and Pamela Nadash will serve as chair and co-chair, respectively; Alisha Sanders as the discussant.


The central part of Jalisco, Mexico, has experienced low-magnitude earthquake sequences and swarms. Although the effects of these earthquakes have been limited to relatively small areas, the earthquakes have caused general alarm among the population and, in some cases, have been catastrophic. These earthquake swarms are significant because they affect the most populous area of the state, including the capital city of Guadalajara. An extraordinary example is an earthquake swarm that started on 8 May 1912 and lasted until September of that year. The region remained seismically quiescent until May 2012, when seismic activity resumed, lasting to the present. We analyze the recent seismic activity, starting with the earthquake of 18 May 2012 (03:07 UT) at the western edge of Lake Chapala and ending with the magnitude 4.2 earthquake on 3 November 2016. Our analysis includes eight earthquakes with magnitudes between 3.5 and 4.8, the revision of hypocenter locations, and the determination of focal mechanism solutions using the inversion of the moment tensor method. When possible, inversion solutions are compared with solutions obtained with the first arrival polarity method. We compare our results for the recent seismicity with the distribution of reported damage associated with historical earthquakes. Our work indicates a N-S trending seismic source zone and an orientation of nodal planes that suggests reactivation of preexisting local faults induced by the interaction of the western border of the Trans-Mexican Volcanic Belt with the eastern border of the Jalisco Block. Central western Mexico is one of the most complex geotectonic regions of the country owing to the convergence of several geological structures whose interactions give rise to a complex seismic pattern . SeismicMw >7) earthquake occurred on 27 December 1568, southwest of Guadalajara near the northeastern corner of the Jalisco Block (JB) [The population of the state of Jalisco (7.4 million) ranks fourth in Mexico, and the state capital of Guadalajara, home to approximately 1.5 million inhabitants, is showing rapid economic growth. Historical records reveal that a major , a region of extension marked by the rift system bounding the JB and the TMVB . The wesThe TMVB is a complex continental arc 1000 km long extending from the western volcano of San Juan to the eastern Gulf of Mexico coast. Its crust is approximately 35–40 km thick in the west and becomes thicker to the east. Tectonic and volcanic activity in central Mexico has produced numerous volcanic centers, grabens, and crater lakes. Many of these tectonic and volcanic depressions are occupied by both graben and volcanic lakes. The Lake Chapala basin is located in the E-W-trending Citala rift, which forms the so-called Jalisco continental triple junction together with the Tepic-Zacoalco and Colima rift. Volcanic sedimentary deposits at the Lake Chapala basin and at the Zacoalco and Colima tectonic depressions are approximately 900–1000 m thick and comprise a sequence of lacustrine sediments and pyroclastic units of ash and pumice [M ≤ 8.2). Recorded evidence indicates the occurrence of several major earthquakes near the coast along the segment Jalisco-Northern Guerrero . Of partMost of these earthquakes are of shallow-depth focus located between the coast and the MAT. Focal mechanism solutions for these earthquakes are of reverse faulting type on a low-angle (~17°) plane resulting from subduction of either the Rivera Plate or the Cocos Plate under the North America Plate . In mostAccording to Suarez et al. , four laMw> 7) occurred at the southeastern border of the JB, probably at the junction of the Tepic-Zacoalco and Colima rifts near the western border of Lake Chapala. The position of the epicenter was estimated [Historical documents indicate that on 27 December 1568, a strong earthquake  in the zone of interest for the period 2006–2016. The figure shows a seismic activity pattern with a nearly N-S trend that clusters near the northwest corner of the Guadalajara metropolitan area.M 4.5) Lake Chapala earthquake and the 11 May 2016 (M 4.8) Guadalajara earthquake, which have larger magnitudes than the other earthquakes analyzed. Both were widely felt in the region, producing slight damage in Guadalajara and other nearby towns.From the earthquakes plotted, two events (Event 1 and 6 in On 18 May 2012 at 03:07 UT (22:07 LT of 17 May), a 4.5 magnitude earthquake at 20.27°N, 103.467°W occurred at 15 km depth. The epicenter was located near the western margin of Lake Chapala and was widely felt throughout the state of Jalisco, including in the Guadalajara metropolitan area. According to the media, approximately 44,000 persons from 163 buildings were evacuated in the downtown area and other zones of the city as a safety measure. Minor damage to construction, such as broken glass windows and cracks and fissures to walls, was reported. Inhabitants of the city described the initial earth motion as a short, strong “push,” and then the amplitude of the motion increased with an up-and-down motion. In Zapopan, underground sounds were heard, and in the area of Tlaquepaque, the earthquake