Endobronchial ultrasound (EBUS) combined with trans-esophageal endoscopic ultrasound bronchoscope guided fine need aspirate (EUS-B FNA) of mediastinal lymph nodes is an established procedure for diagnosis. The main barrier to a combined EBUS EUS-B FNA approach is availability of trained and accredited pulmonologist who can perform procedure safely and confidently. To address this gap, we undertook a training program for experienced EBUS bronchoscopists to train, learn, and incorporate combined EBUS EUS-B FNA into their procedural practice. Thirty-two patients were selected based on CT and or PET findings. Four experienced bronchoscopists participated by reading through learning material, observing 5 cases before performing EUS-B FNA under direct supervision. Forty-one lymph nodes and 6 non-nodal lesions were sampled. EUSAT assessment was performed by supervisor. Learning curves were derived from assessment scores. We observed that learning curve tends to plateau when participant can perform 3 or more consecutive cases with EUSAT score above 50. There were no complications. Our experience suggests that there is relative ease in transition to combined EBUS EUS-B TBNA procedures for mediastinal lymphadenopathy and lung cancer diagnosis and staging for experienced bronchoscopist using a program which incorporates direct supervision, EUSAT assessment, and extension of EUS B FNA training into daily real-world practice. Endobronchial ultrasound (EBUS) combined with trans-esophageal endoscopic ultrasound bronchoscope guided fine need aspirate (EUS B FNA) of mediastinal lymph nodes is an established procedure for diagnosis of mediastinal lymphadenopathy , lung caThere are currently no training guidelines for pulmonologists performing EUS-B FNA. Experienced EBUS TBNA bronchoscopists  have perThe main barrier to combined EBUS EUS-B FNA approach is availability of a trained and accredited pulmonologist who can perform procedure safely and confidently. To address this gap, we undertook a training program for experienced EBUS bronchoscopists, defined as having done at least 40 EBUS TBNA a year and having 3 or more years of prior experience in EBUS TBNA, to train, learn, and incorporate combined EBUS EUS-B into their procedural practice.From 2018 to 2021, patients with mediastinal lymphadenopathy or suspected lung cancer assessed by CT or PET scan to have lesions accessible by EUS-B and difficult bronchoscopy were selected. EUS-B FNA was done on selected patients if para-esophageal lesions were inaccessible by EBUS or if there were patient factors, such as excessive cough prohibiting proper visualization, desaturation, or raised intra cranial pressure.Four experienced EBUS bronchoscopists, with prior knowledge of lung cancer staging, EBUS scope handling and interpretation of endoscopic images of mediastinal structures, were included in the training program. Learning material on technique and anatomical landmarks of EUS-B were distributed to the four participants . They obPatients received topical 1% lidocaine spray for oropharyngeal anesthesia. They were placed in supine position and received conscious sedation with intravenous fentanyl and midazolam. Airway inspection using flexible bronchoscope is routinely done. Aliquots of 1% lignocaine are administered through the flexible bronchoscope for airway anesthesia.All EBUS procedures were performed with a flexible convex probe ultrasound bronchoscope with linear scanning transducer 7.5 MHz . Two types of EBUS needle were available for use (1) 22-G needle  (2) 25G or 22G needle .Cases that required EUS-B FNA after EBUS assessment or were assessed to require only EUS-B FNA had standardized EUS-B procedure as described previously ,4. EUS-BRapid on-site cytology evaluation (ROSE) was done routinely. Aspirated material was smeared onto glass glides, air dried, and fixed in 95% ethanol. Air-dried smears were subsequently stained using Hemocolor stain  and were examined by on-site cytotechnician, who would categorize samples as adequate, defined as more than 40 lymphocytes in high power field or presence of clusters of anthracotic pigment-laden macrophages, or inadequate. Excess material was placed in 10% formalin or directly brought to the laboratory for embedding into paraffin cell blocks for histologic examination using hematoxylin and eosin (H&E) staining. Immunohistochemical staining was done as required to further delineate the type of malignancy.From point of performing EUS-B FNA under direct supervision, participants were assessed prospectively by EUSAT assessment tool which was found to be valid and reliable for assessing EUS FNA performed by training pulmonologist with an echoendoscope. EUSAT has twelve items with a scale of 1–5, with a maximum of 60 points. In our assessment done on site or shortly after completion of procedure, 5 points were assigned for performance of itemized skill on first attempt, 4 points for performance at 2nd attempt with verbal guidance, 3 points for performance after more than 2 attempts, 2 points for performance after more than 2 attempts with verbal guidance, and 1 point for inability to perform itemized skill, and scope is taken over by supervisor.Patient characteristics, participant profile, number of lymph nodes sampled, number of passes made per lymph node, size of lymph node, and whether EUS B FNA result was consistent with final diagnosis was collected. Final diagnosis is based on histological reports, surgical biopsy if available, or electronic records at 6-month follow up.p < 0.05.EUSAT assessment scores were collated and plotted to display individual learning trajectory curves. Statistical analyses using Fisher exact test and logistic regression were performed to investigate association between EUSAT score and correct diagnosis, as well as between EUSAT score, lymph node size, and location. Lymph node location was dichotomized to commonly assessed stations  and less frequently assessed stations . Statistical analyses were performed using Stata . Statistical significance was taken to be Characteristics of patients are as presented in Participant characteristics are as in Sampled lymph node characteristics are in No complications, such as mediastinitis or pneumothorax, were reported. In EUS-B FNA procedures, there were no cases of hypoxaemia and bleeding requiring administration of hemostatic agents.p= 0.109).EUSAT scores are presented in We have found relative ease in training and transitioning experienced EBUS bronchoscopists to EUS-B FNA. Based on learning trajectory curves that tend to plateau at EUSAT score of 50 and above, we propose that experienced bronchoscopists achieving a supervisor assessed score 50 or above for 3 or more cases could be competent to perform EUS-B FNA independently. Using logistic regression, we did not find any association between lymph node short axis diameter and location, or even 4L/7 target location, with high EUSAT score, defined as more than 50. We suggest that temporal improvement in EUSAT scores is attributable to learning effect over time. No association between correct diagnosis and high EUSAT score was found on analysis, and this can be accounted for by effect of direct supervision while participants are learning.Expert guidelines for EUS FNA of pancreas recommended at least 150 cases before competency . In traiIn the study by Konge et al. , using ECurrently, there are no established local or regional training guidelines for EUS B FNA training and accreditation. Experienced pulmonologists who wish to incorporate EUS-B into their practice will be advised to seek training through supervision by trained respiratory or gastroenterology colleague. Our experience suggests that overlapping skills acquired from respiratory and critical care practice, including handling of EBUS bronchoscope, ultrasound image interpretation, and needle puncture and aspiration, contribute to ease of transition to combined EBUS EUS-B FNA.In the study by Leong et al. , learninOur study has limitations. Due to small number of participants, we were unable to examine the correlation between the number of previous EBUS performed and EUSAT score or the increase in EUSAT by repeat examinations. Potential source of bias from use of 1 supervisor assessor instead of multiple assessors. Waiting for more trained expert supervisors, sending video records for independent assessment, and obtaining EUSAT scores from expert performed EUS-B FNA to have a reference score would have delayed development of EBUS EUS-B clinical services. We did not use diagnostic yield as competency outcome as the supervisor is likely to influence diagnostic yield outcome in supervised training. We are unable to account for supervisor influences and effect on EUSAT scores and participants competency to perform independently after 2-year study period. However, we have observed that our bronchoscopists could perform combined EBUS EUS-B FNA procedures independently and, in 2 cases, involving left adrenal biopsy, beyond what was previously done by our unit.In our practice, no strict protocol for systematic EBUS approach to mediastinum evaluation has been instituted. Whether procedure was based on systematic approach or targeted EBUS approach was dependent on individual bronchoscopists. For EUS-B FNA, systematic approach in accordance with EUSAT assessment tool is adhered to in training and practice. In a SCORE study , systemaIn conclusion, our experience suggests that there is relative ease in transition to combined EBUS EUS-B TBNA procedures for mediastinal lymphadenopathy and lung cancer diagnosis and staging for experienced bronchoscopist using a program which incorporates and extends EUS-B FNA training and supervision into daily real-life practice.


