Mozambique’s community health programme has a disproportionate number of male community health workers ). The Government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique.We employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise the findings.n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband’s consent. Training programmes outside of the community were viewed positively as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain.In-depth interviews (Gender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo Province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre. Community health workers (CHWs) are increasingly relied upon to supplement human resources for health shortages in low- and middle-income countries. CHWs occupy a unique interface position between communities and the health system and can reach marginalised communities. Unlike other cadres, they do not operate out of an institutional space, but instead operate within the gendered boundaries of their communities . Though Mozambique’s limited health workforce is one of its greatest barriers to the provision of quality services , 16. RecThe APE programme recommends that the time is divided between curative services and health promotion activities 20:80, respectively. APEs undergo a four-month training programme that reflects this, with emphasis on health care maternal, neonatal and child health, as well as first aid, recognition of common diseases—malaria and diarrhoea—and referral to health units . CurativMozambique sees a disparity in labour force participation between males (75.8%) and females (26.3%) , which iMozambique currently ranks 120 on the gender development index . DespiteDespite the stated intention to increase the numbers of female APEs, there are few available studies that explore the reasons behind this persistent gender imbalance, and none with an explicit gender analysis. One rationale, as cited in the unpublished 2018 strategy document, is the lower level of schooling amongst the female population  , experienced in qualitative techniques, was recruited to ensure a gender-balanced research team in case of sensitive questions. She was trained in qualitative interviewing techniques (e.g. open-ended questions and probes), the research objectives and using the topic guides. Most interviews were conducted in Portuguese by CF. Interviews with male community leaders were conducted in the local language (Xi-Changana) by experienced qualitative researchers, SZ and CG, who were also trained.Interview topic guides, informed by the conceptual framework Fig. , exploreThe recordings were transcribed verbatim and translated into English. Back translation from English into Portuguese was conducted in a small sample of transcripts to assure the accuracy of the translation.Transcripts were read and reread to identify emergent themes. A coding framework was developed in accordance with a thematic analysis , 37. An Written informed consent was obtained from all participants. Ethical approval was obtained from the Liverpool School of Tropical Medicine no. 16-022 and the Institute of Bioethics in Health, Faculty of Medicine/Central Hospital of Maputo no. CIBS FM&HCM/45/2014.n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured gendered experiences of APEs, community leaders and health system staff  . NeverthIf I have to leave here to be in another place, for four months, here at home what is going to be eaten? For example, because now where I am, I only have 10 kg [of rice], I am trying to at least increase again that 10 kg, or this woman [wife at home] is going to haunt you. How is it possible to work to increase that food with that little allowance they gave us? The four-month training that must be completed to become an APE is offered in a central location. APEs who live far away may only return home at weekends, if at all. This residential-style training creates difficulties for some candidates due to their gendered roles at home. Due to a ‘provider’ role, male APEs spoke of the challenges of providing food for their families at home. During the training, they only have access to the allowance provided by the health system as they are unable to engage in any additional income-generating activities that they could at home:In the family, when I leave, I’m the male there (laughter) so no one will be [disciplining] the children for four months. I do not know how I made it staying here because [home] was lacking food…when we were trained it was time of starvation…We also had problems of a lack of food here, if I had a [lunchbox] here sometimes I would carry it to a child at home, but here we had difficulties. But we faced them, we are here, we win. We are winners. Experiences of training were also influenced by national context as shown to the right of the conceptual framework Fig. . For oneFor me it was difficult because I am a mother, I am a father, I have a son who is seven years old… I even asked my sister to go stay with my son, sometimes the night at [8 pm] she sent me a [message] then I seek airtime to call, she just wanted to tell me that at home has no oil, no sugar, has nothing, I was not well trained because it was not always easy. Difficulties facing women who train away from home were linked to marital status. In the cases of single mothers, who were also serving a ‘provider’ role, the stress of not being at home to support and provide for children impacted their training:These examples highlight the socio-economic vulnerability of APEs who risk the welfare of their families and endure stresses to complete the training. The reliance on family members was expressed by both male and female APEs, by women with regard to helping with childcare and by men with regard to helping with farming—emphasising the gendered divisions of labour common to the study sites.Q: Do their husbands agree to let their wives go to the training for four months?R: That, indeed, happened. The APEs that were in the training with our APE, there were three ladies whose husbands did not like and so the [husbands] suspended them from the training. However, when we distributed the cattle offered by PATHFINDER to the other APEs, their husbands complained.Q: What are the motives for men who have suspended their wives from APE training, other than what they have already mentioned related to lack of salary?R: The main reason was related to home activities. They did not see the reason for leaving their homes for an activity that has no benefits. Patriarchal norms that dictate women are not the primary decision-makers in the home meant married women had to seek their husband’s consent and support over their livelihood opportunities. Barriers existed for some women to obtain consent to train away from home, but also to work out of the home, giving up time dedicated to household duties for a perceived lack of financial contribution to the household.In these instances, supervisors were recruited to speak to husbands to gain their support. Yet, it was perceived to be a common barrier; one male APE suggested health system staff should meet with husbands of married female candidates and only recruit those who had the support of their husbands from the outset, to avoid investing in training women who may later quit if ‘the husband starts to make problems’.Despite the issues raised with residential training, participants still felt it was preferable in order to build a cohort. They also spoke of a sense of pride gained from going away and returning ready to serve your community. Men placed emphasis on the benefits of collective learning. For women, however, the benefits also came from being away from the distractions of home life, allowing for focus and punctuality, which speaks to their double burden of household and APE work.Q: In your experience, why do people usually leave?R: Money problems.Q: Is it money for both men and women?R: …It is money because other women sometimes have a husband and the husband lets her go to work and at the end of the month there is nothing, before we were eight months without receiving the subsidy and the husband becomes demoralised, it is preferable to leave because… they do not give you anything Gender and power relations impact on retention in complex ways. Although it was reported both men and women leave due to low subsidies, this appeared to be more pronounced amongst men and shaped by husbands in the cases of married women.Q: You said men usually give up, what are the reasons men quit?R: Because men are the head of the family and all responsibilities rely on them, such as providing money for children to go to school, food and many other things. So, the reasons for many to quit taking in account the amount we receive as subsidy while we have much work to do as APE. It was reported that the male role as the ‘breadwinner’ meant that men would often leave to find better-paid work and were more disheartened about the subsidies being low or delayed.I have worked with many projects but never ceased to be an APE and I will not leave, so far, I want to continue, even without money… A person’s life is not bought. The sentiment that the subsidy was not commensurate to the workload was expressed by many of the APEs both males and females. As well as a leading cause of attrition, limited remuneration was a source of difficulty and stress. In most cases, however, a sense of obligation to the community and limited livelihood opportunities within the rural settings kept many in the role.More and more NGOs coming with more work but no money for that. The first organisation that came in said will give 1200 [meticais to] APEs, and these new organisations that are coming in now are exploiting us, but we will not stop working… We are going to work because we are in our country, in the community, what we are doing is not only helping the community alone, we are helping the whole country… but the country is not giving us priority, it does not value our work… This NGO asks the State, we want APE, they should say ‘we have APE, these APEs are receiving the value of another NGO if you also want to work with APE you also have to give something!’ Does not mean anything working for five NGOs while I'm only receiving salary from one NGO. Female participants in Manhiça, in particular, spoke passionately about feeling exploited by the health system—describing how there is an influx of work from multiple non-governmental organisations (NGOs), but the monthly subsidy does not change to reflect this. The APEs feel they are working to support their country, but yet the country is not speaking up for their rights, describing themselves as ‘slaves of the ministry’.And if the ministry cannot pay us because our level is so low it should train us more us more, increase our training, because we have the capacity to learn more… We are still available to receive more studies, to continue helping the population, but we have to see the subsidy because they are already exploiting us, we are slaves of the ministry, because even servants receive more than we do, but we are doing a lot of work… These quotes demonstrate the APEs had internalised the rhetoric of their work being ‘priceless’ and for the good of their community and country. Women spoke about feeling trapped—unable to earn money due to their low educational status, but at the mercy of the Ministry to offer training to improve it.We hope they will help us, maybe they may give us scholarship so we can increase our level. Don’t you one day want an APE like me, to graduate from university? Wouldn’t you guys like that? Hearing that an APE, a lady was an APE, now she has done a degree. Alongside minimal subsidies, minimal opportunities for new training and career progression are cited as a contributing factor to their sentiment, as illustrated above. Speaking of the opportunities for female empowerment and further education, female APEs felt it would be inspiring for communities to see an APE go on to a university—reflecting how the health system could not only help meet the educational goals for women but also aspirations for this cadre to progress into the formal labour market.…the APE accepted to help the community but did not accept to be exploited, now the APE is being exploited. They are violating the rights of the APEs… they made a doctrine, it says the APE has no right to receive much subsidy because we have the right to go to the farm, do other jobs… but when the supervisor calls to say ‘I am coming to your house, I come to do supervision’, that day even if you have another [job] you cannot leave the house, have to wait for the supervisor to come to do supervision then that day that you were not in that work that sustains you is missing… We are working and we are happy with our work, but our concern is only subsidy… Opportunities for training and education are also linked with policies for remuneration. The relatively low education level of this cadre means they do not qualify for formal paid jobs within the public sector. Currently, the level of education held by APEs fits the role being ‘voluntary’. However, this voluntary status also brings with it its own challenges in juggling APE work with paid opportunities. The voluntary status of the APE role allows for concurrent paid employment; however, in reality, the requirements of the APE work limit opportunities to earn additional income. APEs felt continuously on call and have to attend to patients and their supervisors on demand.Subsidy demoralises us a lot, other APEs eventually get another job, so the boss who employs me, will not accept the rest of the time to work as an APE. For example, you can say that you enter here [at] 6:00, I will leave 18:00 hours, so already for the work of APE I will not do anything because I will leave at 18:00, I cannot do home visits at night, because they will say you are no longer working in health, you want our women (laughs) …We are not well with will, but we are working. [APE FGD Moamba]Balancing time between APE work and additional income-generating work also had a gendered element and posed particular problems for male APEs. They felt if they took another job in the daytime, they would not have time for APE work as it was not deemed appropriate for them to attend to families at night and would be accused of ulterior motives.This demonstrates how policies surrounding remuneration can impact men and women differently on the ground. In this case, the need for additional income restricts men’s ability to carry out APE work effectively due to socio-cultural norms that limit their ability to conduct night visits—which may impact on their retention.Q: Do you think that one of the reasons men tell women to quit is because they do not want them to have their own money, their financial independence?R: No, that's not correct. For example, I am a girl, I am an APE, I am dating a boy from Gaza province, he wants to marry me, well, I can say I have reasons to accept him and quit APE work, but this decision is not about money, it’s because I love him, I want to have my own home and family, as well as conditions to get food and educate my child. It was reported that women often leave if they get married and follow their husbands to their home villages. Supervisors expressed that this can be a problem for the health system once an investment in training has been made, but the woman is no longer able to work. A young, female participant articulated a romanticised rationale for quitting the APE role to start a family and spoke of her aspirations to be able to start a family and provide for them. This highlights the importance of understanding APEs as individuals and not viewing them as a homogenised group. This is particularly relevant in the case of female CHWs where the dominant narrative may be of oppression. Instead, individual circumstances come together to shape individual choices.