There was a significant increase in agreement to improve group identity protections (p<0.001) and no differences on willingness to donate biospecimens to research (p=0.777). When differences were analyzed by race of the participant, non-White participants (n=68) compared with White participants (n=344) were less willing to donate biospecimens in general (p<0.001). Further, non-White participants’ willingness to donate biospecimens decreased (p=0.049) after viewing the play while the white participants’ willingness to donate was unchanged. Qualitative data provided extensive contextual data supporting these perspectives. DISCUSSION/SIGNIFICANCE OF IMPACT: This is one of the first studies to empirically examine the impact of a theatrical performance on both attitudes and behavioral intentions toward research and clinical research participation. Some attitudes changed following the play performance, but there were no significant differences on intention to donate biospecimens for research overall. Future research can further address the value and impact of theatrical performances and other creative arts as tools to engage the public and investigators in dialogue about the ethical issues and complexities in clinical research and further evaluation of the impact of performances on attitudes about research and ethics. Creative arts may be used to motivate investigators and study participants to confront fundamental questions about research participation and trust.OBJECTIVES/SPECIFIC AIMS: Exposure to theatrical performances holds promise for addressing bioethical issues, but there has been little empirical examination of the impact of dramatic presentation on audiences’ attitudes. This study assessed the short-term impact of the play, Informed Consent, on perceptions of trust, willingness to donate biospecimens, attitudes toward harm and privacy among the general public and in faculty, medical and undergraduate students within an academic medical center in the intermountain west. METHODS/STUDY POPULATION: Surveys were administered before and after a staged reading of the play by professional actors. Pre and post survey responses were linked for each participant. Survey items included the short form Trust in Medical Researchers, and single item questions about group identity, of genetic testing in children, and willingness to donate biospecimens. In total, 3 additional questions about harm, consent, and ethical investigator behavior as represented in the play were asked in the post survey. In addition, respondents were given the option to answer open-ended questions through email. RESULTS/ANTICIPATED RESULTS: Out of the 481 who attended the play, 421 completed both the pre and post surveys, and 166 participants completed open-ended questions online ~1 week after the play. Across all participants, there were significant declines for Trust in Medical Researchers and for the survey item “is it ethical for genetic testing in children for adult onset conditions,” (


Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention.Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low . In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff.Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and ‘fit-for-purpose’ workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support.Review of the international literature reveals three broad themes: Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development.Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good ‘fit’ between individual staff and the community ; optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals.Individual and family supports include offering tailored financial incentives, psychological support and ‘time out’.Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packagesOptimal remote health workforce stability and preventing excessive ‘avoidable’ turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include:There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an ‘implementation gap’ in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and ‘filling the gaps’ where necessary. Access to high-quality comprehensive primary health care (PHC) services is vital to population health, because these are the most efficient and equitable way to deliver improved health outcomes , 2. ThisHealth care access issues are largely associated with the persistent problem of health workforce under-supply and maldistribution . In remoOver recent years, policies have increasingly promoted the use of short-term and agency staffing in remote communities . AnecdotWe undertook a comprehensive study of workforce turnover and retention in remote communities in the Northern Territory (NT) . The stuOur research revealed an extremely high turnover of resident staff in the 53 NT Government (NTG) remote clinics examined over the period 2013–2015 . PrimaryLonger-term data for the period 2004–2015 showed there were overall increases in workforce supply, especially for administrative and physical grades  associated with higher use of short-term remote staff . Higher Fieldwork in seven remote communities underscored the fragility of workforce status over time. All clinics struggled to completely fill RAN and AHP vacancies. Community members wanted AHPs and other local residents to be employed by the clinic long term; they highly valued the employment of RANs who were both clinically and culturally competent; and wanted on-country nurse and AHP training . Communi; and NT RANs (57%) [In order to contextualise our findings and the resultant policy implications, we undertook a narrative review of the international literature. We drew on close to a century of combined remote and rural workforce research experience and knowledge of the authors to identify key review papers, and used a snowballing approach therefrom. We drew on English language publications since 2010 (the year that two of the authors published a systematic review on this subject), with direct relevance to remote health workforce in high-income countries . We founNs (57%) . Agency Ns (57%) .In light of this increased reliance on short-term staffing, very high avoidable turnover, the negative impact on effectiveness and cost, and other local and international evidence linking high turnover to poorer continuity of care , 26, theWhilst retention strategies need to be sensitive to local and national context, thematic analysis by the team of conceptual models and evidence in the literature (including reviews of workforce retention strategies) and subsequent synthesis through iterative discussions resulted in several consistent themes emerging from literature covering different geographical areas and dealing with different health professional groups  addressing broader health system issues to ensure a safe and supportive work environment; and (3) providing ongoing individual and family support. We now describe the interventions or workforce retention programmes associated with each of these themes, and then highlight policy implications for government and community-controlled services.Appropriate education: career pathwaysEvidence-based interventions can be grouped into three broad themes relating to (1) Educating health professionals to work in remote areas is best considered in the context of career pathways. The strongest evidence of the impact of education on future rural or remote practice relates to the ‘integrated rural medical pipeline’, which has been developed to ameliorate the geographical maldistribution of doctors. Although little of the existing substantive literature relating to nursing workforce turnover and retention focuses specifically on the remote nursing workforce , 28, theEach component of the ‘pipeline’ independently contributes to increased rural practice and retention of doctors in non-metropolitan areas. The components include prioritising applicants with rural or remote backgrounds –35, and Secondly, undertaking initial medical education in remote and rural areas is effective , 37, incVocational and post-graduate training in rural areas is additive to rural origin –52, and Prioritising remote origin and Indigenous students for university entry ;Maximising early exposure and training in remote areas;Contextualising the curriculum for Indigenous health and remote practice;Providing financial, pedagogical and pastoral support ; andEnsuring a clear, supported career pathway including post-graduate and continuing professional development support, with flexible entry and exit points.The integrated rural medical pathway can be adapted to other remote health professionals, with due regard to specific strategies targeting Indigenous health professional development, such as external study in their own communities . AvailabDeveloping a competent, ‘fit for purpose’ and stable remote health workforce requires strong intersectoral collaboration between the health and education sectors to ensure health service needs are met; together with an employment policy which prioritises Indigenous employment in remote areas with a significant Indigenous population.2.A safe and supportive work environment: a whole of system approachAn appropriately trained and retained workforce is one component of a range of interconnected health system factors which are required to ensure a sustainable and effective remote or rural PHC service , 58.First, adequate service funding is essential. We estimated an average per capita cost to NTG of remote PHC services in 2015 of A$3004, which was only 21% higher than the national average PHC expenditure figure of A$2484 .Secondly, adequate infrastructure is vital to facilitate high-quality, professionally satisfying care. This includes fit-for-purpose clinics, housing for resident and visiting staff, transport, and information and communications technology.Thirdly, different and flexible workforce models  model which offered a transition from acute care to remote nursing; and higher utilisation of Nurse Practitioners in remote areas) or other methods of providing respite and ongoing up-skilling of remote staff should be considered, trialled and evaluated . IntegraLastly, effective co-ordination and management of services, and community participation are fundamental PHC service requirements. Management needs to be strengthened through the employment or development of qualified, competent managers who empower remote teams and create a positive practice environment –62. In r3.Ongoing individual and family supportIn short, the development of a competent remote health workforce within an appropriately resourced, well-managed health system that is flexible and responsive to community and staff needs is an effective retention strategy. Supportive policies include the development and implementation of an equitable, needs-based formula for funding remote health services; and policies that facilitate transition to community control, prioritise Indigenous employment and mandate a culturally safe work context.Hogenbirk and colleagues suggest that there is some diminution of the effect of rural origin on practice location over time, perhaps due to a lack of training opportunities or practice support in rural areas  As profeThe underpinning policy relates to flexibility of employment conditions in order to be able to offer customised retention packages on a case by case basis.Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packagesOptimal remote health workforce stability and preventing excessive ‘avoidable’ turnover mandate alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive policies which we have highlighted include:No one intervention by itself will ensure improved retention. A ‘bundle of interventions’ is needed, drawing on the three main pillars that underpin the remote health workforce strategy outlined above, namely the development of integrated training and career pathways for all remote health professionals; ensuring a safe and supportive work environment; and meeting individual and family needs.There are some knowledge gaps that should inform future research in this area. These include achieving a better understanding of the drivers of very high turnover in the remote health workforce and why retention is better in some communities than others . SecondlDespite these gaps in knowledge, there is sufficient evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The fundamental problem comprises an ‘implementation gap’ in translating extant empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an adequate and equitable service to populations with arguably the highest health needs in the country, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and ‘filling the gaps’ where necessary.


