This study examined community-based rehabilitation (CBR) practice in China on the basis of the development of an evaluation system using current evidence in a real context.A multiple embedded case study design was used to interpret both quantitative and qualitative data. In Part 1, a thematic analysis was conducted to identify the different levels of evidence available in CBR programs in China. Identified themes were then associated with the literature to form a system to code, categorise, and rank the obtained evidence. In Part 2, CBR practice was examined in 12 CBR programs by using the developed evaluation system with the CBR matrix and CBR framework.Six themes under three categorised levels of evidence for demonstrating quality of practice were found. An evaluation system of program practice, based on existing standards to define levels of evidence, was created and used with the CBR matrix and CBR framework to evaluate the quality of practice in 12 CBR programs. The results of a within-case analysis revealed the strengths and areas for improvement in each program. An across-case analysis by using identified correlations revealed the characteristics of CBR practice in China, as demonstrated in the interaction of core CBR components. The content elements of CBR programs were significantly correlated with health outcomes, social development, education, and empowerment. Empowerment was significantly correlated with participant governance and community ownership.The proposed evaluation system, as developed in a real context, is feasible for monitoring and identifying the strengths of and areas for improvement in CBR programs. This study described the characteristics and interaction of different CBR components in CBR practice in China and is pertinent for enhancing the evidence-based practices and quality of CBR programs in China.The online version of this article (10.1186/s12913-018-3838-7) contains supplementary material, which is available to authorized users. Community-based rehabilitation (CBR) is a multisectoral approach, aiming to equalise opportunities and include people with disabilities, while combating the vicious cycle of poverty and discrimination . CBR is The development of rehabilitation services in China has been evolving since its introduction in China in the early 1980s. In the early years, service providers in China were often volunteers with limited training in rehabilitation. With support from central and provincial organisations, grassroots rehabilitation communities have mobilised and coordinated local resources to meet the rehabilitation needs of people with disabilities . EvidencCBR practice in China in the 1990s emphasized on medical treatment and the use of CBR stations as rehabilitation centres in districts . The proThe evaluation of CBR programs in the Chinese context poses specific challenges. Although initial evaluative approaches were inspired from the Western methodologies, replicating Western models led to the exclusion of the cultural and linguistic uniqueness of Chinese communities, which influences the evaluation processes and results . For exaAppropriate veracity of evidence is required to evaluate programs, regardless of whether the comparison is to standards, other programs, or earlier periods. In a recent review of studies on CBR, only 4 of 114 identified studies described the evaluation of CBR programs in the Chinese context . One stuEffective program evaluation is more likely to be achieved if a monitoring and evaluation system is adopted. CBR program evaluation assesses (1) the impact of a programs on people with disabilities and their families, (2) the impact of a program on a local community, (3) the quality of service, and (4) the quality of program management . ComplemThe WHO has developed a conceptual framework for CBR called the CBR matrix . It reflThe CBR Framework  is a fraIdentify and quantify the types of evidence presented in Chinese CBR programs to indicate best practice (part 1).Evaluate and describe CBR practices in China using the identified types and levels of evidence, with the CBR matrix and CBR framework (part 2).This study identified and used appropriate types of evidence to evaluate and describe the quality of CBR practice in China. The objectives of this study were as follows:To meet the first objective, this study used a case study methodology to explore and define the common types of evidence in CBR programs in China. The case study approach is used in qualitative research to explore a case or a system through in-depth data collection involving multiple sources of information . The casFive CBR programs in China were selected. To be selected, the CBR programs needed to meet three of the following five criteria: (1) focusing on the provision of rehabilitation activities for people with disabilities , 31, 34;To guide data collection and ensure consistency, a case study protocol was developed, which included an overview of the study, field procedures, case study questions, and a guide for reporting the case study.The objective of this stage was to identify the type and content of evidence routinely available in CBR programs in China to determine the quality of these programs. Data collection methods used in this phase included interviews, observations, and reading relevant documents Table . A detaiAll interviews were transcribed. Observations and findings from the document review were recorded in a field visit report. The analysis of the transcripts and documents was completed in the original language (Chinese). Using the full set of transcripts and field visit reports, types of evidence to support best practice were identified. A thematic analysis was completed in the following six steps : (1) famTo identify CBR practice in China, the research team used the newly identified system to collect evidence from 12 CBR programs. The case study approach was adopted in Part 2 as well. This study proposed that the quality of CBR practice in China could be documented and defined by using the newly developed ranking system on levels of evidence. Evaluation of service quality is defined as identifying evidence to reveal a program’s functional quality, process of service delivery, service outcomes and the reliability, responsiveness, empathy, assurance and tangibles associated with a service experience . QualityThis stage employed an embedded case study design because it allowed the investigator to study the programs through preselected categories of descriptions as the focus for the study . The preSeven CBR programs were added to the original five programs in Part 1. In total, 12 CBR programs were recruited following the inclusion criteria detailed in Part 1. Data gathered from the original five programs, along with those collected from the new programs, were subsequently analysed.The protocol design and data collection procedures were identical to those in Part 1. Data collection methods were the same as for the first study.A 4-day field visit was again conducted for each program, as in Part 1.All interviews were tape-recorded, and all observations in the field visits were recorded in the field-visit report. Data were recorded as a Microsoft Access file. Evidence of CBR components, as reflected by the respective indicators, in each program was coded and charted according to the elements and domains in the two frameworks. The number of coded themes categorised as oral evidence, documentary evidence or verified evidence was entered into a program summary table. This process was overseen by an adviser and the research supervisor.The collected data were linked to the propositions by formulating two program profiles for each program, one using the CBR matrix and the other using the CBR framework, in the form of a case description matrix for pattern matching. By developing a case description matrix for the programs, evidence was placed within different categories. Pattern-matching techniques were used for relating data to propositions . ThroughWith the quantified evidence (shown in the program summary table) obtained from the two frameworks, the characteristics of CBR practice in China, as revealed by the framework, were compared to define their nature and quality. The number of coded themes under each category was converted to a percentage score to enable comparison of patterns across programs. The practices of Chinese CBR programs were revealed through the integration of results from all programs and using correlations to identify the relationships among the components as reflected through the CBR matrix and CBR framework.Overall, 5 top managers, 5 program managers, 4 deputy managers, 42 people with disabilities, 23 family members, 18 CBR workers, and 7 county officials participated in this study. The research team conducted 35 home visits and observed 8 activity programs in five CBR programs.The six identified types of commonly cited evidence were (1) description of processes, 2) description of outcomes, (3) description of examples, (4) presenting examples, (5) citing program-related documents, and (6) citing case-related documents. The frequency of occurrence of evidence describing practice within each theme was examined by counting coded data in the data material collected from all five programs  oral evidence , (2) documentary evidence, and (3) verified evidence. Citing programs or case-related documents was considered a form of documentary evidence, whereas showing real examples (provided the investigator is considered a credible third party) met the definition of verified evidence. On the basis of these principles, oral evidence was regarded as insufficient support for best practice; documentary and verified evidence was regarded as suitable support for best practice.Seven additional programs were recruited in the second study, along five from the first; together, 12 programs were included. These programs varied in terms of background, funding sources, location, and nature. Among these programs, four were in rural areas and the other eight were in urban areas. Three programs were funded by local government, two by international humanitarian organisations, and three by organisations for people with disabilities; the remaining four were operated by local nonprofit (philanthropic) organisations.Program 1 was a rural program funded by local government. It provided physical and social rehabilitation services, emphasised improving participant outcomes, and possessed a reasonable number of CBR-related program content elements. The program mainly focused on improving health outcomes and advocating empowerment.Program 2 was a foster care program funded by local government. It aimed to improve the health status of abandoned children with disabilities and placed them with families. It was strongest in improving participant outcomes and the social