…Women give up because the husband has a decision at home, to this day there is this, there is a husband who has a decision at home. ‘You should stay here, instead of going to the farm, leave these people, or even leave work, leave these activities here, I say stay here at home.’ Others drink, smoke, these husbands are stubborn, for example, if I come home, I drank, I smoked and I find you, my wife, and there is someone having a test there, I can make you stop [treating them] there and prepare a meal for me at the table…as I am the one who decides here at home… she will quit (the APE) because she wants the save her marriage. He even announces this, ‘you know nothing, your income adds nothing here at home.’ She ends up giving up because no woman will like to always receive beating, punches, slaps and know that I am not gaining anything. Still, it is not always the woman’s choice to quit APE work. Patriarchal norms that dictate that men are the primary decision-makers in the household were also reported to impact on married women’s ability to remain in the role. In this case, husbands’ disapproval was interlinked to APE programme policies—both in terms of the limited income that the role of APE brings in and in the lack of a dedicated health post—which was also cited by many community leaders and APEs as being something that would benefit their work. One male participant described a situation where women who use their home as a place of work could lead to disagreements at home, and even domestic violence.For example, this young man here [an example APE man] receives 1200 [meticais], will he build real home with 1200? His girlfriend wants artificial hair, but this 1200 is not enough, so, if this APE gets a good job he will definitely leave APEs work. If someone tells him that there’s a job opportunity in Inhambane province where he’ll get paid five or seven thousand he will definitely leave APEs work. On the other hand, for an old man it’s different because there are few opportunities due to the age, so old men are likely to remain in their APE work. It is difficult for any old man to quit. He can remain in his community. Well in my group there was a colleague after training worked a few months but ended up giving up, travelled to South Africa but she was not married, even was a young woman in her 20s, so I do not know what was her influence, eventually she abandoned and on her return she wanted to get involved again but she had already been replaced by another colleague. The ability to negotiate alternative outside livelihood opportunities is shaped by gender, age marital status and geographic position. Younger men and women were viewed as being less inclined to stay in the position and more likely to look for job opportunities outside of their communities. Though, it was articulated to be more pronounced amongst young men and associated with their gendered provider role.These examples highlight the need for an intersectional lens when thinking through gender issues, as multiple factors interplay with gender to create unique situations that mean one person may have the ability or desire for higher income that causes their attrition.The role of CHW provides increased agency and status in communities and can be an empowering experience , 39–43. Experiences of training were heavily influenced by gender roles that dictate household chores and child-rearing be predominantly carried out by women. The four-month training programme away from home impacts some women who may find it difficult to eschew their domestic roles, which often include being the primary caregivers to children. Conversely, men’s ability to fulfil the ‘provider’ role for their family was challenged as they rely on the minimal subsidies set out by the Mozambican government and cannot take part in additional income-generating activities for these months. The expectation that the CHW role should fit in with income-generating activities not being met has also been reported in Ghana . ExperieTo support the training of this cadre and ensure that men and women are not limited by their domestic roles, we suggest that residential training be accompanied by childcare provision and a formal salary, with an option to complete the training in shorter modules to allow for breaks at home. Modular learning would also support opportunities for further income generation, which limited men in particular. Residential, modular training with on-site childcare facilities has been rolled out in India to support the female CHWs (known as ASHAs) with childcare obligations, whilst building an immersive and empowering learning experience .Gendered intra-household bargaining and male decision-making power have been well documented with regard to limiting women’s autonomy over health-seeking behaviour in low- and middle-income countries, including Mozambique , 45–47. It is vital to challenge the patriarchal notion that men should make decisions about whether their female household members can work outside the home. Challenging this notion needs to occur in communities with community leaders and APE supervisors who may inadvertently reinforce this notion as they are often called upon to liaise with husbands in instances where spousal consent to work outside the home was sought. The values and ideals of the supervisors are likely to influence this discussion—necessitating a training module for supervisors in how to approach discussions that have important implications for women’s intra-household bargaining power. Work within communities with the help of community leaders may also help to gain husbands’ acceptance, but importantly, also to transform harmful attitudes that see men threatened by women’s earning power or employment status. Challenging patriarchal norms around livelihood decision-making should occur simultaneously alongside supporting and being responsive to the strategic interests of APEs in these settings .The success of gender transformation within the community comes from an Indian CHW programme which conceptualised CHWs as activists to empower the poor and marginalised. This vision was carried through to selection, training, ongoing support and systems of accountability and remuneration and resulted in the empowerment of women in the community . They coNepotism in selection, which has also been shown in the Democratic Republic of the Congo , was linGiven APEs’ essential role in the health care sector, there is a duty to ensure that they are appropriately and adequately supported by the health sector once through the recruitment process. Studies in Zimbabwe, Uganda and Mozambique have linked low and irregular pay and increasing workloads to poor retention and motivation amongst CHWs , 44. OurOur findings corroborate literature from Mozambique and Ethiopia by Maes and Kalofonos  who usedThis highlights the complex issue of voluntary work. Voluntary work has been touted as a way to ensure intrinsic motivation  and sustIn the Mozambican context, volunteerism may reinforce harmful gender norms as men quit for higher-paid positions, but women remain in the role suggesting their labour is cheaper and less valuable. However, care needs to be taken if moving to formalised employment. In India, a reported benefit of keeping the CHW role voluntary is that educational requirements could be relaxed for selection . This woOur findings also linked limited autonomy over livelihood decisions to the inadequate financial gain from the role. Some husbands deemed the role of little value due to the minimal contribution to the household economy. Sen  describeThe call for greater subsidies and formal employment rights, including social security, from the APEs should be heeded. Working at the lower end of the health system hierarchy, APEs are vulnerable to poverty and are overcoming damaging past events involving famine and conflict . The proSome younger female APEs spoke of their choices in choosing domestic work over APE work, but others felt limited in their choices due to their educational level. They articulated their desire to further their education in order to make them eligible for formal employment, better their futures and receive the recognition from the health system they felt they were owed. Developing further training opportunities, building a career structure and allocating sponsored places in higher education schemes for those eligible may be one way to further the transformation of this cadre and contribute to the economy and health workforce. A recent review of government reports by Percival et al. found no evidence that the Ministry of Health prioritised gender equity in its overall human resource strategy and that the promotion of women was not part of the recruitment process for the APE programme . This hiOur research revealed interesting findings around policies on the place of work that have gendered implications for women. Policy dictates that the APEs do not operate out of a health post, but within communities—often using their own or community members’ homes. These policies however disproportionately impact on female APEs who are often not the primary decision-makers within their homes—if they treat clients out of their homes, they may be subject to family disapproval. This disapproval can lead to attrition, but it may also place women at risk of domestic violence, as voiced by a male APE. Violence can be considered one of the ‘most graphic expressions of unequal household power relations’  and can Our study has some limitations that need to be considered; firstly, whilst we set out to explore the reasons behind the low levels of female participation in the APE programme, in Maputo Province, the ratio of women was reported to be much higher than is seen in the North and Central zones of the country. As this is a qualitative work, our findings cannot be generalised to the rest of the country but provide important insights into some of the considerations in recruitment and retention of male and female APEs. Secondly, it would have been beneficial to hear not just from current APEs but from those who had left the programme to explore their lived experiences and the reasons behind their attrition. The sample size of the single key informant was small but adds depth of knowledge and insight into the national context. Another potential limitation was the need to combine the male and female APEs into one FGD due to the limited numbers of APEs in Moamba. We feared this may have created some gendered power dynamics. However, the APEs presented themselves as a team and spoke openly about personal and community gender issues, and we elicited some rich responses this way. Finally, it is important to consider our position as researchers and the impact that our position as outsiders of the community, living in Maputo city and beyond, may have had on respondents. Despite this, participants generally seemed open and willing to talk to us and wanted to share their stories to enact change.Gender, age, geographical location and marital status all converge to influence the recruitment and retention of APEs within the Mozambican context. Research on health systems often focuses on social determinants, such as gender, as isolated factors. Nevertheless, our results highlight there is a need to investigate and understand how different axes of power intersect to create multiple identities. Data on APEs disaggregated by various axes of inequity will be crucial to conduct intersectional analyses in order to support informed decisions in APE policy-making at the national level. Supporting the recruitment of women into the role in line with government targets needs to be accompanied by supportive policies to ensure individuals are not recruited as cheap labour and their unique needs are met. Further, the extent to which APEs can bring their embedded knowledge into policy-making demands attention. This should be accompanied by consideration of existing power structures to ensure APEs have the agency to be heard and hold governing bodies accountable. Policy change must be underpinned by efforts to ensure women are not restricted by the current patriarchal norms within communities, as well as fair remuneration for the cadre. This will contribute to the empowerment of this cadre and redress women’s subordinate position in household decision-making—ensuring they have equal opportunities to enter the APE programme if they so wish.


