The directly observed treatment short-course (DOTS) is one of the most effective tuberculosis (TB) control measures worldwide. However, despite its aim of providing comprehensive and humanistic care, few studies have examined its psychological effects from the patient’s perspective. Thus, this study aimed to evaluate the psychological changes and identify associated factors among patients with TB undergoing the DOTS program in Japan.This cross-sectional study recruited patients with TB receiving the DOTS program via 32 public health centers in four metropolitan cities in Japan. Surveys were administered to the patients and their attending public health or clinical nurses, who were responsible for their care and the DOTS program. Data were collected regarding the patients’ demographic and clinical characteristics, post-traumatic growth (using the Post-Traumatic Growth Inventory-Short Form [PTGI-SF]), and medication adherence, alongside open-ended questions, from 2014 to 2015. Additionally, the patients’ appraisal of the DOTS program’s efficacy and nurses’ assessment of the program’s practices were measured using two original questionnaires. Factors associated with post-traumatic growth were analyzed using variable estimation, correlation analysis, and logistic regression. Thematic analysis was conducted on the open-ended responses.Questionnaires were returned by 127 patients ; 98 (78.4%) of the respondents were men. Their mean age was 63.3 (standard deviation: 15.8) years. The mean PTGI-SF score was 21.7 (standard deviation: 11.1). The logistic regression analysis found that post-traumatic growth was significantly associated with the patients’ appraisal of the program’s efficacy  and nurses’ assessment of the practices . In the qualitative analysis, “Non-acceptance,” “Frustration,” and “Anxiety” were extracted as barriers to treatment; “Fear,” “Acquiring a partner,” “Relief,” and “Belief” were extracted as treatment drivers; and “Life changes” and “Rebuilding oneself” were extracted as treatment outcomes.The DOTS program in Japan improves patients’ treatment adherence and leads to recovery and psychological growth. Even in other regions, it may be effective to incorporate this program’s practices that place importance on partnerships with patients. It is also necessary to continue refined quantitative and qualitative evaluations. Tuberculosis (TB) has one of the highest global mortality burdens of any disease, and while its overall incidence is on the decline, the threat to the developing world is still serious . In the The directly observed treatment short-course (DOTS) has been advocated by the World Health Organization as one of the most effective TB control measures and it is implemented as standard in many countries –6. In prHow effective is DOTS? A Cochrane systematic review found that DOTS-based strategies were not significantly different for resolving poor adherence to TB treatment than self-administered therapy considering the large amount of resources required and the cost implications, and the authors recommended motivating patients and DOTS staff . Thus, hAnother concern is the strong tendency for DOTS-related research to discuss such programs from a purely medical perspective and to consider their efficacy mainly in terms of treatment outcomes and patient medication status . QualitaDespite the strategy’s stated aim of providing comprehensive and humanistic care, few studies have examined the psychological effects of the DOTS program, including in terms of post-traumatic growth, which is a construct defined as the positive psychological change resulting from the struggle with a highly challenging, stressful, and traumatic event . TherefoBased on a previous study , the con.The input included the patients undergoing the DOTS program, which was measured in terms of their demographic and clinical characteristics. The processes included in the DOTS program in Japan were measured using two indicators: the patients’ appraisal of the efficacy of the DOTS program and the nurses’ assessment of the DOTS program’s practicesThe DOTS program in Japan is presented in Fig. The outcome of the conceptual framework was related to the concept of medication adherence and the concept of post-traumatic growth of the patients with TB receiving the DOTS program in Japan.This study employed a cross-sectional design. Questionnaire surveys that included both quantitative and qualitative (open-ended) items were distributed to patients with TB and their attending nurses in four major cities across Japan—Yokohama, Kawasaki, Nagoya, and Osaka—with an estimated total population of 10 million in 2015 . The reap < 0.05 as the statistical significance, an effect size of 0.2, and eight predictors. The estimated minimum sample size required to identify the factors associated with post-traumatic growth was n = 75 : participants were considered non-adherent if they responded “true” to any of the four questions . RecoverThe patients’ appraisals of the efficacy of the DOTS program and nurses’ assessments of the DOTS program’s practices were measured using original questionnaires based on a literature review, interviews with 26 patients , and intThe patient questionnaire also included the following three open-ended questions: “What kind of things did you find troublesome as you went through the treatment?” “What kind of things did you find helpful as you went through the treatment?” and “How did your feelings, thoughts, behaviors, and lifestyle change after starting the treatment?”p = 0.01). Therefore, participants were assigned to a “high post-traumatic growth” (1) or “low post-traumatic growth” (0) group with reference to the means in the analysis. All variables that were significantly correlated (p < 0.05) with the PTGI-SF scores (0–50) were adopted as explanatory variables for the PTGI-SF scores (high = 1/low = 0) in a logistic regression analysis that used the forced entry method, with consideration of the multicollinearity between the independent variables. IBM SPSS Statistics for Windows v. 22.0 software  was used, with the significance level set at 5%.Descriptive statistics were calculated for all demographic variables. The two original questionnaires—the Patient Appraisal of the DOTS Program Efficacy and the Nurse Assessment of the DOTS Program Practice—were analyzed using item analysis (inter-item correlation coefficients) and exploratory factor analysis (Promax rotation) to examine and validate the questionnaires’ structures. Cronbach’s α was used to estimate their validity. The correlation analysis between the PTGI-SF scores (0–50) and each dependent variable was conducted using Pearson’s correlation coefficient. The PTGI-SF scores were determined to be normally distributed using a normality test . In addition, if the patients consented to their attending nurse’s involvement in answering the treatment questions, the nurses identified the patients by their date of birth. Then, the patients who consented to these procedures wrote down their date of birth by themselves. Answering the questionnaire and writing their own date of birth (if they permitted the nurse’s involvement) indicated written consent to participate in the study. The entire process was clearly explained in the questionnaire, and permission was received from the ethics review committee.Questionnaires were returned by 127 patients and 88 public health or clinical nurses. The analysis dataset consisted of responses from 125 participants after excluding two respondents who left numerous questions unanswered. When they were diagnosed with TB, 97 (77.6%) were living in their own homes, while 26 (20.8%) were homeless, living in common lodging houses, on the streets, incarcerated, or in a similar situation. In addition, 62 (49.6%) were living alone, while 61 (48.8%) were living with another person. Forty-eight participants (38.4%) were unemployed, 27 (21.6%) were in “precarious employment” , and 26 (20.8%) were employed full-time. In terms of their educational backgrounds, 47 (37.6%) had graduated only from junior high school, 52 (41.6%) had received only high school education, and 23 (18.4%) had graduated from university or another higher education institution.Many participants (79: 63.2%) had comorbid diseases at the time of their diagnosis; for most participants (88.0%), the DOTS program was their first TB treatment, while 15 (12.0%) had received treatment at least twice previously. Therapy lasted 6, 7–11, and ≥ 12 months for 39 (31.2%), 27 (21.6%), and 10 (8.0%) participants, respectively, and 13 (10.4%) completed their treatment course in under 6 months. Moreover, 23 participants (18.4%) did not know how long they had received treatment, having failed to receive an explanation from their doctor or nurse or simply forgotten. Forty-eight participants (38.4%) received only outpatient services. However, the majority had been hospitalized for their treatment: 15 (12.0%) for < 1 month, 34 (27.2%) for 1–2 months, and 24 (19.2%) for ≥3 months.TB symptom severity was reported as mild, moderate, or severe by 64 (51.2%), 34 (27.2%), and 27 participants (21.6%), respectively. Ninety-eight participants (76.8%) claimed to understand their disease and treatment course after an explanation, while 19 (15.2%) reported “little understanding,” and 7 (5.6%) reported “no understanding.”n = 45: 51.1%). In addition, 15 (17.0%) and 21 (23.9%) nurses provided support once or twice per week and almost daily, respectively. Four (4.5%) nurses explained that they have no regular schedule. Thirty respondents (34.1%) had performed home visits for their patients, 30 (34.1%) had their patients come to public health centers for treatment, and 16 (18.2%) had provided the DOTS program over the phone or via email. Some nurses reported employing multiple DOTS program approaches.The majority of attending nurses provided the DOTS program once or twice per month (n = 28: 31.8%), complications (21: 23.9%), loss of contact (16: 18.2%), drug-resistant TB (10: 11.4%), and dysfunction in family (8: 9.1%). The nurses identified more than one barrier per patient in some cases.The DOTS program nurses reported multiple barriers to effective implementation of the program. These included side effects  were classified as adherent and 31 (24.8%) as non-adherent. Sixty-seven participants (53.1%) reported full or partial recovery after starting the DOTS program, 46 (37.3%) noticed no change in their condition, and 12 (9.5%) stated that they felt worse. In addition, participants had a mean (± standard deviation) PTGI-SF score of 21.7 ± 11.1 points (range: 0–50).p < 0.05); all eight variables were adopted as explanatory variables for the PTGI-SF scores (high = 1/low = 0) in a binary logistic regression analysis using the forced entry method to test for associations between the PTGI-SF scores (between the high group and low group) and other factors in patients undergoing the DOTS program. Significant associations were observed for patients’ appraisals of the DOTS program efficacy  and nurses’ assessments of the DOTS program practice . In other words, participants exhibited greater post-traumatic growth when their recognition of the value of their DOTS program was high and the nurses’ assessments of the DOTS program protocols were more rigorous.The correlation analysis between the PTGI-SF scores (0–50) and eight independent variables were extracted as correlations  to positively affirm their own efforts to seek treatment, and to hear and internalize the encouraging voices of their supporters. These steps foster post-traumatic growth, which makes patients truly feel that their treatment has been effective, and they achieve a sense of accomplishment. The DOTS program provided patients with effective encouragement and motivation, which helped them to perceive its therapeutic effects and feel a sense of achievement. The existence of supporters is effective in helping individuals to achieve post-traumatic growth . SupportOn the other hand, regarding the drug adherence that is the DOTS program outcome, in total, 75.2% of the study population was adherent (compliant with medication), which appears to be almost the same as the rates reported by other studies that used the MMAS-4 to evaluate adherence. For example, 65.4% of participants were considered adherent in China , 76.0% oRegarding implications for practice, the DOTS program in Japan not only improved medication adherence rates but also increased levels of psychological growth. Reducing the TB prevalence by means of the Japanese version of the DOTS program is one of the most pressing challenges in public health, yet also one of the toughest to solve given the high concurrence of homelessness and alcohol and drug dependence in this population. The findings of the current study show that such high-risk patients with TB completed a journey in rebuilding their lives thanks to the DOTS programs, as they recognized their own issues and problems, gave thanks to others, and recovered their self-confidence. While