A Practical Guide to Intensity Modulated Radiation Therapy. Memorial Sloan‐Kettering Cancer Center (MSKCC) Staff, Medical Physics Publishing, Madison, WI, 2003. 450 pp. Price: $125.00. ISBN: 1‐30524‐13‐7.PACS number(s): 87.53.‐j, 87.53.Xd, 87.53.Kn It is challenging to review such a wealth of information and create a synopsis that tries to be fair as well as accurate. This book contains 19 chapters (over 400 pages) of information on IMRT Although the title identifies it as a “Practical Guide” and Dr. Samuel Hellman, in the Foreword, describes it as a “User's Guide,” understandably, there is a distinct emphasis on IMRT as practiced at the author's institution. If you consider the leading efforts of MSKCC in IMRT, any physicist or physician who is serious about delivering IMRT will want this book in his/her library.Although the book contains 19 chapters, I subdivided the book into three sections. The first section is eight chapters of “Introductory IMRT” and comprises about 50% of the book. It is more physics driven and basic, thereby serving as a reference for someone who wants to begin IMRT. These chapters contain definitions of IMRT terminology as well as the history for the ideology that has developed at MSKCC.The second section involves six chapters on the clinical applications of IMRT. The disease sites covered are prostate cancer, head and neck cancer, pediatric cancers, breast cancer, non‐small cell lung cancer, and cancers requiring large treatment fields. These chapters are filled with references to the works of others and the rationale for treatments at MSKCC. Most informative are the fine details regarding anatomy delineation that are frequently hard to extract from papers or talks as well as an honesty about the current status of unresolved issues. In addition the chapters contain excellent, succinct summaries.The last five chapters cover IMRT as an advancing technology. There are chapters on biological models, geometric uncertainty considerations, radiation protection, and advanced planning techniques. As these are current issues, they serve more as stimuli for thought rather than a finished product. I spent more time per chapter here than elsewhere.What will you not find in the book? Other ways and philosophies for doing IMRT! For example, you will find the chapters on optimization and treatment planning marginally useful if you do not use the MSKCC planning system, and you don't. While there are some generic discussions of multileaf collimators from all the vendors, the illustrative examples involve only the equipment at MSKCC. The same is true for the portal imaging system. I thought the book could have used a chapter on immobilization systems and the tricks associated with them.Since IMRT was a major undertaking at this massive institution, many different authors write the chapters. In three chapters I had to read about how to handle the tongue and groove effect of the MLC. In at least seven chapters the phrase “dose painting” was used, but in only one chapter was it stated that “dose painting” would not be implemented until technical issues were resolved. I suspect in later editions this type of disjointed compilation of writings will be smoothed and while annoying, it by no means lessens the value of this work as a reference book. In fact, as a ten‐year veteran of IMRT with only tomotherapy, I believe I will use this book frequently over the next few years and thank the authors for placing all this information in one book.


Introduction: A number of studies published by the World Trade Center Health Registry (Registry) document the prevalence of injuries sustained by victims of the World Trade Center Disaster (WTCD) on 9/11. Injury occurrence during or in the immediate aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent reports of ongoing physical health and mental health problems and overall poor quality of life among survivors led us to undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic exposure on quality of life in disaster survivors. Methods: Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported being injured on 9/11/01. Topics included: extent and circumstance of the injury(ies), description of medical treatment for injury, current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, and inductively open-coded for thematic analysis.Results: Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with exposure to peri-event traumatic exposure ; sub-optimal quality and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of life.Discussion: This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term health problems of disaster survivors are needed in order to support recovery. Whether this is related to injuries sustained on 9/11 or to peri-traumatic exposure to the disaster, or both, is an open question, as it is hard to disentangle the long-term effects of injuries from long-term effects of the traumatic exposure.A study published by the Registry found that over 9,000 (13%) enrollees reported being injured on 9/11.6 The most common injury reported was a sprain or strain.After the attacks, the New York State Office of Mental Health collaborated with New York City and county mental health departments to address mental health needs using two related but distinct response strategies.Information on disaster-related factors that may influence long-term quality of life of survivors can inform the development of strategies to ensure the best possible outcome and recovery for seriously injured disaster survivors. The goals of this qualitative study were to 1) fill in the gaps in knowledge concerning the circumstances surrounding the injuries, 2) determine the short and long term mental and physical health effects of being injured, and 3) assess the social and economic impacts of being injured.,A semi-structured interview script, which was informed by a conceptual model of long-term health impacts in disaster survivors, was used to conduct the interviews. Telephone interviews were conducted on 33 eligible Registry enrollees between March and June 2015 (83% of those contacted by phone agreed to be interviewed). Up to 50 interviews were planned, but saturationPotential study participants were first sent an invitation letter with a description of the study, its purpose and the benefits and risks of participation. Registry recruitment staff called all potential participants to schedule an interview and to obtain verbal consent prior to conducting the interview. Participants were sent a $50 gift card as compensation for their time.Each interview lasted approximately one hour. The interviewer’s guide was developed by all authors with input from other Registry staff. Ethics StatementThis study was approved by the institutional review board of the NYC Department of Health and Mental Hygiene.Data AnalysisUsing a pre-set list of major themes that were based on the conceptual models embedded in the interview script, two members of the research team read and coded the first five transcripts of the recorded data. The analysis was conducted using the block of data for each of the major categories as described in the interview guide. The researchers then met to achieve consensus on the major themes and sub-themes, and to identify and discuss any new themes that emerged from the data. At this stage, the researchers also agreed upon the terminology that would be used for the themes. For example, originally, one researcher listed “Changes in Work Status” as a separate theme, the two researchers agreed to fold this into the “Lifestyle Impacts” theme. One researcher initially referred to any new health problems as “New Health Problems,” which was then changed to “Current Health Status, Functional Physical Status Impairments and Disability.” Once the new terminology was in place, the two researchers then read the next 5 transcripts to ensure that they were coding using the same terminology and pre-set themes similarly. After thorough discussion of the identified themes by all three researchers, further adjustments to terminology were again made at this point to keep the themes to a manageable number . Disagreements about themes were discussed and resolved among coders until 100% agreement on themes was achieved. Two researchers then reread all 33 transcripts and coded them separately. They then met to compare their results and at this point the third researcher assessed the coding and determined an interrater reliability of 0.97.The authors used thematic analysisParticipant characteristicsDemographic characteristics of the participants are described in Thematic analysisThematic analysis yielded six themes related to exposure to WTCD and current quality of life: (1) concurrent peri-event injuries and traumatic exposures on 9/11; (2) timeliness of short- and long-term medical care for injury and mental health care; (3) current health status, functional limitations, and disabilities; (4) lifestyle impact; (5) availability of social support; and (6) economic impact. Interrater reliability for each theme was good (kappa = 0.97). Themes are presented below, with representative quotations selected to highlight key results.Peri-event traumatic exposures and injuriesThe first awareness of the event varied greatly and was dependent upon the participant’s location when the event first began at 8:46am. Some participants were already at their desks, located in either of the towers or in surrounding buildings. Others were at the street level and were about to enter one of the seven WTC complex buildings or other nearby buildings. Unless the participant had a direct view of an airplane making impact, making sense of the situation was initially, at least, virtually impossible. Even participants who heard the first explosion as the plane made impact and reported seeing debris from their office windows could not understand what had just happened. Almost no one initially understood the gravity of the situation or the precariousness of their own personal safety. In these first few minutes, there was a sense of confusion and uncertainty regarding what had happened and how they should respond.Sensory exposure was common. Participants reported seeing and hearing the planes impact the buildings, and seeing the collapse of either the WTC Tower One (WTC 1) or WTC Tower Two (WTC 2), or both. Participants saw people on high floors in WTC 1 waving tablecloths and then jumping out of windows. Participants saw and felt debris from the towers and the impact of the dust clouds. Participants smelled smoke and other odors of building materials caught up in the dust cloud. Participants heard screaming of others when they were in their work area, in the stairwells, and on the street.Participants experienced a wide range of injuries, including, most commonly, eye injury, foot injuries, skin burns, head injuries, contusions, sprains, strains, and broken bones. Several participants experienced injuries almost immediately after the first impact, generally because of resultant damage to their work area . Others who were at street level were injured by falling debris. Still others were injured in the lobby of WTC 1 when a fire ball exploded out of the bank of elevators. Other victims were not injured until they began to evacuate, either from WTC 1 or WTC 2 or from other WTC complex buildings or buildings in the vicinity. Several participants were injured later on, during and immediately after the collapse of WTC 2, at 9:59am, or later still, when WTC 1 collapsed at 10:28am. Participants who were not injured either immediately or shortly after the attacks reported that their injuries occurred during their sometimes extended journey towards home or to another destination.