was felt strongly, although no damage was reported. Jocotepec, a town close to the epicenter, reported fissures in the ground and minor damage. The earthquake was widely felt north and south of Guadalajara and the northern margin of Lake Chapala.An earthquake occurred at 22:35 UT (17:35 LT) on 11 May 2016 near the northwestern limit of the Guadalajara metropolitan area. In Guadalajara, the earthquake caused a disruption in the electrical supply, generating a large vehicle traffic jam and prompting the evacuation of many buildings, although the damage reported was minor .In several buildings in Guadalajara and Zapopan, cracks and fissures in wall plaster were reported. Some brick fences collapsed during the earthquakes. Telephone and electrical services were temporarily suspended. As a measure of precaution, the urban train service was also suspended. A person was injured by a falling rock, and many others with nervous crises were transferred to hospitals for medical attention.The importance of studying the seismic characteristics of the Guadalajara area become apparent from the above mentioned. In the following subsections we analyze broadband seismic data available and present some useful results for the proper seismic risk assessment of the area.From the data available, eight earthquakes were selected for analysis, because these earthquakes were recorded by the permanent stations of the SSN and Jalisco seismological networks and a portable station installed in the outskirts of Guadalajara near the Barranca de Santiago.P and S waves recorded by the permanent and portable seismic stations (short-period and broadband). After testing several velocity models, we decided to use the one proposed by Pacheco et al. [In o et al. , becauseo et al. . The quao et al. .Q) that goes from 0 to 4, with 4 corresponding to an optimal adjustment.The fault plane solutions were obtained through the inversion of the moment tensor (CMT) with the procedure proposed by Dreger and Helmberger  and implIn our analysis, the quality of the inversion varies from event to event. The final results are shown in For Event 1, the accepted inversion was obtained using records from six broadband stations. Assuming that Plane 1 in Q = 0), the fitting appears visually acceptable. Additionally, the resultant fault plane chosen as the rupture plane direction (N-S) is consistent with the one obtained by the polarity of the first arrivals  that occurred in the western flank of Lake Chapala at the junction of Tepic-Zacoalco, Colima, and Chapala grabens. It should be mentioned that the epicenter location falls near the site at which Pacheco et al.  recordedQ = 0. The result indicates a normal faulting mechanism, with the rupture occurring along a plane striking nearly N-S. Its solution is similar to the solution of Event 1. The focal depths of both earthquakes are quite similar, at 13 km and 15 km, respectively.The Event 2 earthquake occurred near the northwestern tip of the Guadalajara metropolitan area about 60 km north of Event 1. The focal mechanism was obtained by inverting records from four broadband stations, and the result is shown in M 4.8) event analyzed in this article. Its fault mechanism was obtained by inverting four broadband stations, as shown in Q = 3. The solution indicates a faulting with a rupture plane striking in a nearly N-S direction. This result agrees with the solution obtained with polarities of the firsts’ arrivals  for each earthquake. The earthquakes that cluster northwest of Guadalajara show a consistent direction NW-SE, whereas Event 1 shows a NE-SW direction. The overall data indicate the existence of a band of tension with direction nearly N-S that roughly coincides with the BJ-TMVB contact boundary. The large extent of the affected area of historical earthquakes and the N-S alignment of the ongoing seismicity suggest that the causative mechanism must involve a structure much larger than the mapped local faults.The recent seismic activity in the Guadalajara area initiated with an earthquake M 4.5 on 18 May 2012 (03:07 UT) occurred in the western margin of Lake Chapala. Afterward, the activity migrated 60 km to the northwest of the Guadalajara metropolitan area in 2015. In the group of earthquakes, two, with magnitudes of 4.5 and 4.8 (Events 1 and 6), stand out. These earthquakes, as mentioned before, were widely felt, and minor damage in Guadalajara and other nearby towns was reported.All the events analyzed show a normal faulting mechanism with a rupture fault plane striking nearly in the direction N-S and mostly dipping about 44°–73° toward the west. The northern cluster of events  have a prominent right-lateral component. Event 1 in the south is a nearly pure normal faulting with a small left lateral component. The distribution of tension axes for the earthquakes shows a preferably NW direction consistent with the proposed motion of the JB toward the west as it rifts from the North America Plate, as derived from other sources of information .The region under study is very complex, and many fault systems have been mapped on geological surveys and satellite image observations in central Mexico , 7, a faS1 Fig(JPG)Click here for additional data file.S2 Fig(JPG)Click here for additional data file.


Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available in U.S. hospitals. STRIDE  is a supervised walking program for hospitalized older adults that fills this important gap in clinical care. This paper describes how STRIDE works and how it is being disseminated to other hospitals using the Replicating Effective Programs (REP) framework. Guided by REP, we define core components of the program and areas where the program can be tailored to better fit the needs and local conditions of its new context . We describe key adaptations made by four hospitals who have implemented the STRIDE program and discuss lessons learned for successful implementation of hospital mobility programs. Hospitalized adult patients spend 95% of their time in beds or chairs ,2,3. PatMany factors may contribute to the negative outcomes related to low patient mobility, including patient-related and treatment factors . The mosInterventions to systematically promote early, safe mobility in older hospitalized patients—designed to address clinical and logistical challenges of promoting mobility—are needed to avert the negative and costly consequences of immobility during inpatient stays. Previous studies have demonstrated the potential of inpatient walking to prevent declines in mobility during hospital stays and to reduce hospital lengths of stay ,17,18,19p = 0.007) [STRIDE  is a supervised walking program for hospitalized older adults focused on maintaining musculoskeletal strength and mobility during hospitalization, a highly vulnerable time for development of disability. It was adapted from a mobility program, studied in a randomized controlled trial in three non-Veterans Health Administration (non-VA) hospitals, that led to reduced hospital lengths of stay . Origina= 0.007) . Based o= 0.007) .Initial positive results suggested that STRIDE had the potential to become a system-wide approach to address hospital-associated disability in the VA; however, differences in resources, staffing, and priorities among other conditions in VA facilities presented barriers to successful implementation at other sites. Therefore in 2016 we launched an ongoing project, Optimizing Function and Independence Quality Enhancement Research Initiative (known as “Function QUERI”) to implement STRIDE in eight additional VA hospitals  in 2017–n = 35 interviews) and summarized into case summaries for each of the four sites. Data from all sources  were combined in a matrix to view emergent patterns that served as the basis for program characteristics and REP adaptations described in We used VA administrative data sources ,26 to deOne of the goals of Function QUERI is to study the process of starting a STRIDE program so that these lessons can be applied in broader efforts to promote hospital mobility programs. Eight VA hospitals volunteered to begin STRIDE programs at their sites and were randomized to begin at a specific time . To dateA one-size-fits-all approach is rarely effective for addressing the barriers of implementing a program in multiple new settings ; therefoAll expansion sites identified a need to improve mobility of their hospitalized patients and selected the STRIDE program as a means to address this clinical problem. The Pre-Conditions phase of REP focuses on leveraging the pre-existing resources in the health care system essential to implementing a new clinical program. Key tasks include identification of local champions or advocates who are essential in establishing widespread buy-in and ensuring the program fits pre-existing culture, local programmatic goals, and resources . Each exThe Pre-Implementation phase focuses on preparation for program implementation and obtaining broad buy-in for the new clinical program. The key tasks include identifying key stakeholders and tailoring the program materials to fit the local context. Each expansion site identified key stakeholders to serve on the local STRIDE implementation team, including VA Medical Center leadership, service-line chiefs, and front-line staff. They identified champions from the services lines with key roles in program implementation. Topics covered during pre-implementation phase calls including describing the intervention protocol  and providing technical assistance to guide sites on options for customization and prepare for program launch. During this phase, the expansion site teams discussed their site’s staffing model, patient eligibility criteria, and target distance and time for daily patient walks. The Function QUERI team conducted a site visit prior to program launch to provide on-site technical assistance  and market the program to local leadership and front-line staff.The Implementation phase begins with program launch and includes ongoing training and technical assistance, program promotion to increase buy-in among front-line staff and leadership, and process monitoring to ensure program feasibility and fidelity to the core components of the STRIDE program. The local STRIDE implementation team at expansion sites received weekly reports of program activity to facilitate ongoing improvements. For example, reports included counts of STRIDE consults and percentage of hospital days that STRIDE patients had at least one documented walk. Data review helped to identify barriers to successful implementation and promote discussion of strategies to overcome these. For example, if the number of consults at an expansion site was low, the Function QUERI and expansion site teams discussed strategies for improvement, such as increased marketing of the program to residents and other medical staff.The final Maintenance and Evolution phase involves compiling program results and reporting to leadership and other relevant stakeholders, as well as using process and outcome results to further refine program implementation for other sites. For example, some sites are reporting data to leadership on veteran satisfaction with the program and relevant performance metrics  on wards which implemented STRIDE. The final phase includes continued technical assistance, continued reports of program activity, and ongoing consultation about program implementation and evolution to ensure sustainability. The Function QUERI team is refining a STRIDE implementation package, with the sites’ input, in preparation for wider-scale dissemination.