Penicillium nordicum up to 83.91%. The developed methodology is thus suitable for screening the antifungals’ role in altering mould ergosterol biosynthesis before their application in real meat products.Antifungal agents are commonly used in the meat industry to prevent the growth of unwanted moulds, such as toxigenic ones, on dry-cured meat products. For enhancing the application of antifungals, their mode of action must be evaluated. Their effect on the mould ergosterol content is one of the most studied ones, since it is the target site of some commercialised antifungals or of those that are in development. The aim of this study was to develop a methodology for determining how the antifungal agents used in the meat industry work. A method for analysing ergosterol was firstly developed using high-performance liquid chromatography with fluorescence detection coupled to a diode array detector (HPLC-FLD/DAD). The chromatographically optimised conditions (gradient and mobile phases) allowed us to reduce the time per analysis with respect to previously published methods up to 22 min. Withing the six checked extraction methods, method 5, showing the best mean recovery values (99.51%), the shortest retention time (15.8 min), and the lowest standard deviation values (9.92) and working temperature (60 °C), was selected. The limit of detection and limit of quantification were 0.03 and 0.1 µg/mL, respectively. All the validation parameters corroborated the method’s suitability. Finally, its feasibility for evaluating the effect of a commercial antifungal preparation (AP) and different herbs that are frequently added to meat products on the ergosterol content of several toxigenic moulds was studied. Differences at the strain level were obtained in the presence of AP. Moreover, the addition of herbs significantly reduced the ergosterol content in  Toxigenic moulds are frequently found on the surface of a wide range of dry-cured meat products ,2. The cThe presence of these unwanted moulds has necessitated the development of several methods to avoid mycotoxin production. The most recently described strategies in dry-cured meat products are related to biocontrol agents employing essential oils  or microFusarium spp. in maize samples [Eremanthus erythropappus essential oil has been also described as a reducer of ergosterol content in Aspergillus spp. [Fusarium gramineareum and Alternaria alternata, respectively [To enhance an antifungal treatment, its mode of action has to be studied before its application. Despite the fact that this aspect has not been fully clarified, several reports have proposed ergosterol as the target site of their activity. Ergosterol is a lipid of the cellular membrane of moulds, which is essential for the growth of their mycelium . Natamyc samples . Eremantlus spp. . Moreoveectively ,21. NeveErgosterol is not water soluble, but appropriately dissolves in acetone and ethanol . AccordiThe aim of this study was to develop a methodology for evaluating the impact of antifungal agents on the ergosterol content of meat product-borne toxigenic moulds. Thus, a method for analysing ergosterol using HPLC with fluorescence detection coupled to a diode array detector (HPLC-FLD/DAD), as well as an extraction procedure based on previously published literature, were firstly optimised. After validating both protocols, their viability to evaluate the effect of a commercial antifungal preparation (AP) and different herbs frequently added to cured meat products on the ergosterol content of several toxigenic moulds was evaluated.All the chemical and chromatographic reagents were HPLC or analytical grade. Acetone, NaOH, 1-butanol, and chloroform were purchased from Scharlab, S.L. . Hexane, methanol, and acetic acid were obtained from Fisher Scientific S.L. . Toluene was purchased from Panreac Química S.A. , and ergosterol ≥95% HPLC grade from Sigma-Aldrich .The AP containing natamycin and PS was supplemented with 60 g/L of NaCl (Fisher Scientific S.L.), following the manufacturer’s instructions .A stock solution (1 mg/mL) was prepared by dissolving standard ergosterol in acetone following the manufacturer’s recommendations. Working solutions were daily prepared in limited light conditions using amber vials by diluting the standard solution in methanol, since it was the main constituent of the mobile phase . They were filtered through a 0.22 µm pore size nylon membrane (Cosela S.L.).18, . The column temperature was established at 25 °C. The flow rate was set at 1 mL/min, and the injection volume was 20 µL. Ergosterol was detected at λ = 282 nm by the DAD and identified by the absorption spectrum of the standard. Calibration curves were built by diluting the stock solution from 0.1 to 100.0 µg/mL.Ergosterol was analysed by a HPLC-FLD/DAD model 1260 Infinity . The column was a Phenomenex Luna Cv/v) 90/10 (v/v) , consisting of methanol/acetic acid 0.05% (eluent A ) and metv/v) 90/10 (v/v); and mobile phase 3 (MP3), composed by methanol/acetic acid 0.05% (v/v) 95/5 (v/v). The selection of the most adequate gradient and mobile phase relied on obtaining a chromatographic peak with a narrow width and symmetric shape, showing the earliest retention time and the shortest run time.After selecting the most appropriate gradient, three mobile phases were checked: MP1; mobile phase 2 (MP2), consisting of methanol/acetic acid 0.1%  was incubated in the presence of three AP concentrations  at different incubation times . These concentrations represented different potential quantities of the AP found in meat products: 10% being a low level of the AP, 50% as a medium level, and 90% as a high level. Samples without AP (0%) were used as positive controls.A total of six methods for extracting mould ergosterol were evaluated. They consisted of two previously reported ones ,24 and mRA) was calculated according to the following equation:The accuracy of each method was evaluated by the percentages of recovery (absolute recoveries) and the method with the best results (≈100% of recovery) was selected. The neat solvent was spiked by adding 10 µg/mL of ergosterol and then extracted following the above-mentioned methods. The results were compared with the area of a standard at the same concentration (10 µg/mL). The percentage of recovery  and limit of quantification (LOQ), linearity, precision, repeatability, within-lab reproducibility, and accuracy .The LOD and LOQ were calculated as the minimum ergosterol concentration level at which the signal exceeded the noise level by a factor of 3  and 10, respectively.R2) in the range 0.1–100.0 µg/mL, and the precision by the analysis of three extractions was determined from the same samples under specified conditions. Both parameters were tested in triplicate.Linearity was determined by applying the coefficient of determination , and P. nordicum BFE 856 from the Federal Research Centre for Nutrition and Food (Germany); the aflatoxigenic Aspergillus flavus CBS 573.65 from Centraalbureau voor Schimmelcultures; and the CPA producer Penicillium griseofulvum IBT 14319, supplied by the Type Culture Collection of the Department of Biotechnology from the Technical University of Denmark. In addition, P. nordicum CBS 323.92, one of the main OTA producers in meat products, was also selected to analyse the ergosterol content after applying rosemary, oregano, and thyme, which are herbs recently described as having antifungal activity in dry-cured fermented sausages [To check the suitability of the developed methodology for extracting and quantifying ergosterol when determining the modes of action of antifungal agents, four toxigenic mould strains were incubated in the presence of AP: the ochratoxigenic sausages  , 1.09 g of Na2HPO4 , 9 g of NaCl , and 1 L of distilled water). Spore suspensions were quantified using a Thoma Blaubrand counting chamber . A concentration of 106 spores/mL of each mould strain was individually inoculated on a dry-cured fermented sausage-based agar  at 25 °C for 7 days. Spores were harvested by scraping the plate surface with a glass rod after adding 3 mL of phosphate-buffered saline . A volugar .Data analysis was carried out using the SPSS v. 20 software . The non-parametric Kruskal–Wallis and Mann–Whitney U tests were applied, since the data failed the Shapiro–Wilk and Levene tests. The statistical significance was established at 18) was selected for the HPLC-FLD/DAD detection method, due to its good peak resolution [A reversed-phase column  was less than 15% . This isWhen the ability of the HPLC-FLD/DAD method to study the mode of action of antifungal agents was evaluated in the presence of different amounts of AP, a lack of detection of ergosterol was observed in the presence of the highest amount . These fWhen searching for reductions in the analysis time, the extraction method is considered to be as important as the detection one. The results obtained when evaluating the six different methods for extracting ergosterol are shown in Furthermore, when comparing Method 2 and those developed from it (Methods 3–6), it appears that the addition of chloroform instead of toluene triggers the improvement of the recoveries. This could be due to the good solubility of ergosterol in chloroform , which mWithin the procedures with the best outcomes, Methods 3 and 5 were the most appropriate. Method 5 was finally selected because of its lower standard deviation values and temperature than Method 3, since the detection of ergosterol can be negatively affected by high temperatures . ConsequThe values for LOD and LOQ were 0.03 and 0.1 µg/mL, respectively, lower than those previously obtained by other authors using HPLC-FLD ,30,42.R2 value is considered an indicator of linearity, and values close to the unit are synonymous to a straight line [The linearity defined by calibration lines relating to ergosterol concentration and peak area gave an optimum value . The R2 ght line ,43, whilght line ,45. In op ≤ 0.05) (data not shown). These features support the use of the method independently of the operator.The calibration curves for intra-day and inter-day repeatability were similar, and demonstrated no significant differences between them, like the ones used for within-lab reproducibility (The extraction and HPLC-FLD/DAD methods were finally used to evaluate the effect of the AP and the selected herbs on the ergosterol content of toxigenic moulds . It shouOn the other hand, the novelty of the method applied with moulds has to be highlighted. The method consists of blocking the moulds’ metabolic activity after sampling using liquid nitrogen , therebyPenicillium species were able to produce higher ergosterol amounts than A. flavus under control conditions. To our knowledge, there are no studies about mould ergosterol levels in a meat-based substrate, but previous studies have demonstrated a higher production of ergosterol in Penicillia than in Aspergilla in PDA and rice [Penicillium roqueforti, affecting the lipid bilayer [Penicillium discolor [Aspergillus fumigatus [It has been described that ergosterol production depends on the mould species and colony age, as well as on the substrate . Accordiand rice ,47. Furt bilayer , while ndiscolor . Additioumigatus .A. flavus CBS 573.65 was not affected in the presence of the AP in this study. This lack of effect of natamycin on mould ergosterol has been previously described in Aspergillus ochraceus, and has been associated with the existence of resistances due to its continuous use; it even could enhance resistance to other polyene antifungals by cross-tolerance [On the contrary, the ergosterol content of olerance .P. nordicum CBS 323.92, all of them significantly reduced the ergosterol content regardless of whether they were in the presence or absence of AP (A. flavus and Fusarium verticillioides, although the minimum inhibitory concentration differs depending on the species [A. flavus [Penicillium expansum [Cymbopogon, respectively, have also shown their effect by decreasing ergosterol in P. expansum [Cynanchum atratum can significantly impair ergosterol biosynthesis in Penicillium digitatum [Regarding the effect of the addition of rosemary, oregano, and thyme leaves against the ochratoxigenic ce of AP . These f species ,51. Rega. flavus . Despiteexpansum ,54. The expansum . Anotherigitatum .P. nordicum. Accordingly, the synthesis of ergosterol has been associated with the OTA production in A. ochraceus and P. verrucosum [Therefore, the ergosterol seems to be the target site of the antifungal action of rosemary, oregano, and thyme, which could explain the reduction of OTA presence detected by Álvarez et al.  when tesrrucosum ,57. NeveA new methodology for the extraction and quantification of ergosterol from toxigenic moulds was developed to be used when evaluating the role of antifungal compounds applied in the meat industry. The method turned out to be precise, fast, and effective for ergosterol quantification in meat product-borne moulds. The method improved the previously developed procedures, due to the reduction of the run time up to 22 min, and consequently, the possible degradation of ergosterol in ergocalciferol. In addition, the methodology proved to be useful for determining the effect of antifungal agents related to dry-cured meat products on the ergosterol content, independent of the toxigenic mould strain. The present method could be thus used as a support tool for improving information about antifungals before their application in meat products, which would enhance their use.


The present study is based on a three-year evaluation of an Israeli training program for local paid elder care workers, called “community care.” Interviews were conducted with all stakeholders involved in the program, including program developers, facilitators, funders, trainees, dropouts, employers, and older care recipients. Qualitative thematic analysis was used, supplemented by quantitative data concerning the program’s inputs, outputs and outcomes. The program had multiple strengths, including a substantial funding stream and a highly skilled and committed team. Yet, out of 130 participants , only 94 completed the program and 31 were later employed as care workers. Three main challenges to the efficacy of the training program were identified. The findings stress the importance of adequately conducting the appropriate needs assessment prior to embarking on a new social program and illustrate the tension between an ideal prototype and real-life constraints.


Background: Several evaluative studies demonstrate that a well-coordinated Integrated Management of Childhood Illnesses (IMCI) program can reduce child mortality. However, there is dearth of information on how frontline providers perceive IMCI and how, in their view, the program is implemented and how it could be refined and revitalized.Purpose: To determine the key challenges affecting IMCI implementation from the perspective of health care workers (HCWs) in primary health care facilities.Methods: A scoping review based on the five-step framework of Arskey and O’Malley was utilized to identify key challenges faced by HCWs implementing the IMCI program in primary health care facilities. A comprehensive search of peer-reviewed literature through PubMed, ScienceDirect, EBSCOhost and Google Scholar was conducted. A total of 1,475 publications were screened for eligibility and 41 publications identified for full-text evaluation. Twenty-four (24) published articles met our inclusion criteria, and were investigated to tease out common themes related to challenges of HCWs in terms of implementing the IMCI program.Results: Four key challenges emerged from our analysis: 1) Insufficient financial resources to fund program activities, 2) Lack of training, mentoring and supervision from the tertiary level, 3) Length of time required for effective and meaningful IMCI consultations conflicts with competing demands and 4) Lack of planning and coordination between policy makers and implementers resulting in ambiguity of roles and accountability. Although the IMCI program can provide substantial benefits, more information is still needed regarding implementation processes and acceptability in primary health care settings.Conclusion: Recognizing and understanding insights of those enacting health programs such as IMCI can spark meaningful strategic recommendations to improve IMCI program effectiveness. This review suggests four domains that merit consideration in the context of efforts to scale and expand IMCI programs. The World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and other partners developed the Integrated Management of Childhood Illnesses (IMCI) strategy in the mid-1990s to address child mortality and improve health care workers’ (HCWs) ability to diagnose, classify, and manage childhood illnesses –5. When While there have been a number of systematic and analytic reviews conducted on IMCI, most emphasize the early stages of implementation and how IMCI contributes to reductions in childhood mortality and its effect on health systems ,12. HansAlthough the existing body of evidence provides analysis of the impact of IMCI, little information exists regarding how the strategy can best be delivered in PHC-facilities from the perspective of HCWs . There iTo address this gap, we conducted a scoping review focusing on the experiences and perspectives of HCWs implementing IMCI in PHC-facilities in LMICs. This review aimed to provide a synthesis of the data and to lay the groundwork for health professionals, public health practitioners and policy makers to draw on perspectives of those at the frontlines of IMCI delivery when determining whether or how to refine program implementation.The scoping review approach was based on the framework developed by Arksey and O’Malley , which oA brainstorming session was conducted to develop potential scoping questions focused around IMCI program implementation. The preliminary question was sent to members of the study team to evaluate its relevance and applicability. After discussions, the scoping question was refined to the following: determine the key challenges affecting IMCI implementation from the perspective of HCWs in PHC-facilities.Following the finalization of the scoping question, core concepts were discussed and a set of keywords identified and narrowed down after checking Medical Subject Headings (MeSH) browser, including Non-MESH terms. Boolean operators were used to exhaust the variations of terms scoped. The final search strings and electronic databases searched are shown in The lead author performed all searches from 27 December 2018–15 January 2019. Three electronic databases were used: PubMed, ScienceDirect and EBSCOhost, to identify peer-reviewed journals relating to the scope of review. Google Scholar was also used to search for publications in the grey literature. Only studies in English and only scientific papers from 2005 to 2018 were included. The majority of LMICs introduced the program by 1999–2004 and initial analytic reviews and a multi-country evaluation study were conducted in 2002–2005 . The 200The lead author listed all details, assessed and read the abstracts and evaluated whether they met the inclusion criteria, and noted themes emerging from analysis using Microsoft Excel. A data extraction spreadsheet was developed to chart the information in the literature, adapted from The Joanna Briggs Institute Reviewers’ Manual . DetailsWe used descriptive statistics to summarize all included studies. Counts and proportions were used to describe all other information gathered such as specific research design, publication details, and locale of the study. We also conducted a content analysis to summarize key concepts from the studies and relating to the study scope of interest . Each teA total of 1,475 publications were screened and assessed for eligibility based on inclusion and exclusion criteria. This scoping review yielded 24 studies . Among these studies, 11 utilized quantitative designs ; eight were mixed-method designs, and the rest used a qualitative design. Three papers utilized a multi-country evaluation survey design. A majority of included studies were conducted in the WHO African region (65%), followed by the Eastern Mediterranean region (15%) and South-East Asia (10%); the remaining studies were conducted in the Americas, Western Pacific and European regions. The reviewed studies differed in study design, number of participants and length of the study. All included studies were published as research articles in peer-reviewed journals, most frequently in Health Policy and Planning (16.7%), BMC Health Services Research (8.3%), BMC Public Health (8.3%), PLOS One (8.3%) and Global Health Action (8.3%).‘The ball is thrown in our court after providing IMCI training by MNCH [Maternal and Neonatal Child Health] program. I am helpless at this level … I am helpless … [’ showing the disconnect between policy makers and implementers. Furthermore, in South Africa, Pandya and colleagues [Nine studies found that poor leadership dynamics and ineffective decentralization were among the main causes of failures in implementation of IMCI programs. A lack of planning and coordination, and wide communication gaps between various stakeholders, contributed to problems of limited coverage. Pradhan and colleagues  expoundelpless … ,’ showinlleagues  concludePandya and colleagues  highligh‘At the moment we do not have money for continuing some of the IMCI activities the way we are supposed to. Donors have shifted to iCCM. We have adopted the IMCI approach as a routine, but we do not have needed resources to sustain some of the core activities including revision of guidelines and refresher training [’.Meanwhile, Huicho, et al  found thtraining ’.