Objective: To provide recommendations for preferred models of follow-up care for stage I-IV colorectal (CRC) cancer survivors in Ontario; to identify signs and symptoms of potential recurrence and when to investigate; and to evaluate patient information and support needs during the post-treatment survivorship period. Methods: Consistent with the Program in Evidence-Based Medicine’s standardized approach, MEDLINE, EMBASE, PubMed, Cochrane Library, and PROSPERO databases were systematically searched. The authors drafted recommendations and revised them based on the comments from internal and external reviewers. Results: Four guidelines, three systematic reviews, three randomized controlled trials, and three cohort studies provided evidence to develop recommendations. Conclusions: Colorectal cancer follow-up care is complex and requires multidisciplinary, coordinated care delivered by the cancer specialist, primary care provider, and allied health professionals. While there is limited evidence to support a shared care model for follow-up, this approach is deemed to be best suited to meet patient needs; however, the roles and responsibilities of care providers need to be clearly defined, and patients need to know when and how to contact them. Although there is insufficient evidence to recommend any individual or combination of signs or symptoms as strong predictor(s) of recurrence, patients should be educated about these and know which care provider to contact if they develop any new or concerning symptoms. Psychosocial support and empathetic, effective, and coordinated communication are most valued by patients for their post-treatment follow-up care. Continuing professional education should emphasize the importance of communication skills and coordination of communication between the patient, family, and healthcare providers. Approximately 26,900 Canadians are diagnosed with colorectal cancer in a single year (Canadian Cancer Society) . With adThe five-year recurrence rate for patients having had curative surgery for CRC is between 20–30% ) worked with Ontario stakeholders to develop an evidence-based guideline using the methodologies of the Practice Guidelines Development Cycle ,6 and thAre there optimal models of follow-up care for persons who have completed treatment for CRC What are the signs and/or symptoms that may signify a potential recurrence of CRC and therefore warrant more investigation?What are patients’ post-treatment informational and support needs regarding their risk of recurrence and common long-term and late effects of CRC?Intended users of this guideline include clinicians ) involved in the delivery of care for colorectal cancer survivors. As well, this guideline could be utilized by healthcare organizations and system leaders responsible for offering, monitoring, or providing resources for colorectal cancer survivorship protocols.First, a search for evidence guidelines and then a search for systematic reviews and primary literature was conducted. Being that this guideline is an update, the search date was based on the previous guideline’s dates, and the search terms were similar to the original guideline. On 8 March 2019, the search terms ‘colorectal cancer’, ‘follow-up’, ‘surveillance’, and ‘survivors’ were used to search for guidelines in the following sources: American Society of Clinical Oncology, Canadian Medical Association Journal Infobase, and National Institute for Health and Care Excellence Evidence Search, National Health and Medical Research Council–Australia Clinical Practice Guidelines Portal, and Cancer Council Australia–Cancer Guidelines Wiki. Evidence-based guidelines with systematic reviews that addressed at least one research question were included and if the guideline had a score of 5/7 or above on the rigor of development section of the AGREE II [Since no guidelines were deemed fully endorsable, a search was conducted for existing systematic reviews on 1 May 2019, and for primary literature on 5 June 2019. The databases searched were OVID MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for the years 2011 to 2019  if uncertainty existed. All reviews and primary studies that met the inclusion criteria underwent data extraction by CZ, with all extracted data and information audited subsequently by an independent auditor (FM). Assessment of systematic reviews was completed using the Risk of Bias in Systematic Reviews (ROBIS) tool ; RCTs viThe internal review included an evaluation of the guideline by the Guideline Development Group Expert Panel and the PEBC Report Approval Panel. A Patient Consultation Group, consisting of patients, caregivers, or family members reviewed the recommendations and provided feedback on their comprehensibility, appropriateness, and feasibility. Then, external feedback was obtained from content experts and target users. First, a targeted peer review where individuals with content expertise identified by the Guideline Development Group were asked to review and provide feedback to the guideline document. Second, relevant care providers and other potential users of the guideline provided feedback on the guideline recommendations via an online survey. The results of the incorporation of this process into the final guideline are described in In total, 22 guidelines were found. Of those, 17 did not meet the inclusion criteria leaving four guidelines relevant to the research questions. In the searches for systematic reviews and primary studies, 3830 articles were retrieved, of which 388 were included in the full-text review. There were 25 systematic reviews considered for full-text review and three met the inclusion criteria and were relevant to the scope of the guideline. There were 388 primary studies that underwent full-text review, seven of which were retained. See The Report Approval Panel members and Guideline Development Group Expert Panel approved the document outlining the results described from processes of n = 182), thirteen responses (7.1%) were received. Comments included a need for additional clarification and concision regarding the recommendations. Final guidelines recommendations reflect the integration of feedback obtained through both internal and external review processes.Five targeted peer reviewers from Ontario, British Columbia and New York state reviewed the document. Comments included additional clarity regarding the surveillance of individual patients. Of the online survey sent to intended users of the guideline  follow-up guideline, the Cancer Care Australia guideline, one RCT, and one retrospective study ,13,21,22The Cancer Care Australia guideline reported that for symptomatic patients, the symptoms will depend on local versus distant recurrence . Local rn = 110 patients), Augested et al. (2013) found that 14 patients had cancer recurrence, seven of whom had symptoms [In an RCT comparing surgeon versus family practitioner follow-up  of recurrence, patients should be educated about these and know which care provider to contact if they develop any new or concerning symptoms. Psychosocial support and empathetic, effective, and coordinated communication are most valued by patients for their post-treatment follow-up care. Continuing professional education should emphasize the importance of communication skills and coordination of communication between the patient, family, and healthcare providers.


