Dakshata program in India aims to improve resources, providers’ competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability.The Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner.p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers.Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.The The online version contains supplementary material available at 10.1186/s13690-023-01028-z. High quality care during childbirth is essential for better maternal and newborn outcomes , 2. AlthDakshata program [Dakshata program incorporated improving resources and program monitoring led by the state [In India, the Checklist was pilot tested to assess the acceptability and evaluate change in provider behaviour in the states of Rajasthan, Karnataka, and Uttar Pradesh , 10, 14. program  where thhe state .Dakshata program, which is one of the first comprehensive quality improvement programs for maternal/newborn care in the country.India has more than 80% hospital deliveries, and a slow declining maternal mortality ratio (MMR) currently at 103 per 100,000  and a stDakshata quality improvement program was planned to be implemented in government-run secondary and primary care hospitals. The JHPIEGO-India office supported the Rajasthan state in scaling-up the program to 20 districts (excluding the 7 pilot districts) in a phased manner, covering over 200 hospitals between 2015 and 2019. The program districts and hospitals were jointly selected by the respective state health departments and the JHPIEGO state consultants; the evaluation team did not have any role in this selection or implementation.The Dakshata program aimed to improve providers’ competence and accountability, while ensuring appropriate resources in labour rooms and wards. The intervention package included: “a) bulk training of 3 days for use of SCC for essential practices in the labour room, b) mentoring and support visit (MSV) package of 3-4 months of on-site pulse training, c) technical support required to ensure availability of resources, and d) technical support to state and country for strategic planning, and monitoring” [Dakshata’s skill building focused on practices from four crucial pause points as in WHO-SCC [The itoring” . Dakshat WHO-SCC : Pause p WHO-SCC , 15. RajDakshata mentors) provided mentoring through a structured 8-visit package (consolidated to 5 visits in late 2018). Mock-drills and feedback in real settings and repeat training were the standard mentoring approaches. The mentors also got involved in problem-solving and team building at the hospitals. The mentors conducted quarterly periodic assessments using a structured format to monitor the progress in the availability of supplies, adherence to essential practices, and record keeping. They provided feedback to hospitals, districts, and states. Table JHPIEGO provided intensive support to state through a team of 3–4 state and 10 district program officers. The JHPIEGO state program officers provided 5 days of training to a pool of handpicked government trainers from each program district, regarding clinical as well as pedagogical skills. These government trainers, under the supervision of JHPIEGO program officers, trained the staff ) from the target hospitals in their districts, for 3 days as per the established labour room protocols and standards. The training was provided at the District hospitals in small batches to facilitate training of at least 80% of the eligible staff without disturbing the hospital-level functioning. Post-training, the JHPIEGO program officers  evaluate the effect on adherence to maternal and newborn health evidence-based provider practices, and stillbirths; 2) assess the efficiency of the program components, monitoring, and accountability to improvement in the quality of services; and 3) assess the adequacy of external support, institutionalisation in government systems, sustainability and scalability of the program.The 20 districts were covered in 2 phases: phase 1 initiated in 2015–16 in 13 districts and phase 2 initiated in 2017–18 for 7 districts, i.e. 20 in total. At the time evaluation was planned, all the program districts had received/just initiated the intervention, and were at different stages of implementation. For this evaluation, we defined four stages of implementation; 1) no intervention started, 2) 3 days of training completed, 3) all 8 or 5 mentoring package visits completed, and 4) at least three need-based mentoring visits completed, and the handover was planned. The progress of the program implementation between January 2016 and January 2020 is presented in Table Using a quasi-experimental study design, we conducted 3 repeated mixed-methods cross-sectional surveys without controls. The first assessment was conducted between October 2017 and February 2018, the second assessment between May and September 2018, and the third assessment between May and September 2019  in the labour rooms of secondary public health hospitals assigned for the The evaluation team identified 5 measurable indicators per pause point, i.e. 20 in total, to assess high quality care. The indicators pertaining to the actual management of the complications, although suggested, could not be used as the number of women with complications was small and the case sheets did not provide sufficient detail due to incomplete or improper documentation during the pilot. The in-facility outcomes included the caesarean section rate, stillbirth rate, and referral of mother and newborn.We estimated the sample size for repeated cross-sectional assessments for cluster  sampling . Fig. 22 We usedWe directly observed (non-participatory) service provided to pregnant women at the time of admission, during, and immediately following childbirth in the labour room 24 hours a day consecutively till the sample size was met, and recorded information using observation checklists. We interviewed pregnant women in the post-natal and post-op wards using a structured interview guide. We extracted information from case-sheets post-discharge onto a data extraction checklist. If the number of discharges was short of 50 during our visit, we included remaining from prior days going backward. We conducted a facility survey to assess general infrastructure and resources and extracted information on childbirth outcomes from birth and referral registers in labour rooms or obstetric wards. Data were collected by qualified nurses who were trained intensively for 5 days, under the supervision of team leads. It took about 5 to 15 days to complete data collection per hospital. We pilot-tested all the quantitative data collection tools before use and developed them into an Android-based application for recording data; and built-in logic checks and restrictions to minimize wrong entries. We used Lenovo tablets for collecting data in the field and uploaded them after finishing data collection from each facility. Data were directly saved on the server from where the central research team extracted data on Stata 14.0.We designed In-depth Interview (IDI) guides, covering key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. We developed guides for different cadres in English. We translated them into the local language (Hindi and Telugu) and back-translated to English, corrected errors and pilot tested them. We conducted interviews in the providers’ workplaces. The interviews with district and facility level stakeholders were conducted by two trained researchers under the guidance of the co-investigator, all of whom were social anthropologists in the health sector. Another two trained research staff conducted in-depth interviews of post-partum women. We audio recorded the interviews, if consent was provided, and took handwritten notes. The team transcribed and translated the recordings. Some of the respondents refused a formal interview so we only had informal discussions and noted important aspects of the program. We also took notes in the meetings with JHPIEGO or State government officials, that could be of significance for understanding the implementation process and strategies.We obtained ethics approval from the Indian Institute of Public Health-Hyderabad. We obtained written informed consent before the interviews. As the observations did not require us to interact with the women giving birth, and we did not want to interfere with the routine process of care, thus we did not obtain beneficiary consent, but we did obtain permission from hospital superintendents and health staff.We used STATA 14.0 for data management and analysis. For each clinical practice, we computed the proportion of adherence for a hospital (cluster) and then computed the average of these proportions weighted for monthly delivery load in the hospitals. We also computed average adherence to the five practices for each pause point, and overall average adherence for the 20 practices. We conducted linear regression for a testing average of proportions over time, and Poisons regressions for stillbirths and referrals. We scored the performance of hospitals and gave a score of one if the adherence to practice was 80% or more. A hospital could get a maximum score of 5 for a pause point, and 20 overall. A score of 4 or more in pause points and 14 or more overall was considered satisfactory. We conducted a qualitative analysis based on pre-defined themes and sub-themes, and also identified new emerging themes. We used Atlas-Ti to code the qualitative interviews and notes. We present integrated qualitative results from all three timepoints accounting for implementation progression and effects on the course.We present results from only Group 1 and 2 sample hospitals, See Additional Table The program in Group 1 progressed from bulk training during the first assessment to complete three need-based mentoring, while Group 2 completed one and half years of need-based mentoring and phased out by handover to Government mentors. Amongst the analysed 24 hospitals, the district hospitals noticed an increase in monthly deliveries, while the delivery load reduced in lower facilities, likely due to increased referrals. The availability of staff and caesarean services were consistent. The availability of 5 out of 6 assessed protocols improved, but the availability of protocols for antenatal corticosteroids and preterm labour were still limited-- found in only 12 and 9 of 24 hospitals, respectively. All amenities for maintaining hygiene improved over time in all hospitals. The availability of essential trays improved in Group 1 facilities to 10 or more, while it reduced in Group 2 to 8 or less, due to ongoing renovations in a few facilities.  