Due to COVID-19 precautions, the Vanderbilt University summer biomedical undergraduate research program, the Vanderbilt Summer Science Academy (VSSA), rapidly transitioned from offering an in-person training program to a virtual seminar format. Our program typically supports undergraduate development through research and/or clinical experience, meeting with individuals pursuing postgraduate training, and providing career development advice. Evidence supports the idea that summer programs transform undergraduates by clarifying their interest in research and encouraging those who haven’t previously considered graduate studies. We were interested in exploring whether a virtual, synchronous program would increase participants’ scientific identity and clarify postgraduate career planning. Rather than create a virtual research exposure, our 5-week "Virtual VSSA" program aimed to simulate the casual connections that would naturally be made with post-undergraduate trainees during a traditional summer program. In seminars, presenters discussed 1) their academic journey, explaining their motivations, goals, and reasons for pursuing a career in science as well as 2) a professional story that illustrated their training. Seminars included Vanderbilt University and Medical School faculty, M.D., MD/Ph.D., as well as Ph.D. students from diverse scientific and personal backgrounds. In addition, weekly informational sessions provided an overview of the nature of each degree program along with admissions advice. Through pre-and post-program surveys, we found that students who registered for this experience already strongly identified with the STEMM community . However, participation in the Virtual VSSA increased their sense of belonging. We also uncovered a gap in participants’ understanding of postgraduate pathways prior to participation and found that our program significantly increased their self-reported understanding of postgraduate programs. It also increased their understanding of why someone would pursue a Ph.D. or Ph.D./MD versus M.D. These changes did not uniformly impact participants’ planned career paths. Overall, by providing personal, tangible stories of M.D., MD/Ph.D., and Ph.D. training, the Virtual VSSA program offered seminars that positively impacted students’ sense of belonging with and connection to the STEMM disciplines. Undergraduate summer research programs are an opportunity for burgeoning scientists to experience research full-time, often at research-intensive institutions. Evidence supports the idea that summer programs transform undergraduates by clarifying their interest in research and encouraging those who haven’t previously considered graduate studies . The benIn the face of the global COVID-19 pandemic, many laboratories were closed or operating at restricted capacity in 2020 and thus most undergraduate students were deprived of an in-person summer research experience. For these current undergraduate students, unable to attend in-person research experiences, we felt that it was critical to continue to provide opportunities to interact with the science community and potentially foster a more profound interest in science. Is it known that representation plays a role in students sense of belonging . This isThe Vanderbilt Summer Science Academy (VSSA) is a summer research program that hosts approximately 100 students each summer from institutions across the country. During a typical year, the VSSA offers weekly research seminars, a wide range of enrichment activities and lectures, as well as social activities for those undergraduates engaged in research on our campus during the summer. The COVID-19 pandemic in 2020 triggered a mandatory closure of Vanderbilt’s in-person summer programming for undergraduates. In response, we set out to design a virtual summer experience that could increase students’ sense of identity and belonging in science. Rather than simulating laboratory research, our goal was to create a virtual seminar series that focused explicitly on telling personal narratives of those in the sciences and as well as discussing post-graduate degree program expectations.We hypothesized that this seminar series would increase students’ sense of belonging. Previous literature supports the notion that scientific identity can be built through non-research interactions . HoweverThis study and the data used in this study were approved by the Vanderbilt behavioral and social sciences IRB review committee . The data were analyzed anonymously.The design of the program is shown in Data were collected immediately after each presentation: In order to correlate identity in a speaker with interest in a specific career path, we administered a simple 2-question survey at the end of each seminar, presented on Zoom. These questions were “How much do you identify with this speaker”, with responses “Strongly identify”, “Somewhat identify”, “Neutral”, “Minimally identify”, “Did not identify” and “How interested does this seminar make you in this path?” with responses “Very interested”, “Somewhat interested”, “Neutral”, and “Not at all interested”. We related the bulk responses to these questions for all participants across all seminars (n = 668) .We utilized a modified version of the Scientific Identity Scale , which iThis study and the data used in this study were approved by the Vanderbilt behavioral and social sciences IRB review committee . http://www.rstudio.com/.) and the tidyverse, ggplot2, and reshape2 packages. Likert scale data were treated as ranked categorical data. The paired data (data of pre- and post-surveys completed by the same student) were analyzed using a Wilcoxon ranked sum test. To compare differences in responses between demographic groups, responses were divided into two groups: group 1 consisted of only individuals who recorded a “positive change”, and group 2 was made up of all other responses. Chi-Squared test of independence analyses were performed to identify potential relationships between these groups.Data were analyzed using R Studio (RStudio Team (2020). RStudio: Integrated Development for R. RStudio, PBC, Boston, MA URLWe were interested in determining whether students who participated in this virtual program developed an increased sense of belonging in the science community and in an understanding of STEMM careers by first analyzing the post-survey responses only. Overall, students reported in the post-survey a strong level of agreement that they learned more about STEMM . DespiteIn order to dissect this further and get a deeper sense of how participation in the program impacted their scientific identity, program knowledge, and career interest, we compared individual students paired pre-and post-program survey data. We were interested to learn more about students’ sense of belonging and how this related to participation in the Virtual VSSA program. Most of our participants already started the program with a strong sense of belonging: Almost half of the participants rated their belonging very high as indicated by "agree" or "strongly agree" to the prompt "I have a strong sense of belonging to the STEMM community." . We nextThe Virtual VSSA program provided participants with diverse, tangible examples of individuals on postgraduate paths so that they could better determine whether they belong in the field. To explore the success of this program, we examined how a participant’s sense of identifying with the speaker could impact their interest in a particular postgraduate degree pathway. Our hypothesis was that if a participant identified with a speaker more strongly, they would be more interested in a given path. Immediately following each seminar, students were asked, "How much do you identify with this speaker?" and "How interested does this seminar make you in this path?". These data were aggregated and analyzed based on the correlation between identification with speakers and interest in the career pathway. We were surprised that in this bulk analysis, so many students identified strongly with speakers. This also was associated with interest in the career pathway of the speaker . This stOne of the most striking effects of the program was the gain in Ph.D., MD, MD/Ph.D. program knowledge for participants. First, we were surprised to uncover a lack of participants’ understanding of post-graduate paths . Howeverboth participants’ sense of belonging to STEMM and their understanding of post-degree paths, we investigated whether these categories were related using a chi-square test of independence. Specifically, we stratified the individuals with a positive