Sinusoidal obstruction syndrome also known as veno-occlusive disease (SOS/VOD) is a life-threatening complication after hematopoietic stem cell transplantation (HSCT). The classical clinical presentation of SOS/VOD consists of hyperbilirubinemia, hepatomegaly, with right upper quadrant pain, ascites and weight gain as the consequence of this primary endothelial injury. Eighty percent of SOS/VOD develops before day 30 after HSCT, but it can be diagnosed later. Due to the lack of sensitive and specific biological markers or imaging tools, SOS/VOD remains a clinical diagnosis.Seattle criteria and Baltimore criteria to diagnose SOS/VOD have been used unanimously for adults and children for the last decades, with minor adjustments. Several shortcomings of these criteria were identified over the last decades, such as the obligatory hyperbilirubinemia (>2 mg/dl) of the Baltimore criteria, the time limit of 20 and 21 days respectively, the arbitrary weight gain of 2 and 5% that were increasingly recognized as obsolete, in particular in the pediatric patient population.The significant differences between adults and children in many aspects such as incidence, genetic predisposition, clinical presentation, prevention and treatment, as well as outcome were acknowledged recently by the European Society for Blood and Marrow Transplantation (EBMT). Consecutively, separate diagnostic criteria for adults  and chilThe pediatric EBMT (pEBMT) criteria aimed predominantly at clinical aspects that have not been considered so far. Anicteric VOD/SOS is observed in 30% of children but also increasingly recognized in adult patients before day +21 post-HSCT , but thaThe major intention of the pEBMT criteria was to trigger early/preemptive intervention with defibrotide (DF). DF demonstrated efficacy for the treatment and prevention of SOS/VOD and received European Medicines Agency authorization for the treatment of SOS/VOD. The importance of timing of intervention with DF was shown in several trials, demonstrating that early intervention with DF is associated with a superior outcome –7.This preemptive approach of the pEBMT criteria inevitably provokes an adjustment of the incidence of VOD/SOS but is intended to improve outcome with regard to morbidity, severity of diseases, hospitalization and mortality. Highly variable incidences of SOS/VOD depending on the criteria used for diagnosis are well known from Seattle and Baltimore criteria with variations of up to 400% , 9 but aUntil recently the proposed criteria were lacking evidence. Recently, Embaby et al.  demonstrIn this Journal, Ragoonanan et al.  comparedTaken together, the recently accumulated, albeit retrospective, data on the sensitivity and specificity of the pEBMT are encouraging but need prospective confirmatory evidence since baseline ultrasound was rarely standard of care in the past and TRT is difficult to assess from patients records properly. With regard to anicteric VOD/SOS and TRT being also prevalent in adults, an update of the diagnostic criteria might be worth a consideration.


Through the First Identify and Refer then Serve and Track (FIRST) Project, individuals and caregivers have critical connections to community organizations and resources to learn ways to handle living with memory problems. The FIRST project integrated new practices into existing programs to address gaps in service and piloted a new dementia-specific case management program. The initial intervention is a system-level change within the County of San Diego’s Aging & Independence Services (AIS) department to identify, pilot, and implement a brief Alzheimer’s Disease and Related Dementias (ADRD) screening tool. The tool was used by non-clinical personnel to identify potential ADRD cases. Individuals who screened positive for possible ADRD were referred to their physicians for an accurate diagnosis. The second intervention consisted of two components: a behavioral symptom management intervention for social workers to use in the home with caregivers and a dementia-specific case management program (including respite care) to improve quality of life and future planning for those with ADRD living alone or with a family caregiver. As of January 2021, 536 clients across several AIS programs have been screened for ADRD, of which, 60% screened positive. FIRST case management has served 196 clients, 70 who lived alone and 126 who lived with their caregiver. Respite was provided to 98 clients totaling to 3,666 hours. This poster evaluates the effectiveness of the program components in increasing dementia capability of an agency, and where applicable, its effect on caregiver burden and self-efficacy.


Describe and evaluate an implementation science network focused on HIV prevention and treatment in New England.In 2014, we established a partnership among university researchers and community stakeholders to stimulate and support HIV-related implementation research. We solicited information from Network members through surveys, interviews at Network events, and dialog with participants. In 2017, we conducted a sociocentric network assessment of collaborations on research projects, grants, manuscripts, and consultations.We identified 988 connections made through the Network that resulted in 185 manuscripts published and 15 grants funded. Our experience indicated that eight factors were instrumental in building and sustaining the Network: (1) acknowledging different perspectives, (2) balancing content and expertise, (3) encouraging consistent engagement, (4) providing seed funding, (5) membership flexibility, (6) maintenance of Network interactions, (7) supporting local HIV prevention and treatment efforts, and (8) maintaining productive relationships with health departments and community-based organizations.Developing and maintaining a regional network on implementation science for HIV prevention and treatment is feasible and can facilitate new and productive partnerships among researchers and community organizations and members. Contributions to the literature▪ HIV implementation science focuses on translating evidence-based interventions into policy and practice for improving the quality and effectiveness of HIV prevention and treatment efforts.▪ A regional network centered around HIV implementation science is an effective way to establish and support collaborative partnerships among agencies, stakeholders, and researchers to address the high prevalence of HIV in small urban areas in New England.▪ Lessons learned in forming and maintaining this type of network can help to encourage and inform the development and continuation of regional networks on HIV implementation science in other parts of the USA and world.Promoting the implementation of prevention and treatment interventions that have been shown to be effective is urgently needed . ImplemeIn the fields of HIV prevention and treatment, there is growing interest in implementation science . It fillThe persistent HIV epidemic in small urban cities has heightened interest in implementing effective interventions as these areas face unique challenges to implementation, including smaller social networks, increased stigma, fewer specialized resources, and migration in and out of rural and large urban centers , 7. HIV The Yale Center for Interdisciplinary Research on AIDS (CIRA) and the Providence/Boston Center for AIDS Research (P/B CFAR) collaborated in 2014 to develop a New England HIV Implementation Science Network (hereafter referred to as the Network) to share regional knowledge to improve HIV prevention and treatment efforts in small urban areas defined as cities with a population less than 200,000. The goals of the Network were to (1) foster partnerships among agencies, stakeholders, and researchers and (2) stimulate and support research and evaluation collaborations across New England, with a focus on implementation science in small urban areas with a high prevalence of HIV. In this report, we describe the establishment of the Network, the lessons learned, and its impact.To form the Network, Yale CIRA and P/B CFAR identified and invited stakeholders, including all regional health departments, AIDS service organizations, HIV providers and clinics, Federally Qualified Health Centers (FQHCs), academic institutions, patient advocacy groups, industry representatives, and non-governmental research organizations to become Network members. To date, the Network has conducted a total of six annual symposia, four supplemental workshops, and multiple leadership planning meetings Table . AttendaOur approach to achieving Network goals included 1) developing an understanding of implementation science research concepts; (2) forming academic-community partnerships around topics of mutual interests; (3) obtaining input from community partners on local needs/priorities; (4) generating research questions that could be addressed through implementation science research; (5) offering support to academic-community partnerships interested in pursuing research funding by linking them to implementation science experts, providing logistical meeting support, and providing seed funding; and (6) encouraging Network members to report their experiences and successes to inform future Network partnerships. Figure  developiThe Network has provided training on implementation science and supported the development of collaborative projects by creating an online Network Resource Center, establishing a joint pilot project award supported by the two centers, disseminating grant opportunities and facilitating discussions to incentivize collaborations, promoting implementation science capacity through webinars, the aforementioned workshops, facilitating matchmaking of researchers and with community/practice partners, and convening meetings to coordinate and refine research project concepts.Quantitative and qualitative feedback was routinely solicited from members about the organization, logistics, and quality of Network activities through electronic surveys, verbal feedback at Network events, informal interviews, and periodic dialog with representatives from the research and practice spheres.At the fourth Network symposium in 2017, we undertook a more systematic evaluation of its impact on building collaborations and projects by conducting a sociocentric network assessment . We askehttps://cira.yale.edu/network); it includes a wide range of resources related to implementation science.In almost all Network meetings, researchers comprised less than half of the attendees. After the initial “kick-off” meeting, participants identified their primary areas of interest and four workgroups were formed around different topics  to develop research ideas. A major goal of the second symposium was to move from “Concepts to Projects.” A third symposium focused on advancing emerging ideas. Subsequent workshops focused on implementation science methods, mathematical modeling, and developing community research capacity. The fourth symposium focused on “Putting Implementation Science into Practice,” while the most recent symposia focused on addressing topics of interest to community participants and providing a mix of capacity building activities to better meet the needs of participants with varying levels of implementation science expertise. The symposia had multiple functions in addition to capacity building and the Network did not provide a structured curriculum on implementation science. Nevertheless, all meetings addressed issues in implementation science to some extent. The issues and topics covered are summarized in Table The sociocentric network assessment documented 988 connections between organizations that resulted in 185 manuscripts published and 15 grants funded. Most connections with research institutions in the Network were with non-academic, implementing organizations. After eliminating multiple connections, there were 579 unique connections from network members at research institutions. Of those, 308 were to implementing organizations, such as health departments, FQHCs, CBOs, and to a lesser extent industry.There were 285 connections generated by Network activities related to research ideas; 200 connections resulted in grant submissions, and 162 connections represented grant-funded activities. Eighty ties represented co-authorships on a manuscript. Using a standard measure of network density  frameworks and practical