To address the issue of high maternal mortality, the Government of Pakistan initiated a community midwifery program in 2006 to provide skilled birth attendance to women living in rural areas. Despite a large investment in the community midwifery program, research evidence from rural districts of Pakistan suggests that the utilization of maternal and newborn services through community midwives is very low. This exploratory study aimed to understand the facilitators and barriers influencing community midwives’ services utilization in district Thatta.A qualitative study was conducted in the rural district Thatta, Pakistan. Key-informant interviews (KIIs) were conducted with district officials of the Health department (Thatta), Maternal and Newborn Child Health Program, and Midwifery Association of Pakistan (MAP). In-depth Interviews (IDIs) were conducted with midwifery students who were currently enrolled in the midwifery program of the district; trained community midwives providing services in district Thatta, and trained community midwives not continuing their profession. IDIs were also conducted with community women to explore their views about the scope of midwifery practice and the factors influencing the utilization of community midwives’ services in district Thatta, Pakistan. Data were analyzed using qualitative thematic analysis.A total of 25 interviews  were conducted. Two overarching themes were identified: (I) community midwives’ skills and competencies; and (II) ownership and supportive supervision. The major hindering factors for community midwives’ service utilization included deficiencies in community midwives’ training particularly in clinical hands-on training, lack of ownership of community midwifery program, and lack of service structure by the CMWs regulatory body.The study has identified serious gaps in the CMWs program at the level of training and supervision of midwives in Pakistan. The study has also identified factors related to the training of CMWs that could facilitate the program in the context of Pakistan and similar settings.The online version contains supplementary material available at 10.1186/s12884-022-04823-8. It is estimated globally that every day about 830 women die due to childbirth and pregnancy related causes, which are preventable . Access There is collective evidence about the role of midwives in positive pregnancy outcomes for women and newborns . MidwifeIn Pakistan, complications during pregnancy and childbirth are the prominent causes of death in women aged 15–45 years, accounting for 12% of all deaths of women of child-bearing age . The MMRDrawing on this evidence, Pakistan introduced a community health worker-based program in 2006, named, the Maternal, Newborn and Child Health (MNCH) program in an attempt to improve maternal and newborn health indicators . There aThe government of Pakistan underwent a major reform of devolution in 2011, resulting in reorganizing the health system at the federal, provincial, and district levels . MidwifeThe community midwifery training originated as a 12 months training program in 2006 with an advancement to 24 months training period in 2018 . MidwifeMidwives are usually the first point of care for women during their reproductive health period in rural settings . AccordiNational figures show that more than 7000 community midwives are trained each year however there is an absence of data on CMWs deployment . ApproxiDespite a large investment by the government of Pakistan in the CMW program, there is poor CMW program functioning in rural districts of Pakistan . The weaThere is a need to better understand the significance and scope of community midwives for the provision of maternal and newborn health services in rural districts of Pakistan and to explore factors influencing CMWs’ utilization of services. To do so, we focused on the views of community midwives and community women of district Thatta; and health officials involved in the training and implementation of the CMW program.In view of the lack of data on poor CMW program functioning in rural areas of province Sindh, the study site selected was rural district Thatta of Province Sindh. Thatta is a predominantly rural district bordering Karachi and Hyderabad, the two largest cities in the province of Sindh with a total population of 979,817 . DespiteThere is a midwifery school in district Thatta that offers 24 months diploma program and trains more than 30 CMWs each year . The curIn order to understand the factors that influence community midwives’ services utilization in district Thatta, the study adapted the community midwifery model, guided by Chitral Child Support Program (CCSP) strategy . The CCSWe explored two factors from the CMW model (I) CMWs’ skills competencies, and (II) supportive supervision in the context of rural Thatta to explore the supportive actions provided to CMWs for their training, deployment, and implementation of the services. These factors guided our research methods in terms of structuring the data collection methods, analysis, and reporting of findings. The result of our study will inform recommendations for training and supportive supervision of the CMW program in rural areas of Pakistan.We used an exploratory qualitative study design by conducting key-informant interviews (KIIs) and in-depth interviews (IDIs) and using a semi-structured interview guide. Three researchers from Aga Khan University designed and conducted the study for the master’s thesis for Health Policy and Management Degree requirement by the first author. All researchers had expertise in relevant areas: SS and AF ; BK . The standards for reporting qualitative research guidelines were used  CMWs’ skills competencies, such as their classroom training, clinical training, skills development and competencies, and their admission criterion (2) Supportive supervision, such as the support from governments and the MNCH program, support from PNC and training school, supervision of training schools, birthing stations, and their services.The interview guides were tailored for each category of participants. The research team reviewed the interview guide for content and flow and trialed the guide for the length of time and appropriateness of the questions. The detailed interview guides are provided as Additional file Due to the restrictions in the district because of the Covid-19 situation, all the interviews were conducted via telephonic calls. These interviews were scheduled according to participants’ preference of time and were audio-recorded following verbal informed consent from study participants. Each interview lasted between 45 to 60 min. The KIIs and IDIs were carried out until the data became saturated and no new information emerged. The lead author was fluent in local languages and carried out all the interviews.The Ethics Review Committee of Aga Khan University, Karachi, Pakistan, gave the ethical approval for the study . Informed verbal consent was translated into Urdu and Sindhi language. Every aspect of the consent form was well explained to study participants including the purpose of the study, possible risks, and discomforts, possible benefits, the confidentiality of information, and data storage for 7 years in a password-protected place with the research team. Informed consent included permission to audio record the interviews and use of anonymized quotes.Data were collected and analyzed through an iterative process and data collection was ceased once saturation was achieved. The audio recordings were transcribed into Sindhi and Urdu languages and later translated into English language and cross-examined by all the researchers of the study team. Two themes from the CMW model were used to guide data coding, data analysis, and reporting of the findings. A qualitative thematic analysis approach was adopted and codes were formulated deductively from the transcripts for the predefined themes . A codebn = 5). Table n = 5) (see Table n = 5), community midwives trained but not working in their professions (n = 5) (see Table n = 5)  who were approached by the study team agreed to participate. Data was collected around two overarching themes of the CMW model (I) CMWs skills and competencies; and (II) ownership and supportive supervision. The themes and subthemes are presented in Table All the participants n = 2 who were“Admission is done district-wise. We take a written exam and interviews for the new selection. Around 120 to 150 candidates appear for the exam but our criterion is according to seats of vacant posts. We select 30 students from Union Councils where there is a need for CMWs” “Midwives are selected from those Union Councils where there is a need for CMW. There is an admission committee in which there is someone from the district office, a district coordinator, the principal of the midwifery school, and a few members from the MNCH office. This makes a committee of 6 to 7 people who do the selection” (District Coordinator MNCH)Midwifery school, Thatta involves an admission committee intended to enroll midwifery students from the areas, where there are no established community clinics. The admission committee comprises of Principal of the midwifery school, the district coordinator for the MNCH program, and district officials  of district Thatta. The students have to undertake a written and an oral exam for their selection to the midwifery diploma program. The students get selected based on the need for birthing stations in specific areas of the district, and not on the basis of merit requirements.“We perform practicums in school. We learn on dummies about the stages of labor, about cervix dilation and its assessment, and also about the obstructed labor and its treatment” (Midwifery student)“Our teachers work very hard. They really want us to save the lives of mothers and newborns in the future. They want us to be popular through the practice of our skills” (Midwifery student)In their interviews, midwifery students acknowledged the learning opportunities they get during their classroom training and during practicums arranged at the midwifery school under the supervision of tutors.