“…then I just heard this horrible, indescribable sound. It sounded like the biggest thing you ever heard was tearing through a jungle. And I turned around and I saw it [the plane impacting WTC 1].”The participant’s location at the start of the attacks at 8:46am also affected the intensity of their peri-event traumatic exposure. As described by one participant, “I said, listen God, make it quick. I don’t want to suffer.” Many participants reported feeling the experience was ‘other worldly’, as one participant noted, “I experienced an alien abduction feeling.” For many participants, a sense of disbelief was common; they tried to make sense of what they were seeing. Dust, darkness, smoke and confusion were commonly reported. One participant, a first responder heading to the complex, reported that when he emerged from the Holland Tunnel, the scene was “a nuclear winter; I just remember the dust and smoke, and the confusion.” There was also a sense of disbelief for some that they were still alive, as one participant, buried in the rubble after the collapse of WTC 2 stated, “I realized, I’m alive.” For some participants, the reality of what they had experienced did not become clear for quite some time after the event. One participant, who woke up later in an intensive care unit, reported, “[The nurse] looked at me and said, ‘you know, you are the luckiest person in the entire world.’”The initial thought of many participants was that they were going to die, as reported by one participant, “It was every man for himself. We just started running.” Another survivor reported a similar situation when WTC 2 collapsed, “I started running and there were just hundreds of people running. And somebody just completely knocked the wind out of me and knocked me across the street itself. And I really thought that I was just going to die there.”Part of the traumatic exposure was related to witnessing people getting injured or killed, in some cases, quite near them. It was clear from the participants’ reports that the traumatic event was a combination of both witnessing the unfolding events, including escaping past corpses in the tower lobby and on the street (remains of jumpers from high floors), as well as getting caught up and injured in the event itself. For instance, several participants were traumatized during their efforts to run away from the collapsing buildings amid the flying debris and resultant dust clouds, not only because they were injured during these efforts, but because they were caught up in stampeding crowds of people who were similarly trying to flee. As noted by one participant, as WTC 1 started to collapse,  “It was the darkest- it was darker than nighttime. It was indescribable really.” In the darkness, people became disoriented, and several of them experienced injuries at this point.Although first responders were on the scene early to direct people out and away from the buildings, many interviewees reported that once WTC 2 collapsed, conditions on the ground rapidly deteriorated, making escape especially traumatic. Visibility became exceptionally poor; as noted by one participant,As the evacuation inside of the buildings proceeded, conditions in the stairwells degraded. At one point, in WTC 2, shortly before the collapse of the building, several participants reported chaos in the stairwell; large cracks appeared in the stairwell walls, all the emergency lights went out, water from broken standpipes was filling in and reached up to the knees of some people, and people began to panic and run down the stairs. Several participants also noted that it was at this point or shortly after they exited the stairwells, they were now without their shoes and experienced foot injuries. “[I was] about 30 feet I'd say from the North Tower when it collapsed. And I was blown about 40 feet in the air. I smacked into a cement wall. I was able to crawl into a room in WTC Tower 6.” Other survivors similarly reported getting thrown in the air as they were hit by flying debris. As noted by one first responder running away from the collapsing WTC 1, “I got maybe about two blocks, 2 1/2 blocks up, and I got hit on the head and I went flying and I think I fell into what was an excavation pit…I was buried over with concrete and debris.” Other participants also reported getting buried under debris, as noted by one survivor, “Since we were so close, you know the force just moved me – I don't know – like 20 feet or however. It definitely blew me a distance. And we were all flattened out. Everybody who was in the area. And then there was that huge gray-black cloud. You couldn't see any sunlight – like just a tad, just a smidgen. And after we were all knocked down ….somebody was on top of me because of the weight of everything coming down. That's when I fractured my rib. And I had my leg pulled up behind me and I had an injury to my knee.”The collapse of the towers was harrowing for several participants as the force of the implosion caused them to be thrown. As noted by one survivor,“I ran towards building five [WTC Tower 5]. That's the shortest entrance you can run to in order to get out of the staircase when the building [started to] collapse. I blacked out and the next thing I know I was on a stretcher and getting medical attention.”Participants reported getting buried under debris and losing consciousness as the towers collapsed. As one survivor of WTC 1 collapse stated, Timeliness of short and long-term medical and mental health care  “did not realize how badly I was injured”, “could not/would not leave my home/apartment,” and, “wanted to be alone/not think about the event.”Immediate medical care for injuries fell into three categories – none, immediate, and delayed. Most, though not all, of those who did not seek any medical care (either immediate or delayed) had ‘less’ severe injuries, mostly cuts and scrapes, foot injuries, and eye irritation. Those with ‘more’ severe injuries received either immediate or delayed medical care for their injuries, with the majority generally receiving care by the end of the day, although some waited days to weeks before receiving care. The reasons for delaying care included,"They got me into triage- I remember screaming, somebody give me some morphine." When they finally arrived at the distant hospital, hours after they had initially sustained their injuries, many of these participants reported that they basically were ‘in shock,’ with many completely unaware of how they had even gotten there. In addition to receiving care and treatment of their injuries, many of the participants who presented to either local or more distant hospitals reported that in addition to treatment of their injuries, they also received pulmonary therapy treatments to help them breathe. No one in our sample reported that the hospital provider recommended that they seek follow-up psychological care, although several were urged to see other medical specialists and/or their family provider.Many of the more severely injured people first had to be evacuated from the immediate vicinity of the WTC to another location. In some cases, this took quite an extended period of time because they were first evacuated by boat to a triage site, usually in Staten Island or New Jersey, and from there they were then taken by bus, ambulance, or private car to a nearby hospital. Even though many of these more severely injured people were in great pain, they self- evacuated or were assisted by ‘Good Samaritans’ to these more distant locations - without benefit of immediate first aid care  or pain medications. As one participant reported, Some study participants who were first responders reported that even though they had been badly injured that day, they still refused medical care. Most felt they were needed on the job and did not want to stop working, others were clearly in shock (they afterward said they could not remember details of how they had continued to perform their duties), some had received head injuries , and others felt it was unseemly to complain about their injuries when so many fellow rescuers had been killed. Other (non-responder) participants declined any offers of care that day as they wanted to reach their own provider near where they lived. However, several did not get to see their own provider for many days, and when they did, the provider also did not discuss the potential need for follow-up mental health care.“I take some NyQuil© and a glass of wine.”Among those with more severe injuries, long-term care and continued health problems were commonly reported. Almost all participants who had sustained serious injuries spoke of the continued need for physical therapy as well as continuing assessment and treatment by medical specialists on a regular basis, such as orthopedists and pulmonologists. Several participants mentioned that long after they had sustained their injuries, they required surgery, sometimes multiple surgeries. Several mentioned that additional future surgeries would be needed to repair ongoing problems, most typically on the knees, shoulders, and back. A few of these participants also discussed being in chronic pain and having a constant need for pain medications. Several participants also mentioned self-medicating after 9/11, including the use of herbal preparations. Persons in the interviews often mentioned heavy alcohol consumption for a short time after 9/11. Participants who reported current self-medicating all had current probable PTSD. One participant discussed problems sleeping because of nightmares and when asked how they managed this, they replied, Current health status, functional physical status impairments and disability“Kids say, mommy look at that man's hands.”Long term disability in those who had suffered orthopedic injuries was not uncommon. In some cases, participants stated that they were partially or fully disabled as a result of their injuries. Some participants stated that they are now disfigured, as noted one participant who had sustained serious burns, and who did not like to go out in public because, as he said,  "[It’s] so bad that I can't even barely tie my shoes or anything like that." One participant who had suffered severe burns spoke of loss of dexterity in hands and loss of sensitivity in finger tips. Physical symptoms and diseases described less frequently included hearing loss, dermatological conditions, autoimmune diseases, and cancer. When discussing his current health and hearing loss, one participant said, “[The doctor] said ‘your hearing loss is remarkably advanced for a man your age.’”Some participants described mobility impairments that required the use of