direct observation, communication with patients, and guidance are crucial components of the DOTS program in Japan, the program strives to go beyond these components by supporting patients’ lifestyles with the help of family and supporters, customizing services to inspire them to improve their health habits, and standing by those who are enduring a great shock or stress . The resThe DOTS program in Japan is one example of a comprehensive community care system , which iThe findings cannot be interpreted as denoting causal relationships with post-traumatic growth-related factors, because of the cross-sectional study design. Further, the study did not account for several conditions and experiences that could have inhibited post-traumatic growth. For example, some patients had TB pleurisy, while others had comorbid diseases, mental illness, or TB recurrence. Moreover, others were older adults who had lived through World War II. New data should be collected and analyzed while controlling for these variables. In addition, the low retrieval rate should be considered; it is believed that the sample size did not represent the population, which has been proven to be a significant limitation in the examination of PTGI-related factors. Further, the open-ended questions were not asked in a way that clearly allowed the patients to judge whether the DOTS program caused changes in their attitudes and daily activities. Therefore, it cannot be refuted that factors other than the DOTS program (during treatment) might have had some impact. Moreover, in this study, the public health nurses who were the patients’ attending nurses were asked to explain the study to the patients. Thus, it is likely that the patients were selected based on the judgments of these nurses. The patients to whom the explanations were given might have been in a psychological position that caused them to feel uncomfortable about refusing to participate in the study. This situation could have skewed the research results in a positive direction for the public health nurses. However, there is the possibility that the DOTS program, which places importance on the partnership between patients and care providers, contributes to the post-traumatic growth of a vulnerable population with a high discontinuation risk. This contribution provides a foothold for presenting the results both quantitatively and qualitatively. A valid and refined quantitative and qualitative evaluation  needs to be continued.The DOTS programs in Japan both improve treatment adherence in patients with TB and enhance their post-traumatic growth. The patients’ appraisals of the DOTS program’s efficacy and nurses’ confirmation of the DOTS program’s implementation may be important contributors to this positive psychological growth. Future work on the subject should endeavor to study the concept in greater detail and to select and refine the evaluation measures.Additional file 1: Table S1. DOTS Program Efficacy—Items of Patient Appraisal.Additional file 2: Table S2. DOTS Program Practice—Items of Nurse Assessment.


Understanding the resident experience is a critical step to creating a sustainable and replicable model of affordable resident-centered housing with supportive services programs. This study thus draws lessons from focus groups with participants in the R3 program for designing and implementing such initiatives in affordable senior housing. Findings indicate that the R3 program brings value to residents: they benefit from reliable information on health-related issues, as well as emotional support and assistance with accessing appropriate care. By focusing on prevention and ensuring timely access to services, findings suggest how the intervention could promote seniors living independently longer and lower health system costs. Results also suggest ways to improve the effectiveness of housing with services programs, including providing clarity regarding the purpose of the program, its components and staffing, building trust between program staff and residents, addressing concerns about privacy and confidentiality, and implementing a multipronged marketing and promotion strategy.


A of system assertions, in a Maude program R that might disprove some of the assertions. The outcome of the technique is a safe program refinement R' of R in which every computation is a good run, i.e., it satisfies the assertions in A. Furthermore, the transformation ensures that no good run of R is removed from R'. Advantages of this correction methodology can be summarized as follows.Program transformation is widely used for producing correct mutations of a given program so as to satisfy the user’s intent that can be expressed by means of some sort of specification . This paper describes an automated correction methodology for Maude programs that is based on program transformation and can be used to enforce a safety policy, given by a set •A fully automatic program transformation featuring both program diagnosis and repair that preserves all executability requirements.•A simple logical notation to declaratively express invariant properties and other safety constraints through assertions.•No dynamic information is required to infer program fixes: the methodology is static and does not need to collect any error symptom at runtime. Specification TableThis paper describes an automated correction methodology that can be applied to impose safety properties on concurrent and nondeterministic software systems that are modelled as Maude programs. Nonetheless, the core idea of our correction transformation can be transferred to virtually any rewriting-based programming language, from simple term rewriting systems and rule-based languages such as CafeOBJ, OBJ, ASF + SDF, and ELAN, to widespread functional languages such as Haskell and Erlang, provided that the transformation preserves the executability conditions required by the language. Indeed, the proposed correction method transforms program rules into guarded program rules whose conditions supersede the  safety assertion checks and are simply evaluated by using the very same rewriting infrastructure of the language. Therefore, the provided assertion checking mechanism can be embedded into any setting that supports rewriting with an effort that depends on the complexity of the chosen formal framework.In the following, we outline the correction procedure for repairing Maude programs with respect to a safety policy that is expressed as a set of system assertions; a similar modus operandi can be followed to replicate this method in different rewriting frameworks such as those mentioned above. The advantage of the technique is that more refined versions of a program can be incrementally built without any programming effort by simply adding new safety constraints into the set of assertions. This makes it possible to adapt existing Maude programs to predefined safety policies and allows the inexperienced user to largely forget about Maude syntax and semantics. An infographic that outlines the basic steps of the correction methodology is given in R is essentially made up of two components, E and R, where•E is a canonical (membership) equational theory that models system states as terms of an algebraic data type, and•R is a set of rewrite rules that define transitions between states and which is assumed to be coherent w.r.t. the equations in the set E.Maude  is a higCanonicity of E and coherence between R and E are fundamental executability properties that guarantee the soundness and completeness of Maude’s evaluation mechanism .•the set D consists of  membership axioms  and equations that are implicitly oriented from left to right as rewrite rules , and•Ax is a set of algebraic axioms that are implicitly expressed as function attributes and are mainly used for Ax-matching.Algebraic structures often involve axioms like associativity, commutativity, and/or identity  of function symbols, which cannot be handled by ordinary term rewriting but instead are handled implicitly by working with congruence classes of terms. More precisely, the membership equational theory E is decomposed into a disjoint union E = D ∪ Ax, wheretopmost Maude programs, that is, Maude programs in which rewrites can only happen at the state top level position. This implies that no local state changes are allowed: in other words, each rewrite step completely replace a state s1 with a new term representing the derived state s2. In , where O belongs to the set {c,o1,o2}. System states are defined by terms of the form3), T is a natural number that timestamps the current configuration, and AC (aperture command) is a Boolean flag that enables changes of the spillway aperture widths only when its value is true.3/min and are specified by the following Maude equationsTo keep the exposition simple, we assume that the basin water inflow is constant, while the basin outflow depends on the aperture width of the current spillway configuration. Basin inflow and outflow are measured in mNote that more realistic scenarios could be easily defined by specifying more sophisticated basin inflow and outflow functions.The dam controller dynamics is modeled by the following eight rewrite rules, which implement system state transitions.The openX-Y rewrite rules progressively increment the aperture width of the spillway s . Dually, closeX-Y rewrite rules progressively decrease the aperture width of a spillway. The rule nocmd specifies the empty command, which basically states that no action is taken on the spillway configuration by the dam controller at time instant T. The rule is fired only when the AC flag is enabled, and its application disables the flag to allow a new basin water volume to be computed in the next time instant. These rules implement instantaneous spillway modifications that do not change the time instant or the basin water volume.The temporal evolution of the basin water volume is specified by the conditional rewrite rule volume that computes the volume W at time T + deltaT, given the input volume V at time T. The parameter deltaT is measured in minutes and can be set by the user. The volume computation changes the input volume V by adding the water inflow and subtracting the corresponding water outflow over the deltaT interval.The use of the AC flag in the rule definitions guarantees a fair interleaving between the applications of the rule volume and the remaining rewrite rules. Specifically, this implies that a new basin water volume is computed after each spillway aperture width modification.DR may reach potentially hazardous system states , since DR does not implement any spillway management policy that safely restricts the applications of the rewrite rules. Thus, the following companion assertion set DA to be enforced is specified in order to apply our correction transformation:Note that computations in 3 to avoid dam bursts and potentially disastrous floods. Assertion a2 specifies that, whenever the basin water volume is greater than 40 million m3, the spillway must be fully open . Assertion a3 requires the complete closure of the spillway when the basin water volume is particularly low (10 million m3).Roughly speaking, assertion a1 states that, in every system state, the basin water volume must be less than 50 million mfirst phase of our correction method generates the equational theory Eq(DA) that includes the following encodings of the assertions in D.AThe These equations allow any renamed system state to be rewritten to fail whenever the corresponding assertion is violated.second phase transforms each rewrite rule of DR into their refined conditional counterpart as follows:The 1 to a state s2 occurs only when s2 does not violate the assertions in D,A thereby enforcing a safe behavior of the corrected dam controller.By using the refined rules above, any state transition from a state shttp://safe-tools.dsic.upv.es/atame. We conducted a thorough experimental evaluation using ATAME that demonstrates good performance  for a number of benchmarks that are available and fully described within the ATAME web platform and in [R' in Maude is more than 50% faster on average than running the original program R in a monitored environment that implements runtime assertion checking.The correction methodology has been implemented in the ATAME system that is available at m and in . As showm and in , transfoDR’ that has been automatically fixed by ATAME.Maude programs can be either uploaded to ATAME as simple “.maude” files or written from scratch. Once the intended assertions have been also introduced inside a dedicated edit box, the correction procedure can be executed by simply clicking the “Fix Program” button, which delivers a coerced version of the program whose computations respect all the imposed assertions. EU (FEDER) and the Spanish MINECO under grant RTI2018-094403-B-C32, and by Generalitat Valenciana under grant PROMETEO/2019/098.This work has been partially supported by the The Authors confirm that there are no conflicts of interest.