application” . However, some participants reported didactic content “too scientific and detailed” , “dry and drawn out” , or “more academic focused than what I deal with on a day-to-day basis” . Educational programs need to address the different levels of experience with implementation science and how it may be defined and utilized differently. Multi-tiered trainings that start out with broad foundational concepts on implementation science and then get more specific depending on the interest and needs of the target audience members may be one way to balance the level of content and expertise presented.A roughly equal balance of academic researchers and community participants ensured that both were represented in smaller breakout groups, where the goal was typically to meet others with a common interest and to develop potential research questions. These sessions provided for a “Great exchange of ideas”  and forged connections, helping attendees to “network with regional colleagues”  and “identify other individuals interested in the same questions that I would like answered” .Ongoing and frequent engagement with a large, diverse membership is needed to maintain long-term interest in and connection to the Network. Long-term interest in and connection to the Network in turn facilitate capacity building in implementation science. Long-term engagement can also facilitate the development of implementation science research projects. Inclusion of all New England states has been desirable to identify and address similar issues across the region as well as to leverage resources, but involvement in in-person events by the more geographically remote of the six states  has proven difficult. Attempts to conduct workgroup meetings by video conference were very challenging because of inconsistent connections and audio quality. Eventually, that approach was dropped, except for very focused, engaged groups. Those meetings were conducted before the widespread use of videoconferencing during the COVID-19 pandemic so this may be much less of a concern for future activities. Large, inclusive meetings are important to establish connections and promote openness, but to achieve results it is necessary to select more engaged members for more focused discussions.Providing seed funding to launch research collaborations for larger studies is essential to move Network member ideas to action and to create mini “learning collaboratives” to cultivate practice-academic research relationships. Time is a key constraint reported by both academic and community participants, and small grants have supported some of the researcher effort required to pursue projects developed during Network events or within Network collaboratives. For example, a “Syphilis to Pre-Exposure Prophylaxis (PrEP)” health navigation project for men who have sex with men (MSM) with syphilis diagnoses was developed during the 2015 Network Symposium with funding from the Connecticut (CT) Department of Public Health. This project was motivated by the rise in number of syphilis cases in the state reported by the local health department and interest in addressing this public health concern among medical practitioners and researchers. These shared interests were discussed at the Network meeting. The experience and connections made among CIRA researchers, health department staff, and local providers stimulated further PrEP linkage efforts in the state and laid the foundation for a successful application for a Centers for Disease Control and Prevention demonstration project funding to CT Department of Public Health in 2018 to promote PrEP adoption among Black/African American and Hispanic/Latino MSM.Network member assessment, surveillance, recruitment, engagement, and re-engagement are an ongoing process that requires careful attention. Membership is fluid and participation can be erratic; people step in and out of the process depending on level of interest, role in the Network, and what is on the agenda that is of interest to different stakeholders. As new people are hired for practice and HIV research positions, and/or different organizations enter the scene due to HIV grant program/funding volatility and other developments, they need to be identified, informed about the Network, and engaged if interested. The experience of existing members also requires evaluation to assess interests/needs for additional support from Network coordinators. It also is important to assess and develop the implementation science skills of members to support advancement of large, funded implementation science research projects.Network maintenance and facilitation require dedicated, appropriately skilled professionals with strong connections to both the practice and research spheres. Building trusting, reciprocal relationships between HIV practice and research sectors also requires having a Network dedicated staff member, and others from Network lead organizations actively involved in the practice sphere, such as attending HIV statewide and community-based meetings in the region, serving on committees, contributing to initiatives such as statewide “Getting to Zero” or “90-90-90” campaigns , 12.Evaluation of existing local HIV programs is often of interest to HIV clinicians and finding ways to support these needs can bridge the practice-research gap and earn more buy-in from practice partners. These projects are an opportunity to build relationships and community research capacity and can even generate data for use in more research-oriented applications , 14. FroDeveloping sustained and productive relationships with state health departments is essential. For example, the 2017 Network symposium included a panel of HIV program directors from the six New England state health departments who presented HIV continuum of care data for their areas and identified research questions of regional interest. This led to a three-state Network study designed to examine issues around the approach to and uptake of partner referral services among MSM living with HIV.Cultivating and sustaining partnerships with CBOs is equally important as they are the front line of the HIV service delivery system where implementation of most HIV interventions occurs. These providers face challenges in selecting and adapting interventions to optimize prevention and treatment outcomes, challenges that can be addressed through implementation science.In this report, we describe the development and functioning of a new regional model for integrating community and academic efforts in implementation science to address HIV prevention and treatment. The Network has stimulated and supported new collaborative research addressing issues of HIV prevention and treatment in small urban areas and enhanced the research capacity of affiliated scientists and community partners to conduct implementation science.Our experience demonstrates that a multidisciplinary and multi-sector research network can foster productive and lasting collaborations between researchers and practitioners with tangible outcomes. To optimize these gains will require sustained and strategic support and facilitation of the process, ongoing information sharing, and regional networking. In the future, we plan to disseminate the lessons learned while expanding the Network and to share successful methods for maintaining collaborative partnerships. We hope to expand engagement to interested parties from other regions of the country through the Department of Health and Human Services’ Ending the HIV Epidemic initiatives. Going forward, dissemination approaches will include publications, conference presentations, and the online Network Resource Center. The Network will support the development and evaluation of initiatives that advance the federal government’s National HIV/AIDS Strategy by supporting the development of interventions tailored to small urban centers and other understudied communities.Now that the Network is running effectively, we will focus more on developing federally funded implementation science projects that build on the unique relationships and collaborations fostered by the Network. Addressing the unevenness in capacity and readiness to engage in implementation science among Network members will be critical to our ability to foster successful grant applications and projects. Implementation science capacity is now much stronger at Network academic institutions due to several new training and grant activities. Thus, in the next phase, we will be able to connect Network members to a broader range of training programs for academic researchers and community practice partners in implementation science methods and community-engaged research. As these programs are refined, we will offer them broadly using digital learning technology.https://cira.yale.edu/network) provides (1) links to training on implementation science; (2) information on current implementation, dissemination, and translation research, using social media/technology; (3) bibliographies; and (4) approaches to address challenges in doing research in small urban areas.To reach a broader audience, we will also expand our online Network Resource Center, providing wide access to materials for those interested in conducting research in small urban centers. The Resource Center (Implementation science has a potentially important role in advancing the goals of the National HIV/AIDS Strategy and the new federal plan to end AIDS by 2030. There is a long history of collaboration among researchers in multiple disciplines  and ther


N = 350) who completed a questionnaire about the challenges of virtual learning followed by semi-structured interviews (N = 10). Observations, journals, and peer-reviewed literature was also used to explore the influence of cognitive, social, and teaching presence on students’ perceptions. The data were analyzed using descriptive statistics and thematic analysis. The researcher found students had a high perception of the three influences of Community of Inquiry framework and were aware of its importance. Furthermore, there were clear relationships between cognitive and teaching presence and cognitive and social presence. The importance of online teaching and learning strategies supports the interactivity of these presences.During the coronavirus pandemic, educational institutions were forced to shift to virtual learning. Drawing on the Community of Inquiry framework and bioecological perspective, this research explores the virtual learning experiences of female college students at one higher education institution in the United Arab Emirates using an interpretive phenomenological paradigm. A convergent parallel mixed method design was implemented with participants ( In response to the coronavirus (COVID-19) threat, higher education institutions in the United Arab Emirates (UAE), like others across the world, cancelled face-to-face classes and shifted faculty and students to online teaching and learning. This move was intended to allow flexibility in teaching and learning while maintaining high learning outcomes and expectations. While many institutions were unprepared to quickly shift to virtual learning (VL), the Higher Colleges of Technology (HCT-UAE) was uniquely positioned. This is mainly because of the institution’s existing use of technology, blended learning, e-portfolios, learning management systems, eAssessment, digital library services, intelligent learning systems, digital services, and infrastructure HCT.0, 2020.Ultimately, HCT’s online courses during the pandemic differed from regularly planned online classes. The success of the new virtual learning environment (VLE), as with traditional learning environments, begins in the classroom. Therefore, research into online learning at HCT was pivotal to understand the obligations and operations of the new approach.Although HCT focuses on technology use, the sudden transition to VL led to a new array of leading and managing learning and teaching in online communities. Geng et al.  refer toHow have cognitive, social and teaching presences influenced Emirati female college students’ perceptions of online classes during the sudden shift to the virtual learning environments?What relationships exist among cognitive, social, and teaching presence and students’ lived experiences during the sudden shift to virtual learning environments?What do Emirati female college students