wheelchairs, walkers, or canes. Others had chronic injury-related health problems (such as loss of range of motion in injured limbs or chronic pain). One participant who reported broken bones in his fingers, reported now having arthritis in those fingers, saying“I’ve got to accept the fact that I can’t do nothing like I used to.” Many seriously injured participants who had previously been very physically active  now reported that they could no longer do these things, as one person noted, "Life has certainly changed."Several participants stated that their injuries resulted in a diminution in their ability to physically perform their normal activities of daily living, such as bathing, dressing, cooking, cleaning, etc. As noted one participant,  “I can't do any [type of] work for any length of time without literally sitting down and trying to catch my breath.” Similarly, another participant stated “Even now, when I start to do anything strenuous, bingo, forget it, it takes me a while to recover from it” Many participants also reported sinus and throat problems such as allergies, throat irritation, and acid reflux/gastroesophageal reflux diseases (GERD). After one participant had an endoscopy, he said he was told that “…it looked like I had swallowed some red hot coals.”In addition to the long-term effect of physical injuries, almost all of the participants reported a variety of respiratory symptoms and conditions, including asthma, reactive airway disease, sleep apnea, bronchitis, chronic pneumonia, and lung problems. These respiratory problems also negatively impacted their current functional status. One participant said"[after 911], I would look at people and I would see their skeleton." When asked how often this happened, the response was, “All the time.” For most participants reporting mental health symptoms, these generally became evident shortly after the WTC event, although others reported that symptoms did not manifest until weeks or months later. Several participants reported that their mental health symptoms have persisted for years. Anxiety symptoms included reluctance to fly, fear of being in crowds or public spaces, other phobias, and nervousness. Some participants reported that they were generally now more “emotional” than they were before 9/11. One participant stated, "I'm very emotional now. Yeah. I am, [I] mean anything, it has me crying." While another said, "Some days I'm fine and then there's other days where I get totally upset." Participants also mentioned having sleep problems, restlessness, nightmares, and insomnia. One participant described "My wife was telling me that half a dozen times I'd be crying in my sleep, yelling in my sleep. She said I'm worried about you. You're not right, you're not yourself. And I knew I wasn't myself. I didn't want my kids going out, I didn't want them going anywhere." Some, but not all, of the participants with these types of symptoms eventually received mental health services such as counseling therapy and prescription medications. Several participants reported that they had moved away from New York City to avoid any reminders of the event, but that even after the relocation, their symptoms persisted.In addition to physical ailments, many of the participants described a range of ongoing mental health symptoms related to the event, including anxiety, depression, panic attacks, and sleep disturbances. Several had been diagnosed with PTSD, anxiety disorder and/or depression by a clinician. Serious mental health problems were noted, as recalled by one person who said, Lifestyle impact  “I left… [or rather] I would say, that I was forced to take early (disability) retirement as a result of it. My wife works now and I just take care of the kids.”Almost all participants reported major changes in their lifestyle after 9/11. Some lifestyle changes were related to the loss of their jobs, and in other cases, changes resulted because of their injuries and subsequent disabilities, as illustrated by this quote,“I'm always one to say that I would never talk about any injuries because 2753 people would've traded places with me that day. So I don't really talk about [my] injuries. But it really did change my life. Especially having a two month old at the time. You [normally] want to be with them all the time and do things. So I've been a lot less active with my younger kid than I was with my now 20-year-old.”Several participants reported that they now had little or no enjoyment in life and that they no longer had any interest in participating in activities they had previously (prior to 9/11) found enjoyable. Examples of these activities included socializing with friends and family, working out, playing sports, outdoor activities with family, working around the house and garden, and playing with their children. One participant said, “If I have to go to the city for a function, I’m a wreck.” When another participant was probed further about their ability to take the subway they said, “I can, but it's not something that I want to do and it's not something – I'll stay up all night before- if I know I'm going to go to the museum or take the train…”Others spoke of missing social or cultural activities because they avoided going into Manhattan or taking the subway or flying on airplanes. A participant commented: “I didn't want to go out, I didn't want to see anybody.” When asked about leisure activities and going out with friends, another participant simply said, “No, that [all] stopped.”Other participants described more extreme social isolation and a near total lack of contact with people and society . One participant commented: Availability of social support “I have to say that I think the fact that I have a very good home life has the biggest impact. I mean my wife is – she's constantly caring for me. Outside of our children I'm her biggest priority. And so I would have to equate her support as being my biggest coping mechanism.” When discussing the importance of the support he received from his wife and daughter, another participant said, “… because if it weren’t for them I don’t know what would’ve happened to me.” Additional sources of social support mentioned by participants were religion, therapy, friends, and volunteer activities.Some study participants discussed different sources of support that helped them, not only recover from the effects of their injuries, but to deal with the totality of the events of 9/11. The most commonly cited source of support was family. One participant said,“You talk to the people you were with that know what you’ve been through. It’s very difficult to talk to other people about it.” This lack of ability to discuss feelings and emotions related to 9/11, coupled with wanting to be isolated from everyone led to estrangement in families.Some participants however reported a dearth of social support. They felt that the only people who truly understood them were other 9/11 survivors. One participant described it as, Economic impact“Economically I’m in a hard spot. I had to take a home equity loan on my house to make ends meet.”Participants reported a variety of economic consequences, and most were negative. Some economic impacts were directly due to an injury sustained on 9/11, including the inability to work and the increased costs associated with medical care. Many of the participants with more severe injuries, as well as those with subsequent health issues, had to retire with disability benefits or take early retirement. One participant on permanent disability said, "I mean the whole event was a severe economic impact because I was basically in a rent-controlled apartment in Battery Park and I had to move. So when I had to move, my rent tripled."Other economic impacts were related more generally to the events of 9/11. Several participants reported that they had lost their job due to company downsizing or going out of business after 9/11. One participant mentioned the financial impact of having to move out of the area, As has been previously reported,,,,,,,As shown in previous studies on 9/11 survivors enrolled in the World Trade Center Health Registry, long-term physical and mental health problems were common.,It was not surprising to find that participants stressed the importance of emotional and social support from friends and family, as high social support and social integration have been shown to decrease the odds of 9/11-related PTSD.Early retirement or disability retirement was commonly reported, many participants were left without important benefits of work. A recent study of WTCHR enrollees found that workers with chronic conditions were more likely to experience early retirement and job loss, and the association was stronger in the presence of PTSD comorbidity.We found that even among those who did not have current PTSD, there was a lack of recovery and diminished quality of life reported. There are a number of possible reasons for this observation. One explanation might be a relatively new phenomenon referred to as “moral injury”.On the other hand, just how participants who demonstrated resiliency were able to do so may be explained by recent work by Richardson (2015) on the role of ‘making sense’ in disaster recovery.There is a growing interest in post-traumatic resilience and post-traumatic growth, which can result from devastating, catastrophic events.LimitationsThis study focused solely on those injured on 9/11 and thus results reported here may not be representative of other non-inured 9/11 disaster survivors. With only 33 participants, this was a small sample, although we did reach thematic saturation. There was also the risk of recall bias, however, we did have data from 2002-2003 on injuries reported at that time and we also framed the questions on their current recovery and everyday functioning. Also, there is the possibility of self-report bias; participants may have provided responses that they felt were socially acceptable. In spite of the potential limitations inherent in the design and sampling, this exploratory study was appropriate for this stage of inquiry and provided unanticipated avenues for further research.In this study we were able to identify serious long-term health and mental health effects related to the WTCD. Among those injured, quality of life was seriously and negatively affected. Public health has a responsibility to aid survivors and community members both immediately following a disaster event and, importantly, in the long-term. Because both natural and human-caused disasters are increasing in frequency and severity, communities and government agencies should prepare now with respect to the provision of short and long-term assessment and treatment for victims of these types of events. The full functioning and participation of all members of the community is essential for community resiliency and recovery following disasters.Due to ethical restrictions, the qualitative data in the study is only available upon request. For further information regarding data availability please contact Lisa Gargano: lgargano1@health.nyc.gov.Lisa Gargano: lgargano1@health.nyc.govThe authors have declared that no competing interests exist.


