Therefore, alternate methods are needed. Mechanical inoculation and spray methods have already been discussed in the literature – and here, we compare these methods with a newly introduced petiole injection technique. Because our interest lies in the development of plant viruses as immunotherapies targeting human health as well as gene delivery vectors for agriculture applications, we turned toward tobacco mosaic virus as a model system. We studied the effectiveness of three inoculation techniques: mechanical inoculation, Silwet-77 foliar spray and petiole injections. The foliar spray method was optimized, and we used 0.03% Silwet L-77 to induce infection using either TMV or a lysine-added mutant TMV-Lys. We developed a method using a needle-laden syringe to target and inject the plant virus directly into the vasculature of the plant – we tested injection into the stem and petiole. Stem inoculation resulted in toxicity, but the petiole injection technique was established as a viable strategy. TMV and TMV-Lys were purified from single plants and pooled leaf samples – overall there was little variation between the techniques, as measured by TMV or TMV-Lys yields, highlighting the feasibility of the syringe injection technique to produce virus nanoparticles. There was variation between yields from preparation to preparation with mechanical, spray and syringe inoculation yielding 40–141 mg, 36–56 mg, 18–56 mg TMV per 100 grams of leaves. Similar yields were obtained using TMV-Lys, with 24–38 mg, 17–28, 7–36 mg TMV-Lys per 100 grams of leaves for mechanical, spray and syringe inoculation, respectively. Each method has its advantages: spray inoculation is highly scalable and therefore may find application for farming, the syringe inoculation could provide a clean, aseptic, and controlled approach for molecular farming of pharmaceuticals under good manufacturing protocols (GMP) and would even be applicable for gene delivery to plants in space.Agriculture is facing new challenges, with global warming modifying the survival chances for crops, and new pests on the horizon. To keep up with these challenges, gene delivery provides tools to increase crop yields. On the other hand, gene delivery also opens the door for molecular farming of pharmaceuticals in plants. However, towards increased food production and scalable molecular farming, there remain technical difficulties and regulatory hurdles to overcome. The industry-standard is transformation of plants  According to a meta-analysis done in 2021, it is estimated that the demand for food will rise by 35–46 percent between 2010 and 2050 . Plant-b tobacco . More reng, Inc. , while Mng, Inc. . Both cong, Inc. , Kentuckng, Inc. . MoleculAgrobacterium tumefaciens-mediated or biolistic particle delivery, with the relatively new short palindromic repeats (CRISPR) associated protein 9 (Cas9) technique being explored . The method may also find interest if or when molecular farming is introduced into outer space . We usedN. benthamiana seeds were planted in Pro Mix BX soil (Greenhouse Megastore) and grown in an A1000 chamber (Conviron) with light at ~100,000 lux, 50–60% humidity, and at 25°C. After 2 weeks the seedlings were transferred to larger pots, and fertilizer was administered once per week . When the plants were 4–5 weeks old, the inoculations were performed as detailed below. After visual inspection and confirmation of symptoms, leaves were harvested 10–15 days post inoculation and stored at −80°C until further processing. Inoculations were carried out via mechanical inoculation of carborundum dusted leaves, Silwet-77 assisted spray (0.02–0.04%), and direct injection into the stem and petiole. 3, 15 and 30 μg of purified TMV in 10 mm sodium phosphate (NaPB) buffer pH 7.4 was used, with 10 plants per treatment. Photographic documentation was carried out on days 0, 8, 10, and 15 post inoculation of TMV. In our studies we used native TMV as well as a Lys-added mutant of TMV, denotated as TMV-Lys described in Carborundum  was gently dusted on three leaves, and subsequently rubbed by hand with 100 μl of TMV  and NaPB buffer pH 7.4 to deliver 3 μg, 15 μg or 30 μg of TMV. Gloves were changed between each plant to avoid carryover of infectious material. Plants were kept in the dark for 1 h post treatment (to avoid burning of carborundum under the grow lights), then were rinsed with tap water and placed into the plant growth chamber.A trigger/spray nozzle  as shown in Insulin syringes with a needle of 8 mm × 31 G  were used, and loaded with 2 μl of 1.5, 7.5, or 15 mg/ml TMV in NaPB buffer pH 7.4 to deliver 3 μg, 15 μg or 30 μg of TMV. The loading site for the syringe was tested in the stem, and petiole. After injection plants were immediately placed into the growth chamber – there was no need to rinse.g for 20 min at 4°C). The supernatant was then filtered through Kimwipes , and mixed with equal parts chloroform/butanol  and mixed for 30 min at 4°C. Then this mixture was centrifuged , and the top aqueous layer containing the plant virus was taken for the next steps. The viral particles were then precipitated using 8% (w/v) PEG (MW 8000 Da) and 0.2 M NaCl ; this mixture was then placed in a shaker overnight at 4°C. The solution was then centrifuged , and the pellet was then resuspended in 0.1 M NaPB buffer pH 7.4. Followed by another short centrifugation , the supernatant was then ultracentrifuged  over a 40% sucrose cushion . The pellet was then left on a shaker overnight to resuspend in 10 mm NaPB buffer pH 7.4. For the final step, the solution is passed through a silica column .The extraction and purification of TMV and TMV-Lys was done as described by To validate the purity and structural integrity of purified TMV, UV-vis spectroscopy, SDS-PAGE, and transmission electron microscopy (TEM) was performed.−1 cm−1.TMV concentration was determined by UV-vis spectroscopy using a NanoDrop Spectrophotometer (Thermo Fisher Scientific) and Beer-Lambert law with the extinction coefficient of TMV at 260 nm of 3 ml mgFor the sample preparation, 2 μg of TMV from the original purified solution were diluted to a final volume of 15 μl with NaPB buffer pH 7.4, to which 4 μl of the 4x lithium dodecyl sulfate (LDS) loading dye (Life Technologies) were added. This solution was then denatured for 5 min at 95°C, and analyzed on NOVEX NuPAGE 4–12% Bis-Tris gels (Invitrogen) in 1x morpholinepropanesulfonic acid (MOPS) buffer (ThermoFisher Scientific). SeeBlue Plus2 was as molecular standard. The gel was ran at 200 V/120 mA for 40 min. Gels were stained with Commassie Brilliant Blue R-250 and imaged using an AlphaImager system (Protein Simple).−1 was placed on Formvar carbon film coated TEM supports  and stained with 2% (w/v) uranyl acetate (Agar Scientific). Images were then taken with a FEI TecnaiSpirit G2 BioTWIN TEM at 300 kV.TMV at a concentration of 0.01, 0.05, or 0.1 mg mlN. benthamiana plants. Using 4–5 weeks old plants and sham inoculations, we noted that 24 h post surfactant exposure, concentrations higher than 0.04% indicated tissue damage which was evident by leaf discoloration or darkening of the leaves; higher surfactant concentrations (>0.4%) resulted in necrotic tissue. We noted that plant age plays a role with older plants (6–7 weeks) being more robust and less necrosis observed at higher surfactant concentrations  and systemic infections were established 10+ dpi. Representative photographs are shown in via agrospray, and gene expression was confirmed 10–14 dpi , and at 15+ dpi systemic infection was reported. Overall, the slightly delayed timeline to establish gene expression and hence infection for the spray vs. mechanical inoculation is in agreement with other reports: while traditional vacuum infiltration takes an average of 4–7 days for gene expression, gene expression is delayed when delivered 0–14 dpi . The pre0–14 dpi . Using hSyringe inoculation showed TMV symptoms at day 10, and systemic infection at day 15. Diverse TMV symptoms were observed with two main two phenotypes: mosaic/mottling symptoms and blackening of the veins  – the laSeveral controls were considered: control plants were cultivated side-by-side in the same growth facility, but in a separate incubator; these plants showed no TMV infection symptoms and are shown in For TMV harvest, all visibly infected leaves were collected. While there was some variation between the yields comparing the three inoculation methods, there was no statistical differences between the methods  imaging was performed to validate the identity of TMV. UV–vis absorbance data indicate an absorbance ratio at 260/280 of 1.2, which is consistent with intact and pure TMV preparationsAgrobacterium-based transformation methods, syringe inoculation does not require the culturing of gram-negative bacteria that (i) can be affected by epigenetic variation, (ii) introduce LPS into the product which then requires additional purification steps, and (iii) add complexity to the manufacturing set up, requiring plants and a fermenter. While Agrobacteria-based transformation is the effective and currently industry-standard, alternate approaches such as syringe inoculation is an interesting technology to explore. There is room