(1)Proactive, no baseline functional deficits required(2)Early enrollment, ideally within 24 h of admission(3)Supervised walking, up to 20 min daily until dischargeThe Function QUERI team viewed the REP Framework as ideal for the rollout of STRIDE because the framework provides a standard structure for specifying core elements of the program while allowing sites flexibility to determine which components can be adapted to local settings. Essential core elements of STRIDE were defined as:The STRIDE team encouraged program adaptations in the areas of how to identify patients for the program  and the role of the staff who would conduct the assessment and supervise the walks (staffing model). Function QUERI’s experience with STRIDE implementation at four expansion sites has resulted in several lessons learned that are relevant for future dissemination efforts and also for individual hospitals interested in starting a mobility program.Due to competing demands on staff time, flexibility around the STRIDE staffing model is important. Decisions about which staff roles are best suited to supervise walks and how these are structured , should be made collaboratively with representation from all key stakeholders. Leadership buy-in and front-line clinical champions have been critical to initiate the program and sustain the weekly consults, gait assessments, and walking sessions. Because most models have incorporated physical therapists to conduct the gait assessment and nurses or CNAs to supervise the walks, effective interdisciplinary communication between those two professional groups is particularly vital. Coordination with other groups charged with improving quality and safety in the hospital, such as fall prevention committees and safe patient handling and mobility coordinators is also key to ensure programmatic alignment. From a training and documentation perspective, providing competency checklists to the facility to adapt for staff training and modifiable electronic health record templates to document gait assessments and walks in a standardized, reportable manner have helped save time and effort for facilities and enhanced the ability of sites to track their progress. The electronic health record templates have included standardized data that can be extracted as structured text fields such as patient enrollment in the program, walk distance and time, and how the patient felt after the walk. The ability to compile these data periodically has helped sites to monitor their progress, troubleshoot issues that arise, and begin to build a case with leadership for program growth and sustainability. For Function QUERI, it is essential that all hospitals use standardized data collection templates to facilitate combining data across sites. For implementation support provided outside of a study context we anticipate that fewer calls would be required to meet the data needs of individual sites.Through interviews with the expansion sites’ staff and leadership, we discovered that service line leadership and other key stakeholders often viewed the STRIDE program as a platform for broader culture change around patient mobility. We found that site personnel usually recognized the value of patient mobility but needed the presence of an evidence-based, implementable program to “jumpstart” change in that area and address the biases of some staff or facility procedures that were hindering mobility. For example, two sites changed activity orders to reduce bedrest orders and encourage ambulation. One site developed a ‘huddle board’ at the nursing station to communicate about patient mobility and STRIDE consults. STRIDE was based on a hospital mobility intervention proven effective in a randomized controlled trial , howeverCombining data from all eight expansion sites that ultimately implement STRIDE as part of Function QUERI will expand our understanding of the impact of hospital mobility programs on patient and system-level outcomes. Our implementation evaluation will focus on the roles of teams in successfully initiating and sustaining STRIDE, and whether a teamwork training intervention can enhance implementation of new clinical programs. Future research should address whether there are differential effects of hospital mobility programs according to patient characteristics  as well as whether extending interventions into the home setting after discharge may be beneficial. Direct patient feedback from pedometers or other activity trackers and/or motivational incentives may offer a means of enhancing activity during hospitalization between STRIDE walks.Although the hazards of immobility during hospitalization have been long-known, sustained solutions to this problem have been elusive. STRIDE offers a promising approach for hospitals to support increased mobility in their patients, thus supporting better patient outcomes and reduced need for post-acute institutional care. As part of the final REP phase (Maintenance and Evolution), we plan to package a clinical program guide to assist with wider dissemination of the STRIDE program to sites outside of the Function QUERI study. Using the REP framework processes may help individual sites considering hospital mobility programs to tailor their program to best meet their needs, while ensuring that key components shown previously to be effective are retained.