“Midwives can be trained only by teachers and principals who have a background in midwifery. We see our midwives being trained by doctors and nurses. They can only teach them theory-based learning. This is why we don’t have skilled midwives” According to the International confederation of midwives, global standards for competencies of midwifery educators include completion of a midwifery education program in theory and practice, registration and licensure to practice midwifery, and two years of completion of midwifery experience . However“We go to civil hospital for our clinical rotations but we don’t perform the skills taught to us during school practicums, we mostly assist senior staff nurses in basic hygiene care and drug administration” (Midwifery student)For the practice of clinical training and to gain hands-on experience, midwifery students are assigned to a public sector District hospital, in Thatta, which is a prerequisite for completion of a midwifery diploma. Students are generally assigned to the obstetrics and gynecology department of the hospital to perform skills under the supervision of staff nurses. However, they usually assist nurses in basic vital signs monitoring and hygiene care of patients, as it was cited by midwifery students:“Students go to civil hospital and practice their skills but the staff present there does not cooperate. Some students get access to the wards and labor room but not all can practice” (District coordinator MNCH program)“We never get the opportunity to perform normal deliveries during hospital rotations. Maybe this is because the hospital staff thinks that we can make mistakes and we are still not eligible to do these cases” (Midwifery student)Nearly all the students mentioned that they were not allowed to conduct deliveries and were not provided with any supervision in case they ever got an opportunity to conduct a normal vaginal delivery. This finding was supported by one of the key informants:“The lack of exposure of community clinics to students is a problem. Students should get exposure to community clinics during their practice. They only work in hospitals and clinical settings during their training, then how can we expect them to work in an entirely different community setting. They are CMWs which means that they have to serve their communities” Almost all key informants mentioned deficiencies in the clinical training of community midwifery students. They mentioned that midwifery students do not get exposure to community clinics or birthing stations during their clinical training. Moreover, they are not provided with opportunities to liaise with senior trained and deployed CMWs in the district. This lack of exposure to community clinics and to communities does not prepare students to work in communities as stated by one of the respondents:“We deal with many high-risk patients with increased blood pressure and many other risks. But with working experience, we have learned to deal with difficult cases” (Working midwife)Midwives develop various skills while providing services in clinics or communities over time. On their own, they learn counseling skills, deal with complicated cases, delivery practices, antenatal assessment, and various maternal and newborn services. Working midwives shared their experiences and learning opportunities they get during their work.“…if training is good, if midwife’s behavior is good and the way they conduct deliveries is good, people prefer to go to midwives.” (Working midwife)All the working CMWs who were interviewed expressed association of their success, with the development of trust with the communities. Some CMWs acknowledged using their professional skills to gain the trust of the communities. A midwife’s behavior and performance attract the community toward CMWs services.“CMWs become self-sufficient when they start practicing their skills and they can earn a good amount if they have well-established clinics” Director General Nursing and Midwifery mentioned that CMWs with hands-on experience and a proficient set of skills could generate good revenue as they are licensed to run their own clinics independently without any supervision.“Out of 100 girls trained, only 5 to 10 open their birthing stations in communities and there again they face a lot of challenges. Most of the time midwives are assigned to medical and surgical wards during their training. The true midwives we want to produce are very few in Pakistan. Otherwise, girls do training for the sake of diploma, the midwives we want who can go to fields with proper training to provide services in communities are very few”. However, no proper training of CMWs is a matter of concern as only the motivated ones are successful in communities and they learn by gaining experience over time, which could result in harm to the pregnant women, fetus, and/or a newborn. Proper monitoring of newly trained CMWs who are deployed in the community is required.“…the late payment to the district coordinator that coordinates and visits birthing stations is a problem. They require some expenditure to visit clinics. MNCH program is facing financial issues which affect monitoring of CMWs of the district” The monitoring and supervision of the CMW program are inefficient as responded by all key informants. Because of inefficient monitoring and supervision, CMWs services delivery remains ineffective. CMW program is one of the vertical programs of the MNCH program in the province of Sindh. The financial deficiencies of the MNCH program hinder the monitoring and supervision of CMWs of the district.“We used to provide monthly reports to the program but we were not getting any incentive in return for it, so we have stopped reporting to them” (Working midwife) “CMWs were supposed to report to us every month. They stopped providing us the reports because of the low-cost stipend that was provided after a long delay, they started taking the jobs and services offered by NGOs and they got disengaged with us (District coordinator- MNCH program)The lack of support and supervision from the MNCH program for example non-provision of stipend, lack of monitoring of CMWs, and non-support for establishing birthing stations in their communities resulted in non-coordination of CMWs with the district coordinator of the MNCH program. CMWs were required to provide monthly reports to the MNCH coordinator. However, out of 110 deployed community midwives in the district, only seventeen CMWs were providing monthly reports to the MNCH program coordinator. The argument provided by CMWs for non-coordination and non-provision of monthly reports exhibited non-supportive actions of the MNCH program.“We don’t know the quality of CMWs we are producing because we have no monitoring and supervision system for training institutes” The monitoring and supervision of training schools are inadequate as reported by key informants. The lack of monitoring of midwifery schools affects the quality of CMWs being prepared at schools.“There is no ownership to monitor CMWs. The MNCH is responsible to plan and implement CMWs program but no one takes the ownership to monitor and fill the gaps and set targets. We do not have a defined structure. If we talk about MNCH, we don’t know about its responsibilities. MNCH looks after CMWs training, but who is responsible to monitor the indicators of MMR and IMR. We don’t have a definite answer”. .The majority of the study respondents reported about lack of ownership of the CMWs program at the national, provincial, and district levels. The lack of coordination to regulate and implement the program is a hindering factor for CMWs services. The MNCH program is directed by top-down management, where district managers are employed at the district level but are administered by the provincial government. The lack of coordination between the managers employed at different levels interposes the service structure of the CMWs program.rom last 2 years our students are not getting their stipend. There is an issue of students stipend, we have complained about it multiple times, but they don’t do anything” “F“Government used to provide us PKR 2000 ($13) after training every month. Since many years, they have stopped this. Now CMWs find work in hospitals and BHUs to earn money” (Non-working midwife)The government of Pakistan set some incentives for midwifery students to facilitate their needs and requirements during training and for deployed CMWs to enable them in the attainment of their catchment populations. Most of the study respondents discussed non-provision and deferral of provision of incentives to midwifery students and deployed CMWs. The non-provision of incentives to midwives of the district discouraged them to work at their birthing stations and they acquired jobs where they could get a fixed salary.“..The late payment to CMWs is a problem. They have to earn money. Another reason is the late payment to the district coordinator. They have to coordinate and visit birthing stations and for that, they require some expenditure. Payments are deferred for 1 to 2 years, so we do not go for visits, because we cannot pay the visit costs from our pockets. There is no proper service structure. If CMWs are trained we do not have service structure to appoint them to RHCs and BHUs” (District coordinator MNCH program)Many efforts have been made by the MNCH program for midwives such as the provision of supplies, furniture, and equipment to establish birthing stations. Despite the efforts, CMWs are not effectively utilizing their services because of late payments to midwives, late payments to district coordinators, and the non-organization of proper service structure for CMWs deployment.“Government should have provided us government setups or jobs after our training. We are struggling in NGOs for the jobs. People are poor in villages. They do not pay for our services. We have to work in NGOs to earn money” (Working midwife)All the CMWs interviewed were employed with NGOs and private organizations. None of them were working at their birthing stations. They were working with organizations where they could earn a fixed amount of salary each month. As CMWs do not have a Basic Salary (BS) scale, every organization set CMWs’ salaries to their choice. They are not provided permanent jobs in the public health system of Pakistan, and the non-provision of government jobs for CMWs is the key hindering factor to the utilization of their services.“We have 2 years midwifery program. PNC only provide us curriculum and very rarely and hardly any support is provided if there is any legal issue or any legal obligation then PNC provides support to CMWs” Pakistan Nursing Council (PNC) is the regulatory body of CMWs. It provides curriculum and certification to CMWs. Thus far, the role of PNC for training and career development for CMWs is undefined and unclear. As the name Pakistan Nursing Council highlights Nursing in its name, it dominantly contributes to the development and growth of nurses as reported by one of the key informants:“For nursing, we think a lot about higher education but for midwifery there is nothing. The midwives who are working will die in this profession being a midwife. There is no growth for them” CMWs of Pakistan face many challenges for career growth. There is a lack of higher education that has added to the indistinctness of the midwifery profession as cited by one of the key informants:The current maternal mortality ratio is 186/100000 live births, a reduction from 276/100000 live births from the 2006–7 survey . Even thThe study has identified important factors that influence CMWs’ services such as their classroom training, hand-on skills, support for clinical practicums, monitoring of training institutions, support for job provision, and support for curriculum and fieldwork. We identified only a few facilitators under the domain of CMWs training yet there were no facilitating factors from the domain of supportive supervision. This marks that these findings are imperative to the program implementers and stakeholders involved in training and particularly in the monitoring and supervision of the CMW program.The study findings suggest that the academic and clinical training of the CMW program has administrative weaknesses. Midwifery students were performing routine tasks during their clinical placements and not the skills that were taught to them in their school. The caveat in the training is the lack or almost absence of hands-on practice for