change in STEMM belonging from those that did not have a positive change and mapped this on their change in program knowledge. Strikingly, there was an increased ratio of students that also reported an increased sense of belonging within the STEMM community .Overall, the results of this study demonstrates how virtual summer programs can benefit students who cannot do summer research programs or are in unable to be in a in-person setting. Even when in-person programming commences, this type of program design may be used to enhance a sense of belonging for students, particularly those early in their STEMM careers. Next steps could include comparing the degree of belonging from seminars as compared to the casual relationships formed during in-person experiences. However our data clearly demonstrate that virtual meetings, on their own, can provide an added sense of scientific identity and community. The benefits gained by participants were no different between students who had other summer experiences, showing that this programming could be beneficial even when normal summer research commences. We highly recommend that R1 research institutions provide this type of experience and partner with non-R1 colleges and universities as a way to expand inclusivity and belonging in STEMM through the virtual, low-cost, non-capacity restrictive medium. Recordings of our series are available for any student or program to incorporate in their curriculum, and we aim to host a similar series for the 2021 season  To begin advertising the virtual VSSA program, the 1167 VSSA applicants were invited to participate. Of this group, 517 registered for the virtual VSSA sessions. Three hundred forty students completed the pre-survey while 136 completed both the pre-and the post-survey. This was the final population analyzed in this study, which represented just over 10% of the entire pool of VSSA students initially contacted. (B) Here we show a list of program elements by week. The program was a five-week program that began June 1(TIF)Click here for additional data file.S2 FigWe examined student’s responses to the prompts regarding their scientific identity (See (TIF)Click here for additional data file.S3 FigWe analyzed the impact of demographic categories on changes in STEMM belonging. Outside of Previous Research , no othe(TIF)Click here for additional data file.S4 FigWe examined student’s responses to the prompts regarding their understanding of post-graduate programs (See (TIF)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.


The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability.QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA).Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team’s self-efficacy to improve quality of care. Guided by the TFA, the QI teams’ acceptability was represented by the respective seven components of the multifaceted acceptability construct.Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.clinicaltrials.gov: NCT02769338.The online version contains supplementary material available at 10.1186/s12913-021-06318-2. Program acceptability by front-line users of an evidence-based, quality improvement (QI) program is a hallmark of successful implementation . Indeed,Designing and implementing an acceptable program among targeted stakeholders is often a key aim of a QI program to promote program local adaptation and program uptake. However, less is known on how to design for program acceptability for complex interventions involving multiple components among multiple clinical users in a real world, healthcare system. Therefore, we applied the TFA to guide a program evaluation of its acceptability by its users, the QI teams, based on their experience with the Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program.The PREVENT program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA) including: lack of protocols, clinical uncertainty about TIA care, and absence of performance data –7. The sThe clinical trial design and protocol have been previously reported . PREVENTThe rationale and methods used for the development of the PREVENT intervention have been described elsewhere . The cliPREVENT employed a bundle of three primary implementation strategies which were previously reported: , 15 (1) Active implementation of PREVENT at each site began with a full-day kickoff meeting facilitated by the coordinating site and included multidisciplinary staff members from the participating site involved in TIA clinical care. Using approaches from systems redesign , 22, sitDuring the one-year active implementation period, the site team members joined monthly PREVENT virtual collaborative conference calls which served as a forum for sites to share progress on action plans, articulate goals for the next month, and review new evidence or tools. The sites’ teams had access to the data Hub, an interoperative web based platform used to provide feedback on quality performance,and the collaborative calls during sustainment after active implementation; however, during sustainment they received no implementation assistance from the external facilitator.We began with a purposive sample at the VA medical facilities which snowballed based on clinical team participation at each of the six facilities. Clinical providers involved in the provision of TIA care at the six PREVENT sites volunteered to participate in the local PREVENT Quality Improvement program. All six clinical champions provided the names of their respective team members. The facility and participant flow has been previously reported . ParticiWe employed a mixed-methods design to measure and evaluate program acceptability based on the of its users, the QI teams. Multiple data sources were triangulated for this evaluation using the Theoretical Framework of Acceptability (TFA) . We condHow helpful was it, if at all, for you to have direct access to the PREVENT facilitator?” “How were you able to use any of the existing PREVENT materials provided by the national program? Which ones?” “How did you adapt to your local facility?”). Moreover, we queried on the multiple components of the TFA. We asked about the following:the burden; the affective attitudes about the PREVENT program; the in-kind,opportunity costs associated with local PREVENT implementation; the QI teams’ experiences and coherence with PREVENT and the implementation strategies; and the appropriateness,ethics & values- of the evidence-based program. We also queried participants within the six teams on their progress in implementing their action plans during active implementation.During the six-month interviews . We conducted mixed-methods, matrix analyses. We compared program satisfaction ratings at the end of active implementation by roles on QI teams (champions vs team support) and subsequently we compared acceptability and appropriateness related codes by satisfaction ratings to elucidate upon program and contextual related factors associated with perceived program acceptability. We further evaluated the temporality effect of acceptability from active implementation through program sustainment. Finally, we assessed perceived effectiveness on the local programs by evaluating which factors made the greatest impact.In Table Team mean satisfaction rating is reported in Table “I was highly satisfied, a 7, because I do think that it [PREVENT] motivated us to look at what was going on and to try to make some positive changes and to work as a team.” [102 12m 3 SV-Site Champion].