Trauma-Informed Learning), a program to identify and prevent relational trauma. Program evaluations revealed nurses felt competent and confident to identify and respond to relational trauma; however, response capacity was inhibited by inadequate parent referral options. In response, MERTIL for Parents  was developed, which is an online, evidence-based, self-paced parenting program that focuses on enhancing parental knowledge of relational trust and its significance for infant development. This low-cost, accessible prevention resource targets emerging relational concerns to reduce later service system engagement. The potential for universal preventative online programs that target parental and relational wellbeing remains under-explored. This paper reports on a protocol for implementing a MERTIL for Parents pilot study describing practitioners’ and parents’ perspectives on program feasibility and efficacy.Early relational health is a key determinant of childhood development, while relational trauma in the parent-infant dyad can instigate a cascading pattern of infant risk. Fortunately, early relational trauma is detectable and modifiable. In 2018, Australian Maternal and Child Health (MCH) nurses participated in MERTIL (My Early Relational for Parents, which entails a 40-minute video, tipsheets, posters, and support resources. Parent data will be obtained at three periods: pre-program, program exit, and program follow-up. Practitioner data will be collected at two periods: pre-parent recruitment and program follow-up. Data collection will occur through surveys and focus groups. Primary parent outcomes will be socioemotional assessments of program efficacy. Practitioners and parents will each report on program feasibility.This study is a mixed methods, parallel armed, uncontrolled, repeated measures design. We aim to recruit 48 Australian MCH practitioners from the states of Victoria and New South Wales. These professionals will in turn recruit 480 parents with a child aged 0–5 years. All parents will receive MERTIL for Parents, with pilot field studies commencing in March 2023. We anticipate that this resource will be a valuable addition to various child and family services, for use in individual support and group work.This protocol describes the feasibility and efficacy of a new online parenting program, MERTIL  Program evaluations, as assessed via surveys and focus groups, revealed most MCH nurses felt competent and confident to identify and respond to relational trauma; however, response capacity was inhibited by inadequate parent referral options for those with sub-clinical presentations. In response, MERTIL for Parents  was developed. MERTIL for Parents is an online, evidence-based, self-paced parenting program that focuses on enhancing parental knowledge of relational trust and its significance for infant development. This low-cost, accessible prevention resource targets emerging relational concerns to reduce later service system engagement. The potential for universal preventative online programs that target parental and relational wellbeing, as well as the development of early relational trust, remains under-explored.Early relational health is a key determinant of childhood development, while relational trauma in the parent-infant dyad can instigate a cascading pattern of infant risk. Fortunately, early relational trauma is detectable and modifiable. In 2018, Australian Maternal and Child Health (MCH) nurses based in the state of Victoria participated in MERTIL for Parents, reporting on healthcare practitioners’ and parents’ perspectives on program feasibility and efficacy, with pilot field studies commencing in March 2023. This study is a mixed methods, parallel armed , uncontrolled, repeated measures design. We aim to recruit 48 MCH nurses and allied health practitioners who will in turn recruit 480 parents with a child aged 0–5 years (inclusive). All participants will receive access to the MERTIL for Parents program, which entails a 40-minute video, tipsheets, posters, and support resources. Parent and practitioner data collection will occur through surveys and focus groups. Primary parent outcomes will be socioemotional in nature to examine program efficacy; such outcomes will include child-parent relationship quality, parental reflective functioning, and child emotional functioning. Practitioners and parents will each report on study program feasibility. It is anticipated that this resource will be a valuable addition to a wide range of child and family services, for use in individual support and group work.This protocol describes the feasibility and efficacy of a new online parenting program, MERTIL relational health [relational trauma presents ongoing and accruing disruption to the infant’s context of early care. Unsurprisingly, relational health and relational trauma impact upon an array of child developmental domains, instigating a cascading pattern of child resiliency or risk. Importantly, relational health elements, including attachment organisation and parental sensitivity [Children develop in a relational context with everyday parent-child interactional patterns contributing to their l health . Relatiositivity –4 are moPreventative parenting programs can be universal, selective, or indicated. Universal programs are those available to all parents; selective programs target parents displaying above average risk; and indicated programs target parents showing signs or symptoms of emerging disorder . ResearcACT Raising Safe Kids [Universal parenting skills-based programs have historically been presented through varied in-person modes, including face-to-face lectures, workshops, and groups. Program examples include CANparent  and ACT afe Kids . Such prafe Kids –9.Despite the availability and evidence supporting these in-person parenting programs, many families, particularly those experiencing numerous vulnerabilities, face multiple barriers in accessing these programs , 11. ForOnline or app-based program delivery provides an avenue to address these limitations, provided intended users have adequate technology access, reliable internet connection, and are digitally literate. Online universal parenting programs can be either entirely or partially self-guided. In partially self-guided programs, clinician support is provided at varying frequency via online, phone, or in-person modalities . Prior mWhile both self-guided and partially self-guided online parenting programs are efficacious, the formation and implementation of wholly self-guided, universal, digital parenting programs has recently gained momentum e.g., , 26. TheDue to their significant preventative potential, online parent resources may reduce the need for later intervention. This may occur by supporting and motivating parents with new knowledge and behavioural skills to independently enhance their parent-child relationship, in turn reducing later burden on service systems. Public health initiatives such as these may empower parents to alter relational trajectories early on, within a preventative approach that is parent-led and strengths-based. This may assist to disrupt emerging disadvantage before reaching pathological thresholds. Equitable access through online platforms has become more important, particularly in the face of the COVID-19 global crisis. Further, evidence shows that these programs promote help-seeking . Finallyfor Practitioners and providing parenting support, they do not have a recommended suite of online parenting programs within their toolbox to assist clients [While numerous clear benefits exist in relation to online, self-delivered, universal parenting programs, certain gaps remain. Currently, there are few brief self-help, psychoeducational program options (either in-person or online) that are suitable for parents at the broad community level, to raise awareness of their role in promoting early relational trust and preventing relational trauma. Second, most parenting resources in this domain exist in the context of in-depth indicated parenting interventions  . While t clients . MCH serfor Parents (My Early Trust-Informed Learning), within the Maternal and Child Health (MCH) sector. The aims of this study are twofold:This paper reports on a protocol for the pilot implementation of a new self-directed, universal, online parenting program, MERTIL for Parents:For practitioners: Examine the programs acceptability and utility for enhancing parent understanding of early relational health; assess the practical dimension of implementing the program within a busy service; and explore population reach.For parents: Examine program acceptability and utility.Determine the feasibility of MERTIL for Parents across selected parental caregiver knowledge, perceptions , and behavioural domains .Evaluate the short-term efficacy of MERTIL for Parents is a new universally available, self-directed, online psychoeducation resource for Australian parents focused on promoting parental knowledge and understanding of relational trust and its significance for infant development. This program is informed by evidence from attachment theory, developmental neuroscience, and psychoanalysis. As a preventative mental health resource, MERTIL for Parents aims to enhance infant-parent relational trust and relational awareness, in turn modifying parents’ attachment security-oriented beliefs, attitudes, and behaviours. MERTIL for Parents builds upon prior research by the authors. In 2018, over 1700 Australian MCH nurses from the state of Victoria participated in MERTIL for Practitioners , a 14-hour self-directed, interactive, professional development program for MCH nurses to identify and prevent relational trauma. The program evaluation from the 2018 Victorian cohort revealed that MERTIL for Practitioners enhanced competence and confidence in nurses’ identification of relational trauma [for Parents was developed. See for Parents logo.MERTIL l trauma . Howeverl trauma . In respfor Parents is accessed via the internet and can be viewed on any online platform . The primary component of MERTIL for Parents comprises a 40-minute pre-recorded video. Video content consists of four ‘chapters’, with each chapter approximately ten-minutes in duration. See for Parents video content. Secondary program components include downloadable parent tipsheets, posters, and professional support contacts. All secondary program elements were developed by the study authors. See MERTIL for Parents is highly engaging, in order to i) enhance program enrolment, ii) deliver memorable content, and iii) maximise successful program completion. MERTIL for Parents was intentionally designed as a very-brief