OBJECTIVE: This study provides a comprehensive overview of the knowledge structure and research hotspots regarding barriers and strategies for the implementation of clinical practice guidelines. METHODS: Publications on barriers and strategies for guideline implementation were searched for on Web of Science Core Collection from database inception to October 24, 2022. R package bibliometrix, VOSviewer, and CiteSpace were used to conduct the analysis. RESULTS: The search yielded 21,768 records from 3,975 journals by 99,998 authors from 3,964 institutions in 186 countries between 1983 and 2022. The number of published papers had a roughly increasing trend annually. The United States, the United Kingdom, and Canada contributed the majority of records. The University of Toronto, the University of Washington, and the University of Sydney were the biggest node in their cluster on the collaboration network map. The three journals that published the greatest number of relevant studies were Implementation Science, BMJ Open, and BMC Health Services Research. Grimshaw JM was the author with the most published articles, and was the second most co-cited author. Research hotspots in this field focused on public health and education, evidence-based medicine and quality promotion, diagnosis and treatment, and knowledge translation and barriers. Challenges and barriers, as well as societal impacts and inequalities, are likely to be key directions for future research. CONCLUSIONS: This is the first bibliometric study to comprehensively summarize the research trends of research on barriers and strategies for clinical practice guideline implementation. A better understanding of collaboration patterns and research hotspots may be useful for researchers. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A247.

There is a lack of knowledge about the successful implementation of family nursing practices. This scoping review maps current knowledge about the implementation of evidence-informed family nursing practices across settings and populations. A systematic search (CINAHL, PubMed, Medline) identified 24 publications, published between 2010 and 2020. We found nurses' implementation experience to be one of disruption, learning, and moving to new ways of practicing. The implementation resulted in benefits to families and self but was marked by fluctuation and partial integration of evidence-informed family nursing practices into care delivery. Uptake was shaped by various contextual determinants, with barriers mainly at the team and organizational levels. We identified low-quality, tentative evidence that capacity-building strategies coupled with dissemination-educational strategies may enable family nursing practice skills and increase the quality of family care. More rigorous research is needed to build further knowledge about effective implementation. Future implementation endeavors should utilize the evolving knowledge base in family nursing and tailor implementation strategies to contextual barriers.

BACKGROUND: Cardiovascular disease has caused heavy health care burdens in many countries, and hypertension (HTN) is a well-known independent cardiovascular risk factor. OBJECTIVE: To assess the efficacy of empowerment strategies that affect systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), quality of life, and self-management behaviours for patients with hypertension. METHODS: A literature search of the Cochrane Library, PubMed, MEDLINE, Embase, Web of Science, and several Chinese medical databases was performed. Study screening, quality assessment, data extraction, and meta-analysis were conducted according to Cochrane standards. RESULTS: Eleven randomised controlled trials with 988 subjects were identified. Relative to control groups, the empowerment strategies showed significant decreases in SBP (the mean difference [MD]=9.46, 95 % confidence interval [CI]=6.36-12.55, p< 0.00001) and DBP (MD = 6.68, 95 % CI = 3.07-10.29, p= 0.0003). However, no significant difference was found in BMI (p = 0.05). Subgroup analysis showed significant differences in the improvement of both SBP and DBP among the various groups, regardless of the duration and type of interventions. DISCUSSION: Empowerment strategies can decrease both SBP and DBP in hypertension patients. However, its influence on patients' BMI, quality of life, and self-management behaviour remains unclear. PRACTICAL VALUE: Empowerment strategies are useful for controlling the blood pressure of hypertension patients.