“I was probably less encouraging about starting than our stroke director [site champion] … because I just wasn’t sure what we were going to get out of it. Although I think I was wrong. I think that we actually did get a lot [out] of it [PREVENT], and it was worth the effort that we did put into it.” [102 6 m 1 SV-Team Member].The following quotations illustrated the differential in ratings between the team champion and team members:“ … we’ve been actually very happy with all this data coming in and putting it together because it’s been very good for us tracking as well as very good for us as a department to show the hospital that initiative like this [PREVENT] count. … the combination of getting different services together, having different goals so that everybody is able to kind of collaboratively accomplish, tracking the data and the web site [data Hub], and having the education from the calls. So all four of those have been fantastic.” [104 12 m 3 SV].Some reported the program was acceptable because a local, collaborative, multidisciplinary team emerged where previously one clinician had been responsible for improving cerebrovascular care at a facility.. “I thought that [PREVENT] was a good program. I enjoyed working with it. I had time constraints, but I think that it was great to hear from other programs and what they’re doing, and I’ve interacted individually…” [102 12 m 3 SV].Other teams reported that they were appreciative of the QI support and the opportunity to learn from other QI teams in the VHA systemOverall, all six QI teams perceived the PREVENT program as acceptable during active implementation. Given that acceptability has been shown to be multifaceted , we appl“I have really enjoyed them [collaborative calls] … You could learn all kinds of things that might not even pertain to [my service area] but might be helpful to me to provide care. I thought that [the data Hub] was very organized to where if I needed to get something quickly and refer to it, it was very organized to where I could get to that quickly, and it wasn’t something that was cumbersome … [In the library on the Hub] I referred to those [guidelines] a couple of times just because I knew that it was an easy spot that I could get [101 12 m 3 SV].I was highly satisfied. This has been a great experience. It wasn’t without its frustrations, but those frustrations were not from PREVENT. Those frustrations were just the facility side here and just trying to make people see what areas that they’re accountable for … [103 12 m 2 SV].“Denoted as how a participant “feels” about a program , the PREit was with the process and the internal factors that we had involved with getting someone to be a consistent champion for Pharmacy. And so I think those very initial struggles kind of still weigh on my mind, and I’m wondering how could we have prevented that.” [105 12m 5 SV]“ … The perceived amount of effort that is needed to participate in the program was considered a burden . During “The expectation to get on the Hub and just stay …. Let’s all stay caught up with the Hub - It’s not realistic.” [103 12 m 1 SV] These leaders; however often supported their QI teams spending time on PREVENT elements.Team members with leadership positions within the organization pointed out the need to justify time spent on PREVENT. Well, I think that I got really frustrated with the without-fail rate because … I just felt that I was working so hard, and I was like trying to cover all of these holes … Our without fail rate was like zero for the month, … I really just wanted to quit [PREVENT] because I just was really frustrated …. The external facilitator RN was really helpful and encouraging …. [by giving suggestions on possible interpretations of the performance data]. … then the next month was better. [103 12 m 2 SV].At times during active implementation the burden became a source of frustration as the team efforts placed in making practice changes did not translate into immediate changes on the performance outcomes shown in the data Hub and this became a source of frustration among team participants. “I think it [kickoff] was a little hard … Because we didn’t have a full team, it just took a long time to get from there to actually doing anything because I was trying to field the team and get them to commit the time. There was a lot of work for two to three months of getting all of the players that we thought should be there to meet with you guys, and then only four of us could come [to the kickoff].” [105 6 m 6 SV].“For some, the effort required of participation was realized by team participants soon after the kickoff. Teams which experienced a slower start during active implementation reported that PREVENT implementation was difficult.even when we you know would have an idea, figuring out who we needed to talk to was often a very complicated and lengthy process. … So I feel like we were really slow to ramp up. [105 12m 12 SV].“ … Despite the level of burden reported, over time in active implementation teams reorganized, emerged and participated in implementation activities during the last half of active implementation between 6 and 12 months and accomplished most of their action plans. Thus, after these accomplishments, the team acceptability ratings were more positive at 12 months compared to at 6 months.“So I think that the (PREVENT) experience itself was extremely valuable, and I think that the opportunity was something that there wasn't something else like it in the VA, and so I appreciated …. So I think that from a facility standpoint, we appreciated shining a light on something and giving us like tools and the opportunity to like self-reflect on how to change something that’s very important …” [106 SUS 1 SV]I have really enjoyed them [collaborative calls] … You could learn all kinds of things that might not even pertain to [my service area] but might be helpful to me to provide care...I think that we all learned a lot. [PREVENT] improved patient care, which was obviously most important I would say … without any downside to it.” [101 12 m 3 SV].“The degree to which the intervention has good fit with an individual’s values , particiComing from research, education and my [pharmacy] clinical arena with my training and background from another VA, I was really happy that we were doing this [PREVENT] here because it kind of aligns with what the kind of environment I’m used to which is quite progressive and data-driven and … metrics and development using technology and dashboards … so I was very enthusiastic and I’m still enthusiastic. [103 6 m 6 SV].“This construct refers to the degree in which the participant comprehends the program and how it works . Team meI thought that [the data Hub] was very organized to where if I needed to get something quickly and refer to it, it was very organized to where I could get to that quickly, and it wasn’t something that was cumbersome.” [101 12 m 3 SV].“Pharmacists were members of all six QI teams and reported familiarity with data and ease of use of the PREVENT data Hub across the teams.“I think the biggest thing is you’ve got to get buy in and get people who are going to be honestly motivated to go through it, and not just necessarily just pick one of the names [of staff] out of a hat. But you really need to have a multidisciplinary group [to represent all the services involved in the EBPs] who’s going to put their honest efforts into it.” [102 SUS 1 SV].then to actually get the buy-in of the neurologists, that’s really where the shift came. Once we got the neurologists to buy into it [neurology based EBP], that’s when the shift happened [in quality improvement]. And so getting them [physicians] on board, on agreeing to it [PREVENT], definitely facilitates it [PREVENT]. Otherwise it’s just a push kind of thing. It’s people individually pulling.” [103 12 m 4 SV].“… We observed that most of the site champions and their colleagues understood the targeted evidence-based practices for acute TIA care at pre-implementation. The challenge at times for some was to get buy in by their colleagues to place efforts on improving the quality of care.“I would say there can never be enough education for your providers and your pharmacists. And repeat messaging is really important. What we found is that the ground rounds implementation [by clinical champion] was great, but it kind of fell off people’s radar like 2 months later. So I had our pharmacy resident go back and remind people again and so I think that is really important especially for sites like us who don’t have a whole lot of TIA patients anyway.” [105 12 m 5 SV].Defined as the “extent to which benefits, profits, or values must be given up to engage in the intervention.”  The loca“I told people we had to do that [PREVENT] because we were told to … Have a good group of people who-they understand sometimes we have to do things that we don’t want to always do.” [104 12 m 3 SV].In another team a service chief simply told the clinical front-line to change a specific practice to improve the quality. Perceived effectiveness of the PREVENT program appeared to be associated with acceptability.You could see the impact [on the performance data Hub] … I was surprised that just the fact of admitting [patients] and making sure that we got all of the testing done [made an impact].” [101 12 m 5 SV].“..we changed the process and so it’s not something that I have to monitor every day … we changed the culture … the strength was that it did not depend on one person in general. I think that [our PREVENT program] showed that also simple changes could make a huge difference.” [101 SUS 5 SV].