Due to the rising demands for a Canadian workforce with science, technology, engineering, and math (STEM)-related education, there is a need to increase youth engagement in STEM education and programming. Research, however, has shown that youth residing in low-income communities are disproportionately affected by psychosocial barriers, which often inhibit meaningful engagement in STEM programming. Visions of Science Network for Learning (VoSNL) was designed and implemented to address these existing barriers. VoSNL is a charitable organization in Southern Ontario, Canada, that provides weekly community-based STEM programming to low-income and marginalized youth during out-of-school time. VoSNL programming is delivered directly within the community and is free-of-charge for all youth in order to minimize barriers of physical and financial accessibility. The purpose of this report was to provide a detailed description of a core program within VoSNL—Community Science Clubs—and summarize the findings of a process evaluation, specifically the successes and challenges of implementing a community-based, out-of-school STEM program.Program successes are outlined along with the challenges that have been identified through program implementation. Successes include (a) delivering the program within a community context, (b) opportunities for consistent engagement, and (c) establishing positive youth-staff relationships. Challenges include (a) navigating community-based issues, (b) conducting outreach and promotion, and (c) accommodating a wide age range of youth. Further, lessons learned from an evaluation of program implementation are also discussed.This report provides one of the first program descriptions and process evaluations of a community-based, youth-focused STEM program within a Canadian context. The findings in this report have helped to improve the delivery and evaluation of the VoSNL program and may act as a catalyst for program expansion to reach more youth in marginalized communities. Further, the findings can also provide a strong framework for programmers interested in implementing STEM youth programming in a community context, assist in the replication of similar models in other locations, and enhance STEM learning amongst youth. There is a growing amount of evidence to support the notion that youth require a strong foundation in science, technology, engineering, and math (STEM) education in order to enhance economic well-being and quality of life during later years in life Ejiwale, . Across STEM pathway was achievement in science and math courses at the compulsory level , which can often augment their marginalization  to 14 communities across the Greater Toronto Hamilton Area (2016). Each CSC engages approximately 15 to 20 local youth, yielding an average of 300 youth engaged in CSC programming annually.The CSCs were developed to provide hands-on STEM engagement opportunities directly to youth living in low-income communities. The program utilizes a The CSCs include active and integrated learning approaches including workshop sessions, guest speakers, field trips, and an annual showcase. The workshop sessions are delivered to all youth from grades 3 to 8 in the form of weekly, 2-h workshops for 7 months of the year (October to April). Over the course of this 7-month period, approximately 23 workshops are offered in different community locations. Workshop sessions are guided by facilitated modules, which involve active, hands-on STEM experiments and activities. Modules are utilized by VoSNL facilitators and volunteers and are designed to build on many concepts taught within the provincial education system for grades 1 to 8. These modules feature career connections and real-world applications related to society, technology, and the environment and also highlight the work of current scientists who are representative of the diverse backgrounds present within the communities. Aside from workshop modules, the CSCs’ host guest speaker visits from local partner institutions and STEM-based organizations to help build community connections and introduce youth to STEM-related career opportunities. Through various partnerships, CSCs also facilitate active learning opportunities through excursions to various STEM-based learning institutions while ensuring transportation and admission costs are covered. At the end of each program year, youth in all 14 CSCs participate in a culminating activity where they share a STEM-based exposition to stakeholders, community members, and the general public with the aim of raising awareness and generating interest about VoSNL’s CSC to the broader community. Further, the event provides an opportunity for youth to showcase their experiments to the broader community  and provides a leadership opportunity for youth to present and learn from their peers.The CSCs are delivered with a focus on developing youth-led inquiry, team-building, healthy competition, and project-based learning. Sessions are led by a VoSNL program facilitator and a team of volunteers who are recruited from neighboring post-secondary institutions and within the CSC communities. Prior to joining VoSNL, incoming staff and volunteers undergo screening processes. All staff are required to have a working knowledge of STEM learning and experience in teaching and facilitation techniques and working within target communities and managing teams. Volunteer facilitators are also required to have a working knowledge of STEM learning; therefore, the majority of facilitators have educational backgrounds in STEM disciplines. However, due to the multidisciplinary nature of the work in these communities, some facilitators are also from teaching or social work fields. Facilitators are trained bi-annually on module delivery, facilitation and teaching skills, club management, community outreach, and youth engagement to ensure techniques and quality of program delivery are consistent.As an extension of engagement, CSC alumni in grades 9 to 12 are provided the opportunity to continue participation as “community ambassadors” where they participate in program facilitation, mentorship, and promotion of CSCs in their respective communities. Overall, the CSC program activities aim to achieve the long-term goal of enhancing youth engagement and academic achievement amongst the target population of youth through five outcomes: (a) increased knowledge and interest in STEM subjects and school, (b) increased school connection and success in STEM, (c) increased self-efficacy and interpersonal and intrapersonal skills, (d) increased understanding of diverse approaches to learning science, and (e) application of transferable knowledge and skills  to everyday life.A process evaluation was conducted throughout the implementation of CSCs. The evaluation of the program processes utilized three sources of data: (a) weekly logs completed electronically by the program facilitators from each CSC location ; (b) end-of-program feedback forms from the facilitators; and (c) end-of-program feedback forms from volunteer program facilitators.The weekly logs included 11 questions and were completed at the end of each workshop session. Fourteen program facilitators  completed this  over the course of the 23-workshop sessions. Questions included point-of-service feedback including attendance, activity of focus, feedback on the module, what worked well, and areas for improvement for future sessions. Responses in the weekly feedback tended to be short and abbreviated, taking 5–7 min to complete. The end-of-program feedback form for program facilitators and volunteers and was also completed electronically. The feedback forms for program facilitators were comprised of 19 questions and included demographic information , as well as overarching open-ended questions regarding what worked well and did not work well during program delivery, feedback on program location for the CSC, and suggestions for improvement related to curriculum development, outreach, and volunteers. Finally, space was provided for participants to include additional comments. Responses tended to be more detailed and reflective than with the weekly logs taking program facilitators and volunteers 15–20 min to complete. The feedback forms for volunteers were comprised of 19 questions pertaining to demographic information, perceived participant outcomes, and the overall volunteer experience. Respondents, specifically 13 (93%) program facilitators and 38 (54%) volunteers, were representative of all club locations, with participation from at least one facilitator from each of the 14 clubs.The data were analyzed using an inductive thematic analysis to help understand program processes  have been included in the following sections. Additionally, the discussion has been integrated into the findings section as well.Four main themes, related to successes of implementation and program delivery of the CSC program in communities emerged during the process evaluation, including: (a) delivering the program within a community context, (b) opportunities for consistent engagement, and (c) establishing positive youth-staff relationships.A key component of CSC success in program delivery was the community context engrained within the program. The CSCs are offered directly to youth within their communities in response to evidence that low-income families are less likely to participate in enriched out-of-school time programs due to lack of available and accessible options The findings of the process evaluation aligned with the literature and revealed the delivery of the CSC program directly within community spaces enhanced accessibility for youth and their caregivers. Program staff acknowledged benefits of direct access to STEM programming within their communities. Specifically, several program leaders outlined: “The area is a good location to have science clubs because it's easy for the kids to get to and the community allows the kids to interact/support each other in and out of club” (PP-L-2016) and “Many of the students live nearby, which makes the building an ideal location as it is easy for them to travel to/from club sessions…it is a good location for [name of club]” (PP-L-2016). Additionally, one program leader stated:Finally, one of the program leaders outlined that the CSC location was ideal “because the majority of kids were walking distance from the location” (PP-L-2016).The more children attended, the more they got to know one another. For example, during the air pressure [module]…one student showed other students how to make paper airplanes who were struggling before. I saw cohesion in our group of 20 students. (PP-V-2016)The CSCs operate consistently on a weekly basis over a 7-month period, delivering a total of 23 workshops at each of the 14 community locations annually. In line with existing research, the consistency of the CSC delivery in communities was identified as being critical for program success. Volunteers described the positive group dynamics of the CSC youth: “I was happy to see that there were students who came in every Saturday without fail, excited to work on science. This was very surprising to me but it definitely motivated me to be more involved” and “[Youth] are committed to attending the