in Group 2. Among other indicators, monitoring the progress of labour  improved to above 50% in both groups.Conducting abdominal and vaginal examinations were high and improved (> 95%) further. Maternal blood pressure and foetal heart sound assessment improved from 52 to 83% in Group 1 and 67 to 97% in Group 2. The change in hand hygiene before the vaginal examination was slow initially. After introducing the alcohol-based hand rubs, it improved tremendously (16 to 73% in Group 1 and 49 to 90% in Group 2). Overall, the average performance during admission consistently improved over time, from 63 to 87% (p = < 0.001) in Group 1, and from 77 to 96% (p = 0.493) in Group 1, and from 86 to 92% (p = 0.017) in Group 2. Among other indicators, induction of labour reduced from 30 to 22% in Group 1 and significantly from 39 to 9% in Group 2. We also noted improvement in pre-heating the warmer, hand washing before delivery, delayed cord cut, mothers’ privacy and counselling for progression of labour (results not shown).The use of clean cord cut was almost universal throughout the study. Pre-filling the injection oxytocin significantly improved from 67 to 97% and 78 to 94% in Groups 1 and 2. But administering injection oxytocin within 5 minutes remained less than 80% in Group 1 while it improved from 83 to 94% in Group 2 over time due to sustained long-term mentoring. The availability of clean and warm towels improved from 47 to 76% in Group 1. Keeping the bag and mask ready dropped from 85 to 70% in Group 1 while it stayed above 90% in Group 2. The average performance during childbirth improved from 74 to 84% (p = 0.001) in Group 1, and from 69 to 76% (p = 0.002) in Group 2.Drying the baby immediately was 85% or above through all three assessments. Within one hour breastfeeding improved significantly from 42 to 79% and 45 to 78%, and the assessment of the mother’s vitals significantly improved from 13 to 67% and 45 to 82% in Groups 1 and 2. The changes in measuring of baby’s weight and assessing the uterine tone were inconsistent; they ended at about 70% or above by the third assessment in both groups. The average performance of evidence-based practices immediately after childbirth improved from 57 to 76% (p = 0.070) in Group 1, and from 44 to 51% (p = 0.008) in Group 2.Measuring mothers’ temperature and counselling for family planning consistently improved in both groups, while counselling for newborn danger signs reduced significantly. The average performance at discharge improved from 24 to 40% (p < 0.001 for both). We additionally charted the average performance as per the program implementation status at any assessment, Fig. The overall average of the 20 scored practices, improved significantly in Group 1 to 72% and Group 2 to 79%  across the groups over one and a half years: in Group 1 from 15 to 2 per 1000 live births and in Group 2 from 25 to 11  Effectiveness of intervention; 2) State’s ownership and program implementation, and; 3) Sustainability. Lastly, we summarise the facilitators and challenges and suggestions for the sustainability and scalability of the program. Table Table Staff gained new knowledge about standards and protocols for delivery care and management of complications. The nurses reported that they felt more competent and confident in conducting low-risk vaginal deliveries by following the checklist and protocols. They were able to manage complications such as PPH and newborn resuscitation and provide stabilising care for complications with existing resources, before referral. They learned how to talk to the client and counsel them. During the second assessment, we observed a deeper understanding of the program and clinical management. Nurses were more elaborate about the comprehensive and structured way of providing care to the mother and the newborn, from admission through discharge and the necessity to perform all the required steps for prevention of complications to get desired outcomes. They reported that earlier it took them much longer and a lot of effort to practice all the recommended tasks. But with time, the tasks seemed easier, and the learnt skills were getting embedded in their routine, as per protocols, followed in a systematic manner.Staff noted considerable improvement in infrastructure, and availability of resources, including protocols, that motivated them and facilitated appropriate service delivery. The periodic assessments by the mentors helped them to identify the gaps and rectify them. Mentors helped in overcoming administrative procedures to avail the resources. They also helped in identifying and instituting local solutions for operational problems.Dakshata program. Hand hygiene was mentioned as one of the practices difficult to follow, especially when the load was high. With the introduction of hand rubs, there was some improvement in hand hygiene. The participants accepted that they had stopped unnecessary induction of labour, multiple PV examinations and inappropriate management such as fundal pressure. They also added counselling to the mothers and attendants before discharge as components of quality service delivery.Earlier the staff perceived quality in terms of infrastructure improvement, availability of relevant trays, sterilisation of instruments, use of gloves and hygiene practices. But after the program, they distinguished quality as improvement in the actual provision of appropriate clinical care and management of complications rather than infrastructure and supplies alone. As told by staff, the emphasis increased on measuring vitals of women, high-risk screening, measuring foetal heart sounds, effectively performing steps in childbirth, administering injection of oxytocin after childbirth, management of post-partum haemorrhage, and use of Magnisium sulphate MgSO4 for prevention and management of eclampsia. By the second program assessment, the staff also emphasised infection control. The nurses mentioned that sterilisation of equipment and use of hypochlorite solution was not done before the Effectiveness of the program was told to be in being able to provide care as per the need of the pregnant women and reducing adverse outcomes. Over time, the staff put more emphasis on physical assessment at the time of admission, filling of partograph, counseling the mother and birth attendant for early identification and tracking of the high-risk cases. The staff talked about the concept of golden minute, newborn care, and resuscitation. A nurse mentioned using balloon tamponade before referring a PPH case which she never did in the past which was also part of training for post-partum hemorrhage management. They also learned and practiced good behaviour with the client.Dakshata program protocols had led to improvement in quality of care and service, reformation in infrastructure and supply, efficient management of complications, reduced referrals, reduced stillbirth, maternal and neonatal deaths. There was an improvement in nurses’ role in decision-making for client care and labour room maintenance.The stakeholders believed that improved care as per We noted a positive change in the service providers’ attitudes toward providing quality services with a clearer understanding of the benefits associated. The staff believed that the mentoring and periodic assessments contributed to the service providers being aware and proactive towards their duties, with an increased sense of responsibility.We reviewed the facilitators, challenges; sustainability, and scalability of program components.The state health department completely owned the implementation of the program and led it with support from the external agency. The national-level stature of the program drove motivated implementation. Rajasthan was among the first few states to successfully implement the program and much appreciated too. State regularly monitored the program activities and performance, undertook timely decisions to fill in the gaps, provided administrative support and resources, and conducted repeated sensitisation and training for lagging practices. We also noted that after our periodic feedback from assessments, the state took appropriate measures to improve services. The state realized that the success of the program needed to be sustained and improvement should continue. Thus, the state recruited 17 district mentors, and deputed in-service block mentors (nurses/doctors), to continue the program after external support was phased out.Dakshata program. Some other fulfilled the essential resource requirements through public-private partnerships or donations. On the other hand, a few interviewees mentioned poor leadership at the district and hospital, and the staff struggled to perform well due to inadequate support.The district mentors appreciated the state leadership and attributed the success of the program implementation to the state government health officers. The commitment and accountability at the state-level trickled to the lower-level administrators, hospitals, and service providers too. Some hospital administrators were very proactively involved in bringing changes through the The state implemented a structured monitoring mechanism, later also strengthened by a newly designed android-based software application. The application helped mentors in conducting on-spot periodic assessments, scoring the performance, and giving feedback to the staff or in-charges. It also helped the district and state administrators to track real-time the hospitals’ performance and mentors’ visits. The district administration in Barmer also periodically reviewed the program in district maternal and child health review meetings.Dakshata training was perceived to be different from previous training, including that for skilled birth attendance. Mentoring and supervision visits and periodic assessments were perceived to be the most prominent feature and strong pillars of the Dakshata program. The staff mentioned that mentoring visits helped them internalize the standard practices without having to put a lot of effort into the learning process. The mock drills and the briefing-debriefing exercises helped in improving clinical skills. All the stakeholders admitted that mentoring in the staff’s workplace was more conducive and regular follow-up improved the sense of responsibility and accountability at all levels. Mentoring visits were of particular importance in setting all the infrastructure and resources right.The hospital administrators and service providers appreciated the short duration and effective mode of training. The The state provided recognition and award  to the best performers. A few providers and administrators felt that these measures encouraged and motivated staff and improved accountability. The review of the program in monthly maternal health meetings at the district and state levels also provided opportunities for cross-learning and finding solutions for common challenges.The stakeholders shared their understanding of factors for the successful sustainability of the program, as well as the threats.The labour room infrastructure and demand supply chain significantly improved and were among the key factors for improvement in staff motivation and service delivery. The mentors played the central role in facilitating these changes, and post phase-out the labour room in charge would need to pro-actively take over this role to maintain resources.Dakshata. The program encouraged and enabled them to improve the quality of services, and these improvements gave them job satisfaction. They aimed to continue the same practices and improve further with guidance.The evidence-based practices improved, and staff noted the difference in their practices pre- and post-The stakeholders mentioned that regular skill upgradation training or mentoring were required to sustain quality services and incorporate newer evidence-based improvements to clinical care.All the stakeholders stated dynamic relationship with JHPIEGO mentors; mentoring and periodic assessments made the program much desired. These JHPIEGO mentors were mostly MBBS doctors, while the new government mentors were a mix of trained para-medical staff and nurses and very few doctors. Administrators told that post-phase out, the government mentors have to do a lot to fill in the shoes of earlier mentors. The service providers were skeptical about the performance after shifting from JHPIEGO mentors to government mentors.The recognition and monetary awards were motivation to continue good work.Janani Suraksha Yojana ensured that the mother stayed at the hospital for at least 48 hours post-delivery, which provided an opportunity to deliver post-natal care. Programs such as Kayakalp helped in instituting sanitation and hygiene; Laqshya had standards for resources and services and provided certification of quality of