“At times, a team member questioned whether their efforts to improve their quality was associated with their quality performance scores. “It was good to see the trending of our data points but you know just based on the numbers that I saw, you know sometimes I had questions about whether or not the number for that month or that I saw for that month was accurately reflecting what was going on at our site.” [105 12 m 5 SV].But then really I guess in our graduation event, the two things I’m most pleased with because we set out at the beginning [team kickoff] that those were really going to be the most useful things to happen and that was the dashboard, identify the patient, and the checklist. … And I think that the team I had was great in terms of being excited about the process and feeling like it was important for patient care. …. And I think we are providing better care than we were by having done the process. And if for no other reason than just raising awareness a lot. You know, I think our primary care providers are more aware, ED is more aware, even our medicine house staff. Then our resident teams are more cooperative with showing up and seeing the patient as opposed to just giving some advice over the phone which they were often apt to do..” [105 12 m 2 SV].“… Teams reported having a sense of accomplishment after participating in PREVENT and completing their action plans. This team accomplishment appeared to associate with perceived acceptability after completing participation in PREVENT as denoted by a team member who was initially frustrated at 6 months with team delays:“… when the team feels like the numbers look good, they’re not pushing, it’s not a priority to make any additional changes … So you don’t feel pushed to the next level because you’re pretty decent where we are [according to the data reported on the Hub and ranked nationally].” [106 SUS 1 SV].Furthermore, viewing positive performance also came with its own caveat. At times positive performance brought complacency among the team participants as demonstrated at one site. The QI clinical teams deemed the PREVENT quality improvement program as acceptable. Overall, the team members reported high satisfaction with the overall PREVENT program after completing 12 months of active implementation. Acceptability grew over time in active implementation. For some participants, perceptions of acceptability were discussed in the context of their local PREVENT achievements and original team goals accomplished at the end of active implementation. For the majority of the teams (5/6), the clinical champions rated their overall satisfaction higher than their respective supportive team members. However this is to be expected because the clinical champions were often the consumers of the PREVENT resources and tools compared to their multidisciplinary team members.Compared to previous research which has often characterized overall healthcare program acceptability , 27 by iThe teams had access to a full-time external facilitator who provided guidance and answered questions about the PREVENT program throughout active implementation. Most of the clinical champions reported downloading the professional materials from the PREVENT program online HUB library and presented to their local clinical providers and staff with often a positive reception.Another topic that permeated across the multiple levels of satisfaction was the access and use of data to inform the teams’ QI activities. PREVENT was the first QI program to systematically provide facilities with quality data on their acute transient ischemic attack care based on a formative evaluation of the VA national healthcare system , 8. TeamFinally, our data demonstrated a temporality effect on perceived acceptability. That is, the QI team participants’ acceptability grew over the course of engaging in active implementation over 12 months. To our knowledge, this study is the first to report temporality effects associated with program acceptability.Moreover, we observed that our QI team participants would often discuss their acceptability in the context of their team’s accomplishments and goal achievements after 12 months of active implementation. For some participants  with previous QI experience, they often perceived PREVENT as highly acceptable early in active implementation at 6 months. For other participants who were delayed with team related issues, their acceptability improved over time as they achieved their action plans and reported an increase in self-efficacy. Future research may prospectively test these relationships among these concepts.Our data collection occurred prospectively across program implementation; however, we queried participants retrospectively after their experiences with the program elements. We did not ask about anticipated acceptability prior to the intervention at baseline. Moreover, our data represents QI teams from the national VHA. Our results may not generalize to other healthcare systems. Finally, we did not feedback our results to our participants for “member checking” . NonetheProgram acceptability varied by temporality and by champion role on QI team. Clinical team members reflected upon the seven components comprising the multi-construct, Theoretical Framework of Acceptability. A complex quality improvement program that fostered a high degree of flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable by quality improvement clinical teams implementing practice changes in a large, national healthcare organization.Additional File 1.Additional File 2.Additional File 3.Additional File 4.


Popliteal artery entrapment syndrome generally causes calf claudication in young active adult. It is resulting of the anatomical relationship between the popliteal artery and adjacent muscles or fibrous bands in the popliteal fossa. We present the case of a 36-year-old male with left calf claudication limb in whom popliteal artery entrapment syndrome was diagnosed, and successfully treated surgically. Popliteal artery entrapment syndrome (PAES) is one of the most common causes of serious disability among young adults and athletes, yet it is underdiagnosed. PAES refers to popliteal artery compression caused by an abnormal anatomy of the nearby musculotendinous structures or surrounding muscle hypertrophy, which can cause various severe complications. We report a case of a young adult patient in whom surgical treatment of PAES was successful.A 36-year-old male with no specific medical history, who was a runner and weight lifter for 10 years, presented with left leg intermittent claudication that appeared in the last 7 months. The pain limited his walking perimeter to 200 meters and was relieved by short rest. It also occurred while driving a car for more than one hour. Physical examination revealed a pulse rate of 65/min and a blood-pressure of 120/80 mmHg. No cardiac abnormality was detected. All pulses were palpable in the lower right limb and only the femoral pulse was palpable in the left one, with an ankle to brachial index (ABI) of 0.4 compared to a normal ABI in the right limb. The left popliteal pulse could be found by using the pocket vascular Doppler, it disappeared with the dorsiflexion of the foot.Doppler ultrasound showed a monophasic reduced systolic blood flow in the popliteal and posterior tibial arteries, the blood flow velocity was lower in the distal vessels. Computerized tomography (CT) - angiography of the popliteal fossa in 4-mm sections showed a popliteal artery stenosis with a post-stenotic dilatation . A magneth postoperative day.Surgical repair was decided using a posterior approach of the popliteal artery. An abnormal insertion into the medial femoral condyle of the accessory head of the gastrocnemius muscle was found . The popAnderson Stuart was the first to describe the anatomical basis of popliteal entrapment in 1879 . PAES prThe most used classification of PAES is the Rich´s classification into five types based on the embryologic aspect , 10: in et al. [Physical examination may find decreased or absent pulses during forced dorsal foot flexion, or signs of decreased perfusion such as pallor, poikilothermia and limb cyanosis in acute cases . Ultrasoet al.  publisheet al. . Angiogret al. .For patients with anatomical PAES, surgery is indicated even when the patient is asymptomatic to avoid irreversible damage , it consPopliteal artery entrapment syndrome is a underestimated etiology of claudication in young sportive people. RMA is the main tool for making its diagnosis. Prognosis depends on the delay of treatment, as any delay can threaten the functional prognosis. Surgical treatment is the treatment of choice.


