Blue Shield of California's Community Health Advocate Program was created to support whole person-health needs by helping individuals of all socio-economic statuses navigate and access community resources, social services, and medical systems. Blue Shield's Health Reimagined team is partnering with medical providers, community resources centers, and community partners to provide intensive person-centered and technology-enabled care to patients, ensuring social needs are met while promoting health equity. A key aspect of the Health Reimagined initiative embeds Community Health Advocates (CHAs) within physician practices serving patients using a payor-agnostic approach, by which Blue Shield aims to increase access to social services and community resources, improve health outcomes, reduce medical costs, and improve overall patient experience. The purpose of this case study is to understand the provider's perspective of embedding a CHA into the care team and the resulting impact on the practice and patients. Blue Shield also sought to identify best practices and barriers of a CHA program within primary and specialty care practices. As part of an ongoing two-year mixed-methods impact evaluation (2019–2021), 10 semi-structured interviews were conducted with a total of 18 providers and office staff at five primary care and specialty practices where CHAs have been embedded. We also conducted two focus groups with the same five CHAs at different points in time. Several themes emerged from the provider, office staff, and CHA interviews. Provider practices found great value in adding a CHA to their care team as the CHA brings flexibility and continuity to patient care. They also found that having access to a CHA with shared life experiences of the communities they served is a key component to the program's success. Providers and staff reported a new understanding of the social determinants of health that impacts a patient's wellbeing with the embedding of a CHA in the care team. Overall, practitioners expressed high satisfaction with the CHA program. During the COVID-19 pandemic, CHAs have been critically important in care, as social needs have increased, and resources have shifted. The CHA program is constantly adapting to address challenges faced by all stakeholders and applying new knowledge to ensure best practices are implemented within the CHA program. With the various health needs of diverse populations and the limited resources available to support these needs, it is imperative to support advocacy initiatives that transform community health . Social Community Health Workers/Promotores (CHW/Ps) are positioned to provide support and identify patients' social needs, help navigate the medical system, and provide referrals and connections to community resources. These public health workers often share a sociocultural background with the patients in the communities they serve, which allows them to establish trust and improve the health system's ability to provide higher quality and culturally appropriate care . EvidencCHW/Ps are traditionally managed by community-based organizations or organizations that function as the liaison between health systems and communities –10. WithWhile research has shown that integrating CHW/Ps into primary care settings is effective and the interventions can result in improved health outcomes,The purpose of this case study is to identify best practices and barriers of a CHW/P program established by Blue Shield of California (Blue Shield). The study shares background about the CHW/P program's approach and findings to date related to the recruitment and training, but primarily the integration of CHW/Ps into primary and specialty care teams and practices. Drawing on results from practice interviews and focus groups, the case study shares key insights and lessons learned from the perspective of providers, staff, and CHW/Ps. While the program is in the pilot phase at the time of publication, there is ongoing evaluation from the program's initiation, which has allowed for continuous learning. This case study focuses on a subset of the CHA programs at one medical group in California across five practices. The case study identifies facilitators and barriers of the program's implementation and early impact to practices and patients from the provider, practice staff, and CHW/P perspectives.Blue Shield reviewed the evidence base for CHW/Ps and began its own program called the Community Health Advocate (CHA) program. Blue Shield adopted the “CHA” title for CHW/Ps to introduce roles within the enterprise and provider partners. Blue Shield first introduced CHAs to the Blue Shield Promise Health Plan (a Medicaid managed care plan) in 2018, with 11 CHAs who served over 4,200 Blue Shield Promise Medi-Cal members by supporting at-risk members with accessing care and addressing health and social disparities.Blue Shield later launched the CHA pilot program across the state in partnership with multiple medical groups and community organizations, as part of the comprehensive Health Reimagined initiative aimed at transforming the healthcare system.A key aspect of the Health Reimagined pilot program embeds CHAs within primary and specialty care practices serving patients using a payor-agnostic approach, meaning the pilot reaches the entire practice's patient population and is not limited to Blue Shield members. This approach is intended to increase access to social services and community resources, improve health outcomes, reduce medical costs, and improve overall patient experience. The pilot program includes a high-touch, personalized provider-embedded and field based-approach to bridge to community resources and integrate social needs in the care plan. The CHAs are an expansion of the care team with workflows built into the day-to-day operations.Patient population reached by the CHA Program: Since the CHA Program's initiation in October 2019, 17 CHAs have served a total of 1,906 patients and created 3,602 referrals, screening their populations for social needs over 2,838 times. A summary of high-level CHA program data by region can be seen in The CHAs serve a diverse patient population. Sixty percent of the patients connected with a CHA were female, and one-third identified as Latino/Hispanic. At initial connection to a CHA, one in three patients who were referred to a CHA reported “fair or poor” health when screened for health-related quality of life measures. Patients reported an average of 19 unhealthy days of the past 30 days, including 7.7 physically unhealthy days and 11 mentally unhealthy days.The top social needs identified from screening patients include housing, access to health care, and unemployment. CHAs made referrals to appropriate community resources to help patients address their unmet social needs. The top referral types were physical health and access to health care, individual and family support, food assistance, mental and behavioral health, and housing and shelter. The types of referrals to resources vary by gender and race/ethnicity. For example, for women, top referrals were for access to health care and mental/behavioral care. For Black/African American patients, the top referral type was for mental/behavioral health, and for Latino patients, the top referral type was for access to health care.The top referral types also varied by practice type. Overall, Mental and Behavioral Health was the most prevalent among primary and specialty care practices. Primary care also had more physical health-related referrals, while specialty care practices had more referrals related to basic needs, such as housing and shelter, and individual and family support. The top referral types varied within each specialty care practice type, as shown in Recruiting CHAs from the communities they serve brings significant benefits for the patient population because those individuals are more likely to have an intimate understanding of the socioeconomic factors faced by fellow residents. Evidence shows the importance of recruiting CHAs who can cross cultural and language barriers to bridge the gaps between providers and communities, and ultimately address key social determinants of health . CHAs muApproach: Blue Shield has a recommended recruitment process to ensure the most qualified individuals are selected for the CHA role  spoken, rapport with organizations, ability to navigate community systems, etc.). Blue Shield's hiring team created the job descriptions medical groups use in their recruiting efforts. A sample job description can be found in Section 1 of the CHA training programs vary in content, focus, education, rigorousness, and time. One limitation to implementing a CHA program in California is the lack of state-level or industry standards for industry preparation . Most trApproach: To address training needs in our state-specific context, the Health Reimagined CHA Program partnered with experts in the field who are familiar with training processes for CHAs across the state. Blue Shield worked in collaboration with various subject matter experts and community-based organizations, such as Partners in Care FoundationBlue Shield engaged with Partners in Care Foundation as a training vendor with years of community-based experience to recruit the right individuals and share meaningful training aimed at refining CHA interactions with patients. The curriculum is designed to be a universal standard for all CHAs and includes various training modules that can be translated to any health setting. Racial justice and equity are themes interwoven throughout the curriculum and in ongoing trainings. CHAs complete training topics specifically focused on equity and inclusion in healthcare. The curriculum also incorporates an understanding of the racial/ethnic disparities in communities and how the CHA role aims to bridge the gap that exists between social and health disparities observed in the community with the care provided by the medical system. The curriculum is currently being used outside of Blue Shield and will be freely available for all Community Colleges in California. The curriculum includes CHA core competency training, behavioral and mental health, field training, and one-on-one mentoring. The mentoring aspect will resume post-COVID-19.Assessment of social determinants of health needs for patients, documenting assessment results, educating patients, and communities, referring patients to community-based organizational resources to close unmet social needs and address health inequitiesActive engagement, building rapport, establishing a trusting relationship, and continuous transparent communication with patients and their family support systemsAssisting patients with problem-solving barriers to health conditions by identifying, locating, connecting to, and navigating needed community and medical system services, including visiting patients at their homes, accompanying patients to medical and related appointments, and assisting patients with completing forms to access needed services.Documenting activities and progress notes in appropriate systems and providing reports to management and providers.Identifying gaps in community resources and medical systems and supporting the implementation of new solutions or services to close identified gaps through advocacy and educationThe Blue Shield CHA training is 40 h of in-classroom instruction and 16 h of mentoring/shadowing in the community. The training curriculum addresses core roles/responsibilities and core competencies, with an emphasis on