consider as challenges in their new virtual learning environments?Students caught off-guard by the sudden shift to virtual classrooms encountered challenges engaging in courses that provided community-based experiences to ensure positive social and cognitive interaction among learners and instructors  expressions where learners share values and personal expressions; open communication, where they develop mutual awareness and recognition; and group cohesion, where they build and sustain a sense of group commitment. Richardson and Swan   to achieve expected positive learning results  Ceci, . These pts Ceci, . Well-deprocess is considered as the bidirectional relationship between an individual, other individuals, and their ecology. Positive interactions are powerful in determining the individual’s development. The person includes the characteristics of an individual’s development including genetic, physical, psychological, and behavioral development. The context of an individual’s development comprises the interacting systems and social characteristics surrounding the individual such as school structures, learning environment, and disciplinary procedures  design that consists of the four main components of the bioecological theory of human development Lerner, . The procontext of learning to determine positive learning outcomes. That is, desired learning experiences emerge through bidirectional interactions between the individual and the wider surrounding systems. The primary focus is on the incorporation of three types of relationships  that are essential in supporting VLE’s effectiveness  will lead to positive learning experiences.Beaver et al.  and RuttThe ecological perspective of teaching and learning in VLEs requires focusing on the tools as well as the context of teaching and learning. In the CoI model, these tools are represented via different strategies that are required to successfully enable each presence to affect students’ learning context, especially the relationships between students and teachers  and students and other students , to result in positive cognitive outcomes (cognitive presence). This shows learners are active participants in the ecology of learning to create their learning through bidirectional interactions. Learning can occur due to the interaction of the individual with the wider community or system, such as the learner and the new virtual CoIs. In VLEs, the combination of personal relationships between the learner and the instructor, and the learner and other learners can lead to positive cognitive outcomes.From the ecological perspective, many interacting influences such as social environment, teaching and design, and cognitive presence affect students’ learning, as presented in the CoI framework. When each aspect of the dimensions of each system positively interacts and supports each other, the learner can achieve better learning experiences. Students are active participants in these interacting systems of VLEs, and their traits affect other learners as well as the system as a whole. Generally, active and positive collaboration within virtual teaching and learning environments can motivate students toward better collaboration with different dimensions of the new virtual learning system for better learning experiences.Under the ecological perspective and guided by the CoI framework, timely access to online materials in the new learning environment is insufficient. Rather, instructors need to contextualize these materials to adjust their teaching to the new virtual environment. Moreover, teaching methodologies and strategies in a VLE drive student engagement supported with assessment and feedback strategies  with family responsibilities or single (n = 200) with responsibilities for families and siblings.Participants were Year 1 female college students enrolled in a teacher education program at the HCT aged between 18 and 22, and married , and the instrument was assessed for fit by HCT instructors who also validated its use for the HCT community. The instrument was found to be valid, reliable, and an efficient measure of the dimensions of social, cognitive, and teaching presence  Yes and (1) No; questions 1–5, 9, 11, 13, 16–17, 19–20 were graded as (0) Yes, (1) No (2) Somehow; questions 8, 10, 12, 14–15, 18, 21, 23–34 were graded as (0) Yes, (1) No, (2) Somehow, (3) I don’t know. The comments regarding students’ challenges working in the online environment, the role of family, culture, and tradition, and the role of the college were grouped under Qs 35–37 which invited open-ended responses. Analyses were performed with simple statistics. The most positive responses received were Q4-clarity of due dates and deadlines (95%); Q6-instructor’s explanation of the subject in a way that enabled learning (99%); Q7-instructor’s provision of activities that kept students engaged (99%), Q9-instructor encouraging students to explore new topics related to the subject (99%); Q13-timely feedback (96%); Q20-all students felt able to disagree with peers online (100%). The most negatives responses were Q19-students being comfortable dealing with other persons online (97%); Q22-the belief that online classes improved their work skills and collaboration (98%).Teachers Presence, I looked at students’ active involvement in class such as their willingness to answer questions or whether they paid attention. This impacted Facilitation since a quiet student suggested non-involvement. I invited two faculty members of the department to recheck my data. They found a few inconsistencies and I changed those before I presented the report to two interviewees to check and ensure I had not misrepresented their views.The qualitative data were analyzed using thematic analysis .Students should be given opportunities to speak and participate in classes to further develop their interests. (Students indicated teachers muted their microphones).Teachers should conduct end-of-class assessments.Students should receive timely feedback on their learning curves and areas requiring improvement.Educational institutions should establish policies about camera use. Students need to turn their cameras on during online classes so that teachers can monitor attendance, moderate discussion boards, and conduct learning activities. . Educational institutions should draft effective policies and ensure strict monitoring of online learning forums to avoid such incidences.Students should be provided adequate support from family members, who should be educated on the requirements of VL.Policymakers should ensure that classes are offered in both the local language and English to increase understanding of concepts articulated in English.State-of-the-art technology should be used to manage learning management systems and facilitate the seamless implementation of classes in VLEs. Since technology is the backbone of VL, students should be provided with high-speed internet at home and teachers should have similar access at their institutions.Further research should be conducted in a similar context to examine design strategies and learning materials that take into account cognitive, social, and teacher presences.Based on the findings of this study, the following are recommendations for Emirati educational institutions with a focus on the contextual effects of the CoI framework and ecological perspective.


Many evidence-based interventions (EBIs) found to be effective in research studies often fail to translate into meaningful patient outcomes in practice. The purpose of this study was to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer (CRC) screening in an urban federally qualified health center (FQHC) and offer actionable recommendations to improve future implementation efforts.We conducted 16 semi-structured interviews guided by the Consolidation Framework for Implementation Research (CFIR) to describe diverse stakeholders’ implementation experience. The interviews were conducted in the participant’s clinic, audio-taped, and professionally transcribed for analysis.We used the five CFIR domains and 39 constructs and subconstructs as a coding template to conduct a template analysis. Based on experiences with the implementation of three EBIs, stakeholders described barriers and facilitators related to the intervention characteristics, outer setting, and inner setting. Implementation barriers included (1) perceived burden and provider fatigue with EHR  provider reminders, (2) unreliable and ineffectual EHR provider reminders, (3) challenges to providing health care services to diverse patient populations, (4) lack of awareness about CRC screening among patients, (5) absence of CRC screening goals, (6) poor communication on goals and performance, and (7) absence of printed materials for frontline implementers to educate patients. Implementation facilitators included (1) quarterly provider assessment and feedback reports provided real-time data to motivate change, (2) integration with workflow processes, (3) pressure from funding requirement to report quality measures, (4) peer pressure to achieve high performance, and (5) a culture of teamwork and patient-centered mentality.The CFIR can be used to conduct a post-implementation formative evaluation to identify barriers and facilitators that influenced the implementation. Furthermore, the CFIR can provide a template to organize research data and synthesize findings. With its clear terminology and meta-theoretical framework, the CFIR has the potential to promote knowledge-building for implementation. By identifying the contextual determinants, we can then determine implementation strategies to facilitate adoption and move EBIs to daily practice. Contributions to the literatureThis research study identified and described implementation barriers and facilitators specific to implementing evidence-based intervention at a large urban federally qualified health center. The barriers we identified in this study are common in clinical practices. We recommended implementation strategies to mitigate these barriers.We found that facilitators that were unique to federally qualified health centers, including the requirement from funders to submit quality measures, the incentive for improvement, and the providers’ commitment to their patients, and all could promote changes and openness to new ways of practice as well as have the potential to mitigate resistance and accelerate the implementation process.The Consolidated Framework for Implementation Research (CFIR) is well suited to evaluate the implementation process of evidence-based interventions (EBIs) to improve a cancer screening program based in an urban federally qualified health center. Data were coded to CFIR constructs without requiring any adaptation, and barriers were easily identified. Thus, CFIR serves well as a pragmatic guiding framework for evaluation.Gaps still exist between identifying evidence-based intervention (EBIs), changes to practice, and improving outcomes for patients , 2. EBIsNumerous theories and models have been proposed to assess potential contextual determinants and inform the implementation of innovations , 13. TheThis study is part of a larger program entitled “Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science-Chicago (ACCSIS-Chicago).” The ACCSIS-Chicago project is part of the NCI-funded consortium, the Accelerating CRC Screening and Follow-up through Implementation Science (ACCSIS) Program. The overall aim of ACCSIS is to conduct multi-site, coordinated, and transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The ACCSIS-Chicago Program aims to implement a multilevel, multicomponent intervention to increase rates of CRC screening, follow-up, and referral-to-care at four FQHCs located in Illinois and Indiana. Findings from this study are used to inform the implementation process of the multilevel intervention in these four FQHCs. This study has been reviewed and approved by the University of Chicago Institutional Review Board (IRB18-1141).The Consolidated Framework for Implementation Research (CFIR) synthesized and categorized constructs across different theories and models and provided a meta-theoretical framework to advance our understanding of implementation across various settings and interventions. The CFIR is composed of five major domains: (1) intervention characteristics, (2) inner setting, (3) outer setting, (4) characteristics