Agency-based supervision is essential to skilled practice and staff retention, directly impacting the quality of services. The Supervisory Leaders in Aging (SLA) program was designed to strengthen supervision of the aging services workforce. SLA was implemented in four states and trained 134 social work supervisors. The purpose of this study was to develop a novel, comprehensive, and practice-informed measure of supervisory best-practices in gerontological social services. The primary outcome for the SLA program was the Practice Inventory for Supervision in Aging Services (PISAS), which evaluated the frequency of recent use of best practices as identified by the project team and vetted by instructors and an interdisciplinary advisory board. Reliability and confirmatory factor analyses were conducted to examine its psychometric properties. Findings demonstrated the scale had good internal consistency reliability (ɑ = 0.88). Confirmatory factor analyses indicated a three-factor solution, 1) Gerontological Social Work Skills, 2) Program Development Skills, and 3) Supervision and Leadership Skills, accounting for 72% of the variability in the 27 items. Gerontological Social Work Skills captured best practices regarding mental health in late life, heightening awareness of elder abuse, and working with families. Program Development Skills captured assessment, measuring outcomes, and translating evidence into practice. Supervision and Leadership Skills captured individual supervision, group supervision and leadership in interdisciplinary practice. Results indicated that PISAS is a reliable and valid measure of use of best practices in gerontological social work supervision. Further implications and limitations of this measure in assessing outcomes of gerontological education and training programs are discussed.


The Family Connections™ (FC) program is a 12‐week support and skill‐training program for caregivers of youth with mental health challenges. The intervention was originally developed with a focus on borderline personality disorder (BPD). It is important to understand the experiences of caregivers in such interventions, as well as its applicability beyond BPD, for the purposes of evaluation and ongoing program improvement.To explore and analyse the experiences of caregivers of youth with diverse mental health challenges and who participated in FC.Semi‐structured interviews with thirteen FC‐participating caregivers of youth with mental health challenges.Thematic analysis uncovered three major themes regarding caregivers' experience with FC: (a) FC increased the caregivers' ability to manage their youth's mental health challenges; (b) participating in FC impacted their intra‐ and interpersonal spheres; and (c) improvements to the program were proposed. Following participation in FC, caregivers felt they learned a new approach to understanding themselves, their youth and mental health, and were better able to manage their youth's mental health challenges.FC is a promising intervention for caregivers of youth with mental health challenges, beyond the traditional BPD focus. The intervention has the potential to provide broad‐based benefits for caregivers and should be considered for implementation and scale‐up across youth‐ and caregiver‐serving organizations. Potential areas of intervention flexibility and improvement are discussed.Caregivers were involved in the program development and facilitation of FC. A person with lived experience was involved with the analysis. Notably, peer‐based programs providing education and support for caregivers have demonstrated positive impacts.Family Connections (FC) is a manualized peer‐based education, skills training, and support program originally created for family members of individuals with borderline personality disorder (BPD). This support model is typically implemented in groups within a community setting and focuses on providing information and skills training to improve family functioning, coping skills, and provide social support.Previous studies evaluating the FC program illustrate benefits ranging from reducing grief levels to improving participants' sense of their knowledge and coping skills and improving family function.Although these studies demonstrate the positive impacts of the FC program in relation to BPD, there is a dearth of information on participants' qualitative experiences of the program, including caregivers supporting youth with mental health challenges outside of the BPD sphere; thus, it remains unclear which elements of the program contribute to these positive outcomes, and whether these findings extend beyond BPD Accordingly, the present study aimed to explore caregivers' experience of an FC program designed for caregivers of youth with diverse mental health challenges, providing a qualitative lens on FC impacts for caregivers outside of the domain of BPD.22.1This study was part of the Research and Action for Teens (RAFT) study, a multi‐pronged, multi‐cente program of research that included an effectiveness evaluation of the FC program adapted for caregivers of youth with mental health challenges. The RAFT study was conducted across three cities in Ontario, Canada .As part of the RAFT Family study, the current qualitative sub‐study took place at Toronto and Ottawa sites. The Thunder Bay site was not included in the qualitative study due to logistical issues associated with conducting in‐person interviews in this location. In this study, interviews were conducted with participants who took part in the FC program post‐treatment. All caregivers actively taking part in the RAFT Family study in Toronto and Ottawa between April 2013 and May 2014 were invited to take partin the qualitative study. All of the interviews were carried out by KW, a psychiatry resident at the time.2.2The sample of the current study consisted of 13 caregivers who participated in the RAFT Family study (Toronto and Ottawa locations) and consented to be interviewed. The invited participants were distributed among the two treatment sites . Of the 13 participants, seven were female, and six were male. The participants ranged in age from 40 to 55. See Table 2.3National Education Alliance for Borderline Personality Disorder (NEA‐BPD) Family Connections .The FC program was based on Fruzzetti & Hoffman's2.4Caregivers took part in semi‐structured interviews at the end of the FC program . Semi‐structured interviews were conducted from April 2013 to May 2014. Interviews ranged from 50 to 105 minutes in duration. The semi‐structured interview guide consisted of open‐ended questions related to the caregivers' experience with their youth's mental health challenges, including questions about their caregiving experiences, the impact of the FC training, and their experience attending the FC group. The interviews were audio‐recorded, transcribed verbatim, de‐identified, and entered into qualitative analysis software NVivo 1227 for a2.5The primary a priori defined topic that we examined was the impact of the FC program on caregivers. Data were analyzed using thematic analysis through an interpretive process.The consolidated criteria for reporting qualitative research (COREQ) guidelines were followed to ensure a comprehensive reporting of our study.3Our analysis identified three major themes regarding caregivers' experience with the FC program: (a) the intervention increased caregiver's ability to manage their youth's mental health challenges; (b) participating in the program enhanced caregiver's inter‐ and intra‐personal spheres; (c) caregivers' experience with the program led to proposed improvements to the program. Emerging from the analysis were several subthemes that helped capture the complexity of each key theme as it relates to the FC program.3.1Caregivers experienced a new understanding of their youth's mental health challenges, increased effectiveness in