ARID1A detected by next-generation sequencing with complete loss of ARID1A expression by immunohistochemistry.SWItch Sucrose Non-Fermentable (SWI/SNF) chromatin-remodeling complex functions collectively as a tumor suppressor and the inactivation of any of its constituent components is frequently associated with tumor initiation and/or progression. Most SWI/SNF deficient tumors share common rhabdoid morphology. ARID1A is the most frequently dysregulated SWI/SNF subunit in human cancer and inactivation of ARID1A is frequent across carcinomatous types while very rarely drives the tumorigenesis of sarcomas. Herein, we report a rare case of primary prostatic undifferentiated spindle cell sarcoma with focal rhabdoid morphology, harboring biallelic inactivation of ARID1A; the predicted inactivating effect of ARID1A deletion was confirmed by immunohistochemical staining. After the surgery, the patient received an alternative combined chemotherapy of doxorubicin and ifosfamide for 5 months. The patient died 9 months after initial presentation due to extensive abdominal metastases.The patient is a 58-year-old man who presented with dysuria and obstructive voiding symptoms for 3 month and was found to have a large, ill-defined, prostatic mass lesion with circumferential extension into the rectal wall on imaging studies. A needle biopsy showed a spindle cell undifferentiated sarcoma of the prostate and the patient was treated by chemotherapy of combined etoposide and cisplatin for 2 months. A subsequent imaging study showed that the tumor was significantly enlarged, and the patient underwent laparoscopically radical prostatectomy. Gross examination showed a disrupted, 10 × 7 × 5 cm, solid and cystic mass involving almost the entire prostate and sparing the seminal vesicle glands. Histologic examination showed that tumor was composed mainly of mildly atypical, oval to spindle-shaped cells, arranged in sheets and fascicles or herringbone-like patterns within a small amount of edematous to myxoid, vascularized stroma. Notably, groups of discohesive rhabdoid tumor cells with eccentric nuclei, prominent nucleoli, and abundant globular cytoplasm were observed. There were prominent mitotic figures, multifocal geographic necroses, and foci of lymphovascular invasion. Immunohistochemistry showed that the tumor cells were diffusely positive for TLE-1 and vimentin and focally positive for epithelial membrane antigen, AE1/3, Cam5.2, SATB2, and CD34 . Next-generation sequencing showed biallelic inactivation mutation of We report an ARID1A deficient undifferentiated spindle cell and rhabdoid sarcoma of the prostate, adding to the growing spectrum of SWI/SNF driven undifferentiated sarcoma. Rhabdoid cells can be a helpful morphological clue for promoting molecular and immunohistochemical analyses for deficiency of SWI/SNF subunits, in the diagnostic workup of undifferentiated neoplasms featuring epithelioid or rhabdoid morphology.The online version contains supplementary material available at 10.1186/s13000-022-01198-4. ARID1A, ARID1B, ARID2, PBRM1, SMARCB1, SMARCA4, and others [ARID1A detected by next-generation sequencing (NGS) with complete loss of ARID1A expression by immunohistochemistry (IHC).The SWItch Sucrose Non-Fermentable (SWI/SNF) chromatin-remodeling complex is a large multi-subunit protein assembly that orchestrates chromatin compaction and accessibility for gene transcription in an ATP-dependent manner –3. The md others , 6. Inacd others , 8. HereA previously health 58-year-old man with an unremarkable medical history presented with dysuria and obstructive voiding symptoms for 3 month. Digital rectal examination revealed a firm to hard, fixed, pelvic mass compressing the anterior aspect of the anal canal. By laboratory examination, the serum carcino-embryonic antigen 2.3μg/l) and prostate-specific antigen  were within normal limits. Magnetic resonance imaging (MRI) revealed a large, ill-defined, prostatic mass lesion with circumferential extension into the rectal wall Fig. a. Positr.3μg/l anBCOR rearranged sarcoma, fluorescence in-situ hybridization (FISH) analyses were performed which revealed negative for rearrangements of both the SYT/SS18 and BCOR loci   and ARID1A exon18 p.Thr1535Argfs *36 (c.4604_4605del). IHC using anti-ARID1A antibody  showed complete loss of expression on the tumor cells  showed SWI/SNF subunits alterations including inactivating mutations or genomic deletions, of which the most common mutated subunit was ARID1A , followed by PBRM1 , SMARCB1 , and ARID2  [ARID1A inactivation has also been found in pediatric neuroblastoma and aggressive meningioma [ARID1A p.Leu657Glnfs*18 detected in the patient’s tumor is a frameshift mutation, which is located in exon 5 of the ARID1A and causes the encoded protein sequence to undergo continuous erroneous changes starting with leucine at position 657 until position 18 is replaced with a stop codon. The detected ARID1A p.Thr1535Argfs*36 is also a frameshift mutation that is located in exon 18 of the ARID1A, causing the encoded protein sequence to undergo continuous erroneous changes starting with threonine at position 1535 until position 36 is replaced with a stop codon. The biallelic inactivation mutation of ARID1A may lead to premature termination of protein coding, resulting in truncated protein products, which may affect the function of the protein. As ARID1A mutations are believed to result in reduced gene expression [ARID1A in this prostatic tumor. From a morphologic point of view, SWI/SNF deficient soft tissue neoplasms usually consist of monomorphic undifferentiated epithelioid to plump spindle cells with some of rhabdoid cytomorphology [SMARCB1 biallelic inactivation in virtually all cases [ARID1A discovered by NGS represents the driven molecular event in the current case.Deleterious mutations of genes encoding subunits of the SWI/SNF complex are commonly found in more than 20% of all human cancers –4. Such n cancer . Mutatiorcinomas , 9. ARIDD1A 4; 0.%, followTP53 alterations in 6 cases, ATRX mutations in 2 cases, and gene rearrangements in 8 cases. Among the latter, 4 gene fusions identified  can be used for reclassification of the cases as specific entities. Among the 9 cases that lacked TP53 mutations, ATRX mutations and oncogenic gene fusions, similar to our case, one high-grade unclassified prostatic sarcoma was described to harbor a pathogenic biallelic inactivation of ARID1A. This case was a 19-years-old male patient whose tumor showed a solid, short fascicles or patternless pattern with necrosis and increased mitosis [ARID1A plus mutations in KRAS, PIK3CA, and EP300. These data suggest that ARID1A mutations may not be non-recurrent genetic events in high-grade prostatic sarcomas. For those with specific differentiation, such as rhabdomyoblastic differentiation, it is unclear whether the detected mutations of ARID1A represent oncogenic drivers or just passenger mutations. Accumulation of more cases along with functional studies of ARID1A inactivation are needed for further elaboration.Primary prostatic sarcoma is an exceedingly rare type of non-epithelial malignant tumor accounting for less than 0.2% of all prostate cancers –14. Typi mitosis . In addi mitosis  had poinSYT/SS18 rearrangements. Undifferentiated spindle cell tumor background with focal rhabdoid cells makes embryonic RMS and malignant peripheral nerve sheath tumor with rhabdomyoblastic differentiation  also enter into the differential diagnosis. However, negative for myogenic markers including desmin and myogenin, can readily exclude the possibility of embryonic RMS, and absence of expression of S100 protein and SOX10 together with retained expression of H3K27me3 disagree with a malignant triton tumor [ARID1A mutations have rarely been documented in prostate carcinomas [Despite extensive immunohistochemical stains along with multiple molecular analyses, the lineage differentiation of the current case is difficult to elucidate and the differential diagnostic spectrum is board. Diffuse and strong expression of TLE-1 as wells as focal expression of multiple epithelial markers strongly suggest the diagnosis of synovial sarcoma, and rhabdoid differentiation can also be seen in synovial sarcoma . Howeveron tumor . Perhapsrcinomas . Sarcomarcinomas . In addircinomas , 22. AbsARID1A detected by NGS with complete loss of ARID1A expression by IHC. Our case adds to the growing spectrum of SWI/SNF driven undifferentiated sarcoma. Because rhabdoid morphology is characteristic of SWI/SNF deficient neoplasms, its recognition can be helpful in the diagnostic workup of undifferentiated neoplasms featuring epithelioid or rhabdoid morphology, in combination with molecular and immunohistochemical analyses for deficiency of SWI/SNF subunits. Inclusion of other SWI/SNF immunomarkers, such as ARID1A, in the differential diagnostic workup of poorly differentiated sarcoma not fitting well-known subtypes, such as SMARCB1 and SMARCA4-deficient sarcomas, is recommended. As ARID1A loss has been associated with improved response to immunotherapy across diverse tumor types [ARID1A mutations in aggressive soft tissue sarcomas may of great clinical significance for targeted therapy.In summary, we describe a rare case of primary prostatic sarcoma that shows undifferentiated spindle cell with focal rhabdoid morphology and harbors biallelic inactivation of or types  and ARIDor types , identifAdditional file 1. Additional pertinent immunohistochemical features of ARID1A deficient undifferentiated spindle cell and rhabdoid sarcoma of the prostate. The tumor cells are diffusely positive for (A) vimentin and focally positive for (B) epithelial membrane antigen, (C) Cam5.2, and (D) SATB2 . (E) The Ki67 proliferation index was estimated at 50%. Immunohistochemical stains are negative in the tumor cells including (F) SOX10, (G) S100 protein, (H) P63, (I) cytokeratin5/6, (J) NKX3.1, (K) alpha-methylacyl-CoA racemase (AMACR), (L) smooth muscle actin, (M) desmin, (N) myogenin, (O) DOG1, (P) STAT6, and (Q) CD117. The expression of (R) H3K27me3, (S) SMARCB1/INI-1, and (T) SMARCA4/BRG-1is retained.