social justice, cultural humility, motivational interviewing, mental health, and health/chronic conditions, that are essential skills for CHAs to perform duties that include:The Blue Shield CHA Behavioral Health training provides an additional 24 h of in-classroom instruction with a focus on behavioral health to support community members (mainly uninsured/underserved/migrants/homeless communities). The behavioral health training included background information on several mental health conditions, including depression, anxiety, PTSD, substance abuse or misuse, and cognitive function, among others. CHAs were also introduced to trauma-informed care and approaches to incorporate into their duties.Evidence shows that CHAs have maximum impact when they are fully integrated into a care team by having defined roles and expectations, clear reporting and documentation structure, and mutual respect with supervisors and clinical staff , 18. TheApproach: Prior to CHA implementation at the medical group's practices, Blue Shield carefully selected the practices in distinct regions across the state of California. Practices shared unique qualities that made them ideal to partner with for piloting solutions based on readiness and other factors . This process involves evaluating the potential sites against baseline criteria and researching the current standing with the partner. Blue Shield presented the program and confirmed the interest of each provider practice, then defined shared goals and objectives of the practices to ensure the success of the CHA program. Following this initial engagement, a readiness assessment was conducted to determine viability for the CHA program. All sites in this study indicated a need for CHAs at their practices.Documenting data on the CHAs daily activities is a key aspect of successful integration into clinical settings. The workflows of a CHA program are strongly influenced by integrating patient medical records with documented interactions between CHAs and their patients. This can be done by implementing a user-friendly, community-based platform that centralizes these functions . DocumenBlue Shield leveraged tools and infrastructure to help facilitate the training and implementation of CHAs as described above. Meaningful data from the tools used to support CHA infrastructure was utilized in the evaluation to understand the impact of the CHAs in the program. The CHAs begin by engaging with the patient, then, screening for social needs using a social determinants of health screening tool called the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE)Blue Shield leverages a tool called mySidewalk,The second tool, Unite Us,In addition to training the CHAs, it is also important to inform the provider and clinical staff on how embedding a CHA in the medical group practice will impact their work. Sharing information on the CHA role, the types of social needs observed in the community, and the capabilities of the CHA with the provider and clinical staff is critical for the success of the program. The CHAs give voice to the patients' social needs and provide a new lens on the lives of their patients for the providers and clinical staff to see. Blue Shield encourages the practices to discuss the CHA program's aims and capabilities with all staff at the practice, and include the CHAs in these meetings where the CHA can share key aspects of their work. CHAs translate data to action by obtaining insight into local community factors with the use of mySidewalk and Unite Us. The CHA can share data and key insights with the providers and staff on social needs that are unmet and discuss how this can impact patient health.Blue Shield recommends the providers and clinical staff engage in regular team meetings to ensure the CHAs have the information they need to succeed, and their patient population receives appropriate services to address their needs. Studies have demonstrated the value of frequent team meetings to discuss progress and outcomes of patient interventions, or to review CHA roles and training . The appEvaluation and quality improvement are integrated into the CHA program pilots that run from 2019–2021. The evaluation approach uses the Center for Disease Control's Program Evaluation Framework to incorporate standards and phases that are “useful, feasible, ethical, and accurate” . The goavia a practice survey.Blue Shield uses a mixed-method approach and incorporates qualitative and quantitative data collection throughout the CHA program's two-year pilot period. Quantitative data collection is ongoing, which includes the number of patient cases opened and closed, social needs identified, and types of referrals to resources. Additional quantitative data is being collected to capture the provider and practice perspectives on the CHA program Research shows that engaging CHAs in the evaluation process is essential, their unique perspectives and roles strengthen the evaluation efforts and help identify unmet community needs . To dateApproximately 9 months after the CHA program was implemented, Blue Shield staff conducted 10 semi-structured interviews with a total of 18 providers and office staff at five primary care and specialty practices where the CHAs are embedded. Interviews were conducted telephonically over a two-week period in June 2020, and each lasted ~ 60 min. Interview domains included provider and staff experience with the CHA program, preparation for integrating the CHA into the practice, impact on the practice and patients, and understanding of the CHA role and social needs of the practice's patient population. The provider/staff interview guide can be found in Section 4 of the Participation in the focus groups and semi-structured interviews was voluntary. The evaluation is conducted for the purpose of Blue Shield's usual qualitative improvement operations. All participants are informed of the goals of the evaluation, what their participation will involve, and how their information with the CHA program will be used for quality improvement.In each focus group and interview, two Blue Shield team members were present, one led the conversation and the second took detailed notes. Recording was not available and thus the detailed and summary notes from the Blue Shield staff were used for analysis. All qualitative data was de-identified and aggregated for analysis. Using qualitative thematic analysis all data was coded using QSR NVivo software to identify themes that highlight provider, staff, and CHA perspectives on the impact of the CHA joining the practice.Five members from the Blue Shield team collected, coded, and analyzed the data from the provider/staff interviews and CHA focus groups. Two team members created initial code books based on objectives of the pilot and core themes of interest, one for the CHA focus groups and one for the provider/staff interviews. To align on definitions and use of the codes, all five team members coded one provider/staff interview. The team discussed differences and aligned on definitions. The remaining interviews were each coded by two team members. The same process was followed for the CHA focus groups. If a new theme was identified through the coding process, the team discussed the potential new code and added if consensus was reached. Prior interviews were re-coded to incorporate the new codes. Codes were then organized into higher level concepts. The team reviewed the emerging concepts and identified themes. Findings were summarized and learnings were shared with stakeholders, including CHAs, providers, and practices. Stakeholder input facilitated the ability to confirm findings and develop actionable learnings for program improvement.Blue Shield found that having a direct collaboration with the medical groups in the recruitment efforts resulted in streamlined communication and yielded successful recruitment results. The candidate pool was diversified, and all candidates considered were well-qualified. The effectiveness supported the overall hiring goal because it was efficient enough to deliver high-quality, more engaged hires that led to a competitive advantage that directly impacts the program. Additionally, the resulting CHA workforce is diverse and shares life experiences with the patients in the communities they are assigned to serve.The Blue Shield CHA curriculum is a compendium of materials from partners, subject matter experts, and several publicly available sources. The CHA curriculum is critical to ensure CHAs are adequately trained and supported so they can be effective in their roles of supporting patients around social needs. The curriculum and training approach is meant to be comprehensive and includes core competencies around social needs and social determinants of health, an introduction to behavioral and mental health tools, mentorship, and one-on-one training. With holistic training, the CHA is able to improve access to health and community services for patients, contribute to community development, and ultimately impact social determinants of health in the local community. CHAs have reported high satisfaction with the content and depth of the training. The CHAs receive continuous training every quarter further supporting the educational material introduced in the curriculum as well as creating opportunities for CHAs to share best practices with other CHAs.In the 10 interviews with providers and staff and the two focus groups with CHAs, interviewees described their perspectives on the role of a CHA, and what factors helped enable his or her success. Key themes are described in this section and are outlined in The CHA Program intentionally hired a diverse CHA workforce that has shared life experiences with the communities they serve . Providers and the CHAs have noted the importance of having CHAs who understand and can relate to their patients and cite this as a key component of the program's success.I have experienced working with the patient and the patient is hesitant to tell me their social needs . Machismo is very established and I'm a 5'1 female, every time I have a new male patient referred by a male friend I'm surprised.” This CHA understood the nuances of gender expectations that existed with her Latino patient, yet the trust and rapport that she patiently established with the patient provided an opportunity to support a patient that may not otherwise have engaged with the practice. Another CHA found that sharing her own story around a local event that affected the community helped patients see her as someone with a deep understanding of the community. The ability to build trust is important with patients, as providers noted that patients may not always ask for help.Shared life experiences or characteristics can help CHAs establish trusting relationship with their patients that has often allowed them to overcome social or cultural barriers with patients. As one CHA recalled, “The providers and staff highlighted several instances where the CHA's shared background or life experiences  enabled the CHA to reach a broader patient population. The shared background, coupled with the additional time the CHA can spend with a patient, allows them to create a connection with the patient beyond what the provider could achieve.The findings are similar to what other studies have shown , that unthere was not a lot of information for all staff at the practices on the role of the CHA prior to implementation” and “the first day I showed up and the clinic staff didn't know what the position was.” In some cases, only practice leadership