parenting program to counter the high dropout rates that have been observed in other online parenting programs [for Parents’ length was to introduce parents to the pivotal elements of relational trust, in a manageable, user-friendly, and time-efficient fashion that could be completed in one sitting or across several brief stints, as parents progress through the program at their own pace. A production team and animator translated the content into an engaging, animated format. See for Parents content.Numerous steps were taken to ensure MERTIL programs . The ratProgram content & delivery. To ensure the evidence-based narrative content was engaging and well received, content included:Moments of humour to balance the program’s occasional heavy content.Lay language to ensure the program’s content was successfully communicated to a varied parent audience.An emphasis on safety, relatability, and acceptance; to this end, the narrator’s voice is warm, calm, non-blaming, and reassuring.Co-designed nature of MERTIL for Parents. The MERTIL for Parents program content was co-designed and co-developed alongside parent consumers, early childhood mental health clinicians, and MCH nurses, from program commencement to completion. This collaborative process enabled the voice of ‘would be’ end-user parents and professional referrers to be heard; prior research has identified this co-design process as enhancing engagement, efficacy, and research applicability [for Parents program.cability , 33. Resfor Parents will be examined via a parallel armed , uncontrolled, mixed methods, repeated measures study design. Practitioners will complete two assessments (pre-parent recruitment and three-month post-program) and parents will complete three assessments . All practitioners and parent data collection and completion will be conducted independently and in parallel.MERTIL Ethical approval for this study was granted by the Human Research Ethics Committee at La Trobe University (HEC: 22096).Eligible study participants will be twofold: i) Australian MCH nurses and perinatal and infant mental health practitioners, and ii) Australian parents. See for Practitioners, ii) work at a participating Australian pilot site, in metropolitan or regional/rural Victorian and New South Wales, and iii) be able to make a follow-up contact  to each of the parents they refer to the program, to gather feedback.To be eligible for study participation, practitioners will: i) have completed MERTIL and perinatal and infant mental health clinics. Enhanced service staff will include not only MCH nurses, but also psychologists, social workers, and psychotherapists. Study participation invitations will further be sent to practitioners who work in both the Universal and Enhanced services.For practitioner participants, two key programs sit within the MCH umbrella: i) Universal services, and ii) Enhanced services . Particifor Practitioners will be provided for the duration of the pilot study. All practitioners will have already completed this training; however, ongoing access will allow practitioners to refresh their knowledge of and skills in identifying early relational trauma, if necessary. Practitioners will also have ongoing access to MERTIL for Parents.For practitioners who decide to participate, free access to MERTIL Consenting parent participants will: i) be the parent of a child 0–5 years (inclusive); ii) be recommended to participate in the program by an early childhood practitioner working at a participating pilot site; iii) aged 18 years and over; iv) currently reside in the state of Victoria or New South Wales, Australia; and v) feel comfortable completing questionnaires and program materials in English.p < .05, with 80% power. To account for parent participant attrition, we aim to recruit approximately 480 parents.Power analysis was conducted using the G*Power 3.1 software to determine the required sample size for this study . A singlWe aim to recruit 48 practitioners, consisting of 24 MCH practitioners from Universal MCH services, and 24 MCH practitioners from high-risk Enhanced services. These practitioners will in turn recruit the above-mentioned 480 parents.for Practitioners MCH nurse and perinatal mental health networks, ensuring a representative sample of MCH nurses and specialist perinatal and infant mental health clinicians from differing Australian geographic locations. Participating sites will include four Victorian and New South Wales metropolitan LGAs and four Victorian and New South Wales regional/rural LGAs, based on pre-existing profession networks. To further ensure representativeness, recruitment will include healthcare practitioners from the Universal and Enhanced MCH services, and from specialist perinatal and infant mental health clinics. All participating practitioners will provide online consent to their study participation.The authors will recruit through their existing MERTIL for Parents and the associated research project, and if the parent verbally expresses interest, practitioners will direct them to the MERTIL for Parents website to register for the study and to access the materials (www.mertil.com.au). Practitioners will provide parents with a printed flyer with MERTIL for Parents details to aid this process. For parents who verbally agree to participate, practitioners will follow-up to gauge parents’ program responses.Parents who meet inclusion criteria will be informed about the study by their MCH practitioner during a visit to a Universal MCH service , or from any Enhanced MCH service engagement . The practitioners will explain MERTIL for Parents website to join the research. Specifically, parents will be met with a webpage popup with a brief research overview and the option to hear more about the study. If parents select to hear more about the research, they will then be automatically prompted to enter their first name and email address. This will trigger access to an explanatory statement of the study and the option to consent to the research. Once the completed forms are submitted, parents will be invited to participate in a brief 10-minute pre-program baseline survey. Completing this survey will grant parents access to the MERTIL for Parents program.During the study pilot phase, parents recommended to the program will go to the MERTIL for Parents. This session will provide a study overview to promote program and pilot study familiarisation. Immediately following this session, practitioners will be asked to complete an online survey to report their first impressions of MERTIL for Parents regarding factors such as perceived program content, length, and suitability.Following informed consent, practitioners will attend a 120-minute web-based information and training session on MERTIL for Parents. This follow-up contact will be via an informal face-to-face chat, phone call, or email. Once practitioners have recommended the program to parents, they will be invited to complete a second survey. This final practitioner survey will assess views on program usability, impactfulness, engagement, and ideas for program refinement and wider implementation. Online focus group interviews will follow to elaborate on survey responses, assess practitioner views and experiences of the program, potential barriers to implementation, and to identify further uses and applications of MERTIL for Parents. These elements will ensure MERTIL for Parents’ co-designed nature endures. See Practitioners will be asked to make contact with parents they refer to the program, within two weeks of recommending MERTIL for Parents website will be welcomed to the pilot study. Recommended parents will be invited to read more about the study. If they consent, these parents will provide their contact details, agreeing to view the study’s explanatory statement and, if they wish, to complete the content form. Once complete, the pre-program parent survey will appear. Parents who arrive at the website, but who were not recommended to the program by their MCH practitioner, will be informed that the program is currently not widely accessible, but will be available to all following the current testing phase.During the study pilot phase, recommended parents who arrive at the MERTIL for Parents program. Participants will have program access for 2 months from consent completion. Immediately upon MERTIL for Parents program completion, Survey 2 will be available (5-minutes). Three-months after completion of MERTIL for Parents, a follow-up survey (10-minutes) will be sent to explore sustained change. As needed, survey reminders will be sent via email at 7- and 14-days after the initial survey. If participants do not complete surveys after these communication bids, no further contact will be made. Consenting parents will participate in a qualitative interview, to further identify their program lived experience, as well as program strengths and weaknesses. See The brief parent surveys before, immediately after, and at 3-months follow-up comprise two sections: i) close-ended questions, and ii) open-ended questions. Upon completion of Survey 1 (10-minutes), participants can access the MERTIL for Parents will be free of charge to recommended parents and caregivers who choose to participate in the research. Following this piloting phase and program refinement, MERTIL for Parents will be made broadly available.During this research and piloting phase, MERTIL for Parents in enhancing socioemotional development. Secondary outcomes include evaluating the feasibility of implementing MERTIL for Parents within Victorian and New South Wales MCH services.Our primary outcome will be to determine the efficacy of MERTIL Baseline and three-month post-program questionnaires. To evaluate program efficacy, participants will complete identical self-report measures pre-program and at three-months post-program  What was most helpful about MERTIL for Parents? This will be sent to parents via email with an attached secure link.Embedded within this study is an internal program evaluation consisting of multiple-choice questions and open-ended text-response questions. Specifically, upon program exit (data collection time two) parents will be asked to complete a five-minute survey relating to program usability and program satisfaction. Example questions asked include: i) for Parents website. This will record program engagement and completion elements such as i) program completion rates, ii) number of access occasions, iii) program components most/least accessed.Parents’ online program usage data will also be automatically collected via the MERTIL for Parents to, practitioners will be asked to complete a brief mixed methods online