Background: National policy approaches to physical activity (PA) promotion and sedentary behaviour (SB) reduction are needed to address rising rates of non-communicable diseases. Understanding the policy process and impact through robust research and evaluation is crucial for facilitating successful reforms in national health policy. This scoping review, therefore, aimed to map the evidence on indicators, development, and content of national PA and/or SB policies globally. Methods: A systematic search of academic and grey literature was conducted through six bibliographic databases, Google, and websites of three large organisations for PA promotion. Results: Out of 24,872 screened documents, 203 publications from 163 studies were selected. The selected studies investigated PA/SB policies in 168 countries worldwide, and we provided summary results for each of the countries. Overall, 69, 29, and 2% of the analyses of national PA/SB policies were conducted for high-, middle-, and low-income countries, respectively. Twenty-two percent of the studies mentioned SB policies as part of their analysis, with only one study focusing solely on assessing SB policies. Operational definitions of policy were found in only 13% of publications. Only 15% of the studies used a conceptual or theoretical framework. A large variety of methods were used for data collection and analysis of PA/SB policy. Conclusions: We found that PA policy research is much more developed than it was considered several years ago. Research around SB policies is still in its infancy, but it seems to have experienced some positive progress in the last few years. Three key issues were identified that should be addressed in further research: [i] there is a lack of PA/SB policy research in low- and middle-income countries, which is an important limitation of the current body of evidence; [ii] the definition of policy varied significantly across studies, and most studies did not rely on any theoretical framework, which may impede cross-study comparisons; and [iii] studies have used a variety of methods to analyse policy, which may also cause problems with comparability. Future PA/SB policy research should aim towards a clearer conceptualisation of policy, greater reliance on existing theoretical frameworks, and the use and further development of standardised methods for PA/SB policy analysis.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost euro196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD. OBJECTIVE: The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations. METHODS: A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration's tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis. RESULTS: Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78%, 18/23), goal setting (behavior; 74%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48%, 11/23) each. CONCLUSIONS: This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area.

This article aimed to analyse the outcome of self-management randomised control trials and their impact upon chronic obstructive pulmonary disease patients' health outcomes using meta-analysis approach. PubMed, Scopus, CINAHL, Web of Science databases and Cochrane Library, were searched for articles between 1990 and December 2015 by two researchers. Self-management programs significantly improved patients' quality of life across all domains of the St George Respiratory Questionnaire (SGRQ) (activity -2.21 (95% CI: -3.61 to -0.80), p = 0.002; impact -3.30 (95% CI: -5.28 to -1.32), p = 0.001; symptoms -3.12 (95% CI: -4.94 to -1.03), p = 0.001; total -3.32 (95% CI: -4.60 to -2.04), p < 0.001), the six-minute walk test (-30.50 (95% CI: 3.32 to 57.68), p = 0.028), and across three domains of the chronic obstructive pulmonary disease self-efficacy scale (negative effect -1.22 (95% CI: -2.31 to -0.14), p = 0.027; physical exertion -1.27 (95% CI: -2.52 to -0.02), p = 0.047; behavioural risk factors -0.58 (95% CI: -0.99 to -0.16), p = 0.007). Subgroup analyses revealed that chronic obstructive pulmonary disease education (p < 0.01) was the strongest component with improvements on all aspects of the SGRQ and the six-minute walk test. Providing an exacerbation action plan significantly improved SGRQ activity and impact scores whilst exercise information had a positive effect on activity and symptom scores (p < 0.05). Interventions with a duration of less than five weeks (p < 0.05) significantly improved symptom and activity scores, in addition to the number of patient hospital admissions. Thus, self-management interventions are effective at improving the health outcomes of chronic obstructive pulmonary disease patients, especially when disease education is provided.