New Child and Adult Care Food Program (CACFP) meal patterns and best practices were implemented nationally in 2017 to address the shift in dietary need from ensuring essential nutrient consumption to chronic disease prevention. Young American Indian (AI) children have disproportionately higher risk of chronic disease. Some AI tribes operate early care and education (ECE) programs and have the opportunity to participate in the CACFP. The purpose of this paper is to describe a CACFP best-practice menu and training developed and implemented as part of the Food Resource Equity and Sustainability for Health (FRESH) study, a community-based participatory research (CBPR) intervention implemented within ECE programs in the Osage Nation of Oklahoma. Site managers and cooks from each of the nine ECE programs attended meetings and provided investigators with feedback that shaped the best-practice menu and training. Each site participated in a three-hour training in January 2018 to discuss the best-practice menu and ways to overcome implementation barriers. Goals of the menu aimed to increase intake of fruit and vegetables and whole grains and reduce pre-fried and processed foods without increasing cook burden. Training included application activities individually and in small and large groups. Though the project is still underway, lessons learned, including the need for technical assistance, improved communication between ECE program staff and food supply vendors, and infrastructure barriers  that challenge workflow, have emerged. Efforts to improve menus in rural and low-income ECE programs must consider these issues in developing feasible intervention strategies. •Tribally-affiliated early care programs have unique barriers to meeting CACFP best-practice.•Community based participatory research provides opportunity to understand barriers.•Enhancing capacity and providing technical assistance may enhance implementation. FurtherIn Oklahoma, 36% of low-income, AI children ages 2–4 years were classified as overweight or obese in 2009 . This peResearch within ECE programs in AI communities is scarce. We conducted ECE program observation within 11 tribally-affiliated ECE programs in Oklahoma. As part of this process, we assessed ECE programs and policies that promote active play and healthy food options, including fruits and vegetables on the menu. We also measured dietary intake and physical activity in AI children attending the tribally-affiliated ECE programs. The AI children that attended a program with opportunities for active play and healthier meal options had 9% lower odds of being overweight or obese compared with AI children who attended a program without such policies in place . To our The National Academies of Medicine  and the In fall 2017, new CACFP meal patterns and best-practices were implemented nationally. The purpose of the updated CACFP meal patterns was to better align them with the Dietary Guidelines for Americans and respond to dietary need shift from ensuring consumption of essential nutrients to prevention of chronic diseases, including obesity . The newThe Food Resource Equity and Sustainability for Health (FRESH) study aims to increase vegetable and fruit consumption and reduce body mass index and hypertension among AI families. Included as part of the study was a CACFP best-practice menu and teacher training to increase vegetable and fruit servings and reduce added sugars, saturated fat, fried and pre-fried foods, and sodium within the Osage Nation ECE program menu. The purpose of this paper is to describe the community-based participatory research orientation used to develop and implement this CACFP best-practice menu and the training of service providers and teachers to implement this menu within ECE programs in the Osage Nation of Oklahoma. We present lessons learned for future interventions to improve the health of AI children within ECE programs.22.1The Osage Nation, located in Northeastern Oklahoma, occupies the state's only federally recognized reservation, which is coterminous with Osage County. The total tribal membership is 11,394, of whom 5682 reside on the reservation . The povIn addition to these public health and social service programs, the Osage Nation operates nine ECE programs: four Head Start programs; four Wah-Zha-Zhi Early Learning Academies (WELAs); and one Osage Language Immersion school. These programs are located in the four Osage communities of Skiatook, Fairfax, Hominy, and Pawhuska. The oldest of the programs, the Osage Nation Head Start programs, began operations in 1979 and continued to add locations until 1985, with enrollment ranging from 19 to 95 children across sites. The WELA facilities opened approximately five years ago and serve between 12 and 26 children across sites. Finally, the Osage Nation Language Immersion School, opened in 2015. There are 34 children enrolled in this program. While all but one of these ECE programs officially participates in the CACFP, they all share one central menu planning team. A registered dietitian oversees the menus. Although the programs are distinct in terms of their educational approaches , they are all located within the Osage Nation and are also similar in demographic makeup.The FRESH study partnership began in 2013 and comprises a multisector group of representatives from various tribal sectors, in addition to university partners. The tribal-university partnership surveyed diverse stakeholders across Osage Nation to assess the feasibility of and community readiness to implement evidence-based strategies to improve the Osage Nation food environment. Participants identified “increasing the availability of healthy foods through tribally owned and operated venues” as the best strategy for implementation, and their scores indicated the “preplanning” stage of readiness . In resp2.2n = 250 families) over a 6-month period. The executive committee developed the following key components of the FRESH study intervention: 1) a 15-week culturally relevant gardening and healthy eating curriculum implemented in the nine Osage Nation ECE programs; 2) web-based weekly workshops for parents to support healthful parenting, sleep, nutrition, and physical activity routines for children; 3) monthly in-person meetings to build local community capacity to create healthier community food environments; and 4) the development and implementation of a comprehensive CACFP best-practice menu and training for the Osage ECE programs. Here we describe the CACFP best-practice menu and training component.The FRESH study was funded in 2016 and is led by the multisector tribal-university study executive committee. The study is a randomized, wait-list controlled trial to evaluate the impact of a gardening and education intervention on vegetable and fruit intake and food insecurity, BMI, and blood pressure among a cohort of AI families  to work with the study executive committee. The first step in this process was to assess the ECE program goals for their menus and training needs. This assessment involved several structured meetings beginning August 2017 through January 2018, when the final menu and training were launched. The meetings included ECE program teachers, site managers, and food preparation staff, and focused on the new CACFP meal pattern changes, community partner food preparation process, vendors, storage, and educational, staff and infrastructure needs.These meetings identified several key issues. These concerns were the limited availability and quality of local grocers across communities and limited availability of vendors, which in turn restricted food access. The group also identified internal factors that focused primarily on local infrastructure needs, such as budget stability, site storage concerns, staff and time availability, and variability in the size of the ECE programs within the communities. For example, although the ECE programs used the same vendor, the vendor delivered twice per week to larger ECE program sites and once per week to smaller ECE program sites, depending on location. Occasionally produce arrived spoiled, and because not all the communities had access to grocery stores with affordable, quality produce in the amount needed, substitution of spoilt produce was not always possible. These factors contributed to the menu variation across ECE program sites.In addition, staff reported that some of the sites had extremely small food preparation and storage areas that precluded larger delivery of non-shelf stable foods . One site reported not having any food preparation or storage space, and all food was prepared at another site and delivered, which placed double the cooking burden on the food preparation staff at the larger site. Some sites had limited food preparation staff and had staff working in the kitchen as well as floating between classrooms or operating as the site director. The concern raised was a lack of time available for any scratch or partial scratch food preparation. A reliance on processed foods that were single-serve or that could be quickly heated and served was considered a necessity.These concerns highlighted the need for accompanying changes to the local reservation food environments and ECE program infrastructures. While the infrastructure needs have been reported by diverse programs elsewhere , the useThe university partners incorporated all of these concerns into a draft best-practice menu and training protocol. The draft menu and training protocol were provided to each of the nine program directors and food preparers. A conference call was held in November 2017 to review the documents with community partners and incorporate additional feedback. University partners also inquired about aspects of the menu that were considered favorable or raised concerns with implementation. These concerns were addressed in a final best-practice menu and training protocol that was delivered and presented at the 3-hour training held in December 2017 in Hominy, Oklahoma. The ECE directors, teachers, and food preparation staff for each program were invited to attend this training. There was representation from all sites at the training.33.1The six-week cycle best practice menu developed for the Osage Nation ECE programs is shown in Several infrastructure concerns could not be addressed. These concerns were the limited access to grocery stores, vendor delivery frequency, and limited space for food preparation and storage. These concerns were raised with parent groups as part of a separate component of the study. In addition, meal planning strategies to reduce storage space and waste  were built into the best-practice menu in efforts to minimize staff burden.3.2A tailored training on the implementation of the best-practice menu and how to implement it amidst the challenges and barriers identified by the community took place in December 2017 at a tribal education facility. The training program itself was based on adult learner needs  and prev3.3The best-practice menu was developed for implementation beginning January 2018. Process evaluation data assessing the implementation of the menus, such as observation of weekly menu, at each of the nine sites was collected by university staff. University staff collected information from the cooks at each site at five different time points from fall 2017 to fall 2018. Staff made copies of the menus that the cooks were using and recorded what was actually served, ingredients, quantity, and preparation methods for a one-week time period . The impact of the best-practice menu and training, along with complete FRESH outcomes, will be reported in future manuscripts. Of the nine ECE Programs, four implemented the best-practice menu in spring 2018, as determined by examining the working menus at each program. All wait-list programs and one intervention Head Start program did not adopt the best-practice menu.4This paper describes the development of a CACFP best-practice menu and additional training for food preparation staff in ECE programs within the Osage Nation. The study process revealed challenges to meeting CACFP best practices in rural, tribal ECE environments. These challenges included limited access to healthy foods, staffing shortages, and limited food preparation space. While these challenges