services in labour rooms and pediatric units.The providers told that the incentives provided under Inadequate antenatal care, high prevalence of severe anaemia, late arrival at the health facility, poor awareness about delivery processes, unhygienic practices, and requests for early intervention or early discharge negatively affected the quality of services. Staff reported referring most of the late arriving complication cases.amidst high patient load worsened the ability to provide quality services and documentation; and postnatal care was negligible. The state recruitment for 800 nurses was on hold for 3 years due to a court litigation. Despite huge improvements, the gaps in infrastructure and supply chain were still pertinent.District-level officials were displeased with political interference that resulted in the irrational positioning of humans and other resources. Some service providers used political influence as a means to escape from their daily duties and responsibilities; they were difficult to supervise or discipline.Dakshata program. In their understanding, the program was only for nurses and support staff.Not all staff were similarly motivated. Most obstetricians and a few medical doctors did not want to participate in the There were certain reports of malpractices, such as doctors referring the patient to his/her private clinic, and staff asking for monetary remuneration for otherwise free services.District and hospital participants reported inconsistent support from the government for adequate human resources, reinforcement of training, and monitoring. Staff perceived that the government had a poor understanding of the practical problems at the bottom level. Staff felt that the Government would not be able to provide proper follow-up mentoring after the phase-out of JHPIEGO mentors.Dakshata implementation program. The suggestions are compiled below in brief.Provide pre-service training and regular refresher training in a systematic manner close to the workplace and update the latest protocols.Establish stringent monitoring and feedback system; strengthen periodic assessments through mentors and reviews by administrators in routine MCH meetings.Empower and support the new government mentors for efficient mentoring and periodic assessments. Monitor mentoring.Ensure minimum human resources as per the load, particularly nurses. Do not rotate staff; commit trained obstetric staff to only obstetric wards or labour rooms.Ensure availability of essential equipment and supplies; maintain consistency.Laqshya and Kayakalp; make use of these for the identification of local problems and solutions. Formation of quality circles/ teams supported by the administration may help.Adopt a quality improvement approach in line with programs such as Establish advisory support and redressal mechanism for technical as well as managerial concerns.Strengthen and improve antenatal care and empower the community regarding obstetric care. Target specifically poor performing and deprived communities.We also asked the stakeholders about the suggestions on how to improve the quality of obstetric care and for In this evaluation of a complex intervention instituted in a public health system of a state with comparatively lower resources and poorer maternal and newborn indicators among states in India , 17, we Overall, of the studied 20 key practices, four were at > 90%, six at 80–90%, seven at 50–80%, and three less than 50%. The evidence from other states in India also suggests that not all the practices were adopted with the same rigour (pause points 2 and 3 were adapted better), and sustainability of the improved practices was challenging , 15, 27.Dakshata the tendency for adherence to regress over time. In our assessment in Rajasthan, mentoring continued for over one-and-half to 2 years which improved or sustained certain practices led to higher caesarean section rates and a higher ratio of referrals in Group 1 representing the initial program stages. With increased resources and confidence gained after the sustained program, the referrals could decrease and stabilise as in Group 2 representing advanced program stages. The stillbirth rates decreased in both the groups; and were close to the state average of 6/1000 live births [Among the two large trials in India, in the BetterBirth trial of Uttar Pradesh, there was a sustained improvement during the 8 months of coaching but noted a drop after 4 months since the coaching ceased; there was no change in maternal or neonatal mortality [e births . Global e births , 13, 29.Dakshata’s success was client-oriented and service provider-centric mentoring complemented by periodic assessments by the technical partner which is reproducible by government mentors. The qualification and capabilities of the mentors, and the support and resources provided to them, especially in a hierarchy-driven environment such as in India, can be the determinants of the success or failure of the program [Dakshata program, unlike other SCC-based interventions, ensured better preparedness and resource availability before initiating capacity building. Frequent transfers and rotation of staff posed a necessity for repeat training and a continuous mentoring program [The technical partner adopted a scientific approach to pilot testing and scaling up, using an adaptive and iterative prototyping approach and sharing information and feedback with key stakeholders . The key program . The sup program , 31, 32, program , 33. The program , 18, 20. program . For susDakshata-related intervention underway when the evaluation commenced. Another observation after phase-out would have provided better evidence on sustainability.The methods considerations and limitations are discussed in detail elsewhere (submitted); however, a few key limitations are worth noting. Some important indicators could not be included as we were not confident of their documentation. There is the possibility of inter-observer bias although we provided repeated training and supervision. There could be the Hawthorne effect  but non-Dakshata program improved to high levels in admission and just before birth (pause point 1 and 2), improved to moderate levels in the first hour postpartum (pause point 3) but stayed poor at faciality discharge (pause point 4) even after one to two years of mentoring. Importantly, the stillbirth rates reduced significantly in both groups over 18 months, significantly better in Group 1 than Group 2. The structured mentoring followed by need-based mentoring with monitoring and administrative support from the state was a successful implementation model. The intensive support from a technical partner (Jhpiego) was essential for resource-constrained states to give them a strong head start. For long-term sustainability, policies are required for building mentoring culture and integrating quality improvement programs.The adherence to practices recommended under the Additional file 1:Supplementary Table 1. Human resource, protocols, hygiene supplies, essential trays in study hospitals, over time.Additional file 2:Supplementary Table 2. Management of complications during childbirth in the study hospitals.


The undersea Hunga Tonga-Hunga Ha’apai volcano erupted on 15 January 2022, causing a tsunami that affected Tonga as well as other countries around the Pacific rim. Tonga’s international borders were closed at the time due to the coronavirus disease pandemic, but clinical surge support was needed to respond to this disaster.Tonga’s Ministry of Health formed the Tonga Emergency Medical Assistance Team (TEMAT) in 2018 to provide clinical care and public health assistance during disasters, outbreaks and other health emergencies. TEMAT was activated for the first time in January 2022 to respond to medical and public health needs following the eruption and tsunami.On 16 January 2022, a five-person TEMAT advance team was deployed to conduct initial damage assessments and provide casualty care. Subsequently, TEMAT rotations were deployed to provide clinical care and public health support across the Ha’apai island group for over 2 months.TEMAT deployed to the islands most affected by the volcanic eruption and tsunami within 24 hours of the event, providing emergency clinical, psychosocial and public health services across four islands. TEMAT reported daily to the Ministry of Health and National Emergency Management Office, providing critical information for response decision-making. All TEMAT actions were documented, and an after-action review was conducted following the deployment.TEMAT’s deployment in response to the 2022 volcanic eruption and tsunami highlighted the importance of national emergency medical teams that are prepared to respond to a range of emergency events. On 15 January 2022, the undersea Hunga Tonga-Hunga Ha’apai (HTHH) volcano erupted violently, triggering an unprecedented plume of smoke and ash, and a tsunami that struck low-lying coastal areas of Tonga’s most populous island of Tongatapu, the nearby island of ’Eua, and multiple islands in the country’s Ha’apai island group, in addition to other countries around the Pacific rim.  in 2018.  and received a cache of equipment and supplies from WHO to ensure self-sufficiency in deployment  aboard His Majesty’s Armed Forces (HMAF) Guardian-class patrol ship, the VOEA Ngahau Koula. This deployment included a five-person TEMAT advance team consisting of two physicians and three nurses,  to Tongatapu and ‘Eua.The five-person TEMAT team was subsequently divided into two teams, with one supporting clinical service delivery on Nomuka and the other travelling on board the HMAF ship to other Ha’apai islands to continue assessments. The people of Ha’apai’s Mango island sighted the HMAF ship and communicated with it using a signal mirror. Upon TEMAT’s arrival onshore, the island’s population was sitting in the open on a hillside as the tsunami had destroyed every structure on the island. On 21 January, another team was deployed with four members: one medical officer and three emergency nurses. They assisted Tonga’s Armed Forces to evacuate the entire population of Mango . Additional TEMAT rotations followed during February and early March 2022 and were based on TEMAT’s initial needs assessment. TEMAT was demobilized in March 2022, following a 7-week deployment to Ha’apai.An after-action review (AAR) of the deployment was conducted in December 2022, which was delayed due to the coronavirus disease (COVID-19) response that was initiated soon after the volcanic eruption and tsunami.  provided by WHO’s Country Liaison Officer in Tonga, who is a psychologist by training, helped some team members to care for the many acute stress presentations that they encountered. As all team members were affected, with their homes covered in ash from the volcanic eruption, and some unable to contact family members, they also required support.While training had been conducted for TEMAT, with 40 members trained in 2018 and 2019, only a small number of those deployed for the HTHH response had been formally trained as TEMAT members before this activation – one of whom was the team leader for most of the deployment period. Significant turnover in the Ministry of Health, as well as competing demands related to COVID-19 preparedness and response, also reduced the pool of trained personnel available to deploy with TEMAT. Some TEMAT members were not aware of its SOPs, reporting procedures and operation of the cache. The need for regular TEMAT member training was another lesson learned from this response.TEMAT’s deployment to Ha’apai in response to the HTHH eruption and tsunami was an effective response that met the health needs of the affected population. It also presented an opportunity for learning and continuous improvement of TEMAT’s capability. The AAR of TEMAT’s HTHH response identified several lessons and areas for improvement. TEMAT’s SOPs are now under review, including inventory lists for clinical and non-clinical cache, deployment checklists and reporting forms and protocols. A TEMAT training and simulation exercise was carried out in April 2023 with support from WHO, using a tailored Pacific EMT member training package. (TEMAT’s deployment to the Ha’apai islands was a challenging test for one of the first national EMTs to be developed in the Pacific, and it provides evidence that national teams like TEMAT are capable of independent, self-sufficient response to emergencies within their borders. (