OBJECTIVE: Several systematic reviews have evaluated interventions that aim to increase mental health service initiation and engagement as well as adherence to pharmacological treatment. No reviews have focused on evaluating these interventions' effects on retention in mental health services, however, which was the goal of this systematic review. METHODS: PubMed, PsycINFO, and Social Services Abstracts were searched for studies that met the inclusion criteria. All studies published prior to March 29, 2015, that compared two or more groups on any measure of retention in mental health services were included. Methodological quality was assessed for each included study. An effect size was calculated for each outcome, although a meta-analysis was not conducted because of heterogeneity across interventions. To facilitate narrative analysis, interventions were categorized by targets-the types of predictors of or barriers to mental health service use that the intervention aimed to address. RESULTS: Eleven studies met inclusion criteria. The interventions produced medium to large effects on retention outcomes. Many interventions addressed more than one target. Interventions that targeted mental health knowledge, mental health attitudes, and barriers to treatment all enhanced retention in mental health services compared with control groups. Most interventions with those targets had a large effect on retention and relatively good methodological ratings. CONCLUSIONS: The most effective retention interventions were comprehensive, addressing mental health knowledge, mental health attitudes, and barriers to treatment. The authors recommend that researchers apply relevant theories to refine these interventions and evaluate the interventions by using rigorous methodology and a range of retention outcomes, mediators, and moderators

BACKGROUND: Digital interventions have been effective in improving numerous health outcomes and health behaviors; furthermore, they are increasingly being used in different health care areas, including self-management of long-term conditions, mental health, and health promotion. The full potential of digital interventions is hindered by a lack of user engagement. There is an urgent need to develop effective strategies that can promote users' engagement with digital interventions. One potential method is the use of technology-based reminders or prompts. OBJECTIVE: To evaluate the effectiveness of technology-based strategies for promoting engagement with digital interventions. METHODS: Cochrane Collaboration guidelines on systematic review methodology were followed. The search strategy was executed across 7 electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, the Education Resources Information Center (ERIC), PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Databases were searched from inception to September 13, 2013, with no language or publication type restrictions, using three concepts: randomized controlled trials, digital interventions, and engagement. Gray literature and reference lists of included studies were also searched. Titles and abstracts were independently screened by 2 authors, then the full texts of potentially eligible papers were obtained and double-screened. Data from eligible papers were extracted by one author and checked for accuracy by another author. Bias was assessed using the Cochrane risk of bias assessment tool. Narrative synthesis was performed on all included studies and, where appropriate, data were pooled using meta-analysis. All findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: A total of 14 studies were included in the review with 8774 participants. Of the 14 studies, 9 had sufficient data to be included in the meta-analyses. The meta-analyses suggested that technology-based strategies can potentially promote engagement compared to no strategy for dichotomous outcomes (relative risk [RR] 1.27, 95% CI 1.01-1.60, I2=71%), but due to considerable heterogeneity and the small sample sizes in most studies, this result should be treated with caution. No studies reported adverse or economic outcomes. Only one study with a small sample size compared different characteristics; the study found that strategies promoting new digital intervention content and those sent to users shortly after they started using the digital intervention were more likely to engage users. CONCLUSIONS: Overall, studies reported borderline positive effects of technology-based strategies on engagement compared to no strategy. However, the results have to be interpreted with caution. More research is needed to replicate findings and understand which characteristics of the strategies are effective in promoting engagement and how cost-effective they are

BACKGROUND: Nursing process is a scientific approach in the provision of qualified nursing cares. However, in practice, the implementation of this process is faced with numerous challenges. With the knowledge of the challenges associated with the implementation of the nursing process, the nursing processes can be developed appropriately. Due to the lack of comprehensive information on this subject, the current study was carried out to assess the key challenges associated with the implementation of the nursing process. MATERIALS AND METHODS: To achieve and review related studies on this field, databases of Iran medix, SID, Magiran, PUBMED, Google scholar, and Proquest were assessed using the main keywords of nursing process and nursing process systematic review. The articles were retrieved in three steps including searching by keywords, review of the proceedings based on inclusion criteria, and final retrieval and assessment of available full texts. RESULTS: Systematic assessment of the articles showed different challenges in implementation of the nursing process. Intangible understanding of the concept of nursing process, different views of the process, lack of knowledge and awareness among nurses related to the execution of process, supports of managing systems, and problems related to recording the nursing process were the main challenges that were extracted from review of literature. CONCLUSIONS: On systematically reviewing the literature, intangible understanding of the concept of nursing process has been identified as the main challenge in nursing process. To achieve the best strategy to minimize the challenge, in addition to preparing facilitators for implementation of nursing process, intangible understanding of the concept of nursing process, different views of the process, and forming teams of experts in nursing education are recommended for internalizing the nursing process among nurses.