for innovation: infection rate, or gene delivery rate may be improved through use of precision syringes to target the phloem or xylem for a desired application. In fact, the application of microneedles for plant engineering has been suggested  as a model system for gene delivery. Successful gene delivery was measured by establishment of infection. While injection into the stem of the plant resulted in systemic toxicity and plant loss, targeting the petiole was found productive with good infection rate and yields comparable to any other method. Each of these methods offer advantages – mechanical inoculation shows a high degree of reproducibility given the ease of the method. Foliar spray application is scalable and may offer a broad platform for agricultural engineering and could facilitate transient gene delivery in large extensions of crops. The syringe inoculation provides an aseptic method that may be suitable for the pharmaceutical industry. Compared with the current standard of uggested .The original contributions presented in the study are included in the article/AM-B and NFS: data analysis, writing and editing, and experimental design. AM-B: experimental work. Both authors contributed to the article and approved the submitted version.This work was supported in part through grants from the NIH (R21-AI161306 and U01 CA218292 to NFS), USDA (NIFA- 2020-67021-31255 to NFS) as well as partially supported by the NSF through the UC San Diego Materials Research Science and Engineering Center (UCSD MRSEC), grant DMR-2011924 (to NFS) and grant CBET-2134535 (to NFS). AM-B is supported by a pre-doctoral fellowship from UC MEXUS CONACYT.NFS is a co-founder of, has equity in, and has a financial interest with Mosaic ImmunoEngineering Inc., and serves as Director, Board Member, and Acting Chief Scientific Officer, and paid consultant to Mosaic.The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Students found the digital resilience program appropriate and were able to apply their newly acquired skills to promote their resilience and learning. Although, several improvements are proposed to enhance the rigor of the digital resilience program, the findings of this study suggests that digital resilience programs are important for students’ well-being.Protective factors that build students’ resilience are known. A six-week digital resilience training program was developed on the basis of theory, evidence, and contextual information. The feasibility study sought to evaluate the acceptability, appropriateness, demand, implementation, and limited efficacy of a digital resilience skills enhancement program for undergraduate students. A single group, pre-test, post-test, concurrent mixed methods design among 10 undergraduate students was conducted in one university in Singapore. The content analysis concluded that students accepted and perceived the digital resilience skills enhancement program as appropriate. Students also proposed several improvements, such as the initiation of the program and revisions to the content. The Wilcoxon signed-rank test found significant improvements in resilience ( The concept of resilience has shifted since its inception. The initial classification of resilience has been associated with individual traits comprising intrinsic factors, such as coping skills and being positive . With thIn line with the contemporary theoretical stance on resilience, this study adopts the definition by Van Breda  that is A better-than-expected outcome refers to a contextualized range of outcomes  across a population ,6. This In spite of the undisputable benefits of resilience in students’ higher education (HE) journey, a meta-analysis reports a global prevalence of 36% for low resilience among HE students . StudentIn addition, the presence and persistent aftermath effects of the coronavirus disease 2019 (COVID-19) pandemic led to heightened mental health issues among HE students ,15. GiveThe interest in resilience training and its impacts is considerable. Two recent meta-analyses ,17 positWith greater advancements in the technological infrastructure and need for remote learning due to the COVID-19 pandemic, institutes of higher learning (IHL) have transited to the digital platform as a medium of instruction ,19. AlthOn the contrary, blended learning considers the use of synchronous  and asynchronous engagement tools  and integrates the merits of face-to-face and online learning . HoweverConsidering the scarcity of resources, preliminary evaluations using a feasibility study design are useful to ensure that a newly curated digital resilience training program is appropriate and sustainable . The guiTo the authors’ knowledge, few studies examine the acceptability, demand, practicability, and treatment dose effect. In addition, resilience interventions thus far are developed and evaluated in other contexts and countries. Given that the environment plays an important part in developing resilience; developing and evaluating a context-specific resilience intervention are important. Therefore, this study seeks to develop and evaluate a digital resilience skills enhancement (RISE) program for undergraduate students using a feasibility study design.A single-arm, pre-test, post-test feasibility study was conducted from October to November 2021. A concurrent mixed-methods approach was used to assess the acceptability, appropriateness, demand and actual use, and limited-efficacy testing of the digital RISE program . The quaThe digital RISE program was offered to all full-time undergraduate students in one university in Singapore. Advertisement posters were disseminated through the university’s online learning and social media platforms. A convenience sampling approach was used to recruit students. Participants were eligible if they were a full-time undergraduate, above 18 years old, could comprehend the English language, and had a device that could connect to the Internet. Students with any self-reported medical history of any mental health conditions or that received similar psychosocial interventions were excluded from this study.The digital RISE program was developed using a three-step approach for the development of complex interventions with reference to Medical Research Council guidance . First, The society-to-cell resilience theory  and the Given that resilience may be developed after experiencing adversity, the transactional model of stress and coping  was usedEvidence was gathered by conducting three systematic reviews ,17,27. FSecond, the meta-analysis  further As part of the development process, a qualitative study was conducted to ensure contextual relevance to the RISE program . The stuThe information gathered from the theories, evidence , and contextual information  was consolidated and mapped. The digital RISE program was designed as six weekly sessions that were hosted on the university’s online learning platform  and madeThe digital RISE program adopted the blended learning framework . In eachContent validation was conducted to assess the quality and accuracy of the RISE program. The health-related website evaluation tool  compriseStudents were recruited from September to October 2021. Students interested in the study expressed their interest through a link provided in the advertisement posters. The primary researcher approached the interested participants and provided them with more information. All clarifications were addressed prior to the obtained informed consent. Participants completed the pretest measures prior to the commencement of the RISE program in October 2021. Following the conclusion of the intervention, students were invited to the complete the post-test in November 2021. The survey comprised a sociodemographic form and three outcome measures . The qualitative data were collected via email correspondence. Participants were provided with a list of open-ended questions and given time to respond. Participants were provided with a remuneration of 10 SGD for their participation.The quantitative measures were collected using Qualtrics and comprised the following domains: (1) sociodemographic data, (2) resilience, (3) social support, and (4) learning. The sociodemographic, academic, and economic characteristics of the students were solicited. Open-ended questions were developed with reference to the guidelines of Bowen and Kreuter  for feasResilience was measured using the Connor-Davidson Resilience scale that consists of 25 self-rated items (CD-RISC-25) . The iteSocial support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS) . The MSPMotivated Strategies for Learning Questionnaire (MSLQ)  was usedOpen-ended questions were curated to explore participants’ acceptability, perceived appropriateness, and actual usage of the intervention . The usaStata version 17  was usedA content analysis  was usedThe concurrent mixed data analysis approach with seven steps  was undeThis study conformed to the Declaration of Helsinki. Ethical approval was obtained from the university’s institutional review board (NUS-IRB-2021-594) prior to the commencement of this study. Participants were informed of the study’s goals and were provided opportunities to clarify their doubts. Written