Contextual research evidence is needed to reduce morbidity and mortality due to chronic but preventable diseases in low- and middle-income countries. Nigeria, Africa’s most populous country, is particularly burdened by these diseases despite its academic and research infrastructure. A major impediment to developing robust evidence on sustainable disease prevention and treatment strategies is the lack of skilled research personnel.This study aimed to identify (1) training barriers for research assistants and coordinators and (2) potential strategies to counter these barriers using a Nominal Group Technique (NGT) exercise conducted at the 2017 conference of the Nigeria Implementation Science Alliance (NISA).A one-hour NGT exercise was conducted with 26 groups of 2–9 persons each (N = 134) drawn from conference attendees. Group members were presented with questions related to the two objectives. Each member was asked to generate, list, discuss and vote on ideas that were eventually ranked by the group. Qualitative Thematic Analysis (QTA) was conducted for the collated responses.The QTA identified 166 training gaps and 147 potential solutions, out of which 104 were ranked. Themes that emerged for gaps included: 1) inadequate mentorship; 2) inadequate training/lack of organized curriculum; 3) limited access to opportunities for training and employment; 4) lack of government funding; 5) lack of interest, motivation; and 6) lack of research culture. Themes for potential strategies to address the gaps were: 1) trainings/curriculum development; 2) research modules implemented in secondary and tertiary institutions; 3) creating a sustainable forum for research-related questions and answers; and 4) advocating for and accessing more government funding for research training.This study identified actionable strategies that reflect practical realities in implementation research in Nigeria, which can guide government agencies, policy makers, research organizations, and local foundations as they work together to increase research capacity in Nigeria. Biomedical research emanating from low- and middle-income countries (LMICs), especially in sub-Saharan Africa, remains disproportionately low despite recent growth in global health research . Publish2589111415Key challenges limiting research capacity-building in Nigeria and other LMICs are: a) few qualified researchers and trained support staff, including research assistants and research coordinators; b) poor research infrastructure, such as low access to computers, laboratories, and broadband internet access; c) lack of expertise in grant writing, manuscript preparation, and access to international published works; and d) disproportionately low funding priority for research by governments and institutions 181920.1819The Nigeria Implementation Science Alliance (NISA) was established in 2015 as a partnership of 20 organizations that included academic and non-governmental organizations, clinical service providers, and policy makers. NISA is focused on facilitating collaboration among partners, enhancing implementation research in Nigeria and the sub-Saharan region, and identifying feasible, culturally appropriate strategies to improve public health through research 21.In September 2017, the third NISA scientific conference was held in Abuja, Nigeria. The conference focused on identifying ways to promote implementation research by building research capacity through training. During the conference, researchers, policy makers, and public health program implementers from Nigeria examined key challenges facing the country in the area of locally available, competent research personnel and possible strategies to bridge existing gaps. This paper documents findings from this group session and provides guidance towards creating a sustainable pool of mid-level research personnel, namely research assistants and coordinators to support a thriving research community.A one-hour structured modified Nominal Group Technique (NGT) exercise  was condThe Nominal Group Technique (NGT) was conducted in two 30-minute phases, with three distinct components designed to maximize participant focus and engagement. For the first 30 minutes, each group member identified challenges and barriers in training research assistants and coordinators in Nigeria, followed by a group discussion that elaborated on the identified barriers. The second 30-minute phase focused on identifying strategies to address the challenges and barriers identified in the previous session. The second phase also involved each group member identifying potential solutions. Each of these 30-minute sessions included three distinct activities, namely (1) generating ideas , (2) listing these ideas, and (3) ranking the perceived barriers and potential solutions identified in the first two steps. Utilizing “brainstorming”, voting and ranking of items as part of this NGT is an effective, efficient and low-cost method of identifying multiple barriers and potential remedies from persons actively involved in implementation projects in Nigeria 2123. Aft21First, all responses were transcribed and entered into an Excel® datasheet and sorted to identify potential duplicate or invalid entries. Statements were reviewed and eliminated if confirmed as duplicate or invalid. All valid responses were collated and sorted and then combined based on recurring themes . For eacEach of the 26 NGT groups independently identified between 4 and 9 barriers and between 3 and 8 potential solutions. Ultimately, the exercise yielded a total of 166 barriers with 104 ranked items and 147 solutions also with 104 ranked items. There were six coalescing themes from the list of barriers and six themes from the list of potential solutions  are consistent with findings from other LMICs . Six theA key strength of this study is that participants include multi-disciplinary frontline staff with an average of 10 years of local field experience in implementing clinical and research projects in Nigeria, unlike previously published data which elicited responses only from academic center-based researchers . AlthougRecently, following activities with NISA, including conferences and deliberations, various organizations and government agencies have made definite commitments toward more investment in implementation research in Nigeria. For example, the National Agency for the Control of AIDS (NACA) in collaboration with the United Nations Children’s Fund (UNICEF) and the Population Council this year launched a pilot project called “Adolescent and Young People Challenge” that seeks to fund innovative ideas led by youth to provide comprehensive HIV education to at least 200,000 Nigerians. This type of initiative can accomplish the broader goal of HIV/AIDS awareness but also increase interest in health care and implementation research among young Nigerian trainees and professionals while matching them with appropriate research mentors. Another example is the Healthy Sunrise Foundation (HSF), a non-profit, non-government organization that has held grant-writing workshops in Nigeria for research assistants and coordinators working with implementation programs . HSF alsAs the NISA platform expands and strengthens, it is important to have greater involvement of in-country academic institutions in understanding the challenges and opportunities for training and employing research assistants and coordinators. This is important because academia has a critical role to play in capacity building for research support staff as well as employing them after their formal training. The future for this looks promising as key universities in Nigeria like University of Nigeria, University of Ibadan, Ahmadu Bello University, and University of Jos have been represented in recent NISA conferences.This study has some limitations. First, the NGT, unlike a free-flowing focus group, has a rigid format and is time limited. To minimize the impact of this limitation, many participants with varying experiences in research were included, thereby ensuring that the perspectives, ideas, and emergent consensus were as representative as possible. Second, as in other group-based research, participants’ expressed opinions and suggestions may have been influenced by others in the group. To reduce the impact of this group factor, we created many small groups instead of a few larger groups. Finally, the authors conducted the analyses and thus may have inadvertently infused their own perspectives in interpreting the data. To minimize this, we have included authors from a wide variety of backgrounds and experiences to ensure balanced perspectives in the analysis and interpretation of the results.Skilled research coordinators and research assistants are the center of the research enterprise and directly responsible for ensuring that research is performed ethically and in accordance with study requirements. In short, they are the lifeline of high-quality, impactful research work 31. The b


Recent advances in unmanned aerial system (UAS) sensed imagery, sensor quality/size, and geospatial image processing can enable UASs to rapidly and continually monitor coral reefs, to determine the type of coral and signs of coral bleaching. This paper describes an unmanned aerial vehicle (UAV) remote sensing methodology to increase the efficiency and accuracy of existing surveillance practices. The methodology uses a UAV integrated with advanced digital hyperspectral, ultra HD colour (RGB) sensors, and machine learning algorithms. This paper describes the combination of airborne RGB and hyperspectral imagery with in-water survey data of several types in-water survey of coral under diverse levels of bleaching. The paper also describes the technology used, the sensors, the UAS, the flight operations, the processing workflow of the datasets, the methods for combining multiple airborne and in-water datasets, and finally presents relevant results of material classification. The development of the methodology for the collection and analysis of airborne hyperspectral and RGB imagery would provide coral reef researchers, other scientists, and UAV practitioners with reliable data collection protocols and faster processing techniques to achieve remote sensing objectives. Coral reefs are under pressure, and as of 2016, 34.8% of the Great Barrier Reef has been affected by coral bleaching, and other reefs worldwide are also experiencing degradation due to industrial and environmental events  [Recent advances in remote sensed imagery and geospatial image processing using unmanned aerial systems (UASs) can enable rapid and ongoing monitoring tools for coral bleaching detection and surveillance. This paper describes a UAS-based remote sensing methodology to increase the efficiency of existing surveillance practices, to detect coral type and coral bleaching, by combining in-water spectral observations and automated classification techniques to determine levels of benthic cover and coral growth in shallow water reef regions. The methodology is evaluated on its ability to identify differences between coral genera, bleaching level, and water depth, with an in-depth accuracy assessment to give insights for further refinements. This shows that UAS-based hyperspectral remote sensing techniques can offer an efficient and cost-effective approach to mapping and monitoring reef habitats over large, remote, and inaccessible areas.The technology used, the sensors, the UAV, and the flight operations are presented in Our approach to generate a predictive reef monitoring system employs multiple stages . The firIn the second stage, images are processed DepthNotes about surroundings LatitudeLongitudeThe third stage combines all the multiple sources of data into a single information system. To do this, individual coral genera are segmented, with the aim of creating a table  that conOnce the table is populated with georeferenced data, the spectral signatures are then extracted to generate a correlation between coral genus and each bleaching level. Results obtained in the correlation analysis are the foundation for the development of a preliminary coral bleaching detection model, which is followed by an evaluation and accuracy assessment to obtain final reef belching detection model.Coral is categorised by the Australian Institute of Marine Science (AIMS) into one of six levels of bleaching through visual inspection, where level one is severely bleached and level six an unbleached healthy coral specimen. Due to water’s optical properties and algal growth associated with reef ecosystems, the spectral properties of a coral sample