were familiar with the CHA's role, and other practice staff were not, resulting in uneven utilization of the CHA's services. Most CHAs said that after several months, relationships improved, as other staff members became more familiar with the role.CHAs report that it takes time to develop good working relationships with providers and practice staff. Some CHAs noted that when they began in their position, other practice staff seemed unaware of the purpose of their role, or how to interact with them. As one CHA said, “felt nebulous because we weren't totally sure how to use the CHA. What the actual role would be.” One provider who was actively involved in the onboarding of a CHA said he did not promote the CHA enough to clinic staff at the start of the program and as a result, the practice was not using the CHA to their full capacity. The provider states, “I assumed that when I told people about and introduced her and gave her a lot of verbal support “hey you guys should try this” I thought if I did that once or twice it would be enough.” Clinic staff had similar feelings to the providers and felt that “people gravitate towards those in charge and don't focus on other members of the team, who may not be involved in practice leadership.” Improving adoption of the CHA was dependent on clearly establishing activities of the CHA role, ensuring that all providers and staff at the practice were aware of the CHA, and continuous communication throughout the practice.Providers and practice staff agreed in interviews that there was an opportunity to further communicate the capabilities of the CHA with the full practice. The CHA role was new at all practices and for some providers having a CHA “Practices that established clear onboarding processes –including introducing the CHAs to the entire staff— reported that integrating the CHA into the practice went smoothly. One practice also emailed all patients to introduce the CHA and highlight how they could support patients. This multi-channel communication strategy helped connect CHAs, practice staff, and patients from the beginning.Practices reported that CHAs were increasingly effective over time, as they continued to carve out their niche in the practice infrastructure. During the COVID pandemic, CHAs have been integral to supporting patients, as social needs have increased, and available resources have changed.Many people live alone, and don't have family nearby and have lost their social support.” Some providers believe that the CHAs are time savers and improve quality of care provided; “the CHA is greatly improving the care we can give to our patients.”Providers often underestimate the level of social needs of their patient population. After having a CHA in their practice, providers consistently note the success of the program and the increased ability of the practice to care for their patients because the CHAs help the entire care team to better understand and address patients' social needs. In the current COVID environment providers recognize the need for CHA services. As one provider mentioned, “this (CHA) is one of those things I didn't really believe in. I was not an enthusiastic adopter. I was foolish. I thought people were doing better than they are, and I was wrong.” CHAs contribute to the provider and practice a new or different perspective of their patients, sharing a window into the patient's life that the provider might not otherwise see, but that can impact the patient's health or care.Several providers initially reported they did not believe their practice needed CHA services. However, after the CHA was integrated into their practice, the providers reported appreciating learning more about their patients' social needs. For instance, one provider had been seeing a patient for 10 years and did not realize the financial burden the patient faced as a result of weekly dialysis until the CHA brought it to the provider's attention. Another provider said “CHAs were successfully integrated into Primary Care and Specialty Care practices in the CHA Program. Across the five practices, there was no clear pattern in facilitators or barriers to embedding CHAs by practice type. Some practices had more bandwidth related to time and staff that facilitated implementing the CHA program and were able to embed the CHA more quickly than other practices. Additionally, while all practices had a provider champion, there were varying levels of readiness and receptiveness by the practice to addressing social needs for patients via the CHA program. Some provider champions were more proactive in communicating the importance of social needs and the CHA to the rest of the practice, which enabled all providers and staff to incorporate the CHA role into the practice workflow, care team, and the broader culture. For the provider champions that were less engaged in communicating the importance of the CHA role, integration into the practice culture and care team took longer.For both primary and specialty care practices, behavioral and mental health was among the most pressing social needs, which coincides with the COVID-19 pandemic. Among the specialty practices, the CHAs were able to tailor their support around specific populations or needs within a smaller scope. For example, a CHA at a specialty care practice coordinated classes with a community-based organization focused on diet and food for diabetes care management. The specialty care practice had an engaged pool of patients with diabetes that benefited from the support of the CHA. In specialty practices, the CHA was often able to focus their support and scope based on the specific needs of the patient population. At primary care practices, the scope of social needs was broader, and the types of support needed by patients varied. In primary care practices, the top referrals to resources were for mental and behavioral health, such as individual counseling, benefit navigation, housing, and transportation. For specialty care practices, the top referrals to resources varied by specialty type. For example, the CHA at an obstetrics and gynecology practice had the highest referrals for mental health, support groups, and housing, while a CHA at an orthopedics practice had the highest referrals for ride coordination, emergency food, and job search. In each of these examples, the CHAs in specialty practices supported patients around social needs associated with the care and management most needed by the specific patient population, whereas the CHAs in primary care practices had more diversity in the types of social needs and the resources they engaged with to best support their patient population.Patients feel empowered by the CHA program and are starting to treat their healthcare differently. CHAs report that some patients have learned to advocate for themselves and are able to ask providers and community organizations for resources at the recommendation of the CHA. With help from the CHA, patients have become more comfortable using the mediums of communication from their providers, such as the provider's online platforms, and are now more engaged with accessing services and communicating with providers.give the patients a lifeline and a personal number they can call.” The trust between a CHA and a patient can translate to improved relationships between patients and providers. As one CHA recalled the story of a homeless patient whom he had supported with accessing housing, the patient now saw the practice as his family and came in several times a month to socialize.CHAs build trust with their patients by sharing their own stories and finding commonality in their experiences with patients. In this way, CHAs can often learn about a patient's needs that a patient would not have otherwise shared with a provider. As one CHA mentioned, CHAs “the doctor is telling them to eat healthy, now this CHA is telling them where they can get these foods.” As the CHA supports the find resources to address the patient's needs, the CHAs also help the patient translate the provider's recommendations, allowing the patient to more fully engage with their own care.For providers, the CHA can support the care and recommendations a provider gives a patient. At one provider's practice, the CHA partnered with a community-based organization to bring nutrition classes for patients into the provider practice. The CHA can help patients put into action the provider's care plan. As the provider noted “During the COVID pandemic, CHAs have been critically important in supporting patients, as social needs have increased, and available resources have shifted. Some providers report their patients are experiencing increased angst, drug/alcohol abuse, domestic violence, decreased physical activity, vaccine confusion and hesitancy, along with stresses from lack of school consistency, loss of jobs and inability to pay for rent, food, and transportation. The additional limitations in support systems, in combination with the above, have also led to role shifts — with some CHAs providing more of a counselor/support role, on top of their roles screening and provider referrals for needs. One CHA described the fear and stress their patient was encountering because of the pandemic and the changes in accessing health care: “Whatever routine the patient had before has mostly been put on hold. Causing tremendous stress.” When supporting patients in quarantine because of COVID, staff also expressed how the CHAs deescalated the fear and stress of being in isolation and reduced unnecessary hospitalizations: “we want to create a trusting relationship and because of the relationship (with the CHA) we've mitigated the need for some patients to be hospitalized.” As patients shifted to virtual care or rescheduling procedures and appointments, CHAs helped to coordinate care for patients and provider overall support during the process.CHAs also described the changing availability of resources for their patients as COVID impacted the availability and funding of all sectors, including the local organizations that patients could be referred to. CHAs had to do additional outreach to resources and think creatively to address patient's social needs.Similar to previous research , 25, 26,Blue Shield has successfully incorporated CHAs into primary care and specialty practices and to those serving mainly commercial patients. The CHA program effectively balances its standardized high-quality didactic and experiential training, while allowing flexibility to adapt training to various practice types and workflows. The CHA program contributes valuable insights into creating and implementing a payer-agnostic, provider-embedded model.While all provider practices found the CHA beneficial to their patients and practice, some had challenges ensuring the full practice understood the role and capabilities of the CHA. There was no observable difference by type of practice, i.e., primary vs. specialty care. Slower adoption of the program and integration of the CHA into the care team differed by practice bandwidth (time and staffing), level of engagement by the provider champion, and overall culture of the practice around the importance of social determinants of health. Discussions are underway with subject matter experts, Blue Shield, and providers and clinical staff to provide detailed education and communication of the CHA program at future implementations and to share best practices from the initial providers. This includes clear communication of the CHA role and abilities, change management among the