status of the children with disabilities. Participant governance was not a major focus, and the program adopted a top-down approach to decision making.Programs 3 and 4 were operated by an international humanitarian organisation. They were located in different provinces. Program 3 was based on a rehabilitation centre, whereas Program 4 was based on community outreaching teams. Both programs focused on raising awareness. Program 3 was the strongest in improving participant outcomes, with its focus being on health and social components. Program 4 was well-developed in the sense that it also achieved social and empowerment components. It was evident that this program possessed a good amount of CBR-related content elements.Programs 5, 7, and 11 were organisations for people with disabilities, all of which emphasised the improvement of psychosocial outcomes of people with disabilities and their families. Program 5 worked with adults with physical disabilities, mainly focusing on improving the components of health and empowerment, but did not enhance the education and livelihood of people with disabilities. The emphasis in Program 7 was on advocating autonomy and independence for people with physical disabilities. Program 11 was a mutual-help group for children with disabilities and their parents. This program focused on improving the social components and the functional outcomes of participants.Program 6 was a community-based vocational rehabilitation program, offering sheltered employment to adults with physical and mental disabilities. It worked on the component of empowerment through the development of job skills and the potential of participants. The results revealed that the operation and management of this program were effective.Program 8 was a home-based program in an urban district operated by an NGO. It performed well at improving the functional outcomes of adults with disabilities and their families and focused on health, social, and empowerment, as presented in the CBR matrix.Program 9 was a community-based program promoting independent living. It focused on improving health and empowerment, but not on the education and livelihood of people with disabilities.Finally, Programs 10 and 12 were rehabilitation centres. They worked to improve the functional outcomes and health status of people with disabilities.The percentage profile Table  showed tThis study identified the use of commonly available evidence in the Chinese CBR context to describe CBR practice in China. The identified evidence was related to audit standards to form a program audit system to understand CBR practice. Along with the CBR matrix and CBR framework, it can be used to monitor and enhance the quality of CBR programs. One advantage of using such an audit system is that it encourages program operators to think of actual evidence to achieve program outcomes. Only having a process in mind or telling a story of change is insufficient for demonstrating best practice. Best practice must be supported with real-world examples, proper written records, or scientific evaluation reports.The terminology used in the proposed audit system is easy to understand. Evidence to support best practice is categorised under three levels with different subthemes: (1) oral, description of processes, outcomes, and examples; (2) documentary, citing case and program documents; and (3) verified, showing real examples and scientific evidence. The terminology was derived from analysing real practice and has resulted in user-friendly terms that can be understood even by workers with a lower level of education. This is relevant and appropriate in the CBR field because community members are mobilised and trained to work with people with disabilities. It encourages the realisation that a proper records or real examples are vital for supporting program achievement.CBR practice in China was revealed in the within-case analysis. Together with the CBR matrix, the analysis showed that most programs promote empowerment and health among people with disabilities. When analysed with the CBR framework, it was evident that most programs (11 of 12) provided sufficient evidence of enhancing participant outcomes. Two-thirds of the programs focused on enhancing the CBR content elements advocacy, networking, family member involvement, neighbours or community member involvement, and CBR personnel development. The obtained documentary and verified evidence confirmed that the programs were developing the CBR program elements. Both the CBR matrix and CBR framework revealed that these Chinese CBR programs developed beyond the provision of health and rehabilitation services to include more CBR elements to enhance the inclusion and participation of people with disabilities.In the 1980s, CBR programs in China were mostly initiated by medical doctors or rehabilitation therapists and operated within the health or social service sectors of local government. They emphasised the outcomes obtained from the provision of appropriate interventions, originally based on a medical model . DiffereHowever, the results of this study show that the components of education and livelihood are not the focus in CBR practice in China. Educational service is operated under the Ministry of Education of the People’s Republic of China. CBR programs in China work to facilitate the integration of children with disabilities into the education system. However, this is frequently limited by architectural barriers, the remoteness of communities, and the difficulties in handling children with severe disabilities. Projects enhancing livelihood in CBR programs were evident , but theThe results of this study show that community participation was not commonly seen in programs. Community participation includes the involvement of people with disabilities in CBR programs, from policy making to implementation and evaluation. Participant governance and ownership in CBR programs were directed by the central government rather than by people with disabilities. Financial support from the central government is regarded as a vital sign of community ownership of programs in China. The program organisers had to set aside their individual agenda and put forward objectives stated by local government.Comparison of programs and the interaction of CBR components was revealed in the across-case analysis. The commonly reported element among the 12 programs was participant outcomes. The content elements in CBR programs were found to be significantly correlated with participant outcomes, health enhancement, social development, improved education, and empowerment. This finding demonstrates the importance of a comprehensive CBR program design to achieve designated CBR outcomes. Such a comprehensive design follows the elements in the domains of the CBR framework : advocacSignificant correlations were also found between the components of empowerment and community ownership and between empowerment and participant governance. Again, this highlights the importance of advocacy, community mobilisation, promoting self-help and mutual-help in the process of empowerment. Community ownership is the actualisation of the rights of people with disabilities. People with disabilities have the right and autonomy to take leadership roles and participate in the community. The process of empowerment clearly interacts with the participant governance and community ownership of programs. Overall, 8 of 12 program organisers provided evidence that they promoted empowerment; however, only a few of them could provide sufficient evidence of attaining community ownership and participant governance. Participant governance denotes a change in traditional power structures within programs or the community . The ChiThe use of a case study approach to build evidence for program evaluation has limitations. The extensive use of empirical evidence can produce a high level of complexity and confusion. This study extensively examined the practices of 12 programs. A considerable amount of information regarding CBR practices in context was collected. This type of approach required a clear and strong framework to prevent a loss of focus while processing the data. Furthermore, a scientific approach to CBR evaluation may not be appealing sometimes because people may think the voices of people with disabilities, which could not be supported with documentary or verified evidence, could not be well-acknowledged in the process of evaluation.A qualitative methodology was used to identify the possible types of evidence available and the feasibility of supporting the practices in CBR programs in China. Themes regarding levels of evidence for best practice were compared with audit standards to delineate a measurement system to describe practice. Used with the CBR matrix and CBR framework, the measurement system provides a mechanism for identifying the strengths and areas for improvement in various programs. It also enables evidence-based practice because formal documentation and the provision of verified information are encouraged when evaluating a program. Evidence-based practice for CBR programs in Chinese communities were explored and documented to enhance further development of CBR in China.Additional file 1:Case study quesions (DOCX 18 kb)