club weekly and they constantly stay engaged and ready to have fun” (PP-V-2016). A volunteer also outlined how:Everyone left smiling ear to ear. When our bus returned at the end of the day, after a barrage of hugs, it melted my heart hearing the students trying to calculate the number of weeks until next fall when Science Club is set to start up again. (PP-L-2016)After the final program event, one leader documented:Research in youth and STEM programming has outlined that programs which engage youth over longer periods of time have a greater impact on positive developmental outcomes than programs shorter in duration As outlined, program leaders within CSCs are commonly STEM professionals or post-secondary students from local or neighboring post-secondary institutions. Mentorship from the program leaders was recognized as having a favorable influence on youth as one volunteer discussed: “Getting to know the kids better really helped them come out of their shell. They became more confident in taking guesses and trying new things knowing that they were in a very open environment that encouraged sharing new ideas” (PP-V-2016). Additionally, a volunteer reflected on this supportive environment as a predominant success of the program:Literature supports these findings as access to meaningful mentorship opportunities from leaders and peers can play a critical role in supporting STEM learning amongst youth within informal learning environments , providing an opportunity to give back to their community and act as a leader and role model to younger youth. Further, these volunteer alumni tend to be close in age to the youth participants . The close age gap provides opportunities for volunteers to share their knowledge regarding the program, academics, and future careers aspirations with the youth , while establishing a relatable connection with the youth participants. Having junior leaders of similar age to youth has been identified as a successful element of program delivery in other youth programs Shaikh, . FurtherEvaluation of the CSC program through program leader and volunteer feedback revealed three challenges related to program implementation. While many of the program successes reinforced existing best practices within literature, the summary of challenges revealed predominantly novel insights in the potential complexity of program delivery within a community context. These challenges included: (a) navigating community-based issues, (b) conducting outreach and promotion, and (c) accommodating a wide age range of youth.Delivering programming directly within communities requires collaboration with key stakeholders, including local social housing providers, post-secondary institutions, and community groups in each community. These stakeholders offered support for CSC programming, including access to space, outreach, and logistics support. In order to ensure maximum accessibility to target youth, CSCs were delivered in residential community spaces  and, in some cases, neighboring schools and/or community centers. This program-delivery strategy, however, was identified as a challenge on a few occasions throughout program implementation. The findings revealed that compromising situations that occurred in the community during programming months may have inhibited youth involvement in CSC. When certain situations arose, such as imminent violence in the community, the CSC program was impacted as sessions were canceled to ensure the safety of the participants and volunteers. Moreover, any issues that occurred within the building  directly affected the program. A number of program session cancelations occurred due to these issues, resulting in missed programming for participants and reduced exposure to the content. One leader reflected on the impact on participant attendance: “We’ve been running low on student attendance ever since the construction cancellation” (PP-L-2016).I’ve seen the impact of our [program] over the year but [the space] is physically limiting and I was worried for a while that if we had any more registrations I might not be able to accommodate the kids that came in. (PP-L-2016)In addition to community situations, limited resources within the community locations were also an identified challenge to program success. Engaging in STEM-based workshops can often require access to specific resources and amenities that are built within the program space, such as internet/technology, a kitchen with running water, and teaching aids . In some communities, there was an absence of these resources in the space provided by community partners as a result of the infrastructure built within the program space itself. As a result of the limited resources available in some of the space provided, the capacity of the location, the delivery of curriculum content, and, in some cases, the development of certain modules was inhibited. One leader discussed:Many times, our materials had been used or stolen by other clubs at the location. Specifically, for the year end event we had materials, such as yeast and hydrogen peroxide stolen, specifically bought for the event. It has been an ongoing issue throughout the year . (PP-L-2016)Another leader reflected: “Access to water (hot and cold) was an on-going issue throughout the year” (PP-L-2016). Additionally, many of the CSC program spaces were shared with various community groups, which was challenging when coordinating program timing and the security of experiment equipment. A program leader commented on the ongoing issue of equipment security:Outreach, promotion, and scheduling conflicts have been a documented issue for service providers within low-income communities . A similar sentiment was echoed at another club: “A couple students had mentioned conflict with timing of Visions of Science due to basketball and soccer practice” (WF-L-2016). This has been identified in other youth program literature as a challenge to reach and engagement  and “Given the age differences of the students, there were some tasks that some really young students could not do…the club would have been more effective in student learning if this group were split into two groups” (PP-V-2016).The CSCs target youth ages 8 to 14 years old. In some clubs, this age difference poses a challenge to effective teamwork and facilitation. Two volunteer facilitators reported issues related to content delivery and suggested potential solutions: The recommendation to separate a large group into smaller groups to optimize program delivery and outcomes has been outlined in other community-based youth programming literature  are there any resources, opportunities, programs, community partners etc. we can connect them with to further their interest so as not to leave them hanging? (PP-V-2016)An unforeseen age-related challenge that emerged in the CSCs was the need to actively engage youth past the cutoff age as one facilitator mentioned:One approach VoSNL implemented to engage those youth is through opportunities to become community ambassadors and volunteers in the program in which they have aged out of. Similar strategies have been utilized in other youth programming contexts, such as summer camps and youth sport programs Although there are several processes of CSC program delivery that have been identified as successful, there remain challenges related to navigating community-based issues, conducting outreach and promotion, and accommodating a wide age range. As previously mentioned, the majority of the community-based issues outlined are external to the program. Considering the nature of the issues, it is imperative to remain committed to the communities served, despite these challenges. Further, as an organization, it is important to recognize and address challenges within program implementation to enhance achievement of intended outcomes and program sustainability (Bean, Kendellen et al., Moreover, the development of workshops to cater to possible resource-related limitations underscores the notion that STEM learning can be adaptable across a range of environments. Additional long-term solutions include working with external partners to introduce necessary resources to community spaces as well as with housing providers to improve infrastructure. In the area of outreach and promotion, future strategies are focused on developing partnerships with other community-based groups. For example, in the summer of 2016, VoSNL partnered with a local community-run sport program to offer STEM-based workshops within their existing basketball camp. Moving forward, similar year-round opportunities and methods will be used to promote the CSCs and engage participants in STEM learning.Based on the identified successes, VoSNL’s CSCs have expanded and moved towards a sustainable program. Through establishing partnerships between housing providers and community groups, the program has scaled from six communities in 2011 to 18 communities across three different regions within South-Eastern Ontario by 2016. This expansion has demonstrated that the model is viable and scalable across different low-income communities with each presenting its own unique challenges and opportunities. Registration intake data collected from 2013 to present indicates that an average 50% of participants are returning to their CSCs each year VoSNL, .community ambassadors. This level of sustained participation further underscores the need and value of consistent programming for youth across communities. Moreover, this level of continued engagement from past participants into a leadership position aids in program sustainability as not only is it cost-effective for a charitable organization to have a large volunteer pool to help facilitate programming, but this also allows for that sense of relatedness discussed previously because of the close age gap between youth and program staff. Further, this addition to programming provides an opportunity for those volunteers to develop leadership skills and contribute to their community by giving back to a program they were involved in, which is the ultimate goal of youth development (Bowers et al., This yearly retention has also facilitated the engagement of participants beyond the projected eighth grade cutoff, where youth would typically age out of the program. Many of these alumni participants opted to continue their involvement by engaging as volunteer facilitators in the CSCs in their respective communities and are now identified as Although improvements can be made to best meet the needs of all stakeholders and overcome challenges to ensure program sustainability, findings from this evaluation have aided in the improvement of delivering VoSNL CSC programming. Further, results from this descriptive report may also act as a catalyst for expanding the program to more participants and communities. This report can provide a strong framework for other programmers interested in implementing a community-based STEM program for youth and can assist in the replication of similar models in other cities and enhance STEM learning amongst youth. Finally, although this report outlines important processes, future research is needed to assess the outcomes and impacts of community-based STEM programming on youth within a Canadian context.


The Philadelphia chromosome contains a fusion gene called BCR-ABL1. The BCR-ABL1 codes for an aberrantly functioning tyrosine kinase that drives the malignant proliferation of the founding clone. The advent of tyrosine kinase inhibitors (TKI) represents a landmark in the treatment of CML, that has led to tremendous improvement in the remission and survival rates. Since the introduction of imatinib, the first TKI, several other TKI have been approved that further broadened the arsenal against CML. Patients treated with TKIs require sensitive monitoring of BCR-ABL1 transcripts with quantitative real-time polymerase chain reaction (qRT-PCT), which has become an essential part of managing patients with CML. In this review, we discuss the importance of the BCR-ABL1 assay, and we highlight the growing importance of BCR-ABL1 dynamics. We also introduce a mathematical correction for the BCR-ABL1 assay that could help homogenizing the use of the ABL1 as a control gene. Finally, we discuss the growing body of evidence concerning treatment-free remission. Along with the continuous improvement in the therapeutic arsenal against CML, the molecular monitoring of CML represents the  CML is a malignant proliferation driven by a characteristic fusion gene called BCR-ABL1 , 3. BCR-The introduction of imatinib, the first tyrosine kinase inhibitor (TKI), has improved the treatment outcomes to such an extent that in many patients the disease burden decreases quickly below the detection limit of classical assays such as bone marrow cytogenetics –11. TherThe main goal of TKI therapy is to achieve a complete cytogenetic response (CCyR), defined as the lack of any detectable Ph+ cells in the bone marrow, within 12 months after starting treatment. CCyR is roughly equivalent to BCR-ABL1 IS ≤ 1%. The therapy for CP-CML is mainly represented by TKIs, which have improved the treatment outcomes compared to previous therapies. For instance, in the IRIS trial, a phase III trial that included more than 1,000 CML patients, and which eventually led to the approval of imatinib, the rate of complete cytogenetic response (CCyR) at 18 months in patients treated with imatinib was 76 vs. 15% for patients treated with interferon (IFN) plus cytarabine . Ever siAP or BP CML should be treated by allogeneic HSCT after inducing remission with TKI and/or chemotherapy, regardless of whether the event occurred at diagnosis or progressed from CP-CML . DependiIn the era of TKIs, for most patients only qRT-PCR is sensitive enough for detecting residual disease in the long term. CML burden monitoring via qRT-PCR was considered even before the advent of TKI , 57, butThe implementation of the BCR-ABL1 assay in the clinical practice was also aided by the development of an international scale (IS). The IS reference is represented by the median value of 30 samples collected from patients with newly diagnosed CP CML who were enrolled in the IRIS trial . Since tThe reference gene for the BCR-ABL1 assay is usually represented by the ABL1. The ABL1 gene was chosen through an international initiative out of a panel of 14 candidate genes and has since become the standard control gene for most laboratories performing BCR-ABL1 quantification . The majOptimal, Warning, or Failure ]. Achieving MMR is associated with a negligible risk of disease progression compared to patients that failed to achieve this milestone –66. HoweBeyond MMR, achieving deeper remission is an important concept as well. Deep molecular remission (DMR) is variably defined as either BCR-ABL1 IS <0.01% (MR 4.0) or BCR-ABL IS <0.0032% (MR 4.5). In the German CML study IV, the life expectancy of patients with MR4 or MR4.5 was the same as that of age-matched population . The samThe absence of any detectable BCR-ABL1 transcripts is termed complete molecular remission (CMR) or molecular undetectable leukemia and it corelates with better outcomes in terms of event-free survival (EFS), progression-free survival (PFS), and overall survival (OS) , 70. DesAt the other end of the spectrum, there is an ongoing research regarding the role of early molecular response (EMR) as a means of predicting outcomes and treatment responses. EMR is defined as BCR-ABL1 IS <10% at 3 months. Achieving EMR is associated with improved PFS and OS compared to patients not achieving this milestone –73.Several studies have shown that the dynamics of the BCR-ABL1 values can be used for devising independent predictors of outcome –76. For Similarly, Hanfstein et al. showed that that the velocity of the BCR-ABL1 decay successfully predicts outcome and that a 0.35-fold reduction of BCR-ABL1 compared to baseline levels at 3 months  defines distinct risk subgroups in terms of overall survival . In ordeThe reasoning behind the mathematical transformation lies in the distinction between ratio and proportion. The aim of the BCR-ABL1 assay is to calculate the ratio between the BCR-ABL1 transcripts and the ABL1 transcripts . However, the actual results of the assay are represented by the proportion of BCR-ABL1 transcripts from the total number of BCR-ABL1 plus ABL1 transcripts . The distinction between ratio and proportion is unimportant when the results of the assay is small, as it is most often the case in clinical practice due to the excellent response to TKIs. In a situation when out of the total number of BCR-ABL1 plus ABL1 transcripts, the BCR-ABL1 transcripts represent 1 part, and the ABL1 transcripts represent 99 parts  ratio using a mathematical correction, such that the ABL1 control gene could be used even for BCA-ABL1 IS values higher than 10% (see below).X) can be extracted from the BCR-ABL1/(ABL + BCR-ABL1) proportion (Y) by the following transformation  .With increasing evidence in support of the predictive and prognostic value of dynamical parameters, it is expected that situations when calculation of BCR-ABL1 IS values higher 10% is required will be more and more often. Using the mathematical transformation presented here, BCR-ABL1 transcripts values above 10% could be reliably calculated without changing ABL1 as the control gene, thus spearing laboratories from the effort of redesigning their assays and helping to translate dynamical parameters in the clinical setting.The possibility to achieve treatment free remission (TFR), a term defined as sustained MMR after TKI treatment discontinuation, was put forward more than a decade ago –82. SincThe ELN guidelines consider that discontinuing therapy is feasible in low-risk CP CML patients achieving MR4.5 that remained in DMR (at least MR4.0) for >2 years after having been on first line TKI therapy at least 5 years. Attempting treatment discontinuation also requires no history of accelerated or blast phase CML and no history of TKI treatment resistance, among others. Access to reliable and quick BCR-ABL1 IS assay with a sensitivity of at least 4.5 MRD is also important.Interestingly, the mechanism behind TFR is not yet fully understood. Several studies brought strong evidence for the fact that TKI therapy does not directly eliminate CML stem cells , 85. AnoAnother possible explanation for successful TFR is that the time for developing a full-blown CML can take several years and that the process could be delayed by stochastic events , 90. As The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.All authors contributed in the design of the hypothesis. VM and CT wrote the manuscript. SS supervised the work. MZ significantly contributed to the revision of the initial submitted manuscript, figures as well as in re-designing and adding new, important paragraphs to the manuscript, and thus contributing to the acceptance of the manuscript.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.