practice to institute effective workflows and increase communication between all providers, staff, and the CHA, and increase awareness of social determinants of health and the link to health care. To address some challenges with data sharing and communication between CHAs and practices, Blue Shield is maximizing the technology and resources CHAs use in their day-to-day work and partnering with providers and medical groups to align on data sharing and access.The pandemic has exposed and amplified long-standing systemic health and social inequities along with the associated increased risk of infection, hospitalization, and death in marginalized racial and ethnic groupsIn response to the added stresses and uncertainties of the COVID-19 pandemic, Blue Shield has implemented Healing Circles, offering them to all CHAs. Healing Circles help people step out of their day-to-day and into a safe and accepting environment where they explore ways of healing. They provide a safe place to discuss the impact of the recent events on the CHAs themselves, their patients, and families, and provide an environment for CHAs to decompress emotionally and mentally. They also provide ways for CHAs to learn to support each other, and practice self- and stress-management tools. Healing Circles have been shown to enhance camaraderie and support for practitioners who work with patients with significant needs . They haBlue Shield values the work of CHAs and recognizes the unique role they play in health care. Blue Shield intends to remain a leader in promoting this work for members, the communities where they reside, and scale similar programs on a broader level so other communities can benefit from this work.A statewide Community Health Advocate Program has the potential to maximize positive impact in addressing Blue Shield members' unique social needs, while improving social determinants of health, and ultimately producing a sustainable, affordable, and equitable reduction in high-cost unnecessary utilization costs. Blue Shield is launching a pilot for Blue Shield members in specific regions to commence the statewide approach. CHAs will serve and conduct telephonic outreach to members at risk of having a need, as well as high-risk members with care gaps, complete a psychosocial assessment, and telehealth solutions as alternatives to home visits. This will allow Blue Shield to proactively reach patients to be connected to CHAs without having to be referred by a provider.,,Building on lessons learned from the initial experience with the CHA program to date and considering ways to address racial inequities, Blue Shield is developing pilots for targeted populations that could benefit from a CHA program. One example is racial inequities in maternal and infant health. According to the US Department of Health & Human Services Office of Minority Health, Black women are three–four times as likely to die from pregnancy-related causes than non-Hispanic White women, and Black infants have over two times the infant mortality rate as non-Hispanic WhitesPart of the evaluation of the CHA program includes the consideration of the financial and social returns for health plans, providers, patients, and community partners. Funding CHAs is a challenge that has been widely identified, as providers or practices alone may not be able to carry the financial burden of funding a CHA role , 30. BluThis case study of the CHA program presents initial data from the provider and CHA perspective and is limited to early learnings of the program. Future work will include additional data sources to complement the current findings, such as completed practice surveys, aggregated patient health outcomes, and Blue Shield member utilization and cost of health care. Additionally, this case study focuses on a subset of the CHA programs at one medical group, thus generalizability to a broader population is limited.The payor-agnostic model of the CHA program presented challenges to implementation, specifically around fidelity of the model as Blue Shield did not have full control of implementation at the practice level. Additionally, the internal evaluation is limited due to the ability to access only Blue Shield members' health care utilization information. Blue Shield does not have access to patient specific outcome data for non-members, thus limiting evaluation of the full patient population at the practices, and as a result, the full impact of the CHA program.The COVID-19 pandemic has impacted the CHA program in multiple ways, such as exposure to the virus among patients and staff, protocol changes to the CHAs workflows and changes to their scope of work, and drastic limitations to in-person care. Each practice site put in different protocols to address the pandemic, resulting in greater variations to the CHA program than anticipated.The challenge of sustainability beyond a health plan's pilot program is similar to that of other organizations that struggle with funding CHA programs. While CHA programs have been shown to benefit providers and patients, ensuring proper funding for CHAs remains an ongoing challenge that requires significant statewide and anchor organization (including CHW organizations) partnerships to resolve.The Blue Shield CHA program continues to address the gaps in recruitment efforts, training and education, and successful integration of CHAs into teams, provider practices, and the community. The program saw positive outcomes from recruiting a diversified pool of applicants, as it supported the delivery of high-quality candidates that directly impacted the program's success. Blue Shield's thorough CHA training curriculum, co-developed with subject matter experts in the field, proved critical to improving access to health and community services and ultimately impacting social determinants of health in the local community. Interviews with all stakeholders around the integration of CHAs into provider practices and the community brought out several themes on what factors enabled CHA success. Providers found value in having access to a CHA workforce with shared life experiences of the communities they served. CHAs embedded in the care team also increased the provider and staff's understanding of the social determinants of health that impact a patient's health. Embedding CHAs in the care team also impacted the patients' engagement with their health and care and allowed them to be more comfortable communicating with providers.While all provider practices reported successful outcomes of embedding CHAs in the practice, the CHA program continues to adapt to address challenges faced by all stakeholders. The COVID-19 pandemic has especially amplified the need to support patients, with increased social needs prevalence in the community. Blue Shield plans to remain a leader in promoting CHA work for all patients and the communities they reside.The data supporting the conclusions of this article will be made available by the authors upon request and with approval from Blue Shield of California's outbound data process.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SC, LP, and JE contributed to conception and design of the program. ST and MA oversaw the data collection and analysis plan. ED, ST, BBe, RP, AL, and LM performed the qualitative analysis. CP and ED wrote the first draft of the manuscript. BBe, LM, ST, and RP wrote sections of the manuscript. BBo, JS, and AC served as subject matter experts and contributed to interpretation and analysis of the findings. All authors contributed to manuscript revision, read, and approved the submitted version.The following authors are employee of Blue Shield of California: CP, ED, LP, RP, ST, BBe, AL, JS, MA, JE, and SC. AC is an employee and BB a provider at Hill Physicians Medical Group. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Climatology has increasingly become an important discipline for understanding tourism and recreation, especially in the era of contemporary climate change. Climate indices, in this respect, have been useful tools to yield the climatic attractiveness of tourism destinations as well as in understanding their altering suitability to various tourism types along with the changing climates. In this study, a major gap for a comprehensive climate index tailored for ski tourism is aimed to be fulfilled. For this purpose, initially the Ski Climate Index (SCI) is specified, based on fuzzy logic and as informed by literature and through extensive co-creation with the ski tourism industry experts, and applied to an emerging destination, Turkey, based on regional climate modeling projections. The index is designed as a combination of snow reliability and aesthetics and comfort facets, the latter of which includes sunshine, wind, and thermal comfort conditions. Results show that the Eastern Anatolia region is climatically the most suitable area for future development, taking account of the overriding effects of natural and technical snow reliability. Future research suggestions include the incorporation of more components into the index as well as technical recommendations to improve its application and validation. Climatology has increasingly become an important discipline for understanding tourism and recreation  is initially specified as informed from literature and through extensive co-creation with ski tourism industry experts in Turkey, where an intensified growth of the sector has been observed over the past two decades and the authorities project the number of domestic skiers to grow into 4 million and the ski resort development investments to add up to €48.5 billion by the 2020s  and those non-snow components related to aesthetics and comfort (AC), such as sunshine, wind, temperature, and humidity.The specification of the SCI is initially based on varied consultations with ski industry experts through the ts ECMWF , the TecSCI. As Mitchell  of overlay within and between the facets of the Mitchell , p. 129 Mitchell , where iMitchell  such as Mitchell . For exaG) value to fine-tune the model increasively or decreasively according to whether the aim is toward the optimal or the potential solutions. The logical operators AND and OR, on the other hand, strictly exclude and include certain inputs, respectively, by defining an intersection set (∩) or a union set (∪) among them. They could be preferred over the mathematical operators to avoid any overestimation should any input sets be potentially correlated.The overlay techniques in fuzzy logic Mitchell  are also3 , the seasonal (DJFM) average number of naturally skiable days in a climatic range of 30 years is fuzzified by the LARGE algorithm, where observation values above a midpoint of 100 days are honored with higher (more than 0.5) membership values.As confirmed by ski tourism stakeholders, snow is the most essential climatic factor, making SR the most important facet, which is a function of depth and duration of natural and technical snow. This facet is primarily measured by the climatic average (30 years) of the number of days with sufficient snow depth for downhill skiing during the winter tourism season from December 1 to March 31 (DJFM). Here, April is excluded, despite its snow accumulation potential, due to the likely backyard behavior of demand, that is, the effects of one’s home weather conditions on her/his ski trip decision  appears to be another component to be considered within the SR facet. As noted by experts and operators, as well as the literature , it is reported that the average snowmaking systems could prepare