Researchers from the Department of Nutrition Science at East Carolina University worked with the Wayne Action Teams for Community Health (WATCH) Clinic, a safety-net clinic in rural Eastern North Carolina, and a local research farm to develop a PRx program for rural patients with type 2 diabetes and no health insurance. Preliminary patient surveys identified high levels of interest in a PRx program and a desire for recipes to accompany the produce. Formative evaluation results via telephone interviews with eligible patients identified transportation barriers to participation and the desire for complementary nutrition education and culinary resources. These results led to a delivery-based PRx program implemented from June through November 2021. Patients received weekly home delivery of an average of 4.7 pounds of fruits and vegetables and complementary nutrition and health education materials and culinary resources . The level of patient satisfaction with the program was high; the reported level of consumption of produce, including unfamiliar produce, was high; educational resources were associated with increased knowledge and motivation to make healthful lifestyle changes, and glycemic control significantly improved. Ensuring that patients have a voice in the design and implementation of PRx programs is crucial to success. Ongoing use of rigorous formative and process evaluations can ensure appropriateness, use, and a positive effect of PRx programs, and they are needed to establish best practices for implementation.Produce prescription (PRx) programs have emerged as a preventive treatment to subsidize the cost of fruits and vegetables for people with lower income and have shown promise in improving diet quality and diabetes-related health outcomes (eg, glycated hemoglobin A Produce prescription (PRx) programs have potential to improve glycemic control for people with diabetes.Delivery-based PRx programs can address transportation barriers for underresourced participants in large rural counties by alleviating the need for participants to find transportation to a farmers market or local retailer. Nutrition, health, and culinary educational resources are desirable and effective in PRx programs.Ongoing use of rigorous formative and process evaluations can ensure appropriateness, use, and effect of PRx programs, and are needed to establish best practices for PRx implementation.One in 10 people in the US has been diagnosed with diabetes; most (90%–95%) are diagnosed with type 2 diabetes  . AlthougOne emerging approach to improve healthy food access and diet quality is the provision of a produce prescription (PRx), which is defined as “a medical treatment or preventative service for patients . . . due to a diet-related health risk or condition, food insecurity . . . and are referred by a healthcare provider or health insurance plan” . PRx proAlthough PRx programs are promising, they can be improved. First, PRx programs commonly use tokens or vouchers, which can be associated with social welfare stigma, and participants typically must drive to an additional and potentially less familiar location  to redeem them –9. SeconThe research team worked with clinic staff and health care providers, including a physician, a nurse, and a case worker, who had knowledge and experience in working with this unique patient population to develop and validate the content of a patient survey. Trained student research assistants collected survey data on iPads from patients via before or after clinic visits in the waiting room of the clinic from February through May 2019. The study team used SPSS version 28.0 (IBM Corp) and descriptive statistics for analysis. Results from this patient survey (N = 185) indicated strong interest in receiving fresh produce (89.0%) and recipes (85.0%), attending taste testing and cooking workshops (73.6%), and obtaining home gardening support (56.3%). Few survey participants indicated receiving food assistance . On the basis of this information, the study team implemented an 8-week food recovery–based PRx pilot program in summer 2019; 30 patients with diabetes or hypertension were enrolled and given weekly produce and recipes . This ea1c (HbA1c) measurements taken, and received a notebook to store weekly educational handouts and recipes and a $20 reloadable Greenphire ClinCard. At the end of the program, participants received $35. Written informed consent was obtained at enrollment. The study was approved by the University and Medical Center Institutional Review Board at East Carolina University.The HEALED PRx program was designed as a pre–post study. It gave participation priority to patients with diabetes and no health insurance because of the high prevalence of diabetes in the clinic population and the region, regional disparities in diabetes, and the lack of access to diabetes resources and programming for uninsured patients in the region. Patients were recruited by telephone and through referrals from on-site clinical administrative staff and health care providers, including a nurse practitioner and a physician’s assistant in May and June 2021. The sample size was determined by a G*Power analysis ,13, whichttps://routific.com). Because the program was implemented during the height of the COVID-19 pandemic, deliveries were contactless. Health education handouts and recipes were provided each week  from a local agricultural research farm. Produce varied by season and was selected by the farm’s director for research purposes rather than profit. Produce was harvested, packaged, and delivered to patients’ homes every Friday for 24 weeks from June through November 2021 by student volunteers. Student volunteers completed 3 delivery routes, which took on average 3 to 4 hours in this large rural county and were created by using Routific . All interviews were recorded and transcribed verbatim. We used deductive content analysis as outlined by Elo and Kyngäs and grouped themes into 3 categories: preferences and promoters, resources, barriers and needs to participate in a PRx program . Four reThe research team collected weekly surveys via a QR (quick response) code on a reminder sheet or follow-up text messages via Twilio with a survey link. Weekly surveys examined use of the delivered produce, health education, and culinary resources. The team also conducted a final survey on program experience and satisfaction in November 2021. All survey tools used HIPAA- secure Research Electronic Data Capture (REDCap) .1c was measured by clinical staff at enrollment (May–June 2021) and at the end of the program (November 2021); these data were then collected by the study team via retrospective medical record review and stored in REDCap (t tests to identify significant changes (P < .05) in HbA1c.A preprogram survey and postprogram survey assessed participants’ fruit and vegetable consumption via an all-day intake screening tool from the National Cancer Institute’s Eating at America’s Table Study . HbA1c wn REDCap . The resThe formative evaluation revealed that all 26 participants were interested in participating in a PRx program. Most patients acknowledged that vegetables were important, yet they were uncertain about their specific nutritional benefits and foods to best manage their diabetes. Nutrition education on specific vegetables or recipes and cooking or taste testing were desired. Reported barriers included limited transportation and complicated schedules. Barriers to consuming produce included family food preferences (dislike of vegetables), a lack of time (busy or constrained schedules), and a lack of motivation to cook. These results were used to prioritize a delivery-based approach, the development of simple, quick recipes, and health education handouts with a focus on nutrition and other healthy lifestyle habits.Forty participants enrolled in the intervention; most (n = 27) were women, 22 were non-Hispanic White, 18 were non-Hispanic African American, and the mean (SD) age was 54.8 (6.6) years. Half (n = 20) were employed and most (n = 25) had an annual household income at or below $29,999. Twenty-one participants completed the weekly process evaluation surveys, and 8 participants completed 5 or more of these surveys. Weekly survey responses showed that respondents used three-quarters or all of the produce each week and the primary barriers to use were unfamiliarity, dislike, or uncertainty about how to cook. Participants reported most produce items as familiar. Feedback on the educational handouts indicated half of respondents reviewed the materials, and of those, most agreed that the information was new and motivated them to make changes in nutrition and physical activity. The overall program experience and satisfaction survey revealed high levels of satisfaction; 29 of 32 participants indicated that that they were very satisfied or satisfied . The sur1c (n = 35) from preprogram  to postprogram  .Participants’ median (IQR) preprogram self-reported total fruit and vegetable consumption increased from 1.2 (0.4–2.0) to 1.6 (0.2–3.0) servings per day preprogram to postprogram. Glycemic control significantly improved: we found a mean decrease of 0.47% HbAThe development and implementation of the HEALED PRx program was guided by a needs assessment, pilot programming, and a formative evaluation that identified barriers to participation as well as resource preferences and needs. By addressing barriers, preferences, and needs, the delivery-based program was well received and helped to increase access to healthy food and nutrition education and improve glycemic control in this rural, uninsured, medically underserved population.1c values among participants declined an average 0.47% from preprogram to postprogram. This clinical improvement was less than the change (−0.8%) reported in a previous systematic review and meta-analysis by Bhat et al; however, this decline is clinically and statistically significant , nutrition, and health risk factors  for delivery may be warranted. Coordination and distribution of produce while participants are on-site for other health or nutrition services may improve access and is used in other PRx programs .It is important to highlight that our study included a specific, southern, rural, medically underserved patient population and was tailored for their needs, and our findings may not be generalizable to the general US population with diabetes. Future PRx programming should identify and address barriers  to ensure access. Evaluation of the use of the PRx and resources needs to be strengthened, and although participant fatigue set in during the HEALED PRx program , process evaluation efforts are critical to evaluate and better understand implementation barriers. A monthly survey may have been better than a weekly survey. Comprehensive evaluation of PRx programs that use rigorous validated tools is critical to identifying optimal approaches to establish best practices for PRx programming to guide and ensure effectiveness.