can vary drastically based on the current conditions, genus, and depth of the area.Our approach was to use survey test sites where experts identified various genera of coral at varying levels of bleaching across a segment of reef, as a reference for approximation of optical variances due to water and algae. The UAV used was an S800 EVO Hexacopter  that weighs 6.0 kg with motors, propellers, electronic speed controllers (ESCs), control and navigation avionics, and 16,000 mAh battery. The frame is fitted with a retractable undercarriage, providing a sensor field of view clear of obstacles. The UAV has a recommended maximum take-off weight of 8 kg, thus allowing 2 kg for sensor payload. A WooKong-M flight controller provides the navigation and control systems of the UAV, and comes with a stabilization controller and GPS unit with inbuilt compass and inertial management unit (IMU). The flight controller has multiple autopilot modes to enable both remote control by operator and autonomous with position and altitude hold, and auto go home/landing with enhanced fail-safe.In this work and methodology, we propose the use of high resolution RGB and hyperspectral UAV-based imagery, as they provide the required level of detail in capturing finer differences in coral bleaching signatures. A Canon EOS 5DS R  digital camera was used to capture high-resolution RGB images from the mission route, and assist in identification and monitoring of coral in the studied area using the imagery augmented by the camera’s GPS coordinates. The camera specifications include full frame (36 × 24 mm) CMOS 50.6-megapixel sensor, 28-mm Canon lens, and a single-frequency GPS receiver. Hyperspectral imagery was acquired using a Headwall Nano-Hyperspec  hyperspectral sensor. This sensor records datacubes of 274 spectral bands in the VNIR (Visible and Near-Infrared) range (400–1000 nm) with ~2.2 nm spectral interval and 5 nm spectral resolution (fwhm with 20 μm slit). This sensor is equipped with a calibrated f/1.8 4.8 mm Schneider lens, which results in 50.7 deg field of view over 640 pixels. The collected hyperspectral data cubes are synchronized with GPS/INS  positioning and orientation information to perform datacube orthorectification.Image stabilization is also an important step, therefore, the hyperspectral sensor was integrated into a S800 UAV by a custom designed gimbal made by Queensland University of Technology (QUT) Research Engineering Facility (REF). This gimbal has 2-axis stabilization, that ensures seamless operation of the push-broom hyperspectral scanner in windy conditions. The gimbal design features carbon reinforcement over 3D printed structure, advanced dampening, brushless motors, and a BaseCam SimpleBGS 32 bit gimbal controller , with the total weight below 1 kg. Mounting the push-broom scanner on the gimbal proved to enhance camera performance in wind gust conditions by ensuring the minimal and consistent required overlaps between consecutive datacubes over the large study area. This leads to an increased overall flight efficiency in real life open environments. Data orthorectification (step 3) was conducted using Headwall SpectralView software, where the individual hyperspectral data cubes are geolocalised and stitched, with verification by the overlay of underwater contours of the reef. The hyperspectral data are then processed with spectral analysis tasks, such as MATLAB Scyllarus open source toolbox, Headwall SpectralView, and Scyven, to obtain radiance values which are then processed with a white reference image to generate the reflectance dataset (step 4). Once obtained, the reflectance dataset is corrected for water depth by running through a noise reduction algorithm (step 5), processed through Scyven using support vector machine automated material discovery, to cluster similar spectral signatures which are geo-referenced (step 6), before being extracted (step 7) for reef indices (step 8) and material classification (step 9).Step 4 orthorectified images were processed with Headwall SpectralView to identify the corresponding per pixel illumination value. Once completed, the image then goes through a semi-automated process in which the image is imported into Scyven, matched with a corresponding white reference illumination pattern (generated from white reference file), then lastly processed to generate the reflectance value corresponding to the white reference.Estimating and correcting hyperspectral imagery for water depth step 5) is a complex process. ENVI offers unique tools for processing characteristics of waterbody features, and this enables quick and easy depth approximation utilizing a bottom albedo-independent bathymetry algorithm that utilizes a log ratio transformer. The log ratio transformer calculates depth independent of the bottom material and brightness (bright sand or dark seabed vegetation). The use of the algorithm means that typical errors caused by varying floor composition [ is a comThe use of additional information from in-water surveys is required for refining and generating accurate depth results with a reasonable degree of error. Agisoft Photoscan gives an alternative approach to the water depth estimation by using the reconstruction of a DEM from multiple overlaying images, which allows depth approximation of larger areas with ease, but comes with a more limited result set where smaller depth changes can be missed.Porites with a bleaching level of four, with one at a depth of 1 m and the other at 2.3 m.To apply depth correction, the effects of the water column must be ascertained, and to do this, the coral samples at varying water levels are compared; To derive the effect of the water column on the data, the log-transformed ratio between the green and blue wavelengths is used, otherwise, the effects of varying benthic cover are also taken into account . Once thThis data is log transformed, and used as input into the equation identified by Mishra, D.  (below),This identified that 6.4% max variation in the spectral signature was due to water column effects, which could be corrected using a noise reduction algorithm, and follows the trend which was identified by Zoffoli, M .In-water survey data contain GPS coordinates that are then matched to imagery. This can be completed by using the orthorectified data to overlay GPS coordinates across the image, and then extrapolating the corresponding pixel coordinates; Expert visual assessment and georeferencing (step 6) are used with the depth-corrected reflectance values (step 5) to extract the mean spectral signature for different corals with different levels of bleaching. Headwall SpectralView is used to identify pixels that contain corals of varying bleaching levels, for which the spectral values are then extracted with Scyven. After each genus of coral has been identified using material discovery, they then need to be compared based on their spectral signatures to identify potential issues with material classification .The next step (step 8) is to calculate coral bleaching indices using the spectral signature extraction (step 7), as well as visual assessment (step 1), and georeferencing (step 6). The indices were selected to evaluate symptoms of bleaching such as higher spectral concentrations in the 400 nm and 750 nm regions. A list of the indices used, as well as their equations, is found in Classification is the next step, where the in-water survey data along with the spectral signature extraction are combined using ENVI to develop pixel-by-pixel analysis algorithms, and also, subpixel  approaches using support vector machine (SVM). SVM was chosen due to the high classification accuracy, ability to handle multiple predictor variables, in-built handling of cases where spectral samples cannot be completely separated, and its ability to handle large datasets. It has also been found that the accuracy of SVM could be further increased if the gamma of images is increased up to a maximum of 75% . This change causes SVMs to be equivalent to naive Bayes classifiers; Zanaty  proposedScyven is also used to apply various noise reduction algorithms and data refinement through targeted unsupervised classification, to identify regions requiring additional accuracy refinements.The site surveyed on 15 March 2017 is at Pandora Reef located in Queensland, Australia . The AusThe orthomosaic of the entire Pandora Reef  assistedProcessing Canon 5DS R images gives significantly better 9.91 mm/px resolution of the orthomosaic/3D mode/DEMl, also bringing larger dynamic range to imagery b, and fuAcropora coral.Airborne ultra-HD DSLR cameras provide researchers with a complex and fully adjustable tool resulting in very detailed snapshots of the marine environment. Larger dynamic range, higher resolution, more accurate focusing and white-balancing comes at the cost of a heavier and larger UAV to carry the sensor. We note also that other factors, such as correct camera settings and camera orientation relative to the sun and the object of interest, position of the sun, tide heights, sea state, and water torpidity, define the success, and sometimes are the most important factors for reef monitoring by remote sensing.Porites massive bleaching level one and six, Porites massive level 4, Goniopora level 3, and Acropora level 2. These spectral similarities will be one of the greatest potential causes of error in the classification step (step 9) and require processing of each identified point to confirm that the classification is correct. This will be done by solely comparing the classifications in the bands where differences are discernible.Porites massive coral with the other object classification omitted for clarity.Material classification through Scyven, although very similar to ENVI, is done by taking the spectral fingerprint data  and thenPorites massive coral indices ( indices . These dOnce the data has been refined, it can then be classified using the extracted spectral signatures step 7  and the The classification uses all the information in the image for classifying the different coral types. The accuracy results in Acropora and Turbinaria genera of coral. This comparison shows the overall difference between the index output and the NDVI, where the NDVI images gives a clear representation, primarily focusing on the healthiest coral. The indices are capable of showing the overall health of the reef by not only showing the healthiest parts, but also all the various genera of coral at different levels of bleaching, and give health approximations based on benthic cover.Different indices were computed in The results of the mean spectral signature extraction show a trend between spectral reflectance and severity of bleaching, which is consistent across various genera of coral. Coral bleaching indices developed from The methodology shown in this manuscript has limitations, and requires careful and detailed planning of in-water and airborne surveys that can affect the overall feasibility and accuracy of the classification. The ability to classify objects can be greatly distorted or made near impossible, depending on water depth and the methodology used. Lesser and Mobley  found thWater turbidity, tidal conditions, and weather conditions all play a part in affecting the overall quality of the captured data. Water turbidity can affect the ability to identify coral in regions and, depending on its level, can prevent the ability to identify any coral. Nonetheless, data with moderate levels of turbidity still have some value in showing the current level of benthos/symbiotic algae in the region. Tidal conditions can cause significant amounts of spume to be created, methods can be employed to remove sections affected, but their effectiveness is limited by the spumes’ location and, where classification is required, can cause serious issues with the overall accuracy of results.The results show that airborne UAV-based hyperspectral imagery has the potential to detect coral bleaching over large areas across multiple coral genera, where accurate visual inspection may not be possible. The methods and workflow developed during this study enabled material classification using both supervised and unsupervised methods to gain results with an acceptable percentage of error. The results presented and coral indices generated will contribute to the generation of valuable information for reef protection by offering methods that highlight possible symptoms of bleaching in a timely manner. It could also be extrapolated to other areas of research in remote sensing, such as mineral exploration, biodiversity, and ecological assessment.