BACKGROUND: Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. METHODS: We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries. FINDINGS: Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries. INTERPRETATION: With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING: Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Background: Substance-specific mass media campaigns which address young people are widely used to prevent illicit drug use. They aim to reduce use and raise awareness of the problem.Objectives: To assess the effectiveness of mass media campaigns in preventing or reducing the use of or intention to use illicit drugs amongst young people.Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 1), including the Cochrane Drugs and Alcohol Group's Specialised Register; MEDLINE through PubMed (from 1966 to 29 January 2013); EMBASE (from 1974 to 30 January 2013) and ProQuest Dissertations & Theses A&I (from 1861 to 3 February 2013).Selection criteria: Cluster-randomised controlled trials, prospective and retrospective cohort studies, interrupted time series and controlled before and after studies evaluating the effectiveness of mass media campaigns in influencing drug use, intention to use or the attitude of young people under the age of 26 towards illicit drugs.Data collection and analysis: We used the standard methodological procedures of The Cochrane Collaboration.Main results: We included 23 studies involving 188,934 young people, conducted in the USA, Canada and Australia between 1991 and 2012. Twelve studies were randomised controlled trials (RCT), two were prospective cohort studies (PCS), one study was both a RCT and a PCS, six were interrupted time series and two were controlled before and after (CBA) studies. The RCTs had an overall low risk of bias, along with the ITS (apart from the dimension 'formal test of trend'), and the PCS had overall good quality, apart from the description of loss to follow-up by exposure.Self reported or biomarker-assessed illicit drug use was measured with an array of published and unpublished scales making comparisons difficult. Pooled results of five RCTs (N = 5470) show no effect of media campaign intervention (standardised mean difference (SMD) -0.02; 95% confidence interval (CI) -0.15 to 0.12).We also pooled five ITS studies (N = 26,405) focusing specifically on methamphetamine use. Out of four pooled estimates (two endpoints measured in two age groups), there was evidence of a reduction only in past-year prevalence of methamphetamine use among 12 to 17 years old.A further five studies (designs = one RCT with PCS, two PCS, two ITS, one CBA, N = 151,508), which could not be included in meta-analyses, reported a drug use outcome with varied results including a clear iatrogenic effect in one case and reduction of use in another.Authors' conclusions: Overall the available evidence does not allow conclusions about the effect of media campaigns on illicit drug use among young people. We conclude that further studies are needed

Introduction Exclusive Breastfeeding (EBF) rates remain low in both low-income and high-income countries despite World Health Organization recommendations for EBF till 6 months. Breastfeeding has been shown to have a protective effect against gastrointestinal infections, among other benefits. Large-scale interventions focusing on educating mothers about breastfeeding have the potential to increase breastfeeding prevalence, especially EBF, up to recommended standards and also to decrease infant morbidity. Methods A systematic literature search was conducted for RCTs and quasi-experimental studies comparing breastfeeding education or support to routine care. The effect of interventions was observed for exclusive, predominant, partial and no breastfeeding rates. The time intervals of interest were day 1, <1 month, and 1 to 5 months. Outcome-specific evidence was graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations were made from studies in developing countries for inclusion into the Lives Saved Tool (LiST) model. Results After reviewing 4600 abstracts, 372 studies were selected for full text screening and 110 of these studies were finally included. Statistically significant increases in EBF rates as a result of breastfeeding promotion interventions were observed: 43% at day 1, 30% at <1 month, and 90% at 1-5 months. Rates of ‘no breastfeeding’ reduced by 32% at 1 day, 30% at <1 month, and 18% at 1-5 months. The effect of interventions on the rates of predominant and partial breastfeeding were non-significant. Conclusion Breastfeeding education and/or support increased EBF rates and decreased no breastfeeding rates at birth, <1 month and 1-5 months. Combined individual and group counseling appeared to be superior to individual or group counseling alone. Interventions in developing countries had a greater impact than those in developed countries.