response to their youth's mental health challenges, and a positive shift in their caregiving experience. Through these experiences, caregivers increased their ability to manage their youth's mental health challenges.3.1.1We were almost like, ready to wash our hands and say, “I can't do anything.” And I still can't believe that the thought crossed our minds at one point. (Participant 1)In participating in the FC program, caregivers reported a shift in the conceptualization of their youth's mental health challenges. Prior to the FC program, caregivers endorsed a range of negative emotions related to their youth's mental health challenges, including frustration, depression, guilt and resignation . One respondent, reflecting on their emotions prior to going through the FC program, said:Almost all caregivers reported an expanded understanding of their youth's mental health challenges. For example, one caregiver shared that prior to the FC program, they interpreted their child's behaviour as something she was doing to ‘torture’ their family. Following the program, they saw her behaviour as something ‘not necessarily in her control…she's just wired that way’ (Participant 1). Others noted seeing signs of mental health challenges but not fully making sense of them before the FC program. Through the FC program, these caregivers reported a new understanding of the issues underlying their youth's behaviour, which shifted some of the emotions that had previously been activated.Caregivers reported increased feelings of acceptance during and following the FC program. Some caregivers felt more accepting of their youth's mental health challenges, their roles as caregivers and their youth's future . Other caregivers described feeling hopeful about their youth's future and prognosis, as well as their ability to handle their caregiver role. Despite sharing many positive shifts in emotions, a few caregivers continued to express ongoing frustration in response to their youth's mental health challenges, particularly related to behaviours they found particularly problematic.3.1.2We knew it was wrong. It didn't work. Not everything works with every child, but we didn't know what to do, because we didn't understand enough about – even though we were reading up on it. (Participant 5)Caregivers reported feeling more effective at responding to mental health challenges when caring for their youth as a result of the FC program. Many reported that prior to the FC program, their typical reactions included feeling confused about how to manage new problems or crisis situations arising from their youths' mental health challenges. This led to frustrating and defensive encounters with their youth and with mental health services. For example, some caregivers resorted to strong measures, such as contacting law enforcement as a response to their youth's mental health challenges, which they later regretted because it often served to compound rather than diffuse a specific issue or situation. The caregivers who reported involving law enforcement stated this was predominantly rooted in uncertainty about how to respond to a mental health crisis:It's not ‘Okay, what do I need to do now?’ It's more “Okay, […] she's upset […], she wants to stay out all night. It must be hard that your friends are allowed to stay out ‘till 6 o'clock in the morning and you're having a fun time and you feel like you're going to be left out. Or you feel like […] you're immature because you have to go home.” Like ‘I'm sure that's really difficult for you.’ And those are things that I wouldn't have really thought about at other times, […] prior to the training. (Participant 11)As a result of participating in the FC program, caregivers felt more effective and confident in their ability to manage their responses should mental health challenges arise in the future. For example, caregivers stated that they now know how to prevent situations from escalating and how to apply strategies in the moment to decrease the likelihood of a negative outcome. Participants also discussed feeling less dysregulated and calmer in crisis situations after participating in the FC program. Reflecting on their shift in reactions, one caregiver shared:Caregivers in the FC program felt the intervention provided them with skills that had been available to them in their previous encounters with the healthcare system. An important area of skill development was being able to better react and respond to challenging, often new and unsettling situations with their youth. Although some found practising the skills challenging, caregivers felt they had a clearer understanding of the challenges their youth were experiencing, which helped increase their effectiveness in providing support to their youth.3.1.3Participants also reported a positive shift in their caregiving experience. Many caregivers reflected on prior negative experiences with their youth, which included attempts to enforce strict or controlling disciplinary strategies and frequent arguments. Less often, caregivers reported avoidance behaviour, such as avoiding their youth during conflict. Caregivers also reported intimidation and problematic contingencies, such as unhealthy negotiation, that is, bribing their youth to behave better.It's just validation defusing when he's really, really angry, […] taking a little bit of time and recognizing or validating why he wanted the car and why it was important for him, and then sort of talking about my concerns. The big ‘ah ha’ in there was, that was the first time that I could actually get him to sit down and listen to what my issues were, because he would usually go into a rage and then we couldn't have a conversation. (Participant 12)As a result of the FC program, participants expressed that they had learned to better communicate with youth, which included both listening more closely and effectively communicating their feelings to their youth. As caregivers worked through the FC program, many identified specific skills , which enhanced communication with their youth. Some even expressed applying these skills in other areas of their lives . One caregiver shared how learning to validate feelings shifted his approach to caregiving:Most of the caregivers discussed applying the skills learned from the FC program to their daily caregiving routine. Several caregivers described themselves as more lenient and patient in their caregiving style. They also endorsed a decrease in their withdrawal behaviours, while simultaneously giving their youth more space.3.2During and after their participation in the FC program, caregivers experienced a better relationship with their youth, a sense of belonging through their relationships with other FC participants, and an increase in self‐awareness and personal control. Overall, engaging in the FC program enhanced caregivers' inter‐ and intra‐personal spheres.3.2.1Caregivers experienced a shift in their interpersonal sphere, with almost all participants reporting a better relationship with their youth following the FC program. Many discussed having a strained relationship with their youth prior to the FC program, including high levels of conflict and a sense of ‘distance’ in the relationship. Reflecting on their experiences after the FC program, caregivers reported feeling more willing to provide frequent support to youth. Some noted that this shift was accompanied by an acknowledgement from their youth that they felt more supported and understood by their caregivers.It's totally different. She hugs me good‐bye. She'll give me a hug, like ‘Thanks for the movie’. […] That's definitely partly a product of me digging in and applying some of these concepts. Yeah, that wouldn't have happened half a year ago — for sure not. (Participant 6)Participants credited their enhanced ability to communicate with their youth as positively influencing their relationship. For