‘There is no open space as the rooms are very small. This fails us to implement the rehydration plan for a dehydrated baby according to the IMCI standards [’. Such poor working conditions led HCWs to suffer from ‘burnout’ , which affected the uptake of the IMCI program.A majority of studies (17 of 24) highlighted issues of inadequate human and material resources. These studies found that some of the IMCI recommendations are not carried out because of insufficient support from the government and stakeholders. Vhuromu & Davhana-Maselesele  exploredtandards ’. Such p‘The last time we received drugs was 6 months back, and most of the commonly prescribed drugs are either finished or about to finish and we will not receive a new supply in the near future [’ Because of these inadequacies, HCWs were dissatisfied with the working conditions when applying some of the IMCI recommendations.The basic materials and supplies required to provide care under IMCI were often lacking. In Ethiopia, Seid and Sendo  showed tr future .’ BecausSeveral studies 14 of 24) highlighted the short duration and cost of IMCI training, as well as poor supervision and lack of follow-up after training, which affected the performance of HCWs. Horwood, et al [ of 24 hiGoga and Muhe  also con‘Participants feel supervisors will police them [’.Seid and Sendo  also repice them ’.Nearly half of the articles included in the review 10 of 24) found that HCWs’ IMCI assessments were not performed consistently and comprehensively, and that clinical activities not related directly to the presenting complaint were frequently omitted. Such incomplete case assessments could lead to misclassification and missed referrals. For example, in Ethiopia, Gerensea and colleagues  document found thThere was notably poor adherence to IMCI case management procedures regarding the prescription of antibiotics . Naimoli‘The problem is when there are a lot of people in the clinic, there is no time for you to go through all those things for the child. You will be working fast fast fast to push the queue. Sometimes, sisters (nurses) will just be looking at conditions that the child has been brought with and then they leave the rest and you find that the child has not received immunizations and stuff like that [’. Further, the IMCI-trained HCWs were also required to provide other health care services, which limited their availability, creating a cycle of insufficient staffing [Further, HCWs faced problems with long IMCI consultations, given the shortage of manpower in their clinics, resulting in longer waiting hours for patients and making it impossible to implement it properly ,37,38. Hike that ’. FurtheThis scoping review examined a range of factors that impede the uptake and implementation of IMCI from the perspective of HCWs, providing further detail to the implementation challenges discussed in Boschi-Pinto and colleagues’ study , which pThe sustainability of IMCI has been considered a major concern among LMIC stakeholders since the beginning of program rollout in early 1990s. Bryce’s review  found thThe lack of training and resources, and minimal supervision after training were among the weakest areas of IMCI implementation, as identified here and in studies of other LMICs ,32,33,43In the light of the WHO Health Systems Framework , it is aMajor progress has been made in terms of HCW knowledge and child health through the accelerated implementation of IMCI when HCWs were adequately supported. Rakha, et al  reportedTo ensure that the IMCI program stays relevant after 20 years, further implementation research is needed to understand what works and what does not at the implementation level ,57. InteDue to its precise inclusion criteria and the large scope of literature on the IMCI program, this review may have inadvertently excluded some articles discussing factors of relevance to implementation of IMCI at PHC-facility level. Although the researchers believed that the exhaustive search terms utilized in this review captured the relevant publications within the scope of interest, we might have missed other relevant studies that were not published in the databases used. However, a biomedical librarian was consulted to help finalize the search strategy, to ensure the most important articles were included. While we believe we have been able to thoroughly describe the literature on IMCI implementation challenges at the PHC-facility level, the diversity of contexts in which IMCI is implemented means that researchers should exercise caution in generalizing findings about the challenges of scaling-up of the IMCI program. Finally, while a second coder was not used to extract themes, we believe this limitation is mitigated by the involvement of co-authors sufficiently familiar with the literature to validate findings.This review demonstrates the range and extent of literature regarding conditions that impede the uptake and implementation of IMCI globally from the lens of the frontline providers. Our review highlighted opportunities to tease out some bottlenecks in program implementation, revealing four critical domains which frequently underpin a negative feedback loop. It shows that the experiences of HCWs in implementing IMCI showed demotivating realities of an unsupportive health system and weak program execution. National and international efforts are needed to magnify the adequate fiscal space for increasing investment in the IMCI program. Government leadership, along with more structured and continued resource and training support, is necessary to foster sustainable IMCI health care services within the needs of the local community. Additional evidence is required on the quality of IMCI program implementation across country contexts and study settings. In this regard, future implementation research should be conducted in PHC-facility settings delivering the IMCI to explore program processes and acceptability by HCWs.Click here for additional data file.


The internet and technology can help older adults connect with family and friends. However, many older adults face obstacles to internet and technology use, such as lack of knowledge or self-efficacy.The purpose of this study was to explore the impact of the AGE-ON tablet training program on social isolation, loneliness, and quality of life.Adults aged >60 years took part in a series of 6 weekly workshops covering the basic features of a tablet. Before and after the program, social isolation, loneliness, social support, and quality of life were assessed. In addition, data on current tablet use and attitudes toward technology use were collected. Satisfaction with the program was also assessed at the end of the study using 6 Likert scale questions.The participants  were predominantly female  and retired . The participants reported that they were highly satisfied with the program. After completing the program, no differences in social isolation, loneliness, social support, or quality of life were found. Frequency of tablet use increased and the attitudes of the participants toward technology improved.The AGE-ON program resulted in increased tablet use frequency and may improve comfort and attitudes toward tablet use among older adults. This program may assist older adults in overcoming obstacles to internet and technology use to better connect with family and friends; however, further work targeting older adults who are socially isolated or at risk of social isolation is needed to more fully understand whether tablet training programs are beneficial in this population.ClinicalTrials.gov NCT03472729; https://clinicaltrials.gov/ct2/show/NCT03472729 Canada’s cohort of adults over the age of 65 years is the fastest growing segment of the population. In 2018, 17.2% of the Canadian population was aged 65 and older; this segment is expected to reach 20% by 2024 . LonelinUse of the internet and technology has been proposed as a way for older adults to connect with family and friends, thus maintaining or even enhancing social connections, reducing loneliness and isolation, and improving quality of life -10. The To date, several internet-based and computer-based training programs have been reported in the literature. A 2012 meta-analysis of 5 studies suggests that computer and internet training interventions can reduce loneliness in older adults, although the included studies reported small sample sizes and had high risk of bias . More reAGE-ON is a series of workshops developed in response to this literature by the Regional Geriatric Program Central (RGPc), based in Hamilton, Ontario. The goal of these workshops is to teach older adults with limited computer knowledge how to use tablet computers to connect with friends and family and gather information related to issues of importance to them. The primary objective of this study was to evaluate the effectiveness of this program at improving the participants’ level of social isolation. The secondary objectives were to explore the impact of the program on loneliness and quality of life in older adults, the participants’ comfort with and use of the tablet, and their satisfaction with the program.This is a single-group pre-post program evaluation of the existing AGE-ON program, which is administered by the RGPc. The study was registered prior to launch . Our original intent was to conduct a randomized controlled trial with a wait-list control group; however, due to feasibility within the RGPc, namely lack of staff time and availability to host a second session at each location for wait-list control participants, this was not possible, and a single-group design was used. All procedures were reviewed and approved by the Hamilton Integrated Research Ethics Board, and all participants provided informed consent.Eligible participants were English-speaking adults who expressed interest in the AGE-ON program. No exclusion criteria were applied. Recruitment was conducted via advertisements in local community newspapers, community postings, online postings, and social media targeting friends and caregivers of older adults from September 2018 to August 2019. All interested participants contacted the AGE-ON program coordinator at the RGPc, who provided information about the workshops and informed the participants about the research. Participation in the research component was optional and was not required to take part in the workshops. Participants did not receive compensation for their participation in the study; however, the program registration fee of CAD $40 (US $28.40) was waived for the participants.Participants attended 2-hour education sessions weekly over 6 consecutive weeks. Each session was facilitated by 1 instructor, with support from 2-4 volunteer university student mentors. The workshops were delivered in several settings, including retirement residences and an auditorium of a local hospital. The AGE-ON program, originally named iLive iLearn Well, was developed in 2014 by the RGPc to help older adults engage with technology and decrease perceived social isolation. The educational content was divided into 5 detailed modules, with 1 education session left free for review and participant-specific questions. The first week of classes focused on learning the basic features of an iPad  and locating