This paper presents the protocol for the National Institute of Mental Health (NIMH)–funded University of Washington’s ALACRITY  Center (UWAC), which uses human-centered design (HCD) methods to improve the implementation of evidence-based psychosocial interventions (EBPIs). We propose that usability—the degree to which interventions and implementation strategies can be used with ease, efficiency, effectiveness, and satisfaction—is a fundamental, yet poorly understood determinant of implementation.We present a novel Discover, Design/Build, and Test (DDBT) framework to study usability as an implementation determinant. DDBT will be applied across Center projects to develop scalable and efficient implementation strategies , modify existing EBPIs to enhance usability, and create usable and nonburdensome decision support tools for quality delivery of EBPIs.Stakeholder participants will be implementation practitioners/intermediaries, mental health clinicians, and patients with mental illness in nonspecialty mental health settings in underresourced communities. Three preplanned projects and 12 pilot studies will employ the DDBT model to (1) identify usability challenges in implementing EBPIs in underresourced settings; (2) iteratively design solutions to overcome these challenges; and (3) compare the solution to the original version of the EPBI or implementation strategy on usability, quality of care, and patient-reported outcomes. The final products from the center will be a streamlined modification and redesign model that will improve the usability of EBPIs and implementation strategies ; a matrix of modification targets  that are both common and unique to EBPIs, strategies, settings, and patient populations; and a compilation of redesign strategies and the relative effectiveness of the redesigned solution compared to the original EBPI or strategy.The UWAC received institutional review board approval for the three separate studies in March 2018 and was funded in May 2018.The outcomes from this center will inform the implementation of EBPIs by identifying cross-cutting features of EBPIs and implementation strategies that influence the use and acceptability of these interventions, actively involving stakeholder clinicians and implementation practitioners in the design of the EBPI modification or implementation strategy solution and identifying the impact of HCD-informed modifications and solutions on intervention effectiveness and quality.ClinicalTrials.gov NCT03515226 , NCT03514394 , and NCT03516513 .DERR1-10.2196/14990 Psychosocial interventions  are a preferred mode of treatment by most people seeking care for mental health problems, particularly among low-income, minority, geriatric, and rural populations -7. DespiThe usability of EBPIs and implementation strategies are a major challenge to successful implementation and one that has largely been largely overlooked by health care researchers who focus on promoting the implementation of evidence-based practices in routine service settings. Usability is defined as the degree to which a program can be used easily, efficiently, and with satisfaction/low user burden by a particular stakeholder . AlthougEBPIs are complex psychosocial interventions involving interpersonal or informational activities, techniques, or strategies with the aim of reducing symptoms and improving functioning or wellbeing . UsabiliImplementation strategies can be defined as methods or techniques used to enhance the adoption, implementation, and sustainment of a clinical program or practice . Most imHuman-centered design  has the potential to improve EBPI and implementation strategy usability. HCD is a field of science that has produced methods to develop compelling, intuitive, and easily adopted products and tools ,33. HCD Discover, Design and Build, and Test (DDBT) framework, a multiphase process that draws from established HCD frameworks [The mission of the University of Washington’s ALACRITY  Center (UWAC) is to study the utility of HCD as a methodological approach to improve the implementation of EBPIs in highly accessible service settings . The research team reflects a diverse set of research and practice experts in mental health services, implementation science, and user-centered design. To support this mission, we created the ameworks  and applDuring the early phases of each study, stakeholders will provide information concerning the main challenges in the use of EBPI or implementation strategy components. Components may include content elements  , modifying and combining EBPI elements so that frontline clinicians serving rural and minority patients can use them effectively and with ease (usability), and developing decision support tools to assist frontline clinicians in the faithful delivery of EBPI elements without the need of expert intervention or supervision . A key goal of our proposed work is to determine the effects of design solutions on implementation outcomes  such as The UWAC Methods Core will achieve its aims by integrating data collected across a series of center-supported research studies. These include three studies articulated at the time of the grant submission  as well Each of the projects will focus on a different aspect of EBPI implementation and include the redesign of a patient-facing intervention, an implementation strategy, or both. In addition to their project-specific data needs, all projects will collect a common core set of data that will be integrated by the Methods Core for collective analyses. Study 1 focuses on improving learnability by implementing a novel EBPI training program to support the delivery of a manualized telephone-based cognitive behavioral therapy (tCBT)  by bacheThe three-phase DDBT framework  is intenDiscover phase to gather information about two sets of information: the context of deployment  and information about the innovation itself , both of which are discussed below. Even if investigators enter into the Discover phase with a particular solution in mind , the appropriateness of those solutions must be continually reassessed with user input. Methodological procedures used across projects in this phase are below.The first step of our framework leverages important aspects of HCD ,47,48, iHCD, and hence, the DDBT framework, emphasizes explicitly identifying the range of target stakeholders to ensure new products effectively meet their needs ,54. ConsIn the learnability study (Study 1), the pool of stakeholder participants will include 15 bachelor degree-level social work students  and educators who are in the position to train these future clinicians . In the intervention usability study (Study 2), users will be master’s degree–level clinicians who deliver behavioral health care in clinics serving Native American and frontier community members as well as representative patients from these communities. The quality of care and decision-making study (Study 3) will target both EBPI-experienced and EBPI-naive care managers in integrated primary care settings. Across studies, recruited representative users will include both those with experience in the identified intervention or strategy as well as novices to ensure broad applicability across stakeholders.All stakeholders will be observed and interviewed to identify key challenges they face in the use of EBPIs and implementation strategies. In Study 1, we will collect information from students and educators through focus groups and individual interviews about topics such as their experiences with distance learning and computerized training (implementation strategies), how they see these technologies fitting into their daily lives, and perceived utility of this form of training in addressing key issues they have experienced as novice users of EBPIs. To achieve convergence within a mixed-methods paradigm , we willAlthough qualitative interviews that clarify perceived challenges in applying EBPIs and implementation strategies are important, they are rarely a substitute for direct observation of professional behavior. Each of the primary research projects will engage in structured observations. In Study 2, for example, watching video tapes of clinician sessions and having the clinician explain their thought processes and the challenges they faced during implementation, can offer suggestions for improvement in the design of an EBPI or implementation strategy. In Study 2, the research team will also shadow representative social workers from clinics serving indigenous peoples to capture existing workflows and identify bottlenecks for implementing EBPIs. In Study 3, the research team will observe clinicians in urban primary care clinics to identify opportunities to introduce decision-support strategies.We will also conduct usability evaluations of each EBPI or strategy. A variety of usability testing techniques exist, which may be applied to either interventions or implementation strategies, including quantitative instruments, cognitive walkthroughs, and lab-based user testing ,36,49,50Discover phase, the Design and Build phase is intended to iteratively and systematically develop, evaluate, and refine prototypes of interventions and implementation strategies using the techniques below. Prototyping and rapid iteration involves a process of making new ideas sufficiently tangible to quickly test their value [Discover phase is conducted with small samples  to answer design questions using paper versions of redesign solutions or storyboards to represent more complex psychosocial processes  [Based on the information gleaned from the ir value . Consistivities) ,67. ThisDesign and Build phase employs the same usability testing techniques described above in the Discover phase . However, across the iterative prototyping process, this testing is increasingly summative (versus formative in the Discover phase) and intended to determine whether identified usability problems and contextual constraints have been addressed [Design and Build phase is most informative when it is compared to similar data collected previously. If intervention or implementation strategy usability has not improved over successive iterations, then additional redesign solutions may need to be explored.The ddressed . TherefoTest phase involves small-scale testing of the intervention or strategy in a form that fully functions as it is intended, with a larger number of users, and in their actual milieu. The emphasis of this testing phase is on user experience, satisfaction with the end design, reported benefit over alternative or existing processes, and implementation outcomes [Test phase, including quantitative usability evaluation instruments [Test phase of these studies will be new to the clinicians. In Study 1 (learnability), 