informed consent was obtained from all participants.A total of 43 students were assessed for eligibility. Fifteen students did not meet the inclusion criteria, and 18 students decided not to participate. An eventual sample of 10 undergraduate students enrolled in the RISE program, with a mean age of 21.5 years (SD = 1.96). The participants were largely ethnic Chinese (90%), female (60%), of Buddhist faith (40%), and single (100%). The demographic information of the students is detailed in Regarding the content, all participants found the materials appropriate and applicable to their concerns. In addition, participants appreciated how the take-home tasks were able to consolidate and support their learning. The use of reflective practices was not well-received, and students proposed alternative forms of take-home tasks to stimulate their interest. Regarding the training duration, all participants felt that the duration of six weeks was suitable to deliver the program, although the duration of the training could be shortened. When asked to propose other forms of resilience-enhancing strategies, participants alluded to the importance of skills that fostered their academic coping. Finally, participants also emphasized the need for information relating to outlets for seeking professional support.The majority of the students verbalized that the training had positive impacts on their resilience, social support, and learning outcomes. In particular, students appreciated how they transferred these skills to their everyday lives. However, the RISE program started during the middle of the academic semester. Students proposed that the training could be initiated at the start of the semester as the current time frame was challenging because of numerous competing academic priorities.n = 8), quizzes (n = 9), and take-home tasks (n = 7) and attended at least two of the three virtual face-to-face discussions (n = 8). This led to a cumulative completion rate of 72% , and their total engagement with the RISE program was 182.66 min . Consistent with the students’ narratives and academic timetables, their engagement with the materials was reduced by weeks 5 and 6 of the RISE program, which were also the final two weeks of the academic semester, wherein their workload was heavier.The majority of the students were able to complete the videos (p = 0.01) (p = 0.09) and its subscales (p = 0.01), with a very large effect . No changes were observed for the other MSLQ subscales.The Wilcoxon signed-ranked test was used to compare the differences between the baseline and post-intervention . The fin = 0.01) , with a ubscales . Regardiubscales , signifiThe mixed data analysis  compriseThis mixed-methods feasibility study evaluated the theory-driven, evidence-based, and learner-centered digital resilience training program among undergraduate students. The qualitative results showed that students found the intervention acceptable and appropriate and that they were able to engage with the RISE program. The quantitative results found that students’ resilience and meta-cognitive self-regulation scores improved after the RISE program. In addition, the students’ completion rate was 72%. This figure was comparable to other reported resilience programs whose completion rates ranged from 55%  to 78% .Although evaluating the efficacy of an intervention is not the goal of a feasibility study , this stOne, the contents of the program were developed based on theories ,26 whereTwo, as part of the developmental process, a qualitative study ensured that the contents and features of the RISE program were cocreated with the target population . With reThree, with regards to the features, the RISE program was hosted on the university’s learning platform. With reference to the theory of online learning , placingFour, the RISE program was largely designed as a self-paced program, allowing learners to have flexibility and take ownership of their learning, which, in turn, created a learner-centered environment ,54. In aNevertheless, students provided several improvements to further promote their engagement in the RISE program. With regards to the take-home tasks, students proposed to have more creative exercises. For instance, reflective practices may be embedded in other forms of activities as opposed to the traditional narrative form. Given that reflective practices are used in discussions  and in tThe findings from our qualitative study  proposedThis study has several strengths and limitations. First, this study adopted a theoretically driven, evidence-based, and learner-centered approach to develop the RISE program. Second, the adaptation of a mixed-methods design allowed a deeper exploration during the evaluation phase of the RISE program, which may not be achievable in a single design. Third, the findings from this feasibility study point toward the development of a larger-scale RCT to evaluate the effectiveness of the RISE program on improving students’ resilience, social support, and learning outcomes.However, this study was limited by the use of a single-group pretest, post-test design, with the interpretation of its findings limited to the acceptability, appropriateness, and implementation of the RISE program. In addition, the study was only conducted in one university in Singapore. Considering the differences across institutions, the RISE program should be evaluated across multiple IHLs. Further, this study recruited a modest sample of 10 students as it sought to test the feasibility of the RISE program. Further work is needed to confirm the effects of the RISE program among undergraduate students. Finally, due to the COVID-19 pandemic, the use of open-ended questions to collect qualitative data through email correspondences may have limited participants’ responses. The use of in-depth virtual interviews should be considered in future trials to gain a deeper understanding of students’ experiences.This feasibility study lends its findings to the development of future resilience programs. First, larger-scale studies using RCT design are needed to confirm the effects of the RISE program in improving students’ resilience, social support, and learning outcomes. While resilience programs have been found to improve students’ resilience , there aSecond, this study found that the students experienced competing priorities when the RISE program was delivered during the semester. Considering that students prefer to receive resilience training during the academic semester, future programs may be incorporated as part of the formal university curriculum. This may provide students with protected time to engage with the RISE program.Third, the current RISE program adopts a blended learning design that may be challenging and resource-intensive. Future RCTs may consider comparing the effects of a blended and an asynchronous online resilience program. This has dual benefits, as it may reduce students’ workload and be less expensive to implement.p < 0.05) and meta-cognitive self-regulation (p < 0.05). However, due to the small sample size, it will be challenging to conclude the positive effects found in this study. Instead, this feasibility study paves the way for future studies using RCT designs to provide further evaluations of the RISE program on resilience, social support, and learning outcomes.This study examined the feasibility of a digital RISE program. The findings show that students found the RISE program acceptable and appropriate and that they were able to engage with the materials. The limited efficacy testing also show that the digital RISE program can improve students’ resilience (


A robust public health workforce in Sudan is essential for accelerating progress toward the Sustainable Development Goals, and strengthening public health education is a priority for the Ministries of Health and Higher Education. Faculty at public health training institutions are a critical resource. Globally, development programs for junior to midlevel public health faculty have been well documented. However, most involved direct partnership between a university from the Global North and only one or two universities from the Global South, only one included an explicit focus on creation of a leadership network, and none were launched as fully virtual collaborations. Therefore, we conducted a mixed-method evaluation of the fully virtual Yale–Sudan Program for Research Leadership in Public Health. We used program records, participant feedback, competency assessment, and network analysis to evaluate 1) participant engagement, 2) change in skill, and 3) change in collaboration. The program achieved a 93% graduation rate. All participants would “definitely” recommend the program and described the live virtual sessions as engaging, effective, and accessible. We observed progress toward learning objectives and significant increases in 13 of 14 leadership and mentorship competency domains. Collaboration across Sudanese institutions increased, including an almost doubling in the number of pairs reporting scholarly collaboration. Eight authorship teams are actively working toward peer-reviewed publications. The program engaged scholars and policymakers from across