Background: Weight loss and physical activity (PA) are recommended for arthritis management. The Group Lifestyle Balance (GLB) Program(TM) is an evidence-based, lifestyle change program for weight loss in individuals with prediabetes, but hasn’t been evaluated in people with arthritis. Purpose: The purpose of this study was to evaluate the effectiveness of an adapted version of the GLB program on PA and psychosocial outcomes related to weight loss among overweight (Body Mass Index >27) individuals with arthritis. Methods: A single-group, quasi-experimental design was used to examine the effects of the adapted GLB program on measures of PA and psychosocial outcomes. All participants (N=15) received the GLB program and completed the following surveys: CHAMPS PA, Self-Efficacy for PA (SE), Social Support for PA (SS), Weight Loss Efficacy (WEL) and Barriers to Healthy Eating (BHE) at baseline, 12-weeks, 6 months, and 12 months. Repeated measures ANOVA and the Friedman Test were used to examine changes over time. Results: Participants (aged 53-79 years) were primarily female (82%), white (94%), and college educated (94%). Significant improvements were found in BHE subsections of self-control and motivation (p=0.002), daily mechanics (p=0.042), and WEL subsections of availability (p=0.049), social pressure (p=0.010), physical discomfort (p=0.011), and positive activities (p=0.007). Weekly caloric expenditure (p=0.004), metabolic equivalent minutes (p=0.022) for all activities, and moderate-intensity activities (p=0.019) also showed significant improvements. However, most improvements were seen in the short-term. Conclusions: The GLB program should be further evaluated for its effectiveness in people with arthritis.


Results from the online survey showed a preference for programs with online  compared to traditional delivery , emphasising the potential benefits on children’s physical activity levels, sleep, and cognitive function. However, after piloting the program, educators preferred to use the book version instead of the video. This program has the potential to become part of daily regular practice. Barriers reported include logistics issues , connectivity issues with internet, and the need for varying activities. There is currently limited evidence on parents’ and early childhood educators’ perspectives on implementing programs that combine cognitive and motor tasks in early childhood. An online survey was distributed across Australia through social network platforms and emails at preschool centres, asking 65 parents of preschool children and early childhood educators about their preferences on program delivery, duration, and mode. Responses from the survey were evaluated in order to develop and pilot a 4 week home-based ( The preschool years (under 5 years) are a critical time for cognitive and behavioural growth, as well as for dynamic and elaborative developmental changes in children’s brain . This peThe World Health Organisation’s  physicalHowever, lack of educators’ time during the school day, limited opportunities for training and professional learning development, limited accessibility of children and preschools to natural settings, as well as safety concerns were reported as barriers by early childhood educators for providing limited opportunities for physical activity participation in preschool services ,6,7,8. OEarly childhood educators’ own perceptions  and personal negative experiences with physical activity can also explain why they can be reluctant in promoting movement sessions during the preschool day . If we wCreating a supporting environment which adopts whole-of-school physical activity policies could be helpful for children’s health and development . SuccessSeveral systematic reviews and meta-analyses focusing on active learning  found that it can improve learning and increase physical activity levels in preschool and primary school children ,15,16,17Notably, the preschool environment is unique as it is the first structured environment most children engage in and it is critical for developing positive attitudes towards school and learning, as well as following rules . Active Emerging evidence on early childhood educators’ perceptions is quite recent, exploring merely opportunities for physical activity practices in general, whereas evidence for parents’ perceptions is scarce. However, the role of parents is important to be considered as they are making final decisions about their children and have an ongoing interaction with educators. Although there is a growing number of active learning programs, there is disperse knowledge on the facilitators and barriers in applying those programs in the preschool environment, with the main focus in the literature being on barriers and facilitators in the elementary classroom ,27,29. AA two-phase approach was used in this study, with results from Phase 1 informing Phase 2. In Phase 1, an online anonymous survey was developed targeting early childhood educators’ and parents of preschool children from the community throughout Australia . The questionnaire requested participants’ demographic information as well as their thoughts on implementing programs that combine motor and cognitive tasks in early childhood, including early childhood and care (ECEC) services as well as at home. In Phase 2, we designed an intervention with cognitively engaging physical activity. We conducted a pilot study of a 4 week home-based program with parents. In addition, we trialled the same program as a 6 week intervention in ECEC services. Parents and educators provided feedback on the programs accordingly responding to a questionnaire sent to them via email.Phase 1 participants included parents of preschool children and early childhood educators from the general community located in Australia including both urban and rural areas. Ethics approval from the University’s Human Research Ethics Committee was sought and received for both phases . A participant information sheet, containing a consent form, was attached at the beginning of the online questionnaire for Phase 1 participants. Participants were requested to  complete and return the consent form, before being able to proceed with the questionnaire. In Phase 2, a participant information sheet, containing a consent form, was given in hard copy to parents and early childhood educators of participating ECEC services. Parents for the home-based program were recruited from the memberships or casual visits of the Early Start Discovery Space of the University of Wollongong, whereas early childhood educators were recruited from invitations sent to directors of local ECEC services. Participants were asked to sign and return the consent forms within a 2 week timeframe from the beginning of this study. Phase 2 participants (home-based and preschool programs) received a book related to the activities, as compensation for their participation. The survey materials were created using the REDCap  platform, were anonymous and had a total duration of 5 min. The link to complete the survey was circulated via social media communication , emails to directors of the preschool centres across all states in Australia, advertised in the official webpage, as well as in Newsletters and Engagement and Network Centres of the University of Wollongong, Australia. It consisted of 18 questions in total: 9 questions with multiple choice options regarding participant demographic information , and 9 questions with pre-filled answers  about perceptions on the potential of applying programs involving motor and cognitive tasks in early childhood. The survey was slightly altered in order to provide questions relevant to both groups (parents and early childhood educators). Example questions included “Would you prefer the program to be delivered in a hard copy or electronic version?” and “Do you consider programs that combine physical activity with learning tasks as an effective way to reduce sitting time in young children?”. The survey questions are provided in A program with cognitively engaging physical activity for preschool children was developed, targeting to enhance their executive function skills and physical activity levels, in alignment with the Early Years Learning Framework . The EarThis program involved videos with cognitively engaging physical activity for preschool children. Its design considered that movement-based experiences adjusted in digital environments can provoke children’s exploration and imagination, and in turn instigate their cognitive development . It was The program consisted of two versions: a 4 week home-based program for parents and a 6 week school-based program for early childhood educators. After the completion of the 4 week home-based program, the 6 week school-based program begun. The program components were similar for both versions. The same videos were shown at ECEC services as in the home-based program. Considering the feedback from the home-based program, the school-based program did not change design or content. However, it included more activities, and the option of using the video, the book, or both. Parents and early childhood educators were asked to play the video and participate in the activities with their children twice per week (at a time convenient to them). The videos included reading sessions and self-explaining activities based on the book “Quincey Quokkas Quo”. This book has been previously shown to support preschool children’s executive function skills . The booParents and early childhood educators were not aware of the group assignment and the existence of different groups. At the end of the program, they were sent an email and asked to provide their feedback on the program, responding on 9 open-ended questions . Similarly, the same questionnaire, including some variation to address the different context, was distributed to early childhood educators via email, after the end of the implementation of the 6 week program. This was adapted from a previous post-program evaluation questionnaire targeting primary school teachers’ perceptions on a program that integrated physical activity within English lessons . The queParticipant answers were subjected to thematic analyses in order to identify themes and patterns, describe and interpret their meaning . A deducCombining motor and cognitive tasks offered innovative ways and opportunities for both parents and early childhood educators to engage with children compared to traditional story time . The need for support was emphasised in several quotes by both parents and early childhood educators regarding resources , additional ideas by the research team, extra training . Although the delivery dose  and time commitment were appropriate, there was a clear preference towards the book over the videos. This was enhanced by technical difficulties that both parents and early childhood educators faced regarding the small size of the book  during the video, along with the background pictures which were considered as distractions. Motivation was another theme that came across from the analysis. Several positive sub-themes were identified as motivational factors for the children and the teachers from the implementation of the program, including increased enjoyment, confidence, and interest, whereas negative factors were not absent, including lack of variety, differences in the student learning style, repetition, task difficulty and class programming. Fewer parents and early childhood educators did not notice any changes on motivational factors. In addition, the academic, cognitive, and motor benefits from the program were emphasised by several teachers regarding improvements on counting, reading, comprehension, reaction time, holistic development, motor skill, and alignment with the Early Years Learning Framework . On the other hand, child attendance at preschool (or lack of attendance due to illnesses), time management issues due to staff rotation, and the use of accelerometers as an additional measurement tool, were considered as implementation barriers by early childhood educators. Lastly, it was suggested that the program could be useful as an opportunity for connections with parents