12 students over two successive cohorts will be randomized to tCBT training as usual  or a redesigned tCBT training that incorporates an adaptive intelligent tutoring system [N=60 patients). Patient participants in this study will receive eight weekly sessions of the tCBT intervention. In Study 2 (usability), six clinicians will be randomized to either PST  or the new, redesigned solution. Each clinician will see five patients (N=30). In Study 3 , six clinicians will be randomized to the usual care delivery model (intervention and strategy) or care supported by the decision-making tool. Each clinician will be assigned five patients (N=30) to deliver up to 10 sessions of PST.The outcomes . This intruments ,36. The truments . Across g system . The intTest phase of the studies will inform future hypotheses about potential targets for EBPI and strategy modification. Because the UWAC studies will be small-scale randomized trials with stakeholders who were not involved in the Discover and Design and Build phases, we will have an opportunity for unbiased comparison of the identified redesign solutions. Additionally, the studies will use a common set of outcome measures in Aim 3 analyses. Because all solutions developed in this Center are aimed at enhancing usability; promoting perceptual implementation outcomes  such as acceptability, feasibility, and appropriateness [Data collected during the iateness  and behaiateness  or each First, three different versions of the well-established System Usability Scale  will be Second, clinician and implementation practitioner perceptual implementation outcomes  will be evaluated via three recently validated instruments . These iThird, each study will collect data on the number of training hours needed before reaching adequate integrity in the EBPI or modified solution as well as the degree of sustained integrity (or integrity drift) over time. Sustained integrity in Study 1 will be measured using Cognitive Therapy Scales . The PSTFourth, implementation costs in each study will include inputs such as the time clinicians devote to learning a new technique, time experts spend delivering training, and costs of any ongoing supervision needed to mitigate skill drift . These cTest phase across projects. The 9-item Patient Health Questionnaire (PHQ-9) [Finally, a variety of patient-reported outcomes will evaluate the effectiveness of redesigned EBPIs or implementation strategies. The Sheehan Disability Scale ,75, a br (PHQ-9)  measuresThe UWAC is designed to allow for integration of data across projects to identify common EBPI and implementation strategy modification targets, develop a matrix of redesign solutions for each target, and determine if these redesigned innovations address the goals of the UWAC.Discover phase of each UWAC project, the Methods Core will employ the techniques described above  to identify modification targets and improve strategy usability. Exploratory qualitative analysis, informed by the Consolidated Framework for Implementation Research (CFIR) [The field lacks methods for understanding usability problems of EBPIs, strategies to support these EBPIs, and methods to intentionally link EBPI usability problems to redesign targets. Aside from a few notable examples of team-based implementation approaches ,78, therh (CFIR) , will alh (CFIR) —will be h (CFIR) ,83, which (CFIR)   design solution types for specific targets and steadily aggregate these across projects into a database to be shared with the research and practice communities.To facilitate aggregation of redesign solutions across studies, we will use FRAME  as a staAim 2 will generate the warehouse of modification targets and redesign solutions organized by modification target type and will share information about less preferred or less usable solutions (as determined by testing with stakeholders). We will make information about these design patterns available in a way that supports both searching for solutions to specific problems and browsing for design inspiration .Test phase of each study is focused on gathering information  for future larger-scale grant applications to test the effectiveness of the adapted solutions. Thus, sample sizes were set primarily for practical reasons and driven by estimated effect sizes rather than hypothesis testing.The final overarching aim of the UWAC is to test whether EBPIs and strategies modified through the DDBT Framework result in improved learnability for clinicians and service systems, EPBI and implementation strategy usability, and sustained quality of care to deliver EBPIs in low-resource community settings. Although the principle of adapting modifiable aspects of an intervention or strategy to the needs of a setting is a central tenet of implementation science, systematic testing of adaptation mechanisms of change is new. Very little research has examined the mediating factors that are most proximal to implementation success . A key gd) and corresponding 95% CI. There will be no subgroup or adjusted analyses. Missing data will be reported with regard to attrition and related feasibility data. Full information maximum likelihood imputation will be used for statistical analyses to include missing data, where applicable. The UWAC Methods Core will aggregate data across projects to facilitate a series of Bayesian meta-analyses. These meta-analyses will summarize the effectiveness of using HCD approaches to improve EBPIs and strategies on each implementation outcome. The Bayesian approach will allow us to adjust our inferential probability assumptions about the effects of HCD approaches on modifications. Bayesian statistics are useful even when studies are conducted in varied settings with varied scientists using varied measures, as each subsequent study represents a form of conceptual replication. Each additional study will improve our ability to draw inference  from the collection of studies while simultaneously preventing false alarms in individual studies resulting from random error.Primary analyses focus on comparison of the key DDBT and implementation outcomes  for the original, unadapted EBPI/strategy as compared to the modified EBPI/strategy. Each project and each outcome can be summarized as an effect size , where these meta-regressions can also control for site characteristics . Similarly, we may be able to examine the effectiveness of specific HCD approaches  for impacting specific implementation outcomes. The ultimate question is one of mediation: Does a DDBT-modified EBPI or strategy lead to better implementation outcomes, which in turn lead to better  patient outcomes? Although the initial center studies are not likely to yield large enough sample sizes to meaningfully test such an implementation mechanism question, the UWAC Methods Core will steadily aggregate data, allowing us to eventually test a range of mediation-focused hypotheses via multivariate network meta-analyses.Aim 3 is centered on clinician- and patient-reported outcomes to ascertain the difference between modified EBPIs and strategies compared to treatment as usual. These pilot randomized controlled trials will generate preliminary data on learnability, usability, and quality of care to inform subsequent tests of these adaptions on a larger scale in low-resource community settings.The UWAC received institutional review board approval for the three separate studies in March 2018 and was funded in May 2018. Approvals for the 12 pilot studies are being obtained as the studies are identified and funded. At the time of publication, data collection for Studies 1 and 2 had been initiated.We acknowledge that learnability, usability, and sustained quality of care are not the only important variables in the implementation of EBPIs and that intervention characteristics feature highly in implementation frameworks. To date, little work has been done to directly address EBPI or implementation strategy complexity and even less work has actively involved end users in the actual design of modifications, from beginning to end. Moreover, while the field is aware that “there is no implementation without adaptation”  and thatIncorporation of HCD methods into implementation science has strong potential to improve the degree to which innovations are compelling, learnable, and ultimately implementable. Both fields share the common objective of facilitating the use of innovative products . An exte


To assess how well Caribbean regional institutions (RIs) met their commitments from the 2007 Port-of-Spain Summit (POSS) declaration on noncommunicable diseases (NCDs), and evaluate the POSS impact on the United Nations High-level Meeting (HLM) on NCDs in 2011 (2011 HLM), HLM NCD review in 2014 (2014 HLM), World Health Organization’s 2025 NCD targets (2025 WHO), and 2030 Sustainable Development Goals (SDGs) agreed upon in 2015.This study uses a method developed by the University of Toronto’s Global Governance Program to measure institutions’ compliance with commitments from a summit and the match with commitments from earlier summits. This approach was supplemented using data from published literature, primary documents, and semistructured key informant interviews to detail how and why Caribbean RIs met the 2007 POSS commitments, how the 2007 POSS commitments led to compliance, and how the 2007 POSS influenced international NCD commitments.Caribbean RIs implemented the 2007 POSS commitments better when they had more public legitimacy, when their missions aligned with those commitments, and when more resources were available to them. Implementation constraints arose from multiple, sometimes competing, interests of the decision-making and national implementing bodies of the Caribbean Community (CARICOM). Internationally, the early, expanding efforts of the POSS pioneers had an initially important but subsequently diminishing impact on the HLMs.For the Caribbean region, the Caribbean Public Health Agency should be funded to lead strengthened Caribbean RIs in coordinated action on NCDs. At the international level, the United Nations should embed NCDs in a “whole-of-global-governance” approach, monitor implementation annually, foster transregional partnerships on NCD-related themes, engage civil society, and support regular regional and global summits to enhance implementation and improvement, aimed at future HLMs on NCDs, the 2025 WHO targets, and the SDG NCD targets. In 2007, the world’s first summit dedicated to noncommunicable diseases (NCDs) was held by the heads of government of the Caribbean Community (CARICOM) in Port-of-Spain, Trinidad and Tobago. At that assembly, the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs was issued. The Declaration contained 27 commitments for NCD prevention and control, including reducing risk factors and improving access to preventive care . AdditioExisting studies have analyzed the preparations, production, and outcomes of the Port-of-Spain Summit (POSS) and their impacts in the short term -4. HowevThis article asks what the longer-term regional and global impacts of the POSS were, as the world’s first summit on preventing and controlling NCDs. It answers by assessing CARICOM members’ compliance with their POSS commitments, how Caribbean RIs met their summit commitments, and how the POSS influenced the United Nations High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases on 19–20 September 2011 (2011 HLM), the high-level meeting of the General Assembly on the prevention and control of NCDs on 10 July 2014 (2014 HLM), and the United Nations 2030 Sustainable Development Goals (SDGs), particularly SDG3  agreed upon at the United Nations Sustainable Development Summit (SDG Summit) on 25–27 September 2015.This study uses a method developed by the University of Toronto’s Global Governance Program to measure members’ compliance with commitments from a particular summit and how well those commitments matched commitments from a previous summit -9.This analysis employs a framework first developed by George von Furstenberg and Joseph Daniels for assessing compliance with Group of Seven (G7) summit objectives, supplemented by Marina Larionova’s assessment of G7 members’ compliance with international and regional organizations’ mandates -11. For Using data collected from published literature, primary documents, and semistructured key informant interviews, the analysis also identifies the influence of the POSS on NCD-related actions taken by regional and global organizations.Bulletin of the World Health Organization, Revista Panamericana de Salud Pública/Pan American Journal of Public Health, Lancet, British Medical Journal, Global Heart, American Journal of Public Health, Health and Place, World Medical and Health Policy,Global Governance, International Organization, International Affairs, and Administrative Sciences. This was supplemented by a systematic search using the University of Toronto Libraries database for combinations of key words on noncommunicable diseases, heart and stroke, cancer, diabetes, chronic respiratory disease, Caribbean Community, summit, United Nations high-level meeting, and Sustainable Development Goals. The most relevant articles are identified in the works cited and in the references of this article.Relevant published literature was identified through scanning peer-reviewed journals on public health and on global governance. These journals included the Primary documents included those in the global summitry archives of the Global Governance Program at the University of Toronto and those provided by the Caribbean Public Health Agency (CARPHA) and key informants. A total of 50 semistructured interviews were conducted between 2010 and 2017, with current and former officials of the institutions of interest. RI responses were assessed according to raw information provided by these key informants, triangulated with and confirmed by publicly available data on specific implementing actions and, in some cases, progress reports provided by the Caribbean RIs themselves.Following standard practice, RIs were conceived as both “actors” and “frameworks for action” . They prMore specifically, CARICOM RIs’ responses were assessed according to those RIs’ speed of starting to implement each mandate, the continuity and completeness of that implementation, and the extent to which members of RIs complied with related commitments.This POSS influence was assessed in a three-step process. First, the POSS Declaration was matched with the 2011 HLM outcome document. Second, the 2011 HLM outcome document was matched with the outcome document from the 2014 HLM. Third, members’ compliance with the commitments contained in all the outcome documents was measured, using methods developed by the University of Toronto’s Global Governance Program. The assessment next traced, through key informant interviews using a snowball technique, the political and diplomatic process from the POSS to the SDG Summit in 2015, at which the SDG targets were agreed upon, using the same methods as those used for the Caribbean RIs, thus adding to works based on research done before the 2011 HLM -17.This research was conducted for the Port-of-Spain Declaration Evaluation Research Group  led by the University of the West Indies (UWI), Cave Hill campus, and funded by Canada’s International Development Research Centre on behalf of the Pan American Health Organization (PAHO) and CARICOM .The POSS Declaration issued 27 commitments that reflected the cognizance of the CARICOM heads of government of their governments’ capacity constraints and the heads’ resolve to have Caribbean RIs provide collective expertise and technical resources to facilitate compliance with those commitments.Very few studies have analyzed either Caribbean RIs’ responsiveness to the POSS commitments or the impact of these responses on CARICOM members’ compliance with those commitments. The Healthy Caribbean Coalition (HCC), a not-for-profit civil society organization comprising over 100 nongovernmental organizations committed to preventing and combatting NCDs in the Caribbean, was one of the few bodies to assess Caribbean RIs’ responses to their POSS commitments, but it did not address factors influencing responsiveness . POSDevaThe speed of responses and completeness of implementing activities varied (data available upon request). The Caribbean Food and Nutrition Institute (CFNI), the Caribbean Epidemiology Centre (CAREC), CARPHA, the Office of Trade Negotiation (OTN), the Caribbean Agricultural Research and Development Institute (CARDI), UWI, and the HCC were timely in their responses and addressed the full range of activities required to fulfill their mandates throughout the evaluation period. (CFNI and CAREC merged into CARPHA in 2013.) The Caribbean Cooperation in Health (CCH) Secretariat and the Caribbean Regional Organisation for Standards and Quality (CROSQ) fared well in their breadth and continuity; however, there was a slight lag in responding to the POSS commitments.Caribbean RI responses related to member compliance with the POSS Declaration varied significantly among the institutions and their specific institutional mandates (data available upon request). Member compliance with commitments related to the mandates of PAHO institutions, UWI, and CCH was much higher than compliance with commitments related to CROSQ and OTN; compliance requiring collaboration with these two CARICOM institutions was significantly lower.Three reinforcing factors supported the speed and ability of Caribbean RIs to undertake activities to meet their POSS mandates and related commitments: institutional legitimacy, material resources, and alignment of the institutions’ mandates with the commitments. The interests of the decision-making bodies and implementing agencies were critical to Caribbean RIs’ impact on member compliance. When the mandates aligned with those interests, Caribbean member states were more likely to adopt the RIs’ policy recommendations. CFNI was wound down in 2012, before CARPHA became operational, which perhaps affected CARPHA’s responsiveness to the POSS diet and nutrition commitments.The POSS Declaration reinforced the institutional legitimacy of existing Caribbean RIs and ascribed legitimacy to new regional institutions . This leSimilarly, the mandate issued to OTN to pursue fair trade policies legitimized its advocacy for prioritizing health in negotiating multilateral trade agreements and assessing the implications of global trade policies on controlling and preventing obesity.Caribbean RIs struggled to address the POSS Declaration commitments using existing institutional and budgetary resources. The POSS did not authorize new monies to fund the mandates or create implementation mechanisms. Subsequent strategies neither assigned nor identified additional funding for these institutions. The ability to utilize existing resources or access additional funding was crucial. CAREC and CFNI were financed through PAHO’s regional budget allocations and extrabudgetary projects. OTN could use existing in-house technical resources, and the HCC successfully attracted regional funding  and inteTo leverage the overarching structure of CARICOM to support CARPHA’s mandate, CARPHA developed platforms that provided sustained involvement with relevant RIs . CARPHA CARPHA also encouraged dialogue between regional decision-making bodies . In collWhen the assigned commitments were aligned with Caribbean RIs’ existing missions, the response speed was not hampered by the extra effort that often accompanies institutions with assigned mandates acting outside their core missions. The CFNI, CARDI, CAREC, CCH, and OTN were already engaged in activities that fell within the scope of their 2007 POSS Declaration mandates and related commitments. OTN was already exploring the intersection of health and trade and reviewing the use of trade policies to address NCDs. The CCH Secretariat had an established regional mechanism for coordinating stakeholder consultation and developing regional health frameworks and strategic plans.POSS also had an early, significant influence on the global governance of NCDs, through the 2011 HLM, the 2014 HLM, and the 2015 SDG Summit, although that influence progressively diminished. The 2011 HLM, held only four years after the POSS, was the second-ever United Nations summit devoted to health . The POSThe 2011 HLM outcome document had only one direct reference to the POSS, but the document put the reference in its preamble’s paragraph, which expressed United Nations appreciation for various regional initiatives to control and prevent NCDs. The 2011 HLM’s 205 precise, future-oriented, politically obligatory and binding commitments substantially matched the 27 POSS commitments . A majorReciprocally, a majority (59%) of the POSS commitments were reflected in the 2011 HLM ones at least once . HoweverUnited Nations members’ compliance with 2011 HLM commitments in the first year after that HLM shows an influential “POSS” push through to 2012 (data available upon request). Of the eight commitments initially assessed for compliance, the six with a matched POSS precursor commitment  had higher compliance by the United Nations’ 40 Western Hemisphere members and by the CARICOM members specifically (data available upon request). If the POSS parent had high first-year compliance from CARICOM members, its matched 2011 HLM offspring had higher first-year compliance too (data available upon request).More specifically, the six 2011 HLM commitments with a POSS parent had an average compliance of +0.27 by Western Hemisphere members, compared to −0.11 for the two commitments without a parent (data available upon request). The increase was even higher for the CARICOM members. However, there was also a similar increase among CARICOM members for commitments without a POSS match, suggesting a more general POSS participation effect.Among the 13 2011 HLM commitments subsequently assessed for first-year compliance, the 9 commitments with POSS parents had average compliance +0.27 higher among CARICOM members than among the other United Nations members of the Western Hemisphere (data available upon request). For the remaining 4 commitments, the average compliance for CARICOM members was −0.07 lower than for the other Western Hemisphere members.This POSS influence was enhanced by higher first-year compliance from CARICOM members with their parent POSS commitments (data available upon request). The three POSS commitments with the highest first-year compliance, averaging +0.14, had their three matched 2011 HLM offspring secure first-year compliance of +0.47. The three POSS commitments with the lowest compliance, averaging −0.49, had their three matched 2011 HLM offspring secure first-year compliance of only +0.09.Assessing CARICOM members’ compliance with their 27 POSS commitments in annual intervals, as measured by the implementation of 14 indicators set out by the CCH in Phase III of the Regional Caribbean Cooperation Strategy, suggests a sustained positive POSS push (data available upon request).  – “Investing in Health for Sustainable Development.”)The political process through which the regional POSS shaped the United Nations’ global NCD regime began by producing POSS with a global vision. The first phase began in 1986, when CARICOM health ministers approved the CCH’s first initiative in which NCDs were a priority. The CARICOM heads of government then approved a regional approach to NCDs at their meeting in 2001 in Nassau, Bahamas. In July 2006 they approved “a special regional consultation” hosted by Trinidad and Tobago, and in February 2007 upgraded it to a regional “summit,” also held in Trinidad and Tobago. The POSS was held in Port-of-Spain in September 2007.The initiative to produce POSS had begun with three members of the Caribbean Commission on Health and Development, some of whom sought a CARICOM summit as a pathway to a United Nations one . EssentiThe second phase started right after POSS, when CARICOM heads of government were told that they needed to take their work further. With PAHO’s encouragement, they injected NCDs into their broader Commonwealth Heads of Government Meeting and the Summit of the Americas, both hosted in Port-of-Spain in 2009. Within the Americas, other regional blocs in Central and South America issued declarations on NCDs .At the United Nations, key individuals from the Caribbean lobbied the United Nations secretary general to hold a high-level meeting on NCDs. They drafted the authorizing resolution in a way that aligned with POSS to benefit all regions.In 2007, the World Health Organization (WHO) began crafting a global plan on NCDs. PAHO/WHO members soon recognized that preventing and controlling NCDs required a political solution involving the highest level of policymakers, namely heads of government. The Caribbean diplomatic missions in Geneva and New York, delegations from Caribbean countries attending WHO and United Nations meetings, and the Norwegian and Russian representatives pushed to pass resolutions at the annual World Health Assembly and at the United Nations, calling for a high-level meeting on NCDs in 2011. Each of the six WHO regions met in the lead-up to the HLM. The first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, held in Moscow in May 2011, provided additional support.During the negotiations on the 2011 HLM outcome document, disagreements arose over targets and indicators, financing, WHO or United Nations leadership, the use of WHO’s “best buys,” and the addition of mental health to the four major NCDs of cancer, diabetes, respiratory disease, and cardiovascular disease. Some United Nations members disagreed with using the term “best buys” but referenced the WHO text that listed those measures. Influential individuals from the Caribbean helped to focus the 2011 HLM on the big four NCDs, as POSS had done. Those individuals also shaped other outcomes in POSS-consistent ways.In the third phase, creating the subsequent 2014 HLM, the direct Caribbean contribution diminished, even though Trinidad and Tobago led the Group of 77 developing countries at the United Nations . AlthougThe next United Nations HLM on NCDs occurred at the United Nations in New York on 27 September 2018. The declaration from that meeting was titled “Time to Deliver: Accelerating Our Response to Address NCDs for the Health and Well-Being of Present and Future Generations.” It emphasized the need to mobilize further political action at the national and global levels to prevent and control NCDs. The next United Nations HLM on NCDs is scheduled for 2025.The fourth phase, securing the SDGs with NCDs included, relied even more on WHO , 33. WHOThe result was the 2015 SDG Summit’s inclusion of an NCD target (reduce premature deaths from NCDs 30% by 2030) in SDG3 on health, as well as the identification of health-supporting measures in other SDGs. The concepts of health throughout the human life cycle and moving from an illness framework to a wellness one were also advanced.This analysis aimed to assess how Caribbean regional institutions met their commitments from POSS, the first political summit on NCDs. The study found that public legitimacy, mission alignment with POSS, and resources enhanced RI compliance. Furthermore, when RI commitments aligned with national interests, CARICOM member-state compliance with the POSS commitments was much higher.When Caribbean RIs’ overall mandates aligned with the interests of respective national decision-making bodies and implementing agencies, member-state compliance with the commitments in the POSS Declaration was much higher. In addition to two Caribbean RIs (CARPHA and the CCH Secretariat), two PAHO decision-making bodies (CFNI and CAREC) were composed of Caribbean health ministers. Similarly, the national implementing bodies of those RIs consisted of health officials who shared similar health interests. These actors played a key role in convening the 2007 POSS and were intimately aware of the directives issued in the POSS Declaration.In contrast, the decision-making body and implementing agencies of OTN and CROSQ are composed of trade ministers and officials accountable to various stakeholders. The processes of those bodies were often stymied as officials sought to resolve competing interests. An example is the CROSQ’s response to its mandate to standardize effective tobacco warning labels. Controlling tobacco use is one of the commitments in the POSS Declaration. It is also a primary mandate of the CROSQ when it comes to standard-setting and quality control. During the CROSQ consultation process, Trinidad and Tobago tobacco manufacturers vigorously opposed initial schedules for rotating health warnings because they felt such warnings would increase their cost of doing business. Some national health-based organizations rejected the tobacco warning labels because they were not far-reaching enough.This analysis highlights the value of funding CARPHA to lead strengthened Caribbean RIs to prevent and control the rising burdens of NCDs. The analysis further shows the value of embedding NCDs in the biggest, broadest, whole-of-global-governance approach at the United Nations and of engaging the private sector, civil society, and mass publics. It also suggests the value of annual compliance monitoring and regular summits to review, reinforce, and improve implementation, now aimed at the 2025 HLM on NCDs and the 2030 SDGs review conference.With the global and regional burden of NCDs still rising rapidly, but with NCDs as only one of the 169 targets in the SDGs, new actions from and in the Caribbean are needed now. These could include regular CARICOM summit sessions on NCDs, interministerial council meetings to review and improve implementation, a streamlined monitoring mechanism benefiting all key actors, the addition of NCDs to the agenda of the European Union’s Latin America and the Caribbean meetings, and continuous comprehensive assessments of compliance with NCD-related commitments from the POSS, CARICOM heads of government meetings, HLMs, and the SDGs, with a focus on the fiscal, economic, and environmental benefits that compliance brings.To show continued global leadership, the CARICOM Quasi Cabinet, the Council for Trade and Economic Development, and the Caribbean finance ministers and foreign ministers should use the intersessional conferences and heads of government meetings to take key decisions on smoke-free public spaces and mandatory food labeling as human rights and consumer empowerment issues. They should also adjust the public tax structure to reduce the consumption of tobacco, alcohol, and sugar-sweetened beverages by Caribbean citizens. To accelerate action, more research on implementation is needed, particularly focusing on barriers to the uptake of evidence, political feasibility, and the building of all-of-society alliances.Research conducted for this analysis was funded by the International Development Research Centre.RPSP/PAJPH or PAHO.Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the