Sudan and the Sudanese diaspora achieved high levels of co-creation and continues despite significant political unrest in the country, serving as a promising model for strengthening of public health education in Sudan. Sudan is the third most populous country in Africa (40 million population),In response, several of Sudan’s leading educational institutions  came together to identify strategies to strengthen public health education. In each organization, junior faculty were identified as a critical stakeholder group, representing the future of public health scholarship in Sudan and responsible for providing public health education for future generations. Although the specific profiles of these junior faculty vary across institutions, they generally have heavy teaching loads, mentorship, and supervisory responsibilities for students and postgraduate researchers and are working to establish funded research portfolios with little formal mentorship or support. Levels of burnout and turnover are high. Faculty development programs to promote mentorship and foster leadership among junior to midlevel public health faculty have been well documented, including in lower- and middle-income country settings.Therefore, we studied the implementation experience and short-term outcomes associated with the Yale–Sudan Program for Research Leadership in Public Health. The inaugural program was designed to foster a network of junior and midlevel faculty with the ability to 1) assume leadership roles within their institutions, 2) serve as more effective mentors to their trainees, and 3) influence scholarship and practice through scientific writing. The partners also acknowledged that training of individual junior faculty members would be insufficient to drive the level of transformation envisioned and committed to fostering organizational systems and dynamics that will allow these rising research leaders to flourish. Therefore, the program included design features and curricular content to 1) foster collaboration between partner institutions in Sudan to capture synergies and leverage the resources of each institution and 2) promote alignment across levels of hierarchy within each institution so that the junior faculty that were at the heart of this program were also well supported by their own mentors. We used a mixed-methods evaluation of the inaugural cohort of the program to assess participant engagement, change in mentorship and leadership competencies, and levels of collaboration. The results are expected to be useful to scholars and practitioners committed to the strengthening of institutes and schools of public health, in leadership development and public health workforce strengthening, and in innovative models for global collaboration.The partnership network was developed through introductory visits among organizational leadership that were catalyzed by members of the Sudanese diaspora committed to strengthening the public health workforce in Sudan. The partnership network included four of Sudan’s leading universities: Ahfad University for Women, University of Gezira, University of Khartoum, and Neelain University. To promote alignment with national public health priorities and practices, the partnership also engaged Sudan’s Federal Ministry of Health (FMoH) and the Public Health Institute, a branch of the Ministry. The Yale School of Public Health provided capacity-building support. Each partner institution identified a coordinator to support communication, contextualize the program, and align with current events in each institution and at the national level. The program was funded by a grant to Yale University from the U.S. Embassy in Khartoum.We aimed to engage junior to mid-career full-time faculty who were currently providing mentorship to more junior scholars, postdoctoral trainees, and/or students. We sent official invitation letters to university deans, asking them to nominate up to five junior to mid-career full-time faculty who they believe would benefit from the program. We also highlighted that their selection should be “rising-star” faculty who have been identified as having high potential to take on more senior roles and who are currently providing mentorship to more junior scholars, postdoctoral trainees, or students. Each nominee was asked to submit their resume, application form, and personal statement to complete their application. Twenty-eight participants were identified to join the program. Each participant was also asked to identify a senior-level faculty member to act as their mentor and champion for their growth during the program. This could have been a new or an existing mentorship relationship, and these champions were engaged in select parts of the program.Creating the Leadership Network aimed to provide an orientation to the program, build relationships among participants and between participants and their mentors, and prepare participants to elevate their careers in the context of both national research priorities and home institution strategic objectives. Fostering Effective Mentorship aimed to equip participants to analyze major theories of mentorship in the context of their own institutions, use approaches and tools to function effectively in mentorship roles, and advocate for their own mentorship and professional development. Leading Research Teams aimed to prepare participants to take on increasing research leadership roles in their home organizations, including leading multidisciplinary research teams and in roles of administrative leadership. Of note, each module of the program was adapted through consultation with the program coordinator from each of the Sudanese partner universities and institutes. A detailed description of the sessions included in each of these modules is outlined in Supplemental File 1.The core curriculum was based on an in-person training program for HIV/AIDS and Tuberculosis Researchers in South Africa, codeveloped with the University of Witwatersrand School of Public Health and Aurum Institute . After an in-depth application review process, nine successful participants were selected to work with a Yale faculty mentor to build an authorship team, identify a target journal, and work toward submitting the manuscript. The collaborative included a launch webinar on practical approaches and best practices for scientific writing, access to an online repository of resources on best practices in scientific writing, self-paced work within mentor–mentee teams, and virtual check-ins via WhatsApp to promote accountability and peer support.The program was delivered as a fully virtual collaboration in the context of COVID-19. To overcome expected challenges associated with the virtual format , we invested in the following: 1) a structured risk assessment with participants to understand and align to their work life , time, and day preferences to ensure their connectivity, preferred way of communication, and workload; 2) a repository of program materials (including live session recordings) for asynchronous access; 3) use of a WhatsApp group chat to foster connection and engagement; and (4) weekly meetings with program coordinators from each site to update on changes in the local contexts as well as to promote troubleshooting and follow-up with individual participants as needed.® and supported by small breakout room facilitation in Miro®, and individual assignments to promote integration and application in participants’ home organization. Each module culminated in a panel discussion that engaged leadership from Sudan and the Sudanese diaspora. Participants committed to approximately 4 to 5 hours of coursework per week. All session recordings and related materials were made available in a program archive on Canvas® and in Box® for future use by participants and replication/adaptation by partner institutions.The blended learning model included asynchronous content on essential capacities and practices, synchronous sessions to foster understanding and integration, and individual- and team-based assignments to reinforce learning and foster systems change. Each module included a set of asynchronous learning materials  delivered via the Yale School of Public Health Canvas platform, one live session per week delivered via ZoomParticipants who engaged in at least 85% of the live Zoom sessions (or accessed the recordings), completed assignments related to creation and use of Individual Development Plans with their mentor/champion and completed the competency self-assessments at the beginning and end of the program earned a certificate of completion from the Yale School of Public Health and their home institution.,Supplemental File 2).We used a mixed-methods design for the evaluation. Specifically, a mixed-method design integrates qualitative and quantitative methods that are complementary in their strengths and liabilities to measure interrelated aspects of implementation, generating a rich understanding of program implementation and allowing for expansion beyond any single data source to understand the impact of the program.t tests to compare changes from the program’s start to the end in average scores for each skill and for the six summary competencies. Similarly, longitudinal