In the past decades, the study of microbial life through shotgun metagenomic sequencing has rapidly expanded our understanding of environmental, synthetic, and clinical microbial communities. Here, we review how shotgun metagenomics has affected the field of halophilic microbial ecology, including functional potential reconstruction, virus–host interactions, pathway selection, strain dispersal, and novel genome discoveries. However, there still remain pitfalls and limitations from conventional metagenomic analysis being applied to halophilic microbial communities. Deconvolution of halophilic metagenomes has been difficult due to the high G + C content of these microbiomes and their high intraspecific diversity, which has made both metagenomic assembly and binning a challenge. Halophiles are also underrepresented in public genome databases, which in turn slows progress. With this in mind, this review proposes experimental and analytical strategies to overcome the challenges specific to the halophilic microbiome, from experimental designs to data acquisition and the computational analysis of metagenomic sequences. Finally, we speculate about the potential applications of other next-generation sequencing technologies in halophilic communities. RNA sequencing, long-read technologies, and chromosome conformation assays, not initially intended for microbiomes, are becoming available in the study of microbial communities. Together with recent analytical advancements, these new methods and technologies have the potential to rapidly advance the field of halophile research. Microbial life is one of the most diverse and bioenergetically dominant forces in the earth’s ecosphere , making In this review, we discuss key aspects of halophile community composition and function that metagenomics has revealed and provide examples of studies in various hypersaline environments for a perspective on analytical progress. We then examine the advantages and limitations of applying shotgun metagenomic sequencing in uncovering the structure and function of halophilic microbiomes. We outline the factors and characteristics that make the deconvolution of halophilic metagenomes a major challenge and propose analytical adjustments to be made when investigating these complex communities. Both experimental design and computation analysis approaches that are appropriate in halophilic metagenomics are summarized. Finally, we discuss novel sequencing technologies that show promise in further propelling the halophile metagenomic field. 16S rRNA gene) amplicon sequencing has revealed the taxonomic composition of a given community through sequencing a small target of the community’s DNA. In contrast, whole-metagenomic sequencing (WMGS) theoretically allows for reconstruction of the entire microbial community’s DNA content. This has led to a number of important findings in microbiome research [Rapid developments in high-throughput DNA sequencing technologies since the early 2000s have propelled our understanding of not only single-organism genetics, but also microbiome community structure and function . Marker research ,13,14, aresearch . However, while sequencing technologies are rapidly developing, producing complete genomes of all the microorganisms found in a community is currently unattainable due to low sequencing coverage of the less abundant organisms. Additionally, sequence repeats and regions of homology between organisms limits genome recovery from short-read data, resulting in incomplete assemblies. Instead, long contiguous pieces (contigs) of genomes are produced, ranging in length from 1 Kbp to 1 Mbp ,17. ThesShotgun metagenomics offers tremendous advantages in recovering taxonomic and functional potential components of microbial communities, but sequencing costs deter some researchers from deploying this approach in their studies. The high average read coverage required for the assembly of a genome from shotgun reads  presents16S rDNA amplicon sequencing, primer choices can have a substantial impact on taxonomic distribution, and it is difficult to reliably amplify multiple domains of life, e.g., Bacteria and Archaea, with the same primer set [16S rDNA amplification, including eukaryotic genomes, DNA viruses, and extrachromosomal DNA, such as plasmids. For example, in a study investigating the community composition of saltern ponds  co-assembly of multiple shallowly sequenced samples or (2) individual processing of a few deeply sequenced samples. Both approaches have their benefits and limitations, depending on the microbiome that is sequenced and the biological question to answer. In the first approach, samples are sequenced with relatively low-read coverage, and reads from all samples are combined during metagenomic assembly A. In resAn alternative approach to co-assembly is to sequence a small number of samples with deep coverage and process them individually B. BecausAn additional consideration in choosing a strategy for metagenomic sequencing and analysis is that of intersample community diversity. Communities in aquatic biomes, such as hypersaline lakes or brine ponds, are often more homogenous, harboring the same microorganisms with different relative abundances at different sampling locations. Under those conditions, a co-assembly strategy for metagenomics, as discussed above, is often preferred ,49,79. IThe take-home message is that, when conducting a halophile metagenomic study, it is especially important to design a sampling and sequencing scheme with statistical questions in mind. Because of the high strain-level diversity typically found in halophilic microbiomes, an experimental design should avoid adding unnecessary replicates into the study, as each added biological replicate will introduce more microdiversity into the data, further complicating the assembly and binning stages of the analysis . In pracWhen processing halophilic metagenome sequencing data, it is important to adjust existing pipelines to accommodate for high intraspecific diversity, G + C content diversity, and underrepresentation in most sequence databases. While this section does not provide step-by-step instructions for bioinformatics analysis, it outlines core considerations and adjustments that should be made when processing halophilic metagenomes. Automated metagenomic analysis pipelines such as metaWRAP  or SqueeThe preprocessing of WMGS data, which typically includes read trimming, duplicate read removal, and metagenomic assembly, is standard for most types of metagenomes. We encourage testing a variety of software and comparing the results to evaluation programs such as FastQC  (for rea16S rRNA genes) with EMIRGE is usually the best alternative [In contrast to assembly, the annotation of halophilic metagenomes for taxonomies and functions can be somewhat compromised because halophiles have extremely limited representation in standard-distribution taxonomic databases ,91, whicernative , as rRNAernative . Functional annotation  in halophile metagenomes is also severely limited by existing databases, especially compared to human microbiomes. Because many halophilic genes are not annotated in NCBI databases, metagenome-inclusive custom or specific databases are preferred because they contain a greater variety of noncultured organisms. In particular, services such as the “Integrated Microbial Genomes and Microbiomes” systems from JGI  include For many metagenomic studies, an important objective is the genome-resolved description of the microbiome of interest, since the analysis of individual MAGs opens up many avenues for more accurate and meaningful functional pathway annotations and strain-level comparative metagenomics. To that extent, the success of metagenomic binning of assemblies depends greatly on software choice, as binning programs perform differently with various data types . AdditioConsidering the overwhelming number of metagenomic bioinformatics tools coming out each year, it is difficult to keep up to date with the best analytical methods. In general, we advise testing and benchmarking multiple software programs for each analytical step to determine the best option, as many conventionally used software programs behave unpredictably with halophilic sequence data. For annotation, emphasis should be placed on high sensitivity rather than high precision, given the database limitations. Beyond shotgun sequencing of a microbiome’s DNA content, there exist a number of other sequencing technologies that have become available and may further our understanding of halophilic ecosystems. Studies applying these technologies to more developed microbial fields, such as human gut microbiomes, have shown their great promise and their potential applications in halophilic microbial communities in the near future. Conventional Illumina sequencing is limited to short DNA fragments (50 bp–250 bp), as errors accumulate rapidly at higher read lengths. However, read length, together with sequencing coverage, is undoubtedly a major limiting factor for metagenomics sequence assembly. Longer reads result in more accurate assembly and reduced chimeras, while they improve the contiguity of the assembly by allowing the assembly of repetitive DNA elements . Recent Chromosome conformation capture with Hi-C is another technology that shows great promise in the field of halophilic metagenomics. A Hi-C assay crosslinks DNA based on spatial proximity: The chimeric segments resulting from the crosslink events are then sequenced, revealing sections of DNA that are proximal to each other. Conventionally used to indirectly measure the proximity between sections of a genome, Hi-C was successfully applied in 2017 to microbiomes to improve binning predictions . ConsideFinally, genome-resolved metatranscriptomics  has been widely used in a variety of microbiomes to interrogate microbial transcriptional activities ,109. MetSuccessful applications of whole metagenomics in halophilic communities has already led to numerous breakthroughs in our understanding of their functional composition, virus–host interactions, and strain diversity and dispersal, and has allowed for the genome extraction of previously unknown halophiles. However, the genomic qualities and composition characteristics of halophilic communities have made them difficult to deconvolute in a metagenomic context, limiting the information that can be extracted from halophilic shotgun metagenomes. Combined with relatively low numbers of cultures of halophiles, this has led to their underrepresentation in existing taxonomical and functional databases, which has further complicated analysis. While in silico deconvolution of halophilic metagenomes is a challenge, it can be accomplished with analysis workflows that account for the specific characteristics of halophile communities. With proper tuning, rapidly advancing sequencing technology has the potential to reconstruct the complete nucleic acid content of halophilic communities, allowing the halophile field to focus on microbial functional activity and interactions.