of individual involved in the implementation, and (5) implementation process. There are 39 CFIR constructs and subconstructs under these five domains, which reflect the evidence base of factors most likely to affect the implementation of interventions . Much ofIn this study, we conducted a formative evaluation using a qualitative study design to gain insights into the implementation process. Clinic providers and staff members involved in the implementation process were selected for one-on-one semi-structured interviews. We used CFIR to guide the evaluation process, from developing interview questions and organizing the coding tree to analyzing data and summarizing findings . ThroughWe conducted semi-structured interviews to assess the implementation experiences of three EBIs that were ongoing in four primary care clinics in an urban FQHC. The FQHC has 11 clinics, with 8 providing primary care services. In 2018, the FQHC provided care to 26,102 unique patients. Over 82% of patients came from racial/ethnic minority groups, nearly one third of patients were uninsured (32%), and 32% were best served in a language other than English. At the beginning of 2016, the FQHC participated in a Centers for Disease Control and Prevention (CDC) funded CRC Control Program and started implementing three EBIs to improve screening rates at its primary care clinics with technical support from the University of Chicago program team. The three EBIs implemented to promote CRC screening include (1) provider reminder, which was generated manually by staff members along with an automated reminder from the Electronic Health Record (EHR); (2) quarterly provider assessment and feedback with the clinic- and individual provider-specific reports capturing CRC screening order rates and screening completion rates; and (3) CRC stewards  to identify patients who needed CRC screening, provide patient education and follow-up with patients to ensure compliance with screening orders. CRC screening rate at the FQHC has been improving, changing from 33.6% in 2016 and 37% in 2017 to 41% by the end of 2018.The FQHC had a total of 48 primary care providers in September 2018 when the sampling procedure began. The primary care providers included 22 physicians, 20 advanced nursing practitioners, and 6 physician assistants. We selected 8 physicians, 4 advanced nursing practitioners, and 2 physician assistants based on their overall individual CRC screening order rates in 2017. Of the 14 providers, 6 were high performers with an order rate at the top 25%, and 4 were low performers with an order rate at the lowest 25%. The range of individual CRC order rates from the selected primary care providers was between 25% and 81%, and the average order rate was 41%. The sample also included all four CRC stewards  and two administrators. We requested one on one interviews with primary care providers, CRC stewards , and administrators via email. The semi-structured interviews were conducted between November 2018 and December 2018. Participants who completed the interview received an honorarium of $50 for their time and efforts. Of the 14 primary care providers invited for the interviews, three providers no longer worked at the FQHC at the time of interviews, and one refused to participate. Thus, the final sample of the semi-structured interviews included ten primary care providers, four CRC stewards , and two administrators.We used the publicly available CFIR Interview Guide Tool to inform our semi-structured interview guide . The semWe conducted a template analysis of interview transcripts to identify themes describing facilitators and barriers to implementing the three EBIs related to CFIR constructs. Template analysis is a form of thematic analysis that emphasizes hierarchical coding and allows a relatively high degree of structure in analyzing the textual data with the flexibility to meet a particular study’s needs . InsteadBefore starting the coding process, the coders  reviewed and discussed the CFIR coding definition, inclusion criteria, and exclusion criteria to come to a collective understanding of the codes. Due to the expansiveness of CFIR constructs, two coders independently double-coded the same transcripts and met regularly to review coding consistency and discuss problematic constructs. The coding team met together after all the transcripts were coded to discuss preliminary themes to reach a consensus. All coding and analysis were conducted in NVivo 12.We conducted interviews with 16 stakeholders involved in various aspects of the implementation process, such as monitoring the implementation, championing the EBIs, and carrying out the EBIs. Table Within the intervention characteristics domain, the codes identified were relative advantage, adaptability, and complexity. The following are themes as barrier or facilitator to implementation efforts:The EHR provider reminder generated alerts when the provider opened the patient’s medical record during visits. Providers needed to respond to the alert by updating the patient’s CRC screening history or ordering a screening test before advancing to the other medical record parts. Although the EHR provider reminder was considered simple and straightforward, some providers grew frustrated and started ignoring the alert knowingly or found ways to bypass them.When patients screen for CRC using the stool-based fecal immunochemical test, lab technicians upload the test results directly to the EHR. However, when patients screen for CRC using colonoscopy, they receive a referral to see an outside provider and complete the colonoscopy at another facility. Most of the time, the colonoscopy results are faxed to the clinic and manually entered into the EHR. Thus, EHR provider reminders might not be accurate or up to date and could create frustration.Although EHR collects a large amount of detailed patient health information, raw EHR data is disorganized and full of uncodified variables. The quarterly provider assessment and feedback intervention organized raw data from the EHR and provided performance evaluation reports at the provider and clinic levels. Providers could compare their performance with other providers at their clinic, and the clinic could compare its performance with other clinics within the FQHC. The quarterly provider assessment and feedback motivated the desire for changes.The implementation of the EBIs was considered straightforward and integrated into the clinic workflow without significant interruption. The leadership and implementation champions’ support and oversight made the adaptation process run smoothly with less resistance.Within the outer setting domain, the codes identified were the needs and resources of those served by the organization, peer pressure, and external policy and incentives. The following are themes as barrier or facilitator to implementation efforts:With 82% of patients from racial/ethnic minority groups and 32% of patients speaking a language other than English, it is challenging to provide culturally and linguistically competent care, let alone provide education in CRC screening and persuade them to comply with screening recommendations.Over the years, efforts to promote breast cancer and cervical cancer screening achieved widespread attention, with the national breast cancer screening rate at 78% in 2016 and cervical cancer screening rate at 81% in 2018 , 41. HowAll FQHCs must submit data that reflect activities in the HRSA-approved health center project. Furthermore, each year health center grantees must report on their performance using quality measures defined in the Uniform Data System (UDS), such as CRC screening rate. The UDS is a standardized reporting system that provides consistent information about health centers and is open to public access.UDS currently assigns quartile (1 to 4) to each quality measure. Clinical performance for each quality measure is ranked from quartile 1  to quartile 4 . Furthermore, in recent years, HRSA has begun providing different Quality Improvement Awards to promote the overall quality, efficiency, and value of the nation’s health centers’ healthcare services. These awards recognize the highest performing health centers and those health centers which have made significant improvements and gains from the previous year. The pressure from competing with other health centers motivates changes and creates an openness to improve the quality of care.Within the inner setting domain, the codes identified were implementation climate, readiness for implementation, culture, and network and communication. For the implementation climate, we also identified three sub-codes: tension for change, organizational incentive and rewards, and goals and feedback. Also, there were three sub-codes for readiness for implementation as well. They were leadership engagement, available resources, and access to knowledge and information. The following are themes as barrier or facilitator to implementation efforts:The target goal for CRC screening rate was not clearly stated, neither at the organizational level nor at the clinic level, which might have hindered the commitment for improvement.The frontline implementers, such as providers and CRC stewards , did not know the organizational goal for the CRC screening rate. The quarterly provider assessment and feedback reports were not communicated directly with CRC stewards . They only learned about the performance of their efforts from their supervisors when the numbers were low and had no knowledge about the targeted number.In addition to the patients’ unfamiliarity with CRC screenings, 82% of patients were from racial/ethnic minority groups, and 32% spoke a language other than English. Providers and CRC stewards  needed print materials covering various CRC screening-related topics in multiple languages, not just information about CRC and different types of screening methods.The FQHC had a strong organizational culture of teamwork. A team approach is necessary to increase CRC screening since CRC is not a discrete event and involves multiple interfaces with health professionals. Because of the patient-centered mentality, there was a sense of commitment to get patients screened for CRC.This qualitative study aimed to identify barriers and facilitators to implement three EBIs through stakeholders’ experience in an urban FQHC, determine which areas can be improved, and ultimately provide recommendations for a new project, ACCSIS-Chicago. We identified seven themes under barriers and five themes under facilitators. We identified two facilitators (adaptability and relative advantage) and two design quality and packaging barriers under the intervention characteristics. Our interviewees gave us detailed accounts of how the EBIs fit into their workflow and how the frequent assessment and feedback reports motivated them to change their ordering behaviors and improve CRC screening rates at their clinic. The two barriers we identified were related to the design and packaging of the EHR provider reminder. The provider reminder was a new feature added to the EHR system, and some providers found it frustrating when they could not advance to other features without addressing the prompt. Some providers identified workaround to bypass the prompt; however, such force flexibility may promote burnout , which sPrior research has reported how outer setting characteristics, such as patient needs , externaThe ultimate goal of this study was to identify possible implementation strategies for a new project that can mplement the same EBIs to promote CRC screening in FQHC settings. Table We will tackle the two barriers related to the EHR provider reminder intervention using a teamwork-based approach to reduce the burden of responsibility. The proposed strategies will enhance, not replace, the EHR provider reminder intervention.