changes in leadership competencies were assessed using the Leadership Competency Assessment (LCA) tool.Supplemental File 3 for the 26 mentorship and 52 leadership skills assessed). We again used paired t tests to evaluate pre–post change in each domain.Third, at launch and graduation, participants completed a confidential online self-assessment survey of their mentorship and leadership competencies. Longitudinal changes in mentorship competencies were assessed using the validated 26-item Mentorship Competency Assessment (MCA).Fourth, participants completed a voluntary, confidential network survey at the start of the program and again at the end of the program. Each participant was asked whether they collaborated with the other participants in the following ways: 1) sharing research in progress, 2) sharing information about funding opportunities, 3) cosponsoring activities (programs/advocacy), 4) financial relationships/contracts, 5) sharing data, 6) serving on professional committees together, and 7) other. Using UCINET software,Information from the four data sources was integrated based on the Kirkpatrick Model, a widely recognized model to understand the results of educational programs at multiple levels from learner reaction to organizational impactThis evaluation was deemed exempt from continuing review by the Yale Institutional Review Board.Following the recruitment process, 28 participants from partner institutions enrolled in the program . In terms of gender, 75% of the participants were women, and 25% were men. In total, 26 of 28 participants (93%) successfully completed the program. The average attendance at each live session was 70%. The panel discussions at the end of each module were a highlight of the program, with 100% of the participants either live-streaming or watching the recording of the panel sessions, and many requesting to share the recordings across their professional networks.After each of the three modules, 100% of program participants stated they would “definitely recommend” the program to peers. Participants also expressed strong satisfaction with session logistics in terms of Zoom breakout room management, live session facilitation, Canvas materials and access, and program communication including initial meetings, receiving schedules, and programmatic updates. perfect and welcoming.All sessions worked well except for connection and electricity problems; on the other hand live sessions and breakout rooms were just positive atmosphere that Yale staff has created to encourage participants to contribute to the sessions has been accepting of different cultures and different levels of abilities.The excellent organization of the program and the such good mixture of theory and practicality.The program is well structured and professionally directed. Live sessions are the best part because of the excellent presenters and the active thoughtful input from participants. For me it has been [the] sense I have the chance to discuss various core concepts in This experience has supported the extension of my learning opportunities, beyond the traditional scope of face-to-face learning. We were challenged to critically analyze our work situations and context, with every discussion and reflection in class.An effective online communication was demonstrated through the interaction and engagement of the instructors with the students. To my belief, the teaching and learning process adopted in the program was well planned and delivered. Thus, it enabled the program to successfully overcome the difficulties typically faced in virtual classes. Participants described the live virtual sessions as engaging, effective, and accessible. Similar to our experiences in adapting other leadership development modules to fully remote delivery in the context of COVID-19, this approach fostered integration of didactic and applied work, and rapid translation of new skills into practice.In the exit surveys after each module, participants reported high levels of understanding toward learning objectives. Between 74% and 100% of participants met each of 11 learning objectives. I realized there are some people who come to discuss with me their career and other issues constantly and I do the same with other. Now I realize this can be more efficient, effective, and structured.I’m interested in organizational dynamics due to my current position in our staff trade union, so understanding and shaping organizational culture were the best to learn about; opening my eyes to new approaches to introduce change.Participants also offered descriptions of early application of their learning.P < 0.05) increases in five of the six domains of the MCA: maintaining effective communication, aligning expectations, fostering independence, addressing diversity, and promoting professional development. Consistent with the curricular focus on the development and use of Individual Development Plans, participants showed the greatest pre–post increase on the aligning expectations domain (1.4-point increase), followed by promoting professional development (1.1-point increase), fostering independence (1.0-point increase), and addressing diversity (1.0-point increase). Participants showed statistically significant (P < 0.05) increases in each leadership domain, including 1) systems thinking, 2) political leadership, 3) collaborative leadership: building and leading interdisciplinary teams, 4) leadership and communication, 5) leading change, 6) emotional intelligence and leadership in team-based organization, 7) leadership, organizational learning and development, and 8) ethics and professionalism. Consistent with the program curriculum, participants reported the highest increase in collaborative leadership: building and leading interdisciplinary teams (1.4-point increase), followed by 1.3-point increases in political leadership; emotional intelligence and leadership in team-based organization; and leadership, organizational learning and development. Participants also showed statistically significant ; significant impact on mentorship and leadership competencies; and measurable strengthening of research collaborations within and across partner institutions. As part of the scientific writing collaborative, eight authorship teams are actively working toward producing peer-reviewed publications.Most notably, the partners overcame barriers expected of a fully virtual program in Sudan  to create a program that was experienced as engaging, effective, and accessible. Further, although the program was launched during a period of relative political stability, active collaborations across institutions have persisted despite the onset of a period of sustained political unrest associated with military rule starting in October 2021.Our results are comparable to those from a similar program for researchers in South Africa , and we achieved high levels of engagement by the champions in live sessions and assignments. Second, in both programs, national partners advocated for the inclusion of panel sessions at the end of each module to contextualize the program content and encourage conversations with leading national scholars and practitioners. Public health and medical professionals from the diaspora have been described as an underused resource for low- and middle-income country health systems strengthening efforts,,Our results should be interpreted in light of several limitations. First, assessment of progress toward program objectives and changes in competencies are based on participants’ self-report, and not corroborated by inputs from supervisors or peers. However, self-reported assessments are a widely used approach, and the results of the LCA, MCA, and network analyses indicate comparable results with previous studies with a similar outcome evaluation setting.The Yale–Sudan Program for Research Leadership in Public Health engaged scholars and policymakers from across Sudan and the Sudanese diaspora, achieved high levels of co-creation with local coordinators, and continues despite significant political unrest in the country, serving as a promising model for continued partnership toward strengthening of the public health workforce in Sudan and other country settings. We expect that our results will be useful to scholars and practitioners committed to the strengthening of institutes and schools of public health, in leadership development and public health workforce strengthening, and in innovative models for global collaboration.Supplemental materials