Social connection is recognized as an important determinant of health and well-being. The negative health impacts of poor social connection have been reported in research in older adults, however, less is known about the health impacts for those living in long-term care (LTC) homes. This review seeks to identify and summarize existing research to address the question: what is known from the literature about the association between social connection and physical health outcomes for people living in LTC homes?A scoping review guided by the Arksey & O’Malley framework was conducted. Articles were included if they examined the association between social connection and a physical health outcome in a population of LTC residents.n = 14; 41%) and social support . A range of physical health outcomes were assessed, including mortality, self-rated health, sleep, fatigue, nutrition, hydration, stress, frailty and others. Findings generally support the positive impact of social connection for physical health among LTC residents. However, most of the studies were cross-sectional  and, of the eleven cohort studies, most  assessed mortality as the outcome. 47% (n = 16) were published from 2015 onwards.Thirty-four studies were included in this review. The most commonly studied aspects of social connection were social engagement (Research has reported positive associations between social connection and a range of physical health outcomes among LTC residents. These findings suggest an important role for social connection in promoting physical health. However, further research is needed to consider the influence of different aspects of social connection over time and in different populations within LTC homes as well as the mechanisms underlying the relationship with health.The online version contains supplementary material available at 10.1186/s12877-021-02638-4. Social connection  is recognized as a key determinant of health and well-being , 2. SystSocial isolation and loneliness are widespread in LTC homes , 12, howTo our knowledge, there are no published reviews on the association between social connection and physical health among LTC home residents. To address this gap, the objective of this scoping review is to identify and summarize the existing research to address the question: what is known from the literature about the association between social connection and physical health outcomes for people living in LTC homes? We chose scoping review methodology to answer a broad research question by assessing published literature in which we anticipated a heterogeneous list of exposures and health outcomes, then to identify and report knowledge gaps –23.This scoping review is a sub-analysis of a larger scoping review, initiated prior to the COVID-19 pandemic, to address a broad set of research questions on social connection among LTC home residents. A protocol for the larger scoping review has been published , and is The review followed the six-stage scoping review framework as developed by Arksey & O’Malley  and LevaA literature search was conducted to identify relevant published journal articles that reported a quantitative measure of social connection among residents of LTC homes. Inclusion criteria specified settings described as LTC homes, nursing homes, or care homes. These terms were selected to reflect terminology differences between countries but also to reflect overlap and international consensus on the definition of nursing home . In thissocial networks, the size and nature of the social network structure as well as characteristics of the social ties, and acknowledge that these networks provide opportunities for social support and social engagement [social engagement, taking part in real-life activities with others [social disengagement [; social support, instrumental, emotional, appraisal, and informational help available [social isolation, a lack of personal relationships [social capital, the features of relationships that facilitate mutual benefits, such as interpersonal trust, reciprocity, and mutual aid [loneliness [social connectedness [perceived isolation [The following concepts were included as aspects of social connection:  social ngagement ; social h others , 28 as wgagement ; social vailable  and sociionships ; social tual aid . The subneliness , social ctedness , and persolation  were alsFor the current scoping review sub-analysis, studies reporting physical health outcomes were eligible for inclusion if they quantified any phenomenon that impacts the bodies’ function, form, or structure , includiwww.covidence.org) and Endnote were used for the review process and deduplication of database results [The original search strategy was conducted by an information specialist who searched in MEDLINE(R) ALL  Daily) and then translated into CINAHL (EBSCO), APA PsycINFO (Ovid), Scopus, Sociological Abstracts (Proquest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid) and AgeLine (EBSCO). Initial searches were conducted from the databases’ inception through to the date the search was executed July 2019) and limited to the English language. The search strategies were updated with additions to acknowledge changes in the MeSH  indexing terms and the searches were executed again in January 2021 , objective, study design, setting , sample , measure of social connection, physical health outcome and a summary of study findings linking social connection and physical health outcomes.Study characteristics were summarized with descriptive statistics, as well as a narrative synthesis. For the narrative synthesis, we took a descriptive-analytical approach . The stuThe initial protocol  describeAs part of the larger scoping review , the sean = 23; 68%) of the studies were published in or after 2010 and just under half  published in 2015 or later. The largest proportion of studies were from North America , mostly the United States . Just under two-thirds  of the studies were cross-sectional and most of the remainder were cohort studies . Among the eleven cohort studies, the majority  assessed mortality as the outcome. Most of the studies described the setting as nursing homes . The number of homes included in the studies ranged from 1 to 653, with a median of 6. The number of LTC residents included in the studies ranged from 40 to 30,055, with a median of 503.5. Mean resident age ranged from 68 to 87, with a median of 83.3. The proportion of females included in the studies ranged from 0 to 87% with a median of 71%.Characteristics of included studies are described in Additional file The most common aspects of social connection assessed were social engagement, social support, and loneliness  were associated with reduced risk of mortality –46. The Six studies assessed the association between social connection and self-rated health. One study found that loneliness was associated with poor health among women but not men . AnotherFive studies assessed the association between social connection and sleep and fatigue. Two studies reported social support was inversely associated with sleep problems , 55 wherFive studies assessed the association between social connection and nutrition and hydration. Results from the studies varied. One study found the association between loneliness and risk of malnutrition or being malnourished was no longer statistically significant after adjusting for appetite, eating difficulties due to oral health problems, symptoms of depression and functional status . SimilarTwo studies assessed the association between social support and stress; in the first, social support was associated with acute (but not chronic) stress  and, in Two studies assessed the association between loneliness and frailty; one study reported loneliness was associated with frailty  and anotSix studies assessed a range of other physical health outcomes. An ecological study found an association between social engagement and reduced MRSA transmission . AnotherThis scoping review of published research identified 34 studies that assessed the association between social connection and physical health in LTC residents. The studies reported a range of physical health outcomes, most commonly mortality, self-rated health, sleep, fatigue, nutrition, hydration, stress, and frailty. While the association between social and physical health has been studied for decades , researcn = 21; 62%) the studies were cross-sectional, making temporal relationships impossible to determine for some outcomes; while it is possible that social connection impacts health, the impact of some of these same measures of health status  on socig., pain  and behag., pain , 9 underg., pain , suggestg., pain , 77, butg., pain  or addreg., pain  – has beg., pain –49, 59, While we acknowledge the policy and clinical practice implications from this scoping review are limited , our stuTo our knowledge, this is the first scoping review of research assessing the association between social connection and physical health specifically among LTC residents. We have highlighted knowledge gaps and identified opportunities for future research, however, the results must be interpreted in context with limitations. First, this is a scoping review , 23, 25 This study identified and summarized published research testing the association between social connection and physical health for people living in LTC homes. While a diverse range of outcomes were assessed, findings generally supported the positive association between social connection and physical health. Still, further research is needed to consider the influence of social connection on health trajectories, compare populations within LTC homes, integrate multiple aspects of social connection, and assess the distinct mechanisms through which these aspects of social connection might influence health in this population.Additional file 1. Search Strategy.Additional file 2. Study Characteristics.


This study examined whether the effects of received and provided social support on blood pressure (BP) would differ by education. Data from 602 African American adults (48-95 years) enrolled in the Baltimore Study of Black Aging—Patterns of Cognitive Aging were analyzed using multiple linear regression. We found no main effects of received and provided social support on BP. However, a significant moderation effect was observed for systolic BP, such that greater received social support was positively associated with higher systolic BP among individuals with low levels of education, adjusting for age, sex, chronic health conditions, and depressive symptoms. The findings demonstrate that social support and education have joint effects on blood pressure, which highlights the importance of considering psychosocial determinants of adverse cardiovascular health outcomes that disproportionately affect African Americans.