Digital therapeutic platforms facilitate health care through patient-centered strategies based on multidisciplinary teams and shared decision-making. Such platforms can be used for developing a dynamic model of diabetes care delivery, which can help in improving glycemic control by promoting long-term behavior changes in people with diabetes.This study aims to evaluate the real-world effectiveness of the Fitterfly Diabetes CGM digital therapeutics program for improving glycemic control in people with type 2 diabetes mellitus (T2DM) after the completion of 90 days in the program.1c (HbA1c) levels after program completion. We also evaluated the changes in participant weight and BMI after the program, changes in the CGM metrics in the initial 2 weeks of the program, and the effects of participant engagement in the program on improving their clinical outcomes.We analyzed deidentified data of 109 participants in the Fitterfly Diabetes CGM program. This program was delivered through the Fitterfly mobile app coupled with continuous glucose monitoring (CGM) technology. This program consists of 3 phases: the first phase is observation, wherein the patient’s CGM readings are observed for 7 days (week 1); the second phase is the intervention; and the third phase aims at sustaining the lifestyle modification introduced during the second phase. The primary outcome of our study was the change in the participants’ hemoglobin A1c levels, weight, and BMI of the participants were significantly reduced by 1.2% (SD 1.6%), 2.05 (SD 2.84) kg, and 0.74 (SD 1.02) kg/m2 from baseline values of 8.4% (SD 1.7%), 74.45 (SD 14.96) kg, and 27.44 (SD 4.69) kg/m2 in week 1, respectively (P<.001). The average blood glucose levels and time above range values showed a significant mean reduction by 16.44 (SD 32.05) mg/dL and 8.7% (SD 17.1%) in week 2 from week 1 baseline values of 152.90 (SD 51.63) mg/dL and 36.7% (SD 28.4%), respectively (P<.001 for both). Time in range values significantly improved by 7.1% (SD 16.7%) from a baseline value of 57.5% (SD 25%) in week 1 (P<.001). Of all the participants, 46.9% (50/109) showed HbA1c reduction ≥1% and 38.5% (42/109) showed weight loss ≥4%. The average number of times the mobile app was opened by each participant during the program was 108.80 (SD 127.91) times.At the end of the 90 days of the program, the mean HbAOur study shows that participants in the Fitterfly Diabetes CGM program showed a significant improvement in their glycemic control and reduction in weight and BMI. They also showed a high level of engagement with the program. Weight reduction was significantly associated with higher participant engagement with the program. Thus, this digital therapeutic program can be considered as an effective tool for improving glycemic control in people with T2DM. Diabetes mellitus affects more than 536 million adults globally, and the incidence is projected to rise to 783 million by 2045 . Type 2 Diabetes care delivery is currently facing challenges such as skewed patient-to-physician ratios ,11, inadFitterfly Diabetes CGM is a 90-day digital therapeutics program that provides personalized lifestyle management support for people with T2DM. This program consists of the initial application of the continuous glucose monitoring (CGM) sensor on the patient and the concurrent detailed profiling of the patient’s glucose readings and fitness and stress assessments by a multidisciplinary care team of experts comprising nutritionists, physiotherapists, and psychologists. In this program, CGM readings are correlated with a vast set of input data  from the mobile app. Artificial intelligence and machine learning predictive models are used to predict the personalized glycemic response of the individuals, by assessing the impact of food, activity, medication, sleep, symptoms, and stress on blood glucose excursions.P<.001) and the time in range (TIR) and the glucose management indicator significantly improved by 4.5% and 0.4%, respectively (P<.001), while the time above range (TAR) reduced significantly by 11% (P<.001). The changes in the CGM metrics in that study indicated that the Fitterfly Diabetes CGM program significantly improved glycemic control in a short duration [In a previous study performed on 64 participants with T2DM enrolled in the Fitterfly Diabetes CGM program , CGM data were analyzed only in the initial 14 days of the program. Participants followed their usual lifestyle in week 1 but a modified lifestyle plan in week 2. In week 2, the mean blood glucose level was significantly reduced by 17.5 mg/dL (duration . However1c (HbA1c) levels after the completion of the program as compared to those in the baseline. We also focused on evaluating the short-term effects of a modified lifestyle plan by using the CGM metrics of the participants, changes in their weight and BMI after program completion, and the effects of participant engagement in the program on their clinical outcomes.The Fitterfly Diabetes CGM program aims at providing personalized lifestyle management with the help of the CGM sensor . The primary outcome of our study was to analyze the changes in the hemoglobin A1c levels >6.5%, (2) age ≥18 years at the time of enrollment, (3) having a smartphone and willing to utilize the mobile app, and (4) having a minimum level of literacy to read and understand the English language. The exclusion criteria for the participants were (1) presence of any physical, cognitive, and psychiatric impairments, which can affect their ability to follow dietary regimens or physical exercise, (2) presence of severe complications , (3) history of unstable angina pectoris or stroke within the past 6 months, and (4) history of surgical procedures, which can affect the ability to follow a dietary regimen. All participants signed informed consent for the use of data for research purposes. Refusal to sign the informed consent form did not affect their participation in the program and the quality of care.This study is based on the analysis of the deidentified data of participants enrolled in the Fitterfly Diabetes CGM program. Participants were recruited through direct referrals by the treating physician or via a social media campaign offering an app-based diabetes management program. Participants were enrolled in the program only after the screening process, which was based on the following inclusion and exclusion criteria. The inclusion criteria for the participants were (1) diagnosis of T2DM with HbAThis study involves secondary analysis of deidentified data, and no investigational product or procedures were used in this study. Thus, no ethics clearance was obtained for this study. All participants were provided care as per normal clinical standards, and there was no change in their treatment from the usual customary care. All participants signed the informed consent permitting the collection of primary data for the secondary analysis of deidentified data for research purposes and publications. Our study guarantees the protection of privacy and confidentiality of participants by ensuring that the study data are deidentified. Participants were not provided any compensation for study participation.The key differentiating features of the Fitterfly Diabetes CGM program are as follows:1c levels; meals; physical activity; anthropometric data such as height, waist circumference, and weight) along with ensuring regular access to diabetes education content  based on evidence-based guidelines. Regular reports  are also created and shared via the mobile app with the participants during the 90 days of the program.Mobile app software: The Fitterfly mobile app software helps in logging of anthropometric and other data , micronutrients , omega-3 fats, and total fiber in various meal items . The food database was created from authentic sources such as the Indian Food Composition tables 2017 and the National Institute of Nutrition, India.Virtual access to nutritionists: Meal logs created by the participants were reviewed by nutritionists, and a personalized diet plan was created and shared regularly with each participant based on their personalized glycemic response. The team made regular calls to assess the goals achieved by the participants and to keep them on track.Virtual access to physiotherapists: Personalized exercise plans were created for participants based on a videocall-based physical fitness assessment in the initial phase of the program by trained physiotherapists. The personalized exercise prescription is based on physical fitness, pain complaints of participants, and physical activity readiness level. Regular calls by physiotherapists were provided to assess the goals achieved by participants and to keep them on track. The participants underwent videocall-based primary fitness assessments using the 6-minute walk test, 1-minute push-up test, wall sit test, 1-minute sit-up test, and V-sit and reach test for the analysis of cardiorespiratory fitness, upper body strength, lower body strength, core strength, and flexibility, respectively, under the supervision of trained physiotherapists at the beginning and end of the program.Virtual access to psychologists: The main objectives of psychological care were to enhance motivation, positivity, and optimism; improve sleep quality; manage stress; and learn