conducting normal vaginal deliveries. Porter and colleagues  suggesteThe results of the study suggest that the hospital staff does not support midwives during their clinical rotations. Literature suggests that midwifery educators or senior midwives are expected to accompany students to their clinical areas . HoweverThe study results also suggest that the training lacks on how to run a small business by establishing their own home clinic or a ‘birth station’ and marketing a small business. As CMWs are not employed by the Government and are expected to earn their income by charging fees for services, it is expected for them to establish birth clinics and operate business to support them financially. This major barrier was identified by numerous studies –40, and Even though the study findings suggest that there is also a lack of ownership and administrative support for the CMW program by the government at the federal, provincial, and, district levels. The weak arrangement of the program at the district level has been highlighted as the main hindering factor for CMWs services. There is a lack of power to district-level managers and the district health system has inadequate administrative and financial control to implement the program. The provincial MNCH program is directed by top-down management where the roles of district officials are not properly defined and the program is financed by provincial authorities which is apparent by fragmentation in the program at the district level . The finThe non-provision of jobs to CMWs in the public health system and no fixed Basic Salary scale for CMWs is an additional barrier to CMWs’ services. The lack of Government support for the provision of government jobs demotivates them to continue their work and they hunt for fixed jobs at different NGOs and private organizations other than the field, they were trained for. The non-retention of CMWs in their professions has been reported in almost all provinces of Pakistan , 37. TheFindings of the study suggest that the regulatory body of CMWs ‘the Pakistan Nursing Council’ only provides curriculum and licenses to CMWs. Pakistan Nursing Council as the name suggests only possesses Nursing regulations and policies as its priority. Literature suggests that CMWs lack autonomy and self-sufficiency in countries where they do not have autonomous and independent regulatory bodies such as Nepal and Bangladesh .Our study has several strengths. First, the exploratory design of this study helped us to understand the factors from all levels of the CMW program from organization to training and implementation. Second, the rigor of the study was achieved by enhancing the credibility of the findings from different data sources. Third, the study offers midwives’ own perspectives on their working conditions and their own thoughts about possible actions to improve them. This can create a basis for further interventional research that can be adapted to the local context. The study also has some limitations. First, the data collection was done through telephonic interviews because of the pandemic situation and the facial expressions and physical observations were therefore missed during the data collection. Secondly, the study focused only on the perspective of the participants who are direct or indirect part of the MNCH or CMW program.In order to address the effective utilization of CMWs services, the study recommends intervening at all levels of the CMW program from planning to implementation. Firstly, the study provides insights to program implementers to rearrange the selection and deployment of CMWs and the training requires strengthening clinical hands-on practice. At least two days in teaching hospitals or primary care BHUs should be reserved for midwifery students to gain experience and get hands-on training. Midwifery students should be taught by certified and experienced midwives and the program should be adjusted to the local context in order to ensure sufficient exposure to community clinics and birthing stations. Moreover, the inclusion of the internship program as part of their training focused on strengthening clinical skills could be a positive addition to the program. Secondly, the MNCH program should work on strategies to empower CMWs and teach them to become respectable entrepreneurs rather than spoon-feeding them. The autonomy and authority of district-level managers for the implementation of the CMW program are very important to apply within the local context. Lastly, PNC should organize a separate division for regulations and curriculum development of CMWs and the inclusion of midwives in its title can gain recognition of this regulatory body working for CMWs.In conclusion, community midwives can play a vital role in reducing maternal and newborn mortality rates and in achieving progress in health service delivery. However, the findings suggest that these improvements cannot be made until the MNCH program and public health system takes action for re-organization and planning of the CMW program. The study provided an extensive understanding of factors influencing CMWs’ utilization of services in district Thatta.This exploratory study provided us with reflections of midwifery students, administrative stakeholders of the MNCH program and district managers, CMWs working and not working in the district, and the community married women about the factors such as CMWs training, skill competencies, and the supportive supervision that influence community midwives utilization of services in district Thatta. It helped us to understand the factors from all levels of the program from organization to training and implementation of the CMWs program. The study has identified only a few facilitators for CMWs skills and competencies yet many serious gaps in the CMWs program at the level of clinical training, deployment, ownership, monitoring, and supportive supervision. These gaps are thought-provoking for policymakers and program implementers to reorganize the CMWs program.In order to address the effective utilization of CMWs services, the study recommended intervening at all levels of the CMW program from planning to implementation. A well-trained, properly deployed, and supervised CMW can deliver the required services in rural areas of Pakistan. This can help to achieve the aim of introducing the CMW program in Pakistan. However, disregarding the supervision and training of CMWs in the health system, the aim of development of this cadre cannot be achieved.Additional file 1. COREQ  Checklist.Additional file 2. Interview Guide.Additonal file 3. Thematic Map.


Learning-focussed educational models require the development of pedagogical, methodological, assessment and technological competences among the faculty community. The COVID-19 pandemic has accentuated the need for this training. This study evaluates the impact of the training project “Educate to Transform” on teacher attitudes, knowledge and on the implementation of innovative teaching methodologies. There were 695 faculty participants in the program conducted at the Universidad Francisco de Vitoria (UFV). Participants included full-time professors (FULL-PROF) and part-time professors (PART-PROF). The measurement instrument was validated using the entire sample and a subsample of 357 participants was used to analyse the impact of the program (pre and post measurement). Professor attitudes and knowledge of or familiarity with innovative methodologies and their application in the classroom were evaluated. The findings show that the program improved the attitudes of teachers towards innovation, raised the level of awareness and number of methodologies implemented in the classroom. The methodology towards more experiential and collaborative learning is effective in transforming teaching practice. Furthermore, the implementation of the program through the CANVAS platform, making teachers live the experience as learners, seems to have contributed to improve the teachers' attitude towards the LMS. The only difference found among the participants was a worse attitude towards innovation on the part of medical teachers, with a clearly differentiated profile of teachers and students, as well as a greater implementation of active methodologies by teachers with a lower teaching load. Overall, it may be concluded that the program achieved its proposed objectives. Professors, as the activators of student learning and a fundamental element in achieving significant change in the quality of higher education  tend to address the professional development of their professors from a conventional perspective, with short training courses that are insufficient and offer limited opportunities for the exchange of experiences Vu, . Many reThe global health crisis caused by COVID-19 has forced universities to address the challenge of digital transformation head-on. The COVID-19 pandemic affected the educational sector throughout the world to go online  or to a “new normal”, characterized by online teaching or in-class teaching that are also video-recorded and/or streamed? This question is part of a wider debate on whether the world and society will be able to take advantage of the changes that have occurred during the COVID-19 crisis with regard to the reduction in greenhouse gasses and waste emissions, and, more generally, towards a more sustainable future  Universities, but rather exploit the digital technologies while keeping a strong link between research and teaching activities and the unique on-campus student experience. This is particularly true in technical-scientific fields, in which the face-to-face practical and research activities  are particularly important. Therefore, traditional Universities should take advantage of the experience gained during the COVID-19 emergency to reshape the content as well as the didactical methodologies of their study programs in order to meet changing students’ needs.In order to be ready for this “new” normality and to succeed in digital transformation (Uni 4.0), Universities – but also more generally countries and policy makers – should consider the key aspects discussed in Section The COVID-19 pandemic has returned us to some of the core questions underpinning systems of HE, such as what are universities for Collini, ? What doEspecially in times of crisis, when the existential questions around the purposes and practices of education become re-emphasized, the act of re-imagining educational utopias is a necessary exercise.Some of the challenges identified and highlighted by many researchers are summarized as follows: Broadly identified challenges with e-learning are accessibility, affordability, flexibility, learning pedagogy, life-long learning and educational policy  in changing the attitudes of professors at the faculty of Universidad Francisco de Vitoria (UFV) and increasing the knowledge and application of innovative methodologies, tools and resources in teaching practice. The ETC training program was conceived as an opportunity to advance in the educational project of the UFV, with an eye to the uncertainties of the 2020–2021 academic year. ETC is based on the educational philosophy of the UFV within the framework of the 2023 Strategic Plan of the university and was designed and implemented as the necessary roadmap to carry out its mission, the search for truth and goodness for social transformation.The first step is to inspire existential considerations in the teacher, thus favouring the creation in the classroom the necessary climate for the formulation and expression of searching questions. In this way, the style of the professor and their teaching strategy affect the mood of the classroom, the participation of the students, their attention levels and understanding and thus taking full advantage of the class , the number of recognised elements involved in teaching work  since its implementation will increase (hypothesis 2), the number of recognised elements involved in teaching work  since its adaptation will increase (hypothesis 3), and the number of teaching elements  that are applied in the classroom will increase (hypothesis 4). That is, from an improvement in the attitude of lecturers, from an improvement in the recognition of the teaching elements involved, with a double perspective: Implementation and adaptation, and from an increase in the application of them.Moreover, it is expected to find differences in attitude, knowledge and practices according to the profile of the participants, being these full-time professors (FULL-PROF) and part-time professors (PART-PROF), and of the faculty in which they teach .The total population of the study consisted of 1.850 people of the Universidad Francisco de Vitoria, consisting of 1.300 full-time professors (FULL-PROF) and 550 part-time professors (PART-PROF).A total of 695 people participated in the study Table , of whomThe complete sample of 695 people was used in verifying the reliability and validity of the questionnaire.To analyse the impact of the training program, the sample consisted of 357 participants who answered both the pre and post evaluation. These participants were distributed in the three editions of the program, 61 participants in the first, 110 in the second and 183 in the third. Of the 357 participants, some 252 were FULL-PROF (70.6%) and 105 were PART-PROF (29.4%). The average age of the participants was 46.14 (SD = 9.79), the youngest was 24 years of age and the oldest 68. By gender, 188 were women (52.7%) and 169 men (47.3%).n = 35), 24.6% from Communication Sciences (n = 88), 16.3% from Health Sciences (n = 58), 11.9% from Experimental Sciences (n = 43), 20.6% from Legal and Business Sciences (n = 74), 12.3% from Education and Psychology (n = 16) and 4.4% from Medicine (n = 16).In terms of the distribution by faculties in which teaching was given, 9.9% were from the Polytechnic School  were formed, together with a community of designers and trainers who were responsible for developing and accompanying lecturers in their experience and learning.The total duration of the program was one month: two intensive weeks of knowledge acquisition in online format, one of tutorials in which to to deepen and reflect on what was learned, and one last week to start to put into practice what had been learned in the assembly of the virtual classrooms of the different subjects. During the months of June and July, to ensure personalised attention and accompaniment of the lecturers, three editions of the program were carried out. In addition, an intensive version (Canvas Express) was designed for new lecturers who joined in September and a reminder course (Canvas Refresh).Three synchronised, online points of encounter were established:Introductory Seminar: to inspire and contextualise change, four models of the training project were addressed , the role of evaluations as part of the learning process, the importance of innovation in teaching practice through different methodologies and the potential of the new platform in virtual learning.Encounter Session: to share, in community, the discoveries and skills acquired as well as to foment links between different models and the path travelled thus far.Closing Session: a plenary session to summarise, in community, the skills acquired and organise their application to the courses, involving the redesign of courses, teaching guides and virtual classrooms.2.Canvas4ALL: an asynchronous, gamified online learning experience in which UFV professors were taken on a virtual tour of various countries considered leaders in education. The aim was to share learning experiences and reflection in pairs before beginning the first mission; the professors selected a community which best fit with their interest in the journey . In each of the five stops on the tour professors were presented with a series of missions to overcome with the aim of discovering best practices in teaching innovation and evaluation using the tools provided by the new Canvas platform. Professors were given personalised feedback on the work submitted for each stage.3.Hinge session: consisting of three sessions designed to guide professors in discovering the educational model of the UFV:Canvas as a pedagogical space: best practices which demonstrate the opportunities for the design and generation of experience offered by the Virtual Classroom.Pedagogical outlook: this addresses questions such as: what is the goal of my course? What are the desired learning outcomes? What should be the teacher-student relation?Formative activities: inviting each professor to rethink science in terms of four broad themes: anthropology, epistemology, ethics and meaning UFV, , p. 13.LevelUP: consisting of a catalogue of 22 asynchronous online seminars to further explore active methodologies, tools and resources to favour effective learning, student autonomy and facilitate the teacher-student relationship. To pass this block professors were expected to develop a proposal for the application of a methodology and/or tool and share it with the rest of the professors and facilitators of the UFV Community.4.Group Tutorials: synchronous online sessions to analyse in-depth the methodologies and tools that raised the most interest during the course.The program was designed applying the pedagogical model of the university (Awake—Discover—Decide). Figure To accompany the professors on their journey a community of change agents, expert in new technologies and methodologies was on hand to accompany professor, particularly in Canvas4ALL (Happeners) and LevelUP (Facilitators).The reliability was evaluated using Cronbach’s alpha and McDonald’s omega. To verify the fit of the resulting Exploratory Factor Analysis (EFA) a Confirmatory Factor Analysis (CFA) was conducted. The CFA tests the theoretical validity of the model, later contrasted with the data drawn from the sample  and after their participation in the program ; regarding knowledge of the implementation of these elements, both prior to the program  and after ; knowledge of the suitability of these elements, both prior to the program  and after ; and their practical application in teaching, both prior to the program  and after participation .Before beginning with the verification of the proposed hypotheses, the results of the three editions of the program were analysed and compared to verify that any particular edition did not unduly effect the results. An evaluation of the sample of participants of the three editions show similar values for attitude, both prior to the program , and towards innovation  and the LMS  . The results show that there was an improvement both in the general attitudes  and their dimensions, both in attitude toward innovation  and toward LMS , both before and after the program was performed.In relation to the differences in attitude change between FULL-PROF and teaching PART-PROF, both groups returned similar results in total attitude (Fp < 0.05) and Communication Sciences  have been found to be the faculties that have the best overall attitude after attending the program. This contrasts with the Medical Faculty, which showed the worst attitude . In the attitude toward innovation, it is the Faculty of Legal and Business Sciences that presents a better attitude , compared with the Faculty of Medicine, which presents the worst attitude . No differences were found in attitude toward LMS.As for the differences between faculties, the Faculty of Experimental Studies , with an increase in awareness of their suitability  and the number of elements applied in the classroom  . No differences were found between faculties.In relation to differences between profiles, the results show that teaching PART-PROF  apply more methodologies after the course of the program than FULL-PROF.   and LMS  (hypothesis 1), the university professors reported that they were familiar with how to implement  (hypothesis 2), the suitability  (hypothesis 3) and the application  (hypothesis 4) of a greater number of active methodologies, tools, evaluation instruments and resources for teaching practice. Furthermore, the elements of teaching practice where there were changes, such as Project Based Learning, Problem Based Learning, cooperative learning and flipped classroom, are student-centred, making the student the active agent in the learning process. This transformation in the attitude of professors with greater familiarity and application of active methodologies, evaluation instruments and multimedia resources, will most likely have a positive effect on the quality of the teaching–learning process. And also, in its ability to design face-to-face courses with the support of technology, such as instructional, pedagogical and didactic design for online or hybrid courses, with active learning methodologies and adequate digital resources and applied in accordance with e-learning quality standards. Facilitating, in turn, the scalability in the implementation of new technologies, thanks to the best digital skills of teachers.The results of the study show that the training program met the proposed objectives and hypotheses. After the implementation of the program there was an improvement in attitudes towards innovation  and Communication Sciences , while the worst attitude was found in Medical Faculty . A possible explanation for the differences found between faculties may be due to the different dynamism and participation in the course. This result could be due to the small number of the sample and to the fact that most of the teachers were external . On the other hand, the profile of medical students, who are very focused on passing a qualification exam, are less receptive to teaching changes, perhaps generating a subjective reluctance on the part of their teachers.The difference between the FULL-PROF  and PART-PROF  in the implemented methodologies could be explained because may be due to a greater resistance to the pedagogical change of FULL-PROF, due to its high workload. While the PART-PROF, having less teaching load, perceive themselves as more available and hence have a better attitude. No differences have been found in terms of knowledge because knowing in both cases comes in the same way, innovation days, dissemination, congresses… the difference is found when applying it in the classroom.In addition to the effect on professors, the design of the training program and its implementation reveal aspects of training that should be taken into account for future actions in teacher training. The results show that the change in methodology towards more experiential and collaborative learning, even in an asynchronous online format, is effective in the transformation of teaching practice. The implementation of the program through the CANVAS platform appears to have helped improve the attitude of professors towards LMS, as their own experience as students using the platform was an opportunity for them to experience first-hand the potential of the platform.It is also a very valuable contribution that the design of training under an experiential methodology, which has made them live the experience of their students in first person, totally changes the teacher's mindset when designing their courses in the virtual classroom. On the other hand, the methodology and the platform used allow the program to have scalability, being able to reach a large number of teachers without making large investments.Future lines of research should explore further the causes of the lack of transfer to teaching practice those methodologies in which there was increased awareness both in terms of application and suitability, as was the case with service-learning. In this case, a possible hypothesis may be the difficulty in implementing this methodology is due to the need for structural resources (Romeu et al., An intelligent analysis of the qualitative information gathered in the training program, learning diaries and action plans submitted by teacher in LMS using Natural Language Processing and Machine Learning, along with self-classification data of teacher by characteristic profiles regarding their attitudes towards experiences and life, will permit the creation of a map of attitudes and aspirations from a new perspective that can aid the development of personalised training programs. This analysis would also contribute to a more complete and consolidated vision of the outcomes of the training programs.One of the limitations of the study is the use of a single source of assessment such as lecturer perception (Madinabeitia & Lobato,


The benefits of near-peer learning are well established in several aspects of undergraduate medical education including preparing students for Objective Structured Clinical Examinations (OSCEs). The COVID-19 pandemic has resulted in a paradigm shift to predominantly online teaching.This study aims to demonstrate the feasibility and benefits of an exclusively online near-peer OSCE teaching program in a time of significant face-to-face and senior-led teaching shortage.A teaching program was delivered to penultimate-year students by final-year students at Manchester Medical School. Program development involved compiling a list of salient topics and seeking senior faculty approval. Teachers and students were recruited on Facebook. In total, 22 sessions and 42 talks were attended by 72 students and taught by 13 teachers over a 3-month period. Data collection involved anonymous weekly questionnaires and 2 separate anonymous student and teacher postcourse questionnaires including both quantitative and qualitative components.P<.001). Teachers felt the program helped them better understand and retain the subject material taught  and develop skills to become effective clinical teachers .On a scale of 1-10, students rated the quality of the program highly  and felt the sessions were highly useful in guiding their revision . There was a significant increase in perceived confidence ratings after delivery of the program (This is the first study demonstrating the efficacy of a near-peer OSCE teaching program delivered exclusively online. This provides an exemplary framework for how similar programs should be encouraged given their efficacy and logistical viability in supplementing the undergraduate curriculum. This coNear-peer teaching has grown in popularity in recent years within medical schools as a means of supplementing the formal curriculum. This paradigm shift was perhaps to be expected, given the sheer volume of literature advocating its benefits and effectiveness. For instance, Rodrigues et al  report oSince the World Health Organization declared COVID-19 a global pandemic, widespread global lockdown restrictions resulted in a shift to online learning and cancellation of most face-to-face teaching and assessments . Even prIn this paper, I aim to outline how an online near-peer Objective Structured Clinical Examination (OSCE) teaching program can enhance the preparedness, knowledge, and skills of both the student and the teacher. In doing so, I aim to demonstrate that such endeavors are practical, reproducible, easy to implement, and valuable adjuncts to the medical undergraduate curriculum.Consultation with the University of Manchester’s ethics decision tool  revealedManchester Medical Society page facilitated advertisement of the program to prospective NPTs and NPLs. NPTs expressing interest were added to a group chat, while NPLs followed a link to join a Facebook page. An instructional sheet was sent to all the NPTs. It incorporated reminders to include disclaimers, keep the presentations under 30 minutes, have them completed by a particular date before being sent for quality assurance by the head of clinical teaching, and include an OSCE practice scenario at the end of their presentations to contextualize the taught content. This ensured session standardization and OSCE relevance.The fourth-year syllabus at Manchester Medical School is split into 2 distinct overarching themes: “families and children” (F&C) and “mind and movement” (M&M). The programs, therefore, consisted of 2 separate weekly, hour-long sessions on Zoom, 1 for each theme. Each session was split into 2 separate 30-minute lessons delivered by 2 NPTs. A total of 42 talks were delivered over 3 months, covering a range of topics within each theme . PresentAnonymized weekly feedback questionnaires, 1 for the M&M and 1 for the F&C theme, were distributed using Google Forms following each session. This functioned as a means of tailoring future sessions toward the needs and wishes of the NPLs.In addition, 2 separate postcourse questionnaires were distributed to NPLs and NPTs at the end of the program  and 4. Tt test analysis compared confidence ratings of NPLs prior to and after the course. The remaining items in the NPL and NPT postcourse questionnaires were analyzed by mean and SD.A paired 2-tailed Two NPTs conducted qualitative analysis of the free-text sections in the NPL and NPT postcourse questionnaires. This involved identifying and agreeing on common themes and categorizing each response appropriately.The 22 sessions (11 for F&C and M&M each) were attended by a total of 72 different NPLs and taught by 13 NPTs. The F&C weekly session attendance ranged from 8-26 NPLs . The M&M weekly session attendance ranged from 11-26 NPLs . Overall weekly attendance across the 2 themes ranged from 21-49 NPLs .t test analysis demonstrated a statistically significant increase in mean confidence ratings following delivery of the program . Quality of teaching, usefulness of the OSCE scenarios, and usefulness in guiding revision were all rated highly , and the remaining indicating it is either somewhat likely or very likely (n=13), or it is somewhat unlikely (n=1). Of 37 students, 23 (62.16%) left comments in the free-text sections. Qualitative analysis revealed 8 broad themes with some overlap .Of 13 NPTs, 11 (84.62%) completed the NPT postcourse questionnaire. Respondents unanimously agreed that engaging with the program helped them better understand the material taught , facilitated long-term retention of the content , helped them develop their teaching skills , was rewarding and motivational in engaging in more teaching in the future , and was highly enjoyable  .Thematic analysis of the 2 free-text sections mostly reinforced findings from these rating questions. When asked what the NPTs felt the greatest benefit of the program was, 3 broad themes emerged, with some overlap .The “any positive comments/areas for improvement” section comprised of 3 comments expressing gratitude for organizing the program. A summary of the key findings from both questionnaires can be seen in In line with the existing body of literature, this study clearly demonstrates the value of undergraduate near-peer programs for both the student and the teacher. Crucially, it demonstrates a significant increase in NPLs’ perceived confidence to sit their OSCE examinations. Simulated OSCE scenarios and the setup of the sessions in helping guide revisions explain this finding. The study also demonstrates numerous benefits obtained by NPTs including enhanced comprehension and retention of the taught materials, development of teaching skills, and increased motivation in engaging with future teaching endeavors.P<.001) in NPLs’ confidence in the OSCE performance. Evaluation of the free-text sections in the weekly questionnaires helped tailor future sessions suitably. For instance, the overwhelmingly positive reaction to the OSCE scenarios prompted organization of 2 sessions focusing exclusively on such scenarios for the final week of the program. The perceived benefit of these scenarios was mirrored in the NPL postcourse questionnaires’ average rating of usefulness of the scenarios ; it also supports the notion that simulation exercises in medical education lead to improvements in knowledge, confidence, and procedural performance upon retesting [A variety of reasons can account for the significant increase  and long-term retention  of the taught material. These findings are supported by multiple prior studies  and analFirst, the data collected and interpreted from the questionnaires in this study mostly deal with perceptions and lack objective measures. Future endeavors will look to collect data from tangible objective outcomes . Second, connectivity issues occasionally interfered with the delivery of teaching and our ability to share media and video clips—a drawback also identified by Mageswaran and Ismail , and 2 oNumerous studies have established the value of the near-peer model in undergraduate medical education, including facilitation of OSCE preparedness ,22. Howe


Substance misuse among adolescents is a public health problem because of its prevalence and consequences.i) To develop a culturally adapted version of the Unplugged program in Chile, renamed as “Yo Sé Lo Que Quiero (YSLQQ)”, for substance use prevention; ii) To evaluate the acceptability and feasibility of its implementation.Pilot study, with randomized controlled trial design, with two arms . The sample consisted of 1,556 students from 6th to 8th grade from six schools (1:1 ratio) in Santiago, Chile. The IG received the 12 sessions of the YSLQQ program and the CG the usual substance use prevention activities. Acceptability was assessed through a student questionnaire, and feasibility through teacher self-report.More than half of the students reported that they liked the sessions. 61.3% were satisfied with the duration of the program and 61.7% with the activities. 68% of students agreed that the program helped them to have more refusal skills towards tobacco, alcohol, and drug use in the future. On the other hand, concerning feasibility and fidelity, 88.9% of the teachers remained faithful to the manual, and 91.6% of the activities were fulfilled according to the manual.The present study demonstrated that “Yo Sé Lo Que Quiero” program is acceptable and feasible for future implementation in adolescents.No significant relationships.


Child maltreatment impacts many young people involved in the child welfare system, and it is important that the resource parents supporting these youth have knowledge and skills in trauma-informed care. The current study is a preliminary evaluation of the Resource Parent Curriculum (RPC), an in-service, 8-module, group-based parenting program developed by the National Child Traumatic Stress Network. Youth and caregiver outcomes were examined by way of a quasi-experimental design that included 22 resource parents in the experimental group and 21 in the waitlist control group and involved baseline, post-program, and 2-month follow-up assessments. For learning outcomes, RPC resulted in improvements in resource parents’ knowledge and beliefs about trauma-informed parenting. While not statistically significant, potential effects included improvements in resource parents’ tolerance of challenging youth behaviors and parenting self-efficacy. For behavioral outcomes, several non-significant potential effects were noted, including improvements in resource parents’ attachment relationships with their youth and increased social supports. This study was the first to evaluate RPC using a quasi-experimental design within a Canadian context and through a virtual delivery. Findings highlighted several benefits of the program and resource parents’ ongoing training needs. In Ontario (Canada), the services of child welfare are triggered once a member of the community  makes a report of suspected child maltreatment or risk thereof, which may include physical abuse, neglect, emotional abuse, sexual abuse, concerns regarding caregiver capacity, and/or exposure to intimate partner violence involving a young person under the age of 16 . CaregivYoung people involved in the child welfare system are at increased risk for physical health problems, poor educational outcomes, mental health difficulties, externalizing behavior, involvement in the justice system, suicidal behavior, and decreased wellbeing overall ,6,7. ResThe recruitment and retention of resource parents are key factors in the delivery of quality foster care services ,12. FactNot only is resource parent retention important, but good-quality resource caregiving is crucial for ensuring positive youth outcomes and resource parent satisfaction ,16,17. YWhile there are several existing programs, the focus of the current study is on the program, Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents, otherwise known as the Resource Parent Curriculum (RPC). Kemmis-Riggs and colleagues  identifiRPC is an 8-module curriculum that was designed to help therapeutic, foster, adoptive, and kinship caregivers, and group home providers, build their trauma-informed caregiving skills. This program was developed in the United States and is intended for resource parents of youth from birth to age 21. The overall goals of RPC are fourfold: (1) Increase knowledge and beliefs related to trauma-informed parenting; (2) Increase caregivers’ ability to tolerate challenging youth behaviors; (3) Increase parenting self-efficacy; and (4) Increase awareness and the importance of self-care and connections with other resource parents . The eigThe objectives of the current study were to conduct a preliminary evaluation of the Resource Parent Curriculum (RPC). This study consisted of a quasi-experimental design that included within- and between-subject factors. The within-subject factor was time point with three levels , and the between-subject factor was group condition with two levels . While the larger evaluation included both primary and secondary outcomes, the current study focused on primary outcomes, which consisted of key variables deemed essential to the research question and directly assessed by the RPC program .Outcomes were organized according to Kirkpatrick and Kirkpatrick’s  four levThe majority of resource parents (90.5%) identified as female and were 47 years old on average (range 23–70 years). The majority identified as white (90.5%) and married (62.8%). For educational background, most had completed some community college (46.5%) or a bachelor’s or undergraduate degree (23.3%). In terms of work, 39.5% of resource parents identified their main activity as caring for family, and the same percentage identified both caring for family and working for pay/profit (39.5%). While almost 20% of resource parents chose not to disclose their income, just over half reported an income (in Canadian funds) of less than $100,000. The majority of resource parents were foster caregivers (69.7%), followed by adoptive (32.6%), therapeutic , kinship (9.3%), future adoptive parents (6.9%), and group home providers (4.7%). Note that values exceed 100% because resource parents could select more than one option. The majority of resource parents (79.1%) indicated that they attended the Parent Resources for Information, Development, and Education (PRIDE) training, which is a mandated pre-service training for resource parents in Ontario. Parents identified additional completed trainings, and responses were wide-ranging . On average, resource parents had been in their role for just under 10 years and had an average of two non-birth children in their care .Knowledge and Beliefs Survey. To assess learning, resource parents completed the Knowledge and Beliefs Survey , which iProtective Factors Survey. Resource parents completed the Protective Factors Survey—Second Edition (PFS-2) , which iParenting Stress Index-Short Form, Fourth Edition. Resource parents caring for youth 12 years of age and younger completed the Parenting Stress Index-Short Form, Fourth Edition (PSI-SF) . The PSIFollowing ethics approval from our university’s research ethics and integrity services, we recruited resource parents through collaboration with two Ontario child welfare agencies and through the community. Resource parents could complete the program without participating in the research. To participate in the RPC program, individuals were required to be a current resource parent in Ontario and have access to a computer or phone with internet. To participate in the research study, they also agreed not to participate in other parenting programs throughout the duration of the research. While group home providers are not traditionally considered resource parents, they nonetheless play a critical role in providing care for youth residing in group home residential placements. Thus, it was deemed important to also offer the intervention to these professionals and include them in the evaluation. To assist them in most accurately completing the measures, group home providers were provided with additional instructions, as some of the measures use language such as “my child”. In particular, they were instructed to consider one particular child with whom they work within the context of their professional role. Baseline assessment occurred approximately two weeks prior to the beginning of the first module. Resource parents had the option to complete the questionnaire online or by paper. Assessments at the three time points were tracked through a code that resource parents developed. The questionnaire package took approximately 30 min to complete, and resource parents received a $25 gift card for their participation at each data assessment cycle.Delivery of the RPC program followed NCTSN implementation guidelines. The program was delivered virtually using a videoconferencing platform due to the COVID-19 pandemic and public health measures. The virtual delivery required only minor modifications to certain activities. The modules were shortened from two hours to 90-minutes in length to reduce barriers to attendance, but all program content was covered. There were six groups in total, including three experimental and three waitlist control groups. The first author was the main facilitator for all six groups. Five of the six groups received eight 90-minute long modules delivered once per week for eight weeks. Due to scheduling constraints, one waitlist control group received 90-minute modules twice per week for four weeks. Five of the six groups were conducted with a co-facilitator with lived experience. There was one group that did not have a co-facilitator due to difficulties finding an available co-facilitator. The facilitator and co-facilitator completed all necessary training available through NCTSN in preparation for facilitating the training.For the experimental groups, a fidelity monitor (a trained graduate-level research assistant) attended each module to ensure the program was being delivered as intended according to facilitator guidelines. All program components were covered according to the fidelity checklist. Program attendance was also collected for all resource parents. The facilitator contacted all resource parents who missed a module and conducted a phone catch-up call to ensure resource parents were exposed to the material. Approximately 60% of resource parents in the experimental condition attended all eight modules, 27% attended seven, 9% attended six, and 4% attended five modules.Within one week after the completion of the training for the experimental group, resource parents in both the experimental and waitlist control groups completed the post-program questionnaire. Two months later, the 2-month follow-up questionnaires were completed. Following this data collection, resource parents in the waitlist control group participated in the RPC program. Two resource parents in the waitlist control group endorsed completing the PRIDE training when asked about participation in other forms of parenting interventions. No resource parents in the experimental condition reported participating in other parenting interventions. While further context or details are not known, depending on the resource parent type, it is possible they had not yet taken PRIDE when they began caring for their youth or were required to take it because it is a ministry requirement for some resource parents in Ontario (Canada).2 = 614.96, p = 1.00). Missing data ranged from 0 to 4.8% at baseline, post-program, and 2-month follow-up. Missing data were imputed using the expectation-maximization (EM) method. No significant issues with outliers, skewness, or kurtosis were found [Questionnaire items were screened prior to statistical analyses for data entry accuracy, missing values, and univariate assumptions. A missing values analysis (MVA) showed that Little’s MCAR test was not significant, and therefore, the data were determined to be missing at random  than in the experimental condition . Thus, this variable was used as a covariate in all analyses. Overall, these results suggest that the two groups were fairly well matched despite the lack of randomization. For all outcomes reported, the impact of the covariate  was not significant.Chi-squared and t-tests, and significant interactions were followed up with independent samples t-tests.A series of univariate analyses were conducted using a repeated-measures General Linear Model. Learning outcomes included knowledge and beliefs regarding trauma-informed parenting, tolerance of challenging behaviors, and parenting self-efficacy. Behavioral outcomes consisted of attachment, social supports, concrete supports, and resource parent-youth difficult interactions. The assumption of sphericity was examined using Mauchley’s Test of Sphericity. If Mauchley’s Test of Sphericity was significant, the assumption of sphericity was violated, and the Huynh-Feld corrected results were interpreted. Significant effects of time were followed up with paired samples t-tests to examine between- and within-group differences at post-program and the 2-month follow-up. Experiment-wise error was a concern due to the inclusion of a series of analyses. Due to the preliminary nature of this evaluation, results with substantial effect sizes that failed to reach significance were still worth considering as areas to explore in future research [Post-hoc exploratory analyses were also conducted for non-significant learning and behavioral outcomes to further explore potential effects given the preliminary nature of this evaluation. Post-hoc exploratory analyses consisted of independent samples and paired samples research . Thus, tp = 0.80). The mean baseline scores for trauma-informed parenting were 4.69 for the experimental group and 4.51 for the waitlist control group, which were not significantly different (see t(41) = −0.81, p = 0.21). These scores were generally on the higher end of the 6-point Likert scale. There was a significant impact of time (large effect) and time X group interaction  = −2.38, p = 0.01), but no significant differences were found between post-program and the 2-month follow-up (t(20) = 1.29, p = 0.11). Similarly, resource parents in the experimental group also reported significant increases in trauma-informed parenting from baseline to post-program (t(21) = −6.37, p < 0.001), but no significant differences were found between post-program and the 2-month follow-up (t(21) = −0.86, p = 0.20). For the interaction, the experimental group reported significantly higher trauma-informed parenting at both post-program (t(41) = −3.04, p = 0.002) and 2-month follow-up (t(41) = −2.37, p = 0.01), compared to the waitlist control.In terms of the General Linear Model, Mauchly’s Test of Sphericity was not significant for trauma-informed parenting . The mean baseline scores were 4.30 for the experimental group and 3.99 for the waitlist control group, which were not significantly different (see t(41) = −1.04, p = 0.15). Scores were generally on the higher end of the 6-point Likert scale. There was no significant impact of time  or time × group interaction  = 0.22, p = 0.42) or from post-program to 2-month follow-up (t(20) = −0.88, p = 0.19). Conversely, those in the experimental group reported significant increases in their tolerance of challenging behaviors from baseline to post-program (t(21) = −2.48, p = 0.01) but not from post-program to 2-month follow-up (t(21) = 0.69, p = 0.25). For potential between-group differences, despite no statistically significant baseline differences, the experimental group reported a significantly higher tolerance of challenging behaviors at post-program compared to the waitlist control (t(41) = −2.07, p = 0.02). However, the scores for the two groups did not differ significantly by the 2-month follow-up (t(41) = −1.60, p = 0.06).For the General Linear Model, Mauchly’s Test of Sphericity was not significant , and the Huynh-Feldt corrected results were used. The mean baseline scores for parenting self-efficacy were 4.86 for the experimental group and 4.66 for the waitlist control group, which were not significantly different (see t(41) = −0.81, p = 0.21). Scores were on the higher end of the 6-point Likert scale. There was no significant impact of time  or time × group interaction  = −0.28, p = 0.39) or from post-program to 2-month follow-up (t(20) = 0.00, p = 0.50). Conversely, resource parents in the experimental group reported significant increases in their parenting self-efficacy from baseline to post-program (t(21) = −2.88, p = 0.01) but not from post-program to 2-month follow-up (t(21) = −0.57, p = 0.29). For potential between-group differences, despite no statistically significant baseline differences between the experimental and waitlist control groups, resource parents in the experimental group reported significantly higher parenting self-efficacy at post-program (t(41) = −2.39, p = 0.01) and at 2-month follow-up (t(41) = −3.05, p = 0.00), compared to those in the waitlist control.In terms of the post-hoc exploratory analyses, resource parents in the waitlist control group reported no significant changes in their parenting self-efficacy from baseline to post-program (p = 0.41). The mean baseline scores were 2.71 for the experimental group and 2.49 for the waitlist control group, which were not significantly different (see t(41) = −1.05, p = 0.15). Scores fell within the mid-range of the 5-point Likert scale. 2 = 0.00, small effect) or time × group interaction . For the post-hoc exploratory analyses, resource parents in the waitlist control group reported no changes in their attachment relationship with the youth from baseline to post-program (t(20) = −1.05, p = 0.15) or from post-program to 2-month follow-up (t(20) = 1.59, p = 0.06). Although resource parents in the experimental group reported no significant changes in their attachment relationship with the youth from baseline to post-program (t(21) = 0.54, p = 0.30), they did report significant improvements from post-program to the 2-month follow-up (t(21) = −1.81, p = 0.04). For potential group differences, the two groups did not differ significantly at post-program (t(41) = −0.28, p = 0.39). However, those in the experimental group reported significantly higher attachment than those in the control group at the 2-month follow-up (t(41) = −1.77, p = 0.04).For the General Linear Model, Mauchly’s Test of Sphericity was not significant . The mean baseline scores were 3.04 for the experimental group and 3.06 for the waitlist control group, which were not significantly different (see t(41) = 0.10, p = 0.46). Scores generally fell within the mid to high end of the 5-point Likert scale. There was no significant effect of time  or time × group interaction  = −0.62, p = 0.27) or from post-program to 2-month follow-up (t(20) = 1.30, p = 0.10). Resource parents in the experimental condition reported significant changes in social supports from baseline to post-program (t(21) = -2.33, p = 0.02), but no significant changes were found from post-program to 2-month follow-up (t(21) = 0.33, p = 0.37). For potential between group differences, although the two groups did not differ significantly at post-program (t(41) = −0.29, p = 0.29), those in the experimental group reported significantly higher social supports at the 2-month follow-up (t(41) = −1.82, p = 0.04).For the General Linear Model, Mauchly’s Test of Sphericity was not significant , so the Huynh-Feldt corrected results were used. The mean baseline scores were 3.80 for both the experimental group and waitlist control group and were not significantly different (see t(41) = −0.02, p = 0.49). Scores fell within the mid to high end of the 5-point Likert scale. There was a significant effect of time , but no significant time × group interaction  = 2.12, p = 0.02), but no significant differences were found from post-program to 2-month follow-up (t(20) = −1.60, p = 0.06). On the other hand, resource parents in the experimental group did not report any significant changes in their concrete supports from baseline to post-program (t(21) = 0.39, p = 0.35) or from post-program to 2-month follow-up (t(21) = −1.05, p = 0.15). For the post-hoc exploratory analysis, potential between group differences were examined. The two groups did not differ significantly at post-program (t(41) = −1.21, p = 0.12) or at 2-month follow-up (t(41) = −1.11, p = 0.14).For the General Linear Model, Mauchly’s Test of Sphericity was significant . The mean baseline scores were 28.60 for the experimental group and 31.80 for the waitlist control group, which were not significantly different (see t(18) = 0.77, p = 0.23). Scores fell within the mid-range of the overall scale. There was a significant impact of time  but no significant time X group interaction  = −0.07, p = 0.47) but did report a decrease from post-program to 2-month follow-up (t(9) = 2.67 p = 0.01). Resource parents in the experimental group did not report a significant change in their difficult interactions with youth from baseline to post-program (t(9) = 1.23, p = 0.13) or from post-program to 2-month follow-up (t(9) = 1.42, p = 0.09). A post-hoc analysis for potential differences between groups was conducted. The two groups did not differ significantly at post-program (t(18) = 1.39, p = 0.09) or at the 2-month follow-up (t(18) = 1.48, p = 0.08).For the General Linear Model, Mauchly’s Test of Sphericity was not significant , the sample size was small, and there were multiple comparisons, so the analyses were underpowered. It would be important for future evaluations to have a larger sample to follow-up on some of the potential effects that were found through post-hoc exploratory analyses. Important areas to further examine may include whether results differed by resource parent type, the dosage and timing of content, setting or format, and the specific intervention ingredients that are most impactful. These dismantling studies are necessary to determine which components of the program are most effective .Another limitation related to data collection was that responses were based solely on resource parent self-reports. Gathering perspectives from multiple informants  would have increased the validity of the findings. There were also several measures that had poor internal consistency, which can be impacted by the number of items in a questionnaire, the sample size, and the level of homogeneity in the sample  . In addiIn terms of the next steps, RPC is over ten years old, so updates are underway to reflect current knowledge in the field. Currently, RPC does not explicitly address how diversity-related factors such as race, gender identity, sexual orientation, religion, and socioeconomic status impact family systems, caregivers, and youth in care. Given the overrepresentation of Black and Indigenous youth in the Ontario child welfare system , updatesYoung people in care cope with high levels of adversity and mental health challenges due to the impact of child maltreatment. The resource parents caring for these youth receive limited support and resources, yet are tasked with many important responsibilities in caring for youth with complex needs. The current study is an important first step toward evaluating RPC using more rigorous methods using a quasi-experimental design within a Canadian context and using a virtual format.While it is important that resource parents be satisfied with the RPC program , they muWhile in-service supports provide resource parents with the necessary foundational knowledge prior to caring for the young person, they must also receive in-service supports that are trauma-informed. Despite this need for in-service supports, there were barriers to partnering with child welfare agencies during recruitment. In fact, the majority of resource parents who expressed interest in the program sought this opportunity outside of their child welfare agency. This speaks to the ongoing training needs of resource parents and suggests there may not be sufficient parenting supports offered within their child welfare agency. Novel programs can be difficult to introduce and implement in organizations due to complex and layered contexts, limited resources, and high staff turnover ,49,50. F


Indicators of quality of life, depression, catastrophizing, and fear avoidance, as measured by the 36-Item Short Form Survey, the Patient Health Questionnaire-9-Item Scale, the Pain Catastrophizing Scale, and the Fear Avoidance Belief Questionnaires revealed significant improvement. Scores did not significantly improve for daytime sleepiness, generalized anxiety, and kinesiophobia, as measured by the Epworth Sleepiness Scale, the Generalized Anxiety Disorder 7-Item Scale, and the Tampa Scale of Kinesiophobia. The results suggest that successful LTOT cessation may be interconnected with improvements in specific psychological states.Improved understanding of psychological features associated with full mu agonist long-term opioid therapy (LTOT) cessation may offer advantages for clinicians. This preliminary study presents changes in psychological outcomes in patients with chronic, non-cancer pain (CNCP) after LTOT cessation via a 10-week multidisciplinary program which included treatment with buprenorphine. Paired  The medical community was called to action by The Centers for Disease Control and Prevention (CDC) 2016 guidelines to decrease exposure to full mu agonist long-term opioid therapy (LTOT) for chronic, non-cancer pain (CNCP) in an effort to stem the resulting sequelae of the increasing incidence of opioid overdose , immune One potential alternative to LTOT is buprenorphine. Buprenorphine is an opioid drug with partial mu agonist properties . It can The primary aim of this study was to identify changes between psychological assessment questionnaires, pre and post LTOT cessation, for patients with CNCP. We present findings from a retrospective analysis in a cohort of patients with CNCP who were successfully able to cease LTOT through participation in a group, multidisciplinary program ,30 that De-identified data were collected via a retrospective review of electronic medical records (EMR) from October 2017 to December 2019, comparing the pre- and post-psychological assessment questionnaire scores of 98 patients with CNCP who successfully ceased LTOT use through participation in a previously described, group multidisciplinary program ,30. QuesThe multidisciplinary program ,30,31 opStudy participants were comprised of the 98 successful graduates of a multidisciplinary LTOT cessation program that commenced between October of 2017 and December of 2019. A total of 109 patients started the program, and 11 either voluntarily left or were referred to a higher level of care due to high acuity comorbidities diagnosed after admittance. Program inclusion criteria were: adult-aged patients who voluntarily enrolled for the purpose of LTOT cessation due to lack of satisfaction with pain control, medication effects, and/or functional capacity while on LTOT. Participants were diagnosed with CNCP from any etiology; had used daily LTOT at the time of admission for a minimum of a year’s duration , or struggled to maintain recent opioid cessation after prolonged use; had previously tried and failed or plateaued in regards to opioid weaning. Program recruitment, exclusion criteria, and criteria for referral have been described elsewhere ,30,31. LStandardized psychological questionnaires were given to each patient at the program orientation meeting and again at the program graduation. Each questionnaire was previously and independently validated. Of note, additional data were gathered throughout the program for the separate analyses of protective and hindering psychological and clinical features associated with LTOT cessation success, and these can be found in earlier publications ,30.t-tests were used to compare dataset means from psychological questionnaires pre- and post-LTOT cessation. Prior to paired comparison, principal component analysis (PCA) was used to compare individual SF-36 subcategory results for the pre- and posttests. The SF-36 is typically reported as 8 individual scores—one for each category. However, since running multiple t-tests for all SF-36 subcategories might inflate the Type I error rate and result in false findings, dimension reduction was employed to minimize the number of variables to be tested. In PCA, data visualization techniques, including the loading plot [Descriptive statistics were derived from retrospective data found in the demographic section of the EMR for program graduates. Paired ing plot ,45 and tThe study began with 109 clinical program participants; 11 left the clinical program and were lost to the follow-up. Thus, 98 subjects (representing 90% of the program participants) remained under observation after the successful cessation of LTOT during the 10-week program  and wereThe reliability index, as measured by the standardized Cronbach’s alpha of the pretest of SF-36 is 0.8899, compared with 0.846 at the posttest, implying that the response patterns to these questions are internally consistent. In the loading plot, the axes of the plots are the principal components, while the variables are symbolized by vectors radiating from the center. Vectors pointing in the same direction, with a small angle between them, implies a positive and close relationship between the variables. Due to this characteristic, they could be loaded into the same component. t-tests.In the scree plot a,b, the t-tests were used to compare dataset means from psychological questionnaires pre- and post-LTOT cessation . Because multiple t-tests were conducted, the Type 1 error rate might be inflated. The Bonferroni correction rectifies the situation by dividing the alpha level by the number of tests. In this case, the adjusted alpha level is 0.05/10 = 0.005. Nevertheless, because the p-value of all significant results is <0.0001, which is far lower than 0.005, the conclusion remains the same.Paired essation . As indiData imputation was considered for this study for the inconsistent n value, but was ruled out because some participants deliberately chose to skip several questions or entire assessments. When data are missing due to inherent lack of randomness, it is impossible to account for systematic differences between the missing and the observed values based on the existing data, especially when the reference data are sparse. Further, when all or many responses in a group of questions are missing, multiple imputation will yield misleading results .p < 0.00l. These findings are consistent with those in previous studies examining mood changes affiliated with problematic opioid use, which have described an intercorrelation between such use and increased depression [This study found that the improvement between the pre- and post-cessation indicators of quality of life, depression, pain interference, catastrophizing, and fear avoidance  among subjects with CNCP who successfully ceased LTOT are significant at the level of pression ,10,11,47pression , catastrpression ,13,38,48pression ,58,59,60Most subjects utilized buprenorphine for LTOT cessation. Buprenorphine acts as a partial mu agonist and as an antagonist at the delta ,55 and kThe effects of both partial and full mu agonist opioid exposure on quality of life have been previously studied. One study showed that full mu agonist opioid exposure lowered the SF-36 score initially, but no difference was found between patients with CNCP exposed to opioids vs. not exposed after 4 years duration . AnotherIn the current dataset, the post-LTOT cessation depression scores (assessed via the PHQ) show a mean improvement from moderately severe to moderate depression, which trends consistently with the results in previous publications. The link between depression and problematic full mu agonist opioid use has been previously documented from a variety of angles. Higher depression scores have been correlated with opioid misuse in CNCP patients with no prior substance use disorder . DepressPrevious reports regarding the PCS and FAB are nuanced. For the PCS, it is interesting to note that a score of 30 or higher was initially validated as clinically relevant ,42. HoweThe optimal cut off for determining significant FAB scores has been studied in several contexts and varies respectively ,62,63,64The BPI scores warrant notice in that their improvement implies a general lack of suffering among the participants, despite LTOT cessation.Equally interesting is the lack of association seen between LTOT cessation and daytime sleepiness, generalized anxiety, and kinesiophobia . Nighttime sleep disturbance and daytime impaired cognition are common anecdotal complaints among patients on LTOT. Disturbed sleep architecture and increased obstructive and central sleep apnea have long been recognized as side effects of chronic opioid use ,71. ThusThe improvement in anxiety (assessed via the GAD) between pre- and post-LTOT cessation was not significant. Previous studies have suggested that a self-medication model has been implicated in inciting, or exacerbating, opioid use disorder for patients with clinically significant anxiety ,16,51, aKinesiophobia (TSK) scores did not follow the significant improvement trajectory of the PCS and FAB- PA. These tools are often grouped together in the category of anxiety, or fear-based, belief and behavior assessments. However, previous investigation into their interchangeability has failed to show cross-over reliability . Of noteThe present findings help to identify psychological improvements associated with successful LTOT cessation. While this study does not prove whether the intervention of the medication changes improved the mood outcomes, or whether the multidisciplinary program promoted a foundation of mood change that allowed for LTOT cessation, it is clear that specific mood improvements were associated with LTOT cessation. With further study, this dynamic may eventually suggest inroads to safer and more optimal treatments in the field of CNCP. Just as previous studies have shown that addressing high fear avoidance and catastrophizing beliefs improved disability measures ,74, the Studies that increase understanding of the clinical features that promote LTOT cessation are timely, yet scant, thus making the present findings relevant, despite the following design limitations: the data for this study were gathered retrospectively from a moderately-sized treatment cohort of non-randomized, non-blinded patients, who were treated in a private practice setting, and demographic subject data is limited. The lack of a long-term follow-up of mood status is also a limitation, and this follow-up would be especially interesting here, as an affiliated study showed prolonged cessation of LTOT in the current group .This study found that improvements in indicators of quality of life, depression, pain interference, catastrophizing, and fear avoidance are associated with successful LTOT cessation in patients with chronic, non-cancer pain who participated in a multidisciplinary opioid cessation program that offered buprenorphine as a substitution. Further research is required to confirm the nature of this relationship. A better understanding of these potentially interdependent clinical phenomena may eventually help clarify and improve interventions for the cessation of LTOT in patients with CNCP.