survey, allowing insight into practitioners’ perceptions of the program. Questions will include: i) Would you recommend MERTIL for Parents to future parents? ii) Would you recommend colleagues encourage future parents to participate in MERTIL for Parents? iii) From your perspective, does MERTIL for Parents fill a current preventative health gap? and iv) Are there any existing gaps in the MERTIL for Parents program? For each question response, options will be ‘yes’ or ‘no’, and then practitioner participants will be asked to expand upon their answer with free text.After practitioners hear from the parents they recommended MERTIL for Parents, four online Zoom-recorded focus groups will be held upon program completion. There will be two practitioner and two parent focus groups held. A subsample of volunteer practitioner and parent participants will join the optional focus groups with each group consisting of 4–6 parents or practitioners. A semi-structured interview schedule will guide focus group discussions. All focus groups will be audio recorded to allow for later transcription and analysis.To further examine the feasibility and efficacy of MERTIL Could you tell us about your MERTIL for Parents experience? ii) What was most relevant to you? iii) Can you see yourself in the future encouraging suitable parents to participate in MERTIL for Parents as a first intervention step? and iv) What are the long-term and short-term implications of programs such as MERTIL for Parents?Example focus group questions will include: i) Could you tell us what it was like to participate in MERTIL for Parents? ii) Since completing MERTIL for Parents, what, if anything, has changed in your thinking, or feeling, or in your behaviour as a parent? iii) In MERTIL for Parents, what was most relevant to you? and iv) Would you recommend MERTIL for Parents to other parents?Example focus group questions will include: i) All professional and parent survey data will be disseminated through Moodle, an online learning management system stored on a secure server, with data transferred securely for analyses. All study data and participant information will be stored securely as per the criteria required by the La Trobe University Human Ethics Committee.All statistical analyses will be conducted using the software IBM SPSS Statistics . DescripFocus groups. All parent and professional focus group interview data will be audio-recorded, transcribed verbatim, and deidentified. Thematic and content analysis will be used to identify themes and sub-themes from practitioners and parent transcript responses [esponses .Free-text surveys responses. For practitioner and parent free-text survey responses, thematic analysis will also be used to identify response themes and sub-themes.Pilot field studies, including recruitment and data collection, will commence in March 2023 with data collection concluding in June 2023.for Parents may not provide adequate content information and support . Second, as frontline services, practitioners may lack the time in session to explain and recommend parents to participate in MERTIL for Parents, due to competing demands and scheduling pressures. Third, as the study population pertains only to practitioners and parents located in Victoria and New South Wales, Australia, generalisability concerns will be present for interstate Australian and international populations. Fourth, as all MERTIL for Parents content is housed online, this may exclude those who lack the technology or skills to participate, especially as on-demand technical support will not be available for live participant trouble shooting. Further, because of this study’s non-randomised sampling strategy, cause-effect relationships cannot be drawn. That is, parents’ socioemotional outcome changes cannot be causally inferred by their MERTIL for Parents participation. Finally, as with all research, there is a risk that attrition rates may be high. All parent data will be self-report in nature, and interpretation of findings will therefore be subject to these limitations.While this study is innovative, we foresee several program content and delivery method limitations: Firstly, it is possible that the brief self-guided content of MERTIL There are multiple strengths to the present study: First, the mixed methods design of this study allows for greater understanding of the program’s impact compared with either qualitative- or quantitative-only designs. Second, diversity of parent demographics and needs will be ensured through recruitment of participants from both Universal and Enhanced MCH services, in both metropolitan and regional locations. Third, socioemotional-specific content may fill an important gap in the available online parenting program market. Fourth, the program’s reach is expected to be wide due to the online delivery method. Finally, strong completion is expected due to i) the program’s brief nature, ii) the engaging, non-judgemental, and supportive program content; and iii) the contribution of MCH nurses, infant mental health experts, and parents in co-designing the program.for Parents. Multi-informant data from parents and varied practitioners will inform future iterations of MERTIL for Parents and universal online relational programs.This study will examine implementation feasibility and efficacy of an evidence-based, online, universal, self-directed parenting program, MERTIL


The California Healthy Nail Salon Recognition Program is a statewide initiative to incentivize nail salons to adopt occupational health and safety best practices such as the use of safer nail products without certain harmful chemicals, ventilation systems upgrade, proper personal protective equipment use, and staff training. This public policy intervention is in response to the call to protect nail care workers, mostly women of color, who bear a disproportionate burden of chemical exposure at work. Because there is an interest to adopt a similar program in the Greater Philadelphia region, we conducted this formative research to document stakeholders’ perspectives on the feasibility of adopting a Healthy Nail Salon Recognition Program in Philadelphia.We conducted semi-structured interviews with a purposive sample of 31 stakeholders in Philadelphia in 2021. Using the Consolidated Framework for Implementation Science as our theoretical framework, we developed the interview guide and analysed the data using qualitative research methods to identify key facilitators and barriers.Key facilitating themes were perceived need and benefits of program to improve workers’ health and working conditions, and willingness of stakeholders to leverage their organizational resources. Barriers included perceived high cost and time commitment from salon owners and employees, lack of funding and implementation leaders at the city government, community members’ willingness to be visible and advocate for the program affected by the stigmas of being immigrant workers, and fear of interacting with authorities, as well as the impact of COVID-19 pandemic.Our results suggest successful adoption of a Healthy Nail Salon Recognition Program in Philadelphia will require outreach within the community to raise awareness of the benefits of the program and close partnership with community-based organizations to facilitate mutual understanding between the authorities and the ethnically diverse nail salon communities. Formative research about stakeholders’ perspectives and key facilitators and barriers to adoption is required prior to launching community-based, occupational health interventions. This study suggests that the successful adoption of the Healthy Nail Salon Recognition Program–a public policy intervention to improve working conditions for nail care workers–will require outreach within the community to raise awareness of the benefits of the program and close partnership with community-based organizations to facilitate mutual understanding between the authorities and the nail salon communities. Findings may inform future development of this policy intervention and advocacy effort from community organizers.Low-wage, precariously employed, minority nail care workers are an underserved community in the US . Safer aSince 2010, with the help of the California Healthy Nail Salon Collaborative, several local health departments in CA have implemented healthy nail salon recognition programs (HNSRP) to incentivize salons to adopt occupational safety and health best practices . Nail saThe Greater Philadelphia region is one of the most populous metropolitan areas in the US and has high concentration of Asian American communities and minority-owned nail salons. While there have been documented health needs in the nail salon community (We used the Consolidated Framework for Implementation Research (CFIR) as the basis for the design of this study. The CFIR incorporates a suite of constructs from the literature that have been associated with effective program implementation. The framework includes five domains  and constructs within each domain . In the n = 4), public health experts (n = 2), community leaders (n = 2), non-governmental organizations (NGO) community outreach workers (n = 2), cosmetology instructors (n = 2), nail supply store owners (n = 3), nail salon owners , and nail salon workers . The Vietnamese nail salon community was the focus of this study due to the high percentage of nail salons in Philadelphia that are owned by Vietnamese.We conducted semi-structured interviews with a purposive sample of 31 stakeholders in the Philadelphia area that included staff members in city and government systems (n = 7), phone calls (n = 18), and in-person visits (n = 6). We conducted 10 interviews in English and 21 in Vietnamese.We identified potential interviewees from publicly available online information on governmental websites, referrals from our community advisory board and our community partner Vietlead , and in-person outreach. We recruited participants via emails (n = 25) and in-person interviews (n = 6) were recorded, translated into English if needed, transcribed, de-identified, and stored in a secure digital folder until the analysis.After agreeing to participate, participants received either an electronic or a physical package that included basic information about the California HNSRP, how to participate, and the criteria to be certified as a healthy nail salon. They also received the interview questionnaire in advance. Our bilingual Vietnamese research team members conducted all the interviews. All phone  employee said:The workforce has limited English proficiency and limited information about what we can do for protection. They might not know what the process is and what their rights are to make that complaint, but as you know in Philadelphia there are a lot of salons… There’s a good amount of work and workers that would need that intervention to make sure that they have proper safety measures at the workplace.Moreover, most participants believed the program would incentivize employers to improve the work environment and being a recognized ‘healthy nail salon’ can also have a positive impact on the salon’s public image and attract more customers. One owner expressed, ‘It helps the owners protect their workers better and protect the customers and the environment.’Most participants  endorsed the program and expressed interest in being involved in the adaptation and implementation of the program in Philadelphia. All of the interviewees believed the program would require hand-in-hand collaboration between the city and the community. When asked about how each stakeholder could play a role in making this initiative happen, many respondents believed either the city’s health department or labor department could take the lead. One city official expressed, ‘Philly is a big union town, so worker rights are very well understood. The labor office is where we should start.’ The director of a grassroots organization for working-class Asian communities said:It would be great if our organization can be part of [the program]. Let’s say the Office of Labor receives city funds to hire a staff member that supports the certification of this program. They could work with community-based organizations like us, which lead to putting together a training program that nail salon owners and workers must go through and commit to implementing these steps. And then you can get city recognition as a certified healthy nail salon. Once that certification happens and the Office of Labor needs to periodically check in to ensure that the practices are in place… and that could also happen with the support of a community-based organization that has established those relationships with those new clients.Most interviewees acknowledged the need for investment in the immigrant nail salon worker community and perceived the program to be a necessary step to create trust and partnership between the city and the community. From the public health perspective, the program was believed to have a powerful impact in facilitating a better understanding of the issues the community is facing and thus would help address the current health disparities and social inequities. A city goverment’s public health expert said:[The program] will help us better understand the health disparities and gaps and negative health outcomes and negative working conditions. What are the biggest issues that are impacting this community and how are they impacting them? It will help us improve health outcomes and hopefully address the health disparities in the nail salon worker community in Philadelphia. I do not think anyone else is going to do it.This initiative can also pave the way for future public health programs and workers’ rights initiatives, as well as community development and empowerment projects. A city official said, ‘The program can assist with community engagement and help the nail salon community feel like they are an important part of the larger Philadelphia community and help people feel like they are prioritized.’ A state official also said, ‘It’s important for the city of Philadelphia, and for the state to know how diverse our communities are and for us to develop programs that can impact that through workplaces, where people get their livelihoods, and we want these communities to be safe at our workplaces.’ One public health expert said, ‘The program might help members of that community to become more empowered to take charge of their own health or to be advocates, or to be more engaged in community level work, community policy, things like that.’ This also translates into the development of projects to empower immigrant-owned, woman-owned small businesses and uplift the entire working-class, immigrant community.Cost and time commitment are the biggest barriers for many owners and workers to participate in the program. Most nail salon workers interviewed work 5–6 days a week, 9–12 h a day, and reported not having time for continuing training and professional development. They said they would be much more likely to participate in the training if it were paid. One salon worker expressed:I think the first is income. If people have enough money to provide for their family, they will have the peace of mind to work. But now they can’t even make the basic income, how can they think about anything else? If they make enough money, they may want to talk with you. But now their income is too low, all they care about is compete for customers, they would not have time for you.Several salon owners acknowledged the benefits of the program and their willingness to change their salon’s environment and working habits but considered the costs to upgrade their nail salons to meet the certification standards to be a prohibitive factor. They expressed concerns that switching to safer products with less harmful chemicals and upgrading the ventilation systems would cost them a lot of money. Most owners said that their family business had already been operating at a very narrow profit margin. Therefore, increased costs could be detrimental to their businesses. An owner expressed, ‘It will be hard for us because we will have to pay more and take care of more things and it will be more restrictive for us to do business.’The program was perceived by some stakeholders as ‘complex’ given language and cultural differences that need to be overcome. Some said it could come across as ‘too niche to be funded’ given the issues in this industry not being well-known at the city level. A director of a community organization said, ‘I think the service industry in general is overlooked by the city… There’s very, very little attention paid to language access. If there was ever a recognition program that was rolled out with language access, primary language access must be at the forefront.’ A state official also expressed concerns about funding sources for this initiative:A potential barrier is that it would seem so specific that it will not be impacting a larger workforce that people will feel like it is too niche to fund. It is about placing the program and how it permeates various aspects of the Philadelphia economy. It would be helpful for people to understand the importance of the program situated within the bigger context.Others disagreed that the program is ‘niche to be funded.’ One participant said:It’s not that the program is niche to fund, but I think there got to be larger education around the nail salon industry, who owns it, how it operates and the work safety standards that need to be implemented or discussed. It’s an issue with education around this workforce at the Philadelphia level in terms of city council and the city offices to learn about the importance of this. It would be good to analyze how these programs came to be in terms of funding, both at the city level but also at the state level. It will be good to present what happened in California with Santa Monica and San Francisco to try to figure out how other states support the implementation of this and having that history will help inform some of the State senators and the House representatives.Language assistance and partnerships between the city and community organizations need to be established at the forefront for the program to be successfully implemented. Ongoing financial and technical support is also needed at every step of the process of planning, implementation, and evaluation.Policy expert participants emphasized the importance of the community’s visibility in pushing forward the adoption of the program at the city level. One city official expressed:I think once you’ve gotten those numbers together, build some momentum behind those numbers, increase the visibility of the program, hold town halls or community hearings or go to City Hall. Visibility is going to be important, but it can be difficult for people to step out in the spotlight. Data along with people showing up to be visible will be helpful in getting people to pay attention.However, the community’s buy-in for the program was affected by an overall lack of awareness of the program. A community organizer said, ‘The barrier for this program is it’s too new so the owners may not be willing to be open-minded. They may understand this issue is important, but the owners and workers are already used to their own ways of doing things. They do not want to change. They don’t think it’s important enough for them to participate.’The community’s willingness to be visible and advocate for the program was also affected by the stigmas of being immigrant workers, fear of interacting with authorities, and lack of trust in the government, as well as the impact of COVID-19 and the associated anti-Asian sentiment. A community leader said, ‘You’re talking about an industry that is mostly comprised of immigrant workers and immigrant small business owners. There are a lot of stigmas to show up to those kinds of things and a lot of mistrust.’ Another community member mentioned the fear of interacting with the authorities eloquently through what he witnessed with his mother, a nail salon worker. He said:You know, my mom is a nail salon worker. All her friends are. When we moved here from Vietnam, we know that is the only thing. If you are a woman and you are Vietnamese immigrant, that is one of the three things you can do. The other two are working in a restaurant or working in a factory, where any of those spaces are also equally exploited. My folks do not speak English and immigrants are afraid of stirring waves and contacting with authority. They just put up with it. My mom was exploited her whole life. But every time I am like ‘you should put a complaint’ and she is like ‘no.’ She does not want to make waves. She does not want to be the one who snitched out… It is just a big shame to have it happen to her in the first place.All the interviewees from the community emphasized the importance of making the intention of the program clear from the beginning and educating the community on the benefits of the program to improve buy-in and encourage participation. One nail salon worker said, ‘You should make it clear that this program is designed to help them and the community, not to report anybody.’Despite the endorsement of the program from many stakeholders, there was no clear consensus on who should be the implementation leader of the program. This is a critical missing piece because the program’s transdisciplinary nature requires an implementation leader to act as a liaison to bring various city departments together to work with the community. According to the interviewees, one of the reasons for this lack of clarity is those city departments, such as the labor department, the health department, and the Licensing & Inspection department, often work in silos with a narrow margin of funding on their own, which makes it challenging to create and manage new collaborative projects. To address this issue holistically, these departments need to work together and community organizations can organize to force the city to pay more attention to these issues.Moreover, the interviewees emphasized the importance of enrolling the ‘actual people’ at the city level on boards to be the champions for the program. One city official said, ‘It depends on who is leading. Philly is a town where it is less about the organization or the name of the organization and more about the actual person. It sucks because then, if the person leaves, there is really no permanence. It can be excellent one year and then not the next year.’ Interviewees also expressed concerns about the sustainability of the program and agreed that one of the city departments needed to house it as an official program, where they could allocate ongoing staff time and resources.The purpose of this study was to bring various stakeholders’ voices to the discussion about potential public health policies to improve the work environment for nail salon workers, a community traditionally underserved in Philadelphia and in the US. One of the key barriers was the lack of buy-in and visible advocacy from the community, which stems from lack of awareness of the program and fear of stigmas of being immigrants. Most nail salon workers are immigrants and refugees . More edAnother barrier was the lack of government funding. This partly stems from lack of awareness of the issues at the city level and the overall underinvestment in this community. Public health literature refers to this phenomenon as ‘structural invisibility,’ society’s privileging and paying more attention to some social group over others, or simply ‘you cannot fix what you don’t see.’ (The program was also perceived as providing better strategies for participatory nail salons to advertise for their business and attract customers. Future research on social marketing could be explored to gain insights into how the HNSRP can impact the public image of nail salons and into ways to support salons to leverage this as a marketing tool. According to many salon owners and workers in the study, local nail supply stores also play a critical role in the success of the intervention given that they are the source where salon owners and workers purchase nail care products and supplies for their salons. Outreach and collaboration with local nail supply stores may also facilitate the program’s uptake.Perceived challenges related to the cost to buy more expensive alternative products, and implement engineering controls, or the time commitment for staff training are not unique to the nail salon industry but well-documented challenges for small businesses in general (Our study has several limitations. The first limitation is the inclusion of stakeholders who speak English or Vietnamese only. While Vietnamese Americans make up a large majority of the very racially and ethnically diverse nail salon workforce (Despite these limitations, the strength of our study is the diverse voices that we were able to bring together to shed light on ways stakeholders could work together to promote health and well-being of an underserved worker community through public policy. Local policymakers, public health practitioners, and community organizers may find our findings useful to inform their next public health programming and/or advocacy strategies. As a continuation of this work, we plan to collaborate with the CA Healthy Nail Salon Collaborative and local health departments that have such programs to identify lessons learned. While our study’s focus is in Philadelphia, various aspects of our findings may have relevance for other municipalities across the US that may contemplate the adoption of similar voluntary programs to meet the needs of the nail salon workforce within their states and preserve the economic stability of small businesses. This type of study may be replicated in other geographic locations to better understand the local political landscape and the level of engagement from CBOs to address the issue in a more sustainable way.We used the CFIR framework to identify key facilitators and barriers to implementing the HNSRP in Philadelphia. The success of this program and many other community-engaging public health interventions, depends on the awareness of the complex underlying social factors that influence the community’s willingness and capacity to participate, effective collaborations between various key players in the public and private sectors, relationship-building between the state and the communities, as well as secured funding for language assistance and community outreach.


On February 6, 2023, a formidable earthquake registering 7.7 on the Richter scale struck the Pazarcık district of Kahramanmaraş province. Mere nine hours later, a second earthquake with a magnitude of 7.6 shook the same region, resulting in a substantial loss of life and extensive destruction. The impact of these twin earthquakes was severe, prompting the declaration of a state of emergency in ten affected provinces. Furthermore, the World Health Organization (WHO) classified the situation as a Level 3 Emergency . AccordiAccording to the Field Observation Report from the Disaster Commission of the Emergency Medicine Association of Turkey (EMAT): In the regions affected by the earthquake, there was a notable upsurge in patient admissions, particularly in the immediate aftermath of the seismic event . As a coThe earthquake resulted in significant damages, including widespread impact on health facilities in ten provinces. Turkey devised two strategies to address the extensive devastation. The first approach involved dispatching both national and international health aid, comprising healthcare workers and essential equipment, to the affected provinces. Additionally, injured individuals were transferred from the damaged regions to healthcare facilities located outside the disaster area. However, due to the large size and high population density of the earthquake-affected zone, Turkey had to implement three distinct transportation measures: transportation of healthcare workers, evacuation and transfers of injured individuals, and transportation of essential medical equipment Table .Step: Providing transportation for health care workers. The earthquake occurred on February 6, 2023, at 04:17. In the immediate aftermath of the seismic event, the advance medical response teams  promptly mobilized via roadways. Despite the establishment of multiple routes, accessing the earthquake-affected regions proved challenging through most of the road network. Several factors contributed to disruptions in road traffic in the days following the earthquake: 1) The damage inflicted by the seismic activity on the road infrastructure, 2) The snowy and cold weather conditions typical of February, and 3) Efforts by civilians residing outside the disaster zone to reach their affected relatives using private vehicles. Health personnel faced the necessity of frequently altering their road routes to reach the disaster-stricken areas. Furthermore, the earthquake caused damage to numerous roads, overpasses, and underpasses, while the harsh winter conditions also impeded transportation on unaffected roadways. To facilitate the timely access of health workers to the earthquake-affected areas, authorities adopted an early strategy that involved employing military and civilian air transport options.Step: Transportation of medical equipment. The main mode of transportation for medical equipment and supplies to the earthquake-affected regions was via road, complemented by the use of air transportation support. The introduction of personnel transportation to the disaster-stricken areas through air travel not only eased the transportation of medical supplies by road but also played a pivotal role in the timely procurement of essential materials for disaster relief.Step: Evacuation and transfers of injured patients. Turkey had to devise an unconventional transportation approach, rarely encountered in the disaster literature. To manage the influx of earthquake-affected patients from seven severely damaged provinces, three major cities , which experienced lesser damage in the disaster, were transformed into Transport Health Centers. These patients were transported to these centers by land, air, and sea and subsequently treated in hospitals resembling field tents within the Transport Health Centers. During the initial stages, patients received primary treatment and were airlifted to distant provinces. According to officials, this strategic approach facilitated the transfer of a total of 1715 patients to hospitals in various cities via airplanes and helicopters in response to the earthquakes centered in Kahramanmaraş. (Fig. In the event of a significant disaster, the implementation and advancement of “Transport Health Centers” as a transportation model should be both utilized and further developed. The invaluable lessons gleaned from past disasters enable societies to enhance their preparedness for future calamities, encompassing both earthquake-related disasters, actions to be undertaken during seismic events, and the streamlining of healthcare service delivery in the post-earthquake aftermath , 4. Cons