OBJECTIVE: Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support. DESIGN: Systematic review. SETTING: Hospital to home. PARTICIPANTS: Older hospitalized adults. MEASUREMENTS: For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based. RESULTS: Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization. CONCLUSIONS: These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.

Cervicobrachial pain is a common cervical spine disorder. It is frequently managed through non-invasive therapy. The objective of this systematic review was to assess effectiveness of non-invasive therapy for the management of cervicobrachial pain, in terms of pain, function and disability. Computerised searches were performed to January 2010. Studies were selected using pre-specified criteria. Methodological quality of included studies was assessed using PEDro and level of inter-reviewer agreement reported using Kappa values. Meta-analyses were conducted on pain scores for similar interventions using DerSimonian-Laird random-effects model to allow for heterogeneity. Effect sizes and 95% confidence intervals were reported. Qualitative analyses, based on Centre for Evidence Based Medicine levels of evidence, were conducted for function and disability. Eleven studies were included in the review. Interventions included general physiotherapy, cervical traction, manual therapy, exercise therapy, and behavioural change approaches. There was inconclusive evidence for the effectiveness of non-invasive management of cervicobrachial pain. Potential benefits were indicated in the provision of manual therapy and exercise and behavioural change approaches to reduce pain. General physiotherapy and traction were no more effective than comparators in reducing pain (level A evidence). Effects of non-invasive management on function and disability were mixed. Future studies should identify which sub-groups of cervicobrachial pain respond to specific interventions.

Fifteen years following the approval of the first human papillomavirus (HPV) vaccine, cervical cancer continues to be a significant source of morbidity and mortality among women in low-resource settings. It is the second-leading cause of cancer-related deaths in women globally and the leading cause of cancer-related deaths in Sub-Saharan Africa. Vaccine delivery and programmatic costs may hinder the distribution of HPV vaccines in low-resource settings, and ultimately influence access to HPV vaccines. While reviews have been conducted on the cost-effectiveness of HPV vaccines, little is known about the cost and effectiveness of vaccination strategies. The purpose of this systematic review was to synthesize evidence on the cost and cost-effectiveness of vaccination strategies utilized to increase access to HPV vaccines. Search queries were created for CINAHL Plus, Embase, and PubMed. Our search strategy focused on articles that contained information on HPV vaccine uptake/reach, HPV vaccination costs, or the cost-effectiveness of HPV vaccination programs. We retrieved 773 articles from the databases, assessed 251 full-texts, and included 15 articles in our final synthesis. Countries without national HPV vaccination programs aimed to identify and adopt sustainable strategies to make HPV vaccines available to adolescents through demonstration programs. In contrast, countries with national vaccination programs focused on identifying cost-effective interventions to increase vaccination rates to meet nationally recommended standards. There is a dire need for HPV vaccination programs and intervention studies tailored to settings in low- and middle-income countries to increase access to HPV vaccines. Future studies should also evaluate the cost-effectiveness of implemented strategies.

To date, the impacts of school-based, peer-led nutrition education initiatives have not been summarized or assessed collectively. This review presents the current evidence, identifies knowledge gaps, and provides recommendations for future research. PubMed, Scopus, ERIC and Google Scholar were searched for refereed Canadian and American primary studies published between January 2000 and November 2013, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventeen articles (11 programs) from Canada (24%) and the United States (76%) were identified. The results were summarized in terms of the study population, program design and main outcomes. Common outcome measures included healthy eating knowledge (n = 5), self-efficacy or attitudes towards healthy eating (n = 13), dietary measures (n = 9) and body mass index (n = 4), all of which tended to improve as a result of the programs. More research is needed to ascertain the effect of improvements in knowledge, self-efficacy and attitudes towards healthy eating on food behaviors. When evaluated, programs were generally well received, while the long-term maintenance of positive impacts was a challenge. Studies of sustainability and feasibility to promote long-term impact are a logical next step