Lifestyle modification is the primary treatment strategy for obesity, hypertension, dyslipidemia, and hyperglycemia. Recently, the Japanese government designed a healthcare retreat program for persons with cardiovascular risk factors. However, the structure and effectiveness of this program has not been fully discussed.Employees of a company group with obesity and one or more other cardiovascular risk factors were enrolled in the study. The participants in the three-day retreat program were compared with those receiving a brochure-based advice for their subsequent changes in the annual health check-up data using the propensity score matching method.Among the 415 eligible employees, 220 underwent the intensive program and 195 received a brochure-based advice. In the propensity score-matched subjects, reduction in body weight , waist circumference , and non-HDL cholesterol  were significantly greater in the intensive care group one year later. The superiority of the intensive program, however, was gradually attenuted for subsequent two years later.This healthcare retreat with counseling and training program would improve body weight and waist circumference for one to two subsequent years. •Lifestyle modification is the primary treatment strategy for cardiovascular disease.•Based on the trans-theoretical model, healthcare retreat program was established.•Mean 2.7 kg reduction in body weight after 1 year in healthcare retreat group•Our healthcare retreat program may supersede conventional approach. Since 2008, the MHLW further forced health insurer to take the 6-month specified formula of health counseling performed by physicians, public health nurses, and registered dieticians for persons having obesity and two or more of either hypertension, dyslipidemia, glucose intolerance, or smoking. Although multiple Japanese researchers have reported improved measurements for the aforementioned risk factors, only 30% of the counselees could attain >3% weight reduction. Additionally, the maintenance of weight loss has been poorly discussed and health professionals worry about the potential for short-term rebound in body weight and other risk factors.In 2015, the MHLW proposed an retreat type lifestyle counseling and training, performed jointly by physicians, public health nurses, registered dietitians, health and physical fitness programmers, and various other therapists, and subsidized the forerunners of such programs. The healthcare retreat program is based on the trans-theoretical model  and lead22.1This study was conducted among approximately 1500 employees of the Sunstar Group  located in Japan. The Industrial Safety and Health Act of Japan requires employers to provide annual health check-ups for employees living in Japan. The Sunstar Group carries out the health check-ups in February and March every year. A health check-up consists of anthropometry, laboratory tests including urine and blood tests, and a self-administrated questionnaire about disease history, family history, and lifestyle.Height and weight were simultaneously measured with a scale . Body mass index (BMI) was calculated as body weight (kg) divided by height (m) squared. Waist circumference was measured at the level of the umbilicus in one's standing position using a tape measure. Systolic and diastolic blood pressure  was measured by an automatic sphygmomanometer . Blood tests were performed to analyze the concentration of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglyceride (TG), fasting plasma glucose (FPG), and hemoglobin A1c (HbA1c) by the Japan Diabetes Society method . Non-HDL cholesterol was calculated from total cholesterol and HDL cholesterol.2.2According to the national strategy, the healthcare personnel of the company group extracted the employees who underwent annual health check-up and met the below-mentioned “aggressive support” or “motivational support” criteria for metabolic syndrome, and invited to the three-day healthcare retreat program (intensive care) at the health gymnasium (Shin-Shin Kenko Dojo) between June and October right after the health checkup. The criteria for “aggressive support” and “motivational support” were as follows: waist circumference ≥85 cm or BMI ≥ 25, with at least one  or two (“aggressive support” level) of FPG ≥ 100 mg/dl or HbA1c ≥ 5.2%, HDL cholesterol <40 mg/dl or TG ≥ 150 mg/dl, SBP ≥ 130 mm Hg or DBP ≥ 85 mm Hg, and cullently smoking.Participants received detailed information regarding their health check-up results at the beginning of the program and attended a series of lectures about metabolic syndrome, cardiovascular diseases, diet therapy, and exercise therapy. Unmilled brown rice and green vegetable smoothies were provided in meals, but animal products were not included. By such meals, total caloric energy consumption was limited to 1200 kcal per day. Physical exercise included aerobics, water aerobics, and walking at 3 metabolic equivalents (METs) for 2 h per day. At the end of the program, the participants decided and declared their own goals.If an eligible employee could not attend the program, he or she received a brochure for general advice .2.3All the candidates for the three-day healthcare retreat program in 2007, 2008 or 2009 were enrolled in this study. Those who left the company group in the subsequent three years were excluded from the study. Then, the study subjects were classified into the intensive care group  or the usual care group (non-participants in the program during the study period).The health check-up data at the baseline and one, two and three years later were collected for each study subject.2.4t-test. Non-normally distributed continuous variables were expressed with medians and interquartile ranges and compared using the Mann–Whitney U test. Categorical variables were expressed as a number count with proportions and analyzed using the chi-square test or Fisher's exact test.Changes in the measurements for each cardiovascular risk factor from baseline to one, two, and three years after the program were compared between the intensive care group and the usual care group. Statistical analyses were performed using Stata Version 15 . Normally distributed continuous variables were expressed with mean and standard deviations and compared using Student's Using a logistic regression model, we calculated a propensity score for receiving (choosing to attend) the healthcare retreat. The variables included in the model  were age2.5Individual informed consent was waived for the use of de-identified clinical data according to the national ethical guidelines of Japan. Instead, an opt-out approach was applied for this study. All personal identifiers were removed before the researchers obtained the dataset from the Sunstar Group. The Kyoto University Graduate School and Faculty of Medicine Ethics Committee approved the study protocol (registration number: R1121).3Among 415 employees who met the eligibility criteria, 220 subjects received the three-day healthcare retreat program at the gymnasium (intensive care group) and 195 received only usual brochure-based advice . As for metabolic biomarkers, non-HDL cholesterol and TG were markedly reduced by 8.8 mg/dl and 27.0 mg/dl on average one year after the program and well preserved thereafter in the intensive care group. The usual care group members experienced a gradual reduction, but the intergroup differences for non-HDL cholesterol and TG were statistically insignificant and attenuated thereafter. Similarly, differences in HbA1c between the groups were reduced as time progressed. SBP was more decreased in the intensive care group than in the usual care group, both one and two years after the program , but the intergroup difference diminished after three years.Finally, we evaluated the proportion of the subjects who achieved 3% reduction in body weight . More th4This is the first study to report the time-dependent effectiveness of a single short-term retreat type health education session for cardiovascular risk factors. Among the employees with cardiovascular risk factors, body weight and waist circumference were significantly or marginally significantly improved after one and two years for those who underwent the three-day healthcare retreat program compared with those receiving the usual brochure-based advice. However, the intergroup differences were gradually for subsequent two years.In this study, the mean weight reduction was 2.7 kg and 55% of intensive care participants achieved >3% weight reduction one year later. Muramoto et al. revealed that 3% weight reduction is the minimum requirement to reduce the risk of obesity-related diseases for the Japanese population . AdditioIn concordance with the changes in body weight and waist circumference, serum non-HDL cholesterol and TG levels were also more reduced in the intensive care group than the usual care group, even though the standard deviations were large and the intergroup difference was statistically insignificant. Waist circumference was also changed by the intensive care. Statistical insignificance would be explained by their substantial food intake-dependent fluctuations of these items.The findings, taken as a whole, indicate that this intervention generated improvements in several cardiovascular risk factors, without any additional organized interventions, lasting up to two years. This indicates that the program made strong and rather long-lasting impacts on the attendees willing to modify their lifestyles. The practical experience of a diet using low calorie food and simple home-based exercise without special equipment guarantees ease, simplicity, and continuity. A well-designed program built on the trans-theoretical model  is anothBecause lifestyle modification can reduce visceral fats, lifestyle modification is the primary strategy for metabolic syndrome . For theThe weight loss effects of this program were slightly attenuated three years later. Over time, some program attendees might abandon their acquired behaviors during the long self-care period. Refresher counseling and training within three years would be necessary to maintain success. Some previous papers discussed the necessity of maintenance interventions . For exaOf note, the employees who did not participate in the program attained some improvement in body weight, waist circumference, non-HDL cholesterol, TG, and SBP during the 3- year follow-up. Even passive yearly guidance using a brochure would prompt employees with cardiovascular risk factors to do some actions and influence their data to some extent. As such, intergroup differences were reduced within three years and the superiority of the program appears diminished, even though the post-intervention rebound was small.This study has some inherent limitations. First, we evaluated the effectiveness based on anthropometric measurements and laboratory data. Our true endpoint is the reduction in mortality and morbidity from cardiovascular diseases. However, it is well known that the improvement of risk factors can reduce the incidence of cardiovascular diseases, and a study using surrogate markers would be of much help to daily health care for apparently healthy persons. Second, the intervention group and the control group of this study could be unequal to each other unlike a randomized controlled trial even though the propensity score matching was applied for the comparison. Nevertheless, randomized trials would evoke special attention in the participants and the study results would be shifted to the better in both intervention and control groups especially in behavior studies. Third, the findings of this study were derived from only males. Females comprise a relatively small number of this population, and age distribution is left-skewed for this company group, which is similar to the general Japanese working population. Since behaviors and risk factor profiles differ greatly by gender, further studies are warranted to elucidate the effectiveness among females. Fourth, this study was carried out in a single workplace. Then, the findings of this study cannot be universally generalized. The study results should be validated in other studies in different settings.5Our healthcare retreat program would improve body weight and waist circumference for two subsequent years and was worth spreading in the working population. And a three-year later refresher training would be recommended.