Anopheles Gambiae and Anopheles Funestus, the two principal malaria vectors in the countries visited, 2) achieving an identification accuracy of ≥90% to the complex level, and 3) accessibility to the speciation data 3-7 days following vector collection. Next steps include optimizing the tool to deploy a minimal viable product for testing in Kenya by the summer of 2020. DISCUSSION/SIGNIFICANCE OF IMPACT: The accurate, high-quality surveillance enabled by this device would allow malaria control programs to scale surveillance to remote regions where an entomologist may not be available, allowing malaria programs to deploy effective interventions, monitor results, and prevent disease.OBJECTIVES/GOALS: Rapid and accurate identification of primary malaria vector species from collected specimens is the most critical aspect of effective vector surveillance and control. This interdisciplinary team of engineers aims to automate identification using a deep learning computer vision algorithm. METHODS/STUDY POPULATION: The team spent August of 2019 observing and participating in control and surveillance activities in Zambia and Uganda. They conducted >65 interviews with key stakeholders across 9 malaria control and surveillance sites, ranging from field and community health workers, to malaria researchers and Ministry of Health employees. Stakeholder feedback validated the need for a more accurate and efficient method of vector identification in order to more effectively deploy targeted malaria interventions. The team set forth in designing and prototyping a portable, automated field tool that could speciate mosquito vectors to the complex level using artificial intelligence. RESULTS/ANTICIPATED RESULTS: The team’s research demonstrated that accuracy, cost effectiveness, and ease of use would be critical to the successful adoption of the tool. Results of initial prototyping, usability studies, and stakeholder surveys were used to determine the tool’s minimal user specifications: 1) the ability to distinguish between


Cholera remains a major contributor of diarrheal diseases and leads to substantial morbidity and mortality, particularly in low socioeconomic settings. Nonavailability of a national cholera control plan in India, compounded by underreporting of cholera cases and deficient accurate cholera hotspot estimates, has made cholera control a challenge. Obstacles in the programmatic introduction of oral cholera vaccine (OCV) lie within the infrastructure—stockpile, costing, distribution system, cold-chain mechanism, vaccine logistics, and lack of strengthened surveillance systems for adverse events following immunization. Sustained political commitment along with collaboration of people working in the media will also determine the policy outcome of OCV introduction in India. Cholera remains a major contributor of diarrheal diseases and leads to substantial morbidity and mortality, particularly in low socioeconomic settings without proper management. In a country like India where 70% of the population reside in rural areas, cholera continues to be a menace. Estimates show over 400 million people in India are at risk of cholera, with 675 188 cases and 20 256 deaths occurring annually [Although an accurate estimate of the number of cholera cases in India is presently unavailable, it is evident that cholera outbreaks have been consistently reported over the years from different regions of India. According to the Integrated Disease Surveillance Program, 559 cholera outbreaks were reported in India during 2009 to 2017, Karnataka and West Bengal being the top contributors. Cholera modelling by Ali et al revealed that of 36 states in India, 24 states reported at least 1 cholera outbreak in the last 10 years, and 13 states were cholera endemic [The World Health Organization (WHO) established a global task force on cholera control (GTFCC), which aims to eradicate cholera by 2030. While this task force emphasizes safe water, sanitation, and hygienic (WASH) measures, cholera vaccines play an additional role in reducing cholera burden, particularly in overcrowded slums with poor hygiene and environmental conditions.Two oral cholera vaccines (OCV), namely Shanchol and Euvichol, are modified bivalent killed whole-cell–based vaccines, targeted at adults and children older than 1 year. WHO recommends administration of 2 doses at an interval of 2–6 weeks, with a booster dose at 3 years, to all eligible age groups in high-risk and vulnerable areas, particularly in a limited-resource scenario [Several vaccine trials conducted by investigators from the National Institute of Cholera and Enteric Diseases under the Indian Council of Medical Research (ICMR-NICED) demonstrated a protective efficacy of ≥65%, almost consistent from 2–5 years postvaccination in the case of whole-cell killed OCV , 5. ThusThis article was based on review of available literature in the public domain along with analysis of hospital-based acute diarrheal disease surveillance data at ICMR-NICED, Kolkata, India. The goal of the review was to summarize evidence available so far on various challenges and bottlenecks for OCV implementation in India. The literature search was conducted using PubMed and Google Scholar, with the keywords “India,” “cholera,” “OCV,” “oral cholera vaccine,” “challenges,” “acute watery diarrhoea (or diarrhea),” and “immunization program.” Publications were included if based on Indian data or Indian scenarios and published within the last 10 years (since 2011). Duplicate reporting of data was addressed by removing the same data from different sources. Papers not written in English were excluded. We sought to document the magnitude of underreporting of cholera cases to the WHO by the Central Bureau of Health Intelligence (CBHI) through the publication of the National Health Profile of India since 2005. This exercise was aimed at demonstrating the extent of the data gap on cholera in the current national reporting systems.Major obstacles in programmatic introduction of OCV lie within the infrastructure—the distribution system, cold-chain mechanism, vaccine logistics, and lack of strengthened surveillance systems for adverse events following immunization to support OCV introduction . BecauseBox 1.Dilemmas for policymakersAbsence of laboratory-based surveillance, therefore priorityApprehension of negative impact on trade, travel, and commerceHotspots based on seroincidence not availableNational cholera control plan not in placeTargeted campaign vs mass immunization.Programmatic challengesTwo doses to be given with a gap of 2 weeksHotspot regions not identified, consequently a large population unit (district/state) may need to be coveredRequires supply of vaccine at a large scaleAdministration of oral cholera vaccine (OCV) to subjects aged >1 year is in discordance with the current universal immunization program in IndiaDemand identification for vaccine to encourage vaccine manufacturers for uninterrupted supplyFinancial implication—cost vs return on investment.Operational challengesUpgrade infrastructure, including distribution channelsIncrease cold-chain system capacityVaccine storage capacity and logistics mobilization at large scaleEvaluation of adverse events following immunization surveillance for ability to support OCV introductionAccurate vaccine demand forecasting and stock management to minimize vaccine wastage.Absence of accurate cholera hotspot data limits vaccine demand forecasting and efficient stock management and wastage minimization. In India currently, OCV-specific training is needed but resources are very scarce. Development of a training program, along with communication tools, messaging, and intersectoral coordination, is a daunting task but is vital for efficient rollout of any vaccine. Social mobilization, advocacy, and campaigning activities are also essential to disseminate information to overcome vaccine hesitancy at individual and community level. Innovation in health communications and community mobilization has been recognized as an efficient strategy for successful vaccine implementation, as evidenced by the Pulse Polio Immunization Program in India .Presently, a vaccination program may be most suitable as a response measure to a cholera outbreak. However, tackling issues like waning immunity, migration, and generation of new birth cohorts into a community calls for repetition of vaccination at a specified periodicity as long as needed to control cholera outbreak. In the absence of documented cholera hotspots in India and considering its huge population of around 1.3 billion, the feasibility and cost-effectiveness of vaccination roll out remains a very serious concern for policymakers, particularly in the context of decreasing gross domestic product (GDP) and further diminution of the proportion of GDP spent on public health , 9.These oral vaccines are part of the nonemergency reserve stockpile of GTFCC. The United Nations Children’s Fund (UNICEF) also maintained the stockpile (around 4.3 million OCV doses in 2016), the bulk of which was intended for cholera-endemic countries . CurrentThis uncertainty from the manufacturer of Shanchol, Shantha Biotech, Hyderabad, regarding expansion of OCV production to fulfil the requirement in India is another major impediment for vaccine roll out . A substOne of the major challenges in controlling cholera is the nonavailability of a national cholera control plan in India. To prioritize any plan for elimination of a disease, a true estimate of the disease is very important. Gross underreporting of cholera cases has exacerbated the difficulty in obtaining an accurate estimate. Anticipation of a detrimental effect on trade, tourism, and political pressure may also be the cause of underreporting and, therefore, cholera control gradually tends to lose priority for policymakers. It is thought that underreporting may take place at the local, state, and national levels, hiding the actual magnitude of the problem . DespiteBecause OCV is targeted at children older than 1 year, OCV vaccination needs to be ideally coupled with a universal immunization program, which mostly targets the infant population. This should be recognized as an opportunity as the birth cohorts can be followed for OCV administration. Feasibility studies could be used to explore complementary and alternative strategies to routine vaccination campaigns. Evidence synthesis at local and regional levels and evidence-driven decision making may be effective in the Indian setting where acknowledging the diversities across demography, climate, and disease profile determines the success of any intervention program . A comprThe Indian National Technical Advisory Group on Immunization (NTAGI) set up a working group on cholera control in 2016, who meet from time to time to disseminate their recommendations . SustainDespite many challenges, there remains a light at the end of the tunnel. On approval from ICMR, ICMR-NICED has initiated a study to estimate the seroincidence of cholera at national and regional levels along with mapping of cholera hotspots. These data may be leveraged during subsequent years for informed public health decision making. Strategic outcomes may be derived from this work, which will facilitate overcoming the existing barriers.The GTFCC Global Roadmap to End Cholera by 2030 may be implemented in a step wise approaches. This may enable policymakers to facilitate development of a national cholera control plan, which would be aimed at both outbreak response and overall cholera burden reduction. As a part of the plan, targeted OCV implementation may be initiated through a hotspot-based approach and subsequently may be scaled up as suggested by the evidence. Harmonization with WASH programs and multisectoral convergence will be imperative for successful implementation of OCV in all sectors. Collaborations across relevant state government departments  would be instrumental in overcoming initial apprehension and vaccine hesitancy, and limitation of logistics problems, and thus will address vaccine preparedness.Surveillance systems, particularly laboratory-based surveillance, needs to be augmented so that true numbers of cholera cases may be estimated, which would be helpful in assessing the impact of a vaccination program. GTFCC is launching a country support platform (CSP) for cholera in 5 countries, to support and facilitate cholera control activities. Establishment of a CSP in India will certainly be a critical step towards overcoming many challenges.Lastly, a sustained political commitment at all levels is necessary for successful implementation of an OCV program, which is possible only through evidence-based policy advocacy. Collaboration with people working in the media is also of great importance because communication remains a key determinant in the success of any vaccine implementation program.