example, they observed a reciprocal shift in their youth's behaviour, with their youth opening up and communicating more. Many of the caregivers described feeling a more loving relationship with their youth after the FC program. Some even reported greater instances of physical demonstrations of affection:3.2.2The first class was great, because all of a sudden, we weren't alone […]. (Participant 8)Most caregivers expressed they felt less alone as a result of their participation in the FC program. Some appreciated hearing their experiences reflected by other group members' experiences during the group discussions. Caregivers repeatedly described the positive impact of sharing similar emotions and experiences with participants struggling with similar issues to them. Many reflected that prior to their participation in the FC program, they had not felt their experiences were relatable, contributing to their sense of isolation and aloneness. Some caregivers reported the connection they felt to their group members extended beyond the group itself, with some participants continuing to get together after the program ended. A few caregivers shared that this sense of belonging had begun with their first FC session:We looked forward every single Saturday to getting there, to learning more. Every time we would go, we left feeling like the weight of the world was lifted from your shoulders, because there's other parents going through what you're going through and we felt empowered because we were learning. […] The parents understand, and you feel like you're helping your child. And it's made a huge difference in our home. (Participant 5)In addition to feeling a sense of belonging, caregivers reported feeling empowered by their shared experiences in the group. One caregiver described:3.2.3I just go for that walk. […] I'll sit on a bench and watch people. So, that's the way I kind of reflect and sort out things and just be by myself. […] I find that's really, really been therapeutic for me. (Participant 3)Many caregivers felt they were coping with their distress better as a result of participating in the FC program. For example, participants described using self‐care strategies they learned from the FC program and that they continued to develop after the program was complete, including exercise, mindfulness, going for walks and taking time to self‐reflect. One caregiver described their self‐care strategies post‐FC:Caregivers further reported a significant shift in prioritizing their self‐care following the FC program, including spending more time socializing with friends. One caregiver reported that their improved self‐care was associated with sleeping better and feeling calmer. Other caregivers disclosed feeling less guilty both about past experiences with their youth and about setting time aside for themselves in the present.I feel empowered. I feel more in control—not of the situation, but of the way that I can feel about it. […] I was completely at a loss and […] now I feel like I can do this. (Participant 11)Many of the caregivers reported that the tools they learned in the FC program helped them to feel more in control, with increased insight into their former caregiving behaviours. One caregiver shared:That is the most enlightening and best part of the sessions. Listening to the stories and the situations that they were in. […] It was the stories from the parents that were the most enriching — and what worked and what didn't work. And my telling my story, because I find the more I go through things in my mind and then verbalizing things, the more validation I get from it and the more that I learn about myself and about the situation. (Participant 3)Some caregivers expressed increased self‐understanding through the process of attending the FC program:Caregivers developed a greater understanding of their own mental health challenges and general state of mind. Overall, caregivers described the program as introducing them to a new spectrum of knowledge and a way to understand themselves and others.3.3Caregivers' experience with the FC program shaped their recommendations around improvements to materials and facilitation, program structure and program components.3.3.1Caregivers expressed appreciation around the psychoeducational materials and style of the facilitators. However, participants also suggested improvements to the group materials. For example, one caregiver expressed wanting to see more examples in the information sheets and handouts paired with the 12‐week curriculum. Another participant suggested having the materials emailed to them prior to the sessions so they could review them in advance.I think these people were experts. Plus, they have… they've seen a lot. […] Almost everything that we've seen, they've seen. And they can relate. But they kept things moving. And they don't let you dwell too much on that kind of stuff, right? When they went through all the different, uh, I don't think you could have done much different or much better. (Participant 9)Caregivers discussed a positive experience with the program facilitation. Many caregivers in the Toronto group highlighted the value of the team‐led approach. Other caregivers in the Toronto group expressed the benefit of gaining skills from the professional facilitator, with some hesitation about the possibility of a peer‐led facilitation model, which they did not experience. Conversely, in the Ottawa group, which was peer‐led, caregivers expressed appreciation around the peer‐led approach:3.3.2I think in the ideal world, you would probably have about 16 of these sessions and then just follow ups, so maybe meetings once a week, or sorry, once a month or something, because you have to keep practicing it. Because the parents who are in these groups, they're under a lot of stress. Yes, we're there for 2 hours, but our learning capacity is not what it is when we have healthy children. (Participant 13)A common suggestion about improving the program was to prolong the length of the sessions and program itself. Some caregivers suggested ideally extending the program past 12 weeks. One respondent shared:A few caregivers proposed additional content, such as additional stand‐alone sessions on mindfulness and self‐care. One participant suggested that time might be reserved at the end of each session to do the assigned homework rather than requiring participants to take it home; they also suggested that even having time after class to simply reflect would be useful. One caregiver shared how they would have enjoyed an FC blog or conference to further discuss the material.A few caregivers found aspects of the sessions to be overwhelming. For instance, some participants found that listening to other parents' experiences was overwhelming or distressing and brought up emotions they experienced as difficult or painful. They felt that extra supports could be offered to offset this potentially overwhelming experience.I would highly recommend it, just — even if you aren’t able to learn the skills, just be in the room with other people who understand your experience. (Participant 2)Overall, the majority of caregivers enjoyed the program and would recommend it to others. For instance, one participant shared:Another suggested that the FC program be made more widely available and accessible.4This qualitative study sheds light on the experience of caregivers of youth with mental health challenges who participated in a 12‐week DBT‐based skills training and support intervention for family members. In extending prior knowledge on support services for caregivers, this study shows the positive impacts of the FC program for caregivers of youth experiencing a range of mental health challenges. The analysis uncovered three major themes regarding caregivers' experience with the FC program: (a) FC increased the caregivers' ability to manage their youth's mental health