The Russian Federation has introduced a vertical large-scale program of ‘dispensarization’ (Program) that includes health check-ups and screenings for the entire adult population. It is expected to improve the results of medical interventions and ensure health gains at a relatively low cost. The major research question: Does the design and implementation of the program meet the expectations?We analyze regulatory acts and the literature on the design and the outcomes of the Program. Physicians’ surveys and interviews are conducted to understand the capacity of primary care providers to meet the requirements of the Program, as well as the link between the early identification of new illnesses and their follow-up management, administration of the program, the barriers to its successful implementation.There is a substantial progress in the coverage of the population and increase in the number of identified illnesses. Some specific instruments of the Program implementation work well, others require more careful design and additional integrative and managerial activities. The capacity of primary care providers does not allow to provide high quality preventive services, as well as to ensure a continuum of preventive and curative work. The pattern of the Program administration facilitates its nation-wide implementation according to the unified rules, but makes it more difficult to account for the local conditions and limits the autonomy of professionals to choose specific population risk groups and a list of services. The interaction of providers in preventive activities is inadequate.The expectations of the Program are too high due to the inconsistencies in its design and implementation. The major lesson learnt is that the program like this should meet the capacity of primary care and be designed as a complex of interrelated activities to identify illnesses and provide their follow-up management.The online version contains supplementary material available at 10.1186/s13690-022-00878-3. The majority of European countries have implemented comprehensive approaches to public health. Population-based check-ups and screenings have become an important instrument of the early identification of illnesses and their follow-up management. These activities are usually viewed as the way to improve the chances of survival for people living with cancer and other illnesses by ensuring that health services can focus on diagnosing and treating the disease earlier . The popThe impact of these activities on health outcomes is not as easy as it might seem. It depends on the selection of preventive services, as well as on the implementation practices in the specific national context. There is a substantial body of literature on the justification of screening programs. Wilson and Jungner  set out Another body of literature addresses the design and organization of screening programs. WHO Regional Office for Europe  suggestsPractically all these studies address the developments in Western countries. Much less attention is paid to the post-Soviet countries. Some of them have deeply rooted traditions of the population-based preventive campaigns. Modern Russia inherited the Semashko model, which had declared the priority of preventive activities. But their implementation after the dissolution of the USSR has been limited by chronic underfunding of health system. Public funding has not exceeded 3.5% GDP over the last three decades . In the The expectations of the Program are very high in Russia. The official attitude is that the early detection of ill health will allow to improve the results of medical interventions and ensure health gains at a relatively low cost. The Federal Ministry of Health (MoH) estimates the contribution of the prevention campaign to ‘keeping people healthy’ at the level of 60% . Also, tThe Program design provides for the specific instruments of its implementation – highly centralized administration, a universal set of services to identify illnesses among centrally determined target groups, methods of planning, reporting, monitoring, etc. Some of these instruments, for example, provision of preventive services in multi-specialty primary care settings, a large-scale promotion campaign, the establishment of special units responsible for this work, are not common internationally.The recently implemented policies to strengthen health prevention in Russia have prompted a number of questions: Does the design and implementation of the Program meet the capacity of the current health system? Do specific Russian instruments really work? Does a highly centralized pattern of the Program administration facilitate or complicate its successful implementation? Which lessons can be learnt from this Program for other the countries? Addressing these questions may be of interest to health policy makers in other countries seeking the ways to improve public health. We explore these questions by reviewing the design of the Program, studying its implementation practices and discussing the results. The selection of specific check-ups and screenings is not discussed in the paper, since it is country-specific and is beyond our research questions.The motivation to produce this paper is to encourage a more careful study of population-based prevention programs, particularly in countries with limited financial resources for health care. Their policy makers often seek ways to solve health care problems through the early identification of new illnesses. The major message is that this activity does not automatically yield health gain. The population-based programs of check-ups and screenings should meet the capacity of primary health care. They should be designed as a complex of interrelated activities to identify illnesses and provide a follow-up management of chronic cases. Physicians should have a discretion regarding the choice of prevention patterns, including the coverage of specific population risk groups and a list of check-ups and screenings. A close interaction of providers in the course of new diseases identification is also needed.Thus, the aim of the paper is to analyze the design, implementation and outcomes of the Program in the context of domestic and international developments in public health.We analyze design, implementation and outcomes of the Program using as research tools the review of regulatory acts and the literature, statistical analysis, physician surveys, face-to-face interviews with physicians and health managers. A framework of the analysis is presented in Fig. We follow a three-step methodological framework. The first step involves the analysis of objectives and design of the Program. The regulation is explored to determine the preventive activities requirements and their matching standard pathways recommended by WHO. We explore the patterns of check-ups and screenings provision, planning preventive activities, reporting outcomes, monitoring, payment methods. The limitations of the design are highlighted.The second step addresses the issues of the Program implementation. It consists of two stages. The first is to highlight the administration of the program at the governmental level. The second is to explore the implementation of the Program at the level of primary health care (PHC) settings. The focus is on the following characteristics of their performance: a) the adequacy of primary care capacity to implement the Program; b) the interactions between providers in terms of the flow of information on the early identification of new illnesses; c) the prevalence of the follow-up management of these illnesses, d) the modes how providers of preventive services choose target groups for screening, plan their activity, report the outcomes. These parameters of implementation are studied with the use of physician surveys and face-to-face interviews.The third step involves the analysis of outcomes of the Program as they are defined in the regulatory acts. The official estimates of the population coverage and the identification of new illnesses are compared with the estimates of physicians obtained through the survey. The collected evidence allows us to come up with concluding points about the potential of the Program to meet the public expectations.To explore the objectives and the design of the Program, we analyze the regulatory acts of the government and the domestic literature on the subject, including the reports in limited circulation, unpublished documents, memorandums, and presentations from our personal collections. The literature on the similar programs in other countries was searched in the MEDLINE data base using the query “screening”, “health check-up”, “public health programs”. All findings were checked manually and around 30% were relevant.The practices of the Program implementation were explored using a physician survey. It was conducted online in April–May 2019 through the mobile ap “Handbook of Physician” (available in Google Play and AppStore) with 540 thousand of registered users. We randomly selected 1100 physicians and feldshers (paramedics) who were directly involved in provision of preventive services in primary care settings under the Program, including district therapists (63.2% of respondents), outpatient specialists (18.7%), general practitioners (9.9%), paramedical personnel (8%). They represent most of regions (81 out of 85 regions of the country) and the structure of population residence . A questionnaire with 25 questions on the above mentioned dimensions of implementation practices was sent to the selected group of respondents  in January 2020 when Covid-19 pandemic had not affected the work of primary care yet. We explored the ways preventive activities were administered in polyclinics with 13 questions . In big polyclinics, they are reinforced by the staff of a preventive unit – physicians and nurses responsible only for preventive activities. Such units exist in practically all urban polyclinics . SpecialThe administration Program is highly centralized and implemented by the federal Ministry of Health. The requirements of planning and reporting are based on the federal regulation. The major indicator is the coverage of the eligible citizens. It is planned vertically – for the entire country, regions, communities, medical organizations, district units served by DPs. Also, the Federal Program of state guarantees of free medical care – the major health planning and funding document – sets the targets for the number of physician visits with the “preventive aim” and their unit cost. Using these targets, regions plan their own volumes of preventive care and their funding with the following distribution of these volumes across communities and polyclinics.In addition to the population coverage, the prevalence of detected cases of illnesses is reported through a vertical chain of governmental agencies and medical settings. This reporting focuses on the cases of circulatory system diseases and cancer. In the latter case, it includes the indicators of cancer identification at first and second stages. Some regions of the country plan the number of new cases identified in the course of the Program implementation and even set targets for this indicator.It follows the lines of planning and reporting. The major indicators of success are a high and growing population coverage, a high share of the early identified cases, and a high share of the identified cases that is subject to dispensary surveillance has been added. However, monitoring the actual follow-up curative activities is not required by the regulation, let alone monitoring the outcomes of dispensary surveillance. The actual health gains of the Program are beyond the scope of monitoring.In addition to the aggregate information, detailed data is collected: the number of specific services, detected illnesses, prevalence of risk factors, the number of patients who need a dispensary surveillance, health groups and their structure. Theoretically, this data allows to analyze the outcomes of preventive activities across stages of the Program, specific screenings, groups of population, geographic areas. But the regulation does not require such a detailed monitoring. Moreover, this information is not open for the public.Preventive services under the Program are reimbursed by regional mandatory health insurance (MHI) funds. The rates of payment are set for a so called ‘finished case of dispensarization’, that is a fixed package of services determined by the regulation for the first stage of the Program. A ‘luft’ of 15% of the number of services is allowed, while all screenings are obligatory. A bundled payment for the first stage is supplemented with a fee-for-service reimbursement of additional consultations and tests at the second stage. The control of the actual number of ‘finished cases’ is conducted by health insurers – mostly private entities that are involved in MHI. In addition to this amount, polyclinics receive a small bonus (around 13–15 USD) for each identified new oncological case [The idea behind this pattern of payment is to motivate providers to supply preventive services. The opposite side of the coin is that this instrument limits the professional autonomy of physicians on the choice of preventive services for an individual. They have to provide the entire bundle of services to be reimbursed, irrespective of the actual need of a patient. Inversely, a necessary test that is not included in the list of the ‘finished case’ will not be paid. Also, the regulation does not provide for additional payment for managing identified chronic cases. Dispensary surveillance is not incentivized by payment methods. This is another limitation of the Program design.The role of a highly centralized administration of the Program is controversial. On the one hand, the federal government has initiated it, provided regions with additional funding, involved providers in preventive activities, made the Program implementation a priority of health policy. The opportunities and benefits of preventive activities are widely presented in the state media and official websites with the focus on the information how and where to pass medical examination. Private employers are legally required to promote the involvement of their employees and to offer them a day-off once a year to undergo the dispensarization. In some regions, temporal offices for check-ups have been established in popular trade and recreation zones, as well as in big educational institutions and industrial centers. In addition to the support activities, administrative pressure is used wherever possible. Public servants, teachers, medical workers, students and some other groups of population are strongly recommended to participate in the campaign. There are voices to introduce financial sanctions for those who ignore the Program. All these strategies contribute to the population coverage.On the other hand, a highly centralized administration has a number of drawbacks. Uniform target population groups and a set of preventive activities limit the flexibility of regions in responding to local needs and special conditions – variation in the disease incidence, the capacity of PHC, the most vulnerable population groups. Centrally established indicators of the population coverage, volumes of preventive care and the number of identified illnesses make regional health authorities and PHC providers look for the ways to reach the targets irrespective of the local capacity to treat new cases. Monitoring the Program outcomes follows the logic of the centralized administration and politically loaded campaigns. The federal MoH makes an emphasis on easily attainable indicators and targets so that to show the progress.“Rigid plans for medical examinations turn dispensarization into a competition of numbers and indicators that are not related to the reality”.“Permanently changing federal rules of dispensarization divert physicians from the actual preventive work and overburden them with routine reporting work”.“Tough federal requirements and plans force providers to distort reports of the coverage and identification of illnesses”.Health managers in their face-to-face interviews indicate that the centralized administration of the Program complicates the actual preventive work. Plans of the population coverage don’t take into account the age structure of eligible groups. If the share of elderly people is high, then the planned targets can’t be reached, because elderly people usually know enough about their illnesses and prefer to see a doctor for curative purpose rather than to have check-ups. If the targets can’t be reached, physicians have to look for the ways how to distort reporting about the coverage of the program. Also, the requirements of the federal MOH often change, which in turn requires changes in electronic forms for medical examinations, procedures of reporting and billing, etc. The citations of interviews:The Program has been implemented in the health system where DPs are overburdened with a curative work. The survey of 1100 physicians  report that health check-ups are conducted by DPs, 13% – by physicians of preventive units, 22.4% – jointly. Only half of DPs always (32.2%) or often (18.2%) receive information about check-up results when they are conducted by preventive units. The rest seldom or never receives it  are unaware of the distribution of their patients across health groups. Check-ups and screenings are conducted, patients with health problems are identified, but many physicians responsible for their follow-up management don’t know about results of preventive activities.Another area of providers’ interaction is between DPs and specialists. Every third DP (34.2%) seldom receives information about the results of the second stage dispensarization, every fourth (24.3%) doesn’t receive it at all. Thus, more than a half of DPs don’t report coordination with specialists involved in the Program.Only 7.7% of respondents indicate that a set of actual curative activities meets the requirements of a pattern of dispensary surveillance issued by the Federal MoH. The majority reports that these requirements are met only for some patients or are not met at all Fig. .Fig. 3DiThe usual practice to evaluate the outcomes of chronic disease management is to look at the number of disability days, emergency care visits, hospital admissions, disease-specific mortality rates . In thisThese findings are similar to a clinical expertize conducted by the private health insurer ‘Rosgosstrah-Medicina’. The analysis of medical records of 7043 patients after their hospital admissions with a stroke or a myocardial infarction indicates that nearly half of these patients have not seen a doctor during the year prior to admission . The natThe revealed interaction of preventive and curative activities does not meet internationally recognized assumption that a screening program pathway should include a stage of the follow-up management of the detected illnesses: ‘ … there is no point in offering a screening program if there are insufficient facilities or health personnel