the variety of available apps. In subsequent weeks, participants learned how to use specific applications, including using the internet, taking and viewing photographs, sending and receiving emails, and using basic apps . The modules were accompanied by a participant workbook that included session content, homework, and additional information to help the participants learn the material. The homework assignments corresponded with the modules; they expanded on specific concepts and skills or prepared participants for future education workshops.Quantitative data were collected at baseline and at the end of the 6-week program during the first and last AGE-ON sessions via paper questionnaires. Follow-up data were collected 1 month following the workshops by a telephone call with a trained research assistant . The primary outcome was change in self-reported social isolation using the Duke Social Support Index (DSSI) . The DSSt test for continuous data and the chi-square test for dichotomous data.All statistical analyses were completed in SPSS version 9.4 (IBM Corporation). Baseline demographic data were summarized as mean and standard deviation or frequency and percentage where appropriate. Changes in outcome measures from baseline to end of study and 1-month follow-up were analyzed using the paired A total of 32 participants took part in the research study over 4 offerings of the program. No participants were found to be ineligible, but the method of recruitment was not tracked. The demographic characteristics of the study participants are presented in P=.22) but did increase 1 month later .There were no significant differences in social isolation when measured either as a total score or as interaction or support sub-scores between baseline and end of study or at 1-month follow-up . MoreoveP=.001) and at follow-up (P=.002). The most common tablet uses were email, seeking an answer to a specific question, internet browsing, and seeking health information. The only statistically significant difference between time points was an increase in the proportion of participants who used their tablet to seek health information .The participants’ self-reported frequency of tablet use increased from baseline to end of study; this increase was maintained at follow-up, changing from an average of several times a month to once a week . There wOverall, the participants were highly satisfied with the program, with 23 (71.9%) of the 32 participants finding the information useful, 22 (68.8%) indicating they would be interested in future workshops, and 25 (78%) reporting they would recommend the workshop to family and friends . HoweverThe purpose of this study was to explore whether taking part in a real world offering of a 6-week tablet training program for older adults reduced social isolation or loneliness or improved quality of life. Overall, despite high levels of satisfaction with the program itself, no changes were observed in our primary or secondary outcomes of interest.These findings are in contrast to a 2012 meta-analysis that found a statistically significant decrease in loneliness scores in older adults when the results of 5 studies were pooled together, with an effect size of 0.56 . Within Our findings are similar to a previous study that found no difference in social isolation or self-esteem in older adults with psychiatric conditions who took part in twice-weekly internet and technology training over the course of 6 weeks . These pAt the end of the 6-week AGE-ON program and 1 month later, the participants’ attitudes toward technology were more favorable than at baseline; also, the participants self-reported that they used their tablets more frequently and for a wider variety of uses. Therefore, we are confident that the program was effective in helping to teach the participants how to use the iPad and that it met their learning needs. It is likely that the lack of change in social isolation and loneliness is not due to a failure of the program in teaching the participants to use the tablet properly but is rather due to the fact that using the tablet itself does not reduce social isolation or loneliness in this population. This is not surprising when we consider the types of activities for which the participants primarily reported using an iPad. The most common activities across all 3 time points were using email, finding the answer to a specific question, and seeking health information. Although email can be used to connect with others, other activities that would likely contribute more to feelings of social connectedness and reducing loneliness, such as audio or video calling, instant messaging, and social media, were reported by less than one-third of participants.An emerging concern with respect to the use of technology is its ability to actually increase feelings of social isolation or loneliness in users. In a recent qualitative study of older adults aged ≥70 years who regularly used social media or social technology, the participants stated that while social media and technology use could certainly strengthen existing social relationships and bring depth and fun to social contacts, technology could also represent an obstacle to real human contact . EncouraSeveral methodological considerations limit the interpretation of our findings. First, as this was an evaluation of an ongoing community-based program, we were not able to randomize the participants to a control group. Second, this study included a convenience sample of highly motivated individuals who were offered free participation in a tablet training program and who mostly had access to a tablet of their own either at home or through a family member or friend. Thus, these results may be less applicable to the broader population. Finally, given the timeframe of the funding opportunity, we were only able to evaluate 4 offerings of the program in which 32 participants took part. Although a large sample would provide greater power to detect statistically significant differences, due to the consistent lack of change in any of the outcomes related to social isolation, loneliness, and social support, we do not believe a larger sample would alter our conclusions.Overall, this study found that while older adults who took part in a tablet training program enjoyed the program and learned skills related to using a tablet computer and technology in general, participation in the program did not result in changes to social isolation, loneliness, or social support. Future work that specifically targets older adults who are socially isolated or at risk of social isolation is needed to more fully understand whether tablet training programs are beneficial in this population.


Dengue virus (DENV) and Zika virus (ZIKV) belong to the flavivirus genus and are antigenically closely related. They also share the same mosquito vector and can cause similar symptoms upon infection. However, DENV and ZIKV infections lead to different clinical sequelae and treatments; therefore, clinicians need rapid and accurate diagnostics capable of distinguishing between the two diseases. Methods: We employed the immuno-magnetic assay technology on a microfluidic cartridge (ViroTrack Sero Zika IgG/IgM) for diagnosis of ZIKV infection based on the aggregation of magnetic nanoparticles. We carried out three serological studies including samples from the Dominican Republic, USA, and Nicaragua, aimed at detecting ZIKV-specific IgG and IgM using the ViroTrack Sero Zika IgG/IgM test. Results: The seroconversion results were comparable with ZIKV IgG and IgM reactivity measured by the commercial ZIKV ELISA kit. The sensitivity and specificity for both ZIKV IgG and IgM tested by the ViroTrack Sero Zika IgG/IgM was approximately 98% and 93%, respectively. Conclusion: Serological detection of ZIKV infection by the new ViroTrack Sero Zika IgG/IgM test shows promising performance and limited cross-reactivity with DENV. Zika virus (ZIKV), an arthropod-borne virus (arbovirus) belonging to the flavivirus genus in the Flaviviridae family, became a global epidemic after its introduction into Brazil in 2014–2015 . Other rThe incubation period of ZIKV is thought to be 3–14 days . The typAs with all flaviviruses, ZIKV is an enveloped, icosahedral virus. Its genome consists of positive-sense single-stranded RNA approximately 11 kb long, containing a single open reading frame encoding a polyprotein that is cleaved into three structural proteins—the capsid (C), membrane (prM/M), and envelope (E) proteins, and seven non-structural proteins—NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5 ,19. The Dengue virus, another flavivirus, shares the same mosquito vector as ZIKV. DENV has four serotypes and is widely spread throughout tropical and subtropical areas such as Asia and the Americas , where ZMeanwhile, quick and accurate serological diagnosis of ZIKV infection is essential for patients needing special attention, such as pregnant women who need be monitored, particularly in the early stages of pregnancy. Therefore, there is an emergent need for rapid diagnostic tests (RDT) for ZIKV infection, especially in resource-limited regions. However, the development of RDTs is challenging, since RDTs are often low in sensitivity and specificity when compared to traditional, more time-consuming diagnostic methods, like the ELISA and plaque reduction neutralization tests (PRNT), which normally need hours to days to perform. https://blusense-diagnostics.com/technology/). IMA enables a novel, rapid and semi-quantitative ZIKV serological diagnostic method. Here, we present the evaluation of detection of ZIKV NS1-specific antibodies by the ViroTrack Sero Zika IgG/IgM cartridge and its performance in distinguishing between the ZIKV and DENV infections.Here we present an immuno-magnetic assay (IMA) for diagnosis of ZIKV infection based on the aggregation of magnetic nanoparticles (MNPs). The assay technology is implemented in a microfluidic cartridge format, which is designated ViroTrack Sero Zika IgG/IgM. The same technology has been implemented in detecting dengue NS1 and IgG/IgM as ViroTrack Acute Dengue NS1 Ag  and ViroTrack Sero Dengue IgG/IgM Ab , which are commercially available products. The cartridge is used in combination with an opto-magnetic reader called BluBox , which is designed for use in laboratories and decentralized settings. BluBox enables the quick diagnosis of multiple viral infections in a few minutes and requires minimal user interaction. The assay technology is based on the use of MNPs coated with viral antigens (ZIKV NS1) that react with ZIKV NS1-specific antibodies. These coated immuno-MNPs are deployed in a magnetic agglutination assay (IMA) with the samples. After incubation in a strong magnetic field, the target antibodies aggregate with immuno-MNPs, which are subsequently measured using an optical-based detection system in the BluBox reader. The details of the process are described on the website of BluSense Diagnositcs . The Nicaraguan Pediatric Dengue