self-control techniques for better adherence to the program and for providing care for diabetes-related distress in participants. The participants are provided with video and activity cards via the mobile app. Regular calls were performed by the psychologists to assess the goals achieved by the participants and to keep them on track. Psychological well-being assessment was conducted using questionnaire-based scales such as Diabetes Distress Scale, Motivation and Attitude toward Changing Health, and Pittsburgh Sleep Quality Index, which were administered using the mobile app at the beginning and end of the program.Remote health coaching: Remote health coaches help the participants with their queries or problems faced by participants through messages and calls.Dashboard: Web-based dashboards helped in integrating all the information and ensured easy access of the data to remote health coaches and experts  during the program.The Fitterfly Diabetes CGM program consists of 3 phases. The first phase is the observation phase, wherein the CGM readings of the participants are monitored for 7 days (week 1) based on their normal lifestyles . The second phase is the intervention phase, during which nutritionists and physiotherapists provide every participant with a diet and exercise plan, respectively, based on their personalized glycemic response data collected from the CGM monitoring sheet. The participants were instructed to follow the modified diet and exercise plan and were monitored again for the next 7 days (week 2) through the CGM device. Feedback regarding stress management and sleep quality was also provided. The third phase of the program aims at sustaining the lifestyle modification introduced during the second phase of the program while including regular feedback and support from health coaches to build lifelong lifestyle changes for better management of diabetes.1c levels. The secondary outcomes of this study were reductions in weight and BMI, psychological well-being, and physical fitness. Before the start of the program, all the participants downloaded the Fitterfly mobile app and trained personnel applied the CGM sensor on the participant. CGM readings were collected on day 7 and day 14 of the program by trained personnel during their personal visits to participants. All the participants completed a profiling questionnaire, which helped in personalizing the participant’s experience. The profiling questionnaires were administered using the mobile app.The primary outcome of this study was to evaluate the change in the HbAP≤.05 considered as statistically significant. The correlation between various factors was studied using Pearson test for parametric data and Spearman rank test for nonparametric data.Statistical analysis was performed using the R software . Continuous data were expressed as mean (SD) and median (IQR). Categorical data were represented as number (%). Shapiro-Wilk test was used for normality assessment of data. Wilcoxon signed-rank test was performed for the evaluation of outcomes before and after the program, with 1c levels before and after the program were provided by 112 participants. Complete weight readings were provided by 109 participants. 2, respectively. Apart from being diagnosed with diabetes, 53.2% (58/109) of the participants had other health comorbidities. The analysis of participants’ usage of antidiabetic agents while on the program showed that 13.8% (15/109) of the participants were using insulin, 40.4% (44/109) were using oral hypoglycemic agents, 20.2% (22/109) were using both insulin with oral hypoglycemic agents, and 25.7% (28/109) were not using any form of antidiabetic medications. Of all the participants, 47.7% (52/109), 32.1% (35/109), 32.1% (35/109), 13.8% (15/109), 8.3% (9/109), and 1.8% (2/109) were using biguanides, sulfonylureas, dipeptidyl peptidase-4 inhibitors, sodium-glucose co-transporter-2 inhibitors, α-glucosidase inhibitors, and thiazolidinediones, respectively.We obtained complete CGM readings from 355 participants at the beginning and after 14 days of the program start date. Complete readings of HbAP<.001). TAR significantly reduced by 8.7% (SD 17.1%) from week 1—from a baseline value of 36.7% (SD 28.4%) to 28.1% (SD 28.1%) (P<.001). No significant increase in time below range (TBR) was observed between week 1 and week 2 (P=.86)  mg/dL from 152.9 (SD 51.63) mg/dL in week 1 to 136.50 (44.26) mg/dL in week 2. TIR improved by 7.1% (SD 16.7%) from week 1—from a baseline value of 57.5% (SD 25%) to 64.6% (SD 26%) ( (P=.86) .1c levels by 1.2% (SD 1.6%) (P<.001) was observed in all the participants—from a baseline mean of 8.4% (SD 1.7%) to 7.2% (SD 1.4%) after the program  reaching the recommended target of HbA1c<7%. Approximately 46.9% (50/109) of the participants showed HbA1c reduction ≥1%, and 86.2% (94/109) of the participants showed reduction in HbA1c levels. Participants with baseline HbA1c<7%, 7%-9%, and >9% showed an average HbA1c reduction by 0.4% (SD 0.7%) (P=.008), 0.9% (SD 1.5%) (P<.001), and 2.6% (SD 1.7%) (P<.001), respectively.A significant mean reduction in HbA program A. Of allP<.001, 2 among all the participants—from a mean baseline BMI of 27.44 (SD 4.69) kg/m2 to 26.70 (SD 4.41) kg/m2 (P<.001).The participants showed a significant mean weight reduction by 2.05 (SD 2.84) kg from a preprogram mean weight of 74.45 (SD 14.96) kg to 72.40 (SD 13.92) kg after the program P<.001, B. Weight1c reduction were further analyzed in all the participants based on their uptake of antidiabetic medications for glycemic control, such as insulin, oral hypoglycemic agents, oral hypoglycemic agents with insulin, and no medications. Participants who were not using any antidiabetic medications were dependent solely on the lifestyle modifications for glycemic control. Similar levels of improvement in TIR were observed in the groups receiving oral hypoglycemic agents, insulin, oral hypoglycemic agents with insulin, and no medications, with an average TIR improvement of 6.6% (SD 17.9%), 5.7% (SD 24.6%), 8.3% (SD 14%), and 7.9% (SD 12%), respectively (P=.94). Similarly, no significant difference in the level of HbA1c reduction was observed between these 4 groups, with a mean HbA1c reduction of 1.1% (SD 1.4%), 1.5% (SD 1.3%), 1.4% (SD 2.1%), and 1.1% (SD 1.7%), respectively (P=.61).TIR improvement and HbAP=.04), call duration , meal entry count , activity entry count , and number of body composition entries .Participant engagement with the mobile app was studied during the entire 90 days of the program. The average number of times the mobile app was opened by each participant was 108.80 (SD 127.91) times (1.2 logins per day per participant). The average call duration per participant was 1.35 (SD 1.10) hours in 90 days. The average number of meal entries, physical activity entries, and number of body composition entries by each participant during the entire 90 days was 242.18 (SD 244.75), 27.65 (SD 42.01), and 29.35 (SD 29.71), respectively. Reduction in participant weight after the program showed significant correlation with the number of times the mobile app was opened . After the completion of the program, the participants showed an average reduction in HbA1c level by 1.2%, weight by 2.05 kg, and BMI by 0.74 kg/m2. Approximately 85.3% (93/109) of the participants showed a reduction in the HbA1c levels after program completion. No significant variation was observed in the level of HbA1c reduction among participants who were using only lifestyle modification and those who used antidiabetic medications for glycemic control. A significant correlation was observed between participant engagement in the program and weight reduction after the program . CGM-based monitoring helps in assessing intraday and interday glycemic excursions, which can involve episodes of hypoglycemia and postprandial hyperglycemia [Our study discusses the real-world effectiveness of the Fitterfly Diabetes CGM digital therapeutics program for improving glycemic control in people with T2DM after 90 days of program participation. The analysis of deidentified data of 109 participants with T2DM showed the short-term changes in glycemic control after the introduction of a modified lifestyle plan, with improvement in TIR by 7.1% along with a reduction in TAR by 8.7% and no significant increase in TBR  over a period of 7 days, indicating improved glycemic control in the participants. No significant change in TBR showed that the modified lifestyle plan did not lead to an increase in hypoglycemia episodes. Earlier studies have shown that reduction in TIR by 10% leads to an increase in the hazard rate for retinopathy progression and microalbuminuria by 64% and 40%, respectively, with every 5% improvement in TIR leading to clear clinical benefit in people with T2DM ,29. Thus1c levels by 1.2%. Clinical studies have shown that a 1% reduction in mean HbA1c levels is associated with a reduction in the risk of myocardial infarction by 14%, death related to diabetes by 21%, and microvascular complications by 37% [1c levels led to 2% reduction in all-cause total health care cost and 13% reduction in diabetes-related total health care cost, leading to per individual annual cost saving of US $429 and US $736, respectively [1c levels after the program, with 46.9% (50/109) showing an HbA1c reduction ≥1%. The program was effective in improving glycemic control in participants with different baseline HbA1c levels, with an average HbA1c reduction by 0.4%, 0.9%, and 2.6% among participants with baseline HbA1c levels <7%, 7%-9%, and >9%, respectively. The participants in our study also showed a significant average reduction in weight by 2.05 kg after 90 days of the program. These results were similar to those reported in studies on other programs using a CGM-based virtual diabetes care for people with T2DM, showing a mean reduction in HbA1c levels by 1.6% (SD 1%) after 4 months [At the end of the 90 days in the program, the participants showed an average reduction in HbAs by 37% . Anotherectively . Of all 4 months .2 [2 was observed in all the participants (P<.001). The reduction in HbA1c levels and improvement in TIR were not significantly different among groups using insulin, oral hypoglycemic agents, insulin with oral hypoglycemic agents, and no medications . Our findings showed that lifestyle modification can play an important role in improving glycemic control in participants not using any antidiabetic medication and that the Fitterfly Diabetes CGM program played a significant role in improving glycemic control in participants with different medication histories.Before the start of the program, 87.2% (95/109) of the participants were in the category of overweight or obesity with an initial BMI ≥23 kg/m2 . A signiP=.04), call duration with coaches (P=.02), meal entry count (P=.01), activity entry count (P=.01), and the number of times the body composition entry (P=.01) was made by the participant. Thus, our study shows that higher engagement with the program led to better outcomes in participants.Engagement with the program was analyzed to understand the importance of level of participant engagement in the clinical outcomes of the program. High level of participant engagement was observed in the program, with each participant having an average count of 1.2 logins in the mobile app per day and a mean meal entry count per participant being 242 times during the 90 days. Weight reduction showed significant association with higher level of participant engagement in terms of the number of times the mobile app was opened (1c levels as the outcome for lifestyle modification can help in achieving goals in a measured way. The CGM-based analysis in the initial phase of the program helped in providing a personalized approach, while the assessment of HbA1c levels at the beginning and end helped in understanding the program results in a resource-efficient and clinically effective manner.The Fitterfly Diabetes CGM program can be highly beneficial to people with T2DM for improving glycemic control. Virtual access to experts from multidisciplinary fields can help in improving diabetes care substantially, especially in low-income countries like India. The application of machine learning and artificial intelligence technology for the prediction of personalized glycemic response with the help of CGM is an emerging technology in India. Further, the program being focused on HbA1c levels. This study was limited by the nonrandomized design, lack of control group, self-selection bias, and referral bias. This study takes into consideration the change in the glycemic outcome of the participants at the completion of 90 days of the program. Further studies using larger sample size, control groups, and longer durations will be required to understand the effectiveness of this digital diabetes care program. Control groups including healthy people without T2DM and people with T2DM without access to the digital therapeutics program can further help in understanding the efficacy of this program. The impact of such digital therapeutic programs on the psychological well-being and the physical fitness of participants will need to be further evaluated.The strength of this study is the analysis of data in real-world settings by using a commercial program. This preliminary analysis of the results was performed on participants with varied ages, treatment regimens, and baseline HbA1c levels, weight, and BMI. Moreover, the program helped in significantly improving glycemic control in people with different baseline HbA1c values and in people on different treatment regimens of antidiabetic medications or not using any antidiabetic medications. During the 90 days of the program, a high level of participant engagement with the platform was observed. Our study also demonstrates a significant correlation between weight reduction and higher program participation metrics. Thus, the Fitterfly Diabetes CGM program can be an effective tool for improving glycemic control in people with T2DM by providing multidisciplinary care based on personalized glycemic responses.Our study shows that participants with T2DM completing 90 days of the Fitterfly Diabetes CGM program showed a clinically significant improvement in glycemic control, as indicated by the significant reduction in HbA


The structure and morphology of LAC, LAC-rGO and LAC-rGO-MnO2 are characterized by the employment of X-ray photoelectron spectroscopy (XPS), X-ray diffraction (XRD), BET analysis, Raman spectroscopy and scanning electron microscopy (SEM). The electrochemical performance of electrodes is performed in two and three-electrode systems. In the asymmetrical two-electrode system, the LAC-rGO-MnO2//Co3O4-rGO device shows high specific capacitance (SC), high-rate capability and excellent cycle reversibly in a wide potential window of 0–1.8 V. The maximum specific capacitance (SC) of the asymmetric device is 586 F g−1 at a scan rate of 2 mV s−1. More importantly, the LAC-rGO-MnO2//Co3O4-rGO device exhibits a specific energy of 31.4 W h kg−1 at a specific power of 400 W kg−1. Overall, the synergistic effect between the ternary structures of microporous LAC, rGO sheets and MnO2 nanoparticles leads to the introduction of high-performance hierarchical supercapacitor electrodes.Biochar derived from waste biomass has proven to be an encouraging novel electrode material in supercapacitors. In this work, luffa sponge-derived activated carbon with a special structure is produced through carbonization and KOH activation. The reduced graphene oxide (rGO) and manganese dioxide (MnO The LAC works as a good 3D substrate for ion transport and capacitor devices based on a uniquely dense and intrinsic multi-channeled arrangement structure [2 nanoparticles based on unique physiochemical properties. The hierarchical 3D structure of LAC, in-situ chemical reduction and metal oxide decoration were obtained by a facile procedure involving the simultaneous hydrothermal carbonization and chemical activation of bio-based precursor and GO reduction. The main objectives of this work were to (i) simultaneously transform luffa sponge into AC along with the in-situ hydrothermal reduction of GO sheets followed by further MnO2 decoration, (ii) to discuss the electrochemical properties of the different composite electrodes, and (iii) to assemble a high-performance asymmetric supercapacitor made of ternary composite electrodes.A supercapacitor is a great supplement for energy conversion and high-rate power supply devices that deliver significant energy with high power density ,2. Recen3, SnO2) . The com3, SnO2) ,16. The 3, SnO2) , include3, SnO2) , lotus l3, SnO2) , puerari3, SnO2) , rice hu3, SnO2) , bamboo 3, SnO2) , coconut3, SnO2) , dead le3, SnO2) , hemp [23, SnO2) , cattail3, SnO2) , sugarca3, SnO2) , sunflow3, SnO2) , corn hu3, SnO2)  and luff3, SnO2) ,32,33,343, SnO2) ,35. For 3, SnO2) . To date3, SnO2) ,32, thre3, SnO2) ,34, carb3, SnO2)  and acticle life ,38. The cle life ,31,32. Scle life ,38,39. Itructure . The LACPotassium hydroxide, sodium sulfate, sulfuric acid (98%), hydrochloric acid (30%) and hydrogen peroxide (30%) were used in analytical grade from Merck  without any further purifications. Graphite powder  and Luffa sponge was purchased from a local market and washed to remove the impurities. The whole conditions for preparing the nanocomposites and carbonization processes were controlled under the argon atmosphere, which is shown in For preparing LAC, 2 g of dried and ball-milled luffa sponge was added to potassium hydroxide solution (6 M) and refluxed for 6 h at 100 °C. This mixture was centrifuged and then pyrolyzed at 800 °C for 2 h. To remove the additional potassium hydroxide, the as-produced biochar was washed with 1 M HCl and followed by rinsing with pour water and finally dried at 120 °C overnight. The LC was prepared with the same condition without any KOH activation.−1) and 2 g dried Luffa powder were placed in an 80 mL Teflon-lined autoclave and maintained for several hours to expand the luffa and heated at 180 °C for 12 h. The prepared material after hydrothermal products were refluxed in the presence of 6 M KOH for about 6 h at 100 °C. Then, this mixture was centrifuged and pyrolyzed at 800 °C.The graphene oxide powder was produced by modified Hummer’s oxidation route. Typically, a 10 mL GO solution (5.0 mg mL−1) while stirring. Then, the pH of the precursor solution was adjusted to 4 by adding 0.5 M HCl. Subsequently, the mixture was stirred for 2 h at 60 °C to obtain LAC-rGO-MnO2 nanocomposite.The LAC-rGO (50 mg) was added to KMnO4 aqueous solution (1.5 g L002) of graphitic layers was calculated based on Bragg’s law from XRD data. Thermogravimetric analysis (TGA) was carried out on a thermoanalyzer . The specific surface area and pore size distribution were obtained using Bruauere-Emmette-Teller (BET) and Barrette-Joynere-Halenda (BJH) methods, respectively, based on the adsorption and desorption behavior of the N2.Different characterization methods have been used to clarify the physical properties, chemical structure and morphology of the final nanocomposites. The FESEM , Raman spectroscopy , XRD , and XPS  (system with monochromic Al KR (1486.6 eV) irradiation), were performed to determine the properties of the nanocomposite. The d-spacing  with carbon black, graphite and polytetrafluoroethylene at a 65:10:20:5 mass ratio, then dispersed in ethanol. In order to distribute suspension over a current collector, a piece of rustproof steel, about 5 mg of the electro-active material and a 1 cm2 current collector were utilized for this purpose. Finally, the electrodes were dried in a vacuum oven at 80 °C for 1 h. Ag/AgCl as reference and platinum as counter electrodes were applied in electrochemical measurement. An asymmetric cell was assembled by using the LAC-rGO-MnO2 as a positive electrode which is produced in this work, and the Co3O4/rGO as a negative electrode in our previous works [−1) was calculated by this equation:Electrochemical measurements for supercapacitive studies  were carried out by using a potentiostat/galvanostat workstation  in 0.5 M Naus works . In thisI is the current density of the CV, ν is the scan rate, m is the mass of the electroactive material, and ΔV (Vc-Va) is the potential window.For the two-electrode system, the SC for a single electrode was calculated by this equation:2 nanoparticles. To better explain the material, the final product (LAC-rGO-MnO2) is like a tree with LAC and rGO as branches and MnO2 as a leaf to produce a fast and reversible ion transfer network. 2 on activated carbon structure. A simultaneous/consecutive process has been developed to prepare an activated carbon-graphene-metal oxide nanocomposite structure as a high-performance supercapacitor electrode. In this process, the bio-based luffa sponge has been properly carbonized and activated along with in-situ thermo-chemical reduction of GO, followed by the deposition of MnO2 samples. 2 composite at 12.7°, 18°, 28°, 37.5°, 42.1°, 49.9°, 56° and 61° can be indexed to α-MnO2 (JCPDS 44-0141) corresponded to (110), (200), (310), (211), (301), (411), (600) and (521) crystal planes indicating successful loading of MnO2 on carbon substrate which is in agreement with and further support the results of FESEM images [2 is related to the structure of exfoliated rGO layers. Furthermore, the peak disappeared (100) after the decoration of MnO2, resulting based on the erosion of carbons in the GO structure after a redox reaction [M images . The bro−1) and G (~1585 cm−1) bands caused by the disordered structure and E2g mode of the sp2 lattice, respectively. The ratio of two peaks (ID/IG) indicates the degree of graphitization of the material. This ratio (ID/IG) is much higher for LAC-rGO-MnO2 and LAC-rGO than for LC, which indicates that the carbon structure is graphitized during the activation and compositing process , potassium carbonate (K2CO3), H2, H2O, CO and CO2, which help to boost the porosity [The KOH activation of carbon structures increases the specific surface area, uniform pore size and controls the functional groups on the surface based on condition and detail. The side products of KOH activation and in-situ reduction were potassium oxide . The SC of the different electrodes was calculated at 156, 248, 388, and 586 F g−1 for LC, LAC, LAC-rGO and LAC-rGO-MnO2 electrodes, respectively, at a sweep rate of 2 mVs−1. The LAC exhibits higher SC compared to LC in all scan rates. The LAC-rGO-MnO2 composite exhibits the highest SC values and remains at 70% at a high rate compared to all other samples. The interfacial of MnO2 and LAC-rGO is a key point to the fast transfer of electrons into the electrode structure. Thus, the excellent specific capacitance of the LAC-rGO-MnO2 electrode corresponded to the high microporous activated surface area (BET data), increased electrical conductivity and both electric double layer and pseudocapacitance behavior.The electrochemical performance was conducted in a three and two-electrode cell in an aqueous solution for electrodes and asymmetric device structure. −1. The nearly symmetric and linear shapes of charge–discharge curves show a fast and reversible reaction on the surface of electrodes, as was shown previously in CV curves as an excellent capacitive behavior. 2 electrodes at various current densities (1–16 A g−1). The galvanostatic charge-discharge curves of LAC-rGO-MnO2 electrodes in various current densities are triangular-shaped, linear, symmetric, and sharp. Furthermore, the reversible behavior, high columbic efficiency, and the ideal capacitor performance of the LAC-rGO-MnO2 electrode can be concluded from the equal durations of charging and discharging. This is due to the uniform distribution of MnO2 nanoparticles on the LAC-rGO structure, resulting in improved electrical conductivity and fast redox reactions. In addition, the LAC-rGO-MnO2 electrode shows a lower IR drop in the same current density compared with the LC, LAC and LAC-rGO electrodes. These results reveal the existence of higher accessible electroactive sites in the LAC-rGO-MnO2 electrode compared to other electrodes.2 electrodes show a vertical line in the low-frequency region and almost the same shape with a loop at a high-frequency region based on ideally combined capacitive behavior. As shown in the high-frequency region, all the EIS curves intercept the real axis , which indicates the amount of redox reaction that takes place at the electrode surface. As expected, the CF increases dramatically with the addition of MnO2 to the carbon structure (LAC-rGO). In general, the parameters fitted with the electrical circuit show the excellent supercapacitor performance of the composite electrode) LAC-rGO-MnO2  with a potential window of 1.8 V. The fabricated asymmetric supercapacitor shows an ideal capacitive behavior with a nearly rectangular shape in CV curves with a potential window of 1.8 V. The SC variation trends as a function of scan rate are shown in −1, the maximum amounts of SC for Co3O4/rGO//LAC-rGO-MnO2 HSC were obtained 286 F g−1. The decrease of a maximum of 52.8% in the SC, even at scan rates as high as 200 mV s−1, is an indication of the outstanding capacitive retaining tendency of the HSC device. Based on the electrochemical measurement, the LAC-rGO-MnOresearch —has been3O4/rGO//LAC-rGO-MnO2 HSC at different current densities. The GCD curves of Co3O4/rGO//LAC-rGO-MnO2 HSC were triangular and symmetric. In addition, these curves revealed a fast I–V response, low ESR, and ideal capacitive behavior, which was also confirmed by CV curves. The specific power and specific energy of the Co3O4/rGO//LAC-rGO-MnO2 HSC as Ragone plots are shown in 3O4/rGO//LAC-rGO-MnO2 HSC device exhibits excellent specific energy (31.4 W h kg−1 at 400 W kg−1). Compared with the other reported HSC devices, including functional biochar//Fe composite biochar (30.8 W h kg−1 at 1000 W kg−1) [2 on nickel foam (23.2 W h kg−1 at 1000 W kg−1) [2//graphene (25.2 W h kg−1 at 2100 W kg−1) [2 nanotubes//Active carbon-carbon nanotubes (24.7 W h kg−1 at 100 W kg−1) [2-Graphitic Carbon Spheres//Graphitic Carbon Spheres (22.1 W h kg−1 at 7000 W kg−1) [2//graphene (10.0 W h kg−1 at 2530 W kg−1) [3O4/rGO//LAC-rGO-MnO2 HSC device illustrated more supercapacitive performances with a high specific energy. W kg−1) , graphen W kg−1) , MnO2//g W kg−1) , MnO2 na W kg−1) , MnO2-Gr W kg−1) , and gra W kg−1) , Co3O4/r3O4/rGO//LAC-rGO-MnO2 HSC was performed at a current density of 8 A g−1 for 20,000 continuous charge/discharge . The electrochemical performance of Co3O4/rGO//LAC-rGO-MnO2 HSC shows a supercapacitor device with excellent properties and good rate capability.The cycling stability of electrodes is an important parameter for supercapacitor devices. The stability study of Coischarge f. The Co2 to further increase the SC and improve the electrochemical behavior. The LAC shows a nearly ideal supercapacitive behavior with proper SC and cycle stability. The increase of SC in the LAC-rGO-MnO2 composite electrode was related to the redox reaction of MnO2 and the high conductivity of rGO sheets. This composite electrode shows the appropriate specific capacitance (586 F g−1) and high cycle stability . The synergistic behavior of the material in composites has been verified via CV and EIS data, demonstrating a larger area of the CV curve and lower Rct (1.1 Ω) of the LAC-rGO-MnO2 electrode. The asymmetric supercapacitor of LAC-rGO-MnO2//rGO-Co3O4 shows good capacitive behavior with an excellent SC of 286 F g−1 at 2 mV s−1 and a great cycle stability of 96.1% after 20,000 charge/discharge cycles. In conclusion, this research shows a good way to obtain new materials with excellent energy storage properties.This study showed that luffa sponge biochar was utilized as a high-performance electrode for supercapacitors. The luffa sponge was first activated with KOH solution and then combined with rGO and MnO