“Huddles” are a structured daily health care team communication process done face-to-face for a brief duration  and involves a team’s full membership. Huddles provide opportunities for team members to communicate and collectively strategize about managing daily patient demands and workflow, address patients’ unique needs and preferences, and improve the provision of preventive services through previsit planning , 55. TheOne strategy to reduce missed opportunities is standing orders. The CDC has recommended standing orders for adult vaccination since 2000 . StandinMedical assistants can check and confirm the patient’s screening status before the patient visits or during the patient intake, and update the patient’s medical record. They can also follow-up colonoscopy reports and update patients’ medical records accordingly.Goals direct attention and action . In orgaSpecific, challenging goals, in conjunction with appropriate feedback, contribute to higher and better task performance . Feedbac. Although many FQHCs have EHRs, most do not have the capacity to implement EHR generated feedback for clinicians because of the lack of resources and technical support. Although during the study period, the research team provided organized data and feedback, long-term sustainability was lacking. Since measuring and reporting outcome data are essential for health care systems to identify opportunities for improvement [One of the strongest facilitators identified during the interviews was the importance of quarterly provider assessment and feedback reports on motivating behavior changesrovement ; in our rovement .Health education has always been a vital component of patient-centered care. With the influx of diverse patient populations  into the health care system, the lack of time for patient education during routine visits, the dearth of non-English educational materials, and the high rates of poor health literacy all make the provision of this vital service more challenging to accomplish. For the ACCSIS-Chicago project, the study team will conduct an online search to locate all available CRC and CRC screening-related educational materials, including materials in different languages, and screen the education materials for accuracy and health literacy level. We will also work with frontline implementers to identify education material needs other than the basic information on CRC, such as patient decision aids and a graphic FIT test instruction card that does not require English reading skills. Furthermore, we will develop a CRC patient education resource guide with the patient education materials we developed and found online.Our study demonstrates the feasibility of using the CFIR to identify facilitators and barriers across different interventions and capture the dynamics of the implementation context while using familiar implementation science terminology to promote greater transferability of findings. This study also provides the necessary evidence for using the CFIR to conduct a formative evaluation to inform future implementation processes. Furthermore, double-coding transcripts provided a rigorous and consistent application of the CFIR codes. However, the use of template analysis and the application of the CFIR domains and constructs as a coding template might have restricted the identification of non-CFIR-related themes critical to the implementation. Also, interviewees’ recall bias may limit findings since implementing the three EBIs began 2 years prior. Our results represent the experiences of one urban FQHC; therefore, themes identified here may not be transferable to other FQHCs, especially FQHCs operating in rural settings.The CFIR comprises five domains and 39 constructs and provides a pragmatic structure to guide formative evaluations and build the implementation knowledge base. Researchers can use the CFIR before, during, and after implementation to identify potential barriers and facilitators from individuals involved in the implementation process. In this study, we conducted a post-implementation formative evaluation using the CFIR to explore what factors influenced the implementation of three EBIs in an urban FQHC. The CFIR, with its clear terminology, allowed us to identify barriers and facilitators to inform future research and provided a template to organize research data and synthesize findings, as demonstrated in this study. Thus, the CFIR has the potential to promote knowledge-building for implementation.In this study, we identified seven barriers that might hinder the implementation and effectiveness of our EBIs. Our findings were consistent with constructs illustrated in CFIR, supporting its use as a guiding framework. These barriers are common in safety-net settings, such as FQHCs, where daily challenges include diverse patient populations, lack of resources, and competing demands. Provider recommendation is a significant predictor for patient adherence with CRC screening –66. Howe


Respiratory morbidity is common in children with neuromuscular diseases (NMD) owing to chronic hypoventilation and impaired cough. Optimal, cost-effective respiratory management requires implementation of clinical practice guidelines and a coordinated multidisciplinary team approach.To explore South African physiotherapists’ knowledge, perception and implementation of respiratory clinical practice guidelines for non-ventilated children with NMD.N= 481).An online survey was conducted amongst members of the South African Society of Physiotherapy’s Cardiopulmonary Rehabilitation (CPRG) and Paediatric special interest groups and purposive sampling of non-member South African physiotherapists with respiratory paediatrics expertise (Most respondents worked in private healthcare, with 1–10 years’ experience treating patients with NMD. For acute and chronic management, most participants recommended nebulisation and 24-h postural management for general respiratory care. Percussions, vibrations, positioning, adapted postural drainage, breathing exercises and manually assisted cough were favoured as airway clearance techniques. In addition, participants supported non-invasive ventilation, oscillatory devices and respiratory muscle training for chronic management.Respondents seemed aware of internationally-endorsed NMD clinical practice guidelines and recommendations, but traditional manual airway clearance techniques were favoured. This survey provided novel insight into the knowledge, perspectives and implementation of NMD clinical practice guidelines amongst South African physiotherapists.There is an urgent need to increase the abilities of South African physiotherapists who manage children with NMD, as well as the establishment of specialised centres with the relevant equipment, ventilatory support and expertise in order to provide safe, cost-effective and individualised patient care. Respondents without either academic, research or clinical expertise in the respiratory management of children with NMD were excluded from our study.n = 5), prior to online distribution. The pilot study aimed to determine the approximate time for completion and whether questions were clear and unambiguous.The self-constructed questionnaire was based on existing clinical practice guidelines and clinical expertise .Vocational background and clinical experience (in the field of NMD) of the participant.Evidence-based respiratory management strategies were recommended for children with NMD in an acute setting , based on a case scenario:Patient X has been diagnosed with a NMD and is older than five years of age and has recently become wheelchair-bound (non-ambulant). He has been admitted to hospital because of a respiratory infection and is presenting with a weak cough. He is haemodynamically stable, but oxygen saturation is 91%, and he is retaining secretions because of an ineffective cough.The four subdivisions of Section B included questions relating to general respiratory care (including ventilatory support), peripheral ACT (secretion mobilisation), proximal ACT (cough augmentation) as well as other physiotherapy and general management strategies related to children with NMD during acute care.Evidence-based respiratory management strategies were recommended for children with NMD in a chronic setting (home or school), based on a case scenario:Patient Y has been diagnosed with a NMD and is older than five years of age. He recently became wheelchair-bound (non-ambulant) and attends follow-up visits at the neuro clinic every 3–6 months, depending on the need. Currently his vital capacity is < 80% predicted value for his age and he presents with a weak cough.The four subdivisions of Section C enquired about ventilatory support, peripheral ACT and proximal ACT, LVR techniques (such as breath-stacking), breathing exercises, respiratory muscle training as well as other physiotherapy and general management strategies related to children with NMD during chronic management.Respiratory management strategies used by South African physiotherapists in the acute and chronic settings, 6 months prior to the survey.https://www.surveymonkey.com/r/8RF3F5J) was distributed electronically to 469 SASP members and six other physiotherapists with experience in NMD. Together with the pilot study participants, 481 eligible participants were requested to participate in the survey , Statistical Package for the Social Sciences (version 23) and STATISTICA® .Data were entered into Excel spreadsheets, therafter the completed survey data (including pilot study responses) were exported to statistical programmes for a combined analysis STATA® , the relevant parametric or non-parametric statistical tests were applied. Chi-square (χ2) tests and/or Yates χ2 tests (depending on the frequencies/responses per cell) were applied to determine the association between vocational background, physiotherapists’ years of experience and respiratory management techniques recommended. Statistical significance was accepted as p < 0.05.Depending on the normality of continuous data  and the SASP Executive Committee (president), as well as the chairpersons of CPRG and Paediatric Special Interest Group granted permission to distribute the questionnaire to their members. Informed consent was obtained from participants by including study information and a confirming consent statement on the opening page of the Survey Monkey questionnaire.N = 481). Minimal changes were made to the questionnaire following the pilot study and therefore these responses (n = 5) were included in the final analysis.A flow chart of survey responses is presented in The total number of recruited participants consisted of 74 physiotherapists who responded to the online survey, as well as five out of the six pilot study participants with a response rate of 16.4% (79/481).64 responses was included in the final analysis, which constitutes a response rate of 13.3% (64/481). The number of responses, however, diminished with every section of the questionnaire  and 10 reported that they had not previously worked with children with NMD or had no experience in the field. These 15 participants were therefore excluded from the original 79 responses. The final sample of ionnaire .n = 37) as compared to approximately 42% (n = 27) working in the public healthcare sector including hospitals , special schools, rehabilitation centres or clinics and universities.Questions on vocational background (area of work) allowed for more than one option to be chosen. The majority of the 64 participants worked in the private sector which included out-patients and hospital wards   reported 1–5 years of experience working with NMD, and two-third of respondents  indicated between 1 and 10 years of experience in this field.Most participants . Participants working in public healthcare were more in favour of the use of breath-stacking during chronic management (n = 8/12) than those from the private sector (n = 3/16).No statistically significant association was found between years of experience in NMD and clinical practice trends such as ventilatory support, oxygen supplementation, ACT and respiratory muscle training. The use of LVR (breath-stacking) during chronic management of children with NMD, however, showed a significant association with the place of work   completed Section B on acute management  recommended alternative cough augmentation techniques such as MI-E, and 22 participants indicated that they were unsure of the use of these devices.Only a minority of participants , breathing exercises  as well as caregiver education and/or support.n = 28) for chronic management are depicted in The responses  Striped, . SlightyRegarding the use of lung compliance (LVR), breathing exercises and respiratory muscle training , percussions, the use of nebulised normal saline for secretion mobilisation, suctioning only if needed and the use of MI-E using both manual and automatic settings. Furthermore, general recommendations for chronic