Cohort Study was approved by the Institutional Review Boards of the University of California, Berkeley, and the Nicaraguan Ministry of Health. Parents or legal guardians of the subjects provided written informed consent, and participants 6 years of age and older provided assent.ViroTrack Sero Zika IgG/IgM—prototype and research use only version  is a microfluidics-based semi-quantitative Zika detection assay based on IMA technology. It is designed as single-use and it is intended to be used in combination with the BluBox. ViroTrack Sero Zika IgG/IgM cartridge and the BluBox are illustrated in In this study, we included samples from different sources. Information about the samples is listed in All patient samples were diluted in sample dilution buffer (provided by BluSense Diagnostics) at a 1:20 dilution.The status of ZIKV- and DENV-specific IgM and IgG antibodies in samples in this study was determined by different reference methods, for example, commercial ELISA kits (tested either in-house or by the provider), the CDC MAC-ELISA, or the dengue inhibition ELISA (iELISA) . In-housIn serological study 1, we included three serial ZIKV samples  from the Dominican Republic . The serum samples were diluted 1:20 with sample dilution buffer and evaluated with ViroTrack Sero Zika IgG/IgM and commercial ELISA kit ZIKA virus IgG and ZIKA virus IgM  according to the manufacturer’s instructions.In serological study 2, we included ten naïve samples and 127 RT-PCR-confirmed Zika cases. These ZIKV-infected samples included 41 samples from the Dominican Republic , 50 samples from Nicaragua  and 36 samples from BARDA collaboration (USA). All the samples were evaluated with ViroTrack Sero Zika IgG/IgM and commercial ELISA , ZIKV NS1 BOB ELISA  for sam. Among tIn serological study 3, we included six different groups of samples from Nicaragua : the first group included 25 pZIKV samples; the second group included 25 DENVpZIKV samples; the third group included 25 pDENV samples; the fourth group included 25 sDENV samples; the fifth group included 20 pDENV_>3 MPO samples; the sixth group included 20 sDENV_>3 MPO samples , and optimized cutoff were carried out with R software.In all violin plots, measurement data (points) with median value (center line), mean value (cross marker), minimum, first quartile, median, third quartile and maximum are presented. Zika IgG/IgM levels measured in different patient cohorts were compared using an unpaired t-test with confidence intervals of 98%. Results were considered to be significant at Evaluation of ViroTrack Sero Zika IgG/IgM for detection of ZIKV-specific IgG and IgM was performed in three sample sets. Serological study 1 shows serological evidence of ViroTrack Sero Zika IgG/IgM by testing ZIKV-specific IgG and IgM in samples collected from three ZIKV-infected patients at different days post-illness onset. In serological study 2, the sensitivity and specificity of the ViroTrack Sero Zika IgG/IgM cartridge was compared to standard techniques in a group of 127 ZIKV-infected samples and 10 healthy control samples. In serological study 3, four groups of samples—specifically, samples from primary ZIKV infections with no prior DENV infection (pZIKV); primary ZIKV infections with documented prior DENV infection (DENVpZIKV); primary DENV infections (pDENV); and secondary DENV infections (sDENV) in early convalescence were tested with ViroTrack Sero Zika IgG/IgM with the aim of assessing the cartridge specificity in relation to DENV infection.ZIKV IgM and IgG values were measured by ViroTrack Sero Zika IgG/IgM a,c in sePromising results in terms of sensitivity and specificity for ZIKV IgG and IgM were obtained . Clear sThe ability of the ZIKV assay to distinguish between DENV and ZIKV cases was investigated on four groups of samples from Nicaragua . In total, 140 samples were tested with ZIKV IgG and IgM assays, respectively. The optimized cutoff for the ZIKV IgG test is 32.17 IMA units, and for the ZIKV IgM is 51.92 IMA units. Results are shown in The violin plots in p value < 0.0001. Furthermore, this difference is also observed from samples collected 3 months post-onset of illness. sDENV_>3 MPO shows a significantly higher IgG level than the pDENV_>3 MPO group sample  , and 20 samples with secondary DENV infection and no previous history of ZIKV infection collected 3 months post-onset of illness (sDENV_>3 MPO). These samples were measured with ViroTrack Sero Zika IgG/IgM for both IgG and IgM, and the result is shown in  0.0019) f.ViroTrack Sero Zika IgG/IgM is a new microfluidic immunomagnetic magnetic nanoparticle-based immunoassay for serology detection of ZIKV infection developed by BluSense Diagnostics Aps. ViroTrack Sero Zika IgG/IgM precisely monitors the seroconversion pattern of three different ZIKV PCR positive patients between 5- and 76-days post-onset of illness. The detected trend of ZIKV-specific IgG and IgM titers is comparable with the reference ELISA results from DIA.PRO. Furthermore, the sensitivity and specificity of ViroTrack Sero Zika IgG/IgM are calculated to be 92% for IgG and 93% for IgM, using ELISA as a standard reference.Due to the highly conserved region in their structure between DENV and ZIKV envelope proteins, it is very difficult to distinguish between ZIKV and DENV based on IgG or IgM tests by using the traditional envelope protein-based assay. The CDC-recommended IgM MAC-ELISA also holds limitations . ZIKV NSIn the next step, ViroTrack Sero Zika IgG/IgM should be evaluated on a larger sample size and more locations of sample origins. Further expansion of the cross-reactivity study with other flaviviruses such as Japanese encephalitis virus (JEV), West Nile virus (WNV), yellow fever virus (YFV) and tick-borne encephalitis virus (TBEV) is needed to precisely assess the cartridge specificity.This section is not mandatory, but can be added to the manuscript if the discussion is unusually long or complex.This section is not mandatory, but may be added if there are patents resulting from the work reported in this manuscript.


By contrast, participants from Mexico City and Santiago de Chile were more likely to stay in geographic units similar to their average SES-of-origin, having lower overall mobility during leisure time: maximum SES percentile difference 1.55  and −0.91 , respectively. PA levels of participants did not differ by sex or SES. Our results suggest that Ciclovía can be a socially inclusive program in highly unequal and segregated urban environments, which provides a space for PA whilefacilitat physical proximity, exposure to new communities and environments, and interactions between different socioeconomic groups.Ciclovía Recreativa is a program in which streets are closed off to automobiles so that people have a safe and inclusive space for recreation and for being physically active. The study aims were: (1) to compare participant’s spatial trajectories in four Ciclovía Recreativa programs in Latin America  according to socioeconomic characteristics and urban segregation of these cities; and (2) to assess the relationship between participants’ physical activity (PA) levels and sociodemographic characteristics. We harmonized data of cross-sectional studies including 3282 adults collected between 2015 and 2019. We found the highest mobility for recreation in Bogotá, followed closely by Santiago de Cali. In these two cities, the maximum SES (socioeconomic status) percentile differences between the neighborhood of origin and the neighborhoods visited as part of the Ciclovía use were 33.58 ( In the 21st century, cities around the world are facing the consequences of rapid, unplanned urbanization [Currently, about 80% of the Latin American population lives in cities, towns, and other urban settlements , with prUrban segregation occurs either by a self-selection process (in the case of affluent groups) or through the inability to pay for desirable locations in a city (vulnerable communities) ,13,14. MIn addition, urban segregation affects people’s lives in various ways. It preserves and exacerbates existing violence and conflicts among groups . Urban sIn Latin America, urban segregation has historically shaped the way cities have grown ,19,26, pWithin this context, innovative public space and transport programs and policies have emerged seeking to activate urban spaces by enabling neighbors and families to socialize and do physical activity (PA). One of these programs is the Ciclovía Recreativa, in which streets are temporarily opened to persons and closed off to automobiles so that people have a safe and inclusive space for recreation and for being physically active . By provThere are around 497 Ciclovía programs in 27 countries globally, with Latin America being the region with the greatest number of regular programs ,31. EvidA better understanding of the potential of the Ciclovía as a socially inclusive program requires a dynamic measure of segregation that, in contrast to the traditional static and spatial segregation measures, recognizes and assesses segregation as a dynamic process that relies on individuals’ daily life routines, as well as on the different ways they or social groups use urban space ,44. In tThis cross-sectional study included data from Ciclovía programs in four Latin American cities: Bogotá and Santiago de Cali, Colombia; Mexico City, Mexico; and Santiago de Chile, Chile. These cities are characterized by having large populations, being highly dense, unequal, violent, and fragmented, and having limited access to recreational resources, including parks .Ciclovía of Bogotá is the program with the largest number of closed street kilometers in the world. It is a multisectoral program inaugurated in 1974 and coordinated by the District Institute of Sports and Recreation. It comprises a 127.69 km circuit that crosses 18 of 20 localities of Bogotá . The sevThis program was inaugurated in 2007 by the Ministry of Environment in partnership with 20 private and public organizations of Mexico City. It consists of 55 km of interconnected streets that are closed from 8:00 a.m. to 2:00 p.m. on the first three Sundays of each month, with about 37 events per year. On average, an estimate of 21 thousand people attends the program every Sunday ,47 Tabl.The Ciclovida, inaugurated in 1996, is a program of the Mayor of Santiago de Cali, led by Cali’s Secretariat of Sport and Recreation. The circuit is segmented in one central lane that goes from north to south, and seven community lanes, for a total route length of 60 km. These lanes are opened for city dwellers every Sunday from 8:00 a.m. to 1:00 p.m. and every Thursday from 8:00 p.m. to 10:00 p.m., with about 93 events per year, and average participation of approximately 30,000 people every Sunday ,48 Tabl.CicloRecreoVía is run by the private consultancy firm Geomás. It was inaugurated in 2006 with one circuit of 5 km that progressively was expanded to 11 circuits, for a total of 38 km. It is composed of seven routes primarily located in Santiago’s affluent north-east area and the historical center, with only one circuit located near middle and lower-middle-income neighborhoods. The events take place from 9:00 a.m. to 2:00 p.m. on Sundays, with about 51 events per year and average participation of 40,000 people every Sunday ,49 Tabl.This study included data from 3282 individuals collected between 2015 and 2019 . In each of the cities, trained interviewers conducted intercept surveys for which participants were selected systematically. Each participant took a questionnaire that lasted between 10–15 min to be completed, and it was done using pen-and-paper in Bogotá, Santiago de Cali, and Santiago de Chile; or the Survey Monkey platform  on a celWe developed a process for harmonization of the surveys following the SALURBAL  protocol . First, Ethical approval was obtained in each country from the principal investigator’s institutional review board. Universidad de los Andes-Colombia Research Ethics Committee in Bogotá (act no. 691–2017), The National Public Health Institute Ethics Review Board of Mexico in Mexico City (act no. 1703), Universidad ICESI Research Ethics Committee in Santiago de Cali (act no. 076), and the Pontificia Universidad Católica de Chile Ethics Committee in Santiago de Chile, approved the study in each of the cities where the study took place. A secondary analysis was approved by Universidad de los Andes-Colombia Research Ethics Committee (act no. 1017).Sociodemographic characteristics included sex, birthdate , age (in Bogotá), marital status , last grade of school completed , car availability in the household (yes/no), home address, including their zip code (only in Mexico City and Santiago de Chile surveys), and participant’s neighborhood socioeconomic status (SES). We computed age from the date of birth to the observation date and classified participants into the following categories: 18–29 years, 30–49 years, or ≥50 years. Marital status was dichotomized into single or living with a partner. In each of the cities included in the study, the participant’s neighborhood was defined as the smallest geographic unit for which there were available data: in Bogotá and Santiago de Cali, we employed the neighborhood level, while in Mexico City and Santiago de Chile, we employed locality and census zones level, respectively. SES variables from each city corresponds to indicators used for statistics in each city. In Bogotá and Santiago de Cali, SES was determined by using the classification from the National Administrative Department of Statistics , which has six categories based on physical characteristics of the household and neighborhood area (SES category 1 corresponds to the poorest and category 6 to the richest) . In MexiTo evaluate self-assessed health status, participants were asked: ‘Compared to people your age, how would you rate your health over the past month?” with the possible choices being “very good” (1), “good” (2), “not good, not bad” (3), “bad” (4), or “very bad” (5). The last three outcomes were then grouped into a “fair” health category. For all cities, except for Santiago de Chile, participants reported their height and weight. Body Mass Index (BMI) was calculated using the WHO criteria .Using the question regarding time participants spent at the Ciclovía program doing PA, we classified participants into meeting or not PA recommendations during the program. Additionally, weekly PA levels during transport and leisure time were determined in Bogotá and Mexico City employing the International Physical Activity Questionnaire (IPAQ)  and the To assess Ciclovía participation patterns, we asked participants: “What is the main activity you perform during the program?”, “How many hours do you usually spend in the program?”, and “How often do you attend Ciclovía?”. Ciclovía users were characterized according to the type of activity they performed during the program , time spent at Ciclovía , and the frequency of participation . Questions about the type of activities they normally do on Sundays if they are not attending the program , their reasons to attend the program , and whether or not they attend the program accompanied  were also included. People accompanied by at the program variable was coded as “came alone” or “came with another person”.We included an item related to participants’ safety perceptions at the program. This question was scored using a Likert scale from 1 to 5, with 1 indicating that the respondent strongly disagreed with the positive safety statement and 5 indicating that the respondent strongly agreed. This variable was then classified into “unsafe”, “safe”, “neither safe nor unsafe” categories.We defined urban segregation as the degree to which people from two or more SES live separately from one another at the different spatial units of the city .The segregation of groups in urban space manifests itself in several ways, and each corresponds to a different aspect of the same phenomenon ,65. The i) is defined asri refers to a particular SES proportion  of the total metropolitan population in that specific geographic unit (i) and “r” indexes the socioeconomic groups  in a specific population [i) is reduced below the metropolitan’s entropy (E). In other words, the entropy index (H) is the weighted average deviation of each geographic unit’s entropy ((Ei) from the metropolitan-wide entropy (E), expressed as a fraction of the metropolitan area’s total entropyit refers to the total population of the geographic unit (i), T is the metropolitan area population, n is the number of geographic units, and Ei and E represent geographic unit i’s and metropolitan area entropy, respectively. The entropy index is at its maximum when urban segregation is at its minimum, meaning that SESs are evenly distributed across geographic units or that all geographic units of the city have an equal proportion of the population belonging to the different SES. In contrast, the index is minimized—and urban segregation is maximized—when any pair of individuals from two different SESs does not inhabit the same geographic unit [For each geographic unit i , located within a metropolitan area, the entropy score  based on the shortest path distance from the origin to destination points through the street network. Datasets included in the analysis were: an origin-destination matrix, the spatialized trajectories of each journey through each city, and an income or socioeconomic proxy variable for each city referenced at the smallest available geographic unit.We calculated the participants’ trajectories through the Ciclovía program from the participant’s origin point to the participant’s destination point. Origin and departure points by study cite are presented in In addition to participants’ trajectories through the Ciclovía program, we calculated the average SES per traveled kilometer of all participants’ trajectories, that is the changes in the socioeconomic characteristics of urban environments during users’ trajectories (to reach the Ciclovías and through the Ciclovía route). We first divided the trajectories every 500 m and spatially join the SES information at the smallest available geographic unit. Then, we grouped all participants by SES-of-origin  and calculated an average socioeconomic score and variance for every 500-m segment of the total traveled distance, which was measured starting from the origin point of all journeys by SES-of-origin category. This estimation allowed us to assess whether the participant’s trajectories transverse different socioeconomic environments.2 test. Second, a multi-level logistic regression model was developed to assess the effects of sociodemographic variables on participation and participants’ PA levels. The multilevel model included two levels: participants of the Ciclovía and study site. All statistical analyses were performed using SAS version 9.2 software , Stata Software version 16.0 , and RStudio  [First, we compiled and harmonized common variables in each of the four cities. Then descriptive statistics (absolute and relative frequencies) were computed for all variables for the whole sample and by city. All comparisons between categorical variables were tested with a Pearson χMA, USA) .Descriptive characteristics of the study population for each city are presented in Most of the participants in Bogotá (58.74%) and Santiago de Cali (65.69%) reported their health to be good, and in Santiago de Chile to be excellent (69.08%). On the other hand, most participants in Bogotá, Mexico City, and Santiago de Cali had normal BMI (52.31%) . The proOverall, most of the participants met PA recommendations during the program (51.13%), ranging from 27.18% (Santiago de Chile) to 87.24% (Mexico City) . In BogoRoughly half of the participants reported cycling during the program (52.67%), and to spend less than 3 h in the program (54.42%) . The majRegarding participants’ safety perceptions, most of them reported feeling safe with respect to crime in the Ciclovía program (65.51%) .Results from the logistic regression analyses are shown in Overall, among the four evaluated cities, Santiago de Chile had the highest SES diversity within its geographic units, and therefore, the lowest level of urban segregation (mean = 0.82 ± 0.13) . AdditioParticipants’ trajectories through the Ciclovía program, as well as, geographical distributions of SES within each city are shown in p-value < 0.001) and 30.38 , respectively, indicating that in these two cities, participants were more likely to visit higher or lower SES neighborhoods than their average SES-of-neighborhood origin, providing participants opportunities to move through different socioeconomic environments through the Ciclovía route. Similarly, participants in Bogotá and Santiago de Cali who departed from high SES areas reached higher socioeconomic mobility than participants from other cities, with a maximum SES percentile difference of −25.60 and −17.25, respectively , as well as the important proportion of participants that achieved at least 60% of the weekly PA recommendations by attending the program (54.42%). It is also important to underscore that meeting PA recommendations in the Ciclovía did not differ by gender or SES. This is especially important in Latin America and the Caribbean Region, the region with the overall highest prevalence of insufficient PA worldwide, particularly among women . TherefoRegarding the Ciclovía program fostering healthy habits, our results suggested that people who attended the Ciclovía have a higher perceived health status: approximately 65% of Ciclovía participants perceived their health condition as either ‘Excellent’ or ‘Good’. Moreover, among the main reasons for participating in the program, as reported by users, the health benefits associated with PA were at the top (74.03%). The promotion of PA often leads to the adoption of other healthy lifestyle behaviors and is associated with numerous behavioral and emotional improvements ,84,85. IThis study is consistent with findings of previous studies, including that Ciclovía encourages people to be physically active, as well as that it has the potential of promoting social cohesion and social capital. In a study carried out in 2013 that evaluated the effect of San Diego’s Open Streets program (CicloSDias) on PA, researchers found that 97% of participants met the 30 min/day guideline, 39% met the 150 min/week guideline, and 27% would have been sedentary without event . SimilarFinally, taking advantage of the temporal nature of the Ciclovía program, as well as, its capability of enhancing the public space function of city streets, over the past few months, urban planners have explored how to apply tactical urbanism measures as a way to respond to all the mobility challenges that have emerged to the COVID-19 pandemic. Tactical urbanism measures are low-cost, scalable, problem-solving responses in the short term aimed at promoting behavioral changes in urban dwellers through innovative interventions . GovernmThis study has strengths and limitations. First, the sample size included in this study is the largest to date in a study aimed at evaluating the Ciclovía program. Furthermore, this is the first study to our knowledge to make a comparative multicounty analysis of four Ciclovía Recreativa programs in Latin America using a dynamic urban segregation index for measuring social inclusion. Unlike studies that used traditional static segregation measures, we employed an objective dynamic measurement that allowed us to better understand the potential role of the Ciclovía program on social inclusion. Despite the rigorous harmonization of the data, the four studies used questionnaires that were previously adapted for each city. Therefore, future studies should consider including diverse cities with the same standardized questionnaires to have better comparability of indicators. Second, using GIS for estimating participant’s trajectories throughout the program assumed routes that did not necessarily reflect those actually taken for program participants. Despite this, modeling routes with GIS has been recommended as an acceptable method for trajectories prediction/estimation, particularly for active commuting . Future The Ciclovía Recreativa program, as implemented in four Latin American cities , can be a socially inclusive program in highly unequal and segregated urban environments. Our results suggested that, in addition to providing a space for PA, the Ciclovía program works as a venue that facilitates physical proximity, exposure to new communities, and interactions between different socioeconomic groups, having complimentary benefits such as getting citizens to share public space and potentially promoting social cohesion and social capital. This study illustrates the importance of implementing public space usage policies, as well as built environment changes in urban settings, to have a population-based impact in aspects of public health, such as social inclusion, equity, and PA.


Translating complex behavior change interventions into practice can be accompanied by a loss of fidelity and effectiveness. We present the evaluation of two sequential phases of implementation of a complex evidence-based community workshop to reduce falls, using the Replicating Effective Programs Framework. Between the two phases, workshop training and delivery were revised to improve fidelity with key elements.n = 361; phase 2: n = 2219) and 6 months post-workshop . Phase 2 participants had an additional follow-up at 12 months (n = 883). Outcomes were the number of falls in the prior 6 months and the Falls Behavioral Scale (FaB) score.Stepping On program participants completed a questionnaire at baseline  and a 0.14 improvement in FaB score  at 6 months. Workshop participation in phase 2 was associated with a 38% reduction in falls  and a 0.16 improvement in FaB score (95% CI 0.14–0.18) at 6 months, and a 28% reduction in falls  and a 0.19 score improvement in FaB score (95% CI 0.17–0.21) at 12-month follow-up.Effectiveness can be maintained with widespread dissemination of a complex behavior change intervention if attention is paid to fidelity of key elements. An essential role for implementation science is to ensure effectiveness as programs transition from research to practice. In the United States, there is little data about the effectiveness of evidence-based falls prevention programs when implemented in community settings. Following adoption, the next phase of implementation should be concerned with strategies for improving program fidelity in the field . Given tStepping On is a community-based falls prevention program that was tested in Australia. Originally led by occupational therapists (OTs), it was shown to reduce falls by 31% in a randomized controlled trial [The Centers for Disease Control and Prevention provided funding in 2007 for a dissemination and implementation research study, which would identify the key elements of Stepping On and build a program package to ensure fidelity of delivery and effectiveness, and maximize dissemination, implementation, and sustainment of the program nationally. Through the CDC award, from 2007 to 2012, we used the Replicating Effective Programs (REP) framework  to reseaThis paper presents pre–post evaluation findings from the two phases of implementing Stepping On. The first implementation phase, 2006 to January 2009, encompassed the initial adoption into eight counties. The second phase, 2008–2011, which encompassed the broader dissemination in Wisconsin, coincided with the changes in the Stepping On implementation package to improve fidelity. Our primary objective was to determine if implementation of the revised Stepping On training and implementation package, with the enhancements to improve fidelity, would be associated with a reduction in the rate of falls among participants. We secondarily sought to determine if a reduction in the rate of falls would differ by location of workshop  or by type of leader providing the workshop.Stepping On is a small-group, self-efficacy-based workshop addressing multiple components of fall risk over seven weekly sessions and a 3-month booster. Group size is typically 10–14 participants. A trained health professional facilitates the sessions, and guest experts , OT, pharmacist, low vision expert, community safety expert) attend selected sessions to address fall risk factors, including low vision, home safety hazards, medications, and risky behaviors such as walking unsafely. A PT attends session 1 to teach balance and strength exercises, which are then practiced daily at home and progressed throughout the sessions. In the original study, community-dwelling adults aged ≥70 who had a fall in the past year or a fear of falling, who were able to walk at least 10 feet without the aid of another person , and who were cognitively intact were eligible to participate in the program .When starting Stepping On in Wisconsin in 2006, we modified the Australian program to increase feasibility of adoption and implementation by deleting the home visit, which in the original program occurred 2 weeks after the final session, and broadening the criteria for who could enroll in the workshop to also include older adults younger than age 70 who were community-dwelling, cognitively intact, and able to walk at least 10 feet without the aid of another person. We also broadened the criteria for a Stepping On leader. The original Stepping On manual stated “This manual is for occupational therapists, physiotherapists, and other health professionals and health promotion workers in the area of falls-prevention with older people” . We inclPhase 1 Stepping On was implemented in eight counties from July 2006 to January 2009 and evaluated through funding from the Wisconsin Partnership Program. In May 2006, nine professionals were trained as leaders, and three older adults were trained as lay leaders through a 2-day training. The trainees read the Australian leader manual , which pFor the phase 1 evaluation, the Stepping On leader invited all workshop participants to participate in a program evaluation, consisting of a baseline questionnaire before session 1 and a follow-up questionnaire 6 months after the last session. Our program evaluation received an exemption from the University of Wisconsin Institutional Review Board.The REP framework was developed by the Centers for Disease Control and Prevention as a blueprint to assist with the systematic dissemination and implementation of behavioral and treatment interventions in community settings, in such a way that fidelity is maintained while adaptability is fostered, toward an ultimate goal of maximizing broad adoption, reach, effectiveness, and sustainment of healthcare interventions . Figure Through funding from the CDC, we accomplished the “pre-implementation” and “implementation” phases of the REP framework, as shown in Fig. Simultaneous with the work of the CDC study, we disseminated Stepping On throughout Wisconsin through funding from the Administration for Community Living. Incorporating the findings generated from the CDC-sponsored study on Stepping On, we iteratively modified aspects of training and delivery of Stepping On in Wisconsin from 2008 to 2011, as shown in Table The Wisconsin Department of Health and Family Services’ Divisions of Disability and Elder Services, through funding from the federal Administration for Community Living, led the implementation and evaluation of Stepping On across Wisconsin from January 2008 through June 2011.Leaders were identified by Aging Units in each county. Leaders were volunteer or were paid by the organization that sponsored them . Leaders worked with sponsoring organizations in their communities to recruit participants and guest experts and facilitate the workshop. Guest experts  were not paid by the program. Participants completed a registration form that screened for falls, fear of falling, and use of a walker indoors. Workshop coordinators or leaders screened out individuals who were noted to have obvious cognitive impairment during the registration process. Some leaders provided the workshop free to participants. In other cases, there was a cost of up to $30.00 for participants.Phase 2 evaluation occurred for workshops implemented between January 2008 and June 2011. Leaders were trained from October 2006 through September 2010. A 1-day refresher training was offered in 2009 to bring leaders trained prior to 2009 up-to-date. Leaders were encouraged to participate in monthly calls with the Stepping On master trainer, which afforded the opportunity to provide updates and reinforce key elements. All new leaders trained from 2008 received one fidelity check followed by a one-on-one coaching session with the master trainer.For the phase 2 evaluation, similar to phase 1, Stepping On leaders invited participants to participate in a program evaluation, consisting of a baseline questionnaire before session 1 and a follow-up questionnaire at 6 and 12 months after the last session. All participants