have been reported in other ECE program settings, both rural and urban ECE , reliancThis study is, to our knowledge, the first to utilize a CPBR approach to develop and implement a CACFP best-practice menu and training for ECE program staff. Previous studies to prevent obesity within ECE programs have focused primarily on individual-level health behavior strategies with children, and less commonly included staff training and technical assistance for menu changes . Three sThough the FRESH study is still underway, lessons learned have already emerged. During the menu and training implementation, we identified the need to include on-site technical assistance at ECE programs to work on goals for efficiency in kitchen workflow and food preparation. Tribally-affiliated ECE, especially in rural areas, have food access and procurement barriers. Understanding of and potential partnership with supply chain, vendors, local grocers, and possibly farmers are important for long-term success in providing healthier nutrition in these programs. Collaboration with the site manager and cook is essential to fully understand perceived and actual barriers to provide training that can provide necessary background rationale for nutrition recommendations, as well as beneficial and productive activities and hands-on training to effect change. The various levels of capacity and infrastructure within an ECE program dictates, to some degree, their ability and desire to strive towards best practices. Even though all nine ECE programs are operated through Osage Nation, Head Start programs have federally mandated performance standards regarding nutrition and physical activity with which they must comply . EnrollmThe challenges identified in this CBPR study can be used by other community-university partnerships to develop similar programs with rural ECE programs, including tribally-affiliated ECE programs, indicating external validity of this process. University partners worked closely with the tribal and ECE program representatives to develop a menu and training that advanced health goals while addressing community-identified barriers with high rigor to the CBPR process enhancing internal validity. Limitations include minimal data on the effect of the menu and training. However, given that the purpose of this paper is to share the process of developing a menu and training, using CBPR orientation, with a tribal community, discussion of the intervention impact is not needed. Future research currently underway will explore facilitators and barriers to improving ECE program menus based on program characteristics and tailoring menu change strategies for these unique environments. We hypothesize that barriers would include vendor delivery schedule, kitchen size and food preparation space, and staffing demands. The present study will yield important findings in the efforts to improve tribal food environments and inform policy makers about the efficacy of menu change interventions in improving child dietary intake and the feasibility of implementing such efforts in diverse ECE program contexts.V. Blue Bird Jernigan conceptualized and supervised the study and assisted with writing. S. Sisson supervised and guided development of the best-practice menu and training, and led the manuscript writing. K. Sleet and R. Rickman developed the best-practice menu and training program, and assisted with writing. C. Love assisted with data collection, data analysis, and writing. M. Williams assisted with conceptualization, data presentation, writing, and interpretation.National Institute on Minority Health and Health Disparities (R01MD011266). The funding agency did not participate in the study design, data collection, analysis, decision to publish, or preparation of the manuscript. All authors approve of the final version. This work has not been published or presented elsewhere. No authors have a conflict of interest. We thank the members of the Osage Nation.This study was funded by the The study was reviewed and approved by the Institutional Review Board of the University of Oklahoma Health Sciences Center.


Progress testing, a regularly administered comprehensive test of a complete knowledge domain, usually serves to provide learners feedback and has a formative nature.Our study aimed to investigate the acceptability of introducing a summative component in the postgraduate Dutch Radiology Progress Test (DRPT) among residents and program directors in a competency-based training program.A 15-item questionnaire with 3 items on acceptability of summative postgraduate knowledge testing, 7 on acceptability of the summative DRPT regulations, 4 on self-reported educational effects, and 1 open comment item was distributed nationally among 349 residents and 81 radiology program directors.The questionnaire was filled out by 330 residents (95%) and 48 (59%) program directors. Summative postgraduate knowledge testing was regarded as acceptable by both groups, but more so by program directors than residents. The transition toward summative assessment in the DRPT was received neutrally to slightly positively by residents, while program directors regarded it as an improvement and estimated the summative criteria to be lighter and less stressful than did residents. The residents’ self-reported educational effects of summative assessment in the DRPT were limited, whereas program directors expected a greater end-of-training knowledge improvement than residents.Both residents and program directors support summative postgraduate knowledge testing, although it is more accepted by program directors. Residents receive summative radiological progress testing neutrally to slightly positively, while program directors generally value it more positively than residents. Directors should be aware of these different perspectives when introducing or developing summative progress testing in residency programs. Competency-based medical education (CBME) flourishes in many countries . ThroughIn the definition of good assessment, acceptability and educational effects are important characteristics , 17. AccRadiology residency in the Netherlands comprises a 5-year competency-based training program. Throughout the training program, radiology residents are formatively and summatively assessed in numerous workplace observations and written examinations, including the Dutch Radiology Progress Test (DRPT). Radiology residency in the Netherlands does not include a board exam, but graduation from the training program has to be reinforced by the national registration committee for medical specialists in order for the resident to register as a radiologist. The DRPT has been a formative assessment tool in the training program since 2003. It is a semi-annual comprehensive radiological knowledge test with required participation during the complete 5-year residency period , resultiThe DRPT’s pass/fail criterion was defined as follows: residents must obtain a pass score for at least three of the five individual tests that are taken in postgraduate years (PGYs) 2.5 to 5. Tests in the first 2.5 years of training remain all formative Fig. . ResidenOur purpose was to study the acceptability and self-reported educational effects of introducing a summative component in postgraduate progress testing within a competency-based radiology training program.We conducted a cross-sectional, descriptive study in Dutch radiology residents and program directors. We surveyed them with a questionnaire to assess acceptability and self-reported educational effects of transitioning from formative to summative progress testing.We performed a PubMed search for relevant questionnaires with the terms “postgraduate education,” “progress test,” and “assessment,” yielding one questionnaire from Dijksterhuis et al. on acceptability and educational effects of formatively used postgraduate progress testing . Based on = 11), single-best-answer multiple choice (n = 2), and free response (n = 2). Items with Likert scales mostly (n = 6) included a 5-point scale, typically ranging from “no(t) …” to “very ….” The other Likert items had a 7-point (n = 4) or 9-point (n = 1) scale with “neutral” or a “neutral”-like answer option in the center of the scale. We chose for these larger scales because in these items, we were interested in the variety of potential responses on both sides of neutral, for which we found a 5-point scale less suitable.The questionnaire consisted of three items on acceptability of summative postgraduate knowledge testing, seven on acceptability of the summative DRPT regulations, four on self-reported educational effects, and one open comment item. Ten items were applicable to both residents and program directors, and five to residents only. As response formats, we used Likert scales (n = 349) who participated in the April 2017 DRPT to complete the questionnaire anonymously in the same session as the progress test, but unaware of their final test scores. These residents comprised 92% of all 380 Dutch radiology residents at the time (31 residents were given dispensation from participation). On the same day, we asked all Dutch radiology program directors (n = 81) by email to complete the questionnaire anonymously. A reminder was sent 3 weeks later. We encouraged residents and program directors to respond to all questionnaire items, but we left them the possibility to not respond to items.We asked all residents .p < 0.001).The questionnaire was filled out by 378 respondents, including 330 residents and 48 program directors . All but 2 questionnaire items (item 9 and the open comment item) were answered by at least 371 respondents. The proportion of absent responses did not differ significantly between respondent groups. Participating residents are shown in Table p < 0.001), with average responses between “fair” to “very fair” on the first two items and “quite important” on the third item.On average, residents tended to find it fair that knowledge tests are part of medical specialty training in the Netherlands, while they regarded an associated requirement to pass as slightly fair Table . They wep < 0.001). Residents responded neutrally to the detailed summative DRPT criterion, while program directors tended to find the criterion slightly light (p = 0.005). Compared with the formative group, the summative group found the criterion significantly harder (p = 0.001) and was less convinced about the ability to meet it (p = 0.001). Program directors estimated the summative DRPT as less stressful than residents (p = 0.001). On a scale of 1–10, residents generally graded the summative DRPT regulation slightly positively (average grade 5.9), whereas program directors (average grade 7.3) appraised it significantly higher than residents (p < 0.001). All groups found that passing a summative DRPT should happen not longer than approximately 1.5 to 2 years before registration as a radiologist.The introduction of the summative DRPT did not evoke a clear opinion among the residents Table , while pp < 0.001). Residents anticipated studying slightly to moderately more for a summative DRPT than for a non-summative test. Compared with the formative group, the summative group reported significantly more preparation for the current DRPT than for the previous one (p < 0.001).Residents tended to expect the summative DRPT to improve the residents’ end-of-training knowledge level slightly Table , while pFigure Open comments were given by 139 (42%) residents and 16 (33%) program directors. Most frequently (approximately one quarter of residents’ and two fifth of program directors’ responses), respondents stated that DRPT test items are too often aimed at factual knowledge that is not relevant for daily clinical practice . Approximately one fifth of residents argued that the DRPT is not representative for clinical performance as a resident or radiologist. Approximately one fifth of program directors responded that progress testing is not suited for summative purposes .In this study, we found that both residents and program directors supported summative postgraduate knowledge testing, although it was more accepted by the latter. Program directors had a higher acceptability of summative radiological progress testing than residents who valued it just above neutral. In