management in NMD included pharmacological intervention, nutrition and hygiene as well as including exercise or games or play therapy in the patients’ home programme to improve their respiratory function.A summary of the favoured respiratory management treatment strategies, for both acute and chronic management, is provided in Six (10%) participants responded to this section, as they treated children with NMD on a regular basis and had used respiratory management strategies in this patient cohort within 6 months prior to the survey.n = 6) used adapted PD, positioning and breathing exercises during both acute and chronic management of children with NMD. In addition, all participants (n = 6) used vibrations during acute care and most physiotherapists (n = 5) used percussions for acute and chronic management and respiratory muscle training during chronic care.All respondents . Selection bias might, therefore, be present, with inadequate representation of physiotherapists working in the South African public healthcare sector. For this reason, future surveys should be conducted via more inclusive platforms such as the HPCSA.All practicing South African physiotherapists are obligated to register with the Health Professionals Council of South Africa (HPCSA), whilst membership of other professional bodies such as the SASP is voluntary and requires additional annual membership fees. Of the South African physiotherapists registered with the HPCSA, approximately 54% are members of the SASP, most of whom work in private healthcare (Fourie p = 0.03) between place of work and recommended respiratory management strategies. Participants working in public healthcare seemed more inclined to use breath-stacking techniques (LVR) for chronic management in children with NMD than those in the private healthcare sector. The reasons for the difference between the healthcare sectors are unknown and should be interpreted with caution because of the small sample size, and therefore, this warrants further research. A recent South African based study, however, indicated that the barriers and facilitators to the implementation of clinical practice guidelines amongst physiotherapists seem to be similar, regardless of geographical location or work context   indicated 1–10 years of NMD experience, but we were unable to show an association between years of experience and clinical practice trends. There was one statistically significant association (n = 6) might not be a true reflection of the physiotherapy management strategies used in SA, but could allude to the fact that few physiotherapists are involved in the management of children with NMD.The low response rate (13.3%) limits the generalisability of the survey results, however, the response rate was similar to another survey conducted amongst SASP special interest groups and higher than other online surveys conducted amongst physiotherapists  and especially chronic management (16/27)  , which could warrant the use of supplemental oxygen. However, hypoxaemia in children with NMD is usually caused by hypoventilation, mucus plugging, atelectasis and/or a respiratory tract infection. Supplemental oxygen should then rather be combined with ventilatory support such as NIV and cough augmentation  in order to address the underlying cause(s) of the desaturation  reported a preference for more conventional peripheral ACT such as adapted PD, positioning and breathing exercises during acute and chronic management. The majority also used percussions, vibrations and EMT. Although these ACT might have clinical merit and are supported by clinical practice guidelines, they do have limitations and precautionary measures should be considered. Breathing exercises, incentive spirometry and PEP might not be as effective in patients with NMD because of their underlying respiratory muscle weakness, unless concomitant ventilatory support is also provided , which aligns with clinical practice guidelines  and chronic (n = 4) scenario, respectively, despite NMD clinical practice guideline recommendations and the progressed respiratory disease of the patients outlined in the case scenarios. Only two participants responded to questions related to MI-E settings for acute and chronic management, and therefore results may not be a true reflection of knowledge or opinion of most physiotherapists in SA.On the contrary, MI-E devices are recommended and used in many developed, high-income countries as an alternative cough augmentation method to curb respiratory deterioration  or mechanically (with a ventilator or cough assist device) and is recommended in patients with NMD. The benefits of LVR include secretion mobilisation, improved ventilation, cough ability and maintaining lung and chest compliance with the aim of decreasing pulmonary function regression and preventing respiratory morbidity (Castrillo et al. Besides these advantages, half the survey participants were unsure about the use of LVR during chronic management and only a minority supported the use of cough augmentation techniques such as breath-stacking and GPB (Castrillo et al. The chronic case scenario depicted a non-ambulant patient with progressed disease and a poor cough effort. Possibly because of the clinical presentation, survey participants could have assumed that the patient would present with severe respiratory muscle weakness and possibly decreased oral control. Not all patients are able to perform GPB or spontaneous breath-stacking as these techniques require good oral control and coordination (Farrero et al. In SA, physiotherapists as first-line practitioners play a primary role in the multidisciplinary team responsible for evidence-based respiratory management of children with NMD in order to prevent, delay and/or manage respiratory complications (Birnkrant et al. Specialist care for NMD in SA is limited and there is an urgent need to increase the abilities of South African physiotherapists as well as the establishment of specialised centres with the relevant equipment, ventilatory support and expertise (Birnkrant et al. This survey provided novel insight into the knowledge, perspectives and implementation of NMD clinical practice guidelines amongst South African physiotherapists. Results from this survey can also inform healthcare managers and policymakers, especially in light of the proposed changes to the South African healthcare system, as well as planning for future clinical trials.


One key strategy to swiftly scale-up the testing capacity for severe acute respiratory syndrome coronavirus 2 has been the re-tooling of existing nucleic acid amplification testing platforms toward the control of COVID-19. Nucleic acid amplification testing platforms available from HIV and tuberculosis control programmes offered a unique opportunity given their large footprint across several countries and the availability of in-service training programmes for the operators. At least three COVID-19 molecular diagnostic assays listed under the emergency use authorisations of the United States Food and Drug Administration or the World Health Organization can be used on platforms commonly available within the HIV and tuberculosis programmes – the Abbott m2000 RealTime System, Cepheid’s GeneXpert® system, and the Roche Cobas 6800/8800 system.3The Director-General of the World Health Organization, calling for increased testing, recommended ‘test, test, test’ as a critical step to contain the spread of the disease.4 have we gone a step too far in refocusing most of the laboratory capacity to COVID-19 testing? Mounting evidence suggests that the ‘covidisation’ of the healthcare system and, more specifically, diagnostics poses a risk to maintaining other routine testing services for the control and prevention of endemic diseases like HIV, malaria, syphilis and tuberculosis.5 Additionally, lockdowns imposed in most countries prevent patients from accessing healthcare and this may result in increased treatment failure among those on medication, and increased maternal and child mortality in the context of poorly attended childbirth and reduced antenatal care. Without intervention, there is a risk of reversing many of the gains achieved towards meeting the targets of the Joint United Nations Programme on HIV/AIDS 95:95:95, the End TB Strategy, and the United Nations Sustainable Development Goals, including ending the ‘big three’ diseases – HIV, tuberculosis and malaria. HIV, tuberculosis and malaria programmes have made substantial progress towards achieving global targets due to massive donor funding. However, the Joint United Nations Programme on HIV/AIDS estimates that there could be hundreds of thousands of extra deaths from HIV if routine services, including HIV screening, viral load and early infant diagnosis, are disrupted.6Although COVID-19 testing volumes in most African countries remain below or at the lower threshold required for relaxing the containment measures (10–30 tests per confirmed case),7 Additionally, disruption of maternal and child health services is estimated to contribute to at least 8% more deaths per month.8 A survey of the Global Fund’s supported programmes across 106 countries revealed that at least 85%, 80% and 76% of HIV, tuberculosis and malaria control services, respectively have been disrupted by the COVID-19 pandemic.9 A recent modelling analysis from the STOP TB partnership further illustrated how an additional lockdown period of three months could lead to 6.3 million more cases of tuberculosis globally by 2025, causing a setback of at least five years on the progress achieved thus far.10 More specifically, the survey revealed that at least 20% of HIV and tuberculosis laboratory services are facing high disruption with much of the advanced diagnostic equipment repurposed and the workforce reassigned for COVID-19 testing. A World Health Organization survey of essential services revealed that HIV testing (n = 38) and viral load monitoring (n = 23) were the two most frequently interrupted testing services in the 61 countries that responded.11 It is important to note that laboratory testing is key to identifying disease cases, breaking transmission chains and monitoring patients on treatment.Eighty-five percent of national-level respondents from 61 countries participating in a World Health Organization, United Nations Children’s Fund and Global AIDS Vaccine Initiative poll reported lower vaccination proportions in May 2020 compared to the level in January 2020 – February 2020.In outbreak situations, healthcare stakeholders at the national level must be able to quickly address testing needs and, at the same time, identify the testing threshold needed to ensure that routine testing services are maintained and health targets for the control of essential diseases remain on track. However, data about the overall function of health services are usually fragmented and rarely realtime on the continent. Furthermore, movement restrictions have further hampered the collection of information on the continuation of essential healthcare services, particularly diagnostics.12 conducted an online survey (June 2020) among LabCoP member countries to seek a deeper understanding of the disruptions in HIV and tuberculosis testing services during COVID-19 diagnosis scale-up. The LabCoP is funded by the Bill and Melinda Gates Foundation and is composed of multidisciplinary teams  with strong collaboration with the ministries of health from 14 sub-Saharan African countries.12 Consensus responses to the survey questionnaire were received from the multidisciplinary teams of 10 of the 14 countries. Among those, nine countries reported a decline in viral load testing volumes, eight reported a decline in tuberculosis GeneXpert testing volumes, while seven reported a decline in early infant diagnosis volumes during the COVID-19 response, thereby confirming the Global Fund survey findings.9 In Uganda, one of the few LabCoP participant countries with a publicly available viral load dashboard for testing services, there was a 28% reduction in viral load test volume (from 104 474 to 74 841 tests) between March 2020, when the first COVID-19 case was reported in Uganda, and May 2020.13 The main reason provided by most countries (9 of 10 countries) for the decline in testing volumes was either the inability of patients to visit the health facilities to access HIV and tuberculosis services due to movement