from all workshops held in Wisconsin during the evaluation period were included in the evaluation. The phase 2 program evaluation received an exemption from the University of Wisconsin Institutional Review Board.The baseline questionnaire in both phases was completed within 1 week before the first workshop session. It included demographic information , use of an assistive device for indoor walking, number of falls in the prior 6 months, and occurrence of any injurious fall . Participants also completed a measure of fall behavioral risk. The number of falls was based on the question, “How many times have you fallen in the last 6 months?” Fall behavioral risk was determined using the Falls Behavioral Scale (FaB) . This meAttendance at weekly sessions was tracked by the leader and returned to the research assistant at the end of the workshop. Participants were deemed “completers” if they attended at least five of the seven sessions.Participants were mailed a follow-up questionnaire at 6 months after the end of session 7 (the last session), and additionally for phase 2 at 12 months after the end of session 7, which included number of falls in the prior 6 months and FaB. If participants did not return the questionnaire by mail within 10 days, the evaluator called the individual to obtain data by phone. Three attempts were made to call by phone. Baseline and follow-up questionnaires included an information sheet explaining purpose, risks, benefits, and voluntary nature.We defined four categories of rural versus urban based on the Rural–Urban Commuting Area (RUCA) codes . RUCA coWe identified all leaders who had taught workshops according to their professional background. The primary professional backgrounds of leaders were PT, OT, or RN; health educator; and social worker; 1802 (74.6%) participants took workshops led by a leader from one of these backgrounds. The remainder of participants  took workshops led by leaders from other backgrounds: fitness leader, licensed practical nurse, speech therapist, PT assistant, executive director of a housing authority, medical technologist, registered dietician, lay volunteer, community partnership coordinator, Aging and Disability Resource Center director, owner of a home care agency, and owner of an assisted living facility. Leaders from these backgrounds were excluded from analysis of the association of type of leader with reduction in falls rates.Mixed-effects Poisson regression models were used to evaluate the impact of Stepping On on the rate of falls. Models included intervention status  as a fixed effect, and subject and the interaction between subject and intervention as random effects. Models were fit separately to all subjects and to prespecified subgroups based on leader type, subject, and site location.Mixed-effects linear regression models were used to evaluate the impact of Stepping On on FaB scores. Models included intervention status  as a fixed effect, and subject and the interaction between subject and intervention as random effects. Models were fit separately to all subjects and to prespecified subgroups based on leader type, subject, and site location. Analyses were performed using the lme 4 package  in R 2.1From July 2006 through January 2009, there were a total of 34 Stepping On workshops held in eight Wisconsin counties, enrolling 361 participants. Figure From January 2008 through June 2011, there were a total of 253 Stepping On workshops held in 43 of Wisconsin's 72 counties, enrolling 2219 participants. Three counties held 15 or more workshops, 6 held 10–14, 10 held 5–9, and 24 held 1–4. A total of 108 leaders held workshops. Figure As shown in Table Table Table The effect of rural versus urban location on falls rate ratio  is shown in Table p = 0.0005 for all participant location comparisons versus urban location; p < 0.0001 for all workshop site comparisons versus urban workshop site).We looked to see if type of leader, or participant or site location affected workshop attendance. Overall, 79% of participants attended five of seven sessions and were classified as completers. As shown in Table p < 0.001) and fewer medical record-verified emergency department visits for fall-related injuries (p < 0.05) [This natural experiment afforded us the opportunity to see if an evidence-based program that was not effective when first implemented in a few counties in Wisconsin could become effective when disseminated statewide with attention to fidelity. Our results showed a significant reduction in rate of falls with the second, but not the first, phase of implementation of Stepping On in Wisconsin. The lack of effectiveness in phase 1 may be attributable to the multiple losses of fidelity when we originally adapted the program for dissemination in Wisconsin. The marked increase in effectiveness that we found in phase 2 may be due to the steps we took to ensure fidelity with dissemination. First, we identified key elements of Stepping On and developed a fidelity tool to track the delivery of key elements across all workshop sessions . We then < 0.05) .There may be other reasons for our findings of improved reduction in falls with phase 2 versus phase 1. The second sample had a higher baseline rate of falls compared to the first sample, and it is possible that the sample in phase 1 was too high functioning to show a significant reduction in falls. The original Stepping On study also noted diminished program effectiveness with those at lower risk for falls.We saw a significant improvement in FaB scores in both phases 1 and 2. Given this, we suspect that improvement in falls behavioral risk was not sufficient to account for the reduction in falls rate with Stepping On. The workshop aims to decrease behavioral risk, but also aims to improve balance and strength. Exercises are practiced in class; and building on adult learning and behavior change principles, participants are nudged successfully to practice the exercises daily at home and progress them in difficulty over time . There iWith phase 2, we saw no difference in rate ratio of falls in comparing program delivery by a health educator or a PT/OT/RN. The rate of falls was reduced more with workshops led by a social worker. It is unclear if this finding was due to chance or due to a difference in skills of social workers versus other health professionals. While traditionally social workers have not been considered as experts in falls prevention, many have expertise in promoting behavior change, which could enhance the effectiveness of program delivery. Overall, our findings confirm that workshops do not need to be led by a physical or occupational therapist or nurse to be successful. Individuals with other health-related backgrounds who have worked with older adults, and have experience with group facilitation using behavior change principles, can take the Stepping On leader training and succeed as leaders.We had hypothesized that the program may not be as effective when delivered in rural compared to urban sites. In general, the reduction in falls rate tended to be higher for participants in urban locations, compared to large rural, small rural, or isolated locations; however, results were only significant for large rural versus urban. We hypothesized that this would, in part, be due to problems with attendance at rural locations, but attendance was only lower at small rural locations. Our finding of a higher reduction in falls in urban settings may be due to chance, but if true, it is unlikely that they are due to differences in attendance. We were unable to measure other factors, such as socioeconomic status or health literacy, that may have distinguished urban versus rural attendees and mediated their ability to benefit from the program.et al. [et al. [This natural experiment represents an example of a successful application of dissemination and implementation science to improve impact with dissemination. In phase 1, we focused on maximizing adoption and sustainability. In phase 2, we used the REP framework to maximize fidelity and reach in both rural and urban areas without sacrificing adoptability or sustainability. Without the application of implementation science principles, we would not have been able to systematically identify key elements and identify and correct lapses in fidelity with broad dissemination. The REP framework has been used previously to guide adaptations of interventions for new settings or target groups, and/or develop strategies to overcome implementation barriers with spread –29. Howeet al.  demonstr [et al.  describewihealthyaging.org) serves as the national purveyor. WIHA holds the nationwide license for Stepping On and can license other organizations to implement the program. The lead trainer at WIHA trains individuals at other organizations to first become leaders and then master trainers, who can train new leaders within their organization, following a train-the-trainer model. Master trainers observe all new leaders to ensure fidelity. As a condition of receiving the license, organizations annually report the number of leaders, workshops, and participants in the program.The Stepping On falls prevention program continues to be implemented, and its reach has expanded nationwide. It has now been implemented in 22 states besides Wisconsin, with over 35,000 total participants to date. The Wisconsin Institute for Healthy Aging (This study has a number of strengths. We used the same methodology for data collection in phases 1 and 2. Between phases 1 and 2, we used rigorous methodology to identify key elements, identify lapses to fidelity, and revise the Stepping On program package, utilizing the REP dissemination and implementation framework. In addition, the reduction in falls rate seen in phase 2 was similar to that seen in the original Stepping On randomized trial, lending credence to the results.et al. showed very similar results to those found here, adding strength to the validity of the results [There are a number of limitations to our work. First, falls were identified by retrospective self-report over a 6-month period. The gold standard for falls reporting is monthly calendar, but as funding was for program evaluation, we were not able to identify falls by the gold standard of monthly calendars ,33. Seco results . Fourth,In summary, this study of the two phases of implementation of Stepping On shows effectiveness in phase 2 that is temporally consistent with changes in program implementation to improve fidelity and effectiveness. Our findings suggest that with widespread dissemination of a complex behavior change intervention, effectiveness can be maintained if attention is paid to fidelity of key elements. Conversely, our study provides a cautionary note that dissemination of complex behavior change interventions without attention to fidelity may result in loss of program effectiveness. This study suggests an essential role for implementation science to ensure effectiveness as programs transition from research to practice.