addition, program directors estimated the amount of related stress to be lower and valued its potential educational effects higher than residents. The varying opinions between residents and program directors may well be related to their different positions in the training program. Program directors carry accountability for the educational program. In their view, having to pass a test may be a better learning stimulus and a stronger proof of competence than merely taking it. Residents on the other hand are the ones who have to pass the test and must potentially face the consequences of failing. Therefore, they may feel more resistance and stress toward summative testing. Stakeholders such as program directors should be aware of these different perspectives when introducing or developing summative progress testing in residency programs. From the residents’ point of view, a program director and administration that are approachable and responsive to the resident’s perspective and concerns will likely contribute to a successful training in radiology . We obseThe present study illustrates implementation of summative progress testing in a competency-based postgraduate training program. Our current DRPT regulations stipulate that residents must pass within roughly the last 1.5 PGYs. From the perspective of competency-based education, this time period seems appropriate to make pass/fail decisions on postgraduate radiological knowledge because the second half of residency is generally the time period that the knowledge level of radiology residents matures . In addiThe utility of an assessment method such as the DRPT can be defined as a function of several variables: reliability, validity, cost, acceptability, and educational effects . PreviouThis study has several limitations. Firstly, the large majority of residents had not (yet) passed a test that actually counted for the summative DRPT criterion. Group perspectives on acceptability and educational effects may change if more residents have taken summative tests. Nevertheless, the present study may provide a good view of residents who are on the verge of a transition toward postgraduate summative assessment. Secondly, we estimated educational effects retrospectively by self-reported questionnaire items. A more precise approach may include prospective study of learning behavior in residents. Thirdly, although we designed our survey with feedback from various stakeholders, further validation of our questionnaire has not yet been performed.Future study is needed to assess long-term acceptability and educational effects of summative postgraduate progress testing. Our study focused on the period of transitioning from formative to summative progress testing, but acceptability and educational effects should be re-assessed once the summative format has been well established. Also, further study is needed to confirm our findings in other specialties than radiology and to assess validity of the summative DRPT format after the current phase of transition.Both residents and program directors support summative postgraduate knowledge testing, although it is more accepted by the latter. Residents receive summative radiological progress testing neutrally to slightly positively, while program directors generally value it more positively than residents. Directors should be aware of these different perspectives when introducing or developing summative progress testing in residency programs.


ChREBP is also expressed in pancreatic islets, small intestine and to a lesser extent in the kidney and the brain. In response to glucose, ChREBP undergoes several post-translational modifications (PTMs)  that will either modulate its cellular location, stability and/or its transcriptional activity. ChREBPβ is a shorter isoform of ChREBP that was first described in adipose tissue and later found to be expressed in other sites including liver and pancreatic β cells. ChREBPβ lacks an important regulatory inhibitory domain, known as LID (low glucose inhibitory domain), in its N-terminal domain and is therefore reported as a highly active isoform. In this review, we recapitulate a recent progress concerning the mechanisms governing the activity of the ChREBP isoforms, including PTMs, partners/cofactors as well as novel metabolic pathways regulated by ChREBP in key metabolic tissues, by discussing phenotypes associated with tissue-specific deletion of ChREBP in knockout mice.Carbohydrate response element binding protein (ChREBP) is a carbohydrate-signaling transcription factor that in the past years has emerged as a central metabolic regulator. ChREBP expression is mostly abundant in active sites of  The mirror experiment, in which ChREBP expression was induced in the liver of SREBP-1c knockout mice, rescued glycolytic gene expression but surprisingly not lipogenic gene expression, despite the well-known role of ChREBP in the control of fatty acid synthesis genes. Nevertheless, this study suggests the importance of the dual action of ChREBP and SREBP-1c in the control genes involved in the regulation of fatty acid synthesis . The liver is the principal organ responsible for the conversion of excess dietary carbohydrates into fat. The resulting triglycerides (TG) can be packed into very low density lipoproteins (VLDL) and either secreted into the circulation, stored as lipid droplets, or metabolized through the beta-oxidation pathway. Insulin secreted in response to elevated blood glucose, stimulates the expression of genes of REBP-1c) . SREBP-1REBP-1c) . Activate (Scd1) . A recene (Scd1) . Viral rynthesis .ChREBP is highly enriched in the liver and has been studied as a master regulator of lipid metabolism . ChREBP ChREBP belongs to the Mondo family of bHLH/Zip transcription factors. The N-terminus domain (1-251 residues) contains two nuclear export signal (NES) and a nuclear localization signal (NLS) regulating subcellular localization by interacting with chromosome region maintenance 1 (CRM1) also referred to as exportin 1 and/or 14-3-3 proteins . The C-tUnder fasting conditions, the glucagon-dependent activation of protein kinase A (PKA)  phosphorO-GlcNAcylation, a post-translational modification dependent on glucose metabolism, and identified to be important for ChREBP transcriptional activity (O-GlcNAcylation occurs on serine and threonine residues through the activity of O-GlcNAc transferase (OGT), an enzyme that adds N-acetylglucosamine (GlcNAc) residues to target proteins thereby modifying their activity, stability and/or subcellular location. O-GlcNacylation. Mutations of these residues at the bHLH/ZIP and dimerization and cytoplasmic location domain (DCD) domains have allowed for the identification of Thr517 and Ser839 as essential sites for the glucose-dependent activation of ChREBP (KO mice) impaired hepatocarcinogenesis driven by protein kinase B/Akt overexpression in mice. Furthermore, siRNA-mediated inhibition of ChREBP in mouse and/or human HCC cells resulted in decreased proliferation and apoptosis.Within the nucleus, ChREBP can be modified through activity . O-GlcNAf ChREBP >. ChREBPf ChREBP . Glucosef ChREBP >. Poungvf ChREBP . The autLpk promoter, thereby acting as a co-repressor of ChREBP transcriptional activity . ChREBPKO mice were reported to die within several days of high-fructose diet (HFrD) feeding -mediated hepatocyte apoptosis. Apoptosis in hepatocytes in these mice was most likely linked to increased cholesterol biosynthesis since inhibition of this pathway via HMG-CoA reductase (HMGCR) or SREBP2 inhibition rescued ChREBPKO mice from HFrD-induced liver injury. A lack of ChREBP was also recently associated with a dysregulation of sucrose and fructose metabolism leading to sugar intolerance and malabsorption in mice (KO and liver-specific ChREBP knockout (ChREBPLiverKO) mice fed with HFrD had previously revealed that hepatic ChREBP deficiency alone does not lead to fructose intolerance but that ChREBP deficiency in the small intestine is most likely responsible for the impairment in fructose tolerance observed in these mice . Fasn, Pklr, ChREBPβ) was observed in livers of rats fed with a high glucose or fructose diet. At the physiological level, increase in the BDK:PPM1K ratio led to the phosphorylation and activation of ATP-citrate lyase (ACLY), thereby stimulating de novo lipogenesis. These findings reveal that BDK and PPM1K may be novel lipogenesis-activating genes regulated by ChREBPβ. Given their role in the regulation of lipid, glucose and amino acid metabolism, BDK and PPM1K could be considered as potential therapeutic targets in the liver in the near future (The first committed step of branched-chain amino acid (BCAAs) catabolism is regulated by the branched-chain ketoacid dehydrogenase (BCKDH) complex which is controlled by two enzymes, the branched-chain alpha-keto acid dehydrogenase kinase (BDK) and the protein phosphatase, Mgr future .Fgf21 promoter has been previously identified in both mice (-74 to -52 bp) and humans (-380 to -366 bp) (ChREBP was recently associated to the production and secretion of hepatokines such as Fibroblast growth factor 21 (FGF21) . FGF21 i-366 bp)  but func-366 bp) . Additio-366 bp) . This li-366 bp) .LiverKO mice exhibit worsened glucose tolerance, while protected from hepatic steatosis. Hepatic ChREBP deletion also resulted in gene expression changes in white and brown adipose tissues, suggesting inter-tissue communication. The contribution of ChREBP to whole body energy balance may therefore rely on its regulation of lipid species and/or hepatokine production contributing to inter tissue coordination of energy homeostasis , which exhibit low lipogenesis rates in adipose tissue, are insulin resistant with impaired insulin action in liver, muscle and white adipose tissue under both chow and high fat diet conditions. ChREBPadiposeKO mice have lower serum levels of PAHSAs, while PAHSA supplementation, in particular the 9-PAHSA isomer, rescues ChREBPadiposeKO global insulin resistance and adipose tissue inflammation, confirming that loss of adipose-ChREBP is sufficient to cause insulin resistance  in adipose tissue . KnockdoChREBP is now a well-established carbohydrate sensor. Although most studies have been dedicated to its implication in the control of the glycolytic and lipogenic pathways, recent data have also unraveled novel contributions of ChREBP in hepatocytes and in fat cells where it could be instrumental in producing hepatokines and/or lipokines triggering inter-organ crosstalk. As discussed, newly identified co-factors (epigenetic modifiers) and/or partners (adipose HSL) in these tissues may also represent potential therapeutic strategies for NAFLD and/or for improving systemic insulin sensitivity. Recent studies have also supported the importance of ChREBP in the regulation of fructose metabolism and have underscored the need for a better understanding of its role and regulation in the small intestine. Lastly, identifying specific and/or overlapping targets of ChREBPα and ChREBPβ in key cell types as well as determining their specific impact on insulin sensitivity will be of particular importance in the coming years.