restrictions aimed at limiting COVID-19 transmission  or patient fear of contracting the disease while visiting health facilities. Five countries reported stock-outs of testing kits, reagents and laboratory consumables as a result of border closures. Four countries indicated that the surge in COVID-19 testing volumes caused or exacerbated the shortage of healthcare workers, as they were reassigned to support the COVID-19 response , thereby affecting the provision of other essential diagnostics based on polymerase chain reaction technology. Whereas 8 of 10 countries reported re-purposing between 25% to 83% of the total HIV and tuberculosis testing equipment capacity in-country for COVID-19 testing, only two countries identified insufficient molecular testing capacity as a barrier to maintaining HIV and tuberculosis diagnostic services. Two separate analyses indicated that most HIV and tuberculosis instruments are often operated below their full capacity,15 indicating that available instruments in most countries may be sufficient to support both COVID-19 and HIV and/or tuberculosis testing. Moreover, under the impulse of strong HIV and tuberculosis disease control programmes funded by the United States President’s Emergency Plan For AIDS Relief and the Global Fund, the equipment is used almost exclusively for one disease area due to vertical programming, despite the instruments’ multiplexing capability and the recommendation to ‘integrate’ testing.16 Additionally, many of the countries who either repurposed HIV and/or tuberculosis equipment for COVID-19 testing or refocused testing still experience challenges in long turn-around times for results, quality assurance and procurement issues, among others, indicating systemic weaknesses that need attention.The African Society for Laboratory Medicine through the Laboratory Systems Strengthening Community of Practice (LabCoP)17 With more than a decade of large initiatives aimed at laboratory system capacity building in Africa, what are we still missing to ensure that laboratory networks can more effectively forecast and organise laboratory services in both routine and emergency situations?The difficulty in scaling the COVID-19 response while maintaining routine testing services for other essential diseases indicates that many countries are still struggling to achieve a multipurpose, resilient and effective laboratory network to address the needs of clinical and surveillance testing services and meet the prevention and control targets for all essential diseases.18 and LabReady to map, analyse and optimise the laboratory network capacity, functions and services. An inclusive approach that fosters strong collaboration across sectors , as well as an evidence-based decision-making process based on available laboratory data, should be used to inform scale-up of testing for COVID-19 and any emerging disease. Our survey has highlighted that evidence was seldom leveraged to inform scale-up of COVID-19 diagnostic services; only one of three countries that reported the procurement of additional molecular testing equipment to support the surge in COVID-19 testing identified a shortage of testing platforms as the reason for the reduction in HIV/tuberculosis testing, whereas only two of the four countries that reported hiring additional laboratory staff identified insufficient staff capacity as a gap.Through the LabCoP country annual self-assessment reports, we have been able to identify some of the inherent weaknesses in the viral load testing cascade, including laboratory network optimisation and monitoring and evaluation (M&E). Laboratory stakeholders at the central level often do not have a comprehensive overview of available resources and capacities across the network, or how these can be leveraged to strengthen the various functions of the laboratory system; for example, how higher-tier laboratories can organise external quality assessment for those in lower tiers. Further, at the laboratory level, managers and directors often lack the managerial skills and leadership needed to organise and implement comprehensive laboratory management systems that enable laboratories to conduct the tiered functions of the network for multiple diseases; these include knowledge in determining staffing levels, testing capacity, and roles and responsibilities, as well as skills in the use of geographic information system tools like LabMap19 Additionally, the African Society for Laboratory Medicine is convening an M&E sub-community of practice of the LabCoP articulated around the delivery of a fit-for-purpose M&E training and mentoring curriculum with the opportunity for direct technical assistance to LabCoP country teams. The key outcome of this initiative is the development or improvement of national dashboards to monitor and evaluate the implementation and performance of the HIV viral load testing cascade and diagnosis of other diseases, including COVID-19. Additionally, it is anticipated that the multi-country discussion will highlight best practices and identify actual needs that will inform the update of the current guidance document for establishing an M&E framework.20To address some of these gaps, the African Society for Laboratory Medicine is working with various stakeholders, including the Association of Public Health Laboratories, the Clinton Health Access Initiative, the Foundation for Innovative New Diagnostics, the World Health Organization, and the United States Centers for Disease Control and Prevention, among others, to develop a leadership and mentorship programme focused on leading and managing tiered laboratory networks to offer clinical care and public health services during routine and emergency situations. A guidance document for scaling up COVID-19 diagnosis within the laboratory network while maintaining essential testing has been developed.The difficulty of scaling up COVID-19 diagnostics while maintaining routine testing of HIV, tuberculosis and other essential diseases relates to pre-existing laboratory systemic weaknesses. Solutions to durably tackle the gaps crippling diagnostic services include better knowledge, management and optimisation of national tiered networks to become more resilient in the face of health emergencies. Attaining skills in the management of laboratory networks and strengthening of M&E systems in-country will contribute to better and faster identification of strengths and bottlenecks and mutualisation of existing resources across the laboratory network for routine and emergency testing needs. Additionally, robust political commitment and sufficient provision of domestic funding are needed to ensure that all local health needs are adequately covered and are not compromised when addressing global priorities.


Globally, the greatest number of older people with HIV (OPWH) are in sub-Saharan Africa (3.7 million). This population will continue to expand with greater access to anti-retroviral therapy. Compared to OPWH in high income counties, these OPWH have constrained access to government and community-based services and largely rely on assistance from family, friends, and neighbors for their social support needs. We examined factors related to perceptions of instrumental and emotional support sufficiency (availability and adequacy) among OPWH age 50 and older in Uganda (n = 101) and South Africa (n = 108). Significant covariates of instrumental support sufficiency included not having an AIDS diagnosis, greater support from family, and less support from friends. Significant covariates of emotional support sufficiency were fewer depressive symptoms, greater support from family, and geographic location (Uganda). Explanation of these findings based on social network characteristics and implications for policy and program development will be discussed.


Our optimized classifier achieved statistically significant higher area under the receiver operator curve (AUC of ROC), accuracy, sensitivity, and specificity than those of SVM using CRIE 3.0 features and SVM using linguistic features of Gunning Fog Index and Automated Readability Index (ARI). The statistically improved performance of our optimized classifier compared to that of SVM classifiers adapted from popular readability formula suggests that evaluation of health communication effectiveness as defined by the principles of the WHO is more complex than information readability assessment. Our SVM classifier validated on health information covering diverse topics  can aid effectively in the automatic assessment of original, translated Chinese public health information of whether they satisfy or not the current international standard of effective health communication as set by the WHO. Effective multilingual communication of authoritative health information plays an important role in helping to reduce health disparities and inequalities in developed and developing countries. Health information communication from the World Health Organization is governed by key principles including health information relevance, credibility, understandability, actionability, accessibility. Multilingual health information developed under these principles provide valuable benchmarks to assess the quality of health resources developed by local health authorities. In this paper, we developed machine learning classifiers for health professionals with or without Chinese proficiency to assess public-oriented health information in Chinese based on the definition of effective health communication by the WHO. We compared our optimized classifier (SVM Effective multilingual communication of authoritative health information plays an important role in helping to reduce health disparities, inequalities in developed and developing countries. Currently, the evaluation of the quality of public-oriented health information focused on readability assessment ,4,5,6,7.More recently, The World Health Organization developed The Strategic Framework for Effective Communications ,11,12. TWithin the WHO Strategic Framework, understandability was assessed in terms of use of plain, familiar language; actionability was associated with the use of messages that are simple, easy to recall, repeated and attention getting; messages that can facilitate the understanding of health risks, specify the steps needed to protect people’s health; messages that help people to implement protective measures by describing the desired action and explaining where to find information and resources that support implementation. Information creditability mandates that fact sheets are updated to ensure technical accuracy and that readers can identify whether they are at risk, understand the scale of the problem, learn ways they can protect their health and safety, recognize the barriers to improvement, recognize the barriers to improvement. Transparency is part of information credibility, particularly for scenarios of high uncertainty. To ensure information credibility, public health information needs to clarify what information is known and what is not known; emphasize that interim public health recommendations could change as new information becomes available, and let audiences know about the limitations of the conclusions from preliminary research findings. Information relevance requires the tailoring of health messages to make the content relevant to the specific audience; address the barriers people may face when trying to take recommended action. This is to engage the target audience, communicate risks effectively, and achieve the desired single overarching communications outcome (SOCO). Lastly, timeliness requires that under public health emergencies, quick release of health information should include symptoms, severity of the threat, where the threat is located or spreading, who is at risk, how people can protect themselves, what is being done to contain the threat, and how to get answers for questions. The general principles and implementation strategies for these principle in the WHO Strategic Framework for Effective Communications lay the foundation for more integrated assessment of online public-oriented health contents. However, without detailed guidelines and quantitative tools, the use of the Framework in practical health information assessment remains a real challenge, especially for languages which lack in standardized readability assessment tools even for basic understandability