and childcare centres, as reported by parents and early childhood teachers. Phase 1 included 65 participants. Four participants did not specify if they were parents or early childhood educators and were excluded from the analysis. Demographic characteristics for Phase 1 participants are displayed in Program delivery, duration, and frequency: When participants were asked about their preferences on program delivery, 26 early childhood educators said that they would prefer an electronic form and 18 a hard copy version of programs. Similarly, 10 parents preferred an electronic form and 7 a hard copy version of programs.n = 14 educators; n = 6 parents), or 10–15 min . Regarding request on recording and reporting children’s daily behaviours to research staff  for 4–6 weeks, few early childhood educators stated that they were able to provide this information daily (n = 3), while most preferred 2–3 times a week (n = 8), weekly (n = 17), or once a fortnight (n = 9). Few parents also stated that they were able to provide the following information daily (n = 2), while most of them preferred 2–3 times a week (n = 5), weekly (n = 6) delivery. There were no parents preferring a fortnight update. Lastly, early childhood educators preferred to be contacted by research staff through email (n = 29), text message on their phone (n = 7), group chat (n = 1), mobile app (n = 2), social media (n = 3), logbook diary (n = 1). Parents stated that the best way to be in contact with research staff is via email (n = 6), text message on their phone (n = 5), group chat (n = 3), mobile app (n = 3), social media (n = 2), logbook diary (n = 1).Program duration see : Most ean = 26), whereas 15.9% (n = 7) responded negatively. Additionally, 64.7% of parents responded positively .Benefits: When participants were asked if a video-based program showing physical activities combined with learning tasks during screen time would be considered as an engaging way to spend quality time with children instead of traditional videos or sedentary passive video games, a positive response  was given by 60% of early childhood educators . In contrast, five early childhood educators reported that they do not use screen time as it is not considered an engaging way for all children .n = 33) and improve self-regulation (n = 31) in young children. Similar approaches were expressed by parents for reducing sedentary behaviour (n = 11) and improving self-regulation (n = 9).In terms of potential benefits arising from combining physical activities with learning tasks see , early cn = 12), space restrictions (n = 9), special equipment required (n = 9), need for training (n = 9). Few early childhood educators (n = 12) reported no barriers. Similarly, five parents reported time restrictions, four space restrictions, five the need for special equipment, and one parent the need for training. Additionally, one parent reported no barriers, four parents commented having children with disability, weather conditions (“high temperatures during summer for outdoor activities”) and lack of awareness of the importance of physical activity, as extra barriers .Barriers: Implementation barriers on physical activities combined with learning tasks reported by early childhood educators were related to time restrictions (Participants included 5 parents from the 4 week home-based program and 5 early childhood educators from the 6 week school-based program. One ECEC service had 2 educators working on different days of the week (they responded on the questionnaire together). Quotes reported by parents and early childhood educators from the cognitively engaging physical activity group were indicated as cognitively engaging physical activity (CPA), whereas those from the cognition group as COG.n = 10). Parent 1 (CPA): “It was a great experience and inspired me to use similar activities in daily reading/play to help my child to develop his math and other cognitive ability.” Parent 1 (COG): “The time commitment was reasonable, the activities were enjoyable and the length of the videos and expectations around record keeping was achievable.” Educator 1 (COG): “The research project was a way to validate learning we see every day”. Specific program elements that parents and educators appreciated included the flexibility of the program, its components and duration of activities, and the engagement with the research team. Parent 1 (COG): “the video was a simple delivery method allowing us all to engage with the activity. Having the flexibility to watch the video at any time was a distinct pro for us. The video was also an appropriate length, it didn’t drag on and we could all maintain our attention. The video narrator came across warm and friendly, encouraging our kids to participate.” Educator 1 (COG): The book itself was interesting and interactive to older children in the group”. Educator 1 (CPA): “Engaging in professional discussions with the team of researchers. The opportunity to contribute to building a local research base of knowledge.” Program experience, benefits and enablers: The program was considered a positive experience for all parents and educators (n = 3) and educators (n = 2) in the cognitively engaging physical activity group liked the combination of physical and cognitive tasks. Parent 2 (CPA): “I like how it embeds math in activities and makes it interesting to children. I feel my son masters the concept better with physical activities and it also trains his reaction ”. Educator 2 (CPA): “We loved the movements with the book and the children were able to pick up the movements quickly when we were reading. We love that literacy and physical movement can increase children’s movement skills and seen this through the program”.Parents : “Just for the video to be clearer… we found it easier to read the children the book ourselves and then do the movement instruction as we read. The video story was hard to hear for a larger group of children”. Two parents also mentioned that a variation of more activities and videos would keep children more engaged. Parent 2 (CPA): “By using a different story each time as my son lost his interest after he watched the same story 3 times.” n = 2), adherence to dosage and compliance (n = 2). Educator 2 (CPA): “A barrier was definitely motivation of the children to engage in repetition using the same book, which then challenged my motivation!” Educator 1(COG): “Having to do the same thing each Tuesday/Wednesday. Our program is very flexible and our groups tend to be from the children’s interests or a happening during the day. Needed the same resource for approximately 3 or 4 small groups. Also, ensure every educator is delivering the program as intended”.Program barriers were linked to keeping children motivated and engaged (n = 6). Parent 3 (CPA): “He did enjoy it more with repetition, once he understood what was expected. He became better at the games, was predicting what would come next, and his counting also improved a little bit.” Educator 2 (CPA): “We have seen an improvement in our children’s interest and enthusiasm as well as improved counting throughout the program and still now. The children are also asking for the book to be read so they can do the movements”. Educator 1 (COG): “No noticeable difference, maybe some in number work”.Program impact: Most parents and educators found an improvement on their children’s counting skills (n = 6). Parent 1(CPA): “He enjoyed it while he was doing it, I just had to motivate him to start sometimes.” Parent 3(CPA): “He did –enjoy—the activities more than the story .” Educator 2 (CPA): “Most of the children enjoyed the program as it was something new and they liked the movement”. Educator 2 (CPA): “We have seen children engaging in these experiences with enthusiasm and we have seen children having more interest in numbers and counting”. Educator 1(COG): “The children did seem to enjoy the program. The tasks were challenging and could be varied”. They were also some mixed feelings on children’s enjoyment. Educators 2–3 (COG): “Only some of the children enjoyed the program.”Program enjoyment: The majority of children seem to have enjoyed the program as reported by parents and educators (Program adoption: Most parents and educators were positive in continuing the activities at home and at school beyond the score of the research project. Parent 1 (CPA): “Possibly, as it would encourage me to do more reading at active times of day, rather than as a calming activity.” Parent 2 (CPA): “Yes, it provided many good examples about how to combine the activity, math, and reading together. I will try to use the similar approach/activities when I read books to him.” Parent 3 (CPA): “Yes. I like that the videos give different options using the same book, but I do prefer doing them while reading the book. The activities are fun and useful, and my 3 kids are enjoying doing them together.” Educator 1 (CPA): “It is something already embedded in our practice, physical activity supports learning retention, allows for modulation of children’s arousal levels supporting regulation. As such, it could potentially be applied as a daily practice in preschools”.However, three educators were more sceptical. Educator 2 (CPA): “It would also be a useful tool to share with families to transfer this learning to home. I think this book is best used in a one on one or small group which would enable the adult to support the child where they were currently at”. Educator 1 (COG): “I think it has potential to be part of the program. We see the value of physical activity and cognition. However, I would like to present it with less expectation of it being a research project”. Educators 2–3 (COG): “We would not like to see the program become part of our regular practice. It was difficult to motivate some of the children that were involved in the program, they did not want to participate at the times that were planned or convenient for our program and they children that had not signed up at times were more interested than the others.” Nevertheless, all educators agreed that the program is aligned with the Early Years Learning Framework . EducatoThis study explored the perceptions of early childhood educators and parents of preschool children regarding programs that combine movements with cognitive tasks. For this purpose, firstly an online survey was created and sent out to participants  in the community, consisting of close- and open-ended questions (Phase 1). Secondly, a program with cognitively engaging physical activity was designed and applied as home-based activities to engage parents and their children, and as school-based activities for preschool centres. Feedback on the program evaluation was received by parents and early childhood educators (Phase 2).Results from both phases showed that parents of preschool children and early childhood educators have generally consistent opinions regarding the benefits of applying cognitive combined with motor tasks in the home and preschool environment. In general, implementing such programs was positively perceived by parents and early childhood educators, highlighting their potential benefits on children’s learning outcomes, enjoyment and their alignment with the Early Years Learning Framework, the guiding curriculum for Australian preschool children . EnjoymeIn particular, Phase 1 was based on previous studies conducting formative research to explore educators’ perceptions on physical activity intervention programs for preschool children  as well Phase 2 focused on the evaluation of the program implementation. Overall, the program was perceived as a positive experience by parents, early childhood educators, and children, with the combination of physical and cognitive tasks being considered as an innovative and interesting component. Children enjoyed participating. Additionally, potential learning benefits emerged for children, especially in the area of counting skills. An important finding from Phase 2 was that parents and educators saw the value of the program and were eager to continue its activities beyond its research scope, by adding challenges and making modifications as needed. In order for active learning to be