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We conducted a participatory health promotion program with grocery store workers using the Healthy Workplace Participatory Program (HWPP) from the Center for the Promotion of Health in the New England Workplace. We recruited a design team made up of six line-level workers and a steering committee with management and union representatives; a research team member facilitated the program. Using a formal evaluation framework, we measured program implementation including workplace context, fidelity to HWPP materials, design team and steering committee engagement, program outputs, and perceptions of the program. The HWPP was moderately successful in this setting, but required a substantial amount of worker and facilitator time. Design team members did not have the skills needed to move through the process and the steering committee did not offer adequate support to compensate for the team’s shortfall. The evaluation framework provided a simple and practical method for identifying barriers to program delivery. Future studies should address these barriers to delivery and explore translation of this program to other settings.Participatory methods used in Total Worker Health More than one-third of current U.S. workers suffer from at least one chronic disease, including heart disease, cancer, diabetes, stroke, and musculoskeletal disorders ,2. Worki® (TWH) approach highlights the need for “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being” [The workplace is an ideal place for supporting healthy behaviors, since workers spend a large portion of their day in the work environment and coworkers and supervisors can provide substantial support. Traditionally, worksite health promotion programs have been separate from other occupational health and safety efforts, and usually target only the individual, ignoring work organization and work environment factors that affect worker behavior. The National Institute for Occupational Safety and Health (NIOSH’s) Total Worker Healthl-being” . The TWHl-being” .Regardless of the level of intervention, the most effective interventions are those that take into consideration the unique characteristics and perspectives of the end users ,14. PartWe sought to evaluate the feasibility of conducting a participatory health promotion program in a retail grocery store setting. We partnered with a regional grocery store chain who expressed interest in supporting their workers’ health. Using the HWPP as a facilitation guide, we formed a team of grocery store workers and evaluated their ability to create meaningful and relevant workplace health activities that promote and support healthy behaviors in their workforce. The purpose of this paper is twofold: (1) to inform others considering a participatory intervention by describing the implementation of this HWPP program, and (2) to describe a framework for evaluating complex TWH interventions, such as the HWPP.This study was an extension of a partnership with a labor union and several regional grocery store chains who had participated in a preliminary study examining workplace factors related to health behaviors and obesity ,34. UponThe study period was from September 2014 to June 2016, during which time we piloted the HWPP program, collected process measures, and collected baseline and follow-up worker assessments by surveys and focus groups. The Institutional Review Board at Washington University approved all research activities and all participants provided informed consent.The HWPP model includes a design team made up of front-line workers and a steering committee comprised of multiple management levels . These tAt study initiation, the research team met with the grocer’s management to describe the study and outline the project’s goal: To trial a participatory process as a method to generate ideas that promote worker health. They outlined the rationale for participatory programs and discussed the expectations and roles of both the employer  and research team. The grocer was willing to trial the program in one store and agreed to: (1) help form a representative steering committee and design team; (2) assist with scheduling design team meetings and allowing design team members to meet during work hours, provided they clock out for meetings; (3) provide a meeting space; and (4) provide access to store workers for data collection. It was expected that the research team would assume responsibility and costs for program facilitation and data collection. The research team also made the decision to pay design team members for their time to attend meetings since they were not able to meet on paid work time; they were paid $25 per meeting.n = 120) and focus groups (n = 19) to gather information about current health status, behaviors, and health beliefs of store workers, as well as information about existing workplace supports for health [A research team member with experience in workplace interventions and group facilitation served as the facilitator; two additional research team members assisted in program development and attended meetings to collect process measures. The facilitator’s role was to guide the Design Team through the IDEAS Tool by teaching them the process, planning and running team meetings, and acting as a liaison between the Design Team & Steering Committee. Along with the research team, the facilitator created an agenda and timeline based on the IDEAS Tool and activities from the HWPP toolkit . The inir health ,42,43,44The research team used experience mapping as way to present the baseline data to the design team in a simple and meaningful way. To complement the survey and focus group data already collected, design team members were asked to complete a store mapping activity in which they drew their store layout and mapped their routes throughout the workday, noting their perceptions of the positive, neutral, and negative impacts on their health. The totality of the formative research was synthesized by the research team and used to create an experience map  that wasThe experience map’s central focus was a persona describing “a day in the life of a grocery store employee.” This story included both work and non-work time to highlight the importance of examining both workplace and personal factors to understand health behaviors and outcomes. Also included in the map was quantitative data from the surveys as supporting evidence for the persona, including disease and symptom rates , information about current health behaviors , and perceptions of workplace influences on health and organizational commitment to employee health. We used a variety of graphics and images to convey ideas and emotions that are not easily expressed in words and numbers. This enabled the research team to present complex information back to the design team in simple graphic format which they could easily digest and utilize to efficiently identify health priorities and goals, workplace barriers to health, and opportunities for intervention.Store workers volunteered for the design team at the time they completed their baseline survey. Because the program is largely driven by the design team, it was essential that we included workers who were interested in the topic and therefore more likely to remain engaged throughout the process. We used the selection criteria outlined in the HWPP Toolkit as a guide for identifying and selecting six to eight workers with the help of store management . The HWPWe created a logic model to guide our evaluation of the HWPP implementation process . We adapThe logic model begins at the left with “Pre-Implementation” elements  in order to assess the preparedness of the workplace to initiate a TWH program. This allows the researcher to provide the necessary training and education on TWH before the program begins, creating the foundation for program implementation. The next section shows elements related to the program implementation process, including the inputs , activities , and outputs . The right side of the model shows efficacy measures including the short-term, intermediate, and long-term outcomes the program is indented to produce. All elements are imbedded within the organizational context, which may directly or indirectly influence program or intervention success. Although the model may coincide with time, it is not intended to be a linear evaluation, but rather a continuous, iterative process. As indicated by the brackets, the evaluation of outputs and outcomes will be fed back to inform inputs and activities. This circular process allows periodic evaluation and adjustment of the program as necessary. The evaluation in this paper focuses specifically on the implementation process within the context of a unionized grocery store setting. Due to time and resource limitations, we did not measure pre-implementation elements or program efficacy.To measure program implementation, the research team collected both qualitative and quantitative data using multiple tools. For each design team meeting, the research team completed field logs and debriefing notes to measure dose (frequency and duration of meetings) and fidelity to the HWPP materials and IDEAS Tool, and rated four dimensions of team member engagement  on a 3-point scale . The design team also rated their own participation and completed meeting reflections . After tWe used SPSS v. 23  to run descriptive statistics for baseline demographics and with store worker follow up surveys for program reach metrics . We rated all process components according to the measures described in our logic model. A process measure of design team participation was the average rating of each team member’s engagement scores across meetings. Qualitative data was not systematically coded, but each qualitative item was reviewed with consensus by the research team to summarize each process measure. Qualitative data was also used to provide descriptive information to support the quantitative results.The participating grocery store chain offered a large, busy store that was located in a demographically diverse neighborhood. This store was chosen because of the diverse employee and customer demographics, as well as the store manager, who was enthusiastic about the program. After the initiation of the program, this store manager was transferred to another store; the replacement manager was not as invested in the study. During the project planning phase, store management agreed to adjust work schedules of design team members so they would be scheduled to work on meeting days, and could attend meetings immediately before or after their scheduled shift; this did not always happen over the course of the program. Store management provided a space for the design team to meet on site, although it was not always private due to limited space options in the store.The selected store employed approximately 159 workers, roughly 40% of whom were full-time employees. We obtained baseline surveys from 120 workers (75% response rate); their demographics are presented in We used all of the IDEAS Tool worksheets, but simplified some of the language to make them more understandable to the design team members. The design team reported that although they understood the program materials when the facilitator guided the process, the worksheets were not intuitive to complete on their own. Thus, the facilitator was a critical part of the team’s success in completing the steps of the IDEAS Tool. The facilitator devoted considerable time over the course of the program to prep, plan, and facilitate team meetings. The majority of the facilitator’s time was spent between meetings, combing through the design team’s materials to condense and simplify the information to help move the team through the program . The criFidelity to the IDEAS process was met and Steps 1–6 were completed by the design team or steering committee . Step 7 Overall, design team members had positive perceptions of the program. They reported that the program met their expectations and positively influenced their health . Five of the six team members felt that the participatory process created opportunities for more open dialogue with management, although they did not feel confident that management would follow-through on implementing proposed activities. In addition, a few design team members were frustrated with being scheduled to work at the time of the team meetings, however they were able to work with their immediate supervisor to attend. Early in the process (Step 1), the design team participated in two rounds of brainstorming which generated a total of 65 ideas grouped into four themes . The team referred to these ideas and themes in Step 2 to identify their goal (“Reduce Stress at Work”), develop three objectives , and create 15 specific activities related to the three objectives. The design team rated these activities during Steps 3 and 4 with the understanding that they would have to “sell” the ideas to management. The team presented their top rated ideas to the steering committee. The steering committee took approximately 7 months to respond to the design team’s proposal; they approved five activities without edit; approved two activities with small changes based on current store logistics; requested more information on four activities; and did not approve four activities .Of the seven activities that were agreed upon by the