The antiviral activities of the title compounds were evaluated against tobacco mosaic virus (TMV) and cucumber mosaic virus (CMV) in vivo. The assay results showed that most of compounds had remarkable antiviral activities against TMV and CMV, among which compounds 4b, 4h, 4i, 4k, 4o, and 4q exhibited good curative, protection, and inactivation activity against TMV. Compounds 4h, 4i, 4k, 4l, 4o, and 4q exhibited excellent protection activity against TMV, with EC50 values of 105.01, 254.77, 135.38, 297.40, 248.18, and 129.87 μg/mL, respectively, which were superior to that of ribavirin (457.25 µg/mL). In addition, preliminary SARs indicated that small electron-withdrawing groups on the aromatic ring were favorable for anti-TMV activity. This finding suggests that 1,4-pentadien-3-one derivatives containing a 1,3,4-thiadiazole moiety may be considered as potential lead structures for discovering new antiviral agents.1,4-Pentadien-3-one derivatives derived from curcumin possess excellent inhibitory activity against plant viruses. On the basis of this finding, a series of novel 1,4-pentadien-3-one derivatives containing a 1,3,4-thiadiazole moiety were designed and synthesized, and their structures confirmed by IR,  Tobacco mosaic virus (TMV) and cucumber mosaic virus (CMV) are two important plant viruses, which can infect at least 125 species of nine plant families and cause significant economic losses in various crops, including tobacco, tomato, pepper, cucumbers, and a number of ornamental flowers . In receNatural products are important sources for drug development, and some natural products and their derivatives, such as limonoids , quassinA  of the compounds are also discussed. To the best of our knowledge, this is the first report on the synthesis and antiviral activity evaluation of 1,4-pentadien-3-one derivatives containing a 1,3,4-thiadiazole moiety.In the further development of antiviral agents, a series of novel 1,4-pentadien-3-one derivatives containing a 5-phenyl-1,3,4-oxadiazole moiety B,  was founE,4E)-1-(4-(2-bromoethoxy)phenyl)-5-substitued phenylpenta-1,4-dien-3-ones 3a–3t were prepared from 4-hydroxybenzaldehyde and aromatic aldehydes via reported procedures + 507.11714, found 507.11646.The structures of the target compounds were confirmed by IR, 4a–4t against TMV were evaluated by the half-leaf method + 507.11714, found 507.11646.Nicotiana tabacum cv. K326, and purified by the Gooding method [TMV and CMV were inoculated in g method .Nicotiana tabacum L. After 1 h, the leaves were washed with water, and after drying, the compound solution was smeared on the left side of leaf and the solvent was smeared on the right side for control. The local lesion numbers were recorded 3 to 4 days after inoculation [TMV and CMV (at a concentration of 6 μg/mL) were inoculated on the whole leaves of the same growing leaves of culation ,39.The solution of the compound was smeared on the left side of leaf, while the solvent was served as control on the right side of leaf. The leaves were inoculated with 6 μg/mL TMV and CMV after 12 h. Then, the leaves were washed with water. The number of local lesions numbers was counted after 3 to 4 days ,39.TMV and CMV was inhibited by mixing with the compound solution at the same volume for 30 min, respectively. Then, it was inoculated on the left side of leaf, and the right side of the leaf was inoculated with solvent and virus mixture as the control. The local lesion numbers were recorded 3 to 4 days after inoculation ,39. The 4b, 4h, 4i, 4k, 4o, and 4q exhibited good curative, protection, and inactivation activity against TMV. Especially, compounds 4h, 4i, 4k, 4l, 4o, and 4q displayed excellent protection activity against TMV, with the EC50 values of 105.01, 254.77, 135.38, 297.40, 248.18, and 129.87 μg/mL, respectively, which were better than that of ribavirin (457.25 µg/mL). Preliminary SARs illuminated that small electron-withdrawing groups on the aromatic ring were favorable for antiviral activity at the same position. This finding suggests that 1,4-pentadien-3-one derivatives containing a 1,3,4-thiadiazole moiety may be used as potential lead structures for development of new antiviral agents.In summary, a serial of 1,4-pentadien-3-one derivatives containing a 1,3,4-thiadiazole moiety were designed for the development of antiviral agents, and twenty novel compounds were synthesized using optimized reaction conditions. The assay results demonstrated that most of compounds exhibited remarkable antiviral activities against TMV and CMV, among which compounds


Scientific and professional development opportunities for early career scientists in low- and middle- income countries (LMICs) are limited and not consistent. There is a disproportionately low number of biomedical and clinical researchers in LMIC’s relative to their high burden of disease, a disparity that is aggravated by emigration of up to 70% of scientists from their countries of birth for education and employment elsewhere. To help address this need, a novel University-accredited, immersive fellowship program was established by a large public-academic-private network. We sought to describe the program and summarize progress and lessons learned over its first 7-years.Hallmarks of the program are a structured learning curriculum and bespoke research activities tailored to the needs of each fellow. Research projects expose the scientists to state-of-the-art methodologies and leading experts in their fields while also ensuring that learnings are implementable within their home infrastructure. Fellows run seminars on drug discovery and development that reinforce themes of scientific leadership and teamwork together with practical modules on addressing healthcare challenges within their local systems. Industry mentors achieve mutual learning to better understand healthcare needs in traditionally underserved settings. We evaluated the impact of the program through an online survey of participants and by assessing research output.More than 140 scientists and clinicians from 25 countries participated over the 7-year period. Evaluation revealed strong evidence of knowledge and skills transfer, and beneficial self-reported impact on fellow’s research output and career trajectories. Examples of program impact included completion of post-graduate qualifications; establishment and implementation of good laboratory- and clinical- practice mechanisms; and becoming lead investigators in local programs. There was a high retention of fellows in their home countries (> 75%) and an enduring professional network among the fellows and their mentors.Our experience demonstrates an example for how multi-sectoral partners can contribute to scientific and professional development of researchers in LMICs and supports the idea that capacity-building efforts should be tailored to the specific needs of beneficiaries to be maximally effective. Lessons learned may be applied to the design and conduct of other programs to strengthen science ecosystems in LMICs.The online version of this article (10.1186/s12909-018-1331-y) contains supplementary material, which is available to authorized users. Establishing sustainable research in science ecosystems in low- and middle-income countries (LMICs) is an urgent priority but no small task –3. In thAchievements in science and medicine that impact humanity in LMICs ultimately depend on communities of scientists and clinicians that live and work in those regions. Human capital development is an important component to improvement of science and medical capacity in LMICs , 3. LocaIn response to needs for enhanced professional development for scientists in LMICs, a novel fellowship training program has been implemented over the past 7 years by a network of public, academic and private partners. Target beneficiaries were Master’s, PhD, and post-doctoral scientists and clinicians who wished to pursue scientific and leadership skills development to complement instruction at their home institution. The program’s central theme was individualized mentoring, and research activities were tailored to the unique needs of each participant. The core program took place annually over a 3-month period in Switzerland, where fellows received on-site tutoring at Novartis’ research and development laboratories followed by accreditation from the University of Basel. Mentoring and collaboration often continued long after completion of the core program. The initiative was named the “Next Generation Scientist” (NGS) program to highlight its stated objective of contributing to the development of future scientific leaders in LMICs.The NGS program recently graduated its 140th fellow. To our knowledge, there have been few capacity-building efforts designed specifically for scientists in LMICs, and still fewer that have attempted to assess their impact and successes . We sougThe NGS program was established in 2011 as part of a multi-faceted effort at Novartis to help build science capacity in LMICs –16, and Each year from 2011 to 2017, an open call for applications was disseminated through public channels. Applicants were entered into a rigorous selection process comprising a dossier review  and up to three rounds of interviews conducted by telephone or in person. Interviews were led by academic researchers, prospective scientific mentors, and trained human resource professionals. Key selection criteria included: academic credentials of the candidate ; ability to match applicants’ research interests and desired skills with an appropriate scientific mentor and host laboratory; and candidates’ long-term commitment to conduct biomedical or clinical research in their home country. The University of Basel and Novartis jointly approved the final cohort of candidates, which typically consisted of 20–25 fellows each year.Scientific mentors at the University of Basel and Novartis participated in a volunteer capacity. Generally, this was because they wanted to engage in an academic-style mentoring program, were interested in the possibility of scientific collaborations with research institutions in LMICs, or were motivated by the opportunity to personally contribute to the advancement of science in LMICs. Mentors were selected based on their specialties and their anticipated ability to dedicate sufficient effort and be effective tutors. Many mentors chose to participate over several years. Mentors were also offered access to mentorship training programs and were provided with operational support from a small core team at University of Basel and Novartis responsible for management of the program. The mentors also participated in periodic meetings for peer support and sharing of mentorship best practices. Fellows and mentors jointly developed a research plan according to the fellow’s interests and skills.The 3-month core program comprised two main components: a bespoke research project and a formally structured science and leadership skills development program. The research project occupied the fellow for approximately 80% of the time spent on-site and was designed to be sustainably implementable within infrastructure at the fellow’s home institution. Research interests of the selected candidates were identified from their application dossiers and matched with prospective mentors that had similar interests and relevant skillsets. The scope of work for each fellow was then iteratively refined through virtual (telephone and email) discussions between candidates and mentors. Whenever feasible, candidates’ home supervisors joined the pre-fellowship discussions to contribute recommendations for technical aspects that would benefit the fellow and the home institution. Once selected, mentors and