A nested process evaluation, within a randomised controlled trial, will explore relationships between program outcomes and quality of intervention implementation of the Lifestyle-Integrated Functional Exercise Program in older people with vision impairment. The Lifestyle-Integrated Functional Exercise Program is a home-based strength and balance program that has been shown to reduce falls in high risk populations. A pilot study showed positive trends in improvements in physical function in older people with vision impairment after participation in the program. The program will be delivered by Orientation and Mobility Specialists, who are experienced in working with people with vision impairment.The process evaluation has a mixed methods design. This includes quantitative , as well as qualitative (open responses from program staff and semi-structured interviews with study participants) data. Process evaluation measures include program adherence (fidelity), complete delivery (dose delivered), participant receipt (dose received) and participant enactment. Using the Behaviour Change Wheel, a logic model was built to explain the intended inputs, outputs, outcomes and relationships to the behaviour change techniques in the Lifestyle-Integrated Functional Exercise Program in older people with vision impairment.The findings of the process evaluation will inform the provision of fall prevention programs in older people with vision impairment by Orientation and Mobility Specialists. To date, there are no proven falls prevention programs which aim to improve physical function and reduce falls in older people with vision impairment. This process evaluation will contribute new knowledge about the implementation of a strength and balance program in this population.ACTRN12616001186448. Registered 29 August 2016.The online version of this article (10.1186/s12913-018-3304-6) contains supplementary material, which is available to authorized users. Older people with vision impairment are eight times more likely to fall than their sighted peers . With anThe Lifestyle Integrated Function Exercise (LiFE) program  has beenA larger scale single-blinded randomised controlled trial known as the PrevenTing Falls in a high risk, vision impaired population through specialist ORientation and Mobility services (PlaTFORM) commenced in 2017. A comprehensive protocol of the PlaTFORM study has been published elsewhere . In brieA process evaluation is particularly important in trials of complex interventions and is a common method in determining the factors which influence the level of success of an intervention . The UK In this paper, we outline the aims and corresponding methods for the PlaTFORM process evaluation. The overarching aim is to understand the relationship between program implementation and acceptability, and program outcomes . More spWe aim to recruit 588 community dwelling people with vision impairment, aged 50 years or above. After baseline assessment, participants will be randomly assigned to the intervention or control group. The intervention group will receive the v-LiFE program plus usual care (an Orientation and Mobility program), while the control group will receive only usual care. This process evaluation will only include data from the intervention group.The v-LiFE program is designed to incorporate strength and balance activities into the everyday activities of older people with vision loss, living in the community, who are at high risk of falls. The intervention group will receive usual care as well the v-LiFE program over five weekly sessions, plus two booster visits and two phone calls within three months. If required, participants will receive up to two additional sessions. All sessions will be delivered in participants’ homes by O&M Specialists from Guide Dogs NSW/ACT. The control group will receive usual care.The strength and balance activities will be catered to each participants’ physical function as they move through the program. As participants improve their strength and balance they will be encouraged to upgrade to more challenging exercises (i.e. reducing their base of support or increasing the weight lifted). O&M Specialists will be able to tailor their approach for each participant, which is in line with consensus that programs need to account for the individual context when delivering interventions . SpecialThe implementation of the v-LiFE program will consist of three essential components : traininMore than 50 O&M Specialists from 10 offices, in six regions of NSW/ACT, will participate in two days of training. To assist in training and participation of those in regional areas, O&M Specialists will be able to take part in one of three possible training sessions . The first day of training will consist of training in the delivery of the v-LiFE program and the second day will consist of training in research procedures. Each session will be facilitated by the same trainers .O&M Specialists will then deliver the v-LiFE program to older adults with vision impairment. This will be completed through (a) five weekly sessions, (b) two booster visits within three months, (c) two support calls after the visits are completed, and (d) if required, two additional sessions. Trainer and participant v-LiFE manuals have been designed for this population, which are to be closely followed in each session. To enhance self-efficacy, O&M Specialists are required to give positive reinforcement, encourage the use of self-monitoring tools and to assist in setting personal goals for short-term achievements.Participants will be required to incorporate the strength and balance activities, learnt during sessions, into their daily activities.sources of behaviour (inner wheel): capability , opportunity  and motivation . These behaviour changes will be facilitated by the O&M Specialists, which fall under intervention functions (middle wheel) of the BCW. Of the nine intervention functions, the components which are particularly relevant for our trial are: education, persuasion, coercion, training, incentivisation and enablement. Within the intervention functions are behaviour change techniques (BCTs), which are the ‘active ingredients’, designed to change behaviour. Guide Dogs NSW/ACT will support the O&M Specialists in their training of the v-LiFE program with participants. The BCW wheel includes seven policy categories (outer wheel), of which, service provision is considered particularly relevant to this study.Michie et al.  developeTable The process evaluation is a mixed methods design. This includes quantitative , as well as qualitative (semi-structured interviews) data collection. Process evaluation measures include program adherence (fidelity), complete delivery (dose delivered), participant receipt (dose received) and participant enactment.Program adherence (fidelity) is a measure of what extent the intervention was developed and used as intended . The theProgram adherence will be measured through direct observation of participant sessions by an observer trained in the delivery of v-LiFE. Each instructor will be observed completing 1–2 sessions with participants, to cover approximately 20% of all v-LiFE program participants. A v-LiFE fidelity tool checklist  is a measure of the number of intended v-LiFE sessions and phone calls provided to participants . In ordeParticipant receipt (dose received) is a measure of participant’s engagement and understanding of the program content of v-LiFE, as well as their satisfaction with the program . ParticiParticipant enactment is a measure of what extent the knowledge and skills gained from completing the v-LiFE program are applied to participants’ everyday life. The v-LiFE program requires participants to actively engage in activities and opportunities that incorporate strength and balance into their daily routines. Habit formation is considered a core component of enabling people to perform LiFE activities routinely . ConsequDescriptive statistics will be used to summarise baseline demographic, vision and functional characteristics of intervention participants. In line with the MRC , quantitThe PlaTFORM study was powered to be able to compare fall rates between control and intervention arms of the main RCT and required a total of 588 participants (294 per group) to detect a 30% between-group difference in falls rate, with 90% power at the 5% level, allowing for a 15% drop-out [Quantitative data will be collected through a number of sources, including: checklists, completion of program sessions and survey answers. Descriptive statistics of process measures will be summarised . A correProgram adherence (fidelity) will be measured through the score attained in the fidelity tool checklist as well as the variability in score attained in the domains within the fidelity checklist  will be measured through number of v-LiFE sessions and phone calls delivered to participants by O&M Specialists, as a continuous variable (range 0 to 11). Program session data will be extrapolated from Guide Dogs CRM database.Participant receipt (dose received) will be measured using AFRIS. This will be measured as a continuous variable (range 6 to 42) where higher scores indicate greater engagement in v-LiFE [n v-LiFE .Participant enactment will be measured using the Self-Report Habit Index as a continuous variable (range 12 to 60). A score of 36 or higher indicates the presence of a habit. Lower scores indicate the absence of a habit [ a habit .Qualitative data can assist in understanding the effects of interventions on behaviour change in complex randomised controlled trails . The semA detailed protocol has been developed for a process evaluation nested within a randomised controlled trial of a home-based strength and balance program aimed at improving physical function, and ultimately, reducing falls in older people with vision impairment. The process evaluation will explore the implementation of the v-LiFE program in older people with vision impairment through investigations of adherence, delivery, receipt and enactment.Ultimately, the findings of the process evaluation will guide the ongoing provision of fall prevention programs for older people with vision impairment. O&M Specialists provide individual programs to enhance the independence and safe mobility of people with vision impairment. However, at this stage, there are no specific programs being delivered to this high risk population, with the aim of improving physical function and reducing falls. This is a unique opportunity to understand the real world impact of program implementation on program outcomes, and translate these findings directly into practice. Garnering the views of participants and what they consider to be acceptable can assist to further refine the program and make it work better for this population. Such an understanding can have further implications for fall prevention of people in other high-risk populations.There are no fall prevention programs based on balance and strength training which have been found to be effective for older people with vision impairment . UnderstOver 50 O&M Specialists will deliver the v-LiFE program to participants, so there is the potential of inconsistencies along service delivery. However, O&M Specialists will receive two days of training in delivery of the v-LiFE program by the same trainers, and will receive the same training materials and ongoing support. The fidelity tool (program adherence) will capture how well the Specialists deliver the v-LiFE program to participants. The large number of Specialists delivering the program allows for a wider reach of the program and reflects real world conditions. Another limitation is that the participants themselves will predominantly be recruited from the Guide Dogs NSW/ACT database and may have already undergone O&M training. As a consequence, these participants may already be quite pro-active, compared to those who may not have accessed rehabilitation services in the past. Thus, participants may already be used to ongoing weekly O&M sessions and be more receptive to this program than someone who has not accessed services.To our knowledge, this will be the first time a process evaluation will be embedded in a randomised controlled trail that looks at strength and balance and falls in older people with vision impairment. The process evaluation will be collecting both qualitative and quantitative data in a mixed-method design, allowing for a holistic understanding of participants engagement with the v-LiFE program.Additional file 1:Appendix 1. Program Adherence (fidelity). v-LiFE fidelity tool checklist, used in each observation of Orientation and Mobility Specialists to ensure consistency in delivery. (DOCX 17 kb)Additional file 2:Appendix 2. Participant Receipt. Semi-structured interviews and survey questions, adapted from the Attitude to Falls-Related Intervention Scale (AFRIS). (DOCX 13 kb)Additional file 3:Appendix 3. Participant Enactment. Survey questions, adapted from the Self-Report Habit Index. (DOCX 13 kb)