check. Chinese is one of the two non-European languages (with Arabic) among the six official languages of the WHO . Despite an increasing interest in quantitative readability assessment of Chinese educational materials, currently there is no internationally validated Chinese readability tools. As a result, the evaluation of the quality of health information in Chinese remains largely understudied nor benchmarked against international health promotion resources in the same language. At the WHO, translations serve as an important channel for the dissemination of public health information. To control for the variability of translated contents, translation professionals at the WHO use enhanced translation strategies (forward and backward translation) to produce multilingual contents of original English health materials ,14. In ohttps://scikit-learn.org/stable/modules/generated/sklearn.svm.SVC.html) (accessed on 1 June 2021) [In our study, we collected and used these materials which have been developed to reflect the principles of effective health communication by WHO health professionals and then thoroughly translated to other official languages including Chinese as training materials to develop machine learning classifiers. The main function of these classifiers was to aid in the automatic evaluation of the communicative effectiveness of health information in Chinese from non-WHO sources, mainly health authorities and health research institutes in China. We trained and validated the classifier on WHO and non-WHO exiting Chinese health materials on a range of diverse health topics including environmental and occupational health, infectious diseases, pregnancy and maternity care, non-communicable disease, tobacco control to ensure its wide applicability. To validate our classifier, we further compared the performance of our classifier with that of the state-of-the-art Chinese readability classifier using Support Vector Machine  ,16 and CA comparable corpus was constructed which contained a large number of health texts of WHO and China health information from credible, authoritative Chinese sources such as national and local research centers, and not-for-profit organizations of health promotion in China . These CCurrently, the assessment of the quality of health resources for readers is based on established readability tools and formula including Flesch Reading Ease Score , GunningIn our study of developing machine learning classifiers to diagnose and predict the overall communicative effectiveness of Chinese health resources using existing WHO Chinese information as benchmarks, we used the latest version of the Chinese Readability Index Explorer (version 3.0). p < 0.001); difficult words , middle-stroke characters , average strokes per character , number of sentences , number of content words , sentences with complex semantic categories , density of content words , number of 3-character words , number of words , and number of characters . The means of 5 linguistic features in WHO Chinese resources were statistically higher than those of non-WHO Chinese resources: average words per sentences , number of single sentences , number of positive conjunctions , ratio of noun phrases , number of paragraphs . The means of the remaining linguistic features in the two sets of Chinese health texts were insignificant with p larger than 0.05. These findings suggest that non-WHO original Chinese health resources were more complex orthographically, lexically, and syntactically and information was presented in larger chunks of paragraphs. By contrast, WHO Chinese resources developed under the principles of information accessibility, actionability, understandability and relevance were statistically less complex in terms of use of difficult words, the average number of strokes (similar to English letters) per Chinese character (similar to English words), the use of sentences containing semantically complex expressions such as polysemous words which are likely to cause confusion or conceptual mistakes. The statistically higher means of 3-character words , and higher ratios of content words in non-WHO original Chinese materials suggests higher cognitive loads of original Chinese public health materials. By contrast, the results demonstrated that WHO Chinese health materials were logically more coherent (use of positive conjunctions). The potential barrier to understand WHO materials was the statistically higher ratios of noun phrases, which could be explained partly by the impact of the original English materials on the Chinese translations, and partly by the specialised genre of medical and health materials. The mean of almost 55% (16) of the total linguistic features were statistically different. The means of 11 linguistic features in non-WHO Chinese health resources were significantly higher that of WHO Chinese health resources: average sentences per paragraph , the effect sizes (Hedges’ g) of eight features were larger than 0.5 as medium effect sizes. Larger Hedges’ g and CLES were indicators of the discrimination effectiveness of the features to separate between WHO and non-WHO Chinese materials. Comparison of effect sizes helped us to further reduce the number of features to be used in training machine learning classifier, i.e., SVM with linear kernel. p values (<0.05) and medium to large effect size : density of content words, average sentences per paragraph, Sentences with complex semantic categories (polysemeous words), average words per sentences, difficult words, single sentences, middle-stroke characters, average strokes per character. After the examination of the effect sizes of linguistic features, we continued with feature optimisation using conditional stepwise logistic regression (software SPSS version 26). The final model selected five features, as they contributed significantly to the model and three linguistic features were eliminated for being statistically insignificant . The seqp values and effect size Hedges’ g), and forward stepwise regression modelling, we optimized the feature set by reducing the original 29 features , SVM_GFI (p = 0.0015) and SVM_ARI (p = 0.0020); SMV_5 had statistically higher sensitivity than SVM_29 (p = 0.0038), SVM_GFI (p = 0.0031) and SVM_ARI (p = 0.0032); and SVM_5 was statistically improved in specificity when compared to SVM_29 (p = 0.0030), SVM_GFI (p = 0.0009) and SVM_ARI (p = 0.0014). The state-of-the-art machine learning classifiers for Chinese written materials is the Chinese Readability Index Explorer (CRIE) which has been developed, tested in the classification of Chinese language educational materials. Recent studies by Sung, et al. ,24 develOur optimized SVM classifier contained only five linguistic features to effectively separate WHO Chinese health resources of higher communicative effectiveness as defined by the Strategic Framework of Effective Communication, and non-WHO Chinese health materials for public communication purposes. The five features model highlighted the key dimensions which distinguished Chinese health information of WHO defined communicative effectiveness from those not: orthographic complexity (average strokes per character); information load , and cognitive load (density of content words). The exclusion of linguistic features which had large effect sizes such as number of difficult words, sentences with complex semantic categories from the optimized SVM model suggests that machine learning differs from statistical modelling, as features which had statistically different distributions in the outcome datasets might not be best discriminating features for machine learning. The result of the comparison between our optimized SVM classifier with the unoptimized classifier using the CRIE 3.0 features shows that the performance of our model improved on the testing data in terms of model AUC, overall classification accuracy, sensitivity to detect Chinese health texts not aligning with WHO defined communicative effectiveness, as well as specificity to diagnose Chinese health texts matching the WHO defined communicative effectiveness, thus suitable for the Chinese-speaking readership globally. We could not directly assess the actual readability levels of WHO and non-WHO Chinese health materials due to lack of internationally validated readability formula for Chinese. We adapted English readability formula Gunning Fog Readability Index and Automated Readability Index to linear SVM classifiers to further validate our optimized classification model. The results again attested to the efficiency and high performance of our model, with statistically much higher accuracy, sensitivity, and specificity for clinical use. In sum, the result shows that our new classifier achieved statistically higher accuracy, sensitivity, and specificity compared to the state-of-the-art machine learning models for classification of Chinese primary, secondary educational materials, as well as linear kernel classifiers adapted from well-established readability formula: Gunning Fog Readability Index, and Automated Readability Index (ARI). Our classifier provided a needed quantitative tool for assessing and predicting the membership of a certain Chinese health text in terms of its communicative effectiveness, that is, whether it aligns with the current level of communicative effectiveness of existing WHO public-oriented health in-formation in Chinese. Improving the communicative effectiveness of multilingual health resources can help reduce the increasing health inequalities and disparities among multilingual, multicultural communities. Despite that readability has a long history in English health resource quality evaluation, the quantitative evaluation of health resources is understudied in languages using distinct writing systems like Chinese. Furthermore, the complexity of effective health communication based on health research insights has now gone beyond readability and understandability. The WHO Strategic Framework for Effective Communications stipulates new principles such as information accessibility, actionability, relevance, credibility, timeliness. Developing separate quantitative instruments to measure these dimensions could be challenging, and theoretically misleading, as specific implementation strategies and methods may well overlap among these large principles. Developing new research instruments like machine learning algorithms can help national and global health professionals to assess the quality of multilingual public health resources in a more integrated, adaptive fashion with significantly improved accuracy, precision, and reliability ,28, as tWe hope to provide international health professionals engaged in multilingual health communication, with or without Chinese proficiency, with much-needed decision aids to assess whether a certain health promotion text in Chinese is suitable for general Chinese-speaking readers, using existing WHO Chinese materials developed under its Strategic Framework for Effective Communications as the international benchmarks of multilingual health communication effectiveness.The simple, easy-to-interpret nature of our tool can be effectively adapted to other languages, especially languages spoken by communities for whom high-quality health information is urgently needed to help reduce increasing health inequalities caused by persistent lack of quality health information and lack to healthcare services.We would like to acknowledge the limitations of our study. The definition of the WHO principles of effective health communications is qualitative and currently very general. Important differences, diversity do exist among populations, communities, and individuals in terms of education, native language and English proficiency, health literacy, socio-economic status, cognitive ability, mental and physical health, cultures, and other limiting factors. To improve the adaptability, precision of quantitative and computational tools to assess the suitability of health materials, there is a need to develop guidelines and evaluation criteria which capture the practical, diverse needs from diverse people and communities. With better targeted evaluation guidelines from health authorities and high-quality materials in English and their translations to other languages, we could improve the computational models to better support evidence-based health information assessment.