Since the launch of the National Diabetes Prevention Program (DPP) in 2010, more than 3,000 organizations have registered with the Centers for Disease and Control and Prevention to deliver the program; today, however, only approximately 2,000 organizations are registered, indicating challenges with sustainability. We used the Program Sustainability Assessment Tool (PSAT) to explore patterns of sustainability capacity among National DPP delivery organizations.We used data from a cross-sectional online survey conducted in August and September 2021 of staff members (N = 440) at National DPP delivery organizations. We conducted a latent profile analysis to identify latent subpopulations on the basis of respondent PSAT domain scores. Regression analyses were used to estimate associations between derived latent classes, PSAT scores, and respondent characteristics.The 4-class model included 4 groups of capacity for program sustainability, ranging from low to high: low (class 1) with 8.0% of the sample, medium-low (class 2) with 22.0%, medium-high (class 3) with 41.6%, and high (class 4) with 28.4%. Program evaluation (mean score = 5.1 [SD = 1.4]) and adaptation (mean score = 5.3 [SD = 1.3]) were the domains with the highest scores, while funding stability (mean score = 4.0 [SD = 1.6]) and Partnerships (mean score = 4.0 [SD = 1.7]) had the lowest scores. In our sample of National DPP delivery organizations, most reported relatively high capacity for program sustainability, and key indicators associated with sustainability capacity were virtual delivery, location of delivery, funding sources, and organization type.Similar to sustainability capacity findings from other PSAT studies, our study found that funding stability and partnerships are areas to strengthen. This insight is useful in sustainability planning at organizational and national levels across multiple programs. The Program Sustainability Assessment Tool is used by health promotion programs to improve sustainability planning. Many organizations deliver the National Diabetes Prevention Program (DPP), but research on this program’s sustainability is limited.National DPP respondents were classified into 4 groups by level of sustainability capacity and the key indicators associated with sustainability capacity: virtual delivery, location of delivery, funding sources, and organization type.The National DPP and other chronic disease prevention programs can use our findings to support the use of the Program Sustainability Assessment Tool to assess capacity of National DPP delivery organizations and other programs and as a first step toward sustainability planning.In 2020, an estimated 96 million adults in the US had prediabetes, a diagnosis that indicates a person is at risk for developing type 2 diabetes . For 20 and sustained  framework’s domain of maintenance  . The stuA movement has begun in recent years to better define, operationalize, and measure sustainability of evidence-based public health programs ,12,13. TLatent profile analysis (LPA) is a statistical method that focuses on identifying subpopulations within a population based on a certain set of continuous variables into mutually exclusive groups or classes, called “latent profiles” ,16. The The objective of this study was to explore patterns of program sustainability capacity among organizations delivering the National DPP by using the Program Sustainability Assessment Tool (PSAT), to understand whether organizations can be categorized into distinct groups based on dimensions of their sustainability capacity and if those groups are associated with specific organizational characteristics. The findings from this research have the potential to support National DPP implementation by providing an understanding of sustainability capacity strengths and weaknesses across different organizations as well as recommendations for capacity building for sustainability at National DPP delivery organizations.This study used data from a cross-sectional online survey conducted in August and September 2021 of staff members at National DPP delivery organizations. The sample included staff members in the following key roles: lifestyle coaches, master trainers, and program coordinators. This study was reviewed and determined to be exempt by the Emory University Institutional Review Board (STUDY00002611).https://sustaintool.org/psat), and 38 Likert-scale items from the Consolidated Framework for Implementation Research (https://cfirguide.org/). Of the 23 items on respondent and organization characteristics, we analyzed 4 items of respondent characteristics  and 12 items on organizational characteristics: 1) recognition in CDC’s Diabetes Prevention Recognition Program (DPRP); 2) length of program delivery, in years; 3) enrollment (the number of program participants enrolled to date in DPP); 4) the number of lifestyle coaches on staff; 5) the number of staff members who are not lifestyle coaches; 6) the number of staff members who are 100% dedicated to the National DPP; 7) type of organization; 8) size of organization; 9) program delivery mode ; 10) location , 11) racial and ethnic composition of program participants; and 12) National DPP funding sources. Because of the large number of variables for respondent and organization characteristics and small sample sizes for some categories of race and ethnicity, we aggregated data to compare organizations that serve either White-only populations or non–White-only populations to understand differential reach to these audiences. This study focused on the analysis of the delivery organization characteristics and the PSAT items. We did not analyze data from the Consolidated Framework for Implementation Research.The survey instrument included 107 items: 23 items about the respondent and the respondent’s organization, 40 items from the Program Sustainability Assessment Tool . Domain scores are averaged and provide a PSAT score of 1 to 7, which indicates the level of sustainability capacity. The higher the score, the greater the sustainability capacity. The PSAT has been tested for psychometric properties in trainings and evaluations with more than 550 people and more than 250 unique programs at state and local levels ,20. ReliStudy participants were recruited from the National DPP implementer population at Emory University’s Diabetes Training and Technical Assistance Center (DTTAC). In the past 10 years, DTTAC has directly trained more than 5,000 lifestyle coaches representing more than 2,000 organizations across all 50 states. The survey was distributed to an email contact list of 6,470 National DPP delivery organizations that have participated in Emory’s DTTAC programs or subscribed to the DTTAC newsletter. The first 336 respondents received a $15 Amazon gift card for their participation. After data cleaning for completion, we included 586 responses (9% response rate) in the analysis. Of those 586 respondents, 440 (75%) had a calculable PSAT score. According to PSAT instructions, averages are totaled and nonresponse items are excluded; in other words, we excluded respondents who did not respond to PSAT items. PSAT scores can be calculated by answering one or more of the items. Of those who responded to the PSAT questions, an average 35  of 40 questions were answered, and response completion ranged from 1 to 40 items.2 and t tests to detect significant differences between groups. The level of significance was set at P <.05 for all analyses.Data were exported from Qualtrics and analyzed by using SAS software version 9.4 (SAS Institute Inc). After data were cleaned, we ran standard descriptive statistics . We scaled (divided by 100) the enrollment-to-date variable to assist with comparisons across other variables after removing 4 outliers above the 99th percentile. We compared respondents with and without a PSAT score; we used χPSAT item internal consistency. We calculated the means and SDs for all 40 PSAT items along with domain averages and the total PSAT score average. We calculated Cronbach α for all domains and the total PSAT score, measuring the internal consistency of the items within each domain scale and the domains together to form the PSAT score.LPA. LPA is a person-centered approach that classifies respondents into mutually exclusive profiles, groups, classes, or clusters  to run a succession of 8 models. Cases with missing items were estimated in Mplus by using full information maximum likelihood. The selection of the best model included reviewing the fit indices and information criteria; latent class proportions and sizes; and the researchers’ interpretation and entropy of the latent classes. All entropy values in the models run were greater than 0.85. After review of fit indices, class proportions, and the visual profiles of each, we selected the 4-class model as the best fit and most meaningful output of class proportions.To estimate associations between derived latent classes and organization characteristics, we conducted multivariable multinomial logistic regression using class 1 (low sustainability score) as the reference group. Respondent organization characteristics in the multivariable multinomial logistic regression included the following variables: the number of program participants enrolled to date, staffing , organization type, organization size, program delivery mode, location, programs with White only and non-White only populations enrolled, and National DPPP funding sources. The final sample for the multivariable multinomial logistic regressions included 259 respondents, which was smaller than our sample of 440 respondents to the PSAT questions because of data missing at random.To gain a better understanding of relationships between variables and compare with the LPA results, in addition to the LPA, we conducted bivariate and multivariable regressions for all key organization characteristic variables with the PSAT score as the outcome. We calculated Pearson correlation coefficients for variables that captured similar dimensions (multicollinearity). For the full multivariable regression model, we combined variables  or eliminated variables  on the basis of degree of correlation and theoretical overlap with other variables. The final multivariable regression model included 21 variables for organization characteristics.After reviewing patterns of missing data, we concluded that data were missing at random, that is, missingness was related only to variables that were collected. We used multiple imputations in SAS software version 9.4 to handle data missing at random for the enrollment (30% missing) and organization size (20% missing). Twenty-one variables on organization characteristics from our main analysis plus 4 auxiliary organization variables related to missingness  were added to the imputation model. We used the fully conditional method to handle the continuous, ordinal, and dichotomous variables. We created a total of 10 imputed data sets and compared these results with the original regression model and the LPA multivariable multinomial logistic regression.Of the 440 survey respondents with a PSAT score, 399 (90.7%) were lifestyle coaches, 387 (88.0%) were women, 264 (60.0%) were White, and 288 (65.4%) were aged 35 to 64 years . Most 5. The mosMost (78.0%) respondents reported offering programs in some type of virtual mode . Respondents reported mostly enrolling White (67.7% of respondents), Black (48.4% of respondents), and Hispanic or Latino (33.4% of respondents) populations. Respondents indicated that their organization