Infant Program: a group-based obesity prevention program facilitated by maternal and child health nurses within first-time parent groups. Six 1.5 h sessions were delivered at three-month intervals when the infants were 3–18 months. A multi-site qualitative exploratory approach was used, and program service providers and parents were interviewed. Numerous interrelated factors were identified, linked to two themes: the transition to parenthood, and program processes. Personal factors enabling engagement included parents’ heightened need for knowledge, affirmation and social connections. Adjusting to the baby’s routine and increased parental self-efficacy were associated with diminished engagement. Organisational factors that challenged embedding program delivery into routine practice included aspects of program promotion, referral and scheduling and workforce resources. Program factors encompassed program content, format, resources and facilitators, with the program being described as meeting parental expectations, although some messages were perceived as difficult to implement. The study findings provide insight into potential strategies to address modifiable barriers to parental engagement in early-year interventions.The ‘early years’ is a crucial period for the prevention of childhood obesity. Health services are well placed to deliver preventive programs to families, however, they usually rely on voluntary attendance, which is challenging given low parental engagement. This study explored factors influencing engagement in the  The ‘early years’, more recently defined as the first 1000 days (conception to 24 months), is widely acknowledged as a crucial period in laying the foundation for life-long learning and development . GloballParents and carers play a significant role in influencing the health and development of their children, and supporting parents to develop their knowledge, skills and confidence regarding child health and development is considered an important public health strategy ,10,11. FAustralian parents are highly receptive to information and support during the first year of their infant’s life, making an average of 11 visits to their general practitioner and 14 visits to their maternal and child health nurse, with the majority of these unrelated to illness . The uniExamining patterns of attendance is considered important to determine if there are sensitive periods when attrition is more likely to occur , and theEnablers and barriers to engagement are most commonly categorised into personal, organisational and program factors. Personal  factors include socio-demographics; physical, financial and emotional resources; and social supports ,35,36,37Studies of the enablers and barriers to engagement have most frequently been conducted in the context of children with behavioural ,25,30,32This study is an exploration of the factors influencing the engagement of first time parents in an early childhood group-based obesity prevention program, from the perspectives of both program service providers and parents across all levels  of program attendance. For the purposes of this study, parental engagement is defined as program recruitment (promotion and enrolment) and program retention (ongoing attendance). Infant Program. R.L. is a postdoctoral researcher with experience in research translation, with specific involvement in evaluating the community-wide implementation of the Infant Program. K.C. is a professor and chief investigator of the Infant Program, responsible for its development, randomised control trial, community-wide implementation, and ongoing evaluation. Ethical approval for this study was obtained through Deakin University (HEAG-H 160_2016) and the Victorian Department of Education and Training (DET 2016_003167). This study used a multi-site qualitative exploratory approach, underpinned by a contextualist epistemology, where knowledge emerges from and is situated within the contexts of the data . UnderstInfant Program is a low dose, efficacious, group-based program for first time parents . There were a lot of things that I was, like, ‘oh now we can do this’ and ‘I should be doing this’. It was really good. I took a lot of notes”“I learned a lot from it. I knew nothing about solids or how to introduce them or when to introduce them. I walked away with a clearer idea … That was the first place that I really learned about that. If I hadn’t gone there I don’t know where I actually would have learned that except from a relative” “It was just nice to have somebody there who was going through the same thing really … you didn’t feel judged because you were all going through that, yeah, having that level of friendship really helped” overwhelming”, “daunting” and “stressful” period, hampering attempts to self-refer or attend program sessions. The desire not to interrupt baby’s routine  was a commonly described barrier across all categories of attendance, further reducing the likelihood of self-referral and attendance. Non- and low attendees, and parents with lower levels of education, described a reliance on informal sources of information, such as family members, friends with children, the internet, and social media, which was viewed as a substitute for program attendance. Parenthood posed some barriers to program attendance in the form of low levels of parental self-efficacy, receiving conflicting information and guidance from informal sources (such as family and the internet), and returning to work. Non-attendees described parenthood as an ““I know it’s really good to get out of the house, but I just felt—and there’s so much pressure to do it. I actually felt like a bit of a failure, because I wasn’t getting there” “I’d attend if it wasn’t his sleep time. I wasn’t going to wake him to go” growing sense of confidence as a parent, especially once infants had transitioned to solid foods; and with mothers returning to work at around 12 months. For high attendees, returning to work was also described as resulting in a loss of social connections with other mothers, which reduced their likelihood of attending the remaining (15- and 18-month) program sessions. Across all study sites, program service providers identified two time periods when program attendance declined; session 3 (infants about nine months) and session 4 (infants about 12 months). Program service providers and low attendees concurred that the main reason for program attrition around nine months was a A number of enablers and barriers to program attendance were described in relation to aspects of program promotion, referral, recruitment, enrolment, scheduling, and delivery. Program promotion and referral‘Key Ages and Stages’ appointments by new parents, program service providers considered the maternal and child health services to be an appropriate mechanism for program promotion and referral. Non, low and high program attendees concurred with this, describing the maternal and child health service as a “highly trusted source of information and referral”. Limited program awareness was considered a barrier by program service providers and participants across all categories of attendance. Parents suggested that promotion of the program should ideally be before the birth of the baby to create early awareness and encourage attendance ahead of (feeding) issues arising, and that this could be done via usual appointments with midwives, general practitioners, obstetrics and gynaecological services during pregnancy. Program promotion through local government websites, libraries, lactation consultants, child care centres, social media, community events and local newspapers was suggested, with non- and low attendees recommending that promotional material should include information about the program content.Given the high uptake of the Program recruitmentnew parent groups as highly efficient, providing a captive audience with existing social connections. Low and high attendees also described new parent groups as important in establishing trusted friendships, which encouraged program enrolment and attendance. Across all study sites, program service providers considered recruitment through existing “I think it’s probably the best way, I would say between 80 and 90% of parents going to those groups would actually express interest … and that cut out a lot of the admin of me trying to follow-up with people, because they were already coming together”“It probably helped hearing about it in the [new parent] group, because I think I went along to at least the first session with some other mums from the same group”every child is different”.The recruitment of new parents who were not members of new parent groups was a challenge for program service providers, and a concern shared by some parents, with the suggestion that multiple promotional channels be used. Some parents commented on the program only being offered to first-time mothers, suggesting that multiparous women be able to attend as ““I’ve got a 2 year gap between my two, so my little one is 6 months old, and there are things that you forget … Perhaps a little refresher course” “It would be great to be able to attend as a second or third time mum for a refresher”Across all study sites, program service providers were concerned about reaching vulnerable parents, specifically Aboriginal parents, culturally and linguistically diverse (CALD) parents, adolescent mothers and disadvantaged parents, who were unlikely to attend new parent groups. Working in partnership with other organisations already accessing these communities was a common suggestion to extend program reach, although this was also considered to be time intensive, requiring additional financial and human resources to adapt program content and delivery. “I don’t think we’re doing a fabulous job of reaching, perhaps, vulnerable families as well as we could be, because they’re not necessarily the families that are going to participate in a new parents group for whatever reason … We’ve probably got the groups there that we could partner with, and I think that’s been one of my really big learnings—don’t try and do it yourself, partner with the agencies that are already in contact with those groups, because there’s absolutely no point in setting it up and doing it yourself” “Often what it takes to engage those more vulnerable families is a lot more work. A lot more time—probably more funding in terms of you know—you’d often need an interpreter. Sometimes you would need an extra staff member, potentially to run a program or to run a session if you had families there who were, you know, English as a second language” Program enrolmentopt-out enrolment approach, with participants automatically enrolled in all sessions from the start, was described positively by program service providers and high attendees. In addition, the integration of the first session of the Infant Program as the last session of new parent groups provided immediate exposure to the program content and format, encouraging program enrolment. While an opt-in  enrolment approach was considered by some program service providers as providing flexibility and a degree of accountability to parents, most described this as an administratively burdensome task. Low attendees also described self-referral as an activity likely to be forgotten given the spacing of the program sessions at three-monthly intervals. Reminder notifications, sent by text message at least a week ahead of a scheduled session, were considered useful, especially given the spacing between sessions and changes to the baby’s routine. Parents suggested that the content of the forthcoming session be promoted with the reminder notification to enhance interest and attendance.An Program scheduling and deliveryprogram venues were considered safe, comfortable and accessible , with adequate parking and space for prams. Providing multiple session options on different days/times was a challenge for program service providers, constrained by the availability of staff and the need to ensure an adequate group size with infants of the same/similar age. Parents reported that limited session options reduced flexibility to attend when circumstances such as the baby’s routine changed, or to accommodate working parents, including fathers. For all study sites and across all attendance categories, “I’m still sort of thinking how we could do that … engage a bit better with fathers … as far as what their working arrangements are” “It’s difficult because your baby obviously does sometimes change their sleep patterns and that sort of thing … It would have been nice to have a bit more options for time” “I thought maybe it would be nice to have two sessions, one in the afternoon and one in the morning, not necessarily on the same day, because that might be really difficult, but maybe in the same week. Just to give parents an option … even after-hours so dads might be able to come”appropriate group size with infants of the same/similar ages was described as an administrative challenge across all sites, and particularly problematic for  areas with low birth rates. Reaching vulnerable parents through existing infrastructure, such as supported playgroups, added further complexity to scheduling, as these groups comprised multiparous mothers and infants of varying ages. Scheduling infants of approximately the same age within groups, however, was appreciated by low and high attendees as it enabled the delivery of program content using an anticipatory guidance approach, providing age-appropriate, timely information. The scheduling of participants to ensure an “I think getting a critical mass of babies at the right age is actually quite difficult … and that is the case for a number of [rural] areas. I think you need a really good system for that, otherwise it becomes all-consuming” “It was going to be age appropriate … If someone had have just thrown a book at us when the kids were born, it wouldn’t have been helpful”group-based format of the program was regarded as an enabler by program service providers and low and high attendees. This format was viewed as providing a relaxed, friendly environment that encouraged peer discussion, social connections and trust, with suggestions that a group size of 10–15 parents was appropriate for good group dynamics.The “The real advantage of these groups is that you do build that trust, and families do feel supported”“I’m a bit of a shy person, so I liked that I could just sit there quietly but still feel part of it. There was no pressure. People asked questions; I didn’t have to, because other people asked valid questions. Then there were conversations going on. It was nice to hear that everyone is on the same page as you”“The main thing I got out of it was listening to other people, their experiences … some real reassurance I suppose and knowing that you were in the same situation as other people, having the same week as other new mums”formal sources of information, with group facilitators described as “trusted”, “knowledgeable” and “approachable”. Dietitians were valued for their specific nutritional knowledge and maternal and child health nurses for their expertise in child health. While parents appreciated the technical knowledge and professional expertise of group facilitators, they expressed a need for them to have experience as a parent, or at least some practical experience working with infants.Across all categories of attendance, parents with higher levels of education showed a preference for hands on” advice, especially recipe ideas. The program resources were valued by parents, with a preference for hardcopy handouts at sessions “to refer to at home” and digital sources that could be accessed if unable to attend.Parents enjoyed external speakers (such as dentists or first aid instructors), and practical ““It would have been good to have extra information emailed to you if you couldn’t attend a session”“Perhaps it could be recorded … like if someone misses a session or you want to re-look at something … or be available online”“I’ve stuck it [handout] on the fridge … from the first session and I still refer to it. It’s good to have something to take away because it’s just really overwhelming”program content appeared to be a barrier for low attendees with higher levels of education, who considered certain messages to be either “too prescriptive”, “too general” or a duplication of the information received at their maternal and child health appointments. Program content regarding screen time recommendations was recalled most often as behaviour that would be difficult to implement given the insidious use of digital technology. Certain aspects of the “They [participants] were often quite surprised to hear the recommendations were no screen time up to two years, and there were lots of questions about ‘well what do we do as parents then for our own sanity?’”“I guess I was a bit disappointed, it didn’t really tell me anything that I didn’t already know. I guess I expected to get more hands on experience out of it. I felt like it was really just general healthy eating guidelines” “Parts of it were great and I got a lot out of it but there were parts where I just thought, ‘I feel a bit judged now’. It was like ‘this is the recommendation’”frequency and spacing of sessions, with a preference for fewer sessions (2–4 rather than 6), spaced closer together (“perhaps monthly” rather than three months apart), completed earlier (within 12 as opposed to 18 months), and linked to reliable sources of digital information. Linked with periods of program attrition, especially after session 4, suggestions were made by program service providers and program regarding the “Three months is a long time in between … if we were to condense it into a shorter timeframe that would be helpful because really, you know, they really need the advice maybe monthly”“We weren’t getting many 15 and 18 month attendees … now we go to the 12 month and we send them out a text message with a link to the [program] website so they can still have access to the information, and they’re more than welcome to call up” Infant Program were related to two interconnected themes: the transition to parenthood and program processes; and across these themes, enablers and barriers were linked to personal, organisational and program factors. This is one of few studies examining the parental engagement specifically of first-time parents in an early childhood obesity prevention program from the perspectives of program service providers and program participants with varying patterns of attendance. The factors affecting parental engagement in the parental knowledge and self-efficacy; social connections, and sources of information and support. A heightened need for knowledge and assurances, especially infant feeding information, and opportunities to share experiences and develop social connections, were described as primary motivators for enrolling in the Infant Program. These enablers, however, were thwarted if parenthood was experienced as stressful and overwhelming, adjusting to the baby’s routine was challenging, and informal sources of information were substituted for program attendance. Personal factors included Program attendance appeared to diminish with the acquisition of knowledge and growing confidence as a parent, especially once infants had transitioned to solid foods; and early program termination appeared to be linked to a loss of social connections with the group once parents returned to work. The link between reduced program attendance and increased parental self-efficacy is consistent with other studies where parents with a lack of confidence in their parenting abilities and a belief in the program benefits were more likely to see the relevance and importance of program attendance ,32,33,35Infant Program is considered a success, despite it potentially leading to reduced program attendance. To this end, the program encourages the attendance of sessions by others involved in the care of the infant  to build a shared understanding of program messages and increase the likelihood of their implementation. Research also continues regarding the efficacy of social media  as a means of directing Infant Program participants to reliable sources of information [Increased parental self-efficacy as a result of attending the ormation ,54,55.A reliance on informal sources of information and support from family, friends with children, the internet and social media, appeared to become a substitute for program attendance, especially for program participants with lower levels of education. Participants with higher levels of education appeared to seek out ‘reliable’ information and showed a preference for formal sources of support, in particular the maternal and child health nurse. These findings are supported by other studies, where the preference to access formal sources of information was found to increase when parents developed a good relationship with the source ,21,34,56program promotion and referral; recruitment; enrolment, scheduling and access. Promotion and referral through the maternal and child health service via routine ‘Key Ages and Stages’ consultations was regarded as an efficient mechanism, given the high uptake of this service and frequency of contact. Broader program promotion, especially prior to the birth of the baby, was recommended, however, to increase program awareness. A lack of program awareness, as identified in this study, is frequently cited as a practical barrier to engagement [Organisational factors affecting parental engagement included gagement ,32,36, ogagement . Effectigagement . Studiesgagement ,60, to pgagement ,18,20. Infant Program via new parent groups was considered an enabler, providing access to parents with infants of the same/similar ages and with existing social bonds. The source of program referral is described in the literature as an important contributor to the likelihood of attendance, with referrals from trusted sources [Recruitment to the  sources  . Providing a narrow range of program times has been reported to limit the attendance of parents with busy schedules , time coThe program venues were described by study participants as accessible, safe and comfortable, thus enabling program attendance; with high patterns of attendance within the rural study site (62.5%). Physical access to programs is described as an important enabler in many studies, especially in rural areas where public transport may be limited or costly ,32,33,36content, format and resources; and delivery by trusted individuals. Program content focused predominantly on infant feeding and active play and therefore met the expectations of participants, however, messages perceived by participants as difficult to implement, such as screen time recommendations, were described as ‘prescriptive’ and ‘judgemental’, especially by program participants with low patterns of attendance. Similar findings have been seen among low program attendees expressing fears of being judged by others or not possessing the necessary skills [Infant Program, participants enjoyed the inclusion of external speakers (such as dentists or first aid instructors) and peer advice (recipe ideas) to augment program information. The group-based approach was described positively by program participants and program service providers, encouraging group discussions and providing opportunities to form social contacts. Nobles and co-authors describe group size as a strong predictor of parental engagement, and found that groups of fewer than 20 participants, as opposed to one-on-one, encouraged social interaction and promoted a sense of belonging [Program factors affecting engagement encompassed the program y skills ,36 and sy skills . The eviy skills ,32. Simielonging . The important role played by group facilitators in creating an environment for social bonding is closely linked to the personal need of participants to share experiences and seek reassurance, often reducing feelings of isolation and normalising concerns . The abiAcross the study sites, the provision of experienced professionals to facilitate groups was a challenge when workforce capacity was stretched by existing clinical workloads. The integration of program implementation as routine practice, thereby attracting organisational resourcing, was described by one study site as a means of addressing workforce capacity. Studies note that the turnover of staff is likely to affect relationship-building and impact program attendance, suggesting the continuity of group facilitators throughout program delivery ,27. These findings align with those identified by others, where parental engagement was enhanced when the program met the expectations and needs of the participants , the proThe study findings provide insights into the factors influencing parental engagement in an early childhood obesity prevention program, and therefore also highlight the changes needed to address modifiable barriers to engagement. While numerous studies focus on the influence of personal factors on parental engagement, there is growing acknowledgement that the majority of modifiable factors are likely to be found within the program and/or its implementation ,27,37. TFuture research considerations include obtaining perspectives from a larger sample of non-attendees, as well as fathers and parents of different ethnicities. Understanding the predictors of engagement for these cohorts could provide additional insights into the strategies needed for equitable program access and uptake, thereby extending the reach, cost-effectiveness and health benefits of the program.Box 1Broader program promotion through multiple channels, with more information about program content and benefitsEarlier program promotion during pregnancy and through initial home visits/home support service, with an opportunity to address potential barriers to attendanceContinued program promotion and referral through trusted sources of information and support, especially maternal and child health services with routine contactCross-promotion and referral through interagency collaborations, especially to reach vulnerable parentsRecruitment through established groups, especially new parent groups, with existing social bonds and groups reaching vulnerable parentsEasy, “opt out” enrolment processes, with automated text reminders a week in advance reminding parents of the focus of the next sessionAlignment of program messages with maternal and child health services, to reach those not attending, and reinforce messages for those attending the programProgram facilitation by maternal and child health nurses and dietitians for their specific expertise, and continuity of group facilitators to build relationships Program adaptations to deliver all sessions within 12 months, to accommodate parents returning to workWhere feasible, providing a variety of session times , accompanied by online program delivery and resources, to ensure a reliable source of information and to support a flexible mode of delivery , especially for working parents, fathers, and geographically dispersed communitiesA key strength of this study is the review of the whole engagement process, from program promotion, referral and enrolment, to implementation and attendance. The study is strengthened further by the inclusion of perspectives from program service providers experienced in all aspects of program implementation across three diverse geographic locations. Although the characteristics of the interviewees were comparable with those of the total sample of survey respondents, this study only interviewed English-speaking, female parents, and had a low overall response rate (10.6%). The study findings may therefore not be representative of all program participants and should be extrapolated with caution. The enablers and barriers identified in this study are similar to those in the literature, however, and therefore could be considered to have broader relevance and transferability to similar programs.As is usual for qualitative studies, the sample size and diversity were challenged by the fact that the responding individuals were likely to be more motivated and to have been more engaged in the program, and that not all participants who expressed interest were interviewed as they were uncontactable or declined. Stratification by program attendance assisted the inclusion of multiple perspectives from non, low and high program attendees. While numbers were small, the inclusion of non-attendees also provided insights into attendance decisions for this typically under-reported cohort. Infant Program, appears to meet this need. Maternal and child health nurses who have an established relationship with parents through routine and regular contact, provide a trusted point of referral to the program, and are in a position to positively influence attitudes to program enrolment from the first home visit after birth. Adaptations to program delivery may be necessary to extend recruitment beyond new parent groups in order to reach more vulnerable parents, where groups are more likely to have infants of mixed ages, and parents from multicultural backgrounds. The transition to parenthood is associated with a period of heightened receptiveness to information and guidance, especially in relation to infant feeding. This transition is also associated with the need for social connections and shared experiences with other parents. A group-based program delivered during the first year of parenthood providing reliable, age-appropriate messages on relevant topics such as feeding, active play, sleep and safety, such as the Infant Program highlight a number of personal, organisational and program barriers and enablers that are interconnected around the adjustment to parenthood and the need for knowledge, reassurances, and social connections. Identifying and understanding these factors is important so that appropriate strategies can be developed to enhance parental engagement and participation in ‘early years’ interventions.The factors influencing parental engagement in the The study findings provide important insights into the decision-making processes of new parents adjusting to parenthood and factors influencing program attendance. An exploration of the enablers and barriers experienced by program service providers advances our understanding of the implementation context and ability to support parental engagement.


Introduction: Cisgender and transgender woman sex workers  are key populations in Malaysia with higher HIV-prevalence than that of the general population. Given the impact economic instability can have on HIV transmission in these populations, novel HIV prevention interventions that reduce poverty may reduce HIV incidence and improve linkage and retention to care for those already living with HIV. We examine the feasibility of a microfinance-based HIV prevention intervention among CWSW and TWSWs in Greater Kuala Lumpur, Malaysia.Methods: We conducted 35 in-depth interviews to examine the acceptability of a microfinance-based HIV prevention intervention, focusing on: (1) participants’ readiness to engage in other occupations and the types of jobs in which they were interested in; (2) their level of interest in the components of the potential intervention, including training on financial literacy and vocational education; and (3) possible barriers and facilitators to the successful completion of the intervention. Using grounded theory as a framework of analysis, transcripts were analysed through Nvivo 11.Results: Participants were on average 41 years old, slightly less than half (48%) were married, and more than half (52%) identified as Muslim. Participants express high motivation to seek employment in other professions as they perceived sex work as not a “proper job” with opportunities for career growth but rather as a short-term option offering an unstable form of income. Participants wanted to develop their own small enterprise. Most participants expressed a high level of interest in microfinance intervention and training to enable them to enter a new profession. Possible barriers to intervention participation included time, stigma, and a lack of resources.Conclusion: Findings indicate that a microfinance intervention is acceptable and desirable for CWSWs and TWSWs in urban Malaysian contexts as participants reported that they were ready to engage in alternative forms of income generation. Since the first cases of HIV were detected in Malaysia in 1986, the epidemic has been largely driven by injection drug use with bridges to sexual transmission . By 2014Microfinance describes a number of financial programmes aimed to alleviate poverty, including vocational training, micro-loans, and micro-savings programmes, to individuals who would otherwise not have access to these financial schemes through conventional channels  ,21. HIV Microfinance interventions targeting CWSWs have shown promise in empowering participants to develop additional sources of income ,21–23 anThere are no known studies examining the impact of these types of interventions on TWSWs’ HIV risk profile; though evidence suggests that their behaviours are influenced by a similar set of factors to those of CWSWs ,9,28. Mon = 19) and TWSWs (n = 16). Fieldwork was conducted in collaboration with three NGOs between March and November 2015. These NGOs provide HIV prevention and social services, such as shelter to marginalized populations, including street-based CWSWs and TWSWs. As these NGOs are directed by members of the transgender and sex work communities, they had strong networks within these groups and were knowledgeable of areas in which street-based sex workers usually procured clients. Participants were sampled from three districts within Greater Kuala Lumpur – including Chow Kit, Gombak, and Cheras – which were reported by NGO staff to have high concentrations of street-based and brothel-based sex workers.Acceptability of the proposed interventions were assessed through individual interviews with CWSWs  and drug using behaviours. For the in-depth interviews, a topic guide was used to examine their previous occupations, experience in sex work, and interest in joining a microfinance intervention. Participants’ acceptance of a potential microfinance intervention were explored through questions gauging their readiness to engage in alternative forms of income generation, including the types of occupations they were interested in, and their interest in different components