to provide treatment for those who need it’. For example, a mass screening program for thyroid cancer in South Korea in 1999 led to the number of cases being detected increasing 15-fold and yet no reduction in mortality from thyroid cancer . In Russ66% of physicians report that they have individual plans of the number of preventive and curative visits, developed by polyclinics administrators. Only 34% plan their activity themselves;59% indicate that the failure to implement individual plans on the number of visits may cause reduction in their remuneration;only 25% of physicians select patients themselves for check-ups and screenings after assessing their risk factors, that is invite those with the highest risks. The majority relies on the centrally determined target population groups.A centralized Program administration sets a chain of vertically determined rules. Physicians involved in the implementation of the Program work according to the rules determined by their polyclinics’ administrators, who in turn follow the commands of the federal and regional health authorities. The following evidence of physicians’ limited professional autonomy is collected in the survey of 103 physicians of multi-specialty polyclinics in Moscow city and Moscow region:Administrators of multi-specialty polyclinics plan the number of visits and the Program coverage in the catchment areas, control the activity of physicians. The professional autonomy of physicians to select their own patterns of preventive work is limited. The face-to-face interviews with physicians confirmed this conclusion.As stated above, the major outcome indicator in the official reporting is the coverage of the eligible population. The Federal Fund of MHI reports that in 2018 92% of eligible population has actually undergone dispensarization, in 2019–110% , while tWe also asked a question ‘Why do you think there is a common opinion in the society that the number of people that have actually undergone dispensarization is lower than official estimates?’ Nearly two thirds of physicians (62.6%) report that the major reason for this opinion is that people are reluctant to undergo dispensarization, therefore physicians have to report an upward distortion of the coverage.The estimates of the number of identified illnesses are based on the reports of the federal MoH for individual years, the reliability of which cannot be verified due to the unavailability of the original accounting information. Particularly impressive are reports of an increase in the number of diagnosed oncological diseases - from 21.3 thousand in 2013 to 55 thousand in 2019, or by 2.6 times. The frequency of newly diagnosed breast cancer in the period 2013–2018 increased from 39.2 per 100 thousand in 2013 to 73.3 per 100 thousand in 2018 or by 1.9 times. For other cancer localizations, the data for individual years are incomparable. In 2018, the MoH gave estimates of the proportion of cancer detected at stages 1–2: cervical cancer - 67.9%, breast cancer - 68.7%, colorectal cancer - 57.1% . ComparaAccording to the same source, the number of diagnosed cardiovascular diseases increased from 1.6 million in 2014 to 8.5 million in 2018, or 5.3 times. Particularly impressive is the dynamics of the diabetes mellitus detection: in 2015, more than 300 thousand cases were detected, in 2016 - already 531 thousand cases, or 1.8 times more. Approximately the same picture is emerging for respiratory diseases: there was an increase in the number of detected cases from 500 thousand to 710 thousand, or by 40% in one year .Health groups characterize the distribution of the population according to the prevalence of pathologies of varying complexity. The share of the third group with the lowest health status increased from 44% in 2013 to 54% in 2018 .Thus, the available official data indicate a significant increase in the coverage of medical examinations, a high rate of disease identification, an increase in the proportion of the population with serious diseases. As indicated above, the official estimates of the coverage are disputed by physicians.The Program of dispensarization in Russia has raised the priority of the population-based preventive activities. The early identification of illnesses is currently viewed as one of the major areas of health policy. Primary care providers are increasingly focused on delivering check-ups and screenings to identify new cases. This work is supported by the government. There is a substantial progress in the coverage of the population and the number of identified illnesses. However, the collected evidence demonstrates major issues that don’t allow to expect substantial health gains – a low capacity of primary providers, the weakness of the follow-up management of identified illnesses.The major barriers to successful outcomes of the Program reflect the characteristics of the current health system governance in Russia. It is highly centralized. Democratic institutions are very weak. The role of regional governments in choosing the priorities of health policy is marginal. Local communities and professional organizations are rarely involved in decision-making on health issues. Patient empowerment practically does not exist. The input of civil society bodies is largely imitative. Therefore, the design of the Program has not been publicly discussed and it has not been adjusted to the low capacity of PHC, as well as to the requirements of holistic provision of preventive and curative services. In the pandemic of COVID-19, the Program has been suspended but will most likely be re-started in the unchanged form.The study has a number of limitations. First, the section on the Program outcomes is based mostly on the official estimates that overestimate the positive input of dispensarization. The reports of the federal MoH claim that check-ups and screenings are the major contributors to the early detection of diseases , 12, butThe design of two physician surveys, as it is seen in questionnaires (appendixes Report bias of the nation-wide physician survey relates to the question about the common opinion that the official estimates of the Program coverage are too high. Most respondents agree with this opinion but attribute it to the reluctance of eligible population to participate in the Program. A logical link between the two is dubious. Physicians tend to distort reporting under the pressure of administrators who are keen about reaching targets. This is a major reason for the overestimate of the coverage.There is some bias in the design of the survey of 103 primary care physicians in two regions of the country. They definitely don’t represent all physicians in the country. The only justification for this small-scale survey is that it is related to a narrow and more or less clear area of professional autonomy limitations. We wanted to receive an additional evidence without conducting a large-scale survey.No single aspect of the research would be sufficiently robust on its own, but the combination of literature and regulatory acts analysis, physician survey, face-to-face interviews, national public opinion surveys and statistical data create a rich picture of how the Program is designed and implemented, what are the barriers to achieving positive outcomes. There are grounds to believe that the generalizability of findings is high.The Program of dispensarization has increased the coverage of the population with check-ups and screenings. The Program aims at increasing the number of identified illnesses with a low priority of the follow-up management of new cases. The empirical evidence indicates that the capacity of primary health care does not allow to provide check-ups and screenings, as well as to ensure a continuum of preventive and curative work. A highly centralized pattern of the Program administration facilitates its nation-wide introduction and implementation according to the unified rules, but makes it more difficult to account for local conditions. The balance between centralized governance and the right of regions to adjust the Program to the local conditions has not been reached yet. This is an important task for any large-scale prevention campaign. Some specific instruments work well, particularly the establishment of preventive units in primary care settings, forming health groups of the eligible population, large-scale support and promotion of preventive campaign by the government. Others require more careful design and additional integrative and managerial activities.The major lesson learnt from this bold experiment is the understanding of insufficiency of a simplistic approach to health care problems by increasing the priority of the early identification of illnesses with the expectation that this may become a ‘magic tool’ of health improvement. The expectations of the program are too high, but there is a lack of consistency in its design and implementation. The population-based programs of check-ups and screenings should meet the capacity of the health care and be designed as a complex of interrelated activities to identify illnesses and provide their management with the focus on chronic cases.Additional file 1.Additional file 2.Additional file 3.