There are large disparities between immigrants and native Norwegians in domains such as health, education, and employment. Reducing such disparities is essential for individual and societal well-being. Social capital is associated with positive effects on these domains, and mentoring programs have the potential to boost social capital. However, few studies have assessed mentoring as a social capital intervention among youth or the potential barriers and facilitators of implementing digitally augmented mentoring.The goal of this paper is to describe a protocol for assessing the implementation and effectiveness of a digitally augmented mentoring program for immigrant youth as a health intervention to promote social capital. The two-stage analytical framework for a pilot study followed by a randomized controlled trial (RCT) is presented. The pilot aims to assess program fidelity and make necessary intervention adjustments before the RCT. The RCT aims to assess the effects of the implemented intervention program on social capital and the relationship between program fidelity and effects.Both the pilot and RCT will use mixed methods with a process evaluation approach used to structure the intervention and a pre-post test survey component to measure social capital and fidelity of program implementation. Interviews will also be used to enrich the quantitative data from the survey.The pilot study is scheduled to begin in fall 2019. Based on data analyses in spring 2020, potential adjustments will be made to the intervention, with findings used in preparation for the full-scale RCT study.Digitally enhanced mentoring programs may be a helpful intervention for providing immigrant youth with tools for increasing their social capital and indirectly improving health outcomes. This protocol provides new knowledge about the implementation and evaluation of such programs.PRR1-10.2196/16472 Globally, significant discrepancies exist between immigrant youth and native-born individuals with regards to school dropout, isolation, unemployment, and health. For example, 71% of immigrants in Norway report experiencing at least one of eight listed health problems compared with 49% of the population at large ,3. TheseSocial capital, a focus of this study, is associated with a variety of positive health outcomes, including self-reported health -6, psychAlthough approaches for strengthening social capital are clearly worth pursuing, interventions to increase youth social capital, such as the one proposed in this paper, are quite new . Little Although one might assume that digital support for this type of mentoring program holds potential for reach and effectiveness, few programs employ digital tools or have been studied systematically ,30. TherThis paper describes a protocol for studying a digitally augmented mentoring program as a social capital intervention for immigrant youth in Norway. The protocol proposes a pilot study followed by a randomized controlled trial (RCT). Ultimately, we are interested in assessing the implementation and effects of mentoring program participation on social capital. A process evaluation framework inspired by a previous study  will be What contextual factors affect the implementation?How is the mentoring program implemented ?What are the participants’ experiences in the mentoring program?Are the measures used for studying outputs and outcomes valid, and are they acceptable and meaningful to stakeholders?The pilot allows adjustments of the social capital intervention before full-scale implementation and the RCT. The intention of the RCT is to investigate the effects of the implemented program on the social capital of immigrant youth, guided by the following questions:To what extent was the intervention implemented (outputs)?What are the effects of the implemented program on social capital indicators (outcomes)?What is the relationship between program fidelity and effects?The study offers both theoretical and empirical contributions. First, much of the work related to mentoring as an intervention has been done in the United States, with primarily qualitative studies in the United Kingdom . TherefoThe logic model ,37 depicThe pilot study focuses on the first three boxes in The framework depicted in The mentoring intervention seeks to address these discrepancies. An important focus is on how the program can strengthen mentees’ networks through information exchange and social contact and increase trust and feelings of belonging . Thus, the study emphasizes outputs and outcomes, as well as the influence of contextual factors on these.The first stage is the pilot study, followed by the RCT. A mixed-methods approach will be used combining quantitative survey instruments (pre-post test design) with qualitative data from interviews and focus groups . The surBoth stages of the study will be conducted in close cooperation with mentor program staff , and with feedback from the youth. The primary unit of analysis for the study is recently arrived immigrant youth, ages 15 to 25 years, attending school. These youth will be in or have completed their first year of Norwegian schooling; therefore, they will have a minimum basic level of Norwegian proficiency. We will offer interviews in Norwegian and English, but will also consider the use of a translator, as necessary, for the RCT to gain a better understanding of the experiences of participants with varying levels of Norwegian language comprehension. Information from mentors and program staff will also be collected. Informed consent will be obtained and the voluntary nature of participation will be emphasized to the youth, with information that they can end their participation at any time. A video will be used to present the research project, handling of data , and privacy issues in youth-friendly language to gain fully informed consent and to increase stakeholder (youth) involvement and interest .For the pilot study, all mentees (approximately 40) participating in four of the mentoring programs will be recruited to participate in the survey at the beginning and end of the program. The majority of these mentees have backgrounds from Syria and Eritrea, and almost all will be attending school. At the end of the six-month program, mentors (approximately 40) from these programs will also be invited to respond to a survey. All mentee respondents will receive small denomination gift cards (approximately $28) on completion of the surveys as a gesture of appreciation for their assistance with the project. We will also discuss how the youth perceive receiving gift cards, with a specific focus on any feelings of coerciveness, to make any adjustments before the RCT. Qualitative respondents will be selected from the individuals providing quantitative information to investigate specific aspects of program fidelity and implementation in more detail.The full-scale RCT will recruit participants from Norwegian schools and include both a control and an intervention group. The study will try to select similar schools for both groups regarding school size, socioeconomic characteristics, and school type (age range of the student body). Within the intervention group of schools, intervention classes will be drawn randomly, whereas control classes will be drawn randomly from the control schools. Participants and nonparticipants will not attend the same schools to avoid contagion effects. The exact number of individuals will be estimated based on a power analysis of data from the pilot study and is anticipated to encompass several hundred youth. Half will be in the intervention group and half in the control group. Students who are not assigned to the control groups for the study will have the opportunity to receive the intervention after the study has concluded. Although all the youth will have a basic level of Norwegian proficiency, additional potential inclusion and exclusion criteria for the RCT will be developed based on findings from the pilot study. Similar to the pilot study, mentors will be surveyed at program conclusion, and respondents will be invited to qualitative interviews and focus groups, to supplement and nuance the quantitative data.After receiving information about the project in the form of a video and giving informed consent, the mentees will receive an individual link to participate in a Web survey. Questions on the mentee survey at program commencement will focus on social capital in the form of relationships with friends, native Norwegians, connectedness to the school environment, and to Norway more broadly. This will be used to test out and adjust measures for the full RCT study based on feedback from the groups. A Web survey will be administered at program completion, with the same survey questions as on the first survey, supplemented with questions about program fidelity (outputs) and a short battery to assess the relationship with the mentor and implementation. Mentors will receive surveys related to program fidelity and the relationship with mentees and staff. Additionally, both mentees and mentors will respond to survey questions on the usability of the digital platform. To supplement the quantitative survey data, qualitative data will be collected from mentors and mentees in interview form for both the pilot and RCT. Individuals will be selected for interviews based on characteristics such as age, sex, immigration background, and length of time in Norway, with a goal to get a very diverse group . InterviThe pilot study has been approved by the Data Protection Office at Oslo University Hospital. All pilot study data will be stored on a secure remote server as per Oslo University Hospital Personal Data Protection regulations. The pilot study is funded by a grant from the Norwegian Research Council and is a partnership between the Center for Shared Decision Making and Collaborative Care Research at Oslo University Hospital, NORCE-Norwegian Research Centre, Halmstad University, the Norwegian Labor and Welfare Administration (NAV), and Fretex.The effects of the program as a social capital intervention will be studied using a two-level clustered randomized trial, with schools randomly assigned as intervention or control schools. The analyses will be at the individual level. In using a randomized comparison of mentees with non-mentees, the effects of mentoring on social capital can be assessed, also controlling for individual differences.Youth in both the intervention and control groups will complete Web surveys. The youth surveys cover questions related to social capital and will be conducted at baseline (before program commencement), six months after the baseline measurement (at program completion for the intervention groups), and six months after program