of the potential intervention. Over the course of fieldwork, interview guides were altered in accordance with themes emerging from the data. Interviews were conducted by members of the research team who were fluent in English and either Tamil or Bahasa Malaysia. This study received approval from the institutional review boards of University of Malaya  and Yale University (USA). Prior to study enrolment, participants were notified of the purpose of the study, their right to withdraw at any point, and that their confidentiality will be maintained. They were also informed of the risks of partaking in this study, which include discussing sensitive topics, such as drug use or sex work. In the event that participants expressed concerns regarding issues addressed during the interview, i.e. experience of interpersonal violence, they were referred to NGOs that could provide assistance. All participants provided informed consent. Confidentiality has been maintained through ensuring that identifying information is concealed, for instance participants were given false names. Interviewers received training on ethics and interview technique prior to and throughout the data collection process.n = 20), Tamil (n = 8), and English (n = 7). Interviews conducted in Bahasa Malaysia or Tamil were first transcribed in the source language then translated by members of the research team. Data was checked by team members fluent in the source language for possible errors during transcription and translation.Interviews were conducted in Bahasa Malaysia  participants were eager to engage in additional forms of income generation due to familial concerns and career aspirations; (b) interest in all proposed components of the intervention were driven by a desire to build their own business; and (c) potential challenges to developing businesses included a lack of financial resources, competition from other businesses, and fear of stigma.Both CWSW and TWSW expressed strong enthusiasm to participate in the proposed microfinance intervention, with many citing sex work as an unstable source of income. For many participants, their involvement in sex work has been intermittent, providing the opportunity to earn additional income when other sources failed to provide enough for them. Under these circumstances, sex work was framed as not being a “proper job” with opportunities for career growth but rather as a short-term and unstable form of income, often referred to as a source of “fast cash”. Puteri, a CWSW, aged 34, said “… they [sex workers] need to live a stable life. Maybe they feel they won’t work as sex workers forever”.I would like a government job but it is hard for transgender people like me… I am interested [in finding other work]. But in job interviews with transgender people like us, many employers reject our applications.Participants described feeling locked out of employment opportunities in other professions, due mainly to the stigma of sex work and drug use. TWSW participants’ employment opportunities were further constrained by proscriptive gender roles in the Malaysian context. For example, many TWSW reported being able to find work in positions typically occupied by females, including bridal make-up artist, or cosmetics sales. Unfortunately, these positions were generally low-wage and vulnerable to seasonal shifts in market demand. For TWSW in particular, access to stable employment opportunities were limited due to implicit and explicit discrimination against transgender persons, making sex work one of the few reliable sources of regular income for them.Employers discriminate against people with different gender identities like transgender and transsexuals but it seems as if they are not discriminating against [cisgender] females. Most of the time in Malaysia employers are only discriminating against transgender and transsexual people.Nor Naba, age unknown, TWSWKamu, 50 years old, TWSWDrug use was also reported as a major obstacle to stable employment and income generation by both CWSW and TWSW. Participants reported being unable to work due to symptoms that they associated with addiction, including fatigue, nausea and body aches. Selly, a 58-year-old CWSW, who reported using heroin on a regular basis, stated, “Now I have back pain. when I’m high I feel stronger. When I’m not high, I can’t even sit up. [I]can’t even lift a feather.”The impact of drug use on securing and maintaining employment was further compounded by the stigma associated with being a person who uses drugs. When applying for traditional employment opportunities, they report being stereotyped as untrustworthy and as criminals, instead of as hard-working people seeking employment. Nor Amal, a 34-year-old CWSW, stated, “Not all drug users are bad, not all drug users love to steal. But in the eyes of the public, ‘the normal people,’ when they find out that someone is a drug user like me…they will be like, ‘mind your shoes, drug users are walking by…’”. Beyond the stigma of drug use, many participants also reported employers’ ability to conduct criminal background checks as a major barrier to employment. For example, participants who had been previously arrested and convicted for drug-related crimes were faced repeated rejection from employers who discovered their arrest and conviction during checks of their criminal history, which are permitted under Malaysian law. One participant reported having been terminated by her employer after they learned of her previous arrest for drug use.[For] My future… I can target [to start a small business]… from starting with a stall, I will have my own targets. I will target to open a restaurant. So it’s like for my own future. If it’s not for my future, it’s for my child’s future. If I can expand my business, then I can leave it to my child. At least my child will not have to go through hardship when she’s all grown up. Who knows she might go to the university, at least my business can back the plan up.Participants’ motivation for engaging in alternative forms of income generation varied by gender identity. Among CWSWs, interest in microfinance and other forms of employment was underpinned by familial concerns and the stigma of sex work. Regardless of age, participants who stressed familial concerns reported that they entered sex work as a means to secure an income. Under these circumstances, microfinance is an opportunity to generate a reliable income, which could yield greater financial stability not only for them, but also their dependants, such as children and other relatives:My dream, is as how people would say, to change. I want to open my own business. Let anyone say anything, never mind it’s okay. Even if it is a small business it’s okay. As long as I can survive until I die, for my children, that is enough. We are getting old each day. Children are also growing up fast.Nor Amal, 34 years old, CWSWPuteri, 34 years old, CWSWI do not want to prolong this sex work, which I am doing, I hope to stop [working as a sex worker] till here… Until now, if I have a chance, of course I would want the best. I do not want to close my eyes and be dead on the road. I do not want that. For example like the saying goes, who is not scared of death? Eventually everyone will die. It is not that I am scared to face death, I am ashamed to face God because I am living an immoral life. That’s the sad part.Some CWSWs were motivated to partake in the microfinance intervention as a means to escape the stigma associated with engagement in sex work. One such participant perceived participation in the potential microfinance intervention as an opportunity for other sex workers to develop “a new life… A different life, not selling themselves, to become someone different”. They frequently described their participation in sex work as immoral, illustrating how shame and stigma can become internalized. Some participants argued that their engagement in sex work was reflective of their overall character. Another participant described a similar association between sex work and her own morality:Mysha, 57 years old, CWSWIf I have the capital I will surely open a business. Even now I am looking at what business to open… That is my aim, make a lot of money and open your own business…. It’s in my mind always. [I] want to do this and that, but [I do not have the] budget yet. Have to work hard, have to do all work, to find the budget.For TWSW, however, long-held career aspirations were a major driver of interest in new forms of income generation and microfinance. Indeed, some had ambitions to employ others or provide a livelihood for family members. For example:I like dance so I want to achieve something [from dancing]… Many transgender [do] not achieve [anything]. They do not have any targets to achieve something. They want to make money, make money, make money. For what they make money? After they earn the money they never put it inside [a bank]. So achieve. If Judie achieve in Indian classical dance, after I’m dead they say, ‘Judie’s a classical dancer, you know. She’s dead already. She’s a good dancer’. You know people talk about me. After five years, I have a dance studio, they come, the teacher say, ‘This is a professional dancer, Judie transgender, she dead in this year, born this year. She’s a transgender. They respect me.’ That I want. I want to achieve something in my profession.Aisha, 30 years old, TWSWJudie, 26 years old, TWSWFinally, a small number of TWSWs noted age as a possible motive for participation; acknowledging that older sex workers seemed to generate less income than their younger counterparts. Stella’s motivation as a 57-year-old TWSW stemmed from the fact that she was not earning enough to cover her living expenses and she had few skills valuable in other areas of the labour market. She stated, ‘Now I’m old it’s so difficult to get money… One night I could get MYR700-plus, now I’m too old to earn that’. Meanwhile, younger TWSWs were wary of engaging in sex work till an old age as they witness older sex workers experiencing poverty. Hence, they perceived economic empowerment activities as an opportunity to develop skills necessary to acquire a small business through the capital they generated through sex work.n = 17) and were able to identify initial steps needed to enter a new profession. The remaining participants were either interested in all components of the intervention but were not sure how to enter a new career (n = 7), or were interested in one intervention component, primarily skill building (n = 9). Interviewees in the latter category were younger, hence, were still able to earn a substantial amount from sex work. Their interest in this component of the microfinance intervention was motivated by their long term goal to save enough money to initiate a business.Two participants stated that they would not be interested in participating in a microfinance intervention as they believed that they were not ready to invest time to focus on learning new skills. Jane, a 49-year-old TWSW, said that she was not interested “because when we have invested in these learning skills [from the microfinance course] for a long time, we have to focus on it completely. But I just can’t right?”