challenges, (b) participating in FC impacted their intra‐ and interpersonal spheres, and (c) improvements to the program were proposed. Participants experienced improved reactions to their youth's mental health challenges, while re‐conceptualizing mental health challenges in general and the mental health challenges of their youth in particular. They also experienced a positive shift in caregiving as a result of the FC program. Participants further shaped recommendations for program improvement.Family members of youth with mental health challenges have been previously found to experience distress, guilt, helplessness, blame and shame.The FC program includes substantial psychoeducational and skill‐building components. Psychoeducation for families of persons with mental health challenges has been shown to have a range of perceived benefits, such as improved outcomes of care and enhanced communication.Current family support services for caregivers of youth with mental health challenges include peer‐led, clinician‐led and team‐led program.These findings have important implications for future research and practice. FC is a manualized, implementation‐ready intervention to support caregivers of youth with mental health challenges. This study demonstrates the substantial benefits of the FC program for caregivers of youth with mental health challenges, suggesting that extensive scale‐up could provide broad‐based benefits for many caregivers of youth across the mental health spectrum, beyond the previous research focus of BPD. FC should therefore be considered for implementation and scale‐up. Those implementing and evaluating FC might consider some potential improvements highlighted by the participants, such as prolonging the length of the sessions and the program itself. The concept of belonging is a theme in our analysis and other research on group mental health interventions and peer supportEssential areas of flexibility for FC include the peer‐led vs. team‐led approaches, as well as the implementation in both community‐based and tertiary care centres, which can be chosen based on local context to support implementation. Caregiver feedback should be proactively incorporated into future iterations of the FC program. Future research should consider the barriers and facilitators to effective implementation in diverse contexts and with diverse participant groups, and also consider a more in‐depth exploration of the peer‐led vs team lead approaches. More in‐depth knowledge on the significance of programs like FC through longitudinal research design is needed to capture the changing dynamics of care, family structures and mental health challenges among youth.4.1One of the strengths of this study is that it highlights the experiences of caregivers and their perspectives on both the value and limitations of the FC program through a qualitative approach. Involving family member consultants during the program design and an individual with lived experience during the analysis was also a strength. Moreover, as previous FC studies focus primarily on BPD, this study extends beyond that diagnostic framework to demonstrate benefits among caregivers of youth with mental health challenges in general. Lastly, a unique feature of this study is the integration of both peer‐ and team‐led approaches in community‐based and tertiary care settings. The study's positive findings across these models provide insights regarding flexible components to support future implementation efforts.This study had several limitations. The participant sample was a small and self‐selecting group, with limited demographical differences . Therefore, the sample may not reflect all caregivers participating in the FC programs and limits the generalizability of these findings. Moreover, our participants were chosen from the Toronto and Ottawa locations—both large urban cities. As the FC program runs across Canada, including more remote settings, our participants may not accurately reflect caregivers' experiences in less populated and rural areas. Lastly, the peer‐led site had the smallest number of participants; this may limit the extent to which comparisons can be made between delivery models.5Our findings demonstrate the positive impact of the FC program for caregivers of youth with mental health challenges beyond the previous focus on BPD. Changes in caregiving styles, intra‐ and inter‐personal awareness, and extended models of peer‐ and team‐led approaches all play important roles. These implications highlight the FC program as a promising program that may substantially improve caregivers' lives and should therefore be considered for implementation by organizations serving youth with mental health challenges and their caregivers. Future research on family‐based studies should examine barriers and facilitators to flexible implementation and scale‐up to bring lasting effects for caregivers.The authors declare no conflicts of interest.Natasha Y. Sheikhan (joint first author) contributed to the analysis, interpretation of data, drafting the manuscript, and revising it. Karen Wang (joint first author) contributed to the conception, design, acquisition of data and revising the manuscript. Tali Boritz contributed to the conception, design, acquisition of data, analysis, interpretation of data, revising manuscript and final approval of version to be published. Lisa D. Hawke contributed to the analysis, interpretation of data, revising the manuscript and final approval of the version to be published. Shelley McMain contributed to the conception, design, acquisition of data and revising manuscript. Joanna Henderson (senior author) contributed to the conception, design, revising of the manuscript and the final approval of version to be published.


Interdisciplinary Collaboration, Mentoring, and Protected Time for Independent Research. Scholars also identified some contrary themes that included: Limited Access to Expenditures, Changes in Individual Mentorship Needs and Areas for Improvement. On a Likert scale , scholars reported high positive influence of the KL2 program on their scope of research (8.7±0.52) and future career (8.5±0.70). They also found mentorship experience with primary mentor (9.6±0.22) and team (8.5±0.54) as well as peer collaboration (8.5±0.67) opportunities highly beneficial to their career and professional development. DISCUSSION/SIGNIFICANCE OF IMPACT: The qualitative study strengthens the reliability of data and scholar recommendations collected via other evaluation measures. Findings broaden understanding of the processes through which program outcomes are achieved effectively and where modifications are needed. An updated program for cohort 3 was guided by cohort 1 and 2 interview responses.OBJECTIVES/GOALS: The Penn State KL2 Career Development Program provides a comprehensive structured training and mentorship to junior faculty scientists (KL2 scholars). The goal of this study is to describe the perceptions of scholars after completion of the training and determine self-perceived impact of the program using exit interviews as a unique method. METHODS/STUDY POPULATION: Ten KL2 scholars (5 from each cohort of 2014 and 2017) participated in the evaluation. We used a descriptive qualitative design supplemented with quantitative data, to conduct an individual in-depth exit interview with each scholar to understand their perceptions on the impact of the KL2 program. Data were collected using a semi-structured interview guide developed by the program directors including scholars and a Likert scale survey. Thematic analysis of the data involved: reading and re-reading transcripts, identifying and categorizing keywords and phrases and developing overall themes that explained the processes within categories. In establishing rigor, two authors carefully coded, categorized and identified patterns and emerged themes which were also reