Compared with the rest of the UK and Western Europe, England has high rates of the infectious disease tuberculosis (TB). TB is curable, although treatment is for at least 6 months and longer when disease is drug resistant. If patients miss too many doses (non-adherence), they may transmit infection for longer and the infecting bacteria may develop resistance to the standard drugs used for treatment. Non-adherence may therefore risk both their health and that of others. Within England, certain population groups are thought to be at higher risk of non-adherence, but the factors contributing to this have been insufficiently determined, as have the best interventions to promote adherence. The objective of this study was to develop a manualised package of interventions for use as part of routine care within National Health Services to address the social and cultural factors that lead to poor adherence to treatment for TB disease.This study uses a mixed-methods approach, with six study components. These are (1) scoping reviews of the literature; (2) qualitative research with patients, carers and healthcare professionals; (3) development of the intervention; (4) a pilot randomised controlled trial of the manualised intervention; (5) a process evaluation to examine clinical utility; and (6) a cost analysis.This study received ethics approval on 24 December 2018 from Camberwell St. Giles Ethics Committee, UK (REC reference 18/LO/1818). Findings will be published and disseminated through peer-reviewed publications and conference presentations, published in an end of study report to our funder  and presented to key stakeholders.ISRCTN95243114University College London/University College London Hospitals Joint Research Office 17/0726.National Institute for Health Research, UK 16/88/06. Patient-centred, mixed-methods approach, based on a robust understanding of the evidence on social, cultural and personal factors that influence adherence to medication to treat tuberculosis (TB).Evidence and experience of adherence captured from a variety of perspectives from across the UK, including patients, their carers and healthcare workers.Generalisable patient population of individuals at risk of non-adherence across low TB incidence settings.Development of a pragmatic and easy-to-use tool that captures the best evidence on adherence and allows its application in the clinic setting.The study culminates in a pilot trial of the manualised intervention; a larger subsequent definitive trial is needed to test whether the intervention is efficacious and cost-effective beyond any initial conclusions regarding validity and feasibility derived from the pilot.Against a background of rising tuberculosis (TB) in the 1990s and 2000s, the need for a comprehensive approach to TB control in England was deemed necessary by Public Health England and the National Health Service (NHS) England. In January 2015, these bodies jointly launched the ‘Collaborative Tuberculosis Strategy for England 2015–2020’.Barriers to optimal adherence to treatment for TB may occur for a number of reasons. These includePatient-related factors, including perceptions and beliefs.Cultural influences and current mental state.Structural economic factors and social support networks.Health service factors that include treatment complexity as well as accessibility of those services and the relationships patients develop with service providers.Non-adherence is not a single issue and may take various forms, for example, suboptimal implementation (skipping doses) or stopping treatment early .Although a series of studies have been undertaken to define the population groups most at risk of non-adherence,In the UK, the development of an intervention to support adherence to treatment that is sensitive to the individual’s cultural background and social circumstances, and can be routinely delivered within the NHS, is critical. To this purpose, a mixed-methods, patient-centred, approach to the study of the modifiable factors that influence patients’ adherence to treatment of TB is required.Can a manualised package of intervention be developed to help overcome the social and cultural factors that lead to poor adherence to treatment in NHS patients in the UK with active TB?To develop, pilot and evaluate process and interim outcomes for an effective manualised intervention that improves the likelihood of adherence to treatment among NHS patients at risk of poor adherence due to social, cultural and structural factors.Synthesise current knowledge on (1) determinants of adherence to treatment for TB and (b) interventions that can support adherence, with particular emphasis on social and cultural barriers .Apply a conceptual framework of adherence endorsed by NICE guidelines  approach)Develop a manualised intervention (a series of systematic actions applied on the basis of a patient’s needs assessment) with multiple components that can identify (1) NHS patients most at risk of non-adherence, (2) the salient modifiable barriers and (3) the tailored support mechanisms required to meet individual patient needs by matching appropriate interventions to specific barriers, as recommended by NICE (Development of Intervention). A manualised intervention was considered to be a suitable approach to managing adherence in TB, as it will enable a set of measures to be applied consistently within different NHS settings that will aid both clinicians and patients throughout the treatment journey. The content of the intervention will use existing support measures, employed in a systematic and structured way, and may also include any new interventions that are developed in response to the formative research. It will be compared with normal care.Pilot the intervention package in people at risk of poor adherence to define how the components work in combination and separately (pilot study).Evaluate the process of implementation of this intervention through describing the challenges and facilitators in delivering the package as intended (fidelity and reach) and assessing the impact of the intervention through evaluation of adherence indicators .Use the findings of the pilot to assess the costs of delivering the manualised intervention in an NHS setting and to guide development of a proposal for a full randomised controlled trial (RCT).This study uses a mixed-methods approach. There are six subsections, reflecting the six objectives: (1) scoping review and conceptual framework, (2) formative research, (3) development of intervention, (4) pilot study, (5) process evaluation and (6) cost analysis and future work. Although the different elements are described separately further, the research activities for each will overlap, and some will run concurrently. The full programme of work and relationships between subsections is shown in To underpin the development of the manualised intervention, the first study subsection will undertake literature reviews to answer the following research questions:What personal, social, cultural, health systems-related and structural factors affect individuals’ ability to adhere to treatment for TB?What kinds of intervention have been developed to address the multiple levels  at which barriers to adherence may operate?What is the evidence for the successful impact of interventions to address barriers to adherence to treatment for TB?These questions will be answered through the three following reviews:A scoping review of qualitative studies that examine the personal, social, cultural, health systems-related and structural factors affecting adherence to treatment for TB from the perspectives of adult patients, caregivers or healthcare providers, as well as studies that evaluate interventions to support adherence to treatment for TB. Data from all settings will be considered, but with a particular focus on low incidence, high income settings.A critical review of quantitative studies examining the personal, social, cultural, health systems-related and structural factors affecting adherence to treatment for TB. This review focuses on low incidence, high income, settings and observational study designs. Given the scoping nature of the review, findings will be descriptively analysed and not be stratified or disaggregated, for example, by site of disease. All relative and absolute measures of effect will be extracted.A critical review of quantitative studies that have examined the effectiveness of interventions to improve adherence in people taking treatment for TB, building on existing systematic reviews, including the provision and delivery of information and/or education; enablers and/or incentives; social support; and case management approaches. Given the more limited literature, both observational studies and clinical trials will be included, from all settings. Findings will be descriptively analysed.Together, these three reviews will enable us to conduct a critical interpretive synthesis of findings from qualitative and quantitative studies examining the assumptions and mechanisms of effect underlying interventions to improve adherence to treatment for TB. Further details on the reviews are available in the full protocol.In line with findings from the scoping review, we will develop topic guides for qualitative interviews exploring current models of TB service delivery in the study sites, providers’ views on the barriers and facilitators for treatment adherence, and TB patients’ and their family members’ experiences of starting and staying on treatment. Details about these guides are available within the full protocol.Adults (aged 18 and over) who are currently taking or recently completed treatment will be identified by the local TB service at four UK sites ) and will be asked to take part in the study. The services have been chosen for their patient diversity, geographical spread and as reflecting the national TB picture. The patient group will be enriched with people who have been poorly adherent to treatment, although we will also include patients who report full adherence so that we can capture what may have enabled them to take treatment as prescribed. With patient consent, family members and/or carers will also be approached and asked to participate.Health and social care workers from both primary and secondary care settings will be directly approached by researchers and invited to be interviewed. All those approached will be aged 18 or over and involved in TB management and care.Three different methods of data collection will be used to undertake the formative research.These will be conducted as individual interviews with approximately 30 participants, using a topic guide. The areas to be explored are self-perception, personal beliefs and practices related to medicine-taking, health literacy and health-seeking behaviour, social support, cultural norms around health-seeking behaviour, and financial and other structural barriers.To ensure that the validated questionnaires ie, BIPQ are These will be undertaken with healthcare providers responsible for multiple aspects of TB care  providers, managers and administrators). They will focus on providers’ perceptions of factors affecting patient understanding of TB and its treatment, service delivery models including staffing, organisation of care and communication. We will interview four to six providers at each site, aiming for a total of 20 interviews.We will use a framework approachThe data collected from the scoping reviews and formative research will be presented to, and synthesised by, an intervention development group (IDG). A manualised intervention will be developed to identify (1) NHS patients most at risk of non-adherence, (2) their salient modifiable barriers and (3) the tailored support mechanisms that meet individual patient needs by matching appropriate interventions to these specific barriers.The IDG will aim to includePatients .Family members/significant others of affected persons.Members of the public.Healthcare professionals (from both primary and secondary care).Other professionals who work with patients/communities affected by TB.The constitution of the IDG will enable a coproduction approach to ensure that the intervention is pragmatic, can be delivered within the context of existing care pathways, and is of benefit to service users and those who are likely to access the intervention.The manualised intervention is likely to consist of a screening and assessment tool, in addition to a package of measures that can be tailored to the needs of individual patients from different population groups.As patterns of adherence may be irregular over time, it is intended that the manualised intervention will be administered to all patients at each patient review. The tool thus needs to be quick and easy to administer. It may be electronically linked to patient records, enabling a comprehensive picture of the risk of possible non-adherence to be developed for each patient, as well as within a clinic population. The various delivery options for the intervention (such as using paper or an app) will be considered during its development stage.The menu of supportive measures may, for example, includeInformational intervention: for example, providing a convincing story setting out the rationale and ongoing need for medication, addressing concerns about potential adverse effects and consequences of treatment and what to do if such events occur .Practicalities and capability-based interventions: video-observed therapy (VOT); DOT; reminders, including text messaging; automated methods for monitoring and feedback, including electronic dosette boxes; use of a medication app; incentives, for example, financial and food vouchers; mitigation; and management of drug toxicity due to treatments.Social and system interventions: offering flexibility in appointments; enhanced guidance on ‘navigating’ clinic pathways; signposting patients to relevant services, for example, housing, drug and alcohol services, and social care; and providing peer support.Once the intervention is developed, proof of concept is required within the real world. This will be undertaken using a non-blinded cluster randomised pilot study that compares the manualised intervention to the usual standard of care in four London clinics treating TB. Two clinics will be randomly allocated to the intervention and two to standard of care. In the latter, the amount of support provided to patients is based on perceived need, as identified by a nurse-led review and a needs assessment. Most patients will have supported self-administered therapy, while others will be offered DOT and/or VOT if this is felt to be appropriate. We anticipate enrolment to commence in January 2020.All consecutive patients aged 18 or over who are about to start treatment for TB, irrespective of the site of disease, will be approached to take part in the study. We will exclude individuals who are unable to provide informed consent, those already on treatment and those who are not expected to live for the duration of the study (a minimum of 6 months from starting treatment). Within the pilot study, it is essential to capture the entire treatment period for each patient in order to assess the effectiveness of the intervention. Due to the nature of the TB patient population in the UK, patients are likely to include people at greater risk of poor adherence, such as migrants newly arrived in the UK, people whose first language is not English, people with a mental health disorder, people taking immunosuppressive therapy or known to have immunodeficiency, those with a previous history of treatment for TB, or poor adherence with anti-TB medication, and people with a current or previous history of drug or alcohol misuse.The purpose of the pilot study was not formal hypothesis testing. Given this, a target sample size of 80 patients enrolled (20 per site) was identified for the pilot study as providing useful information that can help determine whether the intervention will be deliverable within a clinical setting. It will also guide the development of a possible larger definitive study using the intervention. The four TB clinics of interest (in East and North London) each treat in excess of 60 relevant patients per annum.Based on usage of DOT within the clinic populations seen at the treatment sites , we estimate that around 33% of patients will be at risk of non-adherence. Taking this as a minimum , we would expect that at least 26 of the 80 patients recruited will be identified as requiring adherence support. This sample size allows us to measure consent to enrolment for 80 individuals, data completeness for adherence and treatment outcomes for 80 individuals, data on acceptability and feasibility of the intervention package for around 40 individuals, and data on acceptability and feasibility of adherence support for at least 26 individuals .The primary outcome of the study will be level of adherence, measured as the proportion of prescribed doses taken and assessed at 6 months from the start of treatment. In addition to this primary outcome, a number of secondary outcomes will also be measured, as follows:Proportion consenting to the study.Completeness of data for measures of adherence.Proportion of patients withdrawing during the study and the reasons why.Proportion of patients identified as needing adherence support in the intervention arm.Proportion of patients offered adherence support and accepting it in the intervention arm.Documentation of which adherence-promoting activities have been implemented among patients both in the standard of care and intervention arm, and when.Detailed treatment implementation information: for example, proportion of patients completing treatment, proportion of patients still on treatment after 9 months or at study completion (whichever is the earlier).Patterns of adherence (implementation and discontinuation).Impact of manualised intervention on maintaining adherence over the duration of treatment.Process variables: adherence-related PAPA.Our primary measure of adherence will be data obtained from medication monitoring boxes.The patient’s case manager , plus a study research nurse, will apply the intervention in partnership with the patient to identify whether personal, sociocultural and/or systems risk factors are present that suggest likely poor adherence with treatment. If these are identified, then the relevant measures outlined in the manualised intervention that may mitigate these will be reviewed and implemented with the agreement of the participant. These will be continued throughout the course of treatment or stopped if no longer deemed to be relevant or required on reassessment.Study subjects will be seen at weeks 0, 2, 4, 8, 12, 16, 20 and 24 (earliest date of treatment completion). Should they require ongoing treatment after 6 months, they will be seen as clinically indicated. At each review, adherence assessments will be performed, in addition to an assessment of PAPA, the completion of the BMQ and the EQ-5D-5L Quality of Life questionnairesMost patients who do not have clinically important drug-resistant disease receive 6 months of treatment. To allow for treatment interruptions, patients within the pilot study will be followed up to either treatment completion or for a total of 9 months from starting anti-TB therapy.Where possible, univariable analyses will be undertaken to compare each outcome measure listed between study arms (intervention and control). For the primary outcome (adherence), the mean percentage value will be reported by arm (intervention and control) and histograms will be used to describe the distribution of values by study arm. Binary secondary outcomes will be reported by the proportion of individuals achieving the outcome within each arm. The need to adjust for clustering by site and clinical care provider will be assessed using the cluster summary method (a t-test) to compare the cluster means or proportions . An assessment of the balance in baseline characteristics between the study arms will also be conducted. If randomisation has failed to evenly distribute key characteristics , then the cluster means or proportions will be adjusted for these differences before applying the t-test. This two-stage approach to analysis is described by Hayes and Moulton.The analysis of the first three of our secondary outcomes will address the feasibility of a definitive trial following a similar design to the pilot. Analysis of secondary outcomes 4–6 addresses the intervention, and complements the process evaluation (see below). Analysis of the primary outcome and final secondary outcomes around treatment adherence and completion provides initial information—given the modest sample size—concerning the effectiveness of the intervention, and may assist the sample size calculation for the definitive trial. They can also offer an alert in the unlikely event that the intervention is harmful.Although we are undertaking a pilot study and thus the numbers enrolled are small, We will evaluate the implementation process by analysing the challenges and facilitators in delivering the package. The impact of the intervention will be assessed by evaluation of adherence indicators. We will use the findings of the pilot to assess the costs of delivering the manualised intervention in an NHS setting and to guide development of a proposal for a full RCT.The process evaluation will consist of a description of the process of intervention implementation. It will assess how well the manualised intervention achieves its intended aim compared with standard care.We will considerThe fidelity of the intervention as delivered in comparison to how it was designed and envisaged.The reach of the intervention (the proportion of the target group receiving it).The barriers to facilitating implementation of the intervention and how these can be addressed.The pre-existing factors that facilitated implementation.Process measures for each element of the package will be developed once the manual development has been completed and will be used to assess success. They will include acceptability, uptake and change in practice. We will work with patients and staff separately at all four London sites. We will interview 20 patients  and, if possible, 20 healthcare workers (5 at each site). The patients will be selected within each site using purposeful sampling of clinic lists of every patient with active TB, to enable us to reflect the demographic spread of patients.Key outputs will include a qualitative evaluation of delivery, the development of a narrative description of the process of intervention implementation and maintenance, and a quantitative assessment of adherence-related PAPA within intervention and control groups.We will invite participation in the process evaluation from patients enrolled in the pilot study or staff members treating patients at one of the four London sites also involved in delivering the pilot study. They will be included if they are aged 18 years or over and able to provide informed consent. This will include probing anticipated versus real-life delivery of the intervention.In order to generate realistic estimates of the cost of the intervention, cost data from the NHS perspective will be collected during the pilot study using a cost data collection tool used by health economists (the Client Service Receipt Inventory) modified for TB.After the pilot study and process evaluation have been completed, a final intervention package will be designed for use in a definitive RCT of the manualised package of interventions. The design of this final package will be based on the results of the process evaluation and the experience gained during the piloting of the intervention, modifying the definitive trial design and/or data collection accordingly.As documented previously, patient representatives will sit on the IDG for the study. In addition, TB Alert, the UK’s only national TB charity, has membership of the IDG. The role of the IDG, which will meet regularly throughout the study, is described in the section Development of the manualised intervention. At the end of the study, the IDG will be involved in commenting on the findings and contributing to the dissemination plan.The study is sponsored by the Joint Research Office of University College London and University College London Hospitals. This study received ethics approval on 24 December 2018 from the Camberwell St Giles Ethics Committee 207104 8204; NRESCommittee.London-CamberwellStGiles@nhs.net). Findings will be published and disseminated through peer-reviewed publications and conference presentations, published in an end-of-study report to our funder  and presented to key stakeholders.For public enquiries, please contact Marcia Darvell, IMPACT Study Project Co-ordinator, Respiratory Medicine, The Royal Free London NHS Foundation Trust, UCL Medical School Building, Rowland Hill Street, London, NW3 2PF, UK;+4420 8016 8375; m.darvell@ucl.ac.ukFor scientific enquiries, please contact the Chief Investigator Professor Marc Lipman , Respiratory Medicine, The Grove Centre, The Royal Free London NHS Foundation Trust, Rowland Hill Street, London, NW3 2PF, UK;+4420 7472 6452; marclipman@nhs.net.The datasets generated during and/or analysed during the current study will be available on request in a deidentified format and after publication of study outcomes and associated permission from the funder. Requests for data should be directed to Professor Marc Lipman as per the contact details previously mentioned.Our study will develop and pilot a manualised intervention to improve adherence to treatment for TB in the UK using a mixed-methods, patient-centred and provider-informed approach. This will enable us to begin to understand what motivates patients’ treatment behaviour, while ensuring deliverability within the NHS. Our work is based on a robust understanding of the evidence on social, cultural and personal factors that influence adherence, and the interventions that are most effective in addressing these. The study reflects the geographical spread of TB in the UK and captures not only patient and expert clinical and academic experience but also that of family and carers to develop the intervention. A key feature of the study is the coproduction of a pragmatic and easy-to-use tool that uses the best evidence on adherence and allows its application in the clinic setting in a dynamic and iterative way.Although the final pilot study may be limited to a relatively small sample size, it is hoped that its broad patient-centred perspective will make a useful contribution to our understanding of, and ability to deal effectively with, the risks of non-adherence to TB treatment in a population that can find this challenging. As many of the factors influencing adherence are likely to be generalisable to patients with other conditions in both high and low resource settings, this study also has the potential to inform adherence interventions in other disease areas.


Surface cracks on the friction welded interface of dissimilar metals are one of the earliest indications of degradation of the joint, which is a critical aspect for the welding strength. By manual inspection of the friction welded joint, observations of irregularities, porosity voids, crack lengths, cracked surfaces, and depth penetrations of two dissimilar metals can be made. Manual inspection purely depends on a quality expert’s experience of quantitative analysis and knowledge. In this research, an attempt has been made to effectively utilize the image segmentation technique (IST) in the estimation of the welded surface quality of a dissimilar joint by friction welding. The bonding strength between dissimilar metals in friction welding is more dependent on the coefficient of friction between the metallic surfaces. To demonstrate the capability of the image segmentation technique, experiments were conducted with various parameters, such as friction pressure, friction time, coefficient of friction, and torque speed of the rotating work piece. The effect of the coefficient of friction on friction welded surface quality by considering process parameters is estimated by using the proposed technique. Experiments were validated and the results claimed that the proposed image processing approach is efficient in fractured surface crack detection, reducing the computation cost, and providing a high-speed method with greater accuracy in the identification of welded surface defects. It was found that the friction coefficient is dependent mostly on the friction pressure and friction time. Its values range from 0.21 to 0.71, with the highest value of friction pressure at 120 MPa and 500 rpm. The present work deals with the detection of welding defects by means of segmentation based analysis of the welded interface. This method has a significant improvement in the fractured surface, crack detection, and non-welded areas’ detection in terms of pixels at the desired region, and is easy when compared to conventional detection techniques by using an operator’s decisions. In many industrial applications, friction welding (FW) processes can replace traditional joining methods. This is due to its capability of high performance in joining different ferrous and non-ferrous metals . One of This present research work investigates the influence of the friction welding parameters, pressure, rotational speed, and friction contact time, on friction welding of aluminum (Al), brass, and copper (Cu) on the coefficient of friction at the interface, which directly affects the quality of welded joints. In The metal specimens used in the friction welding experiments were cylindrical rods of a 100 mm length and 12 mm diameter. The cylindrical metal specimens were maintained at the exact dimensions to a 12 mm diameter by the turning process. The surfaces of the specimens to be welded were also cleaned with acetone prior to welding. Experiments were conducted using a machine adjusted with a range of nine variable rotational speeds of 250, 375, 500, 750, 1000, 1250, 1350, 1400, and 1500 rpm. Friction torque and friction force were recorded with piezoelectric type sensors located at a fixed fixture in which the stationary specimens were allocated. Welded zone temperatures were recorded with a FLUKE company  product thermal sensor during different process parameters of the FW process. The high sensitivity of the sensor ensured correct readings with a measurement accuracy of 20 °C. The friction welding machine used operated with controlled accuracy and good repeatability of the friction welding parameters. The spindle speed was maintained by an alternating current, and friction forces were read by a piezeo-electric sensor. The spindle motor capacity was 30 W with 3 Phase AC and its operating speed can be varied from 1 to 1000 rpm. All the experimental data with a possible combination of welding parameters were recorded. The machine had a stroke length of 350 mm and a maximum friction force of 300 kN was applied. The spindle speeds were varied in steps up to 500 rpm. Nine different combinations of friction welding parameters were performed as given in There are certain industrial requirements that define their quality standards to meet exactly the customer’s requirements and specifications. It strongly needs specific inspection and testing to be performed on final products in mass or batch productions. The components are inspected by conventional or non-destructive techniques. The scenario image segmentation technique is considered to be a powerful tool for accurate data interpretation in assuring the confirmed process parameters for quality-based products. Image analysis plays an important role in evaluating the desired process by the image acquisition system. In the present research work, image segmentation techniques were applied to enhance and analyze the resultant image and with the help of a knowledge based database in deciding whether the product could pass the quality inspection tests. The acquired images were captured and transferred to the computer for further processing by using the DIGIMIZER Image Analysis Software  for automatic inspection. The acquired images were pre-processed to be enhanced and possible flaws as segments were evaluated and analyzed. The main objective of image preprocessing is to improve the visibility of the captured images to a suitable scale for the human eye. The segmentation process is one of the important image processing techniques for an inspection system. It is the process of dividing and clustering the images into areas of desired segment analysis. A segmentation based routine or algorithm for a friction welding image needs to be bifurcated, like a porous region, edging, surface cracks, crack length, peaks, valleys, and gas inclusions, etc. Particular threshold values are designated for segments in terms of pixels accumulated in the desired region. The quantification of images for crack detection are expressed in terms of the pixels. Once the image segmentation process is completed, the resultant images in terms of segments are analyzed. This is a classifying process of different defects and it is considered a feature or pattern recognition. A general feature extraction and recognition system consists of a segment processor, feature detection unit, and classification unit. From the input file flaws, the pattern and segmented objects were traced. The feature detection unit extracts data information in terms of pixels. The classification unit categorizes features and patterns. In the present work, analysis of the segmented image can be regarded as surface crack detection. The segmentation process was characterized by three different grey levels. The first segmentation level feature was extracted from the desired region. This feature extraction is considered as a surface defect; surface crack length. Subsequently, features were extracted and the repeated procedure covered the desired region of inspection. The DIGIMIZER surface analysis software starts from a fixed location as the starting point in terms of pixels of the current feature to extract. Then, all similar featured pixels close to the starting pixel were evaluated, if a pixel was found to be of the same grey-level as the first feature, then it was confirmed to be of the same featured category and the pixels were evaluated for the total region. Conventional methods were applied for the quantification of similar features, such as porosity area, crack surfaces, crack length, perimeter, feature brightness, etc. the brightness will be expressed in terms of green, blue, and red colors. Once the pattern or features were traced, they were analyzed and compared with previously known patterns for a final decision.The obtained time-relationships of pressure force, friction torque, and temperature were used for determining the value of the friction coefficient at a given temperature. The friction coefficient was calculated from the formula:The intensity of frictional heat generated during the welding of dissimilar rotating surfaces mainly depends on the friction between the two surfaces at a given point of time. The quality and strength of the welded joint are influenced by the input heat energy at the welded zone. The friction pressure and force are assumed to be the constant during the friction welding time. It can be defined that the total input heat energy at the friction welded surfaces at a distance, The total friction torque by integrating with One of the remarkable optimization methods is the response surface method and it can be applied to develop the corelation model, containing effective process parameters in the friction welding process. The developed regression equation gives the response values from the dependent process parameters. In the present case, the output response was the coefficient of friction and other parameters, such as the friction pressure, friction force, friction torque, spindle speed, and friction time, were input parameters. In the first step, a suitable approximate relation between the parameters was developed by using the linear function or quadratic functions by assigning the suitable values to the parameters. The approximate first order model can be expressed as:The higher order equations were used for complex domains, such as curved profiles, surface curvatures, etc. These equations were capable of providing considerable approximation among all the parameters of the process. Linear approximations were more suitable to cover all effective parameters in the desired region:The experiments were based on the design of experiments’ techniques, i.e., composite design available in the library of statistical modelling software, MINITAB-17. When the friction torque was increased, the measured temperatures were also increased. The plot shown in Copper has a narrower heat affected zone compared to aluminum when constant heat input energy was generated. This was due to the higher thermal conductivity value in copper compared to that in aluminum. In general, the friction pressure was not uniform with friction time as the two metal pieces possess different thermal conductivity. The main effect plot shown in From the main effects plot shown in From the main effects plot shown in 2. These optimum parameters were achieved at the 95% confidence limit. In The main effects plot shown in At the weld interface, fracture surfaces are shown in 2) as compared to the background crack area (282.743 Px2), with a less average blue colored mean intensity of 0.0302.The propagation of crack growth and fractured surfaces at the welded interface are crucial to identify. It is difficult to measure the crack length of the open fractured surface based on the available images with dissimilar metals and surface topologies using Non Destructive Testing (NDT), thermography, etc. In such cases, it is more feasible to identify crucial crack lengths and fractured surfaces by means of the image segmentation technique. Based on the friction welding experiments conducted, some of the surface flaws were detected in terms of the crack length and fractured surface area, and they are expressed in different colored intensities, such as red, green, and blue, for quantification of surface defects in pixels. Based on the analysis, it is concluded that in 2 as shown in At the close vicinity of edges, large numbers of cracks are identified when compared to the center region of the welded interface with high colored intensities. In 2. The mean welded area was found to be 212,357.46 Px2. Different colored intensities are given for friction welded tracks at the interface having mean crack lengths of 24.60 Px based on statistical measurements of the segments at the welded interface.It was found on the outer periphery that there are many pores in close vicinity of the metallic interface due to uneven friction forces acting on the welded surfaces at high rotational speeds that leads to porosities. The mean red colored intensities of 0.4603 was more when compared to other welded regions. The maximum crack length was found to be 103.895 Px as shown in The maximum crack length was found to be 23.254 Px, which was less when compared to other parameters of the friction welding process. The screen shot shows the different regions of the flaws at the interface in terms of statistical measurements of the segments’ intensity. The maximum crack length was found to be 23.25 Px for the black colored intensity region, which was a lesser percentage when compared to other blue colored intensities. This black colored region is the subsurface of the interface and contains less number of micro cracks, and in this region, the maximum crack length was found to be 23.25 Px, as shown in 2 and SiC, and the effect of these additions on the coefficient of friction with respect to different process parameters.In the present research, the factors influencing the friction welding process were studied based on the response surface method. The factors considered were the spindle speed, friction pressure, friction force, torque, and friction time. Friction time played a vital role for each experiment and demonstrated that as the friction time increased, more heat input energy overcame the friction and penetrated more into the weld interface without surface cracks. A regression equation correlation was then proposed to evaluate the optimal friction time for a wide range of friction welding parameters. Once the optimal operating conditions were obtained for friction pressure by the response surface method, experimental tests were carried out. The weld quality tests were conclusive and demonstrate that the appearance of the fractured surface occurred at the interface with more peaks and porosities for less friction pressure values. The effect of the experimental tests and results of optimization were in good agreement for the crack length and fractured surface for the lesser values of the coefficient of friction due to more friction forces acting at the interfaces. Experimental validation was carried out by selecting the optimized friction welding parameters and comparing the results obtained from IST micrograph for a good welded joint quality. The morphology of river patterns appeared on fractured surfaces for the lesser friction pressure values and were confirmed with the micrograph obtained from segmentation analysis having more pixels in the fractured surfaces. The appearance of micro cracks at the interface were due to thermo-mechanical coupling effects with less spindle speed and more friction forces during friction welding. The segmentation analysis technique proposed in this work is useful for better controlling the friction welding method. The interface zone, where the fractured surface and crack length affects the strength of the welded joint, are more dependent on the friction pressure, heat input energy, and heat flux generated during friction welding. Therefore, the optimized parameters and regression analysis proposed the effective parameters for a good welded joint. The predicted optimized parameters of the friction welding were in good agreement with the experimental validations. Further studies on crack detection and study of the interfacial fractured surface can be done on additives of reinforcement powder, such as TiO


This paper reports on the first phase of an ambitious program of research that seeks to both understand the risk of homelessness amongst persons with a disability in Australia and shed light on the impact of a significant policy reform—the introduction of the National Disability Insurance Scheme (NDIS)—in changing the level of homelessness risk. This first paper, reports on the level of homelessness risk for persons with a disability prior to the introduction of the NDIS, with a subsequent paper providing updated data and analysis for the period post the implementation of the NDIS. In one sense, this paper provides the ‘base’ condition prior to the introduction of the NDIS but also serves a far broader role in advancing our understanding of how disability and chronic ill-health affects the risk of homelessness. Our research finds that in the period prior to the introduction of the NDIS, a large proportion of people with disabilities were at risk of homelessness, but those whose disabilities affected their schooling or employment were at the greatest risk. Disability is widespread across the Australian population, with almost 20 per cent of people  having some form of disability . The sheThis paper reports on the first phase of a program of research that seeks to understand the risk of homelessness amongst persons with a disability in Australia and shed light on the impact of a significant current policy reform—the introduction of the National Disability Insurance Scheme (NDIS)—in changing the level of this risk. Currently being rolled out nationally, the NDIS will be the largest disability support intervention ever undertaken in Australia, with an annual estimated budget in its first year of $22 billion . It is sThere is now an emerging body of work on housing for people with disability. In Australia, 17 per cent of individuals aged between 15 and 64 are living with disability or a long-term health condition ,4,5. FurThe provision of housing for people with disability has profoundly changed over the past 20 years with the introduction of a long sequence of policy reforms to the funding and delivery of social services across Australia . In receFamilies providing informal care assist in supporting much of this unmet demand; however, reduced household incomes, higher medical and other disability-related expenses present additional challenges in securing appropriate and well-located housing ,16,17. TThe reality of Australia’s increasingly unaffordable housing market and limited disability support up to the first decade of the 21st century has meant that individuals with a disability have often been presented with few, if any, options with respect to their housing, and have poor outcomes that contribute to the risk of homelessness. Individuals with a disability who leave the family home are commonly directed to non-private dwellings such as residential care homes and boarding houses. From their earlier study of housing careers undertaken in Australia, Beer and Faulkner  reportedHomelessness pathways research has, to date, largely ignored the trajectories into homelessness likely to be followed by persons living with disability. Chamberlain and Mackenzie  argued tThe Australian Census of Population and Housing undertaken at the time of these changes  providesIn order to advance our understanding of the prevalence and character of risk of homelessness among the population with a disability or long-term illness, this paper develops an index of the relative risk of homelessness. The index is applied to two large-scale, national datasets to map and compare relative risk across disability type and restriction.In this paper we examine the prevalence of risk of homelessness amongst populations with a disability. Two large Australian datasets were analysed—the Household, Income and Labour Dynamics in Australia (HILDA) Survey and the Australian Bureau of Statistics’ General Social Survey (GSS). We classify risk of homelessness for the Australian population along a ten-point continuum. Those with the highest relative risk are classified at level 10, and those with the lowest risk were classified at level 1. Importantly, our approach builds on previous research which principally focused on the classification of homelessness  and Level of restriction , GSS analysis;Category of disability , GSS analysis; andSpecific disability types , HILDA analysis.Our preliminary analysis revealed that Australian populations with a disability are distinct from populations without disabilities in terms of their risk of homelessness. Therefore, we focus on the relative risk of homelessness among populations with disability in three ways:The following analysis seeks to assess the level of risk of homelessness amongst the population with a disability based upon an analysis of the HILDA and GSS data sets. These two large, robust and valuable datasets collect ongoing health and housing information about the Australian population.The GSS is an ongoing cross-sectional survey conducted by the Australian Bureau of Statistics (ABS) every four years . It collThe HILDA survey is an annual, nationally representative household-based longitudinal survey of around 18,000 individuals. It has been conducted each year since 2001 and now contains 17 available waves of data . The HILWe constructed an Index of Relative Homelessness Risk (IRHR) that allows comparison of the relative exposure to homelessness of a range of disability types, as well as the population as a whole, across the two datasets. The index builds upon previous work on housing precariousness by Mallett et al. . An earlProfound—always needs help/supervision with core activitiesSevere—does not always need help with core activitiesModerate—has difficulty with core activitiesMild—uses aids to assist with core activitiesPersons are classified as having a schooling/employment restriction if they have no core activity limitation, are aged 18 to 20 years, and have difficulties with education, or are less than 65 years and have difficulties with employment.Disability is measured across the population using the two datasets: the GSS allowed the measurement of the level of disability restriction and also by category of disability. The level of disability restriction data was classified by the ABS across five categories , as detaDisability category was defined in the GSS dataset as: sensory , physical, intellectual, or psychological. Within the broader population these groups were unevenly represented; for example, 14 per cent of the sample population were classified as having a sensory disability, 26 per cent having a physical disability, 2 per cent having an intellectual disability, and 5 per cent a psychological disability.The second dataset, HILDA, was used to measure relative homelessness risk for groups across 15 specific disability types: limited use of arms or fingers, hearing problem, difficulty learning or understanding, speech problem, blackouts, fits, loss of consciousness, limited use of feet or legs, difficulty gripping things, nervous or emotional condition that needs treatment, any condition that restricts physical activity or work, disfigurement or deformity, any mental illness that requires help or supervision, shortness of breath or difficulty breathing, chronic or reoccurring pain, long-term effect of head injury, stroke or other brain damage, and other long-term health conditions or ailments.While the results of the analyses of the two datasets are not directly comparable , they do allow us an important insight into the relation between disability and the risk of homelessness from multiple perspectives.In the GSS, a total respondent pool of 11,436 individuals were represented in the analysis of disability by limitation/restriction. Within this total respondent pool, just under half (42 per cent) were recorded as having at least one disability or long-term health condition, and the remaining 58 per cent had none. Among those with a disability or long term health condition, the largest category were those with a non-specific disability, followed by individuals with ‘moderate core activity restrictions’, ‘schooling or employment restrictions’, ‘severe core activity restrictions’, ‘profound core activity restrictions’, and lastly, just over 5 per cent had ‘mild core activity restrictions’.When the characteristics of individuals across this sample were analysed in terms of relative risk of homelessness (as measured by the IRHR), a clear relationship between relative risk of homelessness and the severity of a disability was shown. The strength of this association was statistically confirmed as highly significant (Pr = 0.000). The results are summarised in Examining the figure, the IRHR profile of those without disabilities or long-term health conditions (shown as a solid black line) follows a relatively flat ‘normal-type’ curve. Profiles of those with disabilities differ, in the main being much more concentrated in the mid-value IRHR scores. The exception is the group with schooling/employment restrictions (shown as a dashed black line) who are substantially less concentrated in the lower risk IRHRs (1–4), and much more concentrated than the average in the higher risk categories (8–10). Importantly, an individual with a schooling/employment limitation is almost twice as likely (33 per cent) to be in these extreme categories as someone without a limitation (18 per cent).The analysis focuses on four major categories of disability as classified in the GSS—sensory, physical, intellectual, and psychological. In examining psychological disability, we acknowledge that mental illness is not a focus of this research. However, it is a recognised and much researched cause of homelessness and therefore serves as a useful benchmark when examining the interaction between homelessness and other types of disability.For each category of disability we found a highly significant association between relative homelessness risk and disability type (in each case Pr = 0.000). As noted above, HILDA provides important insights into the wellbeing of the broad Australian population and has the potential to shed light on the housing/homelessness circumstances of those with a disability. This analysis of disability type is based upon a pooled analysis of over 120,000 responses to the HILDA survey over the 9 years where the data was available. This large dataset allows us to robustly examine the prevalence of specific disability characteristics by the relative homelessness risk of individuals. The nature of the HILDA data collection allows for greater precision in the specification of disabilities and in the analysis of exposure to risk. The results, comparing relative risk for individuals who had specific disabilities (in grey), with relative risk for individuals without those specific disabilities (in black), are summarised in A number of findings stand out in these graphs: firstly, in the case of each disability type, individuals with a disability are much less likely to have a low relative homelessness risk  than those without a disability. Secondly, with only one exception, individuals with disabilities are over-represented in the mid ranges of relative homelessness risk compared to those without disabilities. Third, those with physical disabilities tend not to be over-represented, compared to individuals without disabilities, in the higher relative risk of homelessness categories. For these types of disability, similar proportions with a disability are in the higher IRHR categories compared to individuals without. For individuals whose disability is related to mental illness or brain injury, there is an increased likelihood of these individuals having higher relative homelessness risk. We highlight here individuals with difficulty learning or understanding, where almost 25 per cent of individuals with this type of disability are in the most extreme levels of homelessness risk , compared to only 16 per cent of individuals without that disability. Similarly, for individuals with a mental illness that requires help or supervision, the results are even more extreme, with 34 per cent of this population in extreme homelessness risk, compared to 17 per cent of individuals without this type of disability.This paper set out to understand the risk of homelessness amongst persons with a disability in Australia in the early- to mid-2000s, prior to the introduction of a generationally important disability policy reform, the NDIS. The paper examined the level of risk for persons with a disability prior to the introduction of the NDIS, and a subsequent paper will provide updated data and analysis for the period post the implementation of the NDIS. In one sense, this paper simply sheds light on the starting condition prior to the introduction of the NDIS but it has also generated its own unique, and valuable insights, into the impact of disability and chronic ill-health on the propensity to experience homelessness.The analyses presented in this paper have provided confirmation of the underlying assumption of this research: that persons with a disability have a greater exposure to the risk of homelessness than the general population. Importantly however, we showed that the relative risk of homelessness (and hence any resulting policy response) cannot be generalised for the population with a disability because exposure is not evenly distributed amongst those with a disability. Across the analyses, individuals with schooling/employment restrictions, those with psychological and intellectual disabilities, and those with mental illnesses were especially vulnerable to extreme levels of relative homelessness risk. Individuals with each of these restriction types are much more likely than the population without a disability to be at risk of homelessness—of whom approximately one in five were classified at the same extreme level of homelessness risk.Our analysis suggests that during the study period, disability was strongly associated with the relative risk of homelessness and that, within the disabled population, there were differences in risk depending on the severity of restriction and the type of disability. People with schooling/employment restrictions appear to be highly vulnerable to risk of homelessness. The analysis also revealed much higher levels of relative risk for people with intellectual and psychological disabilities. We speculate that these patterns, at least partially, reflect the differential effect of welfare and policy interventions on the relative homelessness risk of individuals with different forms of disability. Because interventions are focused, and also taken up unevenly across a population, welfare protection is provided, but unevenly. This affects IRHR patterns across and between populations, and we speculate that this contributes to different IRHR profiles between disability types. For example, individuals with physical and sensory disabilities have an IRHR profile that is more similar to the population with no disability, and this leads us to question if this is a reflection of the greater effectiveness of housing interventions for this group. Importantly though, the IRHR profile for each of these disability types would doubtless be very different in a policy environment where no welfare interventions were provided, and mapping the IRHR profile changes due to specific large scale interventions is an area ripe for further research.It is also important to note the small but likely influence of age. In the populations classified as having either physical of sensory disabilities, a proportion of these persons would have acquired their disability as a result of natural ageing. In these cases, they have experienced a shorter length of exposure to disability, meaning that many would have spent greater periods of their life course in employment, thereby acquiring housing and financial assets. Such shorter exposure length to disability is likely to provide some protection from relative homelessness risk.Reinforcing the earlier results, this analysis highlights an overall higher relative risk of homelessness for people with mental health and learning related disabilities. Finally, this examination of individual disability types does not capture co-morbidity within the population. Many individuals in our large sample have more than one disability type, and although the effects of co-morbidity have not been included in this study, we acknowledge that this will also influence vulnerability to poorer relative homelessness risk.Our findings reflected the differentiated risk of homelessness across various disability groups in Australia, which in turn indicate the uneven level of government and NGO-provided support available to persons with different types of disability in Australia in the early 2000s. Overall, the paper highlighted a number of sub-groups within the disabled population who are more vulnerable, and hence, need additional  support with their housing. Beyond the insights into extreme risk of homelessness, our modelling has emphasised the uneven exposure that some groups have to moderate homelessness risk. These groups , had a much higher likelihood of classification of a moderate risk of homelessness when compared with those without a disability. This is important because, firstly, these groups tend to be equivalently under-represented in the very low risk categories (representing secure and affordable housing), and also because this reflects housing disadvantage and a potential homelessness precondition, which may not be detected in studies that focus only on homelessness.Overall, we can conclude that in Australia in the early 2000s, persons with a disability had greater exposure to the risk of homelessness than the general population. Individuals with some disability types  were more vulnerable to homelessness, and hence needed additional  support with their housing, but often such support was not provided. Finally, we acknowledge that, while this study has highlighted the differential prevalence of risk across the population affected by a disability, it has not shed light on the triggers or buffers that may increase vulnerability or protection from homelessness. The follow-up paper may show that the risk of homelessness for persons with a disability has decreased since the introduction of the NDIS, but we also need to be open to the possibility that the opposite holds.


Media advocacy plays an important role in public health initiatives, as it can provide vital information to target populations, policy makers, or other relevant stakeholders. Unfortunately, little is currently known about the use of media advocacy to promote occupational safety and health programs. This study explores media coverage related to the Rollover Protection Structure (ROPS) Rebate Programs, which were designed to encourage the use of rollover protection on agricultural tractors, thus reducing the risk of tractor overturn fatalities. The Program’s portrayal in the media, as well as the role that the media has played in implementing and sustaining these Programs.Media articles pertaining to any of the state-based or National ROPS Rebate Programs and published between November 1, 2006 and October 31, 2018 were included for review. Discourse analysis was used to understand the messages portrayed by the media and how those messages shaped the outcomes of the ROPS Rebate Programs.During the study period, 212 unique articles were published about the ROPS Rebate Programs. While these articles all portrayed the ROPS Rebate Programs in a largely positive light, they were used at different stages, from pre-implementation through sustainment of the ROPS Rebate Programs, and to different extents.Media articles have played an important role in implementing and sustaining the ROPS Rebate Programs. Based on the results of this study, more robust and continuous media coverage are important for the longevity and success of public health programs. As it relates to public health, media can both help and hinder efforts. Similarly, media can both influence and be influenced by readers at all levels from policy and decision makers to the general public. As such, media advocacy efforts, which can be defined as, “the strategic use of mass media to support community organizing and advance healthy public policy ,” have bTo help fill this gap, this study seeks to explore and understand a series of media advocacy campaigns surrounding an agricultural safety intervention first developed in New York State and then expanded to additional states and eventually nationally.Given that the average working adult spends more than a quarter of their lives at work , 7, occuIn 2006, the first ROPS Rebate Program was implemented in New York State to reduce farmers’ barriers to installing ROPS on their older tractors. The Program consists of three primary components: 1) a social marketing campaign aimed at raising awareness of tractor overturn fatalities and the Program, 2) a hotline to assist farmers with identifying the correct ROPS kit for their tractor, and 3) a 70% rebate toward the cost of purchasing and installing a ROPS kit . These cDue to the success of the New York Program, the ROPS Rebate Program model was replicated to varying extents in Vermont, New Hampshire, Pennsylvania, Massachusetts, Wisconsin, and Minnesota between 2010 and 2016.In addition to individual state Programs, the National ROPS Rebate Program was launched in 2017 . The NatThough all ROPS Rebate Programs currently operate under the umbrella of the National ROPS Rebate Program, they are referred to as individual ROPS Rebate Programs in this manuscript. This is in order to highlight the role that media has played in each Program, and how differences in these media strategies could have contributed to differing outcomes.The short-term outcomes presented in this study are the amount of funding dedicated to ROPS Rebate Programs, as well as the number of retrofits through the Programs.New York, which was the first state to launch a ROPS Rebate Program, has dedicated the largest amount of funding for rebates, and has thus retrofitted the greatest number of tractors (1765 in 12.5 years). Rebate funding in New York is provided by the New York State Department of Agriculture and Markets.Both Vermont and Pennsylvania fully implemented the three core components of the ROPS Rebate Program in 2010 and 2011; however, both states relied on private donations to fund rebates. Unfortunately, this resulted in the quick depletion of rebate funding and the development of waitlists by 2012. These waitlists continue today. The New Hampshire Program, which is funded through private donations, and the Massachusetts Program, which is funded through the State Department of Agricultural Resources, also implemented all aspects of the ROPS Rebate Program; however, with less emphasis on the social marketing campaign. As such, demand for the Programs is limited, and rebate funding has been sufficient to meet those demands.Both Wisconsin and Minnesota have ample funding, and are able to utilize all aspects of the ROPS Rebate Program. However, while Minnesota’s rebate funding is provided by the state legislature, rebate funding in Wisconsin is obtained through an annual fundraiser. In recent years, organizers of this fundraiser have discussed redirecting the funds to another agricultural safety and health program, thus challenging the sustainability of funding. In response, Wisconsin Program staff have begun efforts to obtain other sources of funding.Finally, the National ROPS Rebate Program has had some success in obtaining rebate funding  and retrofitting tractors (13 since 2017). However, a more important short-term outcome in this case is the preservation of funding for administrative tasks. This includes the cost of facilitating the ROPS Rebate Programs  and working to procure funding in under-served areas. At the time of this study, this funding has been provided continuously since the Program launched.Long-term outcomes of the ROPS Rebate Programs include the number of lives saved, as well as resulting cost savings. Because these outcomes require a great deal of data over a longer period of time, they have so far only been assessed relative to the New York ROPS Rebate Program. Recently published research demonstrates that this Program not only save lives, but are fiscally advantageous, as the cost to administer them is markedly less than the cost of addressing overturn fatalities and injuries once they have occurred . DespiteAs part of the implementation and sustainability strategies, media has been used to varying extents across all ROPS Rebate Programs to share information, promote the Programs, and gain political and public support. Though used frequently to promote the Programs, no pre-planned media advocacy strategies existed for any of ROPS Rebate Programs. Instead, media was used as opportunities arose in the various settings . Despite these efforts, in interviews with stakeholders involved in the implementation of the National ROPS Rebate Program conducted in 2017 and 2018 , the individuals interviewed were generally unaware of media or related political commentary surrounding the National ROPS Rebate Program, thus leaving a major gap in fully understanding the implementation efforts. This study aims to fills this gap by assessing 1) how the ROPS Rebate Programs are portrayed in the media, and 2) how media are used to advance the ROPS Rebate Programs.This study used a discourse analysis for print media approach, which begins with collecting media publications relevant to the topic. In doing so, specific key words are used to monitor media sources for real-time updates and retrospectively search online databases to identify published media reports.Discourse analysis assumes that language both shapes, and is shaped by the real world –17. In aIn conducting discourse analysis of print media, three areas of consideration are of particular interest: the text or news story, the process used to develop the news story, and the news story’s relationship to the audience .Textual analysis, which is most common in discourse analysis  can be lThis links to the process used to develop the media report in that those of differing social status or power (relevant to the media report) may be used in varying ways during the development process. In the case of the ROPS Rebate Programs, an array of individuals from varying backgrounds  are used as sources of information and quoted in media reports.Finally, the language used in the text as well as the power and societal structures defined help to dictate (or are dictated by) the audience for the particular media report. Together, these can be important tools in shaping or reinforcing the readers’ opinion of the topic, the individuals involved, and the societal hierarchy relevant to the issue , 19.Media reports that related to the ROPS Rebate Program were gathered from collections that Program staff had maintained since its inception in November 2006. These collections were developed based on web-based media alerts set up through Burrelles Luce News Clippings and Google Alerts, as well as visual inspection of printed media publications upon receipt. In order to ensure that all media reports were included, ProQuest Newspapers was searched using the key term “ROPS Rebate Program.” All media reports referencing one of the ROPS Rebate Programs and published before October 31, 2018 were included in this analysis. Media reports were excluded if they only mentioned the Program as part of a list of an organization’s services and did not provide additional detail.Media reports were first organized based on the date in which they were published, as well as the specific ROPS Rebate Program that was referenced . Media reports that referenced multiple state Programs, but were published prior to use of the term “National ROPS Rebate Program” were still considered to be related to the National Program. By organizing the media reports in this way, the authors were then able to identify reports that had been replicated either in full or partially. Additionally, this allowed for media discourse to be compared between each of the current ROPS Rebate Programs, as well as states that do not yet have Programs. Analysis of media reports by state was key to the aims of this study, as it allows for assessment of how differences in media strategies can contribute to different outcomes in each case.The lead author, who is heavily involved in the administration of the ROPS Rebate Programs, first inductively coded each media report line-by-line using NVIVO 12 qualitative analysis software . ThroughAn external reviewer who was unfamiliar with the ROPS Rebate Programs provided written summaries of the media reports relevant to each Program. These summaries included overviews of the target audience, key messages, important players, and media strategies used, but did not include in-depth analysis or latent meanings. While conducting the analysis, the authors used these summaries to ensure that their own viewpoints and those of individuals less connected with the ROPS Rebate Programs were maintained and considered in the analysis. Though there were differences in the analyses conducted by the coder and the reviewer, these differences were not related to content. Instead, these differences related to the emphasis given to certain aspects of the data, which was based on each individuals’ knowledge of the Programs. Thus, the minor discrepancies between the coder and the external reviewer served to balance the two perspectives.n = 259) of these media reports were published through non-agricultural media sources  while the remainder appeared in agricultural-specific sources .The earliest identified media report was published in New York on November 20, 2006. During the 12-year period included in this study, a total of 212 unique media reports (i.e. new media reports) were published 357 times  referred primarily to the New York ROPS Rebate Program, 67 (18.8%) to the National ROPS Rebate Program, 40 11.2%) to the Minnesota Program, 32 (9%) to the Wisconsin Program, 13 (3.6%) to the Pennsylvania Program, seven (1.9%) to the New Hampshire Program, six (1.6%) to the Vermont Program, six (1.7%) to states without Programs as of October 31, 2018, and 1 (0.2%) to the Massachusetts Program. The numbers of media reports published about each Program are highlighted in comparison to Program outcomes (rebate funding and retrofits) in Table % to the Based on the numbers of unique media reports published compared to the Program launch dates, New York and, to some extent, Wisconsin, have used media extensively since the launch of the initiatives. New Hampshire, Vermont, Pennsylvania, and Massachusetts similarly used media to launch their Programs; however, these efforts were discontinued after a short time. Both the Minnesota and National Programs have used media to introduce the possibility of a Program, and then have continued to varying degrees after their respective launches. These trends are highlighted in Fig. Based on the media reports review, the origination of these reports (part of the process of developing text) was different across the states. Those published in Vermont, New Hampshire, Pennsylvania, Massachusetts, and Wisconsin primarily stemmed from press releases and announcements provided by Program staff. The New York and National ROPS Rebate Programs’ media involved a mixture of staff-prepared press releases and announcements, political press releases, and organically prepared materials initiated by external journalists and reporters. Finally, on the far end of the spectrum, media reports published in Minnesota were primarily initiated and prepared by journalists and reporters external to the Program.Most often, the media reports included in this paper used quotes and input generated from ROPS Rebate Program staff. Examples of these types of media reports could be found for all Programs. Similarly, examples of media reports that featured farmers could also be identified across all Programs. Though farmers were quoted in media reports across all Programs, such examples were most common media reports about the New York ROPS Rebate Program, while the Pennsylvania ROPS Rebate Program media reports incorporated farmer opinions sparingly. In addition to these two groups, legislative officials were portrayed to a great extent in both media reports about the New York and National ROPS Rebate Programs. Legislative officials were also quoted in Minnesota and Wisconsin, but to a much lesser extent. Lastly, other groups, including insurers and equipment dealers were occasionally quoted. Often, the presence of input by these types of organizations were generally tied to prior support for the Programs by the organizations.Two key audiences were identified in these media reports: 1) the farmers who can participate in the ROPS Rebate Programs, and 2) the potential supporters or funders of the Programs, both legislative and non-legislative.The remainder of the results section is divided into two overarching areas: commonalities across all media reports in this study, and differences between the media reports across ROPS Rebate Programs.Across the board, media reports related to the various ROPS Rebate Programs tended to highlight the important role that farmers play in their communities and in the United States as a whole. These quotations came from a number of different parties, further highlighting the importance of having farmers in the community. Often, individuals who were quoted speaking of farmers’ importance used this as a way to convey the idea that the Program provides a way to thank farmers for their hard work by providing reduced-cost safety technologies (ROPS).“Minnesota’s farmers work hard to feed people around the world, and take care of their families and communities. Minnesota’s new Rollover Protective Structures Rebate Program helps to take care of them by defraying the cost of important improvements to aging farm equipment that would otherwise lack modern safety features,” .In addition to the ROPS Rebate Programs’ staff using media reports as a method for recognizing farmers and thanking them for their work, the vast societal benefits of the ROPS Rebate Programs were also highlighted in much of the media. The immediate and intended benefit of the Program  was highly praised in many media reports.“With increasing use of ROPS on tractors we are seeing fewer accidents and fatalities. This is a very effective program for a lot of reasons. Our research data shows the ROPS tractor safety program has made farm work less dangerous,” .In addition, many media reports highlight other benefits of the Program: the long-term impacts on the individual farms, the economic impact of preventing tractor overturn fatalities, and job preservation at agricultural equipment dealerships and ROPS manufacturing organizations.“What’s more, farmers aren’t just risking their lives when operating tractors without these roll bars, but their entire businesses too,” .Finally, across the majority of media reports, one misconception related to the ROPS Rebate Programs was addressed. This relates to stakeholders belief that farmers’ are not interested in safer work practices or participating in programs such as the NRRP.“An old friend, a very careful man, was killed in a rollover some years ago. Other neighbors and friends have been thusly injured. On occasion, I get into a situation where I myself am afraid. So there is a clear danger that a rollbar would reduce. Yet, I choose not to install one,” .While occasional media reports have quoted individuals, such as the one above, many more have made an effort to highlight farmers’ need and appreciation for the financial assistance that the ROPS Rebate Programs provide, thus negating opposing arguments.“You know, most farmers, dairy farmers, they milk in the morning, do field work, have to milk at night, so safety is always a concern and anything we can do to improve safety is what we look for,” .In addition to these portrayals, another overarching trend in media reports was that often, incorrect information was provided through the articles. In some cases, this misinformation related to the rebate amount, availability or Programs, or the idea that ROPS are only effective when used with a seatbelt . In regBased on the reviewed media reports, media seem to have been used differently across the various ROPS Rebate Programs. In New York and Minnesota, as well as at the National level, media reports seem to be more closely aligned with principles of media advocacy to support implementation and sustainability of Programs. However, in the remainder of the states, media reports seemed to focus less on advocacy and more on awareness-building. Though both strategies can be seen in almost all efforts, this analysis focuses on the primary use of media within each Program.Media in Minnesota was strongest prior to implementation. There, a local reporter prepared a multi-part series on the growing number of fatalities on Minnesota farms, which then sparked the interest of legislators and government officials in the state. In one of the media reports, the journalist stated;“Lawmakers said they were prompted to act by a 2015 series in the Star Tribune that revealed a disturbing spike in the number of Minnesota farmers killed in work-related accidents,” .Though ROPS Rebate Program staff were interviewed for this series, the reporter had developed and executed the series based on his own personal interests and without any prior efforts to promote the Program in Minnesota. After the initial media report introducing the ROPS Rebate Program, attention shifted to the growing interest in funding a Program. In several instances, media reports focused on the past success of the ROPS Rebate Programs in other states and legislative interest in mimicking these efforts.“I thought if other states can do it and feel it’s a worthwhile program, maybe we should try something like that in Minnesota,” .The media reports closely followed the legislative discussions surrounding the ROPS Rebate Program with some reports more positive than others. In publishing this information, a few media reports also presented arguments from those who were opposed to the ROPS Rebate Program. In fact, Minnesota was the only state in which explicit opposition to the Program, or parts of it, was depicted in media reports.“On the other hand, if we want to reduce unnecessary deaths and injuries and as taxpayers are willing to spend an extra $250,000 to do so, would giving it to farmers to buy rollbars for old tractors save the most lives for the money? I think not, but opinions will vary,” .Once a bill supporting the ROPS Rebate Program passed in 2016, the media attention shifted. Rather than focusing on the political debate surrounding the Program, most media reports refocused on letting farmers know how the Program works and sharing early successes before media ended just 3 months after the Program launched.“Since its inception, 150 farmers have been approved for a rollover protective structures…Another 127 farmers have an application pending, some of which are approved and in the process of finding an appropriate rollover protective structure kit,” .Media reports in New York were used initially to support the launch of the ROPS Rebate Program; however, over time, media has been used as an aide to Program sustainment. Initial media reports related to the New York ROPS Program were largely targeted at farmers and focused on explaining and promoting the Program; however, the strategy used transformed over time. Media reports focused more on farmer stories and evidence of lives saved through the Program as well as arguments in favor of the ROPS Rebate Program as an investment opportunity for farmers.“I was very fortunate. It prevented (the tractor) from going all the way over and got the tractor upright. If it hadn’t been on it would have probably rolled over and broke my neck,” .Though most of the media reports published about the New York ROPS Rebate Program focused on sharing information with farmers, these media reports doubled as a way to engage politicians and other supporters in the public discussion of the Program. About three quarters of these media reports included quotes or were written by state legislators who have supported the Program and assisted in securing state-based rebate funding.“In the past few years, I have been proud to have secured $1.2 million in funding, including $250,000 in the new state budget, for a program that helps to protect farmers from tractor rollover incidents,” .In addition, the necessity and importance of legislative support for the Program was often referenced even when legislators were not directly quoted. These quotations served to reinforce the important contribution of political stakeholders.“I am writing to recognize the leadership role that Senator Catharine Young and the New York Senate Agricultural Committee have assumed to protect the lives and well-being of farmers in our area and throughout New York State,” .Media on the National ROPS Rebate Program varied more in its content and intended target audience than coverage related to individual state Programs. These media reports tended to focus almost entirely on generating support from non-farming stakeholders for the National ROPS Rebate Program, with many including direct asks for support .Almost all of the initial media reports about the National Tractor Safety Coalition referred to the group’s push for a National ROPS Rebate Program modeled off those previously mentioned. In general, these media reports shared basic information and provided additional stakeholders with methods of getting involved.“Through a series of facilitated exercises over 2 full days, the group created a vision for tractor safety and made organizational commitments to reduce tractor-related deaths in the United States and to promote retrofits of older tractors with roll-over protective structures (ROPS),” .After the initial media reports about the Coalition, little was published until June 2017 when the National ROPS Rebate Program was officially launched. However, this launch came at the same time in which cuts to the presidential budget severely threatened continuation of the Program.“It has been terminated in the past but the cuts are deeper and we are not sure if we are going to survive so I guess the shortest answer to your question is there would be no program. Why should somebody have to put their life at risk to make enough money to make ends meet? It just seems like- it seems unjust,” .Having made national headlines, the budget cuts threatening the National ROPS Rebate Program were then addressed through many media reports featuring United States Senator Chuck Schumer, then the Senate Minority Leader. These media reports followed Senator Schumer through a series of press-events in which he addressed the need to maintain funding for the Program and vowed to “[do] everything possible to make sure this program, which puts farmers first, is protected,” . In this push, the Senator, and the reporters covering the effort, focused primarily on both the lives saved by the Program, as well as the extensive cost savings seen.“The work done by organizations like the NEC is exactly the type of work the federal government should be investing in: it’s cost-effective, informed by real industry experts, and helps save farmers’ lives every day,” .Similar sentiments are echoed throughout the effort to preserve funding, as well as after a press announcement highlighting the Center for Disease Control and Prevention’s commitment to maintain funding for the Program in July 2018.Aside from New York, northeastern states  focused little attention on sharing Program information through the media. In these states, media reports were primarily limited to the time directly surrounding the launch of each states’ Program. Most of the initial media reports tended to be fact-based and simply described the various aspects of the Program and its importance. In both Pennsylvania and Vermont, media reports were also used to highlight that rebates provided through the Program are from private donations. While well intentioned, these highlights hinted at the potential insufficiency of Program funding and therefore the Program.“[Vermont], meanwhile, is working to secure more private sponsors for the program: The number of sign-ups is about to eclipse the rebate fund,” .Media reports in Wisconsin began briefly before the ROPS Rebate Program was launched; however, the vast majority of the reports were published after the start of the Program. In general, these media reports used a three-piece strategy directed at farmers and dictated by Program staff rather than journalists. This strategy involved advertising for the Program by 1) briefly describing the issue of tractor overturns and the purpose of ROPS, 2) announcing the availability of the Program, and 3) sharing information on how to sign up for the Program.“A ROPS helps prevent injury or death in the event of an overturn. All Wisconsin farmers are eligible to apply for the rebate program, which reimburses up to 70 percent toward the total cost of purchasing, shipping, and installing individual ROPS,” .In using this format, farmer quotes and stories were used; however, this was often done sparingly with little space provided for elaborate descriptions. In 2016; however, several media reports were published promoting the Program as a potential candidate for legislative funding. These media reports tended to be longer and included more detail about farmers’ experiences with tractor overturns as well as general safety issues. Only a handful of these media reports promoting the Program as a possible legislative effort were published in 2016, with one follow-up sharing an unfavorable legislative outcome in early 2018.“This program makes Wisconsin farms safer. It’s very positive that the bill made it through both committees this year, but we’ll need at least one more big push to get it signed into law. This is something Wisconsin farmers need,” .Five media reports were published advocating for ROPS Rebate Programs in states not previously mentioned . These media reports tended to share general information about the nationwide burden of tractor overturns and the need for a ROPS Rebate Program; however, little information was provided about next steps in establishing such a Program. Only one of these media reports was a follow-up to another.The work carried out in this study provides evidence that media advocacy can be effective as a part of public health program implementation. In particular, honing in on correct and positive public health messages, the timing of media compared to that of the intervention, and the individuals involved in creating the media coverage (i.e. reporters and experts) were shown to influence the impact of media on implementation and sustainability of the ROPS Rebate Programs.Across the different Programs, there were commonalities in how the Programs were portrayed that are likely to have had a positive impact, overall, on implementation and sustainability. Overall, the public health messages were positive, highlighting the Program as an expression of gratitude for farmers, the benefit of the Program to farmers and communities, and farmers’ interest in the Program. It was incredibly rare to find media reports with negative portrayals of the ROPS Rebate Program. Though true, it is also important to examine why so few negative media reports existed. First, the ROPS Rebate Programs are intended to save lives, a goal that was met and proven from early on . As humaThough the media reports were mainly positive, some information about the Programs was presented inaccurately. This raises the issue of ensuring that public health messages are clear and that, to whatever extent possible, all individuals speaking with the press are presenting consistent and accurate messages. Such confusion could be problematic for public health programs .While the components of the public health messaging are important, in this study they were not sufficient for creating a meaningful impact on implementation and sustainment of the NRRP. Instead, it is important to examine the differences in media strategies (timing and spokespersons) used across the Programs. For the most part, media reports were published in response to ROPS Rebate Program launches; however, in Minnesota, media reports provided motivation for officials to launch a ROPS Rebate Program. Both of these strategies were beneficial; however, in Minnesota, the burden placed on Program staff and state champions to launch a ROPS Rebate Program was significantly reduced compared to that of other states. This can be important considering that limited project budgets and a wide array of competing priorities can limit the staff and champions’ ability to work on implementation efforts. In addition, in many cases funding is provided through government grants, meaning that that staff (including those working on the ROPS Rebate Programs) are not able to act as political advocates. Thus, media provides an alternative outlet for legislators and others to be educated about the benefits of public health programs.In addition to being helpful prior to implementation, media advocacy after implementation can help sustain public health programs by keeping the program at the forefront. In New York, where media has been used regularly to highlight the impact of the ROPS Rebate Program, funding has been sustained for 12 years. Those states where media ended shortly after implementation tended to be the ones with less successful ROPS Rebate Programs (i.e. fewer rebate dollars and retrofits). Similarly, few stories have been published in Minnesota since the implementation of the Program. While funding was secured for a second year in a row, the amount was reduced and spread across 2 years rather than one. It is possible that the decreased media related to this issue created the illusion that tractor overturn fatalities are no longer an issue, and thus the Program is no longer needed. Further monitoring of media and legislative decisions over the next legislative session will provide additional insight into these trends and their relationship.Given the importance of timing media related to public health programs, the question of generating enough interest to warrant media becomes problematic . In MinnThis was the experience with the National ROPS Rebate Program launch, which was marginally covered by the press. However, a well-placed media report in POLITICO highlighted the financial struggles that the Program faced. A prominent US Senator with an interest in the Program then spurred tremendous media report in response to these issues as he worked to sustain Program funding. Similarly, in New York, legislators have played a key role in generating media about the ROPS Rebate Programs through both press conferences and personally authored media reports. During legislative sessions, the support of these politicians has been crucial for securing or restoring funding for the Program. Such media emphasizes the importance of gaining and maintaining political allies. In addition, the Programs make these alliances visible to the public, including farmers, who can then hold stakeholders accountable .Though political support is extremely important for these Programs, the diversity of expertise  presented in media reports examined in this study is also important for bringing the issue to the attention of diverse readers with a variety of interests. By presenting these diverse viewpoints, the media likely helped to further increase knowledge of, and demand and support for the Program, thus further encouraging legislative action.In gaining traction, either at the policy level or within other groups, the source that media reports are published in can be of importance. Agricultural publications, which are directed primarily at the farm community, are useful in sharing information about the Program with the target population; however, these are less visible to policy makers and other supporters. Similarly, publications targeted at specific groups of stakeholders  can be useful in reaching individuals or organizations who wish to contribute to implementation. While these sources are important, the results of this study show the benefit of engaging policy makers in the discussion. The use of local, non-agricultural media sources , as well as more targeted media (e.g. POLITICO) can be useful in two ways. First, these sources have a greater potential to help capture the attention of policy makers . Second,Based on the results of this study, it is likely that the robustness of the media efforts surrounding the ROPS Rebate Programs can determine the trajectory of the Programs. In particular, media reports that feature a variety of expertise are present in states with strong financial support for the ROPS Rebate Programs. These varied expert views of the ROPS Rebate Program provide ample opportunity for the benefits of the Program to be highlighted in several ways, making it easier to appeal to supporters with varying agendas and views.Moving forward, robust media providing diverse perspectives on the many benefits of the ROPS Rebate Programs could be used as viable implementation strategies as additional states look to launch ROPS Rebate Programs. Ideally, local champions and reporters would work together to provide adequate coverage to begin a “domino effect” similar to what was seen in Minnesota. Once launched, these same collaborations can be used to further highlight the local impact of the Program and engage policy-makers and supporters in public discussions of the Program. By making both the implementation and sustainment of the Program public through use of media, the commitments made by various parties become part of an accountability plan which encourages these partners to continue their support, thus promoting the success of the Programs.This study has two main limitations. First, some relevant media reports may not have been captured at the time of publication or available online at the time of this study. Thus, it is possible that important sources of information were missed. Second, it was outside of the scope of this study to interview the journalists and Program supporters referenced in the media reports for their perspectives on publicly supporting the ROPS Rebate Program. The knowledge that could be generated from such discussions, particularly related to motivation for their involvement in media reports, would be helpful in understanding the relationship between media and the trajectory of the ROPS Rebate Programs. Such interviews could be the basis of a follow-up study.A strength of this study is the trustworthiness of the analysis. Both the first and second authors have been heavily involved in these Programs, and thus, are biased to certain aspects of the media. To reduce this bias and improve trustworthiness of the study, several individuals with different levels of involvement in the Programs were involved in the analysis. This included two authors who are heavily involved in Program administration, two who have primarily been involved in evaluation of the Program, and one external reviewer who had not been exposed to the ROPS Rebate Programs ahead of this study. Though there were no disagreements related to content between the authors’ analysis and that of the external reviewer, the two summaries placed different emphases on different aspects of the media reports. In the results, these viewpoints were combined to reduce any relevant biases.The use of media to implement and sustain the ROPS Rebate Programs has been documented across the different Programs. Those Programs which used more comprehensive media strategies also are those with more promising funding structures and thus greater overall success. Though it can be difficult to distinguish which came first – ample media or overall Program success - this suggests that media advocacy can be an important component of implementation strategies, not just in occupational safety settings, but in public health overall.Such strategies have the potential to not only influence relevant policy-makers, but also require accountability by program supporters who make their commitments public. By identifying appropriate media champions and utilizing media before, during, and after implementation, public health programs can expect to see benefits.