As such, we explored ComSA CD’s implementation from the organizational perspective, seeking to inform program improvements.The Community for Successful Ageing (ComSA) program has implemented overlapping BioPsychoSocial (BPS) components as part of a Community Development (CD) grassroots and volunteer-led initiative. Implementation of such multi-component programming is influenced by known program characteristics including N = 21 participants). Findings were analysed using an interpretative approach and synthesized into a line of argument informing lessons learnt.We conducted four focus groups with program staff, partners and trainers  were needed to persuade volunteers and participants to commit to the program.Coordination and resource allocation were influenced by the complexity of interconnecting BPS components - requiring aligning communication between partners and adapting the BPS sequence, given the separated management structure of program trainers. Efficiency of resource utilization was constrained by the ability to pool and match resources given the limited manpower and community partners who worked-in-silo due to a KPI-centric culture.Collaborative program monitoring and appraisal increased observability of the program’s benefits, but depended on partners’ prior commitment. Despite appreciating its holistic BPS programming, dropout rate was used as a way to gauge program success, which has limited interpretability. Occasional uncertainty about the program value contributed to concerns about duplicating existing ageing programs, particularly those related to the B component.An implementation framework was identified. It is guided by considering the influence of known program characteristics across Lessons learnt for improving BPS programming include (1) eliciting better participants’ buy-in and shared program vision, (2) increasing adaptability of BPS sequence and building a culture of shared values for working together (3) and developing comprehensive monitoring systems for program appraisal. Current empirical and theoretical models on successful ageing emphasize the role of resilience –3 and prThese programming approaches have led to explicit attempts to theorize and test the interconnections among BPS health constructs, and their effect on Quality of Life. Health is conceived as a holistic endeavour in the community development initiative of the wider Community for Successful Ageing program (ComSA CD) in Singapore. The program model theorizes that Biological self-care at older ages can be learnt and maintained. It relates this process to positive ageing perceptions  and the Yet, regardless of BPS theory, implementing the intended program components in sequence, by multiple community partners, poses its own challenges. The purpose of the current analysis is to explore the organizational perspective on the delivery of ComSA CD, unpacking influences on its implementation and lessons learnt to improve BPS programming for older adults’.Referring to the implementation science literature, there are various stages that people undertake when they implement a new technology, or program. These include those related to planning , engaging (participants to enrol in the program), executing, and reflecting/evaluating (e.g. about the program benefits and implementation strategy) . How theThis consists of the organizational contexts that key implementing actors face, such as the leadership quality, governance and communication systems, manpower, funding, as well as convening power of the organization , 16–18. complexity, novelty, and observability of relative advantage influence implementation and ultimately it’s successful diffusion. One way of determining complexity is by assessing the number of program components, numbers and levels of outcomes targeted , they cannot sell it to people. And people cannot rally’ .cohesion within partners’ organizations – which can be described as a genuine sense of all ‘pulling together’ to serve and support beneficiaries –was needed so that centre mangers themselves were ‘willing to work’. This was especially important in the absence of formal accountability since most partners depended on volunteer-led support. This sense of cohesion was suggested to be lacking in certain partner organizations, as commitment from the leaders did not necessarily trickle down to the centre managers . Less committed centre managers were described as providing perfunctory support - ‘reducing themselves to locking and unlocking the centre’ for trainers while others even had problems doing so on time .Regardless of buy-in from leaders, a strong sense of strong rapport with the community was viewed as necessary to persuade older people to commit to the program, especially since most naturally liked being around familiar faces in the community. Centre managers who were well-liked and trusted by older people, were inherently more effective when they advocated for the program. For example, their ‘personal magnetism’ could inspire ‘giving face’ or using their social standing to motivate participation as described– ‘I can just tell them “you all know me, right? So, we’re going to continue with another program now.” They will give me face and come’ .Following which, having As centre managers were local figures who had often established rapport with residents, trainers described how their support was important as they entered the community for the first time – ‘because participants look up to them not us, by the time they know us, half the program is done’ . Simple acts of appreciation, such as ushering and thanking participants for coming, to providing personal reminders to return each week, were powerful tools in boosting attendance. As one trainer explained: ‘when the centre manager wheels the wheelchair-bound lady into class, participants see this man doing this for this lady, they dare not skip class’ .Where centre managers went beyond operational support to elicit buy-in and advocate for the program, this optimized delivery conditions for the trainers. Their physical presence helped extend trust to trainers, boosting trainers’ confidence and ability to build rapport with participants. This also enabled trainers to promote group cohesion in class, a factor described as key in retaining participation across B, P and S program components.extent of program acceptance (readiness to adopt the program). Lessons learnt are therefore connected to eliciting better participants’ buy-in and a shared program vision. Related strategies for this are proposed in the In summary, overall, creating a genuine commitment to the program was seen as the most important influencer on outcomes relating to the aligning communication to coordinate the sequence of BPS components. However, constraints faced by the separated management structure of program trainers necessitated a degree of program adaptation. On the other hand, limited manpower resources and KPI-centric organizational culture influenced the ability to pool and match resources, and therefore the efficiency of resource utilization.Delivering the multiple components of the BPS program across the 13 community sites required a considerable amount of coordination and resource allocation. Required resources included manpower support from centre managers, program trainers, space as well as technical equipment. Herein, the program’s complexity meant that partners had to work more closely in One important aspect complicating the delivery of BPS components, was how the B, P and S components were intended to be experienced sequentially, and also that they required quite different modes of facilitation. For example, compared to teaching B self-care, P guided auto-biographical (GAB) needed a less directive approach, while S activities required more group facilitation to galvanize collective action. Facilitators adept at one aspect of program delivery, would not necessarily be so for another, and trainers were not always aware of the mental switch needed when moving to another program component – ‘I think in the train-the-trainer session, it didn’t cover ‘look your mentality needs to be like this for doing SCOPE [B classroom teaching]; but in SWING [S community-led activities], your mentality has to change’ .aligning communication between partners to ensure the operational demands and timeline of each BPS component complimented existing work schedules was at times challenging. This was particularly relevant for SWING, not only because it was intended to be delivered last, but also because it was a relatively novel component that required experimentation. However, due to the limited volunteer support, partners found it difficult to support the program activities if they were not communicated ahead of time, and their operational demands properly understood. This may explain why one partner perceived having to support the program in a manner likened to ‘filling in the stones as they walk’ . Moving from the pilot-experimental phase, shared web-based scheduling systems, may be needed to improve communication in the scale up of the program.Despite regular and constructive meetings, separated management structure of program trainers, or how the B, and S component trainers were managed by different teams within Tsao Foundation from the P component trainers. Those running the P had additional work roles beyond delivery of guided auto-biographical sessions. This made it harder to coordinate their schedules with B trainers, as well as increase delivery of the P sessions within a short notice. Since the overarching aim was community empowerment, it was seen as optimal to use the B self-care and P guided auto-biography as a platform to build social support before participating in community development initiatives in the S component SWING. Retaining this core element of the program theory while accounting for organizational constraints influenced program adaptation into two tracks .Another barrier was the KPI-centric organizational culture, it was highlighted that doing so created ‘turf issues’ among some centre mangers as they were judged on the number of participants attending their sites . Having a more participant centred mind-set – as was common in more cohesive organisations – helped counter this focus on KPI and ‘working-in-silo’ setup as described: ‘centre manager whose mind-set is really on the senior will be ok with combining and allowing the senior to decide’ .Related to efficiency in resource utilization was the ability to pool and appropriately allocate resources. One way of pooling resources was to bring together participants from different community sites and run combined classes. A larger class size in the B or P program components allowed for a higher trainer-to-participant ratio and also guaranteed sufficient numbers to open a new S group after eventual dropout. However, due to a limited manpower. For example, allocating a non-Malay trainer who did not speak fluent Malay to teach B classes due to the lack of a Malay trainer. The resulting mismatch was seen to compromise cultural competency in understanding ‘what makes them  tick’  and motivating B self-care.Given the multi-ethnic setting  in Singapore, allocating trainers to participants with a similar cultural profile naturally increased their competence in engaging older people. This was at times difficult due to the program adaptation and efficiency in resource utilization were qualified by partners’ abilities to come together and practically share the responsibilities and resources for the program. Lessons learnt are consequently connected to increasing adaptability of BPS sequence and building culture of shared values for working together. Related strategies for this are discussed in the In sum, coordination efforts were defied by the complexity of the BPS program, which was somehow aggravated by more novel and unfamiliar aspects of programming, as described earlier. Outcomes relating to Sustaining partners’ efforts at coordination and commitment across the program’s BPS components, depended by how they monitored and appraised the benefits of the program and their partnership. Engaging in collaborative program monitoring and appraisal was positioned as a feedback loop, connecting back to the level of prior program commitment from partners. Committed centre managers were more likely to be physically present during the program, where they could observe participants and appraise changes, albeit in a subjective way as described: ‘There is one grandma who is very low-spirited. After coming to the course, she is now better’  This contrasted with less committed centre managers who ‘either don’t turn up (in the program), or just show up for a while’ .dropout rate was used as a common but misleading gauge of program progress. Attrition is a known phenomenon in the early stages of recruitment, as one participant noted: ‘One trend is that we have seen lots of attrition [ …] if they manage to get 10 on the first day, then on the second day we might see 5 or 4 or 3. Then, over time, we may only see 4 or 5 only. But some actually told us that this is the normal attrition rate for programs [ …] So I’m not sure about how beneficial it is [using this barometer]’ .The lack of a formally agreed and comprehensive monitoring system among partners was identified. In its absence, duplication of ageing programs in the community, particularly that of B health program component. One challenge was comparing and deciding which B program to advocate to residents: ‘how can we ascertain the value-added-ness of a program? [ …] How can we tell that SCOPE is above the Health Promotion Board or Ministry of Health’s programs?’ .Although partners appreciated the program’s overall BPS structure, its advantage over other ageing programs still sometimes needed ‘selling’ to certain centre managers, who were concerned about sustaining commitment across BPS components. An obvious lesson learnt from these analyses points to the need for Developing comprehensive monitoring systems for program appraisal that can be shared and collected in an objective and standardized way. These should include implementation indicators aligned to the key types of outcomes identified herein.Monitoring and appraising the program’s effects were inherently related to In this study, we illustrated how the implementation of ComSA CD was an overlapping process, consisting of a set of feedback loops, and therefore not a linear process . The keyHowever, one advantage of our implementation framework is the explicit mapping of how different organizational contexts influences different stages of implementation, as well as implementation outcomes arising from each stage. Nevertheless, organizational contexts highlighted in the framework are not meant to be exhaustive. As ComSA CD is driven by voluntary community partnerships, organizational factors influencing its implementation, will likely differ from those influencing the formal, contractually-bound partnerships of corporate organizations.One key finding from this study was that community partner’s’ convening power, and skills to elicit buy-in from residents was crucial to boost program participation . HoweverNovel programs such as ComSA CD are likely to significantly affect work flow and power dynamics between implementers. For example, in galvanizing participants and offering them another platform for action on community issues, the S component SWING was initially seen as contesting the role of grassroots leaders from the People’s Association in managing residents’ feedback. Brainstorming the program’s vision and strategy together, was therefore necessary to build trust, and ease changes to the working dynamics; most notably moving from curation to facilitation of collective action.While our BPS theory suggested that the ideal program flow was to sequentially deliver the B-P-S components, one barrier faced was the separated management of trainers. This is especially relevant for ‘tightly coupled’ programs such as ComSA CD, or multiple-component programs with a fixed sequence. Such program often require more coordination , communiDespite adaption of the program flow, individual empowerment and bonding through smaller groups in the B and P components prior to S SWING facilitated the overarching aim of community development and maintained program integrity. Following which, identifying core implementation techniques that make each BPS component work is key to improving and replicating the program.Similar to other studies, we found that aligning partners’ interests, and managing conflict and turf issues were key challenges faced in community health partnerships , 39. OveAnother key lesson learnt thus refers to the importance of building cohesion and shared values among partners before implementation. Studies have shown how internalization of norms, through leadership and socialization, are critical to governing, ensuring accountability and resolving disputes in voluntary community partnerships , 40. LeaAn emergent lesson learnt was the need for a more comprehensive monitoring system to appraise the program benefits and unique value, in relation to other ageing programs in the community. This was needed for ComSA CD, given the many B programs implemented in the community as part of Singapore’s Successful Ageing Action Plan.Evaluation checklists could serve as a useful tool and communication aid for partners to reflect on program effects, their readiness for program adoption and implementation. Embedding these checklists within quality improvement cycles, to monitor, plan and innovate new joint improvement goals is likely to foster a spirit of learning and experimentation. Furthermore, coordination could be vastly improved by the introduction of shared information management systems such as web-based team calendars for scheduling or decision support tools .Regular communication to collectively specify and re-specify the program’s meaning and theory was central in creating perceptions of fit and trust in the program . This waDue to time and resource constraints, not all community partners were recruited to the FGDs, resulting in a small but targeted sample size. We did however account for the breadth of partners’ perspectives where possible. For example, while we were not able to recruit Malay community partners, we recruited program trainers and centre managers who were in charge of the Malay classes instead. To ensure the validity of the results, we conducted member checks by presenting findings to program staff and partner organizations. Lessons learnt identified on improving BPS programming across the different implementation stages can be transferred across multi-component programs driven by voluntary community partnerships.Organizational factors played a key role in influencing trainers’ ability to elicit change among participants on the ground. Further research testing the optimal sequence (B component SCOPE followed by S component SWING versus P component GAB followed by S component SWING) and the magnitude of change on BPS and Quality of Life outcomes are needed. Such research will enable policymakers and implementers to unpack the ‘black box’ of complex, multi-component BPS health promotion programs, towards successful ageing in the community.


Introduction: With the globalization of higher education through online training, opportunities exist for collaboration between institutions to promote ongoing advancement of healthcare professionals in resource-limited countries. The success of these programs is dependent on the ability of the program to meet the educational needs of the student and assist with implementation of the new information into practice. A post graduate residency program for physical therapists was introduced to Kenya to promote the development of the profession of physical therapy. This study sought to explore barriers that affected participation in the residency program, and how participants perceived the residency program fostered the use of new skills in the clinical environment, as well as the limitations they faced in applying the skills gained through the residency program in a clinical setting.Methods and Materials: The participants in this study were in the third and fourth cohorts of the residency program (n = 27). One-on-one interviews were performed with the residents following completion of the program. A qualitative phenomenology research design was used to describe the manner in which the residency was experienced within the context of the environment in which the experience took place. Descriptions and narratives were obtained from the residents to provide a window into their lived experience.Results: Four themes were discovered: (1) The ongoing challenge to balance often conflicting responsibilities: family, work and education, (2) A need to educate patients and colleagues on newly acquired skills to gain acceptance, (3) Success in the program requires reliance on support networks, and (4) Increased confidence gained in delivery of patient care.Discussion: Although the residents faced obstacles for completing the residency and integrating newly acquired knowledge and skills into clinical practice, they were able to formulate strategies to meet these challenges. Understanding the barriers and facilitators that affect participants in international collaborative efforts may ultimately assist residency and other educational programs in designing new models of education, which will advance the physical therapy profession globally. The increased availability of the Internet and online learning platforms allows students to access courses at university-level institutions across the globe. International education offerings vary from single online courses, to purely online degree programs, to hybrid curriculums that blend online learning with intermittent face-to-face time on campus to fulfill course requirements. Advances in technology and globalization of education programs provide students with opportunities to advance their profession and expand their skill set. However, the costs associated with these programs can be prohibitive to students in countries with limited resources wishing to participate in professional development.According to the World Confederation for Physical Therapy (WCPT), education for entry-level therapists should include a minimum of 4 years of university level courses . There aAccess to professional development opportunities following graduation is limited throughout the country of Kenya . The shoOpportunities for collaboration between international partners may help promote professional growth of participants without incurring excessive costs. One such opportunity lies in the development of a residency education program. A clinical residency program could provide a development opportunity for physical therapists following professional education, designed to advance the therapist's knowledge, skills, and clinical reasoning in a specific area of practice . The resTo promote skill advancement, clinical reasoning development, and use of current evidence in practice, the Jackson Clinics Foundation (Foundation) was invited in 2011 to meet with the administration of Kenya Medical Training College (KMTC) to assist in the development of a transitional Bachelor of Science degree for physiotherapists in Kenya who held a three-year diploma . A collaThe 18-month post-graduate residency program was thus formed in Nairobi, Kenya, and is currently in its 6th year. The program focuses on providing advanced instruction for physical therapists without requiring a change in the entry-level educational structure in the country. The mission of the residency program is to graduate advanced orthopedic practitioners that can lead their communities and local profession in the advancement of clinical care and education . Current research was provided by the instructors of each module to support evidence-based practice . Online The residency was developed using the United States model of residency education for physical therapists. There was a focus to ensure that the residency program, developed in a low-context culture, met the educational needs of the participants practicing in a high-context culture. Within a high-context culture, nonverbal communication is commonly based on an awareness of cultural norms. In a high-context educational system, face-to-face encounters with the instructor are used to explain course requirements and the written syllabus or handouts are often ignored . HoweverDue to specific societal and cultural orientation, students may be more amenable to learn in an environment that supports their cultural orientation to maximize learning . To makeTo understand the residency experience from the residents' perspectives, individual interviews were conducted with the two resident cohorts in 2016. The interviews sought to explore barriers that affected participation in the residency program, how participants perceived the residency program fostered the use of new skills in the clinical environment, and the residents' perceptions of limitations for clinical application of the skills gained through the residency program.Approval for this study was received from the respective institutions. Informed consent was obtained prior to initiation of the study, and the rights and confidentiality of the participants were protected throughout the study.This study utilized a sample of convenience of residents in the third and fourth cohorts of an orthopedic manual therapy residency program in Nairobi, Kenya.A qualitative phenomenology research design was used to describe the manner in which the residency was experienced within the context of the environment in which the experience took place . DescripThe information obtained from semi-structured individual interviews was coded and general themes identified by the primary investigator. NVivo for Mac was utilized to arrange codes. Thick descriptions and narratives of the participants have been provided to inform the themes. To ensure credibility, all themes were confirmed through peer review by a member of the research study team with extensive qualitative research expertise. Member checks were performed with 10 of the residents.Limitations in the qualitative assessment included potential bias in interpretation of the data. Potential bias of the researchers may include comparison of professional DPT students in the United States to residents in Kenya, in addition to bias as professional educators. To attempt to minimize bias, an investigator with no involvement in data collection or residency education performed an external audit of the data. The utilization of a sample of convenience and number of participants also limited generalizability of the qualitative results.A total of Twenty-Seven residents participated in the study with a mean age of 33.3 (SD = 10.2) years. The participants included 15 males and 12 females with mean practice experience of 9.7 (SD = 9.8) years. All participants had completed a 3-year diploma in physical therapy. Their focus of practice included generalists working in both inpatient and outpatient environments (n = 10), outpatient orthopedics (n = 15) and outpatient pediatrics (n = 2).Barriers and facilitators for participation in the residency program and integration of new skills in the clinic were relayed throughout the interviews. Residents discussed difficulty in balancing competing responsibilities during the residency program. With residents required to attend onsite modules in 2-week blocks, they needed 12 weeks of leave from home and work over the 18-month residency program. Female residents in particular discussed the difficulty in maintaining employment, meeting family responsibilities, and participating in the residency program. The residents that lived outside of Nairobi discussed the additional challenges of travel and the cost of staying in Nairobi to complete the onsite modules. In addition, residents relayed that it was challenging to get frequent and extended time off from work to attend the onsite modules. Additional barriers were described related to their ability to integrate new knowledge and skills into their respective clinical practices. The residents discussed the need to provide education to patients and colleagues to assist with acceptance of the change in practice. This facilitated the acceptance of the new skills.To offset barriers, residents discussed support networks that served as facilitators and encouraged them throughout the residency program. Support came from family, employers, and the residency program itself. The residents discussed aspects of the residency that supported their success, including easy accessibility of online materials and the ability to communicate directly with a local administrator. As the residents were able to clinically apply newly acquired skills, their confidence in providing effective patient care increased, further motivating them to continue in the program.Residents with young children reported difficulty in managing family responsibilities and the time commitment required of the residency program. One resident, A.A., stated, “Being a family person, it's hard having your kids to juggle through school and the family. It's hard, but I thank God I was able to get through.” Another resident with a young child, N.K., similarly noted, “I have a small baby. My baby is just growing and sometimes leaving my baby for two weeks, for two weeks [sic], sometimes it's hard.”In addition to the time commitment required for the residency program and the time away from home for the onsite modules, the sacrifice to take time off from work was noted. S.M. explained,You miss work on such day because they tell you no we are not going to pay you and maybe that money was in your budget. So, this is some of the difficulties. Also paying, the paying [sic] back the thing that you lost at work; you have to work overtime, you miss your social life, your family life. So, you pay back heavily to come to class.D.M. described a similar challenge, noting, “The biggest barrier we encountered these schedule [sic] for work and class. It's very difficult for your employer to understand that you need to come to class every cohort and you miss work on such day [sic].”Residents also described difficulty maintaining productivity levels as they attempted to integrate new skills. Many residents also found the number of patients needing treatment often limited their ability to practice all assessment skills learned in the residency program. As explained by S.K.S.;Most of the time we are challenged by the numbers. Although I see between ten and sixteen, I also have other duties to do in the process. So that makes it even more challenging to have adequate time with the patient to do that [sic] examination.M.D. noted strategies to deal with the limitations. “Some things you do for the next, the next visit. You can't do everything all day. So, you're like okay, this is what this is, the presentation. What can I do?”An added financial and time burden was an issue for the three residents that lived outside of Nairobi and had to travel to the onsite residency modules. O.N. traveled a considerable way to Nairobi and described what it meant to him to do so.There be [sic] challenges maybe with finances there [sic] and being somebody that works outside the capital city. I started when I was um at the border of Kenya and Somalia and Sudan. I would come. It's over 1600 kilometers, so travel three days to be here.As the residents integrated newly acquired skills and knowledge into the clinic, they faced the challenge of gaining patients and colleagues acceptance about new techniques that meant a change in practice approach. Residents described the need to educate patients regarding manual treatment options and alternatives to modalities. J.O. explained, “Challenges are there especially when it comes to the patients. It was the patients who are used to, you know, hot packs, ultrasound and all that. Now you are coming to do something else.” T.D. confirmed this observation, explaining:Okay, the problem. Because like if you get those patients who are used to this hot pack and want me to use this. I want to use manual therapy. So, some of them are not really ready to cooperate. They will do everything . They will still say, ‘I want hot pack.’Residents discussed the need to use various strategies to encourage patients to accept new techniques. C.E. noted she focused on flexibility and compromise to gain the patient's acceptance of manual treatment as well as provide the modalities that patients expected, “Sometimes my patients could always want to see like [sic] at least a machine has to be used, but then I struggle to make sure I do manual therapy. Then give the machine to those that like them [sic].”The residents discussed promoting a new approach to patient care by providing formal instruction and education to their colleagues, as well as serving as a consultant to their peers for difficult patients. This transference of knowledge provided colleagues with additional techniques for treatment. A.A. reported the opportunity to provide instruction to colleagues after each onsite module. “In our clinic, we have days where we do Continuous Medical Education. So, during the hours that we're given to do [sic], I come out there. I teach them what I learned from here and they are positive.”Education provided to other disciplines was perceived as being able to improve patient outcomes beyond the immediate physical therapy community and to promote interprofessional teamwork as explained by J.N.Does it really change? I was talking to my colleagues, not only physios but doctors, and I was telling them what I learned in clinical reasoning; the ICF, the manual skills, everything. How everything is good. It is increased [sic], not only when in physio condition, but in general health care conditions. You find that in most conditions, you often have to involve everyone.W.S. further reported providing education through consultation, “I'm actually being consulted with what I am about, [sic] any condition about orthopedics and physiotherapy. Because it gets hard to them [sic], they refer to me. Call me and tell me, we are stuck here. How do you go about this?”The residents noted personal support networks, employer support, and facilitators within the residency program as factors that assisted their participation in the residency program. Support included financial support, emotional support, accessibility of residency materials, and encouragement from mentors from the United States. W.S., who traveled a long distance to Nairobi, described the benefit of receiving support from his family that enabled him to pursue the residency.I got support from my family, very much. And family, including my sister, because I come like four hundred miles away. So, when I'm in Nairobi for the residency, I get support from my sister for upkeep for the period of the module.In addition to financial support, one resident noted the help provided by her spouse in caring for their children. “What really helped, my husband helped me a lot. Supported me with the kids.”Some residents received support from their employers that facilitated participation in the residency. Employer support was described as financial and flexible work assignments within practice areas. J.N. described how she “….got the financial support from the hospital I work. They paid for me. And I think to me, that was the best support you could ever get, allowing me to come.”In addition to financial support, residents noted how their work setting facilitated their learning process by giving them the increased opportunity to practice newly acquired skills in the outpatient setting during the residency training. S.K.S. explained:Yes, the institution allowed us to practice immediately when we started the program. Like me for instance, I used to work in the inpatients, but I was brought to the outpatient where several patients with musculoskeletal issues come to. So, I was able to daily practice [sic] what I learned from school.J.N. also noted support from management as patient satisfaction improved, “The most important is the support from the management. The management actually they are very supportive as a program about getting compliments from my clients and even now trying to engage all of the hospital management to also embrace OMT.”Residents noted the organization and accessibility of resources made available by the residency program helped facilitate participation and completion of the residency. All information necessary for the online modules was available in a cloud sharing account. Residents could download or print the materials while on campus. This negated the need to purchase textbooks or access the internet from community facilities. The residents noted that access to course materials before the onsite modules provided the opportunity for pre-reading and increased preparation for class. O.N., commented, “More so the information that is sent online. It makes it much easier for you to just study from where you are and then when you come, you at least [sic] you've internalized something and you get to flow well with the teachings.”The role of the onsite administrator, who provided residents with a contact during and between modules, as well as coordination of modules, was seen as a strong contributor to the success of the residents' completing the program. Development of a consistent personal relationship between administrator and residents was important in promoting successful interaction between the residency instructors and the residency participants. The onsite administrator was crucial in ensuring consistent, ongoing communication and coordination of the modules. This was recognized as a strong support by O.N.That the schedule has been kind of friendly with the arrangement of the leadership of the Mr. D. He was able to arrange well and then he communicates [sic] people in advance, so that makes it easier for you to plan yourselves to be able to attend. And then he has also been also good in terms of the payments for the school… So, I think that's what assisted in terms of attending.Residents also discussed support provided by the mentors and instructors from the United States, recognizing the value of their encouragement and enthusiasm toward teaching. E.O. explained, “The lecturers they come prepared. They personally, they really encouraged me and when I was ever in doubt they always came and told me that I just didn't think simple. So, they really encouraged me.” This sentiment was reinforced by K.O. who noted, “All the facilitators have been very good and they've also made us come this far, encouraged us, and if we had questions they were ready to answer any questions that we had when we did not understand, the reading.”Residents found the information taught in the residency to be clinically applicable, and the utilization of patients as models in class reinforced how to apply that newly acquired knowledge. The ability to apply the new skills in the clinic led to the residents' perception of improved patient outcomes. As patient outcomes appeared to improve, residents gained confidence and motivation to continue to enhance their skills and knowledge. C.E. commented, “Actually the experience has made me, like I do not fear any of the condition or presentation of patients that has [sic] to my clinic. It has made me like, I am more brave, more able to assess any of the patients and able to treat any of the conditions in regards to musculoskeletal system.” This confidence aided communication with other medical providers. One resident, W.S., who traveled within Africa to provide PT services, noted how increased knowledge allowed him to discuss patient care confidently with others.I would travel with a Kenya team sometimes, athletics team, but there, I would say, you see other stuff physios do and you compare with what you do.You say wow, did I really do anything to help, but after doing this, I think I'm confident enough I can face anybody and I can discuss with my colleagues any condition.Although the residents faced obstacles for completing the residency and integrating newly acquired knowledge and skills into clinical practice, they were able to formulate strategies to meet these challenges. Support from the residency was discussed by residents in relation to program planning to facilitate the integration of online teaching materials into a high-context culture. The residents noted the ability to clarify information provided in the online materials as they progressed through the program was highly valued. They also reported that the instructors willingness to answer questions until the entire cohort understood the concepts being presented was a great asset. This allowed the instructor to give a variety of examples of concepts and decreased the uncertainty of the information provided in online materials. Murray et al.  suggest In addition to teaching concepts, all instructors and mentors from the United States were considered powerful motivators as they encouraged the residents to continue their participation in the program. Collectivism is considered a component of high-context cultures, where the community works together to learn skills and the success of the individual is regarded as a success for the community . The socThe residency program used, an online document sharing portal to provide resources to residents. The cloud sharing application provided a shared folder containing materials and resources for students to access electronically. The folder automatically synced each time the residents were connected to the Internet for onsite modules. This allowed the residents to access updated course materials and literature without having to download each file or having to become accustomed to an online learning management system.Access to materials online has been considered an educational barrier in high-context cultures due to learners having difficulty accessing resources . HofstedIn contrast to facilitating factors identified by the residents for participation in the residency, the female residents in particular noted difficulty maintaining a work-life balance while participating in the residency program. Work-life imbalance is experienced when participation in one role makes it difficult to participate in the other. This results in work and life duties that are incompatible . The conThe residents in this study reported increases in overall job satisfaction as patient satisfaction improved following residency education, despite a lack of change in salary or job promotion. This is different than perceptions of physical therapists in the US., where lack of career advancement through job promotions resulted in decreased overall job satisfaction . SimilarThe Kenyan residents also discussed the need for patient education to develop a shared understanding of a treatment plan that included manual therapy. Patient education provided by the residents appeared to encourage patient willingness to be open to new techniques. McSweeney et al. discussed the need to examine the differences between the healthcare professional's explanatory model (EM) and the patient's EM before planning and providing treatment options . Once thThe residency's hybrid structure was able to meet the students learning needs within a high context culture while providing an affordable education experience. The residents noted several barriers for completing the residency program and incorporating new skills in the clinic, however, they were able to overcome these barriers and successfully advance their clinical practice. Understanding the barriers and facilitators that affect participants in international collaborative efforts may ultimately assist residency and other educational programs in designing new models of education which will advance the physical therapy profession globally.In addition to developing an effective education program through collaboration with international partners, sustainability and independence need to be fostered to ensure continued promotion of the profession within the country. During the first two cohorts, three individuals were identified to participate in the onsite modules as teaching assistants. These individuals were considered by the Foundation and KMTC as those who would ensure sustainability of the program over time. In 2018, all of the courses have been taught by these three individuals, with mentors from the United States providing feedback and instruction on teaching style and module content. One webinar was arranged in which teaching methodology and teaching strategies were taught. In addition, the principles of developing effective presentations were reviewed.In addition to the onsite modules and online courses, mentoring appeared to be a significant contributor to the integration of new skills into the clinic. Up to 150 h of mentoring is required in APTA credentialed residency programs (The initial establishment of the residency program and close oversight by Foundation and US based volunteers over the initial 3 years, followed by a gradual progression toward a self-sustaining program through the training of graduates and strong support from an onsite administrator, has required frequent in-country visits by the United States administrative personnel. Dedication and collaboration of administration and Foundation volunteers has been fundamental to the stability and consistency of the program. Continual monitoring of the program's outcomes is necessary to define areas for improvement during the transition to an independent Kenyan run program. The long-term success of the program is perceived to be dependent on the transfer of responsibility and training to local physical therapists.This study was carried out in accordance with the recommendations of the Kenya Medical Training College Ethics and Research Committee, the Institutional Review Board of Radford University, and the Institutional Review Board of Nova Southeastern University with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by all three above committees.SC performed literature review, designed the methodology, performed interviews, and identified general themes within the data. BL assisted with study design, methodology, the generation of qualitative themes, and with revision and editing of the final document. RJ provided information on the development of the program, lessons learned, and future directions for the program. AF-F and JC provided guidance throughout the project, and assisted with revising and editing the final document.RJ is the founder of the residency program in Kenya. The remaining 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.


This study aimed to develop and verify a sense of coherence (SOC) enhancement program based on salutogenesis for elderly with metabolic syndrome. This study was a quasi-experimental study. The inclusion criteria were patients with metabolic syndrome aged 60 or over who visited the outpatient department of a university hospital and a public health center located in an urban area. The intervention group (n=24) attended the SOC enhancement program. The health promotion theoretical framework, salutogenesis, provided the program structure and conceptual framework of this study. This program included comprehensibility, manageability, and meaningfulness which were core concepts of salutogenesis and consisted of multiple tailored behavior interventions composed of education, Tai-Chi exercises, individual activities, self-monitoring, self-help groups, and individual counseling. This program was provided once a week over 10 weeks, but Tai-Chi exercise was conducted twice a week. The control group (n=25) was provided with general health information once. The interactions between groups and measurement time showed significant differences in self-efficacy (p=.001), perceived social support (p<.001), SOC (p<.001), health behavior (p=.010), and the physical health-related quality of life (p=.001). The metabolic-related physiological indicators showed significant improvement in total cholesterol (p=.004) and LDL-cholesterol (p=.009). This study showed that the SOC enhancement program strengthened the self-efficacy, social support, and SOC in the elderly with metabolic syndrome, improved the health behavior, and was effective in improving some metabolic-related physiological indicators. Based on the results of this study, I suggest to expand the scope of the sense of coherence program and conduct the intervention longer.