completion (12 months after the baseline measurement). Surveys to youth in the control group will be administered at the same time points as for the mentees. Mentors will respond to surveys at program conclusion. Because youth in the intervention group will receive mentoring outside of the school environment, we do not have a specific activity planned for the control group. However, control group youth will be put on a waiting list to participate in the mentoring program after study completion, if they desire. Approval from the institutional ethics board (Data Protection Officer) will be applied for and obtained before RCT study commencement.The following table  summarizMeasures to be used for the study survey are adapted from previous research and large-scale cross-national surveys -48. WherOutputs are the process and mechanisms by which the “problem” and its consequences are targeted. More specifically, this is the implementation of the intervention. An important emphasis is on fidelity of implementation of core program components , and mechanisms of impact (participants’ interactions with the intervention) and the contextual factors that have an impact on the implementation (discussed subsequently). Assessment of fidelity is done using a self-developed scale for the study to match the program environment. Program fidelity is measured using the following indicators (previously described under Background and Context): the total number of dyad meetings held with at least one dyad meeting each month , participation in training before program start, and execution of the main program components, such as network mapping. The proportion of participants that complete the program (reach) will also be assessed. Identification of any deviations or adaptations to these key program components will be noted. Because the intervention also includes a digital component (forums for mentor-mentee contact), log data from the platform, including the number of log-ins and time spent on different parts of the platform, will be analyzed to assess dosage.Relationship quality (mechanism of impact) will be measured using the 14-item Mentor Strength of Relationship scale , adaptedThe outcome variable of interest for the RCT—social capital—includes cognitive and structural dimensions . The cogYouth will also be asked about how often they felt lonely during the previous month   from the ESS  with a rThe structural dimension of social capital relates to the presence and patterns of connections between actors or network characteristics , school connectedness, and civic engagement or organizational participation. To assess network characteristics, the respondents will be asked about the proportion of their friends with a similar ethnic background and religion (bonding), with an immigrant background (bonding), and with a Norwegian background (bridging). This will be assessed using a five-point scale .Civic engagement will be measured using questions about organizations in which the youth are active. The youth will be provided with a list of different organization types  and will be asked to respond if they are a member, have participated previously, or are not a member (similar measures are used in ESS and in the Ungdata survey for Norwegian adolescents ).Patterns and nature of contact with friends and family will be measured in several ways. The youth will be asked if they have at least one good friend that they can fully trust  (questions are taken from Ungdata ). ResponTo measure school social capital and connectedness, several dimensions  will be used. Connectedness will be measured using indicators from the Health Behavior in School-aged Children study protocol questionnaire , as usedDemographic characteristics of the youth in the sample, such as age, sex, length of time living in Norway, and economic status (inquiring about their finances during the past year), will also be included in the survey. Characteristics related to setting  and the digital context in which the respondents participate will also be taken into account. In the pilot study, the usability of the digital platform will be assessed in a survey, which will include questions from the System Usability Scale , a robusQuantitative data will be analyzed using statistical software packages. Descriptive statistics will be presented and pre-post measures used to determine the impact of the intervention on social capital and more distal outcomes. Additionally, because the literature suggests that mentoring produces better outcomes for some groups  over others , we willThis protocol was informed by a prepilot study conducted from January to June 2019 , which fThe pilot study will commence in fall 2019 and conclude in spring 2020. The participants  have already been identified for the pilot portion of the protocol. Efforts related to recruitment for the RCT will begin after the pilot study is finished.The overall objective of this protocol was to present a plan for evaluating the implementation and effects of digitally augmented mentoring relative to social capital among immigrant youth. The main working hypothesis is that students who receive the intervention will have broader networks and higher levels of trust and feelings of belonging  compared with those students who do not receive the intervention. Considering the paucity of research on social capital interventions, the protocol should be relevant for researchers interested in community-based health promotion and in social capital more broadly. More specifically, it provides a framework for analyzing mentoring programs for immigrant youth to see what works under what circumstances and for whom. However, there are some anticipated limitations.Because mentees self-select to the program in the pilot study, these findings may not be generalizable to a larger group; however, this is not the primary objective of the pilot. The RCT should ameliorate this issue owing to the random selection of individuals and classes. Another potential limitation relates to language issues, particularly in the survey instrument. The pilot study is intended to assess the relevance and acceptability of the instruments to the target groups; comprehension will also be a relevant consideration at this stage. Thus, this issue will hopefully be minimal in the RCT. Attrition, particularly after program completion, is another potential limitation, as in most survey research.If this intervention is successful, it may have an impact on the possibility for young people to be better included in Norwegian society. Further work could potentially encompass cost-benefit analyses if there is support for the hypotheses. These preliminary results from the pilot and RCT, if positive, could be promising for a potential expansion of the intervention to other contexts and target groups.


The number of individuals displaced from their original countries due to civil wars, hunger, disasters, and international wars is increasing worldwide day by day. These refugees are more vulnerable to Post-Traumatic Stress Disorder (PTSD).The present study aimed to examine the effectiveness of the intervention program in improving the well-being and reducing Post-Traumatic Stress Disorder (PTSD) among a sample of Syrian refugee women in Jordan who had been displaced due to civil wars in Syria.The study recruited 40 Syrian refugee females in Jordan who were psychologically challenged, with high PTSD symptoms (assessed by PCL) and a psychological well-being impairment (assessed by PWD). The culture of Jordanian society discriminates and affects the Syrian refugee women, rendering them vulnerable to PTSD. Quasi-experimental design was used, wherein the participants were randomly distributed in experimental and control groups (n=20/group). The control group members did not receive any services related to psychological support or psychiatric medications, while the experimental group underwent a counseling program.The present study demonstrated that the intervention program improves the well-being and reduces PTSD among the Syrian refugee women who constituted the experimental group. The intervention program and the PTSD manifestation were not affected by age. The present study recommended that the program be applied to the refugees in Jordan to improve the well-being of the women in the residential areas.Furthermore, an intervention on the Jordanian cultural impact on the refugee camps was also essential if the condition for the female refugees worsened. Lastly, the effect of Jordanian culture on Syrian refugees should be investigated since the literature presented a negative impact. The numAlthough the civil war began in Syria in 2011, it was officially declared by the UN on June 12, 2012 . Thus, mStrikingly, the demographic characteristics of the Syrian refugees’ households in Jordan are alarming . The aveThe unfavorable conditions for the refugees make the women, who are subjected to sexual harassment, rape, forced marriages, early marriages, and constant divorce in Jordan due to the gender-insensitive culture, vulnerable . The JorMeriwether (2018) also reported that in Jordan, the Syrian refugee women are affected by the division of labor; the women perform the household duties, primarily caring for the children, while the male is the breadwinner , 9, 10. Marriages for Syrian refugee women living in Irbid City are determined by Islamic laws and Arabic traditions . Men areDivorce is accepted but decided by the man and usually relies on the obedience index of the woman. Barlas 2019) argued that after divorce, the children are under the care of the father, while the woman is permitted to take care of them . Further argued tA large number of refugees suffer from mental health disorders, such as PTSD, anxiety, and depression, as compared to the general population worldwide. However, it is prevalent in women due to war experiences and trauma before the migration. Moreover, women have PTSD due to post-migration stressors such as separation from families as well as the pressure of settling in a new country . The sitThe symptoms of PTSD may be displayed within a month in a similar event that might serve as the trigger, or the effects could be felt after several years. The symptoms, including intrusion, hyper-arousal, and avoidance, among women living in refugee camps, are distinct as the groups consist of a heterogeneous population. In some cases, irritability, fatigue, restlessness, and sleeping disorders are also associated with PTSD. These symptoms could affect the daily operation of an individual, such as relationships, work situations, and other social-related issues . These w• The well-being of the Syrian refugee women in the experimental group improves as compared to the control group after implementing the counseling program.