Community pharmacists and their teams have remained accessible to the public providing essential services despite immense pressures during the COVID-19 pandemic. They have successfully expanded the influenza vaccination programme and are now supporting the delivery of the COVID-19 vaccination roll-out.This rapid realist review aims to understand how community pharmacy can most effectively deliver essential and advanced services, with a focus on vaccination, during the pandemic and in the future.An embryonic programme theory was generated using four diverse and complementary documents along with the expertise of the project team. Academic databases, preprint services and grey literature were searched and screened for documents meeting our inclusion criteria. The data were extracted from 103 documents to develop and refine a programme theory using a realist logic of analysis. Our analysis generated 13 context-mechanism-outcome configurations explaining when, why and how community pharmacy can support public health vaccination campaigns, maintain essential services during pandemics and capitalise on opportunities for expanded, sustainable public health service roles. The views of stakeholders including pharmacy users, pharmacists, pharmacy teams and other healthcare professionals were sought throughout to refine the 13 explanatory configurations.The 13 context-mechanism-outcome configurations are organised according to decision makers, community pharmacy teams and community pharmacy users as key actors. Review findings include: supporting a clear role for community pharmacies in public health; clarifying pharmacists’ legal and professional liabilities; involving pharmacy teams in service specification design; providing suitable guidance, adequate compensation and resources; and leveraging accessible, convenient locations of community pharmacy.Community pharmacy has been able to offer key services during the pandemic. Decision makers must endorse, articulate and support a clear public health role for community pharmacy. We provide key recommendations for decision makers to optimise such a role during these unprecedented times and in the future. A diverse group of professional and public stakeholders validated our findings from the literature.By using a realist approach, we were able to use a broad range of data, including grey literature.To enable us to develop recommendations in a timely manner the focus of the review was deliberately narrow.The topic could have been informed by other sources of evidence in particular empirical interviews with key stakeholders.COVID-19 vaccination is a rapidly evolving area and this research was based on the best available evidence at the time.Community pharmacy teams have continued to provide essential services during the COVID-19 pandemic. They offer accessibility and medicines expertise to the public, even in challenging times.Evidence suggests that community pharmacy can successfully provide diverse vaccination services including seasonal and pandemic influenza, travel vaccinations and hepatitis B for at-risk groups, within the provisions of the UK National Health Service (NHS) or privately.The COVID-19 pandemic has stretched NHS capacity to safely and efficiently meet public health demands. A role for community pharmacy in the national vaccination service requires an understanding of what pharmacy teams require to successfully deliver essential and advanced services during the pandemic. Such knowledge is timely, given the roll-out of COVID-19 vaccines across the community.Delivering a vaccination programme is a complex process and successful delivery is context dependent. A realist review helps make sense of complex situations,A rapid realist review of academic and other literature, supplemented by input from key actors, was undertaken to understand how and when community pharmacy can effectively support the public health agenda during pandemics such as COVID-19. Rapid reviews aim to ensure findings are generated and disseminated in response to the urgent nature of the situation. To produce this knowledge at pace, we truncated the following review processes:Programme theory development was undertaken within 1 month with input from the project team.Searching was expedited using broad search terms and using a limited number of key data sources.Data analysis and context-mechanism-outcome configuration (CMOC) development focused on where the programme theory was considered most important during COVID-19.This realist review was undertaken within 6 months (August 2020–January 2021), the protocol was published on PROSPEROThe project team met virtually to develop an embryonic programme theory using four diverse documents from an initial search representing a professional journal,Searches were conducted (July–August 2020) using MEDLINE, EMBASE, CINAHL, Web of Science and Scopus for search concepts relating to Pharmacy and COVID by AB  for consistency.EY obtained and screened full texts of all documents meeting the eligibility criteria.Relevant data from the included full-text documents were coded into NVivo by EY, MM and JB. Some codes came from the data ; others were derived from the programme theory  and some were derived using retroduction .The data analysis/synthesis was conducted by EY, MM and JB with input from the rest of the project team to develop and refine the programme theory using a realist logic of analysis. Our analysis generated 13 realist CMOCs, explaining when, why and how community pharmacy can support public health vaccination campaigns, maintain essential services during pandemics and capitalise on opportunities for expanded, sustainable public health service roles. Actor conversations generated further CMOCs related to care for diverse and vulnerable populations, including ethnic minorities.Our realist logic of analysis centred on the following questions:Interpretation of meaning: do the contents coded by the team provide data that may be interpreted as CMOCs?Interpretations and judgements about CMOCs: how do the CMOCs relate to the programme theory?Interpretations and judgements about programme theory: how do the programme theory and its CMOCs correspond with key actor perspectives of reality?Data to answer our questions were iteratively sought across documents. Interpretive cross-case comparison was used to identify and explain the ‘success’ of pandemic community pharmacy interventions delivered in different settings or to different population groups.Key stakeholders, including community pharmacists and support staff , other healthcare professionals and members of the public were consulted on four occasions. The meetings took place over Microsoft Teams and each lasted about 1 hour.Members of the public were drawn from The University of Sheffield’s Patient and Public Involvement database and contacts of the core project team. Groups numbered between 11 and 13 members, with ages ranging from 22 to 74 years, from diverse locations and ethnicities including Black African, Black Caribbean, British Asian, British Chinese, White Irish and White British. Collectively, stakeholders provided feedback and advice on their real-world experience of working in or using community pharmacy.One hundred and three documents were included in this rapid review and were coded to develop and refine our CMOCs and programme theory  are essential first steps in enlisting community pharmacy for COVID-19 vaccination programmes. Regulators must ensure pharmacists have the legal scope to do so (CMOC 2), with community pharmacy input during the development of policies and protocols (CMOC 3), so that final service specifications are flexible and doable within local settings (CMOC 4).In England community pharmacies have government contracts and partnerships to deliver vaccinations and other essential services during emergencies, including the COVID-19 pandemic.In contrast, when clear options for community pharmacy involvement in COVID-19 vaccination programmes were issued through the NHS (CMOC 4), the chief executive of the Association of Independent Multiple Pharmacies commented positively on members’ engagement in delivering vaccines.Community pharmacies have had to manage ongoing essential services, in addition to supporting COVID-19 vaccination delivery during the pandemic (CMOC 6), including delivery of necessary medications (CMOC 7). Given fears and anxieties related to COVID-19 and changes to service delivery, community pharmacies have had to deal with inappropriate behaviours from the public, including emotional abuse and threats of physical abuse (CMOC 8). As an integral public health service, community pharmacy capacity to meet NHS needs will be enhanced through use of information technology (IT) and collaboration with other service providers (CMOC 9).Although attention is focused on a COVID-19 vaccine, community pharmacies offer diverse essential services. In the UK and other high-income countries, community pharmacy services also provide advanced services such as vaccinations.Despite pharmacists’ professional and moral obligations to provide essential services, ongoing persistent ‘under-recognition’ can jeopardise their ability to contribute to COVID-19 vaccinations (CMOC 5) as well as maintain a usual service. Under-recognition has been an issue in previous UK vaccination campaigns; respondents to a survey of Welsh community pharmacists after the 2016 influenza season described providing a ‘mop up’ service for general practitioners (GPs).Multiple required community pharmacy service adaptations have been reported by the UK Pharmaceutical Journal, including change-over in retail space to medication preparation and dispensing, and call-in shopping services for other retail items (CMOC 6). Service adaptations have been affected by hours of operation, available staff and cancellations of contracted services, such as blood pressure testing and smoking cessation support—all with financial implications for pharmacists.Before COVID-19, community pharmacies globally were offering ‘valued-added services’ (VAS) such as drive-thru services, online ordering and communications services  to stay competitive. Many VAS have helped pharmacies adapt more quickly to pandemic restrictions.During the pandemic, ensuring access to needed medications has been a critical pharmacy service, to allay public concerns (CMOC 7).The UK COVID-19 vaccination campaign borrows heavily from previous, successful collaborative influenza vaccination programmes using community pharmacy and GPs (CMOC 9).The pandemic has clearly demonstrated the importance of interoperable, connected IT systems across services.Pharmacy users trust community pharmacies as a reliable source of information (CMOC 10) about vaccines, and pharmacies’ local accessibility and convenience increases the likelihood of users obtaining COVID-19 vaccines through them (CMOC 11). Community pharmacy relationships with vulnerable populations in their local settings may enhance uptake of the vaccine by these groups (CMOC 12). Provision for privacy is an important user consideration. Pharmacy users expect private consultations to preserve their confidentiality (CMOC 13).Public trust in community pharmacists is high—similar to doctors and nurses.This realist review sought to understand how community pharmacy can contribute to the public health agenda during the COVID-19 pandemic, particularly continuation of essential services and engagement in vaccination services.To optimise community pharmacy service during the pandemic, decision makers must endorse and articulate a clear role for these healthcare professionals. The public already endorses advanced roles for community pharmacy , but public awareness depends on what decision makers do and say. Practical decision maker measures include adequate reimbursement to help cover the cost for time, staff and PPE (particularly for a sustainable long-term service); legal (including indemnity), regulatory coverage for advanced roles; and clear and consistent guidance for vaccination preparation and for adaptation of essential services. When given the opportunity, the permissions and resources to do so, community pharmacies have been able to adapt quickly to continue essential services and whenever possible, to offer critical advanced services. Historically, community pharmacies have significantly increased vaccination uptake  given their accessibility and convenience and capacity to adapt to local needs for the general population and marginalised groups.At the time of this realist review, there were no similar reviews on community pharmacy roles with respect to COVID-19 vaccinations. COVID-19 represents an unprecedented situation with limited direct evidence to guide decision-making. However, realist approaches engage with a wider evidence base, including research on past pandemics ,The realist approach uses diverse data, including grey literature. This feature is especially important given a novel and rapidly evolving topic area, such as COVID-19. Multiple researchers with subject matter expertise participated in screening the literature and extracting and coding data, which maximised opportunities to discuss and debate the plausibility of the inferences made. The CMOCs were developed and refined through regular discussions within a team with varied academic and clinical backgrounds. Professional and public stakeholder consultation further refined the CMOCs.All rapid reviews operationalise coverage versus expediency. Other sources of evidence could have informed the review; however, potential gaps were mitigated by stakeholder engagement and expertise within the team. The evidence supporting the CMOCs was based on available time for document review, and during the review period, research, directives and policy related to COVID-19 vaccination rapidly evolved. The programme theory and its CMOCs, however, are expressed in such a way that they can be further confirmed, refuted or refined in the future using additional data.For this rapid review, given our short timeline of 6 months, we initially decided to focus on community pharmacy roles and pandemic response in middle to high-income countries. While we identified data from higher income countries such as Canada, USA, Australia and France, there was very little published from middle-income countries. As such, it is likely that our findings and recommendations are most applicable to high-income countries, although the lessons learnt from high-income countries can serve as an initial reference point for best practice for other countries.Our recommendations can be viewed as ‘how tos’ for other countries to consider within their own cultural and healthcare environments. A number of European and North American countries have introduced legislative changes to extend the role of community pharmacy and thus reduce pressure on other parts of their healthcare systems.Although there are multiple actors involved in pandemic response, for brevity, recommendations  are direAs the CMOCs were refined, ‘tensions’ were uncovered with implications for decision makers, particularly: community pharmacists as healthcare professionals versus retailersAlong the continuum of healthcare from community to hospital, community pharmacy is often the first point of contact for the public. Community pharmacies contribute to primary care services through essential services  and expanded roles ,In Ireland and Canada, community pharmacies are an integral part of national vaccination campaigns.Community pharmacies tend to be defined as premises where medications are dispensed, which compounds the confusion (by the public and decision makers) of professional primary care services versus retailers.Although community pharmacists can provide professional services off premises , they need to maintain their physical premises and staff for financial reasons. In addition, pharmacy users seek out community pharmacy services due to their accessibility and convenience, and without a physical space to engage regularly with pharmacy users, trust building between pharmacists and users is compromised.As evidenced by public media, many countries, including the UK, are declaring service specifications for COVID-19 vaccinations. Community pharmacists can potentially provide vaccination services in two locations.A future realist evaluation involving primary data collection from key actors will inform refinement of the programme theory, CMOCs and decision maker recommendations. This empirical research will address the tensions identified above. Future research will also address issues identified through the stakeholder groups, such as vaccination hesitancy, outside the scope of this review. While this work touched on unique issues for marginalised populations including ethnic minorities, those of lower socioeconomic status and those with disabilities, further exploration is needed.We had initially focused the review on community pharmacy roles and pandemic response in middle to high-income countries, but found limited data in middle-income countries. The findings are thus more likely to be applicable to high-income countries but may serve to inform practice elsewhere. Empirical research using, for example, a realist evaluation approach should be conducted to extend our findings on the role of community pharmacy in COVID-19 vaccination programmes to middle to low-income countries.The COVID-19 pandemic is a worldwide health emergency. Vaccination is key to combating the pandemic. The role of community pharmacy may be both short term and long term; with a potential need for regular annual vaccines. This rapid realist review offers recommendations for decision makers to enable community pharmacy to play a key role, both during these unprecedented times and into the future.


Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.To investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University.A mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained.www.antibioticprescribing.ie.Six key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: Pharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.


Birth weight, birth length, and gestational age are major indicators of newborn health. Several prenatal exposure factors influence the fetal environment. The aim of the study was to investigate the effect of prenatal exposure factors, including socio-demographic, behavioural, dietary, physical activity, clinical and environmental on birth outcomes through the mediation of Favourable Fetal Growth Conditions (FFGC).Data was obtained from six hundred and fifty-six Mother and Child in the Environment birth cohort study in Durban, South Africa from 2013 to 2017. We adopted structural equation models which evaluate the direct and indirect effects by allowing multiple simultaneous equations to incorporate confounding and mediation.newborn weight, length, and gestational age was seen. Gestational weight gain and maternal body mass index in the first trimester exerted a mediation effect between maternal behavioural risk factors and FFGC. Similarly, the level of physical activity during pregnancy was associated with decreased gestational weight gain. The effects of maternal characteristics on newborn weight, length, and gestational age were largely indirect, operating through FFGC as a latent variable.A significant direct and indirect effect of FFGC on Gestational weight gain and maternal pre-gestational BMI were observed to mediate the association between prenatal behavioural risk factors and favourable fetal growth conditions.Retrospectively registered from 01 March 2013. Fetal development is a global public health concern because growth in utero is a good indicator of perinatal and postnatal health . Poor feStudies have examined the relationship between prenatal characteristics and birth outcomes with the mediation effect of favourable fetal growth conditions (FFGC) , 12, 13.FFGC is associated with dimensions that play an essential role in prenatal development such as environmental, genetic or epigenetic factors . Due to A previous study  in DurbaThe Mother and Child in the Environment (MACE) birth cohort is a study with ongoing recruitment in Durban, South Africa. The study enrolled a cohort of 996 pregnant women from March 2013 to May 2017 from public sector antenatal clinics in the study areas. From a total of 996 women, 687 of them were enrolled subjects followed up during their pregnancy, through to labour and delivery, with the remainder having had multiple pregnancies (n = 2); miscarriages (n = 55); still births (n = 25); and termination of pregnancy (n = 2) and were therefore excluded from the cohort. A further 225 participants relocated outside the areas of interest. Excluding 31 participants with postdates birth  reduced the effective sample size to 656 mother-child pairs. This study was developed with data from MACE birth cohort in Durban, South Africa in the period of 2013 to 2017. The inclusion, exclusion criteria of selection of participants is as follows. All pregnant women that were at a gestational age of fewer than 20 weeks and resident for the full duration of the pregnancy in the geographical area within which the clinic was located as well as for the follow-up period of 5–6 years in the cohort were recruited in the study. Women with multiple pregnancies were excluded from the study.2) was calculated using first-trimester weight and height.This study considered both observed and latent variables as prenatal exposure factors. Observed variables include environmental (exposure to NOx pollution), clinical , pre-gestational body mass index (BMIT1), and HIV status (HIV Positive)), maternal age (Mage), and parity (multiparous). Latent variables: diet , physicμg/m3) for participants in the MACE birth cohort was predicted, using land use regression model based on pre-selected geographic predictors, such as land use types, road length, topography, population and housing density with the methodology used in the European Birth Cohorts (ESCAPE). The parameter estimates were used to predict NOx exposure at the residential addresses of the study participants, as detailed in Muttoo et al. 13], and Studies that consider the only birthweight as fetal growth found positive associations of higher maternal pre-gestational BMI and GWG with the risk of larger birthweight of infants –31. Our The strength of this study is the use of the latent variable approach which allows three commonly available birth outcomes BW, BL, and GA as a proxy for the fetal environment instead of using only birthweight on data from a developing country. This provides a very general and convenient framework for statistical analysis that includes several multivariate procedures such as regression analysis, discriminant analysis, and canonical correlation, as special cases. Another strength of our study is the use of maternal exposure risk factors of adverse birth outcomes, such as BMI, exposure to NOx, current and passive smoking habits, alcohol consumption and physical activity during pregnancy. Even “well-behaved” random errors can bias the coefficient estimates of the health effects of not only the fetal environment indicators  but also of the other control variables that are part of the analysis. This happens even if the control variables are free of error . For thiThe main limitation of this study is the use of a single average pollutant NOx exposure levels during the whole pregnancy. The effect of exposure to NOx at different trimesters may have a differential effect on birth outcomes. Another limitation of the study is the absence of the weekly or monthly weight gain measurements. This may have influenced the association with the latent variable and needs to be investigated in other areas with repeated measurement of gestational weight gain.Structural equation modeling allowed an investigation of maternal pre-gestational BMI and gestational weight gain as mediators of prenatal exposures and birth outcomes via FFGC. This methodological approach takes into account the correlation between multiple birth outcomes. Consequently, prenatal behavioural risk exposure was related to severe birth outcomes. Among others, maternal smoking, environmental exposure to smoking and alcohol consumption during pregnancy led to unfavourable fetal growth conditions. Furthermore, high level of mother’s physical exercise was found in the reduction of mothers’ gestational weight gain.