successful, teachers need to implement the lessons as intended, regularly, and accurately. A recent review on active learning  in primary schools showed that adherence to protocols is quite low, while approximately 50% of the programs are currently researcher led, minimising opportunities for real-world applications . Especially when targeting physical activity outcomes, it is well known that preschool children do not meet the physical activity guidelines, whereas opportunities for physically active play led by the teacher (both outdoors and indoors) are limited . IntervePromoting physical activity within the preschool day is essential as it has been found to be positively related to preschool children’s executive function skills, particularly those with low aerobic fitness . In an 8It is imperative to understand and correspond to the needs of early childhood educators to deliver and implement successful physical activity programs. To this vein, we need to consider some barriers and suggestions for improvements reported by both parents and educators, arising from Phase 2: Programs need to be flexible to fit educators’ needs while delivery needs to include adjustments suitable for online environments . Educators also noted that the current program implemented was more suitable for a smaller rather than a larger group of children. Easy access to materials is also important, since the book was easier to use compared to connecting to online resources. Lastly, programs need to include different variations of activities and complexity levels to keep children motivated and engaged.As evidenced in both phases (Phase 1: “We don’t like to use screens in our centre”) along with the preference of educators in Phase 2 for the book over the videos, early childhood educators reported they were hesitant or reluctant in using screens for educational purposes. This is in consistency with current research reporting that educators have mixed feelings about technology use and its potential benefits in early childhood education . Future For instance, educational programs in digital environments that include movements, are considered a healthier way to combine recreational and educational screen time ,46, takiOf note, the current study was conducted during the COVID-19 pandemic, a period in which using screens to teach children has become the norm. Even though the necessity and dependency of technology use has been highlighted, it is also possible that educators, parents and children experienced “screen fatigue”, preferring more physical means of teaching. Having the flexibility to perform this program at home or school environment is another strength of this study, considering that many Australian families withdrew their children from ECEC services in response to COVID-19 pandemic . In 2020Overall, this study showed that combing motor and cognitive tasks was positively perceived by early childhood educators and parents of preschool children, and is feasible to become regular part of daily practices. The suggested approach may include small modifications or alterations of current approaches and strategies used by educators. However, it can offer combined physical and cognitive gains to children. In this study, technology was used as an interactive tool to enhance movement and not to replace movement with screen time. Future research could objectively measure if these programs can reduce screen time and increase children’s physical activity levels using accelerometers.The contribution of this study to the field includes its innovative design and methodology, based on current theoretical frameworks (e.g., COM-B system and movement integration typology ,35,36 alChildren can benefit from the potential positive effects of physical activity on cognition, metacognition, academic achievement and mental health ,51,52. C


The 2006 United Nations Convention on the Rights of Persons with Disabilities states that the achievement of equal rights, empowerment and social inclusion of people with disabilities requires comprehensive rehabilitation services encompassing all components of the World Health Organization Community based rehabilitation (CBR) matrix: health, education, livelihood, social and empowerment. CBR programs specifically aim to deliver such comprehensive interventions. In the present study, we investigate the impact of a CBR program in Afghanistan on all these components.We enrolled 1861 newly recruited CBR participants with disabilities in the study, from 169 villages between July 2012 and December 2013 as well as 1132 controls with disabilities randomly selected through a two-stage process within 6000 households from 100 villages in the same provinces but outside the catchment area of the CBR program. We interviewed them again after one (midline) and two (end-line) years in the study. Using propensity score matching and difference in difference analysis, we estimated the impact of the CBR on outcomes of interest, namely mobility, activities of daily living, communication, participation in social and community life, emotional well-being and employment.Three years on average into the CBR program, participants showed a significant and close to medium effect size reduction in emotional , and social participation challenges ; small to medium effect size reduction in unemployment , activities of daily living , mobility  and communication challenges .Our study indicates that a CBR program may provide positive rehabilitation outcomes for persons with disabilities even in a conflict context, and improve overall well-being of all participants with disabilities, whatever their impairment, individual characteristics and the CBR matrix components considered.ISRCTN50214054. Registered August 5th 2020 - retrospectively registeredISRCTN,  The 2006 United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) states that the achievement of equal rights, empowerment and social inclusion of people with disabilities requires comprehensive rehabilitation services encompassing educational, social, economic and medical interventions . In partCBR programs were introduced in the 1970s as a participatory strategy to use effective, locally-developed technologies and interventions to prevent disability and transfer knowledge and skills about disability and rehabilitation to people with disabilities, their families and the community at large involved in the program. CBR was conceived as a combined effort of a diverse group of actors, including families, communities, disabled people’s organizations, health and social services provided by governmental and non-governmental actors, and, at the center, people with disabilities themselves.Advocates of CBR identify several advantages of this approach over other alternatives. First, CBR is comprehensive; experts have demonstrated that all rehabilitation needs can be addressed through CBR interventions –6. SeconDespite the stated strengths, CBR programs continue to face several critiques linked to field realities. The first is that, while nominally based in values of participation and empowerment of people with disabilities, CBR often reproduce the same top-down service delivery approach of other methods . Second,Despite the proposed benefits of CBR, extensive empirical literature that provides evaluation of the impact of CBR programs in diverse contexts is lacking. Most existing studies do not evaluate the overall WHO CBR matrix but overwhelmingly focus on its health component , 16.Moreover, studies often focus on one condition or type of disability and do not evaluate the impact of CBR programs across disabilities. Notwithstanding the focus of the CBR matrix and the program design on the participation of people with disabilities in communities, few studies examine the contribution of CBR towards fostering empowerment and increasing social inclusion of people with disabilities and their families or change in community attitudes and behavior towards people with disabilities , 13, 17.Finally, sustainability of CBR is overall neglected . This reThe present impact evaluation study carried out between July 2012 and December 2015 contributes towards filling the gap between theoretical concepts of CBR and the actual completion of a CBR program implemented in 13 provinces of north and eastern Afghanistan by measuring the impact of CBR activities on the circumstances and well-being of participants with disabilities. The study aims at advancing knowledge on CBR program effectiveness by investigating the effect of the Swedish Committee for Afghanistan CBR program on mobility, activities of daily living, communication, social participation, emotional well-being and access to employment of persons with disabilities.The present study investigates the impact of the Swedish Committee for Afghanistan (SCA) CBR using a quasi-experimental design on major outcomes of interest after a maximum of 36 months in the study: How do persons with disabilities who received the CBR program’s services fare in terms of challenges in mobility, activities of daily living, communication, social participation, emotional well-being and employment compared to control with disabilities?We used a quasi-experiment because we could not randomly select and assign treatment and control to the two arms of the experiment. The program is offered to all persons with disabilities living in its catchment area and it would have been both unpractical and unethical to withdraw the program to some potential participants. We used propensity score matching (PSM) associated with difference in difference (DD) analysis to minimize critical differences between the treatment and control groups and yield unbiased robust estimates of program effects using a non-parametric regression . PSM wasThe CBR is implemented in 13 provinces of northern and eastern Afghanistan (See Map 1) and provides services to an estimated 2301 persons with disabilities in home-based activities and 1443 children in home-based education in 2018. The program covered 48 districts with over 775 staff, 863  community volunteers and 151  CBR committees. The program is managed from four regional project offices based in Ghazni city (Ghazni province), Jalalabad (Nangharar province), Mazar-e-Sharif  and Taloqan (Takhar province)  of the catchment area of the program, the other inclusion criteria were the ones defined by the CBR program at its start in 2004. At the creation of the program, inclusion was defined under the following criteria: (i) having a disability defined by the WHO guidelines for grassroot disability programs to account for contextual factors as having difficulties  that make it challenging to conduct all the activities that other members of the family or the community do, resulting in community members often considering people with such difficulties as being different or inferior to others and treating them unfairly [mahal close to the other SCA activities such as orthopedic workshops and physiotherapy centers/clinics; (iii) mahals had to be the place of residence of the newly recruited CBR workers before the program could expand progressively to nearby villages until it covered the entire district; iv) the absence in the mahal of a similar intervention by any other organization, and v) the intervention had to be welcomed by the overall village community and particularly the village council or shura; vi) the willingness of person with disabilities and the family members to participate in the CBR programs; and vii) the readiness of a family member to be trained by —and implement— the activities set up by the CBR worker in order for such activities to be ongoing daily, while the CBR worker would check progress made on a weekly or sometimes bi-weekly basis. If a village on the province was not part of the program for whatever reason, it was automatically included in the list of villages for random selection of controls. On average, one CBR worker was serving 100 participants with disabilities per year. Each expansion was decided in agreement with the CBR program management and the new targeted areas were surveyed for identification of persons with disabilities using the same WHO instrument [For the present study, we