was primarily funded or supported by grants (41.6% of respondents), state or local government (23.4% of respondents), or the federal government or CDC (22.5% of respondents) .P =.003) for the National DPP . Almost all  respondents who did not complete the PSAT also did not answer the demographic questions, which were at the end of the survey, indicating they simply did not complete the survey.When we compared the 440 respondents with a PSAT score with the 146 respondents who did not answer the PSAT items, one significant difference was that respondents with a PSAT score were significantly more likely to be program coordinators  scores for individual items in the PSAT instrument ranged from 3.6 (1.9) to 5.6 (1.4) . All iteThe model consisted of 4 classes with mean domain scores that ranged from low to high: class 1 had low program sustainability (8.0% of the sample), class 2 had medium-low program sustainability (22.0% of the sample), class 3 had medium-high program sustainability (41.6% of the sample), and class 4 had high program sustainability (28.4% of the sample) .That we found no distinct patterns among classes indicates that all 8 PSAT domains were consistently scored across capacity levels, strengthening the evidence for internal consistency of the PSAT score, which is the average of all 8 domain scores. All organizations, despite capacity level, tended to have the same areas of strength and weakness. Program evaluation and adaptation had the highest scores in all classes across the model, whereas funding stability and partnerships had the lowest scores. This pattern matches the pattern of domain averages in the raw PSAT scores , furtherIn the regression analyses of data from 259 survey respondents, compared with the class with low program sustainability (class 1), all other classes had on average 5.68 times  greater likelihood of having obtained grant funding to support their National DPP . Compare t = 3.21; P =.001) and rural location  were significantly associated with PSAT score  , not on Program evaluation and adaptation domains had the highest average scores in our sample, which may be explained by the robust standards and guidance provided by CDC’s DPRP. Many delivery organizations are familiar with collecting and analyzing their program data to submit to CDC to maintain their recognition status. Likewise, CDC has promoted various program adaptations to ensure the lifestyle change program curriculum is effective in the communities and populations where they are implemented. The National DPP’s Customer Service Center also provides technical assistance resources for tailoring program elements for various situations.The LPA classes with higher program sustainability capacity (classes 3 and 4) rated the organizational capacity and communications domains highly. Findings were similar in other sustainability frameworks and studies . The orgOne way in which organizational capacity strengths can be seen in our sample is through technology and staffing for virtual delivery. Before the COVID-19 pandemic, only a small number (121 in 2019) of organizations were offering the DPP program virtually ; today, Overall, organization type did not appear to influence sustainability capacity. In our multivariable multinomial logistic regressions of the 4-class LPA model, government and academic organizations were positively associated with the highest capacity class (class 4), which may indicate some benefit of being a government agency or academic institution when considering the long-term delivery and maintenance of the National DPP. Perhaps the staff may have more opportunities and capabilities  to receive funding at these types of institutions. Government agencies, such as health departments, also receive chronic disease funding and technical assistance, which may also affect their sustainability capacity. However, the lack of significant relationships between organization types and sustainability capacity supports CDC’s vision that a wide variety of organizations can deliver the National DPP. More research with a larger sample of National DPP organizations should be used to examine sustainability outcomes  based on organization type.The National DPP and other chronic disease prevention programs can use the findings of this study to support using the PSAT to assess sustainability capacity of their programs and as a first step toward sustainability planning. Future research can build on this work by using the PSAT to assess sustainability capacity at the point of program adoption and how well the measure can predict long-term sustainability outcomes . Providers of implementation technical assistance can also use the PSAT as the first step in an intervention to build sustainability capacity to help organizations with low PSAT scores. People providing technical assistance should pay particular attention to low levels of funding stability and help organizations secure new funding before current sources expire. Lastly, our study found that the National DPP program coordinator was more likely than respondents in other staff roles to complete the PSAT assessment. This finding indicates that the staff in the program coordinator role may be most able to complete organization-level assessments and should be engaged in sustainability planning and these types of studies in the future.Strengths of this study include the use of the PSAT, a reliable measure for sustainability capacity with a large and diverse sample of National DPP delivery organizations. Although we had problems with missing data, we used multiple imputation methods to account for these data and draw meaningful conclusions. Another strength includes the large number of organizational characteristic variables used to study associations with program sustainability capacity scores. One limitation is that we recruited our sample from Emory’s DTTAC contact list; differences between this group and the larger National DPP population of implementers may exist because of resources the Emory group may have received from Emory University. We were also unable to accurately assess whether multiple people from the same organization completed the survey because of inconsistencies in how respondents provided organization names. We acknowledge that this limitation may have resulted in cluster effects. However, upon review of the organization names provided, more than 70% of the data included 1 respondent per organization listed. This large proportion of singletons in the data indicates that clustering cannot be adequately accounted for through methods such as a random effects model because of biases in the random effects estimation . An oppoThe incomplete information on organization name highlights another limitation: the inability to use data directly from the CDC DPRP database due to the federal government’s data use restrictions. Because of these restrictions, we relied on respondents to self-report their organizational information, which was not always complete, even after our attempts to follow up with respondents with missing data. For future studies, we hope researchers will have increased access to CDC DPRP data to better evaluate these implementation science questions at the national level.We used the PSAT to describe the sustainability capacity of National DPP delivery organizations. Understanding sustainability capacity is important to help program implementers with program planning, delivery, and scaling. Maintaining a program over time allows for growth and evolution within an organization in ways such as increasing program offerings, participant enrollment, and reach to new populations . Increas


Stingless bee honey (SBH) is a natural remedy and therapeutic agent traditionally used by local communities across the (sub-)tropics. Forest SBH represents a prime non-timber forest product (NTFP) with a potential to revitalize indigenous foodways and to generate income in rural areas, yet it is also used in a variety of non-food contexts that are poorly documented in sub-Saharan Africa and that collectively represent a significant part of the local traditional ecological knowledge (TEK) passed on across generations. Documenting TEK of local communities in African tropical forests facing global change is a pressing issue to recognize the value of their insights, to evaluate their sustainability, to determine how they contribute to enhancing conservation efforts, and how TEK generally contributes to the well-being of both the natural environment and the communities that rely on it. This is particularly important to achieve in Kenya’s only tropical rainforest at Kakamega where SBH production and non-food uses have evolved and diversified to a remarkable extent.We used ethnographic techniques and methods, including semi-structured questionnaires and recorded interviews. We used snowball sampling, a non-probability sampling method where new interviewees were recruited by other respondents, to collectively form a sample consisting of 36 interviewees (including only one woman).Our results indicate that local communities in Kakamega were able to discriminate between six different and scientifically recognized stingless bee species, and they provided detailed accounts on the species-specific non-food uses of these SBH. Collectively, we recorded an array of 26 different non-food uses that are all passed on orally across generations in the Kakamega community.Our results uncover the vast and hitherto unexpected diversity of TEK associated with SBH and pave the way for a systematic survey of SBH and their non-food uses across a network of communities in different environments and with different cultural backgrounds in the Afrotropics. This, along with parallel and more in-depth investigations into honey chemistry, will help develop a comprehensive understanding of SBH, offering insights into holistic ecosystem management, resilience and adaptation while in the mid- to long-term promoting cross-cultural exchanges and pathways for the revitalization of cultural practices and traditions.The online version contains supplementary material available at 10.1186/s13002-023-00614-3. Uncovering the hitherto unexpected diversity of stingless bee honeys and their non-food uses in Kakamega Forest (Kenya).A total of 26 different non-food uses were recorded , some of which are species-specific to certain stingless bee species in this tropical forest fragment.Knowledge on the uses of SBH is ancestral and is shared orally across generations, with potential for cross-cultural exchanges as well as the revitalization of cultural practices and traditions.The online version contains supplementary material available at 