. Others were eager to participate in a microfinance intervention with the hope that it would enable them to initiate a small business. Their interest in different components of the intervention, including training in professional skills and financial management, varied. Most participants expressed a high level of interest in the intervention and the training offered , you follow your own desires, with no strategies, no plans, and you do things as you please, even if you earn MYR10,000 a month, you will not find it suffice. So from there, I will budget for a car.Dana, 45 years old, TWSWNor Amal, 34 years old, CWSWParticipants reported limited time to attend classes as many engaged in sex work on a part-time basis to supplement income from their primary jobs. They often worked in their primary job during weekdays and in sex work when needed during the evening, leaving a small window of time to attend training workshops. Aisha, a 30-year-old TWSW, reported that she was available only for a few hours on the weekend as on “Saturday, Sunday, there is definitely no leave because there are a lot of customers on these days”. Consequently, concern was expressed over being unable to meet basic financial needs if training occupied time usually allotted for sex work.Other barriers included responsibilities for care of children and lack of access to public transportation. Unlike financial and time constraints, these barriers were perceived as manageable, especially if interviewees were keen on attending workshops. Nor Amal, a 34-year-old CWSW, noted, ‘I will want [to participate] really, because that’s what I’m interested in. If I’m not interested in it, then I will give excuses. I will give a thousand reasons’.I want to rent a space at a Ramadhan bazaar. I planned to make some Kuih [sweets]… I cook myself and then open a stall. But when I asked [about a stall], I learnt that at least you will need to have MYR1000 and that does not include license. If you apply for a license and include the cost of license; it will be over MYR1000, some reach over MYR2000, but there are (some licenses for) also less than MYR1000. I don’t know. I’m also confused which license is right or not.Possible barriers to success in a new, non-sex work occupation were described in terms of lack of resources and knowledge of how to ensure sustainability of small businesses. Participants often commented that although they had developed a business plan, they were unable to establish it as they did not have the capital. These interviewees reported:I want to learn how to save- like [how to] collect money and make a business. I don’t want to just die like this (as a sex worker). I want to save money to open a business. At least when I have all of the money set aside, I want to open a business.Nor Amal, 34 years old, CWSWAadila, age unknown, TWSWCompetition from other businesses were also perceived as a challenge to establishing and sustaining a small business. Some participants were not interested in partnering with others in the community in business ventures; due, in part, to a lack of trust among networks of sex workers. Dana, a TWSW, aged 45-years-old, stated, “I know some families can’t help [with a business] but mine can and we will help each other at all times. Not like friends [other sex workers], they will cheat you eventually.”Participants were also concerned about stigma, which influenced perspectives on training as well as future business opportunities. This sentiment points to the negative influence judgment and stigma towards sex workers could have within a training framework, suggesting a degree of trust and familiarity may be gained when supports are provided by other sex workers. Concerns about discrimination when seeking to operate a business may severely limit actual and perceived economic opportunities outside of sex work. Being HIV positive was described as an added layer of stigma that may drive customers away, as Hazima, a 59-year-old TWSW, said, “If people know I have HIV they won’t come to my restaurant”. Those experiencing additional stigmatized identities may need added layers of support as they seek to develop effective business strategies.Stigma is a challenge; we need to be patient… that is our patience. If our patience is challenged, we would not be there. Let anyone say what they want to say. When they are tired, they will keep quiet. I will turn a deaf ear.Participants argued that they had already developed strategies for coping with stigma as they faced regular prejudice and discrimination in their daily lives. Coping strategies were part of a cognitive process in which they sought to “ignore” stigmatizing behaviours from others in their community. They believed that they were able to develop these cognitive processes from a position of strength fostered from their continual determination to leave sex work.Oh, this [discrimination] is all normal. It is not a big thing for me at all, I don’t make a big fuss. I don’t feel anything… Because we can’t be noticing all of this. It happens when you are young and old. Sometimes, people always like to discriminate. We should just ignore them.Mysha, 57 years old, CWSWWe [other sex workers] need to have a strong spirit, too, don’t get upset over what people have to say. The most important is, straight to the point, we, what we are, what is our aim, we just carry on. No looking left or right, just say what we need to speak. This is a challenge we get from society.Jane, 45 years old, TWSWJune, 33 years old, TWSWYeah, she [a former sex worker] is my friend for life. She has supported me for so long as a good friend. She cannot stand to see me work like this [as a sex worker]… She is the one who taught me how to fry the bananas, fish crackers and so on.Another cognitive process that participants adopted was to draw inspiration from role models in their community who had left sex work for another profession. These role models illustrated that it was possible to overcome barriers associated with stigma to develop a sustainable business. A few role models would offer them advice on how to initiate a business. They reported:For me, I am not scared of discrimination because I see now, a lot of transwomen who run successful businesses. For example, Fatima.Puteri, 34 years old, CWSWAisha, 30 years old, TWSWOther participants were planning to take more direct actions to address barriers related to stigma; a few CWSWs reported that they would initiate their micro-enterprise in a location where their previous history of sex work is unknown. TWSW participants argued, on the other hand, that such barriers could only be addressed through interventions targeting stigma against sex work.This study represents the first in-depth evaluation of the feasibility and acceptability of a microfinance-based HIV-prevention intervention for cisgender and transgender women sex workers who use drugs in Greater Kuala Lumpur. Participants’ socio-demographic characteristics differed slightly from that of other studies charting behaviours of sex workers in other South-East Asian countries, in which participants were often younger –35. MoreOverall, participants expressed a high level of readiness to engage with a microfinance programme. Both CWSW and TWSW were interested in developing their own small enterprises, mostly in the sectors of retail, catering, cosmetology, and entertainment. As many interviewees already had experience managing their own business, they were cognisant of steps needed to initiate their own enterprise but did not know how to make it sustainable. These results indicate that rather than offering beneficiaries’ vocational training for specific occupations, individualized support for development of sustainable businesses should be offered. Microfinance interventions in other countries offering similar types of business-related services to CWSWs have been proven to reduce beneficiaries’ risk behaviours through offering financial alternatives. The Pi Project  in ChennParticipants were, nevertheless, aware of possible barriers to completion of the microfinance intervention. The most prescient barriers were time-related as many participants worked part-time in other occupations, for example as a cleaner, which left a window of a few hours a week to attend classes. Moreover, many participants lacked capital to initiate a small business. These particular barriers could be ameliorated through reimbursing potential beneficiaries for time spent in training sessions  and offePotential barriers to implementation of a microfinance intervention differed according to gender identity; the most pertinent for TWSWs being transphobia. Participants’ accounts pointed to a few possible methods for ameliorating stigma including strengthening of cognitive processes developed for coping with everyday discrimination and drawing inspiration from others in their community who established careers outside of sex work. These coping strategies could be incorporated in the microfinance intervention as a psychosocial component in the form of peer mentoring from prominent sex work activists and entrepreneurs.A potential challenge for CWSWs could be addiction to ATS or heroin. This issue is pertinent among CWSWs in South-East Asian countries as recent research has highlighted that consumption of ATS is prevalent in the CWSW population in Cambodia ,38, VietThe research for this paper had a few limitations; namely, that a convenience sampling approach was adopted owing to difficulties in approaching street-based sex workers who may engage in sex work on a sporadic basis. As outreach workers from collaborating NGOs sampled participants, it was also not possible to collect data on those who declined to be interviewed. Additionally, interviews conducted in languages other than English were not translated according to Brislin’s model, which is deemed to be the most accurate method for translating textual data. Possible errors in translation and transcription were mitigated through regular checks conducted by team members fluent in both languages. Finally, it is important to note that owing to the qualitative nature of this particular study, it is unlikely that the findings would be generalizable to the rest of the sex worker population in Malaysia ,42. As nFindings of this study indicated that a microfinance intervention would be acceptable to CWSWs and TWSWs who engage in drug use in the urban Malaysian context as participants reported that they were ready to engage in alternative forms of income generation and expressed a strong interest in partaking in the potential intervention. The microfinance component of this particular intervention posed to meet the needs of TWSWs as well as CWSWs; both of whom noted a gap in knowledge in developing a sustainable small business.Additional components may need to be added to the intervention to accommodate for the unique needs of TWSWs and CWSWs. These groups experienced stigma differently, many CWSWs had internalized stigma related with sex work, which was apparent by the fact they described their occupation as deeply shameful. They were, thus, unwilling to openly associate with other sex workers, which would sometimes curtail their ability to access services. This particular challenge further highlights the need for an additional psychosocial component to bolster potential beneficiaries’ ability to engage in non-sex work related income-generating activities.Meanwhile, TWSWs perceived transphobia as a potential barrier to initiating their own enterprises. Hence, the incorporation of structural components, in the form of stigma reduction activities in the community, could potentially improve implementation of the microfinance intervention. Structural interventions have shown promise in addressing environmental factors influencing risk behaviours . For exa