interviewed all new 1680 CBR participants included in the program between July 2012 and December 2013. Besides living in one of the 169 villages or urban areas  and 35 for children (DSQ-35) based on the same disability definition as participants to identify all members of the household with disabilities .All study participants were interviewed by the CBR workers with a locally developed and validated questionnaire that inquired about demographic characteristics, socioeconomic status, access to rehabilitation, health and social services, individual functioning, social participation, and additional needs. The questionnaire examined the effectiveness of the CBR program in improving the agency of persons with disabilities to determine their daily lives, participate in different aspects of community life, escape stigma and prejudice, and access various CBR services from the five domains of the CBR matrix  . DisabilAll study participants were interviewed with the same tool three times respectively between July 2012 and December 2013, between July 2013 and December 2014 and finally between July 2014 and December 2015.Six main outcomes of interest were included in the questionnaire and assessed through a range of questions: mobility, activities of daily living, communication, participation in social and community life, emotional well-being and employment. Indexes for each domain were created by generating a sum index score from the component items in the questionnaire. Because outcomes were sometimes different between age groups , sum index scores were based on total points possible for each age group. Each summary index score was then divided by total points possible according to age and converted to a proportional value between 0 and 1. Difference scores between rounds 3 and 1 were then calculated. Thus, a result of .15 indicates a 15% increase in points possible within a given domain. Only employment did not result in an index.The mobility index was composed of five activities with response choices limited to a Likert scale composed of three choices : Can you sit (asked to respondents above 1 year old); Can you stand (above 1 year old); Can you move inside the home (above 1 year old); Can you move outside the home (above 2 year old); Can you walk at least ten steps (above 2 years old).The Activity of daily living index was composed of four activities with the same three response choices: Are you able to eat on your own (asked above 4 years old); Are you able to bathe (above 8 years old); Are you able to use the latrine (above 3 years old); Can you dress and undress (above 4 years old).The communication index focused on the four following functions with the same three response choices: Can you speak (above 2 years old); Can you understand simple instructions (above 2 years old); Can you express needs (above 2 years old); Do you feel confident learning new things (above 4 years old).The social participation index comprised a first item below with three response choices  and four following items with three different choices : Can you make friends outside the family; Are you consulted in family decisions (above 15 years old); Can you join in community activities and ceremonies; Do you feel respected in the community (above 5 years old); Do you feel respected in your family.The emotional well-being index was composed of five items with three response choices : Do you feel sad (above 5 years old); Do you feel angry (above 5 years old); Do you feel worried or distressed (above 5 years old); Do you have nightmares or bad sleep (above 5 years old); Do you have headaches, stomach-aches or nausea (above 5 years old).We asked respondents between 18 and 60 years old if they had a paid job, either in cash or in goods, what was the employment status (7 categories), if it was full time or part time and since when did they work.We did not measure the specific effect of each service delivered by the CBR program. Each participant received services tailored to their needs. The program delivered a set of services including physiotherapy, group training, loans, home based education, center-based education, inclusion in school, home based training, community advocacy and disability awareness. In other words, the present study does not measure the impact of the discrete interventions offered by the program but rather the overall impact of the program as a whole and the combination of interventions on the participants. We cannot assess whether it was the physiotherapy or the home-based education that contributed most to the change in outcomes over time, but rather a combination of interventions as deemed necessary and useful for each participant.shura, education or health shura, district development assembly, CBR committee), and exposure to different types of disasters or negative events  in the last 3 years.Covariates we kept for PSM calculation included gender , age (continuous), cause of disability , disability type , ethnicity , assets owned at baseline in tertile , region  age of onset of the disability (continuous), household education level , working status at baseline  and household income at baseline (continuous). Moreover, people were also matched according to the baseline levels of the impact variables to ensure that CBR participants and controls started off at similar levels. We also included community-level variables such as distance to a road  and its usability for motorized vehicles (usable or not), availability of electricity (available or not), availability or not and distance  to a school and a health center, presence or not of different types of social and/or political groups in the village  were found to be significant predictors at p < .05 level of assignment into the CBR treatment program when compared to reference categories.We used a quasi-experimental approach that mixed propensity score matching with difference in difference (PSM-DD) to measure the effect of the CBR program. We analyzed the three waves of data collected from treatment and control from surrounding communities, from the onset of the program at baseline until end-line. Yet, some CBR participants left the program before because they did not need the services anymore, some migrated and a few died. Some controls left the study because they did not want to participate anymore, migrated or died. As a result, we only have two interviews for them. The PSM framework used baseline data to find the best possible control match to the persons that received the CBR program. It is based on potential outcomes: The comparison group includes people with disabilities who would have been eligible to receive the CBR program services but who live outside of the program’s catchment areas. The assumption is that the decision on which communities are part of the program is based on observable characteristics. We use a vast set of control variables that are expected to influence both exposure of the program and outcome of interest. We controlled in the analysis for personal  and village  characteristics that might have an effect on the impact of the program and were found to also be predictive of exposure to be in the treatment group. We calculated the likelihood of assignment into treatment in the CBR using a probit model based on the same variables used for matching in the PSM. All variables with a few exceptions  were captured to account for all unobservable differences that are stable over time therefore eliminating the risk of selection bias even if some unobservable characteristics that lead to the decision on whether to receive the program could not be captured with the variables (X) [We combined PSM with the difference in difference (DD) approach when different points in time (Ybles (X) . We idenWe estimated these two counterfactuals by matching treatment and control with key characteristics. To overcome the possible selection bias and the absence of independence between effect and treatment, we assumed conditional independence, i.e. that we observed all the baseline variables (X) that led a person to receive the program. We assumed the existence of common support which implies that only CBR participants that have a probability of being treated also found in any of the controls were included in the analysis. Similarly, controls with an extremely low probability of being treated were not included either. This method has the advantage of not requiring any assumption on whether the program has homogeneous or heterogeneous effects on the model errors and by being non-parametric it can be combined with other methods in order to yield more precise impact measures . We used1 (D0) represents the treatment (control) group, wij the nearest neighbor matching weights, and S the area of common covariate support. PSM makes the standard DD assumption more plausible by forming statistical twin pairs before performing the DD estimator.Where DPSM-DD allowed for measuring the relative difference in change in outcomes over time between CBR participants and controls, and counteract the fact that not all variables that led to the definition of a catchment area could be considered, and thus addresses the bias generated by this limitation.We estimated the PSM using only baseline variables to ensure that people were comparable before any interventions took place. We calculated Cohen’s d effect size estimates of the effect of the CBR program. We used STATA 16 for all analyses.We conducted sensitivity analysis to assess the robustness of our model results in which we modified the socioeconomic and community-level characteristics of covariates. We used household monthly income (continuous) instead of the welfare index based on assets owned at baseline. We used a different age limit for working at baseline (15 years old instead of 18). We used the 13 provinces instead of the four regional offices. We also tested whether our results were sensitive to an alternative specification of the outcome variables. We calculated the model for program effect separately on the different items of the five outcomes: mobility , activities of daily living , communication , social participation , emotional wellbeing . We also measured the effect on employment considering working or not as an adult with two different cuts-off at 15 and 18 years old. We found similar significant effects.n = 14, 0.01%) and higher among controls . Yet, there were few significant differences between respondents and non-respondents with respect to the measured characteristics and we therefore assumed that unobserved data were missing at random [We interviewed 1875 new CBR participants and 1305 controls at baseline between July 1st 2012 and December 31st 2013. At endline, 1349 CBR participants and 927 controls were interviewed between July 1st 2014 and December 31st 2015  it combines a measure of outcomes associated with one of the five components of the CBR matrix —health, education, livelihood, social and empowerment; (ii) it addresses the issue of CBR program sustainability by looking at data from three rounds of interviewing the same CBR cohort of participants and controls with disabilities, showing the lasting effect of the rehabilitation interventions; and (iii) it is one of so far only nine identified studies looking at CBR effectiveness carried out in a low income country; the only one in a conflict context. This paucity of existing evidence makes studies like the present one essential to legitimize the promotion of CBR while shedding light on the conditions of its success. This is of utmost importance in LMICs as CBR has been, especially in crisis and emergency contexts, the only set of services available to persons with disabilities, a particularly disadvantaged group in such contexts , 40.The CBR program has a differential impact on the various outcomes indicating that improvement is not uniform but depends on the effectiveness of the program in improving the condition of persons with disabilities within a given domain of the CBR matrix rather than the capacity for change within each domain. The highest positive impact is observed on emotional wellbeing. After 3 years on average in the program, the estimated effect size is − 0.48 The gap between treated and controls is particularly salient because the emotional wellbeing of controls without any dedicated support decreased by 34% during the period. While we observed such an increase in anxiety and distress among controls during the three years of observation, CBR participants showed a continuous improvement. Anxiety and distress are a major ill in conflict affected contexts such as Afghanistan. Literature traditionally attributed mental distress to the violence itself –45 incluAnother important effect of the program was observed on social participation which encompasses important dimensions of social life. The social participation index reveals a person’s sense of self-worth and placement within their family and community, and also indicates to what extent disability isolates a person from family and community daily life. Effectively changing community attitudes resulting in reduced marginalization and discrimination of persons with disabilities is a major milestone difficult to achieve because of deeply entrenched negative beliefs , 55. EarThe significant effect on activities of daily living, communication and mobility demonstrate that a CBR program implemented with limited resources, family support in remote areas prone to violence and disruption associated with conflict, can be effective in providing rehabilitation services through a combination of low cost home-based services such as physiotherapy and access to free orthopedic workshops . LiteratThe program also had a significant marginal effect of 12% on employment of adult participants between 18 and 60 years of age compared to control with disabilities of the same age group. This is a major finding considering there are few interventions and even fewer studies showing the impact of CBR programs tackling the livelihood component of the CBR matrix and supporting employment in LMICs , 61. FurThe fact that the program was effective in tackling emotional wellbeing, social participation and access to jobs shows that it had an effect on prejudice and discrimination that persons with disabilities face in their community, often the most complex and arduous barrier to overcome . In part, careful and ongoing supervision in the field and after data collection, consistency checks as well as random re-interviews of participants has made very unlikely that this bias could change our findings. The items in the emotional index did not have a time limit. We asked respondents to assess if currently they felt sad, angry, worried, or had nightmare without indicating in the last seven days for instance. There has been some contamination of the program as few activities benefited controls. In particular, persons with disabilities from villages outside the catchment area would seek assistive devices  in urban workshops –as well as health rehabilitation services such as physiotherapy in health clinics– run by Swedish Committee for Afghanistan. We found that less than 2% received any kind of service, mostly assistive devices,except for physiotherapy received by 10% of controls (data not shown). Contamination of the program to the benefit of controls means that our findings are probably slightly underestimated. Finally, the selection of catchment areas was not random. However, baseline information shows that CBR participants started worse off than their counterparts, reducing the chance that observed impacts were due to initial differences favoring CBR participants.Our study presents some limitations. First, there was a risk of self-selection in the CBR program. Elderly people and people with associated disabilities were significantly less likely to participate in the program . There wOur results have important implications regarding the capacity of CBR to complement existing government initiatives in addressing the issues related to rehabilitation, autonomy social and economic inclusion of persons with disabilities in a conflict or disaster context and beyond in other LMICs. Better mobility activities of daily living and communication skills are indicators of a CBR program that offers effective rehabilitation services. Most importantly, improvement in emotional wellbeing, social participation and even access to jobs show that the CBR program was also effective in advocating for the rights of persons with disabilities and promoting awareness of disability in the community to fight stigma .The lack of standardization in the CBR program we examined did not allow for identification of specific processes that were most successful in promoting social inclusion. Future research should explore such processes and mechanisms that lead to effective CBR interventions towards persons with disabilities. Process evaluation based on mixed methods to dwell deeper into the process of change using implementation research would help better understand how the program work to be able to standardize the intervention and translate it in a different context.


Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada’s annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used.A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site.Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging , design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead.This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs.The online version contains supplementary material available at 10.1186/s12913-021-06636-5. The prevalence of chronic diseases in Canada has increased dramatically within the last few decades , 2. The The use of team-based primary care has been explored to manage and combat the rise of chronic illnesses . ChronicCanada has a universal health care system delivered under provincial jurisdiction. Ontario, Canada’s most populous province (14.7 million), implemented family health teams (FHTs) as a collaborative primary care model consisting of providers from multiple disciplines including primary care clinicians and allied health professionals . Since tAccessibility limits the impact of FHTs in general, and on patients with COPD specifically, as only approximately 20% of the population in Ontario has access to team care within an FHT , 18. TheIn order to effectively implement chronic disease management programs context-specific guidance is needed . The impUsing an evidence-based implementation framework for evaluation ensures research is theoretically grounded . There aDetermine the enabling and impeding factors to implementation and spread of an interprofessional team-based primary care model, andExplore the peer-to-peer approach to implementing a team-based primary care model.In Ontario, a team-based COPD management program (BCC) based in primary care focusing on patient self-management through education, skills training and case management, was spread from the region where it was originally developed and implemented, to a neighbouring region using a peer-to-peer implementation approach. While current literature lacks a clear definition, or common name for peer-to-peer approaches in implementation, in general terms, peer-to-peer approaches involve using peer-led education and peer assessment as a method to support learning about the intervention –28. UsinCurrent literature lacks context empirical examples of the implementation of team-based primary chronic care models specifically for patients with COPD  as well . Program standardization and evaluation was supported by a program specific technology solution that guided every encounter and captured performance and outcome metrics  came in, they knew what the expectations were, they knew what the outcomes would look like. They had that experience, where we were just fishing and hoping we would get the outcomes we were hoping for, but we didn’t really have the experience with that to confidently approach all those physician groups Participants believed previous program success translated to a smooth process for B-FHT staff in terms of program implementation. “Right away we were sold … it’s an easy sell because they… drop a program and a person attached to it in your lap. It is zero work” . The participants further discussed the low complexity of the implementation. “Once… the patients were being seen, there’s not a lot of other admin, oversight really required. It’s the simplest honestly. So simple… everything just fell into place.” . Providers elaborated on how they felt the implementation was done effectively and efficiently. “It seems really simple … it didn’t really disrupt … your everyday (Provider #1). If we could roll out every single program that way, it’d be great” .Providers felt the recruiting of patients into the program was smooth and effective. Patients concurred with this statement, saying: “[I] flowed right through [into the new program]” (Patient Focus Group #1). Even though patient awareness of the transition into the program was low; providers believed this facilitated implementation because it did not disrupt usual patient appointments. Providers appreciated being able to spend more time focusing on patient transition and less on other aspects of implementation.Providers discussed that prior to implementation of the BCC program, B-FHT had been unsuccessful in their attempts to create their own COPD management program. The relative advantage of the BCC program offered a successful and adaptable solution for their patients..There [were] challenges. One, that there wasn’t an established program, for [the RRT] to mimic. And two … we are a multi-site organization, and with a 0.5 [full-time equivalent RRT] position it is really hard to establish any programming without a consistence presence. Which … just wasn’t possible Physician #1 echoed this explaining the advantage of having a comprehensive COPD specific care program in “free (ing) me up to focus on other things during appointments” (Phone Interview #1). Providers agreed this was a clear benefit of the program. The physician was confident in the abilities of the newly educated RRTs to provide COPD-specific care to the patients. As a result, they were able to focus their time on a patient’s other concerns and needs, allowing for more efficient use of time during appointments.Patients also appreciated the coordinate afforded by the BCC program explaining how they prefer this program to alternatives they have previously experienced. “I’ve got a specialist that I’m not agreeing with and that’s not helping me, I might as well not even go to him. [The RRT in this program] is doing [more for me] than he is” . From the patient’s view, the RRT was delivering better care for their COPD than was the specialist working external to the program.Providers discussed the challenges of adding the program’s new reporting technology on top of existing technology. “They have their own system … I hate adding systems. That was the one thing probably that I really was not happy about … we have an [electronic medical record] (EMR). We’re seeing our patients but will be documenting in [the BCC’s system]” .Providers discussed the patient needs in the community as one of the reasons B-FHT proceeded with program implementation. “COPD was a problem. And COPD patients are complex, time-consuming, and costly. There’s plenty of patients and ongoing work to keep you busy full-time” .Participants described B-FHT’s cosmopolitanism efforts  to be instrumental in implementing the program. There was a shared agreement amongst providers about how “[the BCC’s] guidance was key for us being successful so quickly” . In addition to working with the BCC program team, the B-FHT had the chance to learn from the PCIC and strengthen their coordinated efforts with the local hospital..We actually built it to [be] part of one [program] to refer hospital discharges... with the COPD diagnosis... to automatically send a message to the RRT saying that, that person was discharged B-FHT had a pre-existing relationship with the local hospital, which had been responsible for performing diagnostic lung function testing (spirometry). The collaboration was challenged because the BCC program standard was for the RRT to complete the spirometry in the local B-FHT office. Transferring spirometry from the hospital to the B-FHT office was a concern because it meant shifting care away from the hospital. A compromise was reached allowing B-FHT to maintain the relationship with the hospital and respecting the requisite program fidelity.In implementing BCC, a network of RRTs was created to enhance communication and facilitate a peer-to-peer approach. This was discussed as a key factor for implementation success because it facilitated information sharing across a broad context which informed practice. This peer-to-peer approach facilitated the training of providers within B-FHT and supported implementation of the program. “The RRTs have their own network where they communicate with each other” . “It’s an opportunity for them to … say what’s working, what’s not working, what are they finding out there in the field. They [also] have a [messaging] group” . The peer-to-peer approach strengthened communication between providers within the program. BCC Program leads were seen as a highly valued resource for providers. “[She is] always available if we run into any problems or have questions … [we] just reach out to her directly” .Occasionally, poor communication amongst leadership and providers acted as a barrier to implementation. One provider noted “if [meetings are announced] last minute or we forget… it’s just not going to be priority to move all our other appointments around … . This was especially significant when the meetings included training or were meant to connect new providers.Resource support was also discussed as a factor for successful implementation. Typically, RRTs were newly hired to support program delivery, however “[B-FHT] (used) their existing [RRT] to deliver [the BCC] model” . This was both seen as a facilitator  and as a barrier . With the BCC program, the current RRT role was expanded into a full-time position, making it easier to implement the program in B-FHT’s multi-site clinical setting.Administrative support including affirmation from senior management, secretarial/scheduling support, and chart audit support from the BCC leads was particularly important during the initial stages of implementation. Without this support, RRTs believed they would have had to spend excessive time doing administrative work rather than focusing on patient care. “If you’re rolling a program like this into a [FHT] office without a lot of allied health, those cold calls … for [a patient’s] first visit might be time-consuming if they didn’t have that support” .However, the providers discussed how data in the primary care EMR, distinct from the program electronic health record, was of poor quality. This hampered the ability for the program RRT to identify high risk individuals. Providers felt “better data in [the EMR] would’ve helped. But that’s not… likely or possible” .Peer-to-peer implementation allowed providers to learn about the program and its intended implementation first-hand from experienced RRTs. Providers felt this increased their confidence in program delivery. “I really appreciate having people who are experts in COPD care that can give me recommendations. The more knowledge I start to feel comfortable with … in COPD in particular is because of [the RRT]” .Throughout focus group discussion, patients remarked how “you follow what [the RRT] says and [what] the doctor says and … my quality of life is better” . This trust built between the providers and patients was important for implementation success. Patients reported they felt empowered to manage their care and talked about sharing that with peers and family members.Providers and patients valued the program from the start. This buy-in of the program enhanced implementation. Providers and patients highly valued the RRT role and expressed many positive views about the RRTs: “If we could clone [the B-FHT RRT], that’s part of what has … made it so successful for us is that she was able to just come in” .Support from senior leadership was essential during the implementation process. The initial impetus to implement the program stemmed from collaboration between RRTs, however, the executive director of the site fully supported and actively facilitated implementation. Participants reported buy-in from senior leadership as a major facilitator to implementation. In addition, other primary care providers engaged with the program throughout the implementation process by learning about program offerings and supporting patient recruitment into the program..Initially… we were reminded to refer any of our COPD patients for the [RRTs] to make sure that there was a demand. I would really emphasize the importance of frequent reminders to … everyone who would refer patients to the program, reminding them of what kinds of [patients] they can and should refer Providers praised the BCC’s intensive approach to early implementation. They explained how it resulted in buy-in from the start..That initial, really strong blitz on talking to, providing the education to the physicians, speaking with the physician groups individually, getting the searches ready to go... It seemed like that period was probably short, but intense, and necessary Providers also reported the peer-to-peer approach enabled rapid implementation the program. Peer-to-peer training was conducted by an RRT and supported by a respirologist. Provider #1 said that she “sat with somebody who’d been doing it for twenty, five, and three years” respectively (Provider Focus Group #1). Provider #2 elaborated: “the training piece was also big … that training then does ensure that there’s a consistency in [program delivery]” (Provider Focus Group #1).In an effort to collect data on the implementation and performance of the BCC management program, feedback data was collected by B-FHT and the PCIC. Data was collected using patient satisfaction surveys as well as regular debriefing with stakeholders. This data was then used to facilitate adjustments to the implementation and execution of the program as needed.When discussing the results of this data during reflection of the implementation process, many participants boasted at its success. “I don’t have a single criticism about the program. I really can’t think of how it could have been done better” . “We always look at outcome measures, which are always really positive.” . Providers explained that not only is patient satisfaction increasing but “hospital admissions had been decreased” . When asked to provide advice to other teams considering implementing the program, a key informant said:.Take advantage of this program it is zero work on your end. They will come in and do everything and they will also return. If you are struggling at any point... having trouble identifying patients or... with physician buy-in, if you’re having process issues, they are happy to return... my only advice actually, is “say yes” Patients echoed provider’s positive views of the program and focused their conversation on the care they received from the program. Patients reflected on their own care and found value in their improved overall quality of life: “[The RRT] was very thorough … with their explanations of your puffers [and] your medication … [the RRT] gave you [advice]… I find it very good, helpful (Patient Focus Group #1).This implementation case study was the pilot site to evaluate the opportunity for program spread to multiple sites across multiple regions. All of the CFIR constructs analyzed affected implementation, however five were determined as key enabling constructs (based on the frequency of their occurrence in participant comments and in documents) to consider when implementing a team-based chronic care program such as the BCC program: cosmopolitanism, networks and communication, engaging, design quality and packaging, and reflecting and evaluating.CFIR constructs acting as barriers to be managed during implementation were also identified. These were: complexity (of the new patient reporting system); communication ; and lack available resources .In a systematic review, Kadu and Stolee  evaluateThe strong cosmopolitan relationship developed between B-FHT and the BCC leadership was supported by the evidence-based characteristic of the program. Participants could easily align cognitively and philosophically on evidence-based treatment standards. It also facilitated networking with external organizations. When implementing a chronic care management program, it is important to first consider collaboration with external organizations . The estLiterature on the implementation of chronic care models states that when a collaborative effort is made with external organizations, implementation and sustainability efforts are more effective  and factNetworks and communication or information and communication as termed in Davy et al.  are faciEngaging champions in implementation efforts is a key factor to success . ChampioThe excellent design and packaging of the intervention positively influenced B-FHT’s decision to implement and supported the ease of implementation. The BCC structured program coupled with the support from BCC program team, the PCIC and other RRT networks infused quality within the whole implementation. Literature has shown that poor design quality or lack of attention to packaging can be a barrier to implementation –49. WellIn our study, evidence-based data, specifically regular reflecting on performance metrics and peer-to-peer feedback methods were used effectively to support implementation. Integrating regular monitoring and evaluation throughout program delivery can support implementation efforts . RegularComplexity: When stakeholders believe an implementation is simple, the program is more easily implemented into practice [Patient Needs and Resources: There is consensus in the literature around the importance of considering context in implementation efforts - this should consider factors at multiple levels including patient, provider, team, organization, and community [Relative Advantage: Providers believed the program had a relative advantage to what was currently being offered to patients; this, combined with the perceived need within their community, facilitated implementation. Our results echo the findings of Greenhalgh et al. and others [Readiness for Implementation – Available Resources: There is consensus in the literature that a lack of resources, or a misuse of available resources  can hinder implementation [Self-Efficacy/Knowledge and Beliefs about the Intervention: Ensuring providers possess the necessary skills to achieve implementation goals is essential [There were other CFIR constructs found to be supportive of implementation, but not necessarily as impactful as those already discussed. practice ; overly practice . In our ommunity , 51–53. d others , 51 who entation , 55. In ssential . Low selssential , 57. WheLiterature describes peer-led education as a powerful approach to achieving program goals and objectives –28. To oOur small sample size and in depth look at one case meant there was a potential for both social desirability bias and the Dunning-Kreuger effect  . The latThis study was conducted to understand the facilitators and barriers that affect the implementation of a chronic care management program for patients with COPD in a primary care context. Our aim was to determine enabling factors of implementation and spread of an interprofessional team-based primary care model to support future spread efforts. The five most influential constructs to implementation according to CFIR were cosmopolitanism, networks and communication, engaging, design quality and packaging, and reflecting and evaluating. Our results align with those from the literature including Kadu and Stolee ‘s systemThis study provides a practical example of the various factors that facilitate the implementation of the BCC management program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the BCC program and future implementation of other chronic care programs.Additional file 1. Consolidated Framework for Implementation Research Constructs. This document provides an organized list including the categories and constructs of the consolidated framework for implementation research, as well as a short definition for each construct.