Introduction: Federally qualified health centers (FQHCs) provide essential contraceptive services to low-income individuals; yet, access to all method options, notably intrauterine devices (IUDs) and implants, may be limited at non-Title X FQHCs. The South Carolina (SC) Choose Well initiative is a statewide contraceptive access initiative that was launched in 2017 and extends into 2022. Choose Well established a collaborative network between training and clinical partners and is aimed at facilitating implementation of contraceptive care best practices through capacity-building and training of clinical and administrative staff in partner organizations. The initiative provided funding for workforce expansion and contraceptive methods. We examined perceptions of staff from Choose Well-participating FQHCs regarding contraceptive access during the first 2 years of the initiative, including factors that facilitated or posed access challenges as well as sustaining factors. This study informs the process evaluation of Choose Well while providing data critical for uncovering and scaling up contraceptive access initiatives.Materials and Methods: Interviews were conducted with FQHC staff (n = 34) in 2018 and 2019 to assess Choose Well implementation and were recorded, transcribed, and double-coded via at least 80% interrater reliability or consensus coding. Data were analyzed according to clinical and administrative factors influencing contraceptive access.Results: Increased capacity for contraceptive counseling and provision through training and external funding for IUDs and implants were the most noted clinical factors facilitating access. Streamlining workflow processes was also a facilitator. Buy-in and engagement among staff and leadership emerged as a facilitator at some clinics and as a barrier at others. Policy/structural factors related to costs of devices and insurance coverage were identified as threats to sustainability.Conclusions: The Choose Well initiative contributed to the perception of an increase in contraceptive access at participating FQHCs in SC. Statewide contraceptive access initiatives have the potential to support FQHCs in meeting their clients' contraceptive needs. Organizational buy-in, sustainability of funding, and training are key to realizing the full potential of these initiatives. While federal law requires FQHCs to provide preventive and primary care, including contraceptive care, FQHCs can offer contraceptive services directly or through agreements with other providers. Also, an FQHC system may offer contraceptive care at some, but not all, of its service delivery sites.Due, in part, to funding mechanisms, not all publicly funded safety-net clinics provide equal access to the full range of contraceptive methods.e.g., screening and treatment for sexually transmitted infections and one or two contraceptive methods) and others offering more comprehensive care.10 Center characteristics, the policy environment, and Title X funding influence the range of services offered.In addition, FQHCs vary in the range of contraceptive services offered, with some offering limited services , FQHCs do not receive a portion of the ∼$6 million statewide Title X funding,14 as Title X funding is distributed through the state health department.Title X is the sole federal funding mechanism specifically allocated for the provision of contraceptive services,15 and are less likely to offer contraceptive services that require additional training, such as IUD and implant placement and removal procedures, than Title X-funded family planning clinics.16–18 Without comprehensive clinical practice guidelines and Title X funding, there is considerable variability in contraceptive service provision among FQHC clinics.10FQHCs that do not receive Title X funding are less likely to have on-site availability of contraceptive methods, such as stocking IUDs and implant devices,1 As FQHC's role in delivering contraceptive care within the publicly funded safety-net grows, it is increasingly important to support these clinics and to examine perceptions of staff regarding facilitators and barriers to contraceptive access at their clinics.Despite funding limitations, the number of contraceptive care patients served by publicly funded clinics that do not receive Title X funding nationwide increased by 29% between 2010 and 2016.19 In addition, contraceptive access initiatives promise to expand access to contraceptive care at partner organizations. In SC, Choose Well is a statewide initiative, which is funded by a private philanthropic foundation, aimed at expanding access to contraception and reducing unintended pregnancy. The 6-year initiative launched in 2017 and extends into 2022. In 2017, a total of 20 FQHC systems in SC offered family planning services at 123 clinic sites across the state, and of these, 8 systems and 33 clinics participated in Choose Well. By 2018, additional FQHC systems and clinics had joined Choose Well bringing the number of participating systems to 16 and the number of participating clinics to 57.Nationwide, federal, and state grant funding has facilitated contraceptive provision at FQHC clinics.21In 2017 and 2018, participating FQHCs received funding and support through Choose Well to bolster contraceptive counseling and service provision. Participating FQHCs received capacity building and provider and administrative trainings ; clinic infrastructure and workforce enhancements, including funding for contraceptive methods and staff positions, and technical assistance opportunities.availability dimension of access refers to components of supply and demand22 and explores a specific area of fit between service providers and patients.8 This construct includes providers who are trained and willing to place and remove IUDs and implants, on-site stocking of devices, administrative support for billing and coding for contraceptive services, and enhanced workflow processes.9As a part of the external evaluation of Choose Well, we assessed progress in implementation of the initiative at participating FQHCs during the initial 2 years with a focus on the availability of IUDs and implants. The availability dimension of access, at the organizational and policy/structural levels, will inform prioritizing areas for improvement within FQHC systems/clinics as well as advocacy efforts for policy change, thereby helping to optimize the impact of statewide initiatives on clinical care among FQHCs. This, in turn, will improve experiences with care and reproductive outcomes for FQHC patients.The study aim was to assess changes in contraceptive access associated with the Choose Well initiative and to identify facilitators and challenges to the provision of IUDs and implants as well as perceptions of sustainability of funding from the perspective of clinical and administrative staff at Choose Well participating FQHCs. This information is important for the process evaluation of Choose Well, and more broadly, to facilitate the translation of evidence-based interventions into practice. Specifically, identifying facilitators and barriers within the 23 with administrative staff working at the system/organizational level and clinic staff working to directly support or provide services at the individual delivery sites. The first round of interviews was conducted in 2018 and assessed staff perceptions of Year 1 (2017) implementation of Choose Well. In 2017, 33 FQHC clinics across 8 FQHC systems participated in Choose Well. In 2018, we invited 38 clinic-level staff  and 11 system-level staff  to interview.Semistructured key informant interviews were conducted from July 2018 to September 2019 with Choose Well participating FQHC staff at the clinic- and system-levels. FQHCs are large nonprofit organizations composed of multiple delivery sites,Of those invited, 13 clinic-level staff (34.2%) (representing 13 clinics) and 6 system-level staff (54.5%) (representing 4 systems) completed the first round of interviews.The second round of interviews was conducted in 2019 and assessed staff perceptions of Year 2 (2018) implementation of Choose Well. In 2018, 57 clinics across 16 FQHC systems participated in Choose Well. In 2019, we invited 51 clinic-level staff  and 21 system-level staff  to interview.Of those invited, 18 clinic-level staff (35.3%) (representing 14 clinics) and 8 system-level staff (38.1%) (representing 7 systems) completed the second round of interviews. Across both rounds of interviews, 31 clinic-level interviews and 14 system-level interviews were completed. Of the 31 clinic-level interviews, 8 staff were interviewed in both rounds and counted once, generating a final sample of 23 clinic staff. Of the 14 system-level interviews, 3 staff were interviewed in both rounds and counted once, generating a final sample of 11 system staff, and a total of 34 staff at both levels over the study period . At the system-level, we invited Executive Directors, Directors of Operations/Finance, and Chief Medical Officer/Chief Nursing Officers.At the clinic-level, we invited the clinic administrator and/or lead family planning provider .availability dimension of health care access,22 operationalized in terms of three main constructs  offered a framework for analysis  emerged as a barrier among a few respondents, for instance, the perception that some providers were “not comfortable with doing an IUD” or “have strong beliefs that's always going to be a barrier.”Four themes emerged related to administrative factors influencing contraceptive access, including the provision of IUDs and implants, during the Choose Well initiative: billing and coding for contraceptive services; clinic infrastructure; clinic staffing capacity and buy-in; and clinic workflow and efficiencies. Facilitators were identified across all themes, and barriers were identified in three domains .Related to billing and coding, respondents noted the importance of maximizing reimbursement and increasing revenue potential for contraceptive services. As one respondent noted, “From a revenue generation perspective, the services pay for themselves.…” While some respondents indicated that improvements in billing and coding practice at their clinic(s) had facilitated IUD and implant provision, others indicated that lack of knowledge about billing and coding was a challenge.Regarding clinic infrastructure, robust improvement to electronic medical record or electronic health record systems was noted as a facilitator by some respondents, such as adding templates and conducting upgrades.In discussing staff capacity and buy-in, several respondents noted that buy-in and engagement among both staff and leadership and expanded clinic workforce had facilitated access to IUDs and implants at their clinics. For example, “Our CEO is very supportive. I would think she wants to see [the program] continue and succeed.” Yet, several other respondents noted lack of buy-in to organizational change and workforce turnover as administrative barriers to increased access. Regarding a lack of buy-in: “There's some barriers still where [some providers] think that [implants] are okay, but for an adolescent, an IUD, they're not on board with. We're still working on changing some mindsets.”Enhanced clinic workflow processes, institutionalizing changes into the current system, and tracking and utilizing clinic data were indicated as facilitators of service provision. One respondent highlighted “[reproductive health services are] part of our daily delivery now.” A few respondents, however, noted challenges to updating clinic infrastructure along with difficulties in tracking supplies and methods.Sustainability of funding was examined given its importance in maintaining changes associated with Choose Well implementation. This construct included four domains: funding for provision of enhanced services; health insurance and patient assistance; sustainability of trainings; and perceived value of training .Regarding funding, the availability of the 340B drug pricing program was noted as a facilitator of sustainability. The pricing program was noted “to provide contraceptives to clients whose insurance does not cover it.” Similarly, respondents emphasized continuing to seek other sources of external funding to provide same-visit IUD and implant provision and to order and stock devices on-site.In addition, increasing the number of patients enrolled in Medicaid, enrolling patients in patient assistance programs, and offering a sliding scale fee for uninsured patients were all highlighted as sustaining factors to increased access. One individual at the system level noted: “You're going to get the reimbursement from the insurance companies and from Medicaid. We're trying to get everybody that will qualify on Medicaid, at least for family planning if they don't qualify for the full Medicaid.”Plans to continue to provide staff training and to facilitate transfer of knowledge from trained staff within the FQHC system were also highlighted as sustaining factors. “For example, our providers will already be trained and as we get more providers in, those providers that have already been here and have already been trained, can be preceptors for those new providers.”Respondents noted that expanded training opportunities are critical to increased access. One respondent emphasized, “…without the trainings we couldn't be where we are today.” Other perceptions of sustaining factors included: the applicability of training content to practice and enhanced networking among clinics.Barriers to sustainability discussed were the high cost of devices, high rate of uninsured patients, and restrictive health care policies, such as FQHC clinics not being Title X recipients in SC, and limited insurance coverage for contraception.In this study, we examined perceptions of FQHC clinic- and system-level staff participating in the SC Choose Well initiative regarding organizational factors that facilitated or posed challenges to access to IUDs and implants during the first 2 years of the initiative's implementation. Staff perceptions of the early impact of the Choose Well initiative on contraceptive access at their clinics were highly positive. Staff noted how the initiative had influenced multiple clinical and administrative policies/practices related to contraceptive access. This suggests that statewide contraceptive access initiatives that remove cost barriers to care, while building the capacity of safety-net clinics to provide contraceptive services, have the potential for advancing equitable access to care.Challenges remain, particularly related to sustaining efforts beyond the initiative's funding period and ensuring patient-centered care. On-going evaluation of Choose Well will examine the impact of the initiative at the clinic, population, and policy levels.Findings contribute novel and relevant nuance about access to IUDs and implants among non-Title X funded safety-net clinics in SC. Notably, components of access extend beyond clinical factors, such as on-site stocking of IUDs and implants and availability of trained and willing providers, into administrative factors, such as organizational buy-in, enhanced workflow processes, electronic infrastructure enhancement, and billing and coding support.27 In addition, themes suggest that an increase in funding for IUDs and implants contributed to clinics' ability to stock devices and provide same-visit placements, which contributed to expanded access, as noted previously.28–31 There are varying opinions among clinicians regarding the importance of same-visit IUD and implant placement,32 but respondents in our study emphasized that having the financial means to stock devices and provide same-visit placement procedures positively impacted access to IUDs and implants.Respondents emphasized the benefits of external funding for IUDs and implants to reduce the cost barrier to patients, consistent with previous studies.In addition, increased capacity for and enhanced contraceptive counseling was noted as a primary facilitator of access to IUDs and implants, as it increased patient education and expanded perspectives, such as gaining new viewpoints, examining personal prejudices, and increasing comfort level with discussing contraceptives, among reproductive health providers.3 Although training for IUD and implant provision is recommended for a breadth of providers, including midwives, advanced practice nurses, family medicine providers,33 and adolescent and pediatric providers,34 it is not always included in programs outside of Obstetrics and Gynecology specialties.33 One sustainability strategy emerging from our interviews is the continuous provision of staff training through implementing preceptorship programs with already trained providers.Overall, enhanced training opportunities were perceived to have increased capacity for contraceptive service provision, consistent with previous findings among FQHC clinics.In terms of administrative factors, buy-in and engagement among staff and leadership was the most noted facilitator to increased access to IUDs and implants. Enhanced workflow processes and infrastructure support and improvements in billing and coding were similarly noted to facilitate access to IUDs and implants in our study. Enhanced interclinic networking was also emphasized.35 Optimizing the impact of statewide initiatives on clinical care among FQHCs necessitates attention to securing buy-in through on-going engagement with leadership, staff, and partnerships with other organizations to support internal influence.35 A few respondents also noted challenges related to provider factors .Respondents noted challenges to increasing access to contraception in their clinics, which related primarily to lack of buy-in to organizational change among staff. The systems changes required to implement medical innovations, such as integration of contraceptive care, require administrative support and buy-in from multiple levels within the organization.29 suggesting the importance of on-going education and support for providers. A few respondents also mentioned workforce turnover and on-going issues with billing and coding. Incorrect billing and coding for medical services may lead to denied claims, which threaten the financial capacity for the clinic to maintain a stock of devices.19 Coverage and reimbursement policies across insurance plans complicate billing and coding, and on-going technical assistance for clinics in this area is needed.Providers averse to offering IUDs and implants due to their beliefs and perceptions may hinder patients' access to the full range of method options,19 indicating opportunities for increasing clinic participation in this program.Considering the lack of Title X funding for FQHC clinics in SC, sustaining factors must be considered. Structural factors related to cost of contraceptive services/devices and insurance coverage emerged as prevalent challenges to sustainability. 340B drug pricing was noted as one solution. Previous research indicates variation among FQHC clinics in utilizing 340B drug pricing, with clinics that have on-site pharmacies or receive Title X funding more likely to engage with 340B drug pricing,10 Beyond these approaches, our findings reinforce the need for expanded insurance coverage, particularly in states such as SC that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA), as well as for supportive reimbursement policies to increase access to the full range of contraceptive methods.20 In addition, an important consideration for contraceptive access initiatives is ensuring patient-centered care, including best practices in contraceptive counseling that prioritize patients' needs and preferences and respect patients' reproductive autonomy.36–41Another suggested strategy for sustainability is facilitating patient enrollment in Medicaid. Nationwide, health centers serve about 16% of Medicaid beneficiaries, and Medicaid payments constitute nearly 40% of the revenue of FQHC clinics.N = 34), some members of the participant pool declined to participate, which might have contributed to potential response bias skewed toward participants eager to participate or with positive opinions about IUD and implant access. Due to the nature of qualitative research, researcher bias was a potential limitation of this study. To account for such bias, the study team was composed of a diverse group of people, and a team-based analysis approach was used. Data were double coded using an 80% or greater threshold for interrater reliability, and all differences were consensus coded.This study is not without limitation. While this study included a large number of respondents  and support innovative policymaking and implementation of new delivery channels such as pharmacist prescribing.