mentees were typically in close contact leading up to commencement of the on-site stay . Topics in the scientific curriculum were allocated to groups of fellows who planned and organized seminars which facilitated bi-directional interactions with senior experts. The leadership skills program comprised workshops focused on written and oral scientific communication, self-awareness, and appreciative inquiry . WorkshoIn the final week of the program, fellows formally presented their research project in poster format at a public scientific symposium. The graduation event typically included oral presentations by a small number of graduating fellows and by inspiring leaders in health and science from LMICs. The University of Basel subsequently awarded a University certificate and post-graduate credits using the European Credit Transfer and Accumulation System, a transferable standard for comparing study attainment and performance in higher education across Europe .The University of Basel organized and funded training events that were hosted at their campus. Novartis funded travel, accommodation, health insurance, immigration logistics, and provided a stipend. Laboratory-associated costs were borne by the Novartis hosting laboratories. Every effort was made to ensure that participation in the program was cost-neutral to the fellows and their home institutions. The program was compliant with Swiss law and ethical, legal and financial guidelines of the University of Basel and Novartis.Participants were co-located in student accommodation which allowed for the development of a sense of community among fellows, provided an environment to conduct group project work in an informal setting, and helped the development of a sustainable peer social and professional network. After the fellowship, ongoing exchanges among fellows and their University of Basel and Novartis mentors were encouraged.Demographic characteristics were extracted from fellows’ application dossiers. Fellows’ research deliverables  were used to summarize and categorize research activities.Feedback was continually received over the evaluation period through spontaneous verbal and electronic communication. In addition, a global summit was convened in 2014 and attended by approximately 60 fellows who provided updates on their professional achievements at that time.In February 2017, an on-line follow-up survey , using library packages such as ggplot2 for generation of Figs. Data and graphical analysis were performed using RStudio . There was a predominance of doctoral or early post-doctoral scientists (70%) and an even distribution by gender .The majority (78%) of participants joined the program to learn a new research methodology for implementation back at their home institution. Others chose to develop skills relating to clinical trials; access laboratory equipment, infrastructure, and expertise; and/or use the fellowship to facilitate analyses of their own samples or data. Several fellows concentrated on skills relating to natural products, reflecting their continuing relevance to research programs in their local environments.Fellows’ scientific focus was spread across basic research laboratories, clinical research departments, and drug formulation laboratories. Specific disease area interests were split between communicable and non-communicable diseases. The group comprised about 22% of clinician-scientists  most of whom were hosted in clinical research departments.Follow-up data Table  describiFigure Table The follow-up survey revealed an enduring network after completion of the 3-month fellowship. Nearly two-thirds of participants (64%) reported ongoing regular contact with other fellows and 35% reported sporadic contact. Only 3 fellows reported having no continuing contact with their peers. Ongoing contact was also observed between fellows and their mentors at University of Basel or Novartis; 86% of fellows reported regular or sporadic contact. Active collaboration, as defined by ongoing project-related interactions, was reported by 8% of fellows for peer-to-peer partnerships and by 12% of fellows for fellow-to-mentor partnerships.In open-ended comments on the follow-up survey, NGS fellows reported concrete scientific benefits such as access to equipment and data; expediting completion of post-graduate qualification; and “soft” benefits including networking, reputation, and broadened perspectives on work ethic and culture. Fellows also reported improvements in research productivity via publications, conference presentations, success with funding applications and involvement in clinical trials. As a complement to individual scientific research development, the respondents also provided examples where they themselves transferred skills to colleagues at home. Table A 7-year structured, immersive mentorship program contributed to professional development for a carefully selected group of 143 scientists and clinicians from 25 LMICs. A unique feature of the program was the bringing together of cohorts of researchers at the launch stage of their scientific careers. This appears to have facilitated a sustained network of scientists in LMICs despite the relatively short 3-month duration of the on-site component. The governance of the NGS program was also novel, with voluntary shared responsibility by a range of academic, public, and private partners. Understanding key enablers of the program, and its limitations up until now, is fundamental to improving the program in the future and may inform the design and implementation of similar capacity-building efforts in LMICs.A widely acknowledged success that was highlighted by fellows and mentors was the opportunity for mutual learning in topic areas that would not easily be attained through other mechanisms. By design, fellows benefited from specific scientific and professional development training. In many cases, mentors similarly benefited from the knowledge exchange . In nearly all cases, mentors stated that the lessons they learned about patients, diseases, and health systems in LMICs broadened their perspectives about science and medicine globally in ways that influenced their own professional and personal activities. This gives credence to the Nigel Crisp assertion that “rich countries can learn a great deal about health and health services from poorer ones and that combining the learnings from rich and poor countries can give us new insights into how to improve health” . We suspAnother program enabler was the flexibility associated with fellows’ research curricula. Fellows were not pigeon-holed towards pre-determined activities—rather, research programs were individualized according to the needs of each fellow, agreement between fellows and mentors, and relevance to priorities at fellows’ home institutions and countries. The hosting laboratories at Novartis needed to be able to support the science that the fellow would conduct, but the fellow’s research program did not need to directly advance the research agenda of the hosting laboratory. Providing support for fellows’ research interests was not always entirely straightforward. For example, some projects involved analysis of plant or biological samples from fellows’ home institutions, which required considerable effort by both the home and host institutions to ensure compliance with the ethical-legal regulations associated with cross-border transfer of materials. The benefit, however, was scientific progress and attainment of valuable experience on both sides for implementing globally-focused scientific research. For all projects, research success was a result of thorough planning before the fellowship and on-going interactions afterwards. It was felt that tailoring activities to the needs of fellows was a significant factor in the impressive scientific productivity that resulted (for example see the peer-reviewed publications cited in Table The high retention of fellows in their home countries (> 75%) and employment in the public or academic sector is noteworthy - only 4 scientists reported working for a pharmaceutical company after completion of their studies in contrast to over 60% being employed in the public or academic sector Table . AlthougThe NGS program’s multi-sectoral academic-public-private partnership model worked well. Involvement of the University of Basel as a coordinating entity was instrumental in providing academic credibility, and the collaborative framework that developed with science as an organizing principle helped the industry partner to be viewed as an equal contributor rather than simply a funding source. Within LMICs, the program often served as a complement to locally funded government or non-governmental capacity-building initiatives and in some instances stimulated the establishment of new partnership programs.Much has been written to acknowledge the secondary effects of strengthening research capacity on health in under-resourced environments. These viewpoint and perspectives papers typically highlight existing programs and advocate for new collaborative efforts involving local and international governments, private sector groups and large funding bodies , 3. The Future priorities for the NGS program will be to increase involvement of the home academic supervisors. Our experience has been that home supervisor involvement leads to more successful project outcomes, whereas a lack of involvement could make the reintegration to the home laboratories more difficult. Fellows have highlighted that whilst techniques are relatively easy to transfer back, research culture traits can be more difficult due to a confounding interplay of culture and infra-structure deficits between research sites located in high-income countries and the academic centers in LMIC settings. Closer engagement with the home mentors and institutions might represent one component of a solution. Ideally this would be coupled with enriched and expanded post-fellowship activities. There has been substantial interest from NGS fellows in formalizing post-fellowship interactions, in part due to recognition of the benefits that could be realized by capitalizing on their large, growing network of emerging scientific leaders in LMICs. Preferably, this will be accomplished by putting primary governance of the activities with the fellows themselves. As with many capacity-building efforts, we are currently faced with the challenge of identifying methods for scaling up the program while maintaining the individualized approach that is thought to be crucial to the program’s success. We have initiated exploratory high-level discussions with several major research funding organizations and are hopeful that the program can be grown in future program cycles.The above benefits described notwithstanding, we acknowledge that there are limitations to capacity-building via the approach described, and there were also limitations to our ability to evaluate the program. As with all survey-type methodologies there is the possibility of reporting bias, though we took the exceedingly high response rate (ranging 87–100% across the 7 cohorts of participants) as a sign that reporting bias in this evaluation was likely to be minimal. To mitigate potential bias by the program funders (Novartis and the University of Basel) in the evaluation of the program, we assembled a multi-sectoral public-academic-private team to conduct the study reported here. This team included some supervisors of NGS fellows from their home institutions and were thus in a position to contextualise the overall survey data against their own personal impressions of the impact of the program on their students. The core component of the NGS program is a 3-month intensive