• There is no correlation between the overall well-being or sub-domains due to the counseling program and the participant’s age.• The PTSD score in the experimental group decreases as compared to the control group after implementing the counseling program.• There is no correlation between the level of PTSD due to the counseling program and the participant’s age.2.The present study followed the experimental approach by choosing a quasi-experimental design because the purpose the study aspires to screen the individuals who receive the highest scores in PTSD as measured by the study tool (PCL), in addition to those who experience deficiencies in mental health levels as measured by the study tool (PWD). This procedure prevents the possibility of random selection from members of the study community. Quasi-experimental design is usually chosen in such experimental conditions.2.1The present study recruited 40 Syrian refugee women in Jordan, aged between 30 and 50 years and identified as psychologically challenged. During the identification process in the in-home assessment, a screening criterion was applied randomly to the women residing in Irbid City to include the appropriate participants for the study. The cross-cutting tool by the American Psychiatric Association (2013) was used in the screening, which identified 56 women with the highest scores for psychological challenges . However2.2th Edition (DSM-IV) developed by Weathers & Litz (1994) consisted of 17 self-report items [The PWB was used to measure the specific domains of psychological functioning, which were distributed into six dimensions: autonomy, positive relationships with others, environmental mastery, personal growth, the goal in life, and self-acceptance -24. A qurt items . These irt items . MoreoveThe counseling program for this study was developed based on the analysis of the survival of Syrian women. Three focus group meetings were conducted to obtain a general understanding of the main challenges faced by the participants in daily life while coping as refugees with PTSD. The program consisted of four primary domains, two sessions each. Both sessions targeted each domain and focused on sharing the stories between the participants, using psycho-education techniques to deal with the feelings related to each domain, and finding strategies that would help in coping with the challenges. The four basic domains were alienation, loss and grief, hope and hopelessness, and psychological problems. The program was implemented for 1.5 months, two sessions per week. However, two additional sessions were conducted for the opening and closing, respectively. Informed consent was obtained from the participants in the opening session, as well as for the pre-test, after conveying the regulations for the whole program. The closing session entailed a summary and post-test application. The counseling program was reviewed by experts and academicians in the field of Counseling and Clinical Psychology prior to implementation. The consulted parties modified both the content and procedures to suit the study.2.3The group counseling program was designed based on a number research and literature efforts. Yalom (2005) has extracted number of fundamentals for group counseling which was adopted on the development of this program . He has After developing the first draft of the counseling program, it was shared with both professors in the field of counseling and clinical psychology and professionals who are working with traumatic refugees. This procedure aimed at obtaining their feedback about the program, some modifications were added to the program based on their feedback.2.4The study targeted one of the local associations in Irbid City in Jordan that were dedicated to supporting the Syrian refugees via different psychosocial services. Permission was obtained from the Faculty of Arts Research Review Committee of The University of Jordan, and interested parties were informed before the program was conducted. The participants signed informed consent at the beginning of the study. The participation was voluntary, and the participants had the right to withdraw from the program at any stage of the cycle. Notably, the program was implemented by a clinical psychologist who was a licensed psychotherapist.31).The efficiency of the intervention counseling program that improved mental health and reduced the PTSD symptoms among refugee Syrian women survivors was assessed. A total of 40 Syrian refugee women living in Irbid city in Jordan were recruited for the current study. The means and standard deviation for the overall well-being and sub-domains were calculated for both experimental and control groups (Table 2).The means among the experimental group increased in the post-test as compared to the control group. To test if this difference was statistically significant, a two-way MANOVA was conducted (Table 2).Additionally, the interactive means and standard deviation for the overall well-being and sub-domains were calculated for the counseling program and age (≤ 24 or ≥ 24 years) in both groups (Table 3). The F-values for the counseling program of the overall well-being and the sub-domain are statistically significant at ≤ 0.05 with respect to the post-test for both experimental and control groups, respectively. The means showed that the overall well-being and sub-domains improved after the experimental group underwent the counseling program. Thus, this result supported the acceptance of the first hypothesis that the well-being of Syrian refugee women in the experimental group would improve as compared to the control group after implementing the counseling program.The means showed a difference between the experimental and control groups for both age groups. To test if this difference was statistically significant, a two-way MANOVA was conducted . Thus, the interaction and the difference between the groups and ages were estimated by two-way MANOVA.Additionally, the means of PTSD on the post-test in the experiential group for ≥ 24 years age group also differed from the ≤ 24 years age groups . This result accepted the fourth hypothesis that there is no correlation between the level of PTSD due to the counseling program and the participant’s age.Table 4The PTSD symptoms are classified into four categories: avoidance, adverse changes in the mood and thinking, intrusion memories, and changes in the emotional as well as physical reactions. The nature of symptoms differs among individuals and is subject to time . Thus, w1 and 2) revealed that the well-being aspects of the Syrian refugee women in the experimental group improved as compared to the control group after implementing the counseling program. Interestingly, the control group recorded nearly similar means in both pre- and post-test, while it was improved in all the domains in the experimental group. Nonetheless, the participants improved maximally in adjusting to the environment as compared to other domains. According to a study by Writers (2019), the environment construes the necessary awareness in an individual, thus becoming the most comfortable skill acquired by a person with a psychological disorder [The data analysis (Tables disorder . Other d4) indicated that both age groups respond similarly to the intervention program. These findings were contradictory to those described in the study by Ditlevsen and Elklit (2010), which stated that age is a factor that determines the intervention program and the manifestation of PTSD among trauma victims [The present study showed that age neither affects the counseling program nor the PTSD. The F-value of 0.01 (Table  victims . However victims .5). The score in the experimental group improved because the program worked by minimizing the psychological impact of their trauma, teaching them to enhance their personality traits, such as personal growth, self- acceptance, relation with others, and purpose in life. Also, resilience has been observed to cushion the stressors and assist towards a favorable outcome [The Syrian refugee women’s PTSD scores in the experimental group decreased as compared to the control group after the implementation of the counseling program  suggested that these women have a negative mood and thinking similar to that of a traumatized person . The othThese women show signs of overreaction and lack of tolerance due to lack of sleep and concentration and overwhelming feeling of guilt or shame; this coupled with irritability results in aggressive behaviors . The negIntriguingly, the pre-migration stressors among the women in Jordan refugee camps include the loss of loved ones, family separation, loss of freedom, and challenging economic situations . Before However, another study showed that refugees who have experienced severe trauma are unlikely to develop PTSD. The researchers used two samples of participants constituting 50% refugees and 50% non-refugees. There is a need for immediate steps to provide protection to refuges to help recover psychological suffering arising from trauma and stress . These fHowever, the findings have certain limitations. The mental disorder comorbidities, such as anxiety or depression, which could significantly influence the PTSD and well-being in participants, were not assessed. The specific domains of psychological functioning were not rated by a clinician. Also, DSM-IV was used instead of DSM-V.The intervention program was designed for the Syrian refugee women living in Jordan. The experimental group showed an improved general score in the well-being as well as in the designated sub-domains . However, it was found that age does not affect the implementation of the program. The experimental group comprised of the PTSD sample selected scientifically from among the Syrian refugee women, thus making this program applicable. It could be concluded that the PTSD experienced by Syrian refugee women is triggered by the cultural practice of the Jordanian society that allows abusive marriages and discourages divorce while victimizing women even in the rape situations. The society is both patriarchal and gender insensitive. Therefore, additional studies on the Jordanian culture and its impact on the refugees, especially women living in Jordan, are imperative. The women should be sensitized to advocate for their rights within the refugee camps and avoid early marriages. The women should be taught remedies to fight rape, such as screaming that is discouraged by the Jordanian culture. Lastly, the current program was effective in the intervention of PTSD among the Syrian refugee women living in Irbid City and can be applied to help the majority who are suffering within the different cities of Jordan.


The effects of physical exercise on executive functions (EFs) are well-documented. EFs are involved in daily activities, and their development determines the quality of people’s future life, both in terms of mental health and quality of life. The purpose of the current paper is to evaluate the effects of a physical education program, elaborated within the Enriched Sports Activity Program (ESA Program), an Erasmus + Project, on EFs, namely, visuospatial working memory, inhibitory control, cognitive flexibility, and task switching.1) and May 2018 (t2). At t1, a sample of 357 children from four European countries  performed a cognitive test battery made up of Digit Span Forward/Backward, Stroop Task, and Trail Making Test (TMT), whose order was randomized. From November until May, classrooms from the experimental group followed the ESA Program, while classrooms from the control continued with the ordinary physical education class. At t2, children from both experimental and control groups performed again the cognitive battery.Data were collected on November 2017 (tThe repeated measures ANOVA showed a significant effect of the ESA Program on the TMT B and on Digit Span Backward, but no significant effects were found on Digit Span Forward and Stroop Task.The introduction of a sport program enriched with cognitive stimuli has beneficial effects for children working memory and cognitive flexibility. In the past decades, cognition and exercise have been considered as separate domains and, for this reason, were treated independently . In receMany hypotheses have been provided for explaining this improvement as the increase of the catecholamine levels , which iEFs relate to a set of cognitive abilities that supervise the information processing for the implementation of goal-directed actions and that require a certain amount of memory, attention, inhibition, and self-control . EspeciaHowever, studies hypothesizing a connection between EFs and specific academic skills  found mixed results ranging from a positive influence of physical exercise to none on academic performances. A meta-analysis by Hence, a good development in EF is crucial for youth, since problems encountered in EFs during childhood are related to problems in terms of health, social status, and quality of life later on in adult life . For thiA significant improvement in children’s cognitive abilities due to physical exercise has been found by Considering that physical exercise has beneficial effects on children’s cognition, increasing attempts have been done to implement physical activity programs enriched with cognitive challenges . TuckmanThe success of a sports program depends on its structure and its features. The forecasted physical activity should also challenge children throughout the program. From a motivational point of view , if kidsEnriched Sports Activity Program . The project, which lasted 3 years, aimed at enhancing social inclusion, equal opportunity, and psychosocial well-being in children through an enriched protocol that introduced physical exercises able to stimulate cognitive growth  on children’s EFs. The ESA Program is an enriched physical exercise protocol experimented within the Erasmus + Project e growth . The exee growth . The proConsidering the results retrieved from literature, the physical exercise protocol foreseen by the ESA Program should enhance EF performance in inhibitory control, working memory, and task shifting. Given the developmental phase of participants, ranging from 7 to 14 years, we expect a general improvement of all children’s EFs, but a particular improvement in children who have followed the ESA protocol.1) and in May (t2), at the end of the same school year, within four different European countries  (Data collection took place in the first months of the school year in November (tGermany) . Four hu1 took place within four European countries . After parents’ signature of the consent form, children school classes were split in experimental and control groups. Children from both experimental group (ESA group) and control group completed a battery made up of three neuropsychological tasks derived by the Inquisit Lab platform: the Color Word Stroop Task  for improving children’s EF. The program consisted of 27 units lasting 25 min. The unit was made up of a baseline phase and stimulation phase, and it was obtained through a combination of two features: cognitive stimulus and movement domain. The construct validity was assessed only qualitatively: four experts from psychology and sport science rated the extent to which an exercise could stimulate a specific cognitive function. The discrepancies were solved through discussion.The cognitive stimuli for the stimulation phase could involve inhibitory control, working memory, or task shifting. In the activity stimulating inhibitory control, the coach’s verbal command for an exercise corresponded to the execution of another movement previously associated. For example, the verbal command “Skip-ahead” corresponded to “Kicked-ahead” movement, and the command “Fore-foot gait-ahead” corresponded to “Rear-foot gait-ahead.” The stimulation of working memory occurred through the explanation of a series of exercises that children had to perform in a reverse order. For example, the oral command “Balance on the line-ahead/behind” corresponded to the performance “Balance on the line-behind/ahead.” Concerning the task shifting stimulation, a circuit of exercises was created, and each child had to perform a specific exercise that was different from the others’ one. When the instructor whistled, children had to switch to the exercise that the kid ahead was performing, until all of them had performed all the exercises in the circuit.All the three domains started with a beginning level (B), followed by an intermediate level (I), and finishing with an advanced level (A). The design of the protocol was the following: the first nine units concerned the beginner level of exercise, whose domain was alternatively athletic drill, then sports ball, and finally smart circuits, and whose stimulation concerned alternatively working memory, inhibition, and task shifting. The same structure was kept for intermediate level and advanced level .A series of coaches’ guidelines video tutorials were recorded to maximize the protocol standardization across the European administrators.Descriptive statistics was performed on the sample, including height and weight , 3. AfteF1,355 = 2.26, p = 0.13). No general performance improvement was observed in the Backward recall during time , but children from the ESA Program significantly improved more their performance compared to the control group . No effects of Age were detected in both cases   , 3.F1,338 = 6.98, p < 0.01), but both the Time effect and the interaction between the treatment and the group were non-significant  , as well as the interaction between Time and Group  and the influence of Age  (A significant effect of Age has been found on the Stroop Task ( = 0.35) . Concern< 0.001) .The purpose of the current study was to test the effectiveness of the ESA Program on children’s cognitive performances, in particular, their EFs. The ESA Program is an enriched sports program containing warm-up physical exercises that were modified to stimulate three core EFs  .Some studies have already proven that the introduction of an ESA program enhances cognitive functioning . In thisMoreover, the ESA Program has already shown its effect concerning children’s physical fitness, where moderate effects were found in relation to throwing, jumping, sprinting, and agility . Our samFor the evaluation of the program effectiveness, repeated measures ANOVA was run, revealing a significant effect of the ESA Program on Digit Span Backward and TMT B version. No significant effect of the ESA Program was found on Digit Span Forward nor on the Stroop Task. To summarize our results, the enriched sport program produced positive effects for working memory, task switching, and cognitive flexibility, while no beneficial effects were detected on inhibitory control and short-time memory. Concerning the age of the sample, a significant interaction with the ESA Program was found in the Stroop Task and TMT, indicating that older children significantly reduced the completion time of the task, but the same effect was not detected for Digit Span Forward and Backward.The positive effect of an enriched sports program on working memory is in line with ample research. Both longitudinal and cross-sectional studies underlie a positive association among structured physical activity in childhood with higher working memory performance . KoutsanMoreover, a study by The ESA Program’s effects on TMT B reduction of time is coherent with findings of a previous study carried out by No improvements of the ESA Program were found upon inhibitory control, a result that contradicts other data in literature . HoweverThe review by Some limitations of the present study should be noted. First of all, follow-up measurements were not implemented; thus, we do not have information about the stability of our results during time. Secondly, performances in EFs were detected, but an important limitation is that they were not linked to children’s academic achievement or their reading, writing, and calculating skills. Finally, construct validity was only assessed qualitatively. Given these limitations, future research should investigate the effects of enriched sport programs with accurate construct validity measures on children’s academic achievement with a follow-up period after the conclusion of the program.Providing enriched programs, as the one suggested by the ESA Program, at school may significantly improve children’s cognitive functioning that in turn should have beneficial effects on their academic performances.The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by Lithuanian Sports University’s Research Ethics Committee in Social Sciences. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.AG, AB, and MA contributed to the conceptualization. FŞ, ÖG, SP, VI, YD, DS, AB, and MA contributed to the data curation. AG, SB, and MG-L contributed to the formal analysis. AB and MA contributed to the funding acquisition and contributed to the project administration. FŞ, ÖG, SP, VI, YD, DS, and MG-L contributed to the investigation. AG, MA, YD, DS, and MG-L contributed to the methodology. SP, VI, and MG-L contributed to the resources. FŞ and ÖG contributed to the software. SP, VI, and AB contributed to the supervision. YD and DS contributed to the validation. AG and MA contributed to the visualization. AG, SB, AB, MA, and MG-L contributed to the roles/writing of the original draft. FŞ, ÖG, SP, VI, YD, and DS contributed to the writing, reviewing, and editing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Evidenced-based clinical guidelines for the treatment of low back pain (LBP) consistently suggest educating patients about their back pain, its natural course, and providing advice to keep active and continue working. Despite this evidence, clinicians routinely do not follow these recommendations resulting in ineffective and fragmented care. GLA:D® Back, a standardized care package, was originally developed in Denmark to assist clinicians in implementing evidence-based care. This study will evaluate the feasibility of implementing the English version of the Danish GLA:D® Back program in Alberta, Canada.Thirty-five clinicians from nineteen clinics in Alberta, Canada, participated. Feasibility of program implementation, our primary objective, was evaluated within 3 months. Feasibility success was defined as 50% clinician/clinic adoption in addition to 66–88 enrolled participants registered in the database. Our secondary objectives included collecting data pertaining to clinician confidence, attitudes and behaviour of treating patients, perceived barriers and facilitators of program in addition to collecting patient-data regarding pain, function, general health and self-efficacy.The majority of the clinics  offered GLA:D® Back to their patients within the study period. Of the participating clinicians, GLA:D® Back was delivered by  of clinicians. In total, 78 patients were enrolled in the program and  participants attended the final assessment. Secondarily, clinicians demonstrated a biomedical and behavioural orientation along with high confidence when treating LBP patients while patient outcomes trended toward improvement.The English translation of the Danish GLA:D Back program was feasible for Albertan clinicians to implement into practice in both urban and rural settings. Is the English version of GLA:D® Back feasible when taught and tested in English?Can clinicians trained in GLA:D® Back successfully implement the program?What uncertainties existed regarding the feasibility?The majority of clinicians trained in GLA:D® Back employed the program in clinical practice.Participating clinicians had positive impressions of the program.Clinicians’ ratings of program content, usefulness and novelty were high.Clinicians were satisfied with the translated materials and the program itself.What are the key feasibility findings?Training materials translated from Danish to English can be used to successfully train English-speaking clinicians.Trained clinicians can successfully implement GLA:D® Back in practice.Patient recruitment was difficult in shift workers or those with insufficient resources and/or insurance coverage.What are the implications of the feasibility findings for the design of the main study?Low back pain (LBP) is a common, chronic recurrent symptom that is responsible for more years lived with disability than any other condition worldwide . As a reEvidence-based clinical guidelines for the treatment of LBP consistently suggest educating patients about what back pain is, its natural course, and giving advice about staying active and at work . In addiStandardized care packages based on guideline recommendations are suggested as a tool to assist clinicians in implementing evidence into clinical practice . One sucBased on the success of this approach, GLA:D® Back was created to address people seeking care for persistent or recurrent back pain with the goal of promoting self-management and patient empowerment. The GLA:D® Back program maintains the same core components of patient education, supervised group exercise classes and a registry to record patient and clinician outcomes throughout the program. The program itself is taught to clinicians from approved professions (presently chiropractic and physiotherapy) in a 2-day seminar format which then qualifies attendees to offer to program in their community.To date, the GLA:D® Back program has been launched in Denmark with 619 clinicians trained and approximately 2800 patients registered (April 2018–December 2019). Early indications from Danish pilot data suggest that GLA:D® Back is capable of reducing disability, pain and medication use while increasing physical capacities . To builThis paper reports on a feasibility study where the Danish GLA:D® Back program was translated into English and then subsequently delivered in private physiotherapy and chiropractic clinics in Alberta, Canada. Although cultural, professional and legislative differences may exist between implementation of the program in Denmark versus an English-speaking country, we hypothesize our results would be similar to those described in the Danish pilot .To evaluate the adoption of GLA:D® Back in clinical practice among Canadian clinicians volunteering to the feasibility study.The primary objective of this feasibility study was the following:To evaluate clinician perception of GLA:D® Back training and GLA:D® Back implementation.To evaluate the potential change in clinicians’ beliefs and behaviours about back pain after completion of the program.To describe the patient participants characteristics who enrolled in GLA:D® Back as well as patient self-reported outcomes related to function, pain, general health and self-efficacy.In addition, our secondary objectives included the following:The feasibility study of the GLA:D® Back program was overseen at the University of Alberta and implemented by trained community clinicians based in urban- and rural-based physiotherapy and chiropractic clinics in Alberta. Pre-implementation training of clinicians occurred over a 2-day training course at the University of Alberta. Following training, clinicians delivered GLA:D® Back at their clinics on a voluntary basis. During the course of the study, clinician and patient’s data were collected at baseline and at subsequent intervals via electronic questionnaires administered through Research Electronic Data Capture (REDCap). This study was approved by the Human Research Ethics Board of the University of Alberta Pro00085118). GLA:D® is a non-profit initiative whose name is trademarked by the University of Southern Denmark (SDU). For an overview of the study’s events and chronology, please refer to Fig. 18. GLA:Dalbertachiro.com), and the Physiotherapy Alberta College + Association website , as well as through personal contacts.Clinicians were recruited to the study using content approved for distribution on the Alberta College and Association of Chiropractors website .GLA:D® Back is designed to assist and promote patient self-management and self-efficacy by providing knowledge of pain mechanisms, reducing fear of movement and supporting patients in gaining control of pain, function and also to promote physical activity and exercise . In brieGLA:D® Back was developed around social cognitive theory and cognitive behavioural theory . As suchThe exercise section of GLA:D® Back incorporates strength, endurance and flexibility training divided into eight groups with four levels of difficulty in each . The staFour months after training, clinicians were asked the following questions: When did you start offering GLA:D® Back in the clinic? How many cohorts have you started? What is the number of patients in the registry? Based on the GLA:D® Back 2019 Danish Annual Report , our criClinicians were surveyed at three-time points: 1 week prior to participating in the 2-day GLA:D® Back workshop immediately after the GLA:D® Back training course, and 4 months after completing the GLA:D® Back training course.Specifically, the pre-course survey included closed-ended questions about clinician demographics  as well as an assessment of their confidence with handling back pain patients  and their attitudes and beliefs about back pain . The PCS and PABS were repeated by an electronic survey 4 months following the training course. The PCS is a 4-item scale measuring confidence in managing people with back pain . Each itImmediately following the GLA:D® course, clinicians were asked to rate the course with respect to course content, novelty and usefulness with each of these domains scored on a scale of 0 to 10 (from 0 = “very poor” to 10 = “very good”). Clinicians were also asked to answer survey questions related to the DIBQ (Determinants of Implementation Behaviour Questionnaire) that were adapted for use in GLA:D® Back : tailoring to best-practice low back pain primary care program implementation, and pilot testing in Sweden and Denmark. Manuscript submitted).To better identify and understand barriers and facilitators of implementation, 4 months following the training course, the lead author (J.L.) conducted one-on-one semi-structured telephone interviews with all clinicians. The interview guide was centered on perspectives regarding the content of the clinical intervention and the implementation at their clinic with perspectives on patient recruitment for the program. The telephone interviews were 20 min in duration, audio-recorded, transcribed verbatim and quotes related to various themes of GLA:D® Back were identified by J.L.Patients who expressed interest in the study voluntarily provided their email address and received detailed information about the study as well as an electronic form to provide consent to be enrolled. If enrolled, they then received an automatically generated link to a baseline survey on the day of the first consultation and 3 months later following completion of the GLA:D® program. If there was no response within 3 days, an automated reminder was sent.The baseline survey collected demographic information, information on LBP history, previous treatment, and self-reported risk factors for a poor prognosis (The STarT Back Screening Tool) .Both at baseline, and at the 3-month follow-up, a series of patient reported outcome measures were collected including pain intensity via a numerical pain rating scale (0–10 NRS), activity limitation (Oswestry Disability Index (ODI); 0–100), illness perceptions (the Brief Illness Perceptions Questionnaire (B-IPQ); 0–80), fear of movement (Fear Avoidance Beliefs Questionnaire (FABQ); 0–24), quality of life  and “perceived physical fitness” (0–40) via self-assessed strength, endurance, cardiovascular fitness and balance. The use of pain medication was documented as a binary yes/no response.At 3 months after completion of the program, the above patient-reported outcome measures (PROMS) were collected again in addition to reporting of usage of non GLA:D® interventions . Participants were also asked if they were satisfied with the GLA:D® Back program using a 5-point Likert scale .Finally, results for clinical tests conducted before and after GLA:D® Back were included in the participants database. These measures included physical performance assessed by a standing forward bending test , the Ito extensor endurance test (static extension from 0 s minimum up to a maximum of 3 min), the trunk flexor endurance test (0 s up to a maximum of 2 min in static sit-up position) and the sit to stand test (stand number of repetitions of standing from seated in 30 s).Patient adherence was measured by the number of sessions attended.In this feasibility study, we limited participation to 20 clinics who each conducted a single GLA:D® Back intake of no more than 10 participants/clinic. Clinician participation was capped to 20 clinics due to the size of our training facility. As for the limit of 10 patients per GLA:D® class, this is the number described as optimal by the GLA:D® Back originators. As such, no formal sample size calculation was performed.Descriptive statistics were performed for all quantitative data collected.Feasibility of adoption was based on multiple measures including the (1) number of clinics that offered the GLA:D® Back program and registered participants into the clinical registry within the first 3 months of the feasibility study, (2) number of clinicians that did the same, (3) the total number of participants enrolled in GLA:D® Back in that time period and (4) participants that finished the course with a final exit assessment and (5) the number of completed participants questionnaires at the 3-month follow-up.Clinicians attitudes and beliefs about back pain were measured by describing group medians, first and third quartiles on the PCS, and the PABS at baseline and 4-month follow-up. To evaluate the with-in clinician change on the PABS, the median change scores were calculated together with first and third quartiles.Subsequent inferential analyses were carried out in an exploratory manner using R software (Version 3.6). We employed the Wilcoxon signed rank test to evaluate the change in both clinician and participants’ measures as many of these outcomes did not meet established assumptions for parametric testing.For the qualitative feedback collected through semi-structured interviews, the use of thematic analysis was employed pragmatically by grouping quotes into themes relating to the clinician course, participants’ education, participants’ exercise, participants’ recruitment and the logistics of implementing the program in clinic. All clinicians were accommodating to the procedure and the interview feedback resulted in rich information to improve upon the GLA:D® Back program.n=25 physiotherapists, n=10 chiropractors) with varying clinical experience  participated in the 2-day course. All clinicians 100% (35/35) completed the GLA:D® Back pre-course survey and the post-course survey. At 4 months, 77% (27/35) of clinicians completed the follow-up survey. Sixteen clinics were represented by two clinicians and the three rural clinics were represented by one clinician each. Six out of the fifteen clinics were concurrently offering the GLA:D® knee and hip program and 13/35 (36%) of clinicians have referred patients to the GLA:D knee and hip program , self-employed 31%) or employees (33%) at a clinic with (71%) being physiotherapists and (29%) chiropractors. Most clinicians had greater than 11 years of experience (56%) in clinical practice. Six percent (6%) had prior experience teaching GLA:D® knee/hip program, and 58% were familiar with the GLA:D® knee/hip program (Table % or empln=49) being females (Table n=39) of participants were taking over the counter or prescription medications and had slightly higher than moderate B-IPQ scores median difference: 6.5, (p=0.015) (Table p ≤ 0.001), and had a medium perception of physical fitness at baseline with a value of 19 (range 0–40) and a median increase of 3 (p=0.031) (Table Most participants (60%) had experienced LBP for more than 1-year and had prior treatment for more than a 4-week duration (69%). The average age of patient participants was 56 SD=13) years old with 66%  offered GLA:D® Back to their patients within the study period. Four clinics, three urban clinics and one rural clinic did not start the program because of difficulty recruiting patients from colleagues at their clinics , a perceived lack of the ideal patient for the program or their clinic was not ready to start the program in the first 3 months following training. GLA:D® Back was delivered by  of clinicians. The 10 clinicians who did not deliver the intervention expressed the intention to deliver the program in the future. One clinician who delivered the program reported that they would not offer the program again in the future as “it does not fit with my practice style”. The 15 clinics that actively participated in delivering the program enrolled a total of 78 participants who also attended the initial assessment (range 1–7 participants per group) within the first 3 months after having taken the course. Out of these fifteen clinics, ten clinics had a group size of at least 4 participants. Of these seventy-eight participants,  attended the final assessment with nine participants dropping out for various reasons including a change in diagnosis of their condition (i.e. ankylosing spondylitis), worsening of symptoms unrelated to the back (i.e. shoulder), worsening of back symptoms, moved locations or experienced a change in their work schedule. Of the enrolled seventy-eight participants,  completed the 3-month follow-up survey.p < 0.001). The PABS indicated the clinicians had a combined biomedical and behavioural orientation with more of a preference for behavioral before the course. Clinicians showed significant differences in the PABS Biomedical Subscales  and PABS Biopsychosocial  which indicated clinicians were moving towards a behavioural orientation , cost of the program and committing 8 weeks for the entire program.…we surveyed patients and asked what would work best; either afterwork or sometime mid day…I think in general we took the mid day one because we had more people (available) from that end…but I think timing [of the program] was one of those[negative] factors…a third factor was we found some people just couldn’t commit for eight weeksStatements about barriers included scheduling issues and length of the program:…we ran a Facebook campaign for almost two months with no response…we decided external referrals were not happening…then had a meeting to decide if we’re going to recruit candidates internallyA few clinicians informed us that they would not be able to perform recruitment for various reasons including having too few patients with the required profile and having very few patients interested in the program with statements such as:I thought the 2-day course flowed very well…the instructors are very knowledgeable. I felt like we had some fun doing it. I thought the course was very well done…I would rate the course as excellentClinicians evaluated the course with high scores for each of content, usefulness and novelty Table . This viI also plan on… flagging patients who I think are moving into, or already have moved into chronic or recurrent back pain and making sure that I'm discussing this possibility [of GLA:D® Back] with them. And …immediately, my mindset is, okay…let's make sure I funnel these patients that way [into the GLA:D® program].Patient recruitment: Clinicians found the 2-day clinician GLA:D® course made them more aware of which participants would benefit from the program with statements such as:It is a novel form of treatment that allows the patients to take care of their own issues…by using GLA:D® , it’s the exercises and knowledge that gives them [the patient participants] a long term tool that they can take home with them…showing them that movement is good and it’s not necessarily one inherent movement that is going to cause them to mess their back up…but the more movement the better…understanding that movement is good.Clinician participants’ experience with GLA:D® Back: When asked about patients’ experiences, clinicians made statements such as:The first couple of weeks, everyone was warming up to each other in the group…now it’s a lot of fun. Everyone is really interacting with each other and enjoying each other. And it’s cool because there is now a team dynamic of learning.Group exercises: Clinicians communicated about group exercise with statements such as:…we had one patient that had a positive straight leg raise coming into [the program] and couldn’t sit for more than 20 minutes and three quarters of the way through the program she drove 5 hours…. I asked how was sitting for that long… She just looked at me with a blank look… Then she said… you know I just realized that I didn’t have a problem.Increasing capacities with exercises: As for the effect of exercise, clinicians made statement similar to these comments:n=2) reported that they did not receive the education portion of the program and key messages during the exercise sessions which may have a negative effect on post intervention outcomes seen after the intervention.After the GLA:D® Back intervention, 84% of the 78 participants reported that they attended two of the education sessions and 74% of participants attended 11–16 exercise sessions throughout the 16-session program. A small proportion of participants (n=52) had a median improvement of 1 repetition on a chair stands during 30 s (p<0.001), a median improvement of 32 s (p<0.001), on the trunk flexor test (range 0–120 s), and a median improvement of 80.5 s (p<0.001) on the extensor endurance test (range 0–180 s)  Table .Table 4p<0.001), on the FABQ (range 0–24) and a small median improvement of 6.5 (p=0.015), on the B-IPQ surveys  on the ODI and moderate median improvement of 2 on NPS Back pain (< 0.001) and moderate improvement of 1 on NPS Leg pain (p<0.001)  Table .At the 3-month follow up, most patient participants (76%) were satisfied or greatly satisfied with the GLA:D® Back program and 37/50) or 74% of participants used the GLA:D® Back at home although this is not a requirement of the program  were able to form a group of at least four patient participants.Clinicians’ evaluation of the course was positive which may have been associated with our successful adoption rate. Also, clinicians held a moderately high orientation for a behavioral approach to care both before and after the 2-day course which also may have contributed. Small changes were observed in clinician PABS scores indicating that clinicians held a strong belief both for biomedical orientation and behavioural before the course. Congruence between clinician beliefs and the underlying principles of the GLA:D® Back program also favoured adoption. Interestingly, practitioner’s confidence was relatively unchanged from baseline to 4 months following the training course which may relate to the experience level of the clinician cohort, the practice orientation of this cohort of clinicians, the quality of the training session or other factors not measured here. As such, these results are for a fairly short period following clinician training. Longer term studies will be needed to determine if these changes are sustained.Clinicians mentioned in the interviews that GLA:D® Back built a strong group dynamic that could be an important factor for development of self-efficacy through vicarious experience by observing other people in a similar situation. Clinicians’ also suggested that the program builds up physical capacities to match daily demands of participants’ activities. These two observations are important in this type of evidence-based program which is based on the Social Cognitive Theory (SCT) targeting the patients’ goals as SCT provides opportunities for social (group) support through instilling expectations, self-efficacy, and using observational learning and other reinforcements to achieve behavior change, while considering their individual capacity for performance .Most participants enrolled in GLA:D® Back (60%) had LBP for greater than 1 year indicating that the majority of participant reports majority of participant reports of pain duration were congruent with the inclusion criteria for the program. This is important because clinicians were appropriately targeting patients with recurrent or persistent LBP which is the condition the program was designed to address. This suggests that through intentional enrollment by clinicians, curiosity by patients or a combination of both, the majority of those in the program had persistent or recurrent LBP. Further studies should be considered to evaluate how the GLA:D® Back program may perform when used with similar populations but in different situations such as pre-surgery waitlists or post-surgical recovery.All patient factors evaluated were done so as an exploratory exercise given the lack of a sample size calculation in this feasibility study. The B-IPQ and SF-36 did not demonstrate a significant change over time. In this case, the measurement duration may not have been enough to counteract multitude of factors that may impact a person’s beliefs and quality of life. The FABQ also showed significant improvement which suggests the education and exercise components of the program may directly address this concept. In this study, patient capacity improved as demonstrated by the performance measures. Combined, these results may motivate clinicians and patients similarly and endorse this mode of program delivery.Feasibility may depend on clinicians properly informing patients of what to expect in the course in terms of fees, group setting and availability. Although some clinicians from this study had difficulties running the program, we found that the most motivated clinicians with a large heterogeneous LBP population were the greatest adopters of the GLA:D® Back program. Both GLA:D® Back programs in Alberta and Denmark had similar challenges with adoption. Unfortunately, as the only program outside of Denmark conducting GLA:D® Back thus far, lessons of how to improve uptake are still evolving. These lessons may include offering a wider range of program times to accommodate a range of patient schedules, emphasis placed on the potential benefits of group vs individualized programming and identifying ways to decrease out-of-pocket costs for patients to take the course.This was a feasibility study and therefore was not designed or powered to fully evaluate clinician/participants outcomes. We did not evaluate the fidelity in treatment delivery and do not know to what extent the program was delivered as intended. A future trial to evaluate the efficacy or effectiveness of GLA:D® Back is a potential consideration. This work represents the first publication of data related to an English implementation of the GLA:D® Back program which provides a basis for its use in Canada and other English-speaking jurisdictions.Possible directions for future studies would be to transition to a study design that evaluates the effectiveness of GLA:D® in terms of pain, disability, and self-efficacy.The English translation of the Danish GLA:D® Back program was feasible for Albertan clinicians to implement into practice in both urban and rural settings.