a base layer in 72 hours  are also measured with respect to their likelihoods of occurrence. In the case of Turkey, the ideal threshold for the SUNSHINE (SS) duration per day, which takes account of the cloud cover, is set as a minimum of 6 hours—higher than the Alpine threshold of 5 h/day  and a temporal resolution of 3 h under historical and future datasets. The critical SWE values are computed for each grid by considering numerous parameters such as land type, soil information, net surface heating, and soil or snow heat capacity since the land surface processes are coupled to the RegCM via the Biosphere-Atmosphere Transfer Scheme  software for both temporal ranges, the point data are rasterized in the ArcGIS software, based on their actual spatial resolution, for further fuzzification processes where the observed values are assigned with fuzzy memberships and hierarchically overlaid according to the parameters summarized in Table The results section is organized into, first, an overall examination of the spatial distribution and the future temporal shift of the SCI and its sub-index scores Figs.  and 2, tSCI scores over Turkey  projections of 971–2000 Turkey’s near future 2021–2050) climatological potential in terms of ski tourism development is projected to shrink  Global Moran’s Index value of 0.52, indicating that the extreme deviations are spatially clustered  was suggested by means of fuzzy logic, where the SR facet had the dominating role on the overall performance and the AC facet, based on sunshine, wind, and thermal comfort conditions contributed to further refinement. The results revealed that all other physical and human factors being equal, the climatologically primary zones for ski tourism development in Turkey lie in Eastern Anatolia, currently almost underutilized, and posing an opportunity for the future of the region. In this respect, more development proposals may need to be considered especially in the provinces of Hakkari, Bayburt, and Bingöl, while those projects planned in the Central Taurus and the Eastern Black Sea regions may need to be reconsidered due to their deteriorating snow conditions and/or exposure to strong breezes and high cloud cover. In any case, it is imperative that the considerations on SCI performance for future projects be based on projections, rather than the conventional observation-based decision-making, to account for the impacts of climate change. Then, however, the projections need to be based on the outputs of as many climate models and representative concentration pathways as possible, which is a major limitation of this study. Employment of non-hydrostatic regional climate models would also increase the quality of outputs with their ultra-high resolutions that account for topographic diversities. Otherwise, further statistical downscaling techniques  factors besides snow conditions. For example, an existing ski area that is projected to get more snowfall in the future, but also more stormy days, may not be as viable as one may interpret on snow data only. Unlike the natural and/or snow-only indices  and Kurban Bayramı , which are dated according to the Islamic Lunar Calendar and will in the near future fall into the ski seasons, are potentially significant periods of high demand for domestic as well as the emerging Western Asian markets. The 2-week long school break in February is another period to be considered, especially as a spatiotemporal dispersion of this period is sometimes on the policy agenda (Demiroglu Future studies on the SCI and its applications could focus on further iterations with the field experts, as well as the growing econometric studies on the demand side (see Mayer et al.


Background: Schizophrenia has brought a serious disease burden to China. Under the background that community rehabilitation has become the mainstream treatment model, the long-acting injection (LAI) can better prevent recurrence. Some districts in Beijing have also issued policies. This article aims to find out patient's current attitudes toward LAI and provide policy suggestions.Methods: Some patients with schizophrenia in the communities are selected, while the survey format is face-to-face conversation. The content of the self-made questionnaire includes patients' willingness and reasons for accepting LAI treatment. Descriptive statistics, t-test and F-test are used to process the data from questionnaire surveys.Results: About 10% of respondents have had experience using LAI and the current utilization rate is 2.4%. Respondents' willingness to accept LAI is generally low (only 18.1% are willing). The main reason for willingness is no need to take medication every day, while the main reasons for unwillingness are high cost, fear of injection and lack of understanding.Conclusion: Beijing community patients are not very optimistic about LAI's cognition and willingness. Medication habits play an important role in their medication selection decisions. Intervention such as educate clinicians and patients about LAI and provide free injections to patients can be imposed. The promotion of LAI still has a long way to go. Schizophrenia is a type of severe mental disorder. The disease has positive psychotic symptoms  and negative psychotic symptoms [lack of motivation, decreased feeling of pleasure, emotional retardation . Its typOne type of antipsychotic medicine is long-acting injection (LAI) including first-generation depot antipsychotic (FGDA) and second-generation depot antipsychotic (SGDA) . As a neThe development of LAI is a big boost to “Deinstitutionalization,” making it possible for more patients to return to the community. For a long time in the past, due to the limitations of poor oral medications and poor adherence, hospitalization was the mainstream treatment for schizophrenia. “Deinstitutionalization,” which originated in the late 1950s, is a process led by the American government to reduce the size of mental health specialist medical institutions, to reform the mental health model, and to change ideas , communiIn recent years, the prescription rate of LAI in developed countries such as Britain or France in Europe and Singapore in Asia has been maintained at a relatively high level (~20–40%) –25. As tThe previous literature has shown that the reasons for the low utilization rate of LAI are complex, and the attitude of clinicians and patients is an important factor . A studyThis study is a cross-sectional survey. The data is collected from the registered patients with schizophrenia in Beijing communities through a questionnaire, which is primarily in the form of face-to-face interviews and with telephone interviews for respondents who have difficulty in moving. The samples are obtained by multi-stage stratified sampling using the following steps: Firstly, the 16 districts of Beijing are divided into three layers according to the special policy status of LAI, including those that have been implemented for more than 1 year (Chaoyang and Fengtai), have just begun to implement (Tongzhou and Fangshan) and have no special policies (the other 12 districts). Secondly, one district is randomly selected from each of the first and second layers, and two districts are selected as representatives from the third layer. Finally, two communities are selected from each district according to the topographical features , and cluster sampling is performed on all registered patients who meet the inclusion and exclusion criteria. Calculate the required sample size according to the sample size formula:Taking α = 0.05, π = 50%, and δ = 0.05, considering the loss rate of special populations, the sample size is increased by 30%. A total of about 500 samples are drawn from the layers according to the ratio of 4:3:3. There are currently about 50,000 registered patients with schizophrenia in Beijing, and the sampling ratio is about 1%. The survey is conducted anonymously and don't contain any identifiable information. Every interviewee participates voluntarily and signs an informed consent form. This study passed the ethical review of the Medical Ethics Committee of Capital Medical University.The inclusion criteria for survey subjects of this study are as follows: (1) patients meet the ICD-10 standard and have been diagnosed with schizophrenia. (2) Be at least 18 years old and have a health record in the community. (3) Not currently in hospital, and properly managed in the community. There are also exclusion criteria: (1) Patient has another co-morbid mental illness. (2) Has a high risk of suicide. (3) The physical condition of the patient is insufficient to complete the investigation or refuse to provide valid information. The study lasted for 3 months from August to October 2020. A total of 496 valid data are obtained, including 197 cases in Chaoyang District, 142 cases in Tongzhou District, 96 cases in Changping District, and 61 cases in Mentougou District. The response rate of each community is not <75%.This study uses self-made questionnaires. To ensure the quality of the questionnaire, two measures are taken: In order to ensure the rationality of the questionnaire, this study uses the expert consultation method to determine the questionnaire items. After about 4 rounds of consultation, the first version of the questionnaire is finalized. The experts in related fields, including four professors of mental health and health economics, three clinicians from psychiatric hospitals, and three psychiatrists from primary health institutions have been consulted. In addition, a preliminary survey based on a small sample has been used to modify instruments.This questionnaire consists of the following three parts. The first part is the basic information, including age, economic status, occupational status, education level, course of disease, and hospitalization experience. The second part is related to the patient's treatment plan. The investigator would ask the patients about the following information in turn, including medication adherence in the past year, current treatment ways, satisfaction with oral medication treatment and efficacy, whether they have heard of LAI and information acquisition channels, and whether they have ever used LAI in the past. The measurement of medication adherence refers to the questionnaire of Kishimoto et al. . Before t-test and analysis of variance to compare between groups to explore whether there are differences in patients with different characteristics in willingness to accept LAI, SNK-q test and LSD test are used for post-inspection. All processes of statistical analysis are carried out in SPSS 26.0 software.In this study, an electronic questionnaire system is used to input and collect data. For measurement data such as willingness scores, the average and standard deviation are used to describe its characteristics; for enumeration data such as basic information and reasons for selection, frequency and percentage are used to describe its distribution. This study mainly use The demographic characteristics of the overall respondents in this study are shown in As shown in The willingness to accept LAI and reasons why respondents make such choices are also shown in As shown in This study has initially grasped the current attitudes of schizophrenic patients in Beijing community toward LAI. The following valuable findings in this study can be emphasized.The results of this study show that the utilization and awareness rate of LAI among patients with schizophrenia in the Beijing community are very low. Recent epidemiological studies have found that the prescription rates of LAI in clinical settings vary between 20 and 40% in European countries , 24, 36,In addition, this study also finds that although patients' attitudes toward LAI are still generally negative after the investigator's science popularization, a sizeable proportion (18.1%) of patients show preference for LAI. The systematic review of Waddell and Taylor in their analysis of 12 articles on LAI use has come to the same conclusion . When anThis study also reports that those who obtained LAI knowledge from the news media have the highest willingness to accept. In China, the government has strict supervision over the news media , which iThis study finds statistically significant differences in LAI acceptance willing by education level. Existing researches have not studied the attitude of patients with LAI from the factor of education level. Although LAI has been clinically used in the United States and European countries for a long time, it is not long in China and unfamiliar to most Chinese patients. Roopun et al. have pointed out that strengthening education can potentially improve treatment acceptance . PatientRegarding the reasons for accepting LAI, about 70% of LAI supporters said that the convenience of not taking medication every day is the reason why they prefer it, which is similar to the results of Wehring et al. . HoweverIn conclusion, the education of both clinical psychiatrists and patients on LAI knowledge needs to be strengthened urgently. Das et al. have pointed out that the patient's preference can only be exercised when they have information about other available alternative treatment options, while the information about the choices needs to be provided by the psychiatrists . And theThis study makes significant contributions to the current field of mental health and the treatment of LAI. First of all, unlike most previous clinical studies based on patients in psychiatric hospitals , 60, thiThis study also has some limitations. One is that this study uses non-standard self-made questionnaires for on-site surveys. Because there is no standard questionnaire for LAI research, this study can only formulate a questionnaire containing the research information based on the literature , 62 and This study uses a cross-sectional design to conduct a site investigation of schizophrenia patients in Beijing community, and evaluates the attitudes toward LAI and the reasons for their preference. Results have proved that patients as a whole are not willing to accept LAI treatment due to various reasons, and the current utilization rate is low. Policies can be tilted toward the publicity and education of LAI for clinicians and patients. As an important tool to promote the transformation of the mental health community model, LAI helps recover patients to return to society and is worthy of vigorous promotion. In the context of economic globalization, popularizing LAI treatment is not only a more cost-effective way to maintain social stability, but also a big step for China's schizophrenia treatment ways to be in line with the world.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The protocol of this study was approved by the Medical Ethics Committee of Capital Medical University (NO: Z2020SY123). All respondents were voluntary and written informed consent was obtained. All data collection is anonymous.JZ contributed to the conception and design of the study. JZ, YC, WL, QH, BL, YX, RX, and LJ organized the data collection. WL performed the statistical analysis. JZ, YC, and WL wrote sections of the manuscript. All authors contributed to the manuscript revision, read, and approved the submitted version.This study was supported by the Beijing Municipal Natural Science Foundation (Grant no. 9192004) and the National Natural Science Foundation of China (Grant nos. 71573182 and 71974133).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In February 2021, a new Ebola virus disease outbreak was confirmed amid the COVID-19 pandemic in the Democratic Republic of Congo. Although the country has successfully contained the outbreak amid its fight against the COVID-19 pandemic, the epidemiological situation is still concerning, primarily due to the risk of an increase in the number of COVID-19 cases. The coexistence of both outbreaks increased the burden on the country’s health system mainly because Ebola response programs were redirected to the COVID-19 national response. Strategies adopted and lessons learned from previous Ebola outbreaks were crucial to developing the COVID-19 national response. To tackle the challenges of combating both the viruses, it is essential to adopt multidisciplinary measures such as prevention, education, and vaccination campaigns, promoting hygiene and social distancing practices, and improving diagnostic and management protocols. This paper discusses the efforts, challenges, and possible solutions to grapple with Ebola amid the COVID-19 crisis in DRC successfully. To the editor,Democratic Republic of Congo’s (DRC’s) largest-ever outbreak of Ebola virus disease (EVD) spanned from August 2018 to June 2020, which recorded 3481 cases and 2299 deaths in North Kivu, South Kivu, and Ituri provinces [Although DRC has successfully contained the Ebola outbreak, the country’s epidemiological situation needs to be closely monitored. The data from May 15, 2021, suggest that the percentage of COVID-19 cases in DRC has dropped by almost 30% in the last week; however, WHO still reported 271 new cases and three deaths within that period , 5. ThisIt is noteworthy to mention that a hostile climate, poor road networks, ruthless terrain of deep rainforests and savannas, and extreme poverty make DRC’s public health infrastructure eminently vulnerable . In the The COVID-19 pandemic negatively impacted the epidemiological control of several infectious diseases worldwide –10. For Although COVID-19 has introduced significant obstacles that threaten the health, wealth, and social structure of DRC, several lessons learned from managing the previous calamitous Ebola virus eruptions have been crucial in initiating the existing COVID-19 health responses. These include collaborating with community representatives and organizations to elucidate the disease and circulate important information to the public in native languages. The foundations and workforces of the Ebola virus have been redistributed to the COVID-19 response. UNICEF redirects additional staff, provides medical tools for Ebola cases in North Kivu, and works closely with local health organizations to contribute to source control and disinfecting activities .Vaccines are essential to strengthen immunity against both COVID-19 and Ebola virus disease. More than 1.7 million vaccines of COVID-19 have been delivered to the capital city of Kinshasa by COVAX. AstraZeneca vaccine is being used because it meets the storage circumstances, i.e., 2–8 °C in DRC .The failures and challenges encountered in dealing with the recent Ebola outbreak in the DRC point towards the need for more comprehensive measures to guarantee a more effective national response, both in the prevention and control of future outbreaks of Ebola and other infectious diseases in the country. The first point to be addressed is the need for a greater understanding of the gaps and flaws of health security in the DRC. For this, it is necessary to reassess the congruence between the measures of prevention, detection, and response to Ebola outbreaks and other acute public health emergencies adopted by the country and the recommendations of the International Health Regulations (IHR) of the World Health Organization. It is necessary that the monitoring and evaluation of the recommendations of the IHR through the voluntary Joint External Evaluation (JEE) is carried out continuously and frequently, following the outbreaks of re-emerging infections, and especially in public health crises that provide a favorable environment for the occurrence of new emergencies, such as the COVID-19 pandemic, humanitarian disasters, and conflicts. This is essential to determine the actual capacity of the DRC, in the present context, to prepare and respond to future public health threats through a coordinated response.The JEE is also considered necessary to guide the effective redirection of monetary, human and infrastructure resources, preventing public health emergencies from becoming environments conducive to the resurgence of previously controlled diseases due to the uncoordinated reallocation and prioritization of resources. The responsible institutional bodies must establish well-defined health safety protocols regarding the necessary actions to prioritize resources and address any gaps.The second point is the planning strategy, which must focus on preventing, detecting, and responding to the risks of new Ebola outbreaks. For prevention, it is essential to strengthen warning systems to detect the occurrence of isolated cases of Ebola as soon as possible and begin contact tracing to prevent the spread of the disease, such as isolation of suspected individuals and those who have had contact with someone with a suspected or proven diagnosis of Ebola.Furthermore, a strengthened health care strategy is necessary for DRC since conflicts, political turmoil, and current lockdowns and social distancing protocols due to COVID-19 have made it extremely difficult to access health services in some areas and communities. Active and passive surveillance within each community should be carried out, especially those that pose a greater risk for the resurgence of Ebola cases. Telemedicine services also play an essential role in surveillance, either by monitoring suspected individuals in locations with difficult access or allowing collaboration between specialists trained in identifying and managing the disease and health professionals with a comparatively lower level of expertise.Conducting robust epidemiological analysis based on previous outbreaks is critical in anticipating new cases and preventing future outbreaks. Since genetic analysis confirmed that the index case of the last EVD outbreak was related to an EVD survivor from the 2018–2020 epidemic , and EVDAs past outbreaks have demonstrated the critical importance of social mobilization to reduce EVD transmission in the community, it is also necessary to improve communication with the population and the dissemination of correct information to demystify false news and fight disease-related stigma, which can lead to greater hesitation in seeking timely medical care. It is also desirable to enable risk communication in local languages for rapid identification of warning symptoms. This can be done by seeking support from local leaders, particularly religious leaders and other important groups in the community.Such health education campaigns should also emphasize prevention strategies and clinical characteristics of Ebola virus transmission, reaching as many people as possible, especially populations at risk. The media and social networks can also disseminate information and guide people on the measures to be taken in case of clinical suspicion or contact with the virus. It is necessary to reinforce the importance of notifying cases and isolating possible suspicions, as well as the need for strict hygiene and safety protocols to be used while burying the victims of the disease.Since adopting a preventive approach is cost-effective in places of difficult epidemiological control during outbreaks, developing an effective and accessible vaccine against EVD would be the central pillar of prevention against the disease, especially in contexts of health challenges, such as the COVID-19 pandemic. Highly effective vaccines are now available for Ebola virus disease and were instrumental in ending this epidemic in just 3 months. Therefore, there is a need to implement EVD vaccination strategies in at-risk communities. As a country at high risk for Ebola outbreaks, to ensure a rapid response in cases of imminent disease, national and international coordination groups must maintain a stock of EVD vaccines and distribution protocols and conduct emergency vaccination campaigns in accessible and convenient centers, especially in areas susceptible to outbreaks.The confluence of two lethal viruses, COVID-19 and Ebola, serves as a potent reminder of the necessity to reinforce medical and public health capacities in DRC. While the latest EVD outbreak is over, the threat of future outbreaks should not be underestimated. As the nation strives to recover from the social and economic toll of the pandemic, it is important that the leadership keeps financing the health system in a dedicated effort to improve surveillance, testing and tracing capacities, awareness programs and protective vaccination campaigns. It is essential to adopt multidisciplinary measures such as promotion of hygiene and social distancing practices, and improvement of diagnostic and management protocols, to coordinate a timely response to future EVD outbreaks while ensuring an equitable distribution of resources between the country’s two crises.


The burden and causes of residual malaria were investigated between 2015 and 2019 through 5 research projects coordinated by the Special Program for Research and Training in Tropical Diseases (TDR), cosponsored by the United Nations Development Programme, UNICEF, the World Bank, the World Health Organization (WHO) and the WHO Global Malaria Programme. The 5 projects included 10 countries in 4 WHO regions: Africa, the Americas, South-East Asia, and the Western Pacific. The countries represented a range of malaria endemicities, from low to high levels of transmission. The main findings of the projects indicate that overall the core malaria vector control tools  were not deployed in the optimal way and/or not efficient in many settings of the supported projects. Furthermore, vector biting behavior and human activity–associated factors strongly contributed to malaria persistence. Changes in vector species composition and abundance, with an increase in outdoor biting, were also reported. Some of these factors may be an adaptation of the vectors to the deployment of the tools and/or can be linked to other sectors, such as agricultural practices, environmental changes, social factors, and water management. Human behaviors and sleeping habits that included activities and sleeping outside villages in unprotected dwellings were another part of the problem. The evidence collated demonstrates the need for new approaches, such as the multisectoral one and new vector control tools, all adapted to the local contexts and integrated into current malaria programs. Plasmodium, transmitted by infected mosquitoes belonging to the genus Anopheles. The major species of parasites infecting humans are Plasmodium falciparum and Plasmodium vivax. Although great progress has been achieved in reducing the malaria burden and the number of deaths in the past 20 years, an estimated 228 million malaria cases and 405 000 deaths, in 87 countries were reported in 2018 [Malaria is a vector-borne disease caused by parasites of the species  in 2018 .Anopheles arabiensis in Africa [Anopheles dirus in Asia [Anopheles albimanus and Anopheles darlingi in the Americas [However, it has been recognized that these core interventions are not covering the full spectrum of malaria transmission, and even with full coverage some transmission can persist. Residual malaria transmission is thus defined as follows: “Some residual malaria parasite transmission will occur, even with universal access to and usage of ITNs or in areas with high IRS coverage. Residual transmission occurs as a result of a combination of human and vector behaviours” . Residuan Africa , Anophel in Asia , and AnoAmericas . The WorA collaboration between the Special Program for Research and Training in Tropical Diseases (TDR), cosponsored by UNDP, UNICEF, the World Bank, WHO, and the WHO Global Malaria Programme was initiated in 2015 to provide information on the magnitude of residual malaria transmission in different situations and settings and to determine (1) the contribution of residual transmission to the overall burden of malaria, and (2) the main specific causes of the residual transmission. An open call for applications to support research projects in all the WHO regions affected by residual malaria was launched, to identify through standardized protocols the main factors driving this transmission, including social behaviors or activities that increase human exposure to mosquito bites, environmental changes, and other factors affecting vector resting behavior, feeding, and species composition. The objectives of the applications were to produce updated data from selected settings of low to high malaria transmission on the magnitude of residual malaria and to produce scientific evidence on the causes of this residual malaria through investigations of entomological, social and environmental determinants. After the call and the transparent selection process through an external ad hoc committee, 5 multicountry research proposals were supported encompassing 10 countries within 4 WHO regions . The mains findings from the projects are reported below.A. darlingi to clarify whether changing mosquito behaviors could be due to cryptic species.The overall objective of this project was to investigate the status of the persisting malaria in the Peruvian and Brazilian Amazon areas, along Mazán River  and in Mâncio Lima . Specific objectives included the following: (1) to compare prevalence/incidence of infections among households with or without bed net use and with or without IRS, (2) to investigate the social and environmental determinants of malaria transmission through a combination of household surveys and satellite imagery, and (3) to determine the vector biology metrics and bionomics according to genetic characterization for the main vector The results on the coverage of the core tools showed a different situation in Peru and in Brazil. In the Brazilian study site, 50.7% households had received long-lasting impregnated nets (LLINs) in 2014–2015 . The depP. vivax and P. falciparum, respectively. The main vector was found to be A. darlingi, and heightened risk of infection was mostly associated with individual behaviors, such as going to bed indoors after 10 pm which increased risk because of the outdoor biting behavior of the vectors [The malaria transmission patterns were also very different in the 2 countries. In the study site in Brazil, the annual parasite incidence was 17.26 per 1000 persons at risk , with th vectors . ConversA. darlingi, but a very low entomological inoculation rate   and no differences across age groups. The main vector was also er year)  and a reA. darlingi aquatic habitats [A. darlingi populations showed different degrees of diversity within different locations, but the results did not provide evidence for the occurrence of subspecies and/or genetic bases for behavioral differences.This project also tested new technologies through drone-based high-resolution mapping to identify and characterize habitats  and throA. darlingi, no significant association was found between malaria infection and sleeping under an LLIN, linked to the evidence that the vector is biting mainly outdoors. New technologies were also tested to better map and understand the relationships between disease transmission and the ecology of the vectors. Evidence indicates that this region is most likely facing a residual malaria situation owing to mosquito biting behavior and human behavior involving staying outdoors late into the night. To control this transmission, new tools are needed.This study addressing malaria transmission in study sites of 2 countries of the Amazon region shows that with the main vector species, The objectives of the project were to determine the magnitude of the residual malaria transmission relative to the overall burden of the disease in the Greater Mekong Subregion, to produce scientific evidence on the entomological, epidemiological, social, and environmental risk determinants, and to propose protocols and tools that can be used to address the residual malaria transmission challenges.P. vivax infection , Anopheles maculatus s.l., Anopheles minimus s.l., Anopheles annularis s.l., Anopheles barbirostris s.l., and Anopheles culicifacies s.l. This abundance of different vectors with different biting behaviors increases the exposure of the human populations to bites at different times and places when people are not under nets. These data clearly demonstrate that the full coverage of the at-risk populations in both study sites in the 2 countries was not achieved, because of a lack of nets, lack of replacement of deteriorated nets, or human behaviors in the farm plots or in forest foraging activities. The primary biting vectors in the study site in Thailand are active in the early evening or late morning, with between 20% and 38% of bites occurring when people are not under the nets . High vapm and minimal evidence of transmission risk in the village was found. with almost no vectors collected and a biting rate of less than 1(bite) per night. However, biting in the farm huts and forest occurred at much higher rates, with most bites due to A. dirus s.l. (about 95%) or A. maculatus s.l. Indoor (farm hut) and outdoor biting rates were 4.38 and 6.21, respectively, and the biting rate in the forest was 4.73. A. dirus s.l. biting rates peaked in the evening between 8 and 10 pm, and almost all bites (>90%) occurred before 11 pm [In the Vietnamese study site, 100% of biting from secondary vectors occurred before 10 This study reached the conclusion that the current malaria transmission in the study sites of the Greater Mekong Subregion may in part be because full coverage of the core tools has not been achieved. However, even if the coverage were high, about one-third of the transmission is happening when people cannot be under nets, for different reasons. The key gaps that need to be addressed to reduce the current transmission in this region include achieving universal coverage and full efficacy of the bed nets (including in farm huts and forest) and addressing outdoor transmission in the daytime and early evening through novel personal protection tools.The main objective of the study was to quantify and characterize the residual malaria transmission in communities where transmission persists though LLIN coverage is high , throughAnopheles funestus than for A. arabiensis in the studied villages in Tanzania [A. arabiensis is now the most abundant malaria mosquito in rural southeastern Tanzania, >80% of the ongoing malaria transmission in the studied villages was estimated to be caused by A. funestus, which occurs in smaller numbers but has higher infectious rates. This project was carried out in 9 villages of the Morogoro region in Tanzania and in 2 villages around Bobo-Dioulasso in Burkina Faso. The main findings show that the EIR in the studied villages in Burkina Faso, with 255.45 infectious bites per person per