mentored research experience, and there are natural confines to the extent of professional development that can be achieved in this time-limited period. While for many participants the core program set into motion long-term collaborative activities (which was encouraged), these activities were not supported with dedicated resources. Another potential inherent weakness with the program design was mentoring of fellows outside of their home institution. This required added financial resources and logistical considerations, and temporarily removed scientists from the precise environments where capacity-building is needed. However, the rationale was to enable sufficient exposure to new resources  that would enrich their professional development; in addition, this approach served to facilitate peer-to-peer networks that would likely not have been established to the same degree without bringing fellows together face-to-face. Quantifying and valuing the multiple hard and soft dimensions of long-term impact of capacity development programs remain challenging. Logistical impracticalities preclude the conduct of a controlled study – we propose the development of methods to quantify the social impact of capacity development programs in monetary terms, similar to the valuation of an environmental footprint , 22. TheThis 7-year structured, immersive mentorship program with 143 scientists and clinicians from 25 LMICs provides an example for how multi-sectoral partners can contribute to scientific and professional development of researchers in LMICs. Our experience substantiates the view that capacity-building efforts in LMICs should be tailored to the specific needs of beneficiaries to be maximally effective. Lessons learned may be applied to the design and conduct of other programs to strengthen science ecosystems in LMICs.Additional file 1:NGS Survey Instrument. (PDF 156 kb)


Frontline healthcare workers are critical to meeting the maternal, newborn and child health Sustainable Development Goals in low- and middle-income countries. The World Health Organization has identified leadership development as integral to achieving successful health outcomes, but few programs exist for frontline healthcare workers in low-resource settings.An 18-month pilot leadership development program was designed and implemented at Greater Accra Regional Hospital, a tertiary care facility in Ghana. A multi-modal training approach was utilized to include individual coaching, participatory discussions, role plays, and didactic sessions on leadership styles, emotional intelligence, communication, accountability and compassionate care.A cross-section of 140 staff from 8 distinct hospital wards and 19 ranks were involved in various components of the leadership program from January 2014 to June 2015. At baseline, the primary leadership challenges and goals of the staff included: interpersonal communication, institutional logistics, compliance, efficiency and staff attitudes. Thirteen participants developed a total of 17 leadership projects to apply their training, many of which focused on improving challenges in organizational culture and systems through bettering leadership skills and interpersonal communication. The staff highly valued the program and found it beneficial to their work.Self-selected individual leadership projects mirrored areas of concern found in the needs assessment, indicating that the program was successful in achieving its goals. The on-site nature of the program was cost-effective and led to maximum staff participation despite clinical responsibilities. A longstanding relationship between the design team and the local hospital staff allowed for an exploration of approaches, many of which were new to the local context. Further research is needed on adapting the program to other settings in Ghana and integrating it into broader systems strengthening interventions. This pilot program was well received and warrants further adaptation and scale up. Ending preventable maternal and neonatal death is at the core of the Sustainable Development Goals’ third objective of ensuring healthy lives and promoting well-being for all ages, where all children across the globe reach their fifth birthday and no woman dies as an outcome of pregnancy or childbirth. The vast majority of maternal and neonatal deaths occur in low-resource settings and many could be averted by strengthening health systems and processes through which care in pregnancy, during labor and delivery, and immediately postpartum are delivered , 2. LeadSeveral leadership programs in low-income settings have been reported in peer-reviewed and other literature, such as the Senior Leadership Program at the National University of Rwanda School for Public Health for district hospital medical directors ; mentoriThis paper describes the design, implementation and evaluation of an eighteen month-long leadership training and coaching program for physicians, nurses, and midwives from January 2014 through June 2015 developed at a tertiary referral facility, Greater Accra Regional Hospital (GARH) in Accra, Ghana. The program was part of a multi-year partnership between GARH and Kybele, a non-profit humanitarian organization which promotes safe childbirth and compassionate care worldwide through collaboration with health professionals. GARH is one of the country’s largest obstetric referral centers within the Ghana Health Service, with a 90-bed maternity unit providing comprehensive care for more than 8000 annual births, the majority of which are transferred from peripheral facilities with complications. Ghanaian maternal mortality ratios (MMR) in regional and teaching hospitals such as GARH are reported as high as 957–1004/100,000 live births, though the national MMR is 319 . The neoThe program concept was developed based on discussions with the hospital management team responsible for maternal and neonatal health, observations of care by visiting clinical experts, and mortality audits. Observations revealed poor accountability regarding patient care, occasional verbal abuse, and poor communication with patients regarding labor progress, treatment plans, and newborn health status. The audit found avoidable leadership gaps associated with deaths at GARH, such as delays in calling a physician, inadequate patient surveillance and monitoring, and lack of consequences for poor performance leading to recurrent errors. The gaps identified were primarily in four areas that became the pillars on which the leadership program was based Table : (a) adaPerinatal Leadership Forum (PLF), consisting of physicians, nurses and midwives, was charged with championing leadership development across the organization. They met twice, forming a team charter to guide their work, and participated in the training sessions and individual coaching. Members of the PLF were interviewed to identify key leadership challenges and goals, and their responses were categorized into themes and later incorporated into training sessions. The other two groups were formed and designated as the Leadership Ambassadors and the Clinical Champions. Leadership Ambassadors were doctors and senior midwives responsible for bridging communication gaps between frontline staff and upper management. Clinical Champions were frontline midwives and nurses responsible for promoting leadership and quality within various clinical wards such as the labor and delivery unit, operating theatre, recovery room and newborn intensive care unit). Staff members in each group were carefully selected for their initiative and enthusiasm, and they represented all levels and ranks of the organization and all departments involved in maternal and neonatal care.Having established the major areas of concern through the audit, the program design was further customized through a comprehensive, participatory needs assessment to understand the leadership challenges that staff faced. Three leadership groups were established to provide input for the needs assessment, feedback on program design and ultimately participate in the majority of the program. The The needs assessment illustrated the leadership challenges most salient to the cross-section of healthcare providers at GARH and the goals they wanted to pursue during the leadership training. Some examples of the challenges reported are shown in Table The results from the needs assessment were used to refine and customize the program design to make it more relevant for the participants. The program still focused on the four key components of accountability, decision-making, communication and compassionate care. However, the scenarios developed for the workshops, and the examples used in the discussion and role-play sessions were based on the challenges and goals identified by the participants, and the coaching sessions were tailored to address the challenges and goals. Staff goals for the leadership program were ranked by frequency Fig.  and orgaDuring the needs assessment, members of the PLF were interviewed to identify key leadership challenges and goals, and their responses were then categorized into themes to be later incorporated into training sessions. These sessions commenced in January 2014 with multiple two-day workshops on emotional intelligence and Goleman’s Leadership Styles  held forThe teaching methods in the workshops were intentionally diverse and multi-faceted and included short didactic lectures, participatory role-playing, live coaching demonstrations, interactive group discussion, “appreciation circles” to build trust and community through shared gratitude and esteem for one another, personal reflection, small group feedback, and experiential storytelling exercises. Workshop participation was capped at 20 individuals to encourage interaction in small groups.Workshops were coupled with individualized coaching sessions by the leadership consultant throughout the program. Staff involved in coaching volunteered themselves for coaching or were encouraged to participate by the leadership consultant based on observed responsibilities or responses during leadership training sessions. Coaching focused on identifying individual leadership challenges and developing leadership projects that were targeted to overcome these challenges. The Wilber Four Quadrant Model was again used because it allows for the opportunity to work on both individual and organizational leadership projects, thus allowing participants to select projects which were most relevant to them. With support through the coaching sessions, participants were encouraged to consider their priorities as leaders in their organizations, select a project that was meaningful and motivating to them, and apply the leadership skills they had learned in the workshops. The Wilbur model facilitated this well.All leadership program activities were held on-site at GARH to facilitate wide participation and to lower program cost. No remuneration or per diem stipends were provided to staff for their participation.A five-point questionnaire was administered at the conclusion of the program asking participants to assess the most personally valuable components of the program, the most meaningful teaching methods for learning and leadership development, the leadership challenges and priorities that were well addressed or not fully addressed, and their overall perceptions and feedback on the leadership program. Additional evaluation was conducted during the individual coaching sessions, asking participants in a one-on-one setting to report on their major takeaways from the program, specific challenges they aimed to address using new leadership skills, and progress towards achieving their leadership goals and objectives.During