The objectives of our study were to examine within a one group pre- and post-test design 1) the feasibility of implementing the program in two regions of French-speaking Switzerland, 2) the effects of the program, and 3) the participants’ use of the trained strategies in daily life.Persons with dementia experience a progressive decline associated with an increasing dependency. Most of the support they require to stay at home comes from their informal caregivers (IC). Dementia informal caregiving imposes high costs on IC’s health and quality of life, related to long periods of chronic stress. Based on evidence that more adequate coping strategies can reduce chronic stress and its negative consequences, and that psycho-educative interventions have the broadest effects on IC quality of life, the program “Learning to feel better… and help better” was developed in French-speaking Canada. This group intervention focusing on coping with the daily stress of dementia caregiving showed efficacy in decreasing the behavior problems of the person with dementia and the associated stress reactions in their IC. A mixed-methods concurrent nested design was used to quantitatively evaluate the feasibility, the effects on five core outcomes, and strategy use in daily life. Additional qualitative data documented in depth the acceptability and impact of the intervention.d = 0.41, p < .05), psychological distress  and self-efficacy . The qualitative results emphasized the benefits of a group format: Participants felt understood by peers, could build new social bonds and experienced reduced social isolation. Data regularly collected in daily life showed that participants were using more and more over time the strategies they learned , particularly reframing.We analyzed 18 complete data sets. Regarding feasibility, qualitative and quantitative results converged towards a very good acceptance of the program and a strong implication of the participants. Regarding effects, the program resulted in substantial and significant improvements in burden (This study expands on the original one conducted by the developers of the program in French-speaking Canada, by showing the feasibility and the very promising effects of this intervention in two regions of French-speaking Switzerland. Dementia is one of the main cause for disability and dependency in older people, with 46.8 million people affected worldwide in 2015. Due to population ageing, in the absence of a cure, we expect 75 million of persons living with dementia in 2030, and 132 million in 2050  had more painful and hard circumstances, so I said to myself, this is it, what I can expect for myself […]. It was very real. A bit too concrete, but this also allowed me to see the limits. How far I can go.»A participant, who was new to the caregiving role, felt enabled to anticipate and to set limits after listening to the experiences of exhaustion and heavy burden of other participants.«Yes, I had a moment, two or three moments, where it was very hard for me during this course. It was perhaps when there were people who shared too much violent detail, which I wasn’t prepared for. That distressed me a bit. And then reality hits you.»Listening to the experiences of others was not always described as an opportunity to learn. Some participants reported getting upset while listening to the burdening stories of others, or finding it painful to imagine they could be facing similar situations in the future.«It brought me a fantastic well-being. Because you feel a bit lonely in the world, when you are like this, but then I saw, there are lots of people with the same problems as me.»Being in a group with other ICDs made the participants feel less alone. They realized that others shared the same problems or had similar difficult situations.«We need to talk about our experiences, and to talk to others who know and others who also share the same [experiences], even though they have no solutions, they share. Emotionally they can understand the burden of it, they can understand the degree of isolation that we can feel in this [situation].»The participants enjoyed feeling deeply understood by other caregivers with similar experiences or by group leaders with extensive knowledge in this field.«It is clear, we were a small group, this also allowed us to develop the things we needed in parallel to the program. Suddenly we were a bit more than a program. It made the work valuable. We could really talk about practical cases […]. »Participants valued being in a small group, allowing a focus on the specific needs of each participant and discussions on practical issues related their specific situations.«Me, I made friendships in the group. […] It is true, we will stay in contact. So we were not going to go our separate ways, on the contrary we exchanged our telephone numbers and all that and said we are going to meet regularly.»The participants reported that they felt connected to the other participants and described feelings of friendship, empathy and solidarity. They appreciated and underlined the importance of their experience and that of others never being judged. Such a benevolent environment enabled the participants to build supportive relationships, which they expect to persist after the end of the program.«The program gave me a good structure to think about how to approach difficult situations at home and also other things. It gave me a good structure to guide my thoughts, just the basic structure for difficult situations, emotions (…), and me, I had enough structure to hook onto and that immediately meant something to me.»This category shows the strongest connections to the content of the program and to the aim of empowering the participants. Many of them reported that the program helped them changing their way of thinking by recognizing and modifying unhelpful thoughts.« I learned to manage my behavior. I was, before I came, more impatient, I was more aggressive. I am less [aggressive], a lot less. Well, it can still happen at times when I am very tired […], but I am a lot less aggressive with him now, because before I blew up at every moment. Well anyway, now I have learned [to manage my behavior], this is positive. »Working on unhelpful thoughts also enabled them to see their situation in a less dramatic light and to manage negative emotions.«[…] and also to be able to change the things a bit for me. To think a bit more about myself. Doing activities, going to the cinema with my friends a bit more often, to the theatre, and taking some time for myself, that is very important.»The importance of taking some distance and taking better care of themselves were mentioned as helpful insights gained during the program.«To say, ok: what do I do? I know he is ill, I know that he doesn’t have the capacity anymore, so it is not about me. I have to understand that. It [the program] brought greater understanding about the attitude of my husband [and] his behavior.»A deeper understanding of the disease and its symptoms empowered the participants to have more patience, to adapt their communication and to cope better with difficult behaviors of the person with dementia.«Then you recognize some openings for getting help. We know where to call, and who to turn to when something happens. This has been very positive.»Information about, and contact details for diverse support organizations were experienced as helpful and facilitating access to support.This study aimed at 1) assessing whether the program “Learning to feel better… and help better” could be implemented in French-speaking Switzerland, 2) testing if the effects documented by the developers could be replicated in this new context, and 3) exploring the participants’ use of the trained strategies in daily life. Globally, feasibility was very good except for recruitment, and effects were positive and substantial, thus encouraging further dissemination of the program. The group format was a strong asset according to participants, and the use of reframing progressed the most over the course of the intervention.Regarding feasibility, our qualitative and quantitative results converged towards a very good acceptance of the program and a strong implication of the participants. Recruitment was however challenging. The main barrier was the duration of the program, which discouraged many ICD from participating, as it was too demanding for them, particularly for older persons and those working full-time. Although underuse of diverse support options is very common among ICD and not specific to this program , we planRegarding effects, the program resulted in substantial improvements in burden, psychological distress and self-efficacy. As in the developers’ study  conducteThe qualitative results emphasized the benefits of a program offered in a group format, in line with results of a meta-analysis showing that psycho-educative interventions in a group format significantly reduced depression in ICD while individual ones did not . Our parOpenly sharing experiences also facilitated social comparison and anticipation, having both negative and positive aspects. On the positive side, social comparison encouraged participants in their way of handling some situations and invited them to try new options by providing positive examples of management. Hearing others’ experiences also helped them get prepared for new challenges in their caregiving. On the negative side, participants were confronted with the painful experiences of others and detailed descriptions of the disease-related decline, which generated strong negative feelings in some of them, for a limited time. These feedbacks highlight some other processes at play beyond the training of coping strategies, many of them related to the complex mourning associated with dementia caregiving .Moreover, the present research used an innovative data collection method to document strategy use. Collecting such information in daily life regularly throughout the intervention proved feasible despite the chronic stress experienced by ICD. These data confirmed that participants were using more and more over time the strategies they learned, and showed that reframing progressed the most. This last finding is in line with the results of a meta-analysis of 11 interventions for ICD comprising this strategy, which documented improvements in anxiety, depression and subjective stress - although no systematic effect was found for coping, subjective burden, reactions to the behaviors of the person with dementia, or institutionalization . NotablyOur less clear results regarding the use of problem solving and support seeking could be due to our questions being too general, as suggested by the high rates of mastery observed already at intervention start. These questions may have failed to capture what our participants did express in their qualitative feedbacks, about having found innovative solutions to their problems, and knowing better where and how to obtain the support they need. Our findings may also be limited by the lack of follow-up data, as some strategies take time to bear fruits, particularly in the area of support seeking. For example, organizing a day-care center for the person with dementia often spans over weeks between the first contact with the institution and the establishment of an adequate routine for all the persons involved. In the same line, managing the difficult behaviors of persons with dementia remains one of the most challenging caregiving task . TherefoThis study expands on the original one conducted by the developers of the program “Learning to feel better… and help better” in French-speaking Canada, by showing the feasibility and the very promising effects of this program in two regions of French-speaking Switzerland. The original efforts of our study to document the process of the intervention by measuring strategy use in daily life also pave the way for further research aiming to clarify the (most) active components in supporting ICDs. Our next challenge will be to shorten this program and to improve our recruitment procedure in order to make this helpful program accessible to more informal caregivers of persons with dementia.


Introduction: Effective interventions to increase HPV vaccination are needed to reach national vaccination goals and to reduce later HPV-related cancer disparities. We used Intervention Mapping (IM) to develop and adapt a theory- and evidence-based educational intervention targeting parents of Hispanic adolescents to increase HPV vaccination.Methods: We followed IM steps 1–6 to: (1) develop a logic model and identify modifiable factors associated with vaccination among Hispanic adolescents by conducting literature reviews, focus groups, and in-depth interviews with Hispanic parents; (2) develop outcomes, write performance objectives, and develop a matrix of change objectives; (3) develop and identify a program theme, program components, theoretical methods, and practical applications; (4) develop an intervention design plan; (5) develop implementation strategies; and (6) develop an evaluation plan. We completed Steps 1–6 for to develop an intervention targeting parents of females, and we followed the steps again to adapt the program once HPV vaccine recommendations included males.Results: The program Por Nuestras Hijas (For Our Daughters) included two components: a print fotonovela and a tailored interactive multimedia intervention (TIMI). The program utilized the methods tailoring, targeting, framing, anticipated regret, modeling, skill building, and education and counseling to target the following determinants: parental knowledge, attitudes, self-efficacy, skills, perceived benefits/barriers, perceived susceptibility, perceived norms, and outcome expectations as modifiable factors influencing HPV vaccination. Lay health workers implemented the program in community clinics. A logic model of change guided evaluation planning. We later adapted the outcome and intervention content for parents of Hispanic adolescent males and changed the theme to Por Nuestros Hijos (For Our Children). Throughout the development and adaptation processes, we relied on theory, empirical evidence, and new data to make decisions.Discussion: IM provided a systematic methodology for program development and adaptation. Tasks in each step built upon one another integrating findings from the literature, previous research, qualitative findings, and theory to develop two educational programs for parents to increase HPV vaccination. The systematic process allowed us to develop messages and materials targeting factors beyond HPV knowledge or awareness to create behavior change. Persistent human papillomavirus (HPV) infection can lead to anogenital cancers, oropharyngeal cancer, and genital warts . In 2017The HPV vaccine can protect against the types of HPV that can lead to cervical cancer, other anogenital cancers, oropharyngeal cancer, and genital warts in both men and women. The Centers for Disease Control Advisory Committee for Immunization Practices (ACIP) recommends providers administer the HPV vaccine to adolescent males and females at ages 11–12 . While HTheory- and evidence-based interventions have been shown to be more effective than non-theory based interventions . IntervePor Nuestras Hijas (For Our Daughters), included a print fotonovela and a tailored interactive multimedia intervention (TIMI) delivered as an application on a tablet. Fotonovelas are brief print stories with pictures and dialog popular among Hispanic populations in conveying health information. Once recommendations changed and included HPV vaccination for boys, we used IM to adapt the interventions, repackaged as Por Nuestros Hijos (For Our Children).This paper describes the use of IM to develop and adapt two interventions for parents aimed at increasing HPV vaccine uptake among Hispanic adolescents. These interventions were developed as part of a larger comparative effectiveness study to develop and evaluate a print vs. tailored intervention delivered by lay health workers in clinic settings. Initially, we followed IM to develop interventions focused exclusively on parents of Hispanic female adolescents to increase HPV vaccination among this population. The interventions, packaged as Intervention Mapping guides program planners through six steps from needs assessment to program evaluation. The steps include: 1) developing a logic model of the problem, (2) identifying program outcomes and objectives, (3) designing the program, (4) producing the program, (5) planning for program implementation, and (6) planning for evaluation . Below w developiThe purpose of IM Step 1 is to conduct a needs assessment and develop a logic model of the problem (parent hesitation or inaction regarding adolescent child's HPV vaccination). To inform our needs assessment and logic model, we identified the following: (1) the burden of cervical cancer among low income or underinsured Hispanic women; (2) rates of HPV vaccination among low income and underinsured Hispanic female adolescents; (3) Hispanic parental beliefs, barriers, or attitudes toward the HPV vaccine amon; (4) and parental decision-making processes for obtaining the vaccine for their daughters.promotora  association to help guide program development, implementation, and adaptation decisions.IM recommends first forming a planning group made up of community stakeholders, members of the target population, and potential program implementers who work collaboratively with intervention developers to identify health problems and work together to develop solutions . Our plaThe team conducted a literature review to identify factors related to parental acceptance of the HPV vaccine and parental beliefs and attitudes related to HPV vaccine decision-making. A medical librarian skilled in designing systematic reviews developed our search, which included MeSH terms related to HPV vaccination, parent decision-making and vaccinations, parental acceptance of the HPV vaccine, and parental beliefs and attitudes toward the HPV vaccine for their daughters. Studies conducted in the United States between 2001 and 2010 published in English were included in the search. Studies were not limited to those with Hispanic participants only.Finally, focus groups and in-depth interviews were conducted with Hispanic parents of adolescent females aged 11–17 years to further understand parental acceptance of the HPV vaccine for their daughters and beliefs and attitudes related to the vaccination. Research staff placed recruitment flyers in local community centers and clinics serving predominantly Hispanic populations. Parent eligibility requirements included: (1) identify as Hispanic/Latina/o; and (2) report having a daughter aged 11–17 years. Bilingual facilitators trained in qualitative research methods conducted a total of four focus groups and two in-depth interviews. All focus groups and interviews were recorded and later transcribed for analysis. All participants completed informed consent documents prior to the focus group or interview, and all received a $25 gift card for participating.The purpose of IM Step 2, is to state program outcomes and objectives and develop a matrix of change objectives to guide program development. During this step, we stated the overall behavioral outcome to be accomplished as a result of our intervention and developed a detailed list of performance objectives, or sub-behaviors needed in order to achieve the outcome .To construct the matrix of change objectives, performance objectives were included as row headings and modifiable factors positively associated with vaccine decision-making (determinants) as column headings. IM Step 1 findings informed the selection of determinants for the matrix. We crossed performance objectives and determinants to produce change objectives. Change objectives describe what must change in the determinant in order for an individual to perform the performance objective . The matThe purpose of IM Step 3 is to develop a program theme, identify program components, map change objectives and determinants to theoretical methods, and develop practical applications to operationalize methods. Our team collaborated with the planning group to develop a theme for the intervention, identify program components, decide on tangible products for parents, and discuss how parents would interact with the intervention. Guided by tables of methods to address specific determinant in the Intervention Mapping text , the groFor both program development and adaptation, a production plan guided the creation and adaptation of materials. The plan included detailed flowcharts, developed mock-ups, created content, and produced all materials. To produce materials, collaborators included an application design team, a graphic designer, a talent consultant and agency, a video production team, actors, video editors, and a photographer.In IM Step 5 for both program development and adaptation, we developed implementation strategies to build lay health worker capacity to deliver the program. To do so, we completed IM Steps 1–4 again with lay health workers in mind. This included identifying specific steps lay health workers would have to do in order to implement the interventions, determinants that may influence lay health workers' abilities to implement, theoretical methods to influence those determinants, and materials needed to deliver the interventions.As a first evaluation step in both program development and adaptation, we validated that program content was consistent with the program plan by comparing content with the matrix of change. Creating a table with all determinants, change objectives, theoretical methods, and practical applications enabled us to assess whether the interventions addressed each change objective.Next, we designed a comparative effectiveness study to assess the intervention effect on increasing vaccination uptake among Hispanic adolescents. Previous IM Steps informed the evaluation in several ways. First, the matrix of change objectives guided measurement development since they clearly describe the specific changes expected because of the program. The logic model guided development of indicators and measures to identify predictors, mediators, and moderators of HPV vaccination. The logic model of change also guided the evaluation of program implementation and informed our process evaluation. A complete description of the group randomized controlled trial including results is forthcoming. However, in short, thirty federally qualified health centers and community clinics to participate in the study. Lay health workers recruited participants from within the clinics and followed protocols to assess eligibility, obtain informed consent, administer surveys, and implement the interventions.During program adaptation Step 1, the aim was to identify factors associated with parental vaccine decision-making for males that may differ from those identified for parents of females. If significant differences existed, the program would likely require more extensive adaptations. Similar to methods in Step 1 for program development, we described the disease burden among the target population, parental barriers to obtaining the HPV vaccine for their sons, and the parental decision-making process for vaccinating sons.An updated literature search was conducted in PubMed for studies assessing the following: (1) correlates of HPV vaccination in boys; (2) parents' acceptance or intention to vaccinate their sons against HPV; (3) parents' attitudes, knowledge, and acceptability of the HPV vaccine for male adolescents; and (4) barriers to HPV vaccination for male adolescents. The search was limited to US populations and to studies published in English through January 2015.Step 1 also included three focus groups and five individual interviews with 20 Hispanic parents of males ages 11–17 recruited from local community centers and clinics. The purpose was to understand parental beliefs about the HPV vaccine for males and to understand parental decision-making to vaccinate their sons. Trained bilingual facilitators conducted the focus groups and interviews, which lasted between 60 and 85 min each. All sessions were conducted in Spanish. Facilitators obtained informed consent from each participant prior to each session, and all sessions were recorded and transcribed for analysis. Parents received $20 gift cards for participating.Throughout the adaptation process, we considered whether the adapted intervention needed a new behavioral outcome and whether steps parents took to obtain the HPV vaccine for sons different from steps for obtaining the vaccine for daughters. All steps outlined above were followed to state the adapted behavioral outcome, identify adapted performance objectives, and create an adapted matrix of change objectives.During program adaptation, we reexamined the program theme, components, and theoretical methods, and practical applications to assess applicability to our new population. To ensure all content was relevant, we compared change objectives from the matrices for males to the materials previously developed for females. For example, if a change objective stated specific knowledge a parent should have, all materials were checked for that content. For all change objectives not addressed in the materials, we created new content.The literature search resulted in 30 studies examining factors associated with HPV vaccination among adolescent females. Modifiable factors associated with HPV vaccination included knowledge, attitudes toward the HPV vaccine, self-efficacy and communication skills, perceived benefits of the vaccine, perceived barriers to vaccination, HPV risk perception, and concerns about HPV vaccine safety –26. Non-Findings from the focus groups and interviews confirmed that the modifiable factors identified in the literature search were applicable to our population. For example, Hispanic parents had low knowledge and awareness about HPV and the HPV vaccine, and parents expressed concerns about vaccine safety and side effects. Importantly, parents wanted information on how to speak with their daughter's provider about HPV and the HPV vaccine.Our complete logic model of the problem included the behavior of interest (lack of HPV vaccination), the related health consequences , and determinants, or parental factors associated with the decision not to vaccinate Figure .The overall behavioral outcome focused on parents: Parent will obtain the HPV vaccine for daughter. We identified five performance objectives associated with the outcome Table . DetermiPor Nuestras Hijas (For Our Daughters)” to convey a message of protection. Throughout the program, the theme was interwoven in two ways: (1) highlight that the HPV vaccine protects daughters from the human papillomavirus; and (2) highlight that parents protect their daughters from cancer by obtaining the HPV vaccine for them. The intervention follows the story of a mother gathering information about the HPV vaccine and making the decision to vaccinate her daughter to protect her against cancer. This protective framework is effective for this population. Messages that specifically frame the HPV virus as a threat to daughters and mothers as protectors increase Hispanic mothers' intentions to vaccinate their daughters (The team developed the theme “aughters .fotonovela and a tailored interactive multimedia intervention (TIMI) delivered on a tablet. The two components conveyed the story of the mother in both video and print format. Print fotonovelas are illustrated brief stories with pictures and dialog accompanying the images. Fotonovelas are soap-opera style stories, popular in Spanish-speaking societies and are often used to describe and educate Hispanic audiences about health topics. They often employ theory and evidence-based methods such as social modeling and vicarious learning, and have been shown to be effective in helping individuals personalize health issues, identify with and internalize the information being presented, and engage in positive health behaviors . A video production team with experience in health-related productions filmed and produced all scenes, and a graphic designer created presentations with voiceover for the TIMI. The design team received all material and created the tablet-based application  a list of resources available to help cover the cost of the vaccine; (2) information about HPV and the HPV vaccine; (3) a calendar to help parents keep track of dosing schedules; and (4) a place for mothers to write down questions about the vaccine to ask their health care provider.We created a storyboard for the e Figure . In addifotonovela have previously been reported (fotonovela-based education (41%) was less than the iPad-based TIMI (67%) education intervention.The cost of developing the TIMI and reported . As reflPro Salud, the lay health worker program headquarters. As a part of the training, medical experts presented information about HPV, the HPV vaccine, and cervical cancer. Each presentation ended with a question and answer session. The goal was to provide the lay health workers with a working knowledge of HPV, cervical cancer, and the HPV vaccine. We also used skills training and modeling approaches to prepare the lay health workers for their role in educating parents. Lay health workers learned how to use the program materials and how to respond to participant questions or concerns through both didactic presentations and facilitated practice session. Lay health workers took turns administering the program materials to build skills and self-efficacy. During this time, research staff circulated around the room to observe, assist, and offer feedback and reinforcement. Additional training topics pertained to evaluation efforts (see IM Step 6).For implementation, the target behavior was “Lay health worker will deliver the educational interventions with fidelity,” and performance objectives included (1) adopting the role of lay health worker, (2) locating eligible parents, and (3) conducting sessions with parents. Determinants included knowledge, skills and self-efficacy, attitudes, perceived norms, and outcome expectations. After completing the matrix of change objectives, we identified the following theoretical methods: information, modeling, feedback, reinforcement, and active learning for use in the implementation intervention. These methods were operationalized through presentations, activities, and practice sessions during a 2-day training session at To assess content validity, we created a table mapping all program components back to change objectives and determinants Table . The tabfotonovela and TIMI study arms. We conducted follow up surveys and accessed patient vaccination records to assess vaccination status at 6 months after baseline. Results are forthcoming. During program development and implementation, we also assessed the cost-effectiveness of developing and implementing the interventions (Por Nuestros Hijos (described below) is currently underway.We recruited 1,398 parents of adolescent females in participating clinics as part of the group randomized controlled trial to assess the effectiveness of the two interventions. Trained, bilingual data collectors approached parents in clinic waiting rooms, assessed eligibility, and obtained informed consent from those agreeing to participate. Data collectors administered baseline surveys to all participants and lay health workers administered the interventions to those in the ventions , 41. FinDuring the literature review, thirty-two relevant articles were identified after screening 1,032 title and abstracts. Similar to female adolescents, determinants for vaccinating adolescent males included parental knowledge, self-efficacy, skills, perceived benefits of the HPV vaccine, perceived susceptibility to HPV, perceived social norms, outcome expectations, and HPV vaccination attitudes. Parental intentions to vaccinate their sons were higher if they had daughters who were previously vaccinated against HPV , 43. FurFocus groups and interviews revealed knowledge gaps about HPV-related cancers among males. Some parents were also unaware the HPV vaccine was available for males. Other knowledge gaps included parents confusing HPV with the herpes simplex virus (HSV) and parents now knowing condoms do not provide complete protection against HPV. Finally, parents reported receiving conflicting information about HPV from multiple sources. These results informed new content included in the adapted intervention.The adapted program focused on a new outcome (HPV vaccination of sons). However, the target population, Hispanic parents, and the desired behavior, HPV vaccination, remained the same. Therefore, performance objectives were unchanged, and the matrix of change included most of the same change objectives. Minor changes included updating the knowledge change objectives to include male cancers and genital warts and removing change objectives regarding concerns about sexual disinhibition. For parents of daughters, we originally included content that assured parents daughters were not more likely to initiate sex at a younger age or to engage in risky sexual behaviors after vaccination. For parents of sons, we did not emphasize this point since it was not an identified barrier in the literature review or focus groups and interviews.Por Nuestras Hijas (For Our Daughters) was changed to Por Nuestros Hijos (For Our Children) to reflect that the program now contained information for parents of daughters and sons. The adapted program included the original story of a mother of a daughter and included a new story following a mother gathering information and deciding to vaccinate her son. The adapted program used the same program components, methods, strategies, and practical applications with one addition. Text message reminders, or cues to action, were added as a during Por Nuestros Hijos (For Our Children) to target HPV vaccine series completion behaviors.Our original theme and program title fotonovela aimed at parents of Hispanic males. Language in text message reminders to increase series completion were based on our previous work regarding linguistic agency and HPV vaccination intentions  did not change from Por Nuestras Hijas (For Our Daughters). Lay health workers continued to implement the program. The two primary adaptations to training content included: (1) providing information about HPV-related cancers affecting males, and (2) describing the updated ACIP recommendations to include HPV vaccination for adolescent males.Our implementation plan for delivering Por Nuestras Hijas (For Our Daughters), an intervention targeting parents of Hispanic females. The process relied on evidence and theory to drive development of the logic model of the problem, program outcomes and objectives, program design, program production, development of an implementation intervention, and evaluation. As guidelines changed to include HPV vaccination for males (We used Intervention Mapping (IM) to systematically develop and adapt two interventions for parents of Hispanic adolescents to increase HPV vaccine uptake. We first followed IM to develop or males , we usedOur program adapted for Hispanic parents of adolescent males required minimal adaptations. IM can guide program planners in making adaptations that are more significant by systematically guiding decision-making throughout the process. This is helpful as program planners identify evidence-based interventions developed in one context and adapt them for another . ChangesPor Nuestros Hijos required mostly surface-adaptations since the behavioral outcome, determinants, and performance objectives were similar to the original program. Surface adaptations are smaller adaptations that tailor a program to a new audience, but do not necessarily add new program components or address new determinants. In Por Nuestros Hijos, example surface adaptations included changing characters to include males, altering scripts to include HPV-related cancers related to males, and updating the HPV guidelines to include males. Some program planners may follow IM and find that deeper adaptations, or more extensive changes to the original program, are needed to adapt an existing program for a new population. For example, IM Step 1 may identify a new determinant relevant to the new target population. This would then add to the matrix of change objectives. Planners would then identify new methods to target that determinant, new practical applications, and new intervention materials addressing the new change objectives—activities associated with more extensive adaptations to the original program.Por Nuestras Hijas (For Our Daughters), we used modeling to address parental self-efficacy in asking the provider questions, requesting the vaccine, and scheduling subsequent doses. We also used modeling to address parental outcome expectations. In this way, and based on the IM logic model of change, modeling was a critical method for creating parental behavior change. Modeling was the mechanism through which we expected to increase self-efficacy, to create positive outcome expectations, and to ultimately increase vaccination behaviors. In adapting the program, we retained modeling as a method since determinants were identical, and we adapted the original scripts to include language relevant to parents of males to operationalize the method.Further, IM assists program planners in identifying the most salient methods, applications, or program components critical to program effectiveness. For example, in Interventions targeting multiple factors associated with a health behavior are critical to behavior change, and interventions specifically targeting HPV vaccination sometimes fail to address more than one factor associated with parental decision-making. Interventions to increase HPV vaccination among adolescents often provide only educational information or cues to action  for parents . EducatiPor Nuestras Hijas (For Our Daughters) and Por Nuestros Hijos (For Our Children), IM provides a user-friendly, iterative stepped approach to facilitate development and adaptation guiding researchers and public health practitioners every step of the way.The steps that guided program development and adaptation are applicable to a broad group of researchers, program planners, and public health professionals. IM was specifically designed for use in public health settings, not just academic research settings, providing public health practitioners the tools and resources to develop theory- and evidence-based interventions specific to their context . IM provPor Nuestras Hijas (For Our Daughters) and Por Nuestros Hijos (For Our Children) interventions to assess their efficacy in increasing HPV vaccination in Hispanic adolescents and in changing psychosocial determinants. These studies will provide important information regarding the effect the interventions on the knowledge, beliefs and attitudes that influence HPV vaccination along with information about the efficacy of the two program components. If the interventions are effective in increasing vaccination, they could be adapted for other populations using the process we outline in this paper.Future studies should evaluate the There are limitations to our development and adaptation process using IM. Participants in the focus groups and interviews self-selected to be a part of our needs assessment work. Their attitudes toward the HPV vaccine may differ from those of other parents who did not participate. We therefore may not have captured all determinants relevant to our target population. While we conducted systematic reviews of the literature to also identify determinants, the qualitative nature of the needs assessment process may limit generalizability. Additionally, the program is limited in reach since participants were low income and underinsured Hispanic parents in an urban setting. The programs may not be effective among Hispanics in other settings, and messages may not resonate for other race/ethnicity populations. Further, while our team had resources to train and implement the intervention using lay health workers, clinics and other organizations utilizing this program in the future may not be able to employ this implementation strategy. This potentially limits program reach. Similarly, clinics or other organizations may not have capacity to implement text message reminders to target HPV vaccine series completion. Our development and adaptation processes and outcomes did not account for these differences in resources for future program adopters.This study was carried out in accordance with the recommendations of UTHealth Science Center at Houston with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the University of Texas Health Science Center at Houston Institutional Review Board.MF, SV, LS: Study and manuscript conceptualization; SR: Background, methods, results, discussion; AR, LS, and MF: Contributed to background, methods, results, discussion; DL: Contributed to methods.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Evidence-based programs (EBPs) offer proven ways to promote health and prevent disease among older adults in their communities. EBPs are based on rigorous study of the effects of specific interventions or model programs, demonstrate consistently positive changes in important health-related and functional measures, and have tools in place to maintain program access, quality, and efficiency across diverse settings. The University of North Carolina at Chapel Hill’s Center for Health Promotion and Disease Prevention (UNC HPDP), in partnership with the Evidence-Based Leadership Collaborative (EBLC), has established a review process and Review Council to identify new community programs that meet the evidence-based program criteria established by the Administration for Community Living (ACL), one of the chief U.S. federal agencies responsible for aging programs. Approved programs are then eligible for Older Americans Act Title III-D and other discretionary funding to support organizations that deliver EBPs to improve older adult health. The review process assesses the effectiveness, outcomes, and evaluation of the program, information about program implementation, training, and other key elements for successful program dissemination. The Review Council consists of national leaders with expertise in program research, evaluation, and implementation. The review process is supported by the ACL-funded National Chronic Disease Self-Management Education and Falls Prevention Resource Centers. This session will describe the ACL evidence-based health promotion program criteria that must be met for approval; an overview of the review process; and how researchers can submit their programs for review. Time will be allowed for questions, discussion, and research to practice implications.


We retrospectively analyzed serum IgM antibodies (Abs) to influenza viruses from two tertiary hospitals in Beijing from December 2016 to February 2018. Samples from 36,792 patients, aged 0–98 years, were collected and tested. Among the patients, 923 children from two winter flu seasons were assayed with both antigens and IgM Abs to Flu A and Flu B and assigned as paired groups. Another 2,340 adults and 1,978 children with only antigen tested in the 2016 and 2017 winter flu seasons were named as unpaired groups. IgM Abs-positivity rates in children were 0.80% and 36.57% for Flu A and Flu B, respectively, peaking at 4–5 years of age. For adults, the Flu A and Flu B IgM Abs-positivity rates were 10.34% and 21.49%, respectively, peaking at 18–35 years of age. The trend of temporal distribution between the children and the adults was significantly correlated for IgM Abs to Flu B, but not for Flu A. Compared with unpaired groups, the detection rate of Flu A antigen was significantly higher than IgM Abs in children, whereas frequencies of IgM Abs were higher than antigen in adults. Incidence of Flu B antigen was sharply increased in 2017 winter than in the 2016 winter in both children and adults, but no concomitant increase was observed in IgM Abs to Flu B. For paired children groups, incidence of Flu B antigen in the 2017 flu season was significantly higher than that in the 2016 flu season; in contrast, positive rates of IgM Abs in the 2017 flu season were even lower than those in 2016. Considering antigen detection may reflect the Flu A/Flu B epidemic, our results indicate single-assayed IgM Abs were less effective in the diagnosis of acute influenza virus infection, and the use of this assay for epidemiology evaluations was not supported by these findings. The epidemic of influenza is an important public health problem in worldwide . InfluenFlu A has been isolated from various species, including humans, contributing to substantial viral heterogeneity, resulting in the production of various subtypes with the potential to cause human pandemic ,6. In coIndeed, during the 2017–2018 winter season, China experienced a national wide influenza epidemic. Reported influenza cases throughout the entire nation in winter of 2017 (December 2017 to February 2018) increased 5.7 times as compared with that in winter of 2016 (December 2016 to February 2017). According to unpublished data acquired from the Centers of Disease Control and Prevention (CDC) of China, at least half of the identified viruses belonged to the B/Yamagata lineage during the 2017 winter flu season ,13. The Developed since early 1980s, most publications about serum IgM Abs assay were based on complement-fixation tests , while tData were analyzed anonymously. The studies did not involve any health-related patient information and were approved by the Ethics Committee of both Beijing Children’s Hospital and Beijing Tsinghua Changgung Hospital .ILI cases were defined as previously described . In totaA Respiratory Tract Profile (IgM) kit  was adopted by the two hospitals. Based on the titer plane technique using infected cells/cultured bacteria, this test kit is designed for the in vitro determination of human IgM Abs to Flu A, Flu B, and another six atypical respiratory pathogens, including adenovirus, respiratory syncytial virus, parainfluenza virus, chlamydia pneumoniae, legionella pneumophila, and mycoplasma pneumoniae using serum/plasma samples. Detections were performed qualitatively according to the manufacturer’s instruction: Apply 30 μl of diluted serum or plasma samples to each reaction field of the reagent tray, incubate for 30 mins at room temperature, then rinse the BIOCHIP slides with a flush of phosphate buffer solution (PBS) -Tween, followed by applying 25 μl of fluorescein labeled anti-human globulin to each reaction field, Incubate for 30 mins again, then wash with the new PBS-Tween for at least 5 mins, Place embedding medium onto a cover glass to read the fluorescence with the microscope. Fluorescence results were read by experienced technicians.A D3 Ultra DFA Respiratory Virus Screening & ID Kit  was used at Beijing Children’s Hospital for influenza antigen detection. This kit uses viral antigen-specific murine monoclonal antibodies that are directly labeled with fluorescein for the rapid detection and identification of seven respiratory viruses, including Flu A, Flu B, respiratory syncytial virus, adenovirus, parainfluenza 1, parainfluenza 2, and parainfluenza 3. Tests were performed manually, the sputum or alveolar lavage were collected, after addition of PBS and vortex, centrifuge to wash up mucus and set aside the supernatant for viral isolation. The prepared cell suspension were dripped onto a 10-well slide and air dried. Fix the cells to the slides using fresh, chilled acetone and incubated with DFA screening reagent. Rinse the stained cells using de-mineralized water, and then using a fluorescence microscope with magnifications between 200 to 400 times by experienced technicians.Clearview Exact Influenza A&B was used at Beijing Tsinghua Changgung Hospital for influenza antigen tests. This kit is a product of Alear subcompany . The reagent is coated with anti-influenza A and anti-influenza B NP in one strip, enabling differentiation between Flu A and Flu B. Undiluted swabs were used for the detection, and all specimens were tested in a single experiment. The IRDT method had been compared with RT-PCR methods, the positive consistency was 54.3% and negative consistency was 97.3% and the two methods had concordance at 86.9% for Flu B; the positive consistency was 47.83% and negative consistency was 98.65% and the two methods had concordance at 87.82% for Flu A .2 tests and Fisher’s exact tests were used as appropriate. To compare trends of monthly distributions of IgM Abs between children and adults, Spearman tests were performed for the correlation. All tests were two-tailed, and results with p values of 0.05 or less were considered statistically significant.Statistical analysis was performed using SPSS . For comparisons of categorical data, χFig 2). In pediatric cases, the general positivity rate of IgM Abs to Flu A was 0.80% (278/34665) and 36.57% (12676/34665) to Flu B. In adult cases, the general positivity rates of IgM Abs to Flu A and Flu B were 10.34% (220/2127) and 21.49% (457/2127) respectively.All 36,792 ILI cases were divided into eight age groups. Significant differences of the two IgM Abs distributions were found among groups .The detection rates of IgM Abs to Flu A were higher in adults than in children (p < 0.01), with the highest detection rate (12.69%) in the 18–35-year-old group . The IgMThe data collected were covering from December 2016 to February 2018. The distributions of IgM Abs to Flu A and Flu B in children and adults were summarized in terms of temporal sequences. Generally, similar trends were observed between children and adults, with both IgM Abs increasing from autumn to winter and decreasing from spring to summer . For IgMSignificant correlation in the IgM Abs to Flu B could be found between children and adults (p = 0.02). Two gentle peaks presented, with the first occurring from December 2016 to February 2017, and the second occurring from September to November 2017. It is worth noting that in the winter of 2017, during the epidemic of the B/Yamagata lineage, the positive rate of IgM Abs to Flu B was consistently stable in adults and even decreased in children as compared with that in previous months .Considering that contemporaneous antigen results, which were detected at random, may indicate the epidemic intensities of certain pathogens, we compared the influenza antigen and IgM Abs results during the 2016 and 2017 winter flu seasons , Fig 4. For Flu B detection, the positivity rate of Flu B antigen was zero in children, whereas the IgM Abs to Flu B was 50.68% (p <0.01) in the 2016 winter flu season. In the 2017 winter season, the positivity rate of Flu B antigen in children was 23.22%, but the IgM Abs to Flu B was 31.83% (p <0.01). In the 2016 winter season, the positivity rate of Flu B antigen in adults was zero, but the IgM Abs to Flu B was 28.33% (p <0.01). During the 2017 winter season, the positive rate of Flu B antigen was 12.77%, whereas the IgM Abs to Flu B was 24.17% (p <0.01). Antigen of Flu B was sharply increased during winter 2017 compared with that during the previous winter in both children and adults, and the result was consistent with the data released by the CDC of China. HoweverThere were 923 hospitalized pediatric patients with ILI simultaneously analyzed for influenza antigen and IgM Abs (519 in the 2016 and 404 in the 2017 flu seasons). Significant differences between antigen and IgM Abs distribution were observed. The positivity rates of Flu A antigen were 7.32% in the 2016 winter season and 15.84% in the 2017 winter season (p <0.01), whereas in both seasons, the detection rate of IgM Abs to Flu A was less than 2%. The positivity rates of Flu B antigen were 0.39% in 2016 and 8.66% in 2017, whereas those of IgM Abs to Flu B were 18.69% in 2016 and 9.41% in 2017. Antigen detection of Flu B in the 2017 flu season was higher than the 2016 flu season (p <0.01); on the contrary, IgM Abs to Flu B in the 2017 flu season were even lower than those in the 2016 flu season p <0.01; . The incIn clinical setting, ILI cases might be attributed to seasonal Flu A and Flu B virus infections, newly pandemic viruses, such as p(H1N1), and other respiratory pathogens ,20. RapiDetection of specific IgM Abs against viruses and other atypical pathogens has been widely applied for the diagnosis of respiratory infection . Using eHowever, the assay is widely taken advantage for single detection use in the clinical setting. The improper use may lead to clinical misdiagnosis and mistreatment. A study once indicated that IgM Abs to Flu A, as determined by the IIFA method, could be used for diagnosis in 64% of single sera with complement-fixation Abs titred between 32 to 256 . AnotherIn this study, we reviewed and summarized the results of single serum IgM Abs to Flu A and Flu B viruses in 36,792 ILI cases, and compared IgM Abs with unpaired and paired antigens tests over the same period, with purpose to offer insights on rational screening methods selection facing the epidemic of Flu A and Flu B viruses. To the best of our knowledge, this is the first report demonstrating the correlation of IgM Abs to Flu A and Flu B with influenza antigen detection. Beijing Children’s Hospital and Beijing Tsinghua Changgung Hospital are two tertiary hospitals in Beijing; one is located at the south end of the city, and the other is located at the north end of the city. As a result, patients are representative of the epidemiology of the whole city. All IgM Abs had been screened using the IIFA product by EUROIMMUN at two hospitals.The IgM Abs to Flu A and Flu B was related to ages. Notably, the rate of IgM Abs was very low in children less than 1 year old, whereas IgM Abs to Flu A and Flu B both increased significantly with aging. IgM Abs to Flu B peaked (51.07%) at 4–5 years and then declined gradually with age, while a considerably high frequency (14.79%) was maintained in over-60-years group. Children under 1 year age live in a relatively closed and safe environment and keep neutralizing antibodies from their mothers, thereby avoiding influenza virus infection. On other hand, children ages 4–5 years old attend kindergarten and usually they are active to public facilities and therefore have more exposure to influenza viruses . The incIgM Abs to Flu A remained less than 2% in five pediatric groups and then reached to the peak in the 18–35-year-old group, subsequently showed a gradual decrease with age. The low positivity rate of IgM Abs to Flu A in children deserved further study to clarify. Our speculations to this result are, comparing with adults, children live in a relatively simple and secure environment, so the transmission route may be cut off; the immune response to Flu A virus is relatively week in children so less antibodies produced; some ILI symptoms in children are result of other respiratory virus infection. However, comparison of the frequency between antigen and IgM Abs may provide other insights. In both adults and children, antigen to Flu A was detected with a substantially higher rate in 2016 (23.68%) and 2017 (10.62%) winter flu seasons. This is in controversy to the considerably low rates of IgM Abs to Flu A in children (0.16% in 2016 and 1.37% in 2017). Of the 923 children with paired detection results of both antigen and IgM Abs, similar disagreement results were observed, antigen to Flu A was detected with 7.32% in 2016 and 15.84% in 2017 winter flu seasons, but the IgM Abs to Flu A were less than 2% in children. Flu weekly report from Chinese National Influenza Center had it that subtype H3N2 of Flu A was the major circulating strain in 2016 and 2017 winter flu seasons in China . The antAnalysis of monthly distribution of IgM Abs indicated that both IgM Abs increased from autumn to winter and decreased from spring to summer. The trends of IgM Abs to Flu B were consistent between children and adults . HoweverThere was an epidemic of the B/Yamagata strain in winter of 2017 in Beijing ,13, the There were some limitations of the present study. To determine the presence of influenza infection, the standard method should be virus culture combined with IIFA or hemagglutination inhibition tests in cultured cells. However, in this study, we compared IgM Abs screening data with antigen tests. We could not determine whether vaccination had an effect on IgM Abs detection. According to a survey, the general influenza vaccination rate in China is less than 3%, but approximately 10% in Beijing . TherefoIn conclusion, we retrospectively reviewed the presence of IgM Abs to Flu A and Flu B in ILI cases from December 2016 to February 2018. The results indicated that IgM Abs were distributed across different age groups, with Flu A peaking in the 18–35-year-old group and Flu B peaking in the 4–5-year-old group. Seasonal distribution was also observed. Of clinical significance, single assayed IgM Abs were less effective for the diagnosis of acute influenza virus infection owing to lack of detection of IgM Abs to Flu A in two winter flu seasons in children and IgM Abs to Flu B in the 2017 winter flu epidemic in both children and adults. These results do not support the use of single IgM Abs assay for diagnosis and epidemiological evaluations. Thus, further studies are needed to develop new broad spectrum of influenza diagnostic assays based on serum.S1 TableP values of comparing the positive detection rate of IgM Abs between age groups for Flu A and Flu B.(TIF)Click here for additional data file.


In Zimbabwe, there is a gap between sexual violence (SV) survivors' health care needs versus the existing facilities. Harare city started Sexual Gender Based Violence (SGBV) project in 2011, with the aim to reduce SV morbidity.Only 592 (42%) of 1425 SV survivors reported for medical services within 72 hours in 2015. HIV post-exposure prophylaxis (PEP) is effective within 72hours of post exposure. We evaluated the program performance in Harare city.We conducted a process-outcome evaluation using a logic model. We purposively recruited all eight SGBV sites and key informants. We randomly selected 27nurses into the study. Interviewer-administered questionnaires and checklists were used to collect data. To generate frequencies, means and proportions we used Epi info 7.The program adequately received inputs except for counselling rooms (1/8). About 4285 survivors were recorded from 2013-2016. Of these, 97% were counselled, 93% received HIV test, 41% reported to the clinic within 72hrs of post-rape, and 12% received PEP. About 16% of the total survivors were followed up. The programme failed to meet its targets on decentralised sites (8/10), awareness campaigns(16/32) and sensitisation activities(16/32). About 500(12.5%) IEC materials were distributed. All 96-targeted supervisory visits were achieved. Two ofeight district supervisors were trained. Majority of health workers (25/35) citedlack of awareness as major reasons for underperformance.Availability of resources did not translate to program performance. Most survivors were not reporting to the clinic timeously due to the low level of awareness of the programme to the community, hence were not protected from getting HIV through PEP. The programme was not well disseminated, as most supervisors were not trained. Following this evaluation, we distributed150 IEC materials to each of the eight facilities. A follow-up study on outcomes of clients referred for services and training of district officers were recommended. Sexual violence (SV) refers to any act attempt or threat of a sexual nature that results or is likely to result, in physical, psychosocial and emotional harm . Sexual Study design: We conducted a process-outcome evaluation using the logic model. This was used to assess the inputs, which were injected into the program, the processes carried out, the outputs realised and the outcomes of the SGBV program  percentage reduction in psychosocial disorders and Increased access to thecomprehensive medical package.Study setting: We conducted the study at Harare City SGBV clinics.Study population: Nurses in the facilities that offer SGBV services were recruited into the study. The HIV Program Manager, the District Medical Director (DMO) and the Reproductive Health Program Manager were recruited as key informants.Sample size calculation: Using Dobson formula:2 = 1.96, p = 0.021(Gender links (2010) in Gauteng, South Africa [Where ZSampling procedure: SGBV program Coordinator, HIV and opportunistic infections and antiretroviral therapy (OI/ART) focal persons, district medical officers (DMO), district nursing officers (DNO), reproductive health program manager and HIV program manager were purposively recruited into the study as key informants. All nurses who participated in the program in the district were includedin the study, except those who were on leave.Pretesting: The data collection instruments were pretested at Mbare polyclinic for validity and reliability. Ambiguous questions were corrected accordingly.Data collection: We used an observational checklist to check for availability of inputs for the program including health-worker training register, register for SGBV survivors in the program, SGBV program stationary, and SGBV policy guidelines, budget requests, reports on SGBV awareness coverage for the district. To assess the output and outcome indicators as well as resource availability we conducted records review. Interviewer-administered questionnaires were used to elicit information on operations of the program, reasons why survivors are not accessing quality post-rape services promptly from study participants. Key informant interview guide was used to gather information about the number of health workers trained in SGBV management. The checklist structured from US Centers for Disease Control and Prevention (CDC) guidelines on programme evaluation, were used to quantify the resources required to run the programme [rogramme .Data analysis: We used Epi-info version 7 to generate frequencies and means. Qualitative data generated from open-ended questions were sorted and analysed for content. Summaries of this data were presented as frequencies and proportions of responses.Permission and ethical considerations: We sought permission to carry out the study from Harare city ethical review board, and the Health Studies Office. We also sought written informed consent from the health workers. Participants were given the freedom of choiceto either participate, decline or withdraw from the study at any given time. Confidentiality was assured and maintained throughout the study by; interviewing each participant privately and ensuring that no information obtained was disclosed to any persons other than those relevant to the study. Also, names of participants were not includedinthe questionnaires. All questionnaires were kept confidential.Demographic characteristics of study participants: We interviewed thirty-five study participants with the majority being females 91% (32/35). The majority 27(77.1%) were nurses offering SGBV services in Harare City. The median years of service were 11 years . The median age was 36 years .Inputs Injected into the SGBV Program: The program adequately received targeted resources as far as guidelines, IEC materials registers, HIV test kits and fuel were concerned. The program had one of eight targeted rooms for counselling of the SV survivors  of clients were followed up. The programme failed to meet its targets on decentralisation of SGBV sites (8/10), awareness campaigns (16/32) and sensitisation activities (16/32) ( (16/32) .Outputs of the sexual gender based violence programme: The programme did not meet the targeted number of health care workers trained in SGBV program (80/100). The number of clients followed up (700/4285), and clients reported with 72 hours (1758/ 4285) and received PEP post-sexual violence (1758/1213) were below the target. The targeted number