Results suggest that store owner training was the most influential strategy and that the implementation of more BE strategies does not necessarily lead to proportional increases in stocking and sales. Selected BE strategies appear to be an effective way of increasing stocking and sales of WIC foods in small urban food stores.Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) redemption rates have been declining in many low-income urban settings, potentially related to aspects of the food environment. B’more Healthy Corner Stores for Moms and Kids was a feasibility trial in Baltimore City that aimed to test multiple behavioral economic (BE) strategies in 10 corner stores , to evaluate their influence on the stocking and redemptions of WIC foods. Tested strategies included in-person storeowner training, point of purchase promotion, product placement, and grouping of products in a display. All four strategies were feasible and implemented with high reach, dose delivered, and fidelity. Additionally, text messaging was found to be an acceptable form of intervention reinforcement for storeowners. Analyses to assess change in stocking of WIC foods, total sales of WIC foods, and sales of WIC foods to WIC clients, revealed consistent positive changes after implementation of the store owner training strategy, while changes after the implementation of other strategies were mixed. Furthermore, WIC food sales to WIC clients significantly increased after the simultaneous implementation of two strategies, compared to one ( Poor diet quality is one of the largest risk factors for death and morbidity in the United States and is related to healthy food availability, food insecurity, and obesity ,2. In BaRevisions to governmental assistance nutrition program guidelines to address dietary requirements and obesity, such as those by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), have improved the food environment by increasing access to healthy foods and beverages ,8. HowevBehavioral economics is widely recognized as having the potential to achieve immense public health impact at low-cost . BE prinPrevious intervention trials in Baltimore City have utilized BE techniques, such as POP posters and shelf and menu labels, in small food stores and carryout restaurants to promote WIC-eligible foods and modify consumer food behavior, with mixed results ,26,27. T(1)To evaluate change in stocking and sales of WIC foods in small urban corner stores by four different BE strategies implemented separately (Treatment 1).(2)To evaluate change in stocking and sales of WIC foods by combined BE strategies (Treatments 2–4).(3)To evaluate change in consumer selection and purchasing of WIC foods by four different BE strategies, implemented either alone or combined (Treatments 1–4).Little research has tested and compared the implementation and impact of various BE strategies. And, no studies have attempted to identify optimal BE strategies for shifting the stocking and sales of WIC-eligible foods by implementing and comparing multiple BE strategies in small food stores. Thus, the objective of the present study was to test multiple BE strategies, alone and in combination, in small urban corner stores, in order to evaluate its influence on stocking and sales of WIC foods. The specific aims were:B’more Healthy Corner Stores 4 Moms and Kids (BHMK) was a randomized, controlled feasibility trial in 10 corner stores  seeking to identify optimal low-cost BE strategies to increase WIC participation in Baltimore City, MD, USA. The Baltimore City food environment consists of 633 corner stores, 185 convenience stores, 47 supermarkets, and six public markets . AdditioBHMK was a one-year funded pilot intervention. Recruitment and baseline data collection occurred from February through March 2017; intervention implementation and post-intervention data collection was conducted from April 2017 to January 2018. The trial employed the BE principle of nudging and was informed by social cognitive theory ,32,33,34n = 103) [Participating stores were recruited in low-income healthy food priority areas in Baltimore City, MD, and included ten corner stores. The BHMK study team obtained a list of WIC-authorized stores (n = 103)  from then = 103)  and scren = 103) , and werFollowing recruitment and baseline data collection, participating stores were randomized to one of five treatments , where tTwo videos were developed and available in three languages . Video one, 4:16 minutes in length, discussed the benefits of maintaining WIC eligibility and reviewed the stocking of WIC-eligible products and challenges that corner store owners may face. Video two, 9:48 minutes in length, discussed strategies for corner store owners to increase their WIC product sales and introduced corner store owners to forms of verbal encouragement or nudging techniques. During week one of implementation, corner store owners, with oversight of project interventionists, viewed the two videos on an iPad in their preferred language. During weeks two though four of implementation, interventionists reviewed a nudging guide with each corner store owner. The nudge guide consisted of four reminders/ nudges for corner store owners on ways to help their WIC customers  and provided sample phrasing . Following each week’s training corner store owners answered four knowledge questions to assess information retention.Posters and shelf labels were developed by study and Maryland WIC staff. A total of four posters were developed and differed in color and promoted foods for four WIC-eligible developmental age groups . Poster In cooperation with corner store owners, the project interventionists moved WIC products to either the front of the store or to eye level; and in some instances, WIC products were moved to both the front of the store and eye level. Corner store owners were offered six possible display racks and asked to choose one. Choices ranged in size from 18 to 72 inches and were made of various materials, including wicker baskets and restaurant quality steel. Each chosen display was ordered, delivered, and assembled in each corner store in a location decided in cooperation between the project interventionist and the respective corner store owner.All eight intervention corner store owners were enrolled in a text messaging service  at the beginning of the intervention. Text messages reinforced the BE strategy or combination of BE strategies employed in each store at that time. Similar to the training materials, text messages were available in Korean, Chinese/Mandarin and English. Corner store owners received two to three text messages  per week during each intervention treatment. Text messages were only sent during treatment periods. The text messaging component was assessed in terms of acceptability which was defined as the willingness of store owners to accept the text messaging intervention strategy by remaining enrolled in the text messaging service for the duration of the intervention. Similar definitions of acceptability have been previously used . Prior to the start of the BHMK intervention, a baseline Store Impact Questionnaire (SIQ) was completed to assess corner store owner characteristics, including decisions regarding food stocking and self-efficacy to stocking healthier products. The SIQ was repeated post-intervention. At pre- and post-intervention and at each intervention treatment , BHMK data collectors conducted an Environmental Assessment (EA), which assessed stocking and owner-reported sales of WIC foods in the prior 7 days, and total WIC redemption in the prior 30 days. Store owners were compensated for their time, after the completion of each EA and SIQ, with a ten-dollar gift card. a priori .Data managers worked with data collectors to ensure all forms were complete without missing or ambiguous entries. Data was then entered and cleaned by the data manager and research assistants into Microsoft Accessp < 0.05. Statistical analyses were conducted in STATA 14 .Prior to and for the purposes of analysis, WIC foods were divided into seven groups based on the 2017 Maryland WIC-Authorized Foods List . DescripThe BHMK intervention trial was Institutional Review Board (IRB) exempt, as it was not considered as human subjects research by the Johns Hopkins University IRB. a priori set standards for process evaluation , and a significant decrease in the average number of WIC-eligible infant foods stocked following the implementation of three BE strategies . No other statistically significant changes in stocking or unit sales were observed for individual food groups  strategies on the stocking and sales of WIC-eligible foods in small urban food stores. Results from the BHMK intervention trial demonstrate that it is feasible to implement four BE strategies , product placement, and grouping of products in a display) both alone and in combination in WIC-authorized corner stores in Baltimore City, MD with high reach, dose delivered, and fidelity. Additionally, results suggest that text messaging was an acceptable form of reinforcement, given that all store owners remained in the program.Store owner training appeared to be the most consistently influential form of BE intervention strategy, whereas results following implementation of other strategies were mixed. Our findings suggest that more BE strategies do not necessarily lead to increased sales and stocking of these foods. We postulate that store owner training had the most influence on stocking and sales of WIC foods because of the intensity of implementation. Store owners were required to watch the same training videos and answer knowledge questions repeatedly. Once learned, knowledge could not be removed. Whereas strategies like POP or grouping of products in a display, which have been previously demonstrated to impact food behavior , requireResearch suggests that subtle cues such as product placement should be effective at reducing consumption of unhealthy foods and increasing the purchase and consumption of healthier foods ; howeverThe study had several limitations. General declines in WIC sales associated with electronic WIC (eWIC) introduction may have impacted findings. eWIC implementation in Baltimore City commenced 1 July 2017, around the same time BHMK Treatment 2 (implementation of two BE strategies) was completed. After Treatment 2, we observed declines in total unit sales of WIC-eligible foods to all customers  and averOther limitations include the small sample size and sales being a corner store owner self-reported measure. Lastly, there may have been the potential for selection bias, as the 12.5% of the store owners who agreed to participate in our study may differ from overall owners of WIC-authorized stores. Thus, results of this study have limited generalizability. Recommendations for future trials include (1) increasing the study duration and sample size to account for seasonality and baseline variability; (2) using and reporting process evaluation measures to monitor intervention implementation and provide context for intervention results; (3) refining and testing optimal store owner nudging and training strategies.The literature describes various ways BE strategies have been used to influence food choice and purchasing behaviors but lack a comparison of optimal strategies. This study provides a first attempt at making these comparisons and serves as a reference for future interventions aiming to modify food behavior though BE strategies. In addition, while the use of BE strategies to influence food behavior is increasingly common, no studies have compared the implementation and impact of multiple BE strategies for government food assistance programs. This was one of the first intervention trials to do so and therefore the data provided will be helpful for developing sustainable interventions employing BE strategies, and supporting policies.