steering committee, five were implemented by the design team by the end of the study period; two were not completed because they needed other resources to implement . Surveys at follow up from 105 store workers (67% response rate) showed the activities noticed most often by workers were ones that were implemented in the breakroom: the new employee refrigerator and discounted bottles of water. Activities that were delivered in other areas of the store were implemented intermittently, and not noticed by many workers. Only six workers said they did not notice any of the implemented program activities. Similarly, utilization of the activities was higher for those implemented in the breakroom and for the activities that did not require much extra effort by the workers. During store worker interviews, workers either were excited about the new health activities and wanted to see more implemented or they had not heard of them. Those that had not heard of the activities indicated that direct communication from store management about new health opportunities may be more useful than printed materials placed throughout the store. Only one of the five workers reported health behavior changes based on an implemented program activity; other workers said that they appreciated the effort, but that none of the implemented activities impacted their personal behaviors.Implementation of the HWPP was moderately successful in the grocery store setting as demonstrated by good fidelity to program materials, design team engagement in the IDEAS process, and the number of and uptake of program activities in a relatively short time period. This success can be attributed mostly to the design team’s interest in the program and the extra time spent by the facilitator to move the team along; leadership support, including lack of active participation by the store management, was the main barrier to further success. The logic model provided an effective and simple framework for evaluating program implementation and allowed us to better understand the workplace factors necessary for success, as well as challenges or barriers that might be overcome with program modifications or additional resources. The HWPP offers multiple tools that can be used in conjunction with this model including the organizational readiness checklist to evaluate Pre-Implementation and the Management Dashboard and PERS tools to evaluate the Inputs, Activities, and Outputs under Program Implementation.The program inputs  provided a good structure for the program. The HWPP materials were extremely helpful for the facilitator, although the language was somewhat confusing to the design team. High fidelity to the recruitment criteria led to high engagement and enthusiasm of design team members. The design team’s interest in health and improving their store was vital to their success. The design team members had strong and consistent attendance and participation during meetings, yet seemed to lack the skills needed to progress through all steps of the program. They proceeded well with the initial steps to assess the workplace, identify problems, and come up with solutions, but struggled with the subsequent steps required to create a realistic plan to present to the steering committee. It is likely the design team members had not previously had the need nor opportunity to use these skills in their jobs. Employees may develop these skills through their jobs or by participating in employee-management teams for other business reasons. However, teams consisting of employees without these skills may be unable to effectively design and implement workplace changes without additional external support or training ,19,54,55As a result, the team required substantial assistance from the facilitator to organize information and develop plans to complete each step of the process. The time demands on the facilitator far exceeded our expectations. It is possible that the steering committee or store management could have assisted the design team with some steps. We were careful to include various levels of leadership (including union representation) on the steering committee; however, there was a discrepancy between the stated support  and the actual support received . Earlier and more frequent involvement from the steering committee in the design team meetings may have mitigated the need for substantial facilitator resources.The main program activity, the IDEAS Tool, was delivered as intended. With support from the facilitator, the design team was able to meet, agree on a goal, and develop specific activities for each objective to propose to the steering committee (Steps 1–5A). The team’s inability to meet outside of scheduled meetings and the steering committee’s prolonged delay in responding to the design team’s proposal left no time in the study period to complete IDEAS Step 7 , or initiate another cycle of the IDEAS process. Without this entire action-feedback cycle, the potential for organizational learning was decreased. This long delay also affected morale and enthusiasm, which resulted in two members leaving the design team. Additionally, the design team’s meeting location may have been a problem for some team members. The onsite meeting space was not private; store managers and other employees frequently passed through the meeting space, causing the design team to feel uncomfortable sharing information. Despite these challenges, the program produced worthwhile outputs, demonstrating program success and a positive design team-steering committee collaboration. Overall, the design team had a positive impression of the process noting an increased comradery with team members and healthier behaviors as a result of the intervention. Some team members reported a sense of self-efficacy for continuing the program, while others did not think they could continue without the research team there to facilitate and hold management accountable. Further, data from surveys and interviews showed that store workers were aware of and utilized the workplace activities developed by the design team, indicating relevance to the target audience. Feedback about the methods used for communicating the activities was helpful in explaining possible reasons for non-awareness.We encountered several challenges during the program that are best described and understood in the pre-implementation and context elements of the logic model. Most importantly, this pilot project grew out of an existing collaboration with a union and three regional grocers. During the planning phases, because only one grocer volunteered to participate and then offered only one store as the test site, we did not have the opportunity to assess organizational readiness at the corporate or the store levels, nor were we able to choose a site that demonstrated readiness to change. While the initial store manager was enthusiastic, he was transferred to another store early in the study and the manager who replaced him was not as invested. The new store manager’s lack of interest in the program filtered down to the design team who felt that their efforts were not appreciated. Over time, the design team’s level of enthusiasm and engagement in the process decreased. Many previous studies have shown that lack of organizational readiness and leadership support are critical factors to program success ,55,56,57We also faced obstacles related to the labor-management structure and agreements and differences between the different unions. The design team was challenged to find activities that applied to employees from the various unions, since the health benefits varied between different unions. This made it difficult for the design team to promote or build upon existing health resources. Due to labor contracts, design team members were not allowed to meet on paid work time. The research team addressed this by paying team members for their time to attend meetings; we do not know if the team’s attendance and engagement would have been different had they been allowed to meet on paid work time. Scheduling design team members to work on meeting days also proved to be difficult, which meant that design team members were asked to come in on their days off. These payment and scheduling challenges made some design team members question management’s support and willingness to follow through on proposed activities. The issue of paid time to participate on a design team is a problem when trying to implement a participatory program in hourly-paid workers. Management support should include compensating design team members for their time, and ensuring protected time for team members to develop their ideas.Research has demonstrated a clear link between worker health and productivity, and investing in employee health has become a popular strategy for improving business outcomes ,55,56,58Our research study had several limitations. As described, workers were not able to attend meetings during work time and therefore were paid by the research team to attend. The collection of data for the process evaluation may have had an impact on the program’s delivery. It is not known if the successful delivery of the program in one store will be generalizable to other retail locations, with different workers, management, facilities, and culture. In addition, we have limited data on whether the observed program implementation had an effect on the health behaviors of workers.There were also several strengths to the study, including our relationship with the store that allowed us access to employees and support for the research, in addition to the facilitator’s strong rapport with the design team. The detailed process measures allowed us to evaluate the fidelity of the program implementation and note which components were problematic and should be improved in future trials. The HWPP materials provided a useful structure and guide to make decisions throughout the process.Participatory methods like those used in the HWPP may be useful in developing TWH interventions that address a variety of work factors that affect worker health. Our recommendations for those who may choose to use this program are: (1) Assess organizational knowledge, readiness, resources, and commitment; build in time prior to implementation to educate leadership and ensure that they understand the program goals, processes, and expectations; (2) Include and budget for a knowledgeable facilitator who has good communication, planning, and organizational skills; (3) Choose team members who are enthusiastic and have good communication, planning, and organizational skills (or ensure that the steering committee can assist); (4) Schedule in-person meeting time to complete the activities for each step (rather than assume the team will complete things outside of meetings); (5) Customize the worksheets for the audience and add materials as necessary to aid the team through the process; (6) Involve the steering committee early in the process and ask them at the onset of the program to play an active role in planning and implementing solutions; and (7) Build in time and resources for periodic evaluation and modifications that may result from the evaluation.Participatory programs such as the HWPP show promise as a methodology for creating effective Total Worker Health interventions. This approach is useful for developing activities that can be used by workers and are relevant to their health. This is particularly important for workers in lower paying jobs or in jobs that have complex or chaotic work environments which present other challenges for good health behaviors. The detailed evaluation showed that substantial resources are needed to deliver the program and that enthusiastic, consistent, and active support from management is a critical determinant of success. The broader workplace context may also present challenges which should not be minimized or ignored. Future research studies should explore creative approaches for addressing organizational/contextual challenges that arise during participatory programs and should examine the efficacy of participatory programs. The logic model in this paper offers a framework for evaluating both implementation and efficacy, while considering the unique organizational contexts in which the intervention occurs.


Most children in families with low income do not meet dietary guidance on fruit and vegetable consumption. Fruit and vegetable prescription programs improve access to and affordability of health-supporting foods for adults, but their effect on dietary behavior among children is not known. The objective of this study was to describe the extent to which exposure to a fruit and vegetable prescription program was associated with changes in consumption among participants aged 2 to 18.t tests to compare change in fruit and vegetable consumption (cups/day) between first and last visits and multivariable linear regressions, including propensity dose–adjusted models, to model this change as a function of sociodemographic and program-specific covariates, such as number of clinical visits and value of prescription redemption.We used data from a modified National Cancer Institute screener to calculate fruit and vegetable intake among 883 children who were overweight or had obesity and participated in a 4- to 6-month fruit and vegetable prescription program at federally qualified health centers during 4 years (2012-2015). Secondary analyses in 2017 included paired We found a dose propensity–adjusted increase of 0.32 cups  for each additional visit while holding constant the predicted number of visits and site. An equal portion of the change-score increase was attributed to vegetable consumption and fruit consumption (β = 0.16 for each).Fruit and vegetable prescription programs in clinical settings may increase fruit and vegetable consumption among children in low-income households. Future research should use a comparison group and consider including qualitative analysis of site-specific barriers and facilitators to success. Fruit and vegetable prescription programs increase access and affordability of healthy foods among adults, but their effect on children’s dietary behavior is not known.Among families with children who were overweight or had obesity  in a 4- to 6-month prescription program at federally qualified health centers, we found a dose propensity–adjusted increase in fruit and vegetable consumption of 0.32 cups per day for each additional visit, with an equal portion attributed to changes in vegetable consumption and fruit consumption.Clinically based fruit and vegetable prescription programs with nutrition education may be an effective way to improve diets for children in low-income households.In 2007–2010, just 40% of children aged 1 to 18 years met the US Department of Agriculture fruit intake recommendations; 7% met vegetable recommendations ,4. Low-iHealthy food programs at farmers markets and grocery stores provide financial incentives for obtaining fruits and vegetables at the point of purchase –9. Incen1c levels  was a 4- to 6-month intervention, conducted during 4 years (2012–2015), that targeted change in dietary behavior among children and teenagers aged 2 to 18 years. Health care providers at federally qualified health centers enrolled patient participants who were overweight or had obesity (1 child per household); inclusion criteria consisted of a diagnosis of overweight or obesity based on body mass index (determined by weight-for-age), parental consent, patient willingness to participate, and family intent to make at least 3 program visits. Recruitment methods, including enrollment caps, were determined at the discretion of each site . The proOf 1,269 participants, we included 883 in the analytic sample from 12 clinical sites in Connecticut, Maine, Massachusetts , Rhode IThe primary independent variable of program exposure was the number of clinical visits attended by the participant family, and the secondary variable of program exposure was the amount of FVRx redeemed. Data for the dependent variable, recent fruit and vegetable consumption , were collected by program providers at each clinical visit by using data from surveys adapted from the National Cancer Institute’s Eating at America’s Table Study Quick Food Scan, which was validated in adults but not in children ,18. SurvWe used data on children’s fruit and vegetable consumption (cups/day) at first and last visits to characterize change over time; we further examined fruit and vegetable consumption data against the USDA age- and sex-specific fruit and vegetable consumption recommendations  and calct tests compared daily fruit, vegetable, and combined fruit and vegetable consumption from first to last visits, regardless of the total number of visits, whereas linear regression models examined mean change in fruit and vegetable consumption as a function of sociodemographic and program-dose covariates. Significance was set at P < .05.We used Stata software version 13 (StataCorp LLP) for all statistical analyses. We used descriptive statistics  to summarize the distribution of study variables. Paired Unmeasured covariates associated with greater program adherence may have contributed to greater change in fruit and vegetable intake over time, suggesting that unmeasured confounding could account for any dose-response relationship instead of program effectiveness. To adjust for these confounders, we first determined predicted dose propensities for visits and FVRx redemption by using the following covariates associated with visit number and FVRx redemption: participant’s race/ethnicity, sex, and age group; highest level of education of mother or primary caretaker, household size; enrollment in federal food assistance programs , program year, and clinical site. Linear regression models then estimated the dose propensity–adjusted association of FVRx redemption with mean changes in consumption; in this way, we compared changes in consumption along with measures of both expected and actual program exposure . We chose to use change scores, as opposed to controlling for baseline intake, because of the large differences at baseline in fruit and vegetable consumption between frequent and infrequent visitors . In the The mean age of the 883 participating children was 10 years; most (80%) were younger than 13; more than half (54%) were female . Sixty-oAverage household redemption of FVRx prescriptions during the program was $361. Most participants (69%) made 3 or 4 clinical visits over an average period of 87  days in a single program year during their enrollment. Average FVRx redemption proportion was 59%; 9% of families exceeded the theoretical maximum for redemption. Three of the 12 clinical sites enrolled almost half of all participants (49%). Approximately one-quarter of participant data were collected from each program year, with slightly more from 2014 (29%).t tests, the mean change in combined daily fruit and vegetable consumption from first visit to last visit was 0.26  cups. Similarly, linear regression models adjusted for sociodemographic and program-related covariates showed a significant dose-response increase of fruit and vegetable consumption of 0.32 cups per additional clinical visit   . We founIn dose propensity–adjusted regression models holding constant the predicted number of visits and clinical site , the assUsing causal inference methods to account for measured and unmeasured confounders, we found a significant and meaningful change in children’s fruit and vegetable consumption associated with dose of program exposure (number of visits). We found a significant increase of nearly a third of a cup in mean fruit and vegetable consumption, which, despite programmatic and study differences, was greater than the overall total increase in fruit and vegetable consumption (nearly a quarter-cup) among participants in a large-scale nutrition incentive study, which focused on adults . The proIn systematic reviews of nutrition interventions for children aged 12 or younger, most increases in consumption are attributed to increases in fruit and less so in vegetables . SimilarPerhaps surprising was the lack of association between increased total prescription redemption and increased fruit and vegetable consumption, suggesting a possible substitution effect as families reallocated spending and limiting an anticipated long-term effect of such a program. The clinical encounter and/or nutrition education may have had a greater influence on behavior change than the financial incentive. This possibility is consistent with a 2016 review of 33 price interventions promoting healthy dietary behavior among adults, which found that the most effective programs at increasing consumption included nutrition education .Differences in food access  or capacity  among sites may also have affected increases in fruit and vegetable consumption, consistent with a previous analysis of a subset of this FVRx data set . The sitStudy strengths include accounting for possible self-selection bias and control for some measured and unmeasured confounders by using change scores and causal inference methods, specifically dose propensity–adjusted regression models. In addition, the study capitalized on a large data set from a novel program operationalized in a clinical setting. Program implementation under real-world conditions, rather than in a controlled trial, has helped the institutional operators iterate program design over the years. For example, concerns over limited access to farmers markets led to a partnership with a national retail chain in 2017 and 2018 to increase shopping convenience and possibly overall FVRx redemption. Although our results may have limited generalizability, outcomes from this real-world natural experiment offer proof of concept to help lay groundwork for a prospective trial.Our study had several limitations. We relied on self-reported dietary intake. Nutrition interventions that rely on self-reported dietary intake are often limited by design, but they can inform dietary guidance and public health policy . ReliabiOur sample’s average baseline consumption of fruits and vegetables was higher than national rates, particularly for lower-income households ; on the Despite these limitations, our findings support growing interest in collaborative partnerships between the health care sector, farmers markets, and community organizations, to address poor diet and, by extension, overall health. With a growing number of prescription-based incentive programs now at the local, city, and state level , it is critical to conduct more rigorous studies to determine best practices to achieve highest impact, including tests of geographic location, retail type (market vs grocery store), and food-type restrictions. Because most prescription programs rely on grant funding, which may be unsustainable, more evidence on the cost-effectiveness of the FVRx intervention for chronic disease prevention is warranted before health care organizations or insurers will agree to integrate it into their care portfolios. In addition, studies using true experimental design with complementary fruit and vegetable assessment tools, such as 24-hour recall, could bolster the scientific evidence base. Overall, more consistent use of selected indicators or measures across prescription programs could improve the ability to assess outcomes and improve program design on a larger scale.