the individual coaching sessions, participants were encouraged to take part in developing leadership projects that allowed them to apply the skills they learned in concrete ways. Thirteen participants developed projects primarily reflecting challenges in organizational culture and systems that they attempted to address through developing better individual and group leadership skills. The leadership consultant guided participants to develop specific action plans and goals for accomplishing their projects and followed-up in subsequent sessions to assess progress toward project achievement.As indicated by the emerging fields of improvement and implementation science , leadersA breakdown of the leadership program components and staff attendance can be found in Table Overall feedback on the participants’ experience with the leadership program was overwhelmingly positive. There was a consensus among staff that the program was effective in improving skills and that it should continue. Some sample comments, all of which were anonymous, included: “The program has built excellent leaders and managers and should be extended nationally for all health workers,” “The leadership program has given me confidence and skills to give effective care,” and “The program will go a long way to impact the lives of the staff.”Overall, the leadership initiative at GARH proved to be a novel program that was well received. The topics of leadership style, emotional intelligence, compassionate care, and respectful confrontation were entirely new concepts for nearly all staff, and the participants engaged with the content and assignments with enthusiasm. The high level of participation and time commitment by so many staff, without remuneration, is noteworthy and indicative of the value they place on improving leadership, management, and accountability in their workplace. The needs assessment expressed a consistent message from across wards and ranks of the need for improvement in key areas—namely, holding people accountable while improving interpersonal communication, making improvements to logistics and processes, increasing staff compliance to protocols, and increasing positivity of staff attitudes.The issues identified by staff as their most salient challenges closely correlated with the most highly ranked leadership goals, particularly improving interpersonal relationships and communication, improving staff welfare and support, and improving staff attitude. The leadership program aimed to address these key areas by using a mix of didactic and experiential learning, focused on personal reflection to develop individual leadership skills that could then be used to bring about improvements to the system.This emphasis on building personal leadership skills meant that the program was designed to break down traditional hierarchical barriers between senior management and frontline workers in Ghana by involving both ranks in the same program. Management and staff were brought together in the same space to discuss individual behaviors and communication patterns and to learn styles of respectful confrontation to deal with situations affecting effective patient care. Participants eagerly engaged in these activities during the training.The fact that a variety of program components and leadership teaching methods were highly ranked by participants indicates a need for further analysis in two areas. The first is a deeper assessment of the best contextual approach to build a sustainable leadership program to develop decision-making, accountability, compassionate care, and communication skills to improve maternal and neonatal mortality in tertiary facilities. This program reflected the approach of the leadership consultant who believed that changes to the system could come about when carefully selected staff worked diligently on their own thoughts, feelings and attitudes, and applied these new leadership behaviors to their everyday work. This is a time-consuming and resource-intensive process, which alone is not enough to tackle the types of projects that surfaced as priorities in Table power distance using the Hofstede model, meaning that “people accept a hierarchical order in which everybody has a place and which needs no further justification” [individualism, which indicates a high value placed on the individual and high expectation that one will look out for one’s self-interest. Ghanaians, however, score low on this dimension, suggesting higher value is placed on belonging to the collective and “taking responsibility for fellow members” [Second, the approaches for “leveling the playing field” between higher and lower ranking positions in the organizational hierarchy to break down barriers in communication and interpersonal tension between staff is a countercultural practice in Ghana. Kybele had worked with GARH for several years prior to the introduction of the leadership program, and therefore had personal relationships with leadership and staff, which may have facilitated staff engagement in a program designed and led by a leadership consultant from a Western country. Further research is needed before transferring this approach to other settings. There are major differences in the way that these cultures view individuals in their workplace, with Ghanaians scoring high on ication”  while Wemembers”  of one’sSome additional limitations should be noted. The relatively short time period of the leadership program (18 months) resulted in limited analysis of the long-term impact of the program. Follow-up research is needed to illuminate the sustainability of skills learned by staff through the program and the achievement of leadership projects initiated. The focus of the program was on changing attitudes and behaviors; therefore, further time and efforts would be needed to show the impact of the program on specific maternal and child health outcomes. While participation in the program was impressively high, the time-constraints of staff members, who were juggling their clinical responsibilities with the added time commitment of the leadership sessions, may be another limitation in more extensive programming.Globally, designing and delivering leadership programs aimed at frontline staff remains a significant gap in LMIC. The pilot leadership program at GARH developed by Kybele showed that participants were highly interested in the topics of leadership development, which appeared relevant to key challenges in the workplace—both interpersonal and operational. Staff involvement in designing the interactive delivery model of the program resulted in a positive experience of the training and useful skills learned. The leadership projects provide further evidence of the staff's motivation in using the skills they have learned to address challenges in their work. There is a significant opportunity to build on the learning from this effort to develop a leadership curriculum. It was felt that reducing mortality and making more efficient use of resources required systematic improvement of service delivery processes in addition to strengthening leadership and therefore should not be undertaken as independent leadership projects isolated from other improvement activities.Leadership development is clearly an essential component of quality healthcare and additional emphasis is warranted in LMIC to develop a new generation of leaders for the health system. This pilot research adds to the small but growing body of literature examining leadership programs that specifically target frontline healthcare workers in low-resource settings. The distinct aspects of this program included the multi-modal teaching methods  and the cross-sectional involvement of participants from the organizational spectrum of ranks and specialties. While the program described here has demonstrated the feasibility of developing a successful cost-effective leadership program for frontline health workers, future research in this very important area must be encouraged and undertaken.


Background: In Lagos, Nigeria, approximately 33% of the population suffers from hypertension, yet antihypertensive treatment coverage is low. To improve access to care, a decentralized pharmacy-based hypertension care model was piloted. This study reports on the recruitment strategies used and is part of a larger study to evaluate the feasibility of the care model.Objective: To describe our experience executing three different strategies to recruit hypertensive patients in the program: community hypertension screenings, hospital and pharmacy referral.Methods: Individuals with elevated blood pressure and no history of cardiovascular disease were referred to the program’s recruitment days to see a medical doctor for hypertension diagnosis and enrollment. Individuals were referred from community screenings, tertiary hospital outpatient clinics, and pharmacies participating in the program. For the community screenings, we report the number needed to screen (NNS) to find one individual with elevated blood pressure, the NNS to enroll one individual in the program, and factors associated with enrollment in the program among participants referred.Results: We recruited 226 individuals (69%) in the program via the pharmacies, 97 (30%) via the community screenings, and 2 (<1%) via hospital referral. At the community screenings 3,204 individuals participated, 729 (23%) had elevated blood pressure and 618 (85%) were eligible for referral of whom 142 (23%) visited the recruitment days, and 97 (16%) enrolled. The NNS to find one individual with elevated blood pressure was 5, and the NNS to enroll one individual was 34. Enrollment in the program was associated with advancing age, blood pressure ≥160/100 and currently using antihypertensive medication.Conclusions: Despite the potential attractiveness of community screenings to identify and refer individuals with hypertension, enrollment in the program was low. For future programs we recommend pharmacy referral as individuals seem more inclined to access care through healthcare providers they are familiar with. In Lagos, Nigeria, around 33% of the population suffers from hypertension ,2, whichet al. [In SSA, community screening events are often held to reach and detect individuals with a disease or at risk for developing it. Hypertension screening events are also common . Due to et al.  report tIn addition to identifying individuals at risk for CVD, improving accessibility to good-quality hypertension care is necessary to reach the 25% hypertension control target in Africa. Data from Nigeria show control rates of hypertension being between 3% and 9% . Hence, What is the number needed to screen (NNS) to find one individual with elevated blood pressure?What is the NNS to successfully enroll one individual in the pilot program?What factors are associated with enrollment among those referred to the pilot program?What are the most important reasons for non-enrollment in the pilot program?The three strategies used to recruit hypertensive patients in the pharmacy-based hypertension care pilot program were (1) community hypertension screening events, (2) referral of hypertensive patients from Lagos University Teaching Hospital (LUTH) outpatient departments and (3) identification of individuals with elevated blood pressure at the pharmacies participating in the pilot program. The aim of the study was to describe our experiences executing each recruitment strategy, with a specific focus on the community screening events. We evaluated the community hypertension screening events using the following research questions:The key component of the pharmacy-based care model was task-shifting from medical doctors to pharmacy staff by using a mobile application , developed by OMRON Healthcare and their technical partners. Cardiologists remotely monitored patients accessing hypertension care at the pharmacy by review of their blood pressure data, related complaints, and drug prescriptions through the mHealth app. The pharmacist counseled the patient on drugs and lifestyle interventions, performed routine blood pressure monitoring, and dispensed drugs to the patients. Cardiologists and pharmacists were jointly responsible for remote patient monitoring and management, and communication between them was primarily through the mHealth app. Pharmacists and cardiologists received a fee for each patient monitored.Recruited patients were registered in both the pilot program and mHealth app and were expected to stay in the pilot program for approximately six months. The patient participation fee was 250 Naira per month , excluding the costs of medications. A more extensive description of the care model is provided elsewhere .Through community hypertension screening events, we targeted individuals living nearby the pharmacies who were not yet aware of or not yet receiving care for hypertension. Ten community screening events, two events near each participating pharmacy, were held mostly on Saturdays between February and April 2016. The events were organized by OMRON Healthcare and implementing partners. Community mobilizers actively sensitized the community about the events by engaging community leaders, advertisements, music and community volunteers. Screening staff registered individuals voluntarily attending the screening and medical doctors from LUTH measured the participant’s blood pressure after rest during registration, see At LUTH we targeted patients visiting the cardiology, family medicine and community medicine outpatient clinics who deemed eligible for their hypertension care to be managed at the pharmacy during the pilot program, rather than at the hospital. During the recruitment period, medical doctors at these outpatient clinics were asked to identify individuals with elevated blood pressure and patients already managed for hypertension and refer those who were potentially interested in the pilot program.Through the pharmacies participating in the pilot program, we targeted individuals who already patronized the pharmacy. These pharmacies provided free blood pressure measurement services at their customers’ request or based on presenting signs and symptoms. The pharmacists referred customers with elevated blood pressure and a potential interest in the pilot program to the recruitment days and reminded them if necessary.To be recruited into the pilot program, individuals identified with elevated blood pressure had to attend one of the recruitment days at LUTH (twice a week from February to May 2016) or one of the participating pharmacies. Initially, pharmacy-based recruitment was only planned at two pharmacies far away from LUTH, but after two weeks this was adjusted (as attendance at LUTH was low) and between 5 and 12 additional recruitment days were organized at each of the five pharmacies.At recruitment, the pilot program’s resident cardiologists or medical doctors under supervision of a cardiologist assessed eligibility. The criteria for inclusion in the pilot program included individuals aged 18 years and above and a (new or previous) hypertension diagnosis confirmed by the cardiologist or medical doctor. Exclusion criteria were: (1) individuals with a previous history of cardiac failure, stroke or renal disease; additional risk factors for CVD identified by the cardiologist or medical doctor; individuals with an SBP ≥180 mmHg and/or DBP ≥110 mmHg were not suitable for the pilot program, as more comprehensive monitoring may be desired, which could not be guaranteed during this pilot phase; (2) individuals not permanently residing in Lagos State; and (3) pregnant women (self-reported). Individuals who were not eligible for the pilot program received lifestyle advice if applicable and were referred for regular hypertension care at a public or private health facility.We collected data during both the community screening events and at the recruitment days. During screening and recruitment, blood pressure was measured on the upper left arm at heart level after at least 5 minutes of rest in a sitting position using a validated automatic blood pressure device . At the community screening events, screening staff used pre-numbered duplicated record forms to organize the screening and referral process. They recorded blood pressure, age and gender for all screening participants. Additional information on the medical history, interest in the pilot program, and contact details were recorded when participants had elevated blood pressure. Screening staff provided participants with a copy of their screening results as a take-home medical record. Research staff copied data from the forms anonymously in an electronic database. For all individuals attending the recruitment days, the research staff collected data on eligibility, anthropometric and blood pressure measurements as part of the pilot program’s feasibility study.Data were analyzed using STATA version 12 . We used multivariable logistic regression analysis corrected for clustering at the community screening event level to evaluate the association between enrollment and age, gender, blood pressure classification and hypertension status among community screening participants eligible to participate in the pilot program.In total 3,204 individuals participated in the community screening events, of whom 729 (22.8%) had elevated blood pressure . The occurrence of elevated blood pressure was similar among women and men, but participants with elevated blood pressure were older  were referred to the recruitment days of the pilot program, 109 participants (15.0%) were referred to regular hypertension care because of ineligibility or because they were already in hypertension care with a doctor, and 2 participants (0.3%) were erroneously excluded at screening . Of the The number of individuals needed to screen (NNS) to find one individual with elevated blood pressure was 5, while the NNS was 34 to successfully enroll one individual in the pilot program. The NNS to find one individual with elevated blood pressure and to find one individual enrolled both decreased with advancing age . Among cForty-five participants (31.7%) who visited the recruitment days were not eligible for inclusion in the pilot program. The hypertension diagnosis was not confirmed for 34 (76%) of them, their mean SBP was 140.5 mmHg (SD 8.2) at the community screening event. Furthermore, the medical doctor deemed 11 participants (24%) not suitable for the pilot program. The main reasons being the participant did not need medication or could benefit from lifestyle treatment alone (n = 4), the blood pressure was severely high (n = 3), the participant had comorbidities (n = 2) or the participant was already in care with a medical doctor (n = 2).Community-screening participants aged 65 and above had the highest likelihood to enroll  in the pilot program compared to individuals below 35 years . IndividThree individuals were referred for recruitment from the LUTH outpatient clinics compared to 258 referred from pharmacies. Eventually, 2 individuals referred from LUTH and 226 individuals (87.6%) referred from the pharmacies enrolled in the pilot program. Of the individuals referred from the pharmacies, 29 (13%) were newly diagnosed with hypertension. In total, 33 individuals were not eligible to participate, 20 of which were not confirmed to be hypertensive by the medical doctor. For 11 of the individuals, the medical doctor considered the pilot program not suitable, the main reasons being: the patient did not need medication (n = 2), the blood pressure was severely high (n = 3), the patient had comorbidities (n = 5) or the patient was already in care (n = 1). The reason was unknown for the remaining two individuals.An additional three participants who were seen at the screening events, but initially not eligible, later enrolled in the pilot program via the pharmacies. In total 328 patients enrolled in the pilot program, 69% via pharmacy referral, 30% through community screening events, and less than 1% via referral of the LUTH outpatient clinics.This study was part of a larger study investigating the feasibility of a pharmacy-based hypertension care model that included an mHealth app for remote patient monitoring by cardiologists in Lagos ,14. The Although we found a high proportion of individuals with elevated blood pressure during the community screening events (NNS = 5), this was lower compared to previous studies in Lagos –3. The pFurthermore, the screening events attracted a substantial proportion of individuals who appeared already aware of their condition and on antihypertensive medication. These participants were more likely to enroll in the pilot program compared to those unaware of their hypertension status or not yet in care. However, we had anticipated to identify the latter groups. A study into the reasons why individuals participate in health events such as community screenings would therefore be worthwhile.Low attendance on the recruitment days following the community screening events, despite several attempts to reach individuals by phone. This may have been because screening participants did not have a prior relationship with the pharmacist, as opposed to referrals from the pharmacy. Our qualitative research showed that the relationship with the pharmacist is an important factor in healthcare-seeking behavior and retention in care . During Low numbers of individuals utilizing healthcare providers after community and home-based screening events was also observed in other sub-Saharan African settings –18. SomeRegarding the third lesson, the reasons why referral via LUTH was not successful in recruiting patients in the pilot program included conflict of interest, as the departments needed to reach their patient targets, medical doctors being on strike, and potentially eligible patients did not live near the pharmacies .The lessons learned from the recruitment strategies cannot be generalized to recruitment in regular hypertension care as patients were recruited for a specific pharmacy-based pilot program with its own specifications and individuals needed to be eligible for the pilot program. One of the strengths of this evaluation is that we used individual level data obtained at several community screening events. A limitation of our evaluation is that we were unable to collect the number of people approached at LUTH and the pharmacies for referral to the pilot program, but only collected data of individuals who visited the recruitment days. Nevertheless, the available data provide lessons for future recruitment activities, suggesting that if decentralized pharmacy hypertension care is implemented in comparable settings, recruitment could focus primarily on pharmacy clientele. Our study confirms the limited value of community hypertension screening events in this setting.We found that pharmacies are essential in the recruitment of hypertensive patients in a pharmacy-based hypertension care pilot program. For future programs we recommend the use pharmacy referral as individuals are more inclined to access care through healthcare providers that they are familiar with. Recruitment through community screening events and a hospital’s outpatient clinics resulted in a lower number of recruited patients than expected. More research is needed to better understand why individuals newly identified with hypertension do not access care, as different approaches may be needed to enroll them in care.