Generally, structural destruction of lung parenchyma, such as pulmonary emphysema, is considered to be related to the low diagnostic yields and high complication rates of lung biopsies of peripheral lung lesions. Currently, little is known about the clinical outcomes of using endobronchial ultrasound with a guide sheath (EBUS-GS) to diagnose peripheral lesions in patients with emphysema.This retrospective study was performed to identify the clinical outcomes of EBUS-GS in patients with pulmonary emphysema. This study included 393 consecutive patients who received EBUS-GS between February 2017 and April 2018. The patients were classified according to the severity of their emphysema, and factors possibly contributing to a successful EBUS-GS procedure were evaluated.P = 0.007). There were no procedure-related complications. The presence of a bronchus sign on CT (P <  0.001) and a “within the lesion” status on EBUS (P = 0.009) were independently associated with a successful EBUS-GS procedure. Although the diagnostic yield of EBUS-GS in patients with moderate-to-severe emphysema was relatively low, a bronchus sign and “within the lesion” status on EBUS were contributing factors for a successful EBUS-GS.The overall diagnostic yield of EBUS-GS in patients with no or mild emphysema was significantly higher than in those with moderate or severe pulmonary emphysema  contains supplementary material, which is available to authorized users. Low-dose computed tomography (LDCT) is widely used for lung cancer screening in high-risk individuals such as those with pulmonary fibrosis or chronic obstructive pulmonary disease, and its value for reducing mortality rate was clearly demonstrated in the US National Lung Screening Trial . AlthougThe National Comprehensive Cancer Network recommends histological examination for patients with a solid nodule greater than 8 mm on the initial LDCT screen . Lung biRadial probe endobronchial ultrasound using a guide sheath (EBUS-GS) has been widely used to diagnose peripheral lung lesions, with an acceptable diagnostic yield and a low complication rate –11. UntiThis retrospective study was performed using an EBUS-GS database to investigate the clinical outcomes of EBUS-GS in patients with pulmonary emphysema. The patients were examined between February 2017 and April 2018 at Pusan National University Hospital, a university-affiliated tertiary referral hospital in Busan, Republic of Korea. A total of 393 patients with peripheral lung lesions who received EBUS-GS during the study period were selected for the present study. The Institutional Review Board of Pusan National University Hospital approved this study, and the requirement for informed consent was waived because of the retrospective nature of the study (no. H-1809-013-071).CT scans were obtained in the full-inspiratory state using a commercial CT scanner . Images of the whole thorax were taken using the following CT parameters: 120 kVp; 100–250 mAs; tube rotation, 0.5; and slice thickness, 0.625 mm with an interval of 0.625 mm. Axial, coronal, and sagittal images were displayed with mediastinal  and lung window settings .A peripheral lung lesion was defined as an intrapulmonary lesion beyond the segmental bronchus visible on the axial CT scan. The mean diameter of a peripheral lung lesion was defined as the mean of the maximum transverse diameter and its perpendicular diameter on axial images with a lung window setting. As in a previous study, peripheral lung lesions were classified as solid, ground-glass opacity, mixed, or cavitary . BronchuThin-section CT scans were reviewed by an experienced thoracic radiologist. Emphysema was defined as a low-attenuation lung area lacking a distinct wall . The extEBUS-GS was performed using the standard techniques of Kurimoto , and allAny complications that developed after EBUS-GS were evaluated as described in previous studies , 19. BriU test was used to compare continuous variables. Multivariate logistic regression analysis was used to examine independent factors related to successful EBUS-GS. A P-value < 0.1 was considered significant in the univariate analyses, and P-values < 0.05 were considered significant in all other analyses. SPSS for Windows  was used for the statistical analyses.All results are presented as median values (interquartile range [IQR]) for continuous variables and as numbers (percentages) for categorical variables, as appropriate. The categorical data were compared using Pearson’s chi-square or Fisher’s exact test, and the Mann–Whitney P <  0.001). The median forced expiratory volume in 1 s and the forced expiratory volume in 1 s/forced vital capacity ratio were significantly lower in patients with pulmonary emphysema than in those without pulmonary emphysema . Otherwise, there were no statistically significant differences in baseline characteristics between patients with and without pulmonary emphysema. The clinical diagnoses of all study patients are presented in Table Of the 393 study patients who received EBUS-GS, pulmonary emphysema was found in 129 patients (33%). The baseline characteristics of the patients with and without pulmonary emphysema are shown in Table P = 0.148). In addition, there was no statistically significant difference in the diagnostic yield of EBUS-GS between patients with mild, moderate, or severe pulmonary emphysema . However, the overall diagnostic yield of EBUS-GS in patients with no or mild emphysema was significantly higher than in those with moderate or severe pulmonary emphysema , a greater proportion of mild pulmonary emphysema , the presence of a bronchus sign on CT scan , and “within the lesion” status on radial probe EBUS . Multivariate logistic regression analysis, which was performed to verify the independent factors associated with successful EBUS-GS, showed that the presence of a positive bronchus sign  and “within the lesion” status on radial probe EBUS  were independently associated with a successful EBUS-GS in patients with pulmonary emphysema (Table Factors affecting the diagnostic yield of EBUS-GS in patients with pulmonary emphysema are compared in Table P = 0.004), and patients with mild pulmonary emphysema were significantly more likely to show “within the lesion” status on radial probe EBUS than those with moderate-to-severe pulmonary emphysema . Otherwise, there were no significant differences between the two groups, including the mean lesion diameter, the distance from the pleura to the lung lesion, and the characteristics of the lesion on CT. An additional multivariate logistic regression analysis was conducted to identify factors predicting successful EBUS-GS in patients with moderate-to-severe pulmonary emphysema  and “within the lesion” status on radial probe EBUS  were independently associated with a successful EBUS-GS in patients with moderate-to-severe pulmonary emphysema.Table No mortalities or life-threatening complications were associated with the procedure during the study period. None of the patients with pulmonary emphysema developed a pneumothorax, severe hemorrhage, air embolism, or pulmonary infection.In general, the incidence rate of pneumothorax of any type after percutaneous lung biopsy is 15% . The desPrevious studies have reported that the position of the radial EBUS probe during the procedure, lesion size, malignant status, and the bronchus sign on CT contribute to successful EBUS-GS , 23, 24.The diagnostic yield of EBUS-GS in patients with mild pulmonary emphysema was similar to that in those without emphysema. Moreover, we found that the diagnostic yield in patients with moderate-to-severe emphysema was significantly lower than that in patients with no or mild pulmonary emphysema. Emphysema is characterized by the destruction of lung parenchyma and alveolar attachment . In geneEBUS-GS is generally considered to be a safe procedure in comparison with surgical biopsy and percutaneous lung biopsy . Hayama Some limitations of this study should be acknowledged. First, this retrospective study was conducted at a single institution, and there is the potential that selection bias could have influenced our results; therefore, it is difficult to generalize the findings. Second, the number of enrolled patients was relatively small. In particular, the EBUS-GS complication rate may have been underestimated because of the small study population. Third, all EBUS-GSprocedures were performed without the assistance of a navigation system, such as electromagnetic navigation bronchoscopy or virtual bronchoscopy , 11. To EBUS-GS was shown to be a safe procedure with an acceptable diagnostic yield, even when performed in patients with pulmonary emphysema. The presence of a bronchus sign and “within the lesion” status on radial probe EBUS were useful predictors for a successful diagnosis.Additional file 1:Table S1. The affecting factors for diagnostic yield of EBUS-GS in moderate-to-severe pulmonary emphysema. (DOCX 17 kb)