of IEC materials to be distributed (500/4000), monthly supportive and supervisory visits (96/96) and clients who received STI PEP (2770/2770) were achieved , from zero to 761 cases. Proportions of SV survivors who received PEP increased again from zero out of three in 2013 to 509 (31%) out of 1669 in 2016. Those who received counselling increased from 33% in 2013 to 65% in 2016  knew the main objectives of the SGBV program. One (25%) of four doctors knew the tools used to monitor the program. All nurses trained on management of SV survivors were knowledgeable in all areas assessed. One (25%) of four district nursing officers knew the correct standard treatment guidelines for the management of SV survivors. All doctors (100) knew the standard guidelines for management of sexual violence survivors. However, three (75%) of them, did not know the management process for sexual violence survivors.Reasons for late reporting to the hospital by sexual violence survivors: Information on reasons for late reporting was extracted from the SV register. The health workers were also asked on the reasons for theunderperformance of the program. Out of 1669 SV survivors in 2016, a total of 908 (54%) did not report timeously to the hospital for quality services. The main reasons recorded in the registers were survivor not aware of the health facilities that offer post-rape services 398 (44%),late disclosure of the survivor to the guardian or partner 202 (22%), no bus fare 167(18%), fear of being harmed further by the perpetrator 97(11%). Of the 35 health workers interviewed Majority 25 (71%) cited the lack of awareness of the program as a major reason for underperformance.et al. 2015, South Africa,unwanted pregnancies could be prevented by ensuring adolescents have access to information on sexuality and are supported to build good social and decision-making skills in a supportive environment [The study findings demonstrate that lack of awareness of the program and its services was a major factor that enhances thelate presentation of SV survivors to the clinic. Closely related to the late reporting was fear of being harmed further by the perpetrator manifested especially in thecontext of late disclosure of the survivor to the guardian or partner. This study sought to answer "why the SV survivors were not accessing quality post-rape services promptly?" Therefore, we evaluated the performance of the SGBV programme. It is evident from the study that the program was not well disseminated as no district officers were trained on SGBV. This finding maybe due to lack of integrated planning between donors and Harare city senior management. The lack of training among district officers explains why the supportive visits were not being conducted as targeted. This finding threatens the sustainability of the program in the city. The adequate funding injected into the program did not translate to the good performance of the program. Contrary to the findings by Vetten 2007, which showed SGBV programs lack specific budgets, resulting in implementation problems, this program was adequately funded . Howeverironment . In thisironment , 17. It ironment .The low level of the programme awareness may suggest under-estimation of the prevalence of sexual violence in Harare. We also found out that the program did not achieve its targeted decentralised health facilities. This might be explained by the unmet targeted number of health care workers trained in SGBV program. For the program to come up with stand-alone sites, human resources would be needed. Our study suggests that the low proportions of clients that received pregnancy ECP might have been due to the sending back of clients who would have reported to the clinic during busy hours of the clinic as reported by the nurses. These survivors would be advised to report after four days or so, due to overwhelming workload. This actis not ethical according to the WHO guidelines on themanagement of sexual survivors . This acWe concluded that even though this programme was adequately funded, it was not well disseminated. There is no joint venture in planning and implementation of the program between the Harare city district supervisors and MSF, hence planning and integration was lacking. District supervisors were not actively involved in the supervisory activities of this program. Nurses had higher program knowledge as compared to their supervisors. There is still low level of awareness of the program to the community. Based on the findings of this study, a follow-upstudy to check if the referred clients received the intended services were recommended. The study recommends training of district officers on themanagement of SV survivors so that they can have the capacity to conduct the supportive supervisory activities.Integrated planning between donors and senior management as a foundation for successful program implementation was also recommended. The public health officer facilitated the distribution of the IEC materials to all stand-alone sites.Sexual violence against women is a massive cause of morbidity and mortality but remains overlooked. While rape will always be a traumatic experience and a violation of human rights, the effects of this trauma for an individual may be different in different contexts. Hence quality care should be rendered to these survivors.Availability of resources does not translate to program performance. Therefore, inputs need to be converted to outputs through activities.Programs need to be well disseminated for them to be sustainable. Knowledgeable workers are key to the implementation of the programme. Hence there is need to train HCW before the program starts.The authors declare no competing interests.


Emergency medicine training programs face many challenges in creating and maintaining high quality didactic and asynchronous learning experiences. To address these challenges, our team created two tools. First, we designed the Emergency Medicine Curriculum Assessment Tool (EMCAT) to help program leaders compare their didactic program to the Model of Clinical Practice established by the American Board of Emergency Medicine (ABEM). Second, we created a catalog of free, open-access medical education (FOAMed) resources based on the ABEM Model subcategory. Residency leaders can use EMCAT to identify the underweighted topics in their conference program and then access the resource catalog to find educational content matched to their areas of increased need. To date, five programs have implemented EMCAT and users from over 72 countries have accessed nearly 1,000 resources. Both EMCAT and the resource catalog are available free online. This medium looks like the spreadsheets that are familiar to most academicians. AirTable™ allows several fields having relationships to many items (as opposed to the “one-to-many” structure of programs like Microsoft Excel™). This is advantageous due to increased data integrity and the ability to quickly examine multiple facets of a dataset at once. Our tool helps to import years worth of curriculum data retrospectively from programs like Microsoft Excel™. It also allows setting up seamless, automated prospective data collection by integrating it with existing methods to keep track of conference schedules such as Excel™, Sheets™, and Google Calendar™, etc.DescriptionWe created the EMCAT to help emergency medicine residency programs assess their didactic curricula in comparison with the American Board of Emergency Medicine (ABEM) Model of Clinical Practice . To suppEMCAT can be used retrospectively or prospectively to assess existing or plan future curricula. Prospective use is simple: program leaders enter their future educational sessions directly into the tool and code it with the appropriate date/time, format , and topic (from the list of ABEM Model subcategories). An option of recording additional information such as attachments, speaker name, and session location is also available.Using EMCAT retrospectively requires leaders to assemble their existing curriculum, usually in the form of their conference schedule, with supplementary material such as Simulation and Journal Club topics, etc. Once information is uploaded to EMCAT, each session needs the coding with one or more ABEM Model of Clinical Practice subcategories.www.mededguru.org to “plug the holes” in their existing educational program by browsing for the specific ABEM Model subcategories in which their curriculum lacks coverage.In either case, to allow separate views EMCAT is pre-programmed to group the provided data in different ways. Selecting the “Grouped by ABEM Model Subcategory” view allows leaders to identify both areas of redundancy and gaps in coverage quickly. With their identified gaps in hand, program leaders can then use the resource catalog at We designed EMCAT for the EM residency program leaders around the world who seek to improve their off-shift curriculum . EMCAT allows program leaders to easily compare their existing curricula to the ABEM Model of Clinical Practice, to identify gaps or underweighted areas, and to fill the gaps by accessing high-quality emergency medicine educational resources online. It is also essential for faculty members to have a variety of educational resources that they can choose from and use to teach. Our resource catalog provides a collection of simulation cases, resources for the flipped classroom and variety of Free Open Access Meducation (FOAMed) resources screened for quality and content which is easily accessible to all, including the audience from low- and mid-income countries where EM is still developing as a specialty and the faculty members do not have access to high-quality educational resources that they can use to teach the residents. Our resource catalog provides different types of filters to help the users find the exact resource type. We also wanted to provide a starting platform for the learners and educators to use FOAMed effectively.mededguru.org (March 2018 through July 2018), we have had 9,870 page views from users in 72 countries (Figure Since the soft launch of We feel that our EMCAT tool will help residency programs to find any gaps in their current curriculum in the United States and with little modification we will be able to offer this tool to emergency medicine residencies in other countries. On the other hand, our resource catalog is continuously screened and updated for high-quality educational resources and is available to help educators, emergency medicine faculty members, residents, medical students, physician assistants and nurses nationally and internationally.