year, is >30 times higher than in the studied villages in Tanzania, with 8.34 infectious bites per person per year . The 2 sTanzania . FurtherHigh resistance of all malaria vectors to the pyrethroids commonly used in LLINs was observed in the studied villages in both Tanzania and Burkina Faso, and this was confirmed by very low mortality rates observed when mosquitoes were exposed to bed nets collected from the households in the 2 settings. The studies of human behaviors demonstrated that community members in both settings tended to spend most of the early night outdoors, only moving inside their houses at around midnight. No major means of protection against mosquito bites were observed being used outdoors. In the studied villages in Burkina Faso, a significant proportion of people in the studied communities were observed to sleep outdoors at night during the dry season, owing to the hot climate. Again, no major protection against mosquito bites was observed being used in such circumstances. In both settings, the beliefs of the communities around malaria were inaccurate in many cases, and mosquitoes were believed to be just one way of acquiring malaria.This study concluded that malaria transmission in the 2 settings continues despite high coverage of the recommended tools and may be associated with several factors, such as a decrease in susceptibility of the vectors to the insecticides used for LLINs and IRS, outdoor biting, and the human behaviors of staying or sleeping outdoors with no protection against mosquito bites. Consequently, the core recommended tools of LLINs and IRS are increasingly compromised by insecticide resistance of the vectors, but malaria transmission also persists because of the outdoor biting caused by both mosquito and human behaviors. To address these issues, better management of the insecticide resistance is required, and efforts should be made to provide complementary protection for people spending time outdoors.The objectives of the proposal were to characterize outdoor malaria transmission in different epidemiological settings with scaled-up coverage of LLINs/IRS and to compare with indoor transmission, to determine the contribution of various mosquito behaviors and levels of insecticide resistance to the residual and/or persistent malaria transmission, and to investigate human behavioral/occupational factors associated with exposure to mosquito bites.Anopheles nili and Anopheles moucheti were less abundant than the secondary ones [A. funestus s.l. and A. arabiensis were also found to be exophilic and highly zoophagic. More mosquitoes were collected outdoors than indoors . The EIR for the study area ranged from 10.95 to 65.7 infectious bites per person per year (The results on the coverage of the recommended tools (LLINs and IRS) show that in the selected studied sites in Cameroon and Kenya, the LLIN coverage was close to 90%, and in Ethiopia it was close to 70% . The malary ones . Some enper year . Anopheles gambiae s.l., Anopheles coustani group, Anopheles pharoensis, and Anopheles squamosus, with high numbers again collected outdoors and from animal shelters and human households with animals. The peak biting activities for the main vectors were between 6 and 10 pm. Regarding the susceptibility to insecticides, a high resistance level to pyrethroids was detected for A. gambiae in all studied sites in Cameroon, in accordance with recent reports on the evolution of pyrethroid resistance across the country. In the studied sites in Kenya, the main vectors had variable susceptibility to insecticide products, and resistance to pyrethroids and DDT was reported as well as in the villages in Ethiopia, where mosquito mortality rates after exposure to different insecticides showed that populations of A. arabiensis were resistant, with high variability to pyrethroids and DDT. In the villages in Ethiopia, the main malaria vectors were found to be pm, but adults aged 15–64 years went to bed later, between 10 and 11 pm. These data show that even children were exposed to mosquito bites between 6 and 8 pm, and most adults were exposed to mosquito bites during the full biting peak (between 6 and 10 pm).In the villages in Cameroon, the communities were found to be aware of malaria and on the use of preventive vector control measures, but the nets were in poor condition with holes and were sometimes destroyed. In the other settings in Kenya and Ethiopia, community awareness of malaria and the use of preventive vector control measures was not reported, but very high net coverage was found in households, and the human activities in the late evening and early morning were not associated with disease transmission. In most settings in the 3 countries, human sleeping hours were not associated with disease transmission, which was significantly related to the use of nets, though in the Ethiopian villages most children <5 years of age were asleep before 8 In conclusion, and though the use of LLINs by the village populations in the 3 countries was very high, the persistence of malaria transmission in the study sites may have different causes, such as insecticide resistance, outdoor biting, and exposure during peak biting times. Some shift in vector species and behaviors may be related to the deployment of the tools (LLINs and IRS), with secondary vectors more abundant and outdoor early evening biting behavior. These findings highlight the need to ensure that the recommended tools, such as LLINs and IRS, are efficient, with nets that are not deteriorated and management insecticide resistance ,and to search for additional tools to control outdoor early evening malaria transmission.Plasmodium species, 13 overlapping Anopheles vector species, and diverse geographic, ecological, and climatic zones. The overall objective of the project was to better understand the determinants of persisting malaria transmission in selected studied sites in Madang Province  and New Ireland Province  in PNG. More specific objectives were (1) to determine the prevalence and distribution of malaria infection in the villages located in the 2 different provinces, (2) to characterize the local vector population abundance, composition and behavior, and (3) to identify mosquito-human contact patterns and human behaviors.Papua New Guinea (PNG) has the highest malaria transmission rates in the Western Pacific Region and exhibits a particularly complex malaria epidemiology with 4 P. falciparum and P. vivax infections. A marked seasonality was reported, with transmission peaking between August and November, and the malaria cases were mostly in children <10 years old, with the peak of Rapid Diagnostic Test (RDT) positive children at age 5 years.The main findings revealed that LLIN coverage differed greatly between the 2 areas, and, surprisingly, the malaria incidence was much higher in the villages having the best coverage. LLIN coverage ranged from 81% to 94% and from 29% to 39% in the studied villages in Madang Province and New Ireland Province, respectively . In MadaP. falciparum and P. vivax infections were very similar. In Madang villages, the dominant vectors were Anopheles farauti sensu stricto and Anopheles koliensis, with indoor and outdoor EIRs of 24.6 and 35.8 bites per person per year, respectively, for a total of 60.4 infectious bites per person per year  during the peak vector biting period in their village.In Lemakot, per year . The insThis study shows that the malaria transmission in the studied sites in PNG is very heterogenous, and the evidence indicates that differences are more related to the vector species than to other factors. In the area with the high transmission rates, the coverage and use of LLINs on susceptible vectors was very high, demonstrating that in this specific situation the core tools (LLINs and IRS) are not protecting the population sufficiently. Malaria transmission is persisting because of outdoor biting and exposure during peak biting times (when people are not under a bed net). It is unclear whether the main malaria vectors have adapted their biting behavior to the deployment of the tools with more outdoor biting in the early evening, or whether their behavior has remained unchanged, in which case the core tools are unlikely to be sufficient to eliminate malaria in the country. Again, these findings highlight the need to develop additional tools to control malaria transmission targeting vectors that exhibit outdoor biting behavior in the early evening.Malaria transmission is persisting in many settings in the world, despite the deployment of effective LLINs and IRS coupled with appropriate and timely case management. The difference between residual malaria when tools are well deployed and efficient, and persisting malaria due to a lack of deployment or efficiency is clearly not easy to determine, because several confounding factors are acting. This observation makes it almost impossible to determine the burden of purely “residual malaria,” owing to gaps in effectiveness of well deployed interventions. The studies outlined above indicate that vector control tools are not implemented well in many settings, and improved implementation is needed.The efficiency of the tools may also be compromised by the decreased susceptibility of the mosquito vectors to the insecticide used. The impact of this decreased susceptibility on the LLIN and IRS efficacy is not well known in terms of transmission, but there is a need to clarify the situation in each local context. The management of insecticide resistance through regular monitoring and adaptation measures, such as ease of selective pressure and changes in product class , is now Several other important factors were identified that contribute to the persistence of malaria. At the sites studied in the African countries, Brazil, Peru, Thailand, Vietnam, and PNG, the outdoor biting early in the evening and concomitant with human activities outdoors is not covered by the currently available protective tools. It is difficult to determine whether this behavior is an adaptation of the vectors to the tools or to the human activities, since both are evolving dynamically in their specific contexts. In other settings with good coverage of LLINs, such as in the studied sites in Vietnam, the foci of malaria transmission moved from villages to farm plots and forests, with secondary vectors implicated. Consequently, new approaches are needed to control the vectors in these new transmission places and to protect the populations in these settings. In the villages investigated in Tanzania, another mosquito species is emerging as the main vector . In the The main outcomes of these studies reiterate the need to integrate into existing malaria programs new vector control tools that are adapted to target local vector behaviors, such as outdoor biting, and that are appropriate for the local human populations, such as those who engage in forest foraging. For that purpose, new approaches must be developed, including multisectoral approaches in which the health sector and other sectors work together to address the linked challenges, such as insecticide resistance related to the insecticide pressure on agricultural pests, or water management (dam construction) creating new aquatic habitats and resulting in changes in vector composition. The implementation of multisectoral approaches to address the challenges of vector-borne diseases prevention and control will be investigated through further TDR case studies into real-life situations and in relation to theoretical knowledge .