Pledging lifelong loyalty to an ingroup can have far-reaching behavioural effects, ranging from ordinary acts of ingroup kindness to extraordinary acts of self-sacrifice. What motivates this important form of group commitment? Here, we propose one especially potent answer to this question–the experience of a visceral sense of oneness with a group . In a sample of British football fans, a population in which high levels of lifelong loyalty are thought to be common, we first examined the hypothesised relationship between fusion and perceptions of lifelong loyalty to one’s club. We further explored the hypothesis that fusion and lifelong loyalty are not merely a reflection of past time investment in a group, but also reflect a deeper, memory-based process of feeling personally shaped by key group events, both euphoric and dysphoric. We found broad support for these hypotheses. Results suggest that feeling personally self-shaped by club events , rather than time invested in the club, leads to greater identity fusion to one’s club. In turn, fusion engenders a sense of lifelong club loyalty. We discuss our findings in relation to the growing literature on the experiential origins of intense social cohesion. Ingroup loyalty–faithfully sticking with one’s ingroup through thick and thin–courts reciprocal commitment from other group members, thus making group behaviour more predictable and stable , 2. DeclThe social identity perspective offers one account of group loyalty. Social identity refers to a person’s sense of who they are in terms of group membership . If an iHowever, high identification with one’s group may not be the only route to group loyalty. Recent research has delineated a complementary and potentially more behaviourally potent mode of ingroup cohesion known as 'identity fusion’ –7. WhereStrongly fused persons, emboldened by a sense of personal agency, invulnerability, and sense of familial ties to group members, are willing to put their lives at risk to save ingroup members , 13, 14 Here, we explore one particularly important form of ingroup loyalty–lifelong loyalty. Lifelong loyalty refers to a willingness to stick with one’s group in perpetuity, remaining faithful to the group through good times and bad and therefore forgo opportunities to abandon the group in favour of more attractive ones , 17, 18.Fusion is likely to be an especially strong predictor of this form of loyalty because for fused individuals, to be unfaithful to the group would be to betray not only the group itself  but also the essence of their personal self , 15, 19.If fusion engenders lifelong group loyalty, what triggers fusion? The answer may lie in a framework recently developed by Whitehouse and Lanman . This frAnother key prediction originating from Whitehouse and Lanman , 26 is tIn addition to testing for affirmative support for hypotheses derived from Whitehouse and Lanman (19), we also sought to examine a potentially more parsimonious alternative explanation for the development of fusion and ingroup loyalty: cognitive dissonance , 33. Groor negative (dysphoric) events both predict fusion to club.The present study tests three hypotheses. Our first hypothesis is that while identification, past investment, and fusion all predict loyalty when individual relationships are examined, only fusion and past investment predict loyalty when entered into a regression simultaneously. Second, we predict that perceptions of self-shaping events affect loyalty via fusion rather than via past investments . Third, we predict that perceptions of self-shaping events following positive (euphoric) rd October– 2nd November 2015). Ethical approval was obtained from the School of Anthropology and Museum Ethnography Research Ethics Committee (SAME REC) in accordance with the procedures laid down by the University for ethical approval of all research involving human participants. Participants provided electronic informed consent by checking boxes on a screen in a similar fashion to check boxes on a printed document. Consent was recorded in the survey software and participants could not proceed to the main survey without reading and checking the consent pages.We focused on a group domain central to modern life for billions of humans across the globe–football (or soccer) fandom . We targN = 140) was advertised to a diverse cross-section of football fans through social media (Twitter and Facebook), online football forums, and fan blogs, as well as via student and subject-pool mailing lists. Participants could win one of three £100 prizes for completing the survey. To reduce the likelihood of participants rushing the online survey, we informed them of the estimated time required to complete it. We expected that most participants would prefer to complete a brief survey, thus we chose when possible to use abbreviated measures.A short online questionnaire , 80.82% were male , 9.6% left education at or before the age of 16, 23.3% had college education (16–18 years), 41.1% had undergraduate education, and 22.6% had postgraduate education. The male skew is broadly representative of gender imbalances in wider football fan demographics and was thus considered relevant to our target population. 94.3% of our sample spoke English as a first language.Of the 146 participants (α = .89). Example items include ‘I am one with [my club], ‘I have a deep emotional bond with [my club]’, ‘I’d do more for [my club] than any other fan would’ and ‘[My club] makes me strong’.Identity fusion was assessed using the 7-point verbal scale [I identify with [my club]’.Identification was assessed using the 7-point single item measure : ‘I idenα = .82).Ingroup loyalty was assessed via six questions using a 7-point response scale. Items were generated based on definitions of ingroup loyalty, and survey questions from Van Vugt & Hart (2004). The six items below were included regarding the individual’s preferred team. The questions were reverse scored so that high scores reflected high loyalty. The scale was internally consistent (How likely is it that you will remain a fan of [club] for the rest of your life? (Extremely likely vs. Extremely unlikely)‘Even though I may not want to now, I will probably end up switching to a different team’ (Extremely unlikely vs. Extremely likely)‘I will never stop supporting [club]’ vs. ‘I won’t support [club] for long’‘Nothing could stop me being a fan of [club]’ vs. ‘Nothing could keep me a fan of [club] forever’‘When [club] has just lost, I…‘…am as strong a fan as ever’ vs. ‘…come close to switching teams’‘I could never stop being a fan of my team’ vs. ‘I don’t mind which team I support’Self-shaping club events were assessed via two questions using a 7-point response scale . One question asked about euphoric events: ‘To what extent have your team’s wins shaped you as a person?’ The second question asked about dysphoric events: ‘To what extent have your team’s losses shaped you as a person?’. We then calculated a mean ‘self-shapingness’ score. The score composed of the two items was internally consistent, α = .82Duration of support was used as a measure of past investment and thus the amount of experienced dissonance. Participants estimated how many years they had supported their team for. We calculated a single variable by making raw years of supporting the team as a percentage of the participant’s age. As our sample included a broad range of ages (18–76) it was sensible to view years of support in relation to the individual’s potential number of years of support. We repeated our analyses using both the age and raw years of support variables and these analyses were similar to those using the single ‘duration of support’ variable, though years of support had a better predictive value than age (Supporting Information 2). Descriptives and correlations for all variables are reported in R2 = .03, F(139) = 3.75, B = .16, p = .06), investment entered in block 2  = 19.11, B = .44, p < .01), and fusion entered in block 3  = 16.96, B = .28, p < .01)  see . ConsistR2 = .16, F = 13.24, B = .33, p < .01. . We also re-ran the model replacing fusion with identification as the mediator and found the model was not supported  due to the null relationship between identification and self-shapingness.A simple mediation analysis was conducted using ordinary least squares path analysis in Hayes’s PROCESS macro (Model 4) for SPSS . Bias-corrected bootstrap analyses based on 5,000 bootstrap samples were run. In the model the outcome was loyalty, fusion the mediator, self-shapingness the predictor, and past investment a covariate  = 18.16, B = .34, p < .01  and euphoric self-shapingness .In model 2 the outcome was loyalty, fusion the mediator, dysphoric self-shapingness the predictor, and past investment a covariate . As seenOur results indicate that identity fusion provides a novel explanation of group loyalty, independent from the effects of identification and cognitive dissonance. In support of Whitehouse & Lanman’s earlier assertion (2014), we provide the first evidence that identity fusion is not simply a by-product of cognitive dissonance. We also found evidence to support the claim that identity fusion arises once an individual has experienced group events that they believe to be personally self-shaping. In addition, we found that euphoric and dysphoric events, when seen as highly self-shaping, were both likely to result in strong levels of fusion and lifelong loyalty.This study provides further evidence that certain group events  have the power to strongly shape personal identity and the relationship between personal and social identities , 24. In Our results also support and extend understanding of the role of cognitive dissonance in relation to lifelong loyalty. One’s past time invested in supporting the ingroup represents an extension of the free-choice paradigm, whereby the individual’s past choices affect their future behaviours and beliefs , 40. OurOur results specifically identified self-shaping group victories and defeats as key to the relationship between fusion and lifelong loyalty, which supports the current theory that one’s personal and social selves can ‘fuse’ together resulting in an extraordinary pro-group mentality , 26, 41.Our study is not without limitations. First, this study was correlational in nature and, though our proposed direction of causality is supported by theory, we cannot be resolutely decided on this. With this study as a basis, future experimental work could address the causality issue. Second, this study used self-reports, which are potentially marred by problems of subjectivity, bias, and deliberate deceit , 43. SelAs such, the self-reporting issue leaves this study open to the criticism that unconscious processes could be motivating a sense of self-shapingness following a dysphoric event (e.g. to reduce dissonance), when the individual hasn’t actually been transformed in any empirically discernible fashion. Such a claim would be hard to demonstrate scientifically, but future research should aim to investigate such claims by accessing participants’ unconscious responses, perhaps using implicit association tasks. Nevertheless, self-report measures are quick and simple to administer and are thus used regularly in psychological research. In this exploratory study, our self-report measures of self-shapingness were brief and future research will need to explore issues of construct validity in more detail.Third, we propose the development of two measures for inclusion in future related projects. The relationship between self-shapingness and reflection  is left unexplored in this study, a relationship that we imagine will be fruitful to researchers investigating the antecedents of identity fusion. Measures of affective intensity in relation to significant events were also omitted from this study and future research could explore ways of appropriately testing affect post-event. By improving our understanding of the affective processes underlying the perceptions of self-shapingness, we stand a better chance of comprehending how self-shapingness–one of the first proposed mediators of identity fusion–occurs.Finally, and perhaps most importantly, are limitations associated with a convenience sample. While the variability of football clubs sampled, age range, and mix of educational background goes some way to achieving a representative sample, issues of selection and social acceptability biases cannot be dismissed. Further research would need to be conducted, ideally with a new population, to confirm the generalisability of our claim that a sense of being shaped by intense shared events, including dysphoric self-shapingness, mediates the relationship between fusion and lifelong loyalty independently of cognitive dissonance.Research into identity fusion and its antecedents offers us unique opportunities to understand some of the most extreme social behaviours in our species and has the potential to help us channel the pro-group sentiments of fused individuals for the good. For instance, research could tell us if individuals who have been shaped by trauma and despair are more inclined to act with hostility to out-groups, perceiving out-groups as threats based on their self-shaping memories, or whether euphoric self-shaping experiences foster acts of extraordinary self-sacrifice and acts of charity. By deconstructing the path(s) to fusion and understanding each stepping stone in the process, research can help develop cognitive and therapeutic approaches to de-fusion in order to realign individuals away from groups that pose societal risks. Such research may thus provide a practical tool for national security–be it curbing local football hooliganism or fighting the global ‘war on terror’. The possibility of creating de-fusion programmes opens up an ethical minefield and the development of any such initiatives would need thorough research in place to support them, as well as wide discussion involving all potential stakeholders. With the knowledge that dysphoric events contribute greatly to fusion, we are also in a position to advocate a reduction in the ill treatment of marginal groups; for these are the experiences likely to hold together disenfranchised collectives built on values of self-preservation and out-group hostility.S1 File(SAV)Click here for additional data file.S2 FileAnalyses including the duration of support and age variables.(DOCX)Click here for additional data file.


Guillain-Barré syndrome (GBS) and Fisher syndrome (FS) are immune-mediated peripheral neuropathies, and most of these cases were known to be associated with a preceding infection. Recent reports evidenced an increase in the number of infectious disease cases after the earthquake. The aim of this report is to investigate the incidence and clinical features of GBS and FS after the Great East Japan Earthquake. We found GBS and FS patients had markedly increased in 2011, the year of the earthquake. In regard to an antecedent illness, gastrointestinal infection was significantly increased in GBS patients after the earthquake. These results suggest environmental factors including infectious agents and stress caused by the earthquake might have been involved in the outbreak of the diseases. The Great East Japan Earthquake, with the epicenter ∼70 km east of Miyagi Prefecture, occurred at 14:46 on 11 March 2011. An extensive area of the coast of this district was severely damaged by the tsunami and the number of fatalities exceeded 28,500 (Shibahara P < 0.05). Gender, age, cerebrospinal fluid protein levels, treatments, and prognosis showed no differences after the earthquake. GBS patients with gastrointestinal infection as an antecedent illness had significantly increased to 63% in the year after the earthquake compared with before . Gastrointestinal infection has been linked to axonal GBS . We could not test antibodies against Campylobacter jejuni in our patients.All hospitalized patients diagnosed as GBS or FS from 1 March 2007 to 28 February 2013, in two major hospitals located in Sendai-city, Miyagi Prefecture, were analyzed. The area covered by these hospitals did not change after the earthquake. There were 26 patients of GBS and 10 patients of FS. The new-onset patient counts were collected from March to the following February in each year. The annual incidence of GBS and FS before the earthquake was about five patients per year, but in March 2011 to February 2012, the year just after the earthquake, such patients had markedly increased (Fig. According to previous reports concerning the earthquake, gastroenteritis outbreaks were sometimes prolonged after the disaster because of the continuous sanitary problems of the refuges or lifeline problems (Karmakar et al. In conclusion, GBS and FS cases increased during the several months after the earthquake and gastroenteritis was the most prevalent preceding infection in the GBS cases during this period. Although this study included only a small number of patients, the findings suggest environmental factors including infectious agents and stress caused by the earthquake might have been involved in the outbreak of the disease.


Francisella tularensis is a facultative intracellular pathogen, and is the causative agent of a fatal human disease known as tularemia. F. tularensis is classified as a Category A Biothreat agent by the CDC based on its use in bioweapon programs by several countries in the past and its potential to be used as an agent of bioterrorism. No licensed vaccine is currently available for prevention of tularemia. In this study, we used a novel approach for development of a multivalent subunit vaccine against tularemia by using an efficient tobacco mosaic virus (TMV) based delivery platform. The multivalent subunit vaccine was formulated to contain a combination of F. tularensis protective antigens: OmpA-like protein (OmpA), chaperone protein DnaK and lipoprotein Tul4 from the highly virulent F. tularensis SchuS4 strain. Two different vaccine formulations and immunization schedules were used. The immunized mice were challenged with lethal (10xLD100) doses of F. tularensis LVS on day 28 of the primary immunization and observed daily for morbidity and mortality. Results from this study demonstrate that TMV can be used as a carrier for effective delivery of multiple F. tularensis antigens. TMV-conjugate vaccine formulations are safe and multiple doses can be administered without causing any adverse reactions in immunized mice. Immunization with TMV-conjugated F. tularensis proteins induced a strong humoral immune response and protected mice against respiratory challenges with very high doses of F. tularensis LVS. This study provides a proof-of-concept that TMV can serve as a suitable platform for simultaneous delivery of multiple protective antigens of F. tularensis. Refinement of vaccine formulations coupled with TMV-targeting strategies developed in this study will provide a platform for development of an effective tularemia subunit vaccine as well as a vaccination approach that may broadly be applicable to many other bacterial pathogens. Francisella tularensis is the causative agent of a fatal human disease known as tularemia . This formulation was designated as TMV-multiconjugate vaccine . Based oTwo different immunization schedules were used. In the first immunization schedule (Schedule I) C57BL/6 mice were immunized intranasally (i.n.) with 60μg of TMV monoconjugate or TMV-multiconjugate vaccine. Mice were immunized i.n. with 30μl (15μl/ nostril) volume of each of the vaccine formulation or the TMV controls. Booster vaccinations using dosages similar to the primary immunization were administered on days 7 and 14 after the primary immunization. Mice receiving 30μg of TMV alone and administered in a fashion similar to the vaccine groups were kept as controls . Mice weF. tularensis [F. tularensis SchuS4 strain [Mice immunized employing schedule II were vaccinated only with TMV-multiconjugate vaccine. C57BL/6 mice were immunized i.n. on day 0, 5 and 14 with a total of 60μg of TMV-multiconjugate vaccine. These mice also received similar vaccination dose of TMV-multiconjugate vaccine subcutaneously (s.c.) on days 3, 7 and 14. Control mice received 30 μg of TMV following the immunization schedule identical to those for the TMV-multiconjugate vaccine group . All vaclarensis ,34,44. T4 strain  and the F. tularensis antibody levels in vaccinated mice following the immunization schedules described above, ELISA was performed using lysates made from F. tularensis SchuS4 or LVS strains. The formalin fixed SchuS4 was obtained from BEI Resources, Manassas, VA. For ELISA 96-well microtiter plates were coated with 1×107 CFU/ml of either F. tularensis SchuS4 or LVS in bicarbonate buffer. F. tularensis-specific antibody levels for total IgG, IgG1, IgG2a and IgG2b in serum samples collected from immunized mice on 28 post-immunization were determined by ELISA. Serum collected from naïve mice or mice that received TMV were used as controls. To determine the level of antibodies induced against each individual protein of the TMV-monoconjugate or the TMV-multiconjugate vaccine each individual ELISA was performed by coating plates with 1μg of each individual purified recombinant OmpA, DnaK and Tul4 proteins. The protein specific total IgG levels were determined in serum from vaccinated mice collected on day 28 post-immunization. Antibody titers were calculated from linear regression curves as the inverse of the serum dilution that showed an OD450 value 2.5 times above the controls, and expressed as Log10 values.For determination of anti—Francisella OmpA, DnaK and Tul4 proteins, western blot analysis was performed. Serum collected on day 28 from mice immunized with TMV-multiconjugate vaccine utilizing Schedule II was used for western blot analysis. Eight micrograms each of F. tularensis LVS and SchuS4 lysates were resolved on SDS-PAGE, transferred to nitrocellulose membrane and blotted against pooled serum from immunized mice. Serum collected from mice immunized with TMV was used as a control. To determine if antibodies from immunized mice reacted with recombinant proteins as well, 1μg of purified recombinant proteins were used in western blot analysis.To determine if antibodies generated in vaccinated mice are capable of identifying native and recombinant 100 (1×105 CFU) dose of F.tularensis LVS on day 28 of the primary immunization. The actual numbers of F. tularensis inoculated into mice at that time of challenge were confirmed by plating serial dilutions on MH-chocolate agar plates and counting the colonies 48 hours later.To determine the protective efficacy of TMV-vaccine against a high challenge dose of LVS, all immunized mice were challenged i.n. with 10×LDAll the challenged mice were observed daily for signs of morbidity and/or mortality for a period of 21 days. To monitor the progression of infection all challenged mice were weighed every day until they regained their original body weight.All data for antibody levels of immunized mice were statistically analyzed using InStat program (Graph-Pad Software). The results were expressed as Means ± S.D. The survivals data were expressed as Kaplan-Meier survival curves and statistical significance for survival results were evaluated by analyzing the mean time to death by the Log-Rank test.F. tularensis SchuS4 dnaK (FTT1269c), ompA (FTT0831c), and tul4 (FTT0901) genes were expressed in E. coli as N-terminal 6X-His tagged proteins and purified by metal affinity chromatography. The purity of these recombinant proteins was confirmed by SDS-PAGE and western blot analysis using anti-His monoclonal antibodies. Bands of 70kDa, 47kDa and 17kDa confirmed the identities of DnaK, OmpA and Tul4 proteins, respectively . Mice were bled on day 28 post-immunization and antibody responses were determined. Higher levels of ted mice . Determited mice . Antigented mice . CollectFrancisella specific IgG2a and IgG2b antibodies were observed in immunized mice. However, as observed for TMV-monoconjugate vaccinated mice, higher levels of IgG1 antibodies were also observed in TMV-multiconjugate vaccinated mice . The total IgG responses observed on days 14 (not shown) and 28 were much higher than those observed with the TMV-monoconjugate vaccine . IgG isoted mice . The levted mice . CollectF. tularensis SchuS4 and F. tularensis LVS. No differences in IgG, IgG1, IgG2a and IgG2b antibody levels were observed when ELISAs were performed using F. tularensis SchuS4 and LVS lysates  improves the antibody response compared to the other two vaccination strategies. It was observed that the total IgG and IgG1 antibody responses did not differ from mice vaccinated with TMV-multiconjugate vaccine using Schedule I . However lysates . These r vaccine .100 dose of F. tularensis LVS on day 28 post-primary immunization and observed for a period of 21 days for morbidity and mortality. Only 25% of mice immunized with TMV-monoconjugate vaccine survived the challenge while 100% of control mice receiving TMV succumbed to infection by day 11 post-challenge. Measurement of body weights showed an identical pattern of body weight loss between TMV-monoconjugate vaccinated and TMV control groups till day 7 post-challenge after which mice destined for survival started to recover their body weights ; or a mixture consisting of each protein individually conjugated to TMV (TMV-multiconjugate vaccine) were used. Both the vaccine formulations resulted in generation of antibodies against all three recombinant proteins. Most importantly, these antibodies recognized native Francisella as well as recombinant proteins. These results indicate that the purification or conjugation procedures did not alter conformation of the epitopes recognized in native OmpA, DnaK or the Tul4 proteins.The goal of this study was to explore vaccine potential of a multivalent subunit vaccine against tularemia using an efficient TMV based delivery platform. The premise behind utilizing a novel TMV-conjugated vaccination strategy is based on the proven efficacy of TMV vaccines in stimulating robust immune response without the requirement of an additional adjuvant . In ordeFrancisella specific total IgG response and the titers went up from days 14 to 28 post-immunization (not shown). Although, IgG1 was the most predominant antibody isotype, higher levels of IgG2a and IgG2b antibodies were also detected in this group of immunized mice. It is noteworthy that both the IgG2a and IgG2b antibodies have been shown to be protective against F. tularensis infection [When immune responses were compared between mice receiving TMV-monoconjugate and TMV-multiconjugate vaccine using a similar vaccination regimen (Schedule I), a weaker antibody response was observed in mice vaccinated with monoconjugate formulation. These results indicate that conjugating all proteins to a single TMV virion is not an ideal approach for development of a TMV-based tularemia vaccine. The poor antibody response could be due to preferential conjugation of one of the three proteins in the conjugation mix or due to antigenic competition. The antibody responses observed against OmpA and DnaK proteins does support this notion. It was observed that TMV-monoconjugate vaccinated mice induced antibody response against Tul4 protein were similar to those observed for TMV-multiconjugate vaccine formulations however, the response against OmpA and DnaK were significantly lower than that observed for the latter vaccine formulation . The binnfection ,56. Coll100 dose (1x105 CFU) of Ft LVS, corresponding to the weak antibody response only 25% mice were protected with TMV-monoconjugate vaccine formulation. However, with multiconjugate formulation the protection levels were nearly 40% and an aggressive immunization marginally improved the protection to 50%. Collectively, these results demonstrate that TMV can be used as a carrier for effective delivery of multiple F. tularensis antigens. The TMV-conjugate vaccine is safe and multiple doses can be administered in mice without any adverse reactions and immunization with F. tularensis antigens conjugated individually and blended in a multivalent composition induce a more potent immune response than the formulation in which all of the three proteins are conjugated to a single TMV virion. Most importantly immunization with TMV-conjugated F. tularensis proteins can protect mice against lethal doses of F. tularensis LVS.We further investigated if an enhanced immune response can be generated following an aggressive vaccination regimen with the TMV-multiconjugate vaccine. We administered booster vaccinations by alternating i.n. and s.c. routes. The intent was to induce potent systemic as well as local mucosal immune response by administering vaccine by both i.n. and s.c. routes (Schedule II). However, the immune responses did not differ from those observed in mice receiving only two booster vaccines (Schedule I). We speculate that the failure to observe further amplification following an aggressive vaccination could be due to an excessive antigenic overload. When vaccinated mice were challenged intranasally with 10LDF. tularensis. Future studies to improve the level of protection would require generation of TMV-multiconjugate vaccine by incorporating additional immunoprotective antigens of F. tularensis and inclusion of suitable adjuvant(s) to generate potent humoral and cell-mediated immune responses and induce long-lasting immunity against tularemia caused by F. tularensis SchuS4 strain.In conclusion, this study provides a proof-of-concept that TMV can serve as a suitable platform for simultaneous delivery of multiple protective antigens of


There has been growing interest in using telehealth to increase access to parent-mediated interventions for children with ASD. However, little is known about how parents engage with such programs.This paper presents program engagement data from a pilot study comparing self-directed and therapist-assisted versions of a novel telehealth-based parent-mediated intervention for young children with autism spectrum disorders (ASD).Parents of young children with ASD were randomly assigned to receive a self-directed or therapist-assisted version of ImPACT Online. Parent engagement and satisfaction with the different components of the program website were examined using the program’s automated data collection and a post-treatment evaluation survey. We examined the relationship between program engagement and changes in parent knowledge and implementation and participant characteristics associated with program engagement.F2,24=17.65, P<.001. In total, 85% of participants completed the program, with a significantly greater completion rate in the therapist-assisted group (N=27): χ21=5.06, P=.03. Lesson learning activities were visited significantly more often than the supplemental activities . Multiple regression controlling for pretreatment performance indicated that program completion  predicted post-treatment intervention knowledge, and program completion  and group assignment  predicted post-treatment intervention fidelity. Partial correlations indicated that parent depressive symptoms at pretreatment were negatively associated with program completion , but other key parent and child demographic factors were not. Post-treatment measures of website usability , treatment acceptability , and overall satisfaction  were all related to program completion.Of the 27 parent participants, the majority were female , married , with a college degree or higher , and less than half were not employed outside of the home . The mean chronological age of the child participants was 43.26 months, and the majority were male  and white . Most of the families  resided in a rural or medically underserved area. Parents logged into the website an average of 46.85 times, spent an average of 964.70 minutes on the site, and completed an average of 90.17% of the lesson learning activities. Participants in the therapist-assisted group were more likely to engage with the website than those in the self-directed group: Parent engagement and satisfaction with ImPACT Online was high for both self-directed and therapist-assisted versions of the program, although therapist assistance increased engagement. Program completion was associated with parent outcomes, providing support for the role of the website in parent learning. This program has the potential to increase access to parent-mediated intervention for families of children with ASD. The past 20 years have seen a dramatic increase in the proliferation of telehealth—the delivery of health and mental health information via the Internet and related technologies. There are numerous potential advantages of the use of telehealth to augment or even replace traditional service delivery models. Perhaps most appealing is its potential to increase access to evidence-based interventions for individuals living in rural and underserved areas at a significantly reduced cost . Such prTelehealth’s ability to increase access to services in a cost effective manner  indicateThere has been growing interest in the use of telehealth for delivering parent-mediated interventions for children with ASDs -26. ChilAlthough the evidence base at this point is very limited, several quasi-experimental and single-case design studies have demonstrated the potential of telehealth to deliver parent-mediated intervention for children with ASD. Parents generally find such programs to be acceptable , and proThese studies are encouraging and suggest that telehealth, should it prove efficacious in larger trials, may be an effective method for increasing access to parent-mediated interventions for families of children with ASD. However, there is very little known about factors that influence parent engagement with such programs. For example, it is not clear what types of parents choose to enroll in telehealth-based parent-mediated intervention programs and whether they are different from parents who enroll in traditional parent-mediated intervention programs. It is also unclear whether specific supports provided during the program influence program engagement. Several studies have suggested that therapist assistance can positively influence participant engagement with cognitive-behavioral therapy (CBT)-based telehealth interventions for mood and anxiety , and remFinally, little is known about parent and/or child characteristics that are associated with program engagement in telehealth-based parent-mediated intervention. Across a range of health information technologies, participants’ computer/Internet self-efficacy, as well as the perceived usefulness and ease of use of the technology have been associated with technological acceptance , suggestIn this paper, we present data about program engagement from a pilot study of ImPACT Online, a telehealth-based parent-mediated intervention for young children with ASD. Specifically, we examined (1) the demographics of parent and child participants who enrolled in the program, (2) the overall level of program engagement among parents of children with ASD, the components of the website that parents used most and least often, and parents’ perceptions of the usefulness of the different program components, (3) whether therapist assistance influenced engagement with or perceived usefulness of the program, (4) whether parent engagement with the website was associated with changes in parent intervention knowledge and intervention fidelity, and (5) whether pretreatment participant characteristics  and/or parents’ experience with the program  were associated with greater engagement with the website.Diagnostic and Statistical Manual – 4th Edition, text revision (DSM-IV-TR) criteria [Participants included 28 parents of a child with ASD between the ages of 27 and 73 months. Participating families were recruited from agencies serving children with ASD  and online. Recruitment focused on underserved communities as defined by residence in a rural  and/or medically underserved area/provider shortage area . All children met criteria for Autistic Disorder or Pervasive Developmental Disorder, Not Otherwise Specified based on the criteria  and the criteria . ParentsFamilies without a personal computer, webcam, or high-speed Internet in the home were provided the required technology. One family suspended treatment for 7 months in the middle of the program due to a significant health problem. This family’s data were excluded from analysis as their pre-post data were not comparable to the other families’, yielding a total of 27 participants. All parents gave informed consent for their own and their child’s participation under the oversight of Michigan State University’s Human Research Protections Program. Participating families provided demographic information and completed a standardized battery of assessments of parent and child functioning in the lab and family home at intake. Children were matched on expressive language on the Mullen Scales of Early Learning  and thenParents assigned to the self-directed group received access to the secure, password-protected ImPACT Online website for up to 6 months. The program was adapted from Project ImPACT, which is a naturalistic, developmental-behavioral, parent-mediated intervention for young children with ASD . The webParents could also access supplemental material outside of the weekly lessons. Supplemental material included a Video Library that contained longer video examples of adults using all of the intervention techniques together, a Resources page with links to autism informational websites, and a moderated Forum that allowed parents to share information with other parents. Parents received weekly “Tip of the Week” emails that provided tips for implementing the intervention techniques along with a link to the program to encourage program use. Parents in the self-directed group were able to contact project staff via phone or email for assistance with technology-related problems  but were given no assistance or support in learning the intervention from project staff outside of the self-directed website. See Parents assigned to the therapist-assisted group were given access to the ImPACT Online website and were encouraged to work through the program at the same pace as the self-directed group. Parents also received two 30-minute remote coaching sessions per week  via Skype video conferencing software by a trained therapist to assist them in learning the intervention. Skype was selected as the primary video conferencing software during the development phase of the program based on feedback from focus groups with parents and providers indicating that parents would be most comfortable using Skype (over other available systems) based on its simplicity and familiarity. Parents in this study were made aware that Skype was not Health Insurance Portability and Accountability Act (HIPAA)-compliant during the consent process.The first coaching session of the week involved the coach and parent and was used to help clarify the content of the relevant lesson and help the parent apply the information to their child. The second coaching session of the week involved the coach, parent, and child and was used to provide the parent with “live” feedback on their use of the intervention techniques as they practiced with their child.Parents provided demographic information about themselves and their child at intake. Parent demographic variables included gender, marital status, education level, employment status, and residence in a rural and/or medical professional shortage area. Child demographic variables included age, gender, and race/ethnicity. Parents also provided information on the type and hours per week of all nonstudy treatments  their child received. Children were administered the Mullen Scales of Early Learning  by the sParents completed a modified version of the Computer-Email-Web Fluency Scale (CEWFS)  at intakParents completed the Center for Epidemiological Studies-Depression Scale (CES-D)  at intakParents completed the ImPACT Knowledge Quiz. This 20-item, multiple-choice quiz measures comprehension of the key elements of Project ImPACT, at intake and post-treatment to measure changes in their intervention knowledge. Data were missing at post-treatment for one participant.Parents were videotaped during a parent-child interaction in their home at intake and post-treatment to measure changes in their intervention fidelity. Parents were asked to play with their child for 10 minutes and have a small snack or meal with their child. Parent behavior was scored for correct use of the intervention strategies using the Project ImPACT intervention fidelity checklist . Each ofProgram engagement was calculated from the ImPACT Online website’s electronic tracking of user behavior. Several different metrics of program engagement were calculated, including (1) average number of logins to the site, (2) average duration of time spent on the site across the intervention period, and (3) program completion, which was defined as completion of at least 75% of total learning activities across the 12 lessons (out of a possible 71). In addition, we examined the average duration of each login, the average number of days to program completion, and the times of day when logins occurred.To better understand how parents used the program, we calculated the average number of visits made to each of the lesson learning activities  and supplemental materials , as well as the percent of each type of lesson learning activity completed.At post-treatment, parents were asked to complete an evaluation survey measuring treatment acceptability, website usability, and overall program satisfaction. All items were rated using a 7-point Likert scale, with higher scores indicative of greater satisfaction. Parents rated the acceptability of the treatment using a 30-item questionnaire  adapted Parents in the coaching group were also asked to rate the quality of the therapist relationship using the following items: (1) “My coach was interested in me,” (2) “My coach understood me,” and (3) “My coach understood my child, and the perceived helpfulness of (i) the weekly discussion sessions with the trainer, (ii) the weekly coaching sessions with my child.”The data were examined for normality using visual analysis of the data distributions and the inspection of the skewness coefficient. All variables were found to be normally distributed with the exception of overall satisfaction, which was subject to ceiling effects. Thus, we used nonparametric tests  for analyses involving the overall satisfaction variable and parametric tests for all other analyses.t tests and chi-square tests as appropriate to examine group difference on pretreatment characteristics. There were no significant between-group differences on participant characteristics at intake.As shown in As can be seen in F2,24=17.65, P<.001. Follow-up tests revealed that the therapist-assisted group demonstrated significantly greater program engagement on both metrics than the self-directed group  using a multivariate analysis of variance (MANOVA), and program completion using chi-square. There was a significant effect of group on program engagement: roup see . The theF1,25=241.86, P<.001) favoring the therapist-assisted group, and a main effect of program component . Follow-up paired t tests indicated that parents were most likely to visit the homework, followed by the reflection, manual, and slideshow, and then the self-check and exercises. Parents visited each of the lesson learning activities more often than the supplemental materials . There was also a significant group x program component interaction. Follow-up independent samples t tests indicated that the therapist-assisted group visited the self-check, exercises, homework, reflection, and video library significantly more than the self-directed group . However, the groups did not differ in number of visits to the slideshow, manual, resources, and forum.We then compared the average number of visits parents made to each program component  using a mixed-model, repeated-measures ANOVA with group as a between-subjects variable and program component as a within-subjects variable. There was a main effect of group  favoring the therapist-assisted group, and a main effect of learning activity . But there was not a group x learning activity interaction (P>.05). Follow-up paired t tests indicated that parents completed the reflection  significantly less often than each of the other lesson learning activities , with the exception of the slideshow for which the difference was marginal (P=.095). There was no difference in completion rates between any of the other learning activities.The number of visits to each learning activity contained in the lessons may be slightly misleading as a metric of engagement, as the different activities may pull for a different number of visits. For example, parents may only visit the self-check questions once in order to assess their comprehension, whereas they might return several times to the homework page in order to complete or review their homework plan. Therefore, we also examined the percent of learning activities that parents completed, regardless of the number of visits that this took. Again, there was a main effect of group  or website usability . There was a marginally significant group difference on parents’ rating of overall program satisfaction, with parents in the therapist-assisted group rating the program significantly higher  than those in the self-directed group .Parents rated the intervention content as highly acceptable  and the website as highly usable . In addition, parents indicated that they were highly satisfied with the program overall . The therapist-assisted group rated the quality of the therapist relationship uniformly highly . There were no group differences on ratings of treatment acceptability  because it is a conservative indicator of exposure to program content across intervention delivery modalities . For theF3,25=4.81, P=.01. After controlling for pretreatment intervention knowledge, program completion was a significant predictor of post-treatment intervention knowledge: beta=.45, t=2.45, P=.02  and program completion  were significant predictors of intervention fidelity at post-treatment. This result indicates that both therapist assistance and program completion make independent contributions to gains in parents’ accurate use of the intervention techniques with their child.The full model predicting parents’ post-treatment intervention knowledge was statistically significant: 5, P=.02 . This fiFinally, we examined the extent to which parent and child demographic factors at pretreatment and parent program evaluation variables at post-treatment were associated with program engagement. Again, we focused on program completion as our measure of program engagement. To do this, we calculated partial correlations between participant demographic variables at intake, program evaluation variables at post-treatment, and program completion, controlling for group assignment. Parent demographic variables included education level (no college degree vs college degree or higher), marital status (married vs not married), employment status (employed full or part time vs not employed), residence in underserved area, computer/Internet self-efficacy, and depressive symptoms. We did not examine parent gender as there was only 1 male parent participant. Child demographic variables included age, gender, race/ethnicity (majority vs minority), developmental quotient, autism severity (ADOS comparison score), and hours of nonstudy intervention. Program evaluation measures included treatment acceptability, website usability, and overall program satisfaction.r24=-.42, P=.04  were significantly associated with program completion.Of all of the pretreatment parent and child demographic factors, only parent depression was significantly associated with program completion: 2, P=.04 . ParentsIn this study, we examined parent engagement with a novel, telehealth-based parent-mediated intervention for children with ASD. Overall findings indicated that parent engagement and satisfaction with ImPACT Online was high for both self-directed and therapist-assisted versions of the program, although therapist assistance increased engagement. Parent outcomes were associated with program completion, providing support for the role of the website in parent learning.Parents who enrolled in this study were quite similar to participants in studies of traditional parent-mediated interventions for children with ASD . Like moWe found high rates of program engagement among parents, with overall completion rates similar to those found in studies of traditional parent-mediated intervention programs for children with ASD ,72. PareParents were more likely to engage with certain program components than others. Specifically, the learning activities contained in the lessons were visited significantly more often than supplemental materials. Among these learning activities, parents were significantly less likely to complete the reflection than the other learning activities. Interestingly, the forum was rarely visited and only three parents posted to the forum even once. Models of technological acceptance that claim the perceived usefulness and ease of use a technology  have a strong influence on its use . This fiTherapist assistance positively influenced parent engagement with the program. This finding is consistent with research on telehealth-based behavioral interventions; therapist support increases engagement with the program as well as overall outcomes ,74. In oParent completion of the learning activities on the website was a significant predictor of gains in parent knowledge and intervention fidelity. This finding suggests that program engagement was associated with gains in both conceptual and procedural knowledge of the intervention regardless of group assignment. Our regression model indicated that group assignment was also a significant predictor of gains in parent fidelity, which suggests that therapist assistance provided an additional benefit above and beyond completion of the tutorial for procedural knowledge. This finding is consistent with a large body of literature on parent training, which suggests that coaching is an important component for improving parent use of intervention techniques ,49,75,76We examined a number of pretreatment parent and child demographic variables as potential predictors of parent program engagement. Only one of these variables, parent depressive symptoms, was significantly associated with program completion. Parents who reported more depressive symptoms at intake were less likely to complete the program than parents who reported fewer depressive symptoms. This finding is consistent with research on traditional parent training that has found that pretreatment parent psychopathology, particularly depression, increases the likelihood of attrition ,77,78. TIn contrast, all of the post-treatment evaluation items were related to program engagement. The relationship between these factors and engagement is complex. Perceived usefulness and ease of use have consistently been found to predict behavioral intention to use a new technology and are considered important antecedent determinants of technological acceptance ,81. At tTaken together, these data provide support for the potential of telehealth to deliver parent-mediated interventions to parents of children with ASD. Additional research will be important to determine whether the same patterns and predictors of program engagement emerge in larger samples.


Little effort has focused on the role of volunteer-led out-of-school time (OST) programs  as key environments for the promotion of healthy eating and physical activity habits among school-aged children. The Healthy Kids Out of School (HKOS) initiative developed evidence-based, practical guiding principles for healthy snacks, beverages, and physical activity. The goal of this case study was to describe the methods used to engage regional partners to understand how successful implementation and dissemination of these principles could be accomplished.HKOS partnered with volunteer-led programs from 5 OST organizations in Maine, Massachusetts, and New Hampshire to create a regional “learning laboratory.”We engaged partners in phases. In the first phase, we conducted focus groups with local volunteer program leaders; during the second phase, we held roundtable meetings with regional and state program administrators; and in the final phase, we conducted additional outreach to refine and finalize implementation strategies.Implementation strategies were developed based on themes and information that emerged. For enrichment programs, strategies included new patch and pin programs that were consistent with the organizations’ infrastructure and usual practices. For sports programs, the main strategy was integration with online trainings for coaches.Through the engagement process, we learned that dissemination of the guiding principles in these large and complex OST organizations was best accomplished by using implementation strategies that were customized, integrated, and aligned with goals and usual practices. The lessons learned can benefit future efforts to prevent obesity in complex environments. Out-of-school time (OST) presents an opportunity to foster healthy eating and physical activity habits among school-aged children. Structured, staff-led, after-school programs have been the target of several obesity prevention studies –3. HowevDevelopment of actionable guiding principles for healthy eating and physical activity with input from 9 national OST organizations Development of implementation and dissemination strategies regionallyDevelopment and validation of evaluation tools Evaluation of effectiveness regionallyImplementation and evaluation nationwideThe guiding principles developed in our first stage were designed to be evidence-based, practical, and accessible: Drink Right: choose water instead of sugar-sweetened beverages; Move More: boost movement and physical activity in all programs; and Snack Smart: fuel up on fruits and vegetables. The next stage of HKOS was to support our partner OST organizations in disseminating the guiding principles to their local program leaders. To do this, we engaged regional OST partners in an iterative process to develop strategies for implementation. Here we describe that process and the resulting strategies.The objective of the HKOS initiative was to increase opportunities for healthy snacking and physical activity in volunteer-led OST programs through dissemination of the guiding principles. Volunteer-led OST programs have many characteristics that affect adoption, including variability in access to resources, organizational structure, and communications channels. As volunteers, program leaders have limited time and a high turnover rate; therefore, training and implementation efforts must be simple and ongoing. To develop successful strategies to disseminate the guiding principles nationwide, we created a “learning laboratory” and partnered with volunteer-led OST programs in Maine, Massachusetts, and New Hampshire. In these 3 states, the rates of childhood obesity mirror national rates . PartnerWe engaged stakeholders to acquire diverse perspectives at the local, state, and regional levels. The decision to engage stakeholders was based on theoretical and practical considerations. From a theoretical perspective, stakeholder engagement is grounded in the key ethical concepts of participation, empowerment, fairness, and justice . At a prEngagement occurred in 3 phases . The oveIn the second phase, we extended focus group findings through roundtable meetings with regional and state program administrators . Depending on the organization, some regional or state administrators are paid staff. Program administrators are responsible for a range of functions, depending on the organization, including promoting the programs, registering local groups, training program leaders, and managing funds. The objective during this phase was to confirm focus group findings, develop tangible strategies, and begin dissemination of the guiding principles in partner programs. In the final phase, we conducted additional outreach to volunteer program leaders and administrators to further refine findings and finalize materials. This outreach included presentations, attendance at their organizations’ events, and key informant interviews. Research protocols were approved by the Tufts University Social, Behavioral and Educational Research Institutional Review Board.We conducted focus groups with program leaders to gain insights to help inform next steps in dissemination, which included gathering resources to populate the Healthy Kids Hub, a website designed to connect staff and volunteers with educational materials, tools, and other resources. Therefore, the primary objectives of the focus groups were to understand the facilitators of and barriers to implementing the guiding principles and resources we could provide to address them.In total, we conducted 6 focus groups with program leaders from Boy Scouts, YMCA, 4-H, and Pop Warner Football and Cheer. Because of scheduling constraints, we could conduct focus groups only during youth soccer’s off-season, making recruitment of soccer coaches challenging. Each focus group comprised program leaders from a single organization, had 8 to 12 participants, and was less than 90 minutes long. In total, 56 program leaders participated. A pre–focus group survey was completed by participants to gather data on demographics, length of time associated with their organization, and preferred channels for communication. The mean age of participants was 42 years . Sixty percent of participants were female; 80% were non-Hispanic white, and 66% had worked in the OST organization for 5 or more years. The data analysis followed the accepted practices of grounded theory approach . Three rFocus group participants indicated that implementation of the Drink Right and Move More guiding principles would be easier and more relevant than Snack Smart. Move More was already part of the mission of some groups, and many viewed Drink Right as already being implemented . Barriers to Snack Smart were cited at the organizational level and included policies, existing practices, reliance on partnerships to finance healthy snacks, food insecurity or poverty, and the influence of food advertising. Children’s preferences for less healthy foods and lack of interest in physical activity were also mentioned as barriers to implementation of the guiding principles.We identified themes related to factors that would facilitate implementation of the guiding principles. These included program assets such as supportive organizational policies, formal infrastructure for training and leadership, and strategic partnerships. Program leaders also expressed an interest in learning more about children’s health and indicated that the guiding principles would largely integrate into their existing values, which included promoting the health and well-being of the children they served.During the focus groups, participants were prompted to describe the types of materials and resources that would be the most helpful for implementing the guiding principles. They expressed interest in 3 types of resources: 1) discounted products , 2) educational materials targeting parents , and 3) mechanisms for connecting with other program leaders  and community resources to support the guiding principles .Feedback from the focus groups indicated that a dissemination strategy that put the burden on individual leaders to champion adoption of the guiding principles in the organization could be problematic, especially in programs that depended heavily on unpaid volunteers for administration and operations . This feedback influenced us to develop a plan that would use existing communication and training channels and that would institute policy changes in the organizations, such as a youth soccer requirement that all new coaches take a HKOS-developed online healthy habits training.In Phase II, we engaged program administrators working at the state or regional level in half-day roundtable discussions with the objectives of raising awareness about the childhood obesity epidemic and the purpose of the guiding principles. We further aimed to establish state- and regional-level strategies for collaborative HKOS implementation and dissemination.One roundtable meeting was held at a central location in each state. At the Maine roundtable, 10 of 16 invited program administrators attended; in New Hampshire, 7 of 12 invited administrators attended; and in Massachusetts, 12 of 30 invited administrators attended. In each state, a national YMCA representative also attended. Youth soccer was not represented in New Hampshire, because there was only one state program administrator at the time, who was unable to attend; Pop Warner was not represented in Maine, because this program is not active in that state. For administrators who expressed financial barriers to attendance, we offered a stipend of $150 to offset travel costs.During the roundtable meetings, we provided program administrators with background information on the childhood obesity epidemic as well as evidence supporting OST programs’ role in obesity prevention. We held a facilitated discussion to garner their reactions to the information presented and to learn their perceptions of the barriers to and facilitators of implementing the guiding principles. Feedback clustered around 3 major themes. First, dissemination would likely be facilitated by the simple, actionable nature of the guiding principles. Second, there was concern about the potential loss of revenue from extending the Drink Right and Snack Smart principles to food environments outside of regular program meetings, such as concessions stands, Boy Scouts “trading posts,” or camp stores. Third, participants said that it would be most effective to reach program leaders through their existing training and communications channels, confirming a major theme from the focus groups. Program administrators also indicated that the information we provided was a powerful motivator and should also be shared with program leaders, because it challenged common assumptions. For example, we had shared research findings that children are physically active for only about half the time during a typical sports practice ,17. The The focus groups and roundtable discussions provided a more in-depth understanding of each organization that guided our dissemination strategy of tailoring the guiding principles to each organization’s unique programming and communication channels. Our main objective in this phase was to obtain information and feedback from program leaders and review existing program materials to determine strategies for integrating messages into them. We also aimed to deepen existing relationships and engage with any program administrators who were unable to attend the roundtable discussions.Our team delivered presentations during our OST partners’ regional meetings, attended OST events, and conducted key informant interviews (by telephone) with program leaders and administrators. For example, regionally we made presentations at several events, including a New England Region Pop Warner Football and Cheer League President’s meeting and a New England Area Scout Executive’s meeting. At the local level, HKOS hosted booths and delivered presentations at events, such as a Boy Scout Council’s Chuckwagon Derby and a youth soccer league tournament. In these settings, we engaged troop leaders, coaches, and youth in interactive activities related to the guiding principles, promoted adoption of them, and gathered additional feedback on the best way to reach program leaders with messages and materials. Once connections were made, these program leaders became advisors on future materials and plans. For example, an additional focus group was held with 4-H program leaders to obtain feedback on content and usability of the Healthy Kids Hub website.During the final phase of engagement, major differences among and within the organizations were identified, including the variability of program leader training  and communication channels . This information reinforced the need to customize our approach and to integrate strategies into existing structures. As a result, organizational variability was recognized and respected, extra demands on program leaders’ time were limited, and dissemination of the principles was relevant to the organizational context.For enrichment programs, the main implementation strategies resulting from the engagement process were trainings that promote activities consistent with the organization’s infrastructure or usual practices, such as youth earning a patch or pin on meeting goals related to the guiding principles . For theInformation learned from the engagement process was used to develop strategies for implementation of the HKOS guiding principles that can improve the likelihood of their successful dissemination. We learned that it is important to customize strategies and materials to align with the organizations’ usual practices, goals, and values.Integration of the custom materials into leader trainings and organizational policies increased the potential for sustainability. Incorporating the guiding principles into new leader trainings  and handbooks  may cause a shift in cultural norms that could affect the next cohort of program leaders and gain momentum in the future. Ideally, this approach removes the onus from program leaders to adopt the guiding principles and makes the behaviors synonymous with participation in the program.The results of our engagement process further suggested that dissemination would be most effective by reaching program leaders through their organizations’ existing communication channels. This process worked best when the HKOS team proposed and developed customized resources and then sought feedback at the program level for refinement. The SCOUTStrong Healthy Unit patch is a clear example of a tailored resource that was integrated into the existing SCOUTStrong program in the OST organization and disseminated through the existing communication channel of district roundtable meetings.Development of the customized materials and online training modules required the investment of substantial time and resources. The HKOS team that worked on this regional effort comprised a full-time project manager, 2 full-time research coordinators, and several Tufts University staff and faculty members who provided guidance and input on all aspects of the initiative. The potential reach justifies the more intensive inputs; our success with regional programs has led to interest in and adoption of our materials and trainings at the national level of our partner organizations and in similar OST organizations . The materials and new leader training modules developed in this regional project have been promoted on the national websites of 4 of the 5 partnering organizations, with the potential to affect millions of children. Therefore, our iterative process of engagement was successful in allowing us to navigate and affect multiple levels of these large and complex national organizations. By necessity, the development and initial adoption of the guiding principles occurred at the national level, effectively a “top-down” approach. Through the engagement process in the 3 states, we were able to integrate this approach with “bottom-up” strategies for successful local implementation and dissemination.Although this work was conducted in volunteer-led OST organizations, we believe the approach to engagement and the lessons learned could be applied to many endeavors to disseminate consistent evidence-based principles across multiple organizations. Important insights were gained with each iteration and by engaging more than one organizational level. This engagement process may generalize to many other types of organizations that are similarly complex. Our findings about the importance of customization and integration are also likely to generalize to other settings, including nonvolunteer organizations, given the ubiquitous challenges related to staff turnover and limited resources, as well as the importance of stakeholder ownership and support in enhancing adoption and implementation .The guiding principles are a powerful, policy-oriented approach to obesity prevention. They are a mechanism for unifying multiple OST organizations around consistent public health goals in a way that can complement efforts in other environments that children encounter. The stakeholder engagement process provided multiple insights to enhance dissemination of the guiding principles in this setting.


Drug court provides community-based treatment to individuals with substance abuse problems involved in the criminal justice system. The program offers comprehensive treatment as an alternative to incarceration. Past research has suggested there are sociodemographic and other personal characteristics that may impact an individual’s success in this type of program. The purpose of the current study is to examine factors associated with treatment completion among a random sample of program participants.A stratified random sample (n = 534) was selected from the total participants in Kentucky Drug Courts  from July 1, 2006, to January 1, 2011. The stratification was utilized to ensure participants were selected from all KDC sites, proportionate to the percentage the site represented of the total KDC population. Data utilized for these analyses were gathered from: the baseline assessment at program entry (a modified version of the Addiction Severity Index (ASI); [Overall, of the 534 individuals selected as part of the stratified random sample, 36.3 percent were program graduates (n = 194). Enter binary logistic regression was utilized to examine factors associated with program completion. There were several variables positively associated with program completion including: increased age (p < .001), reporting race as Caucasian (p = .015), being single/never married (p = .004), no past history of alcohol/drug treatment (p = .019), not reporting a pension for psychiatric disability (p = .007), no referrals to short-term residential treatment (p = .033), and not having any programmatic sanctions (p = .002). There were several variables negatively associated with program completion including: having less than a high school diploma (p = .038), being unemployed (p = .011), no referrals to outpatient substance abuse treatment (p < .001), and number of positive drug tests (p = .019).Understanding factors associated with program completion is important for multiple levels of programming. First, identifying characteristics of individuals most associated with program graduation can help with targeting screening and program assessment. Further, identifying characteristics of individuals most associated with program noncompliance can help with identifying individuals most at risk within the program to develop appropriate treatment and service planning.


Nourishing Networks (NN) is an innovative interprofessional learning program delivered in 2009 and again in 2014 for health professionals managing eating disorder clients in rural NSW. It was designed to enhance local networks and improve the knowledge, skills and attitudes of health professionals working with eating disorder clients.Impetus for re-delivering the program was high turnover of staff in rural communities and need to increase awareness of existing services. Identification of clients late in the course of illness remained a reoccurring issue.The original program consisted of a 10 week self-directed learning program with videoconferencing and a one-off workshop for health professionals. The revised program utilised a travelling roadshow to three rural locations to provide better access for outlying sites. This provided increased opportunities for networking and upskilling to a wider audience. The revised program attracted a greater range of health professionals with further involvement of general practitioners. Overall the program trained 254 participants, from nine different health professional backgrounds.Nourishing Networks has led to improvements in clinician confidence in identifying and assessing eating disorder clients, improved quality of referrals to existing clinicians, new services in some rural communities and an increase in GPs prepared to manage the clients.


In 2007, the Centers for Medicaid and Medicare Services (CMS) created a novel payment program to create incentives for physician’s to focus on quality of care measures and report quality performance for the first time. Initially termed “The Physician Voluntary Reporting Program,” various Congressional actions, including the Tax Relief and Health Care Act of 2006 (TRHCA) and Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) further strengthened and ensconced this program, eventually leading to the quality program termed today as the Physician Quality Reporting System (PQRS). As a result of passage of the Affordable Care Act of 2010, the PQRS program has expanded to include both the “traditional PQRS” reporting program and the newer “Value Modifier” program (VM). For the first time, these programs were designed to include pay-for-performance incentives for all physicians providing care to Medicare beneficiaries and to measure the cost of care. The recent passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act in March of 2015 includes changes to these payment programs that will have an even more profound impact on emergency care providers. We describe the implications of these important federal policy changes for emergency physicians. In 2001 the Institute of Medicine published a landmark review which noted that there were significant gaps in the quality of healthcare being delivered in the United States.On October 31, 2014, the CMS released its 2015 Medicare Physician Fee Schedule Final Rule, which detailed changes to the federal quality reporting requirements for payment of physician services.The American Board of Emergency Medicine (ABEM) promoted an additional 0.5% incentive for Medicare fee for service work by attesting to participation in the 2014 PQRS program. There is no ABEM incentive currently in place for performance year 2015 or beyond.To avoid the 2% penalty, EPs must participate in the traditional PQRS program and report performance on established quality measures. To date, there are currently five ways to report performance for participation in the PQRS programs for emergency physicians  and 2b. One aspect of the PQRS program is the notable lag between the performance and payment periods. Specifically, dollars paid  in 2015 for physician services are based on a two-year “look back.” Meaning that in 2015, payment for services to Medicare beneficiaries is based on how a provider on quality measures in 2013. This is also true for the VM Program. Therefore, the reported data are unlikely to be actionable for quality improvement nor allow patient consumers timely assessments to make care utilization decisions. The 0.5% bonus offered for participation in the PQRS Maintenance of Certification program (as that offered by ABEM) expired after 2014, and performance of these quality improvement activities in not set to be publically reported.In 2015, CMS retired 50 quality measures including four of the five that were previously commonly reported by EM providers as part of the 2014 “emergency care cluster.” These include PQRS #28: Aspirin for AMI, #55: 12-Lead Electrocardiogram for syncope, #56: Pneumonia (community-acquired pneumonia): Vital Signs, and #59: Pneumonia (CAP): Empiric Antibiotic. The list of remaining measures potentially applicable to EM is limited . Claim s13Groups are required to report on nine measures across three domains. A performance score of zero does not satisfy the requirements. Given these requirements and the available measures pertinent to EM, it is unlikely that the typical individual emergency physician practice will be able to satisfy the reporting requirements. As such, most will be subject to the Measure Applicability Validation (MAV) process. Through this process CMS groups PQRS measures into measure clusters. CMS expects that if a provider reports on one measure in a cluster that the provider could report on additional measures within the same cluster. CMS reviews the provider’s claims to see if the provider could have reported on additional measures within the cluster. If CMS finds that the provider could have reported additional measures within the cluster but did not, the provider will be deemed as failing the MAV process and a PQRS payment adjustment may apply. If CMS does not find additional measures within the cluster that the provider could have reported on, the provider will be deemed as passing the MAV. CMS established an alternative option for satisfying reporting for emergency physicians by defining an “emergency medicine cluster” . It is rQualified clinical data registries (QCDRs) are an alternative PQRS reporting option. QCDRs are certified registries of quality metrics that allow providers to report on a different set of measures than those in PQRS. The measures in QCDRs must be approved by CMS, but they do not require National Quality Forum (NQF) approval, streamlining the measure development process. Although not an option for EM in the past, in 2015 CMS approved two QCDRs for EM reporting.Section 3007 of the Affordable Care Act (ACA) mandates that CMS begin applying a VM payment adjustment, based on cost and quality metrics, to physician payments starting in 2015.The benchmarks for 2015 VM performance are based on 2014 performance. A national mean is calculated by including all physician groups with 100 or more EPs. Quality measures that are new in the performance period are not benchmarked in the quality composite calculation during the following one year. Medicare Spending Per Beneficiary (MSPB) costs are the sum from three days before to 30 days after index admission. Attribution is given to those who charged the most Medicare Part B (provider) charges during the index inpatient stay. The EM codes (99281-99285) are exempt from attribution.Participation in the VM program is similar to those for PQRS . Physician VM payments for 2015 excluded physicians who provide services in rural health clinics, federally qualified health centers, critical access hospitals (CAHs), and groups physicians participate in Medicare Shared Savings Program Accountable Care Organizations (ACOs), pioneer ACOs, and Comprehensive Primary Care Initiatives. However, these groups are included in 2015 performance for 2017 VM payments. During this same performance period nurse practitioners, physician assistants and clinical nurse specialists’ costs will be attributed to their associated TIN. The VM program requires participation in the traditional PQRS program (described above). Failure to participate in the PQRS program will affect both traditional PQRS payments (-2%), in addition to VM payments (−4%) for a maximum of a −6% penalty for groups with 10 or more.Patient attribution for EP performance is based on a retrospective assignment based on claims. The methodology is the same as Medicare Shared Savings Program assignment to an Accountable Care Organization.In April 2015 the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) was passed by Congress.Alternative payment programs (APM) have yet to be fully specified. Until the regulations are written, it is unclear exactly what the impact will be on EM. However, it is critical that EM begins to develop model programs that may be a way to generate innovative payment models which describe the value of high quality emergency care services. Recent work facilitated by the Brookings Institute that described the need for payment innovation for acute care services is an important first step in this development.Hospitals have a growing number of required quality reporting programs that are similar to, but distinctly different from, the provider-based PQRS program. These include measures described within the Outpatient Quality Reporting, Inpatient Quality Reporting, Value-Based Payment, and Core Measure. CMS has been clear that it intends to increase the amount of money at risk for provider performance. Now MACRA defines that at least 20% of physician’s Medicare payments will be at risk in the next decade. Continuing to research to evaluate the opportunities for emergency medicine to show economic value to the system are critical for our specialty.