10.1186/s13002-023-00614-3. The relationship between local communities and the forest in the Afrotropics is deeply intertwined, shaped by centuries of coexistence, dependence, and cultural significance. This relationship is multifaceted and encompasses ecological, social, economic, and spiritual dimensions that are key to rural livelihoods . TropicaApis mellifera, is one of these natural substances and has been gathered in Nature since ancient times [Worldwide, natural remedies derived from insects and their by-products have long been used in traditional or folk healthcare . Honey pnt times  and praint times . Interesnt times . Stinglent times  among otnt times .Meliponula bocandei produces up to 5 kg of honey; while M. togoensis produces 3 kg of honey and M. ferruginea produces 2 kg of honey. The cost of 1 kg of SBH in Kenya varies between USD 15 to USD 30 depending on either purchased from the local communities or urban areas, respectively. This, in turn, offers the potential to sustain livelihoods through diversification, to secure food and medicine provisions, to revitalize indigenous foodways and to safeguard TEK base in African (sub-)tropical forests [Non-food uses of SBH are particularly developed in East Africa, including in Kenya, where SBH is informally reported to be commonly used as medicine, food and in traditional rituals . In Keny forests , 14.In this study, we aim to contribute to the body of ethnobiological research by documenting and discussing TEK relative to (i) stingless bees (ii) their honeys and (iii) non-food uses of SBH by the local communities living around the Kakamega forest in Western Kenya. Our goal was specifically to investigate and characterize the diversity of non-food uses of SBH, with the perspective to hybridize our surveys with advanced analyses of honey chemistry across a wider network of communities and thereby develop a comprehensive understanding of SBH composition, variation and uses in the Afrotropics.The research took place in Kakamega Forest reserve  in Western Kenya Fig. , 40 km nicipe, Nairobi, Kenya), started working with local communities one decade ago to find ways to replace exploitative and destructive harvesting methods with well-designed hives and suitable stingless bee beekeeping management practices [Even though the forest represents a highly valuable source of food, wooden materials and herbal medicine for local communities, its area has been halved over the past few years because of unsustainable pressure on resources and a lack of environmentally-friendly and sustainable alternatives for local community income generation . To overractices . This exractices , 17.icipe, and we used the snowball sampling method [icipe’s network. Non-food uses of SBH were transcribed and recorded for each stingless bee species in an Excel spreadhseet  in March and April 2022 with questionnaire surveys and in-depth interviews, lasting up to one hour. Some interviews were performed in English, others required translation assistance provided by an in-between person fluent in English, Swahili, and Luhya. The survey  medicine provision (79%), (2) income generation (74%), and 3) food provision (74%), and the most domesticated species are  food proIn this study, we shed light on hitherto unexplored aspects of the Traditional Ecological Knowledge (TEK) associated with stingless bees and the non-food uses of stingless bee honey (SBH) in Kenya. In line with what has already been documented in other regions of the world –22, we rIn Kakamega, meliponiculture is often perceived as a predominantly male occupation, due to the necessity of leaving home and children for extended periods of time, venturing into the forest to find active colonies of stingless bees. The social and cultural norm in Kakamega includes a division of labor between men and women where the latter are responsible for maintaining the household and looking after children, which explains why only one woman was interviewed. In Kaijado County (Kenya), women are prohibited from transporting honey as beekeeping is considered a male-dominated activity , and ratM. ferruginea honey to treat wounds [M. bocandei and M. lendliana are preferred to heal skin problems. Additionally, SBH is commonly utilized for its potential in treating dysentery rather than for alleviating constipation in Kakamega. In Burkina Faso, honey  is also used to alleviate menstrual pain [M. lendliana is preferably used in that context. The well-established antibacterial and anti-inflammatory properties of SBH, as well as its ability to stimulates tissue regeneration, further contribute to its regular use in healthcare.Several applications of SBH mentioned by the respondents Table  are const wounds  and to at wounds , whereasual pain , but amoual pain . Similarual pain , 31 honeSBH is found to be a near-perfect Non-Timber Forest Product (NTFP); and in East Africa SB products (SBP) have been sourced since many decades from wild colonies using harvesting practice that destroy nest and therefore occasioning colony loses . CurrentBy emphasizing the need for greater focus on analyzing local social and cultural values associated with non-timber forest products (NTFPs), our study sheds light on meliponiculture as an activity that safeguards an important part of the cultural heritage shared within local communities. Meliponiculture is a way to sustain livelihoods, to secure food and medicine provisions, to revitalize indigenous foodways and to safeguard indigenous knowledge base in African tropical forests, while promoting a more sustainable use of natural resources. Beyond Name; age; genderAddress: county, village, GPS coordinatesAcademic levelOccupationPhone numberHousehold size + positionTribe/communityPersonal informationWhich ones?Local taxonomy (how you differentiate each species)Name in local language meaningDo you know stingless bees?Which species are mostly found in your area?Which species do you domesticate? Why?Are stingless bees important to you? Why?Traditional ecological knowledge on stingless beesDo you use stingless bee honey? For what? How? Taste characteristics?Where do you obtain these hive products from?When is the honey used? Special occasion? Daily?What role  do stingless bee honey play in your culture? Beliefs?Do you use other products of the hive? For what? How?Where did you get knowledge from? Who did you transfer this knowledge to?Have you ever heard of any other possible uses of stingless bee’s honey?Local knowledge and non-food uses of stingless bee honeySince how long have you practiced meliponiculture?Have you been trained on modern stingless beekeeping? If yes, by who?What are your motivating factors to do stingless beekeeping:How many stingless bee hives do you have in total?In which type of structure do you house the stingless?Where do you keep colonies that you domesticate?If baiting swarms, what method do you use?How do you obtain your starter colonies?What are the natural enemies and pests affecting your colonies?Are you facing any challenges in keeping stingless bees?Quantities of honey harvested per hive per species? After how many months?How do you conserve (storage) harvested hive products?Do you sell the products? If yes, how muchWhere are the products sold? Locally or out of Kakamega ?Who are your clients?How do you advertise your products? Online, mouth to mouth, radio, TV…Personal experience with stingless beekeepingAdditional file 1. Non-food uses of honey for each stingless bee species.


Immunosuppressive medication therapy after organ transplantation is essential for preventing transplant rejection and minimizing the need for re-transplantations. Nonadherence to immunosuppressant therapy has been identified as a major risk factor for acute complications and allograft rejection, as well as late graft rejection, and a return to dialysis after failed renal transplantation, leading to an increase in health care costs and potentially even death.To evaluate clinical and economic outcomes of a mandatory transplant specialty pharmacy program implemented for the membership of a national commercial health plan for post-renal transplantation patients, as compared with membership using traditional retail pharmacy services. This program was delivered by a designated specialty pharmacy, which met requirements for contracted rates and provision of clinical programs and services.The study is a 1-year retrospective claims analysis after the implementation of a transplant specialty pharmacy program that, in addition to medication dispensing, includes adherence and clinical management programs, patient education, and counseling services provided by transplant pharmacology experts. Renal transplant patients using the specialty pharmacy program were matched to those using retail pharmacies utilizing a propensity score-matching technique based on logistic regression. Primary outcomes were financial, which included pharmacy medication costs, medical inpatient and outpatient costs, and overall health care costs. Patient adherence to transplant medication therapy and health care resource utilization were also evaluated. One-year outcomes post-specialty pharmacy program implementation were compared between the two groups with t-tests for continuous variables and chi-square tests for nominal variables.After propensity score matching, 519 patients were identified per group for analysis. Baseline parameters were similar between the two groups. The mean total health care cost during 1 year of follow-up was 15% lower in the specialty pharmacy program group . Similarly, the mean transplant-related medical cost was 42% lower in the specialty pharmacy program group , with lower cost, although not statistically significant, in both the dialysis-related and the nondialysis-related costs. The transplant-related office visit costs  were significantly lower for the specialty pharmacy program cohort, while the inpatient and outpatient transplant-related costs were lower but not statistically significant in the specialty program. The weighted medication procession ratio (MPR) was higher ; the number of patients with a medication gap or who discontinued was lower  in the specialty pharmacy program members than in the retail pharmacy members.This specialty pharmacy program is associated with lower transplant-related medical costs and lower overall health care costs, as well as higher transplant medication adherence within the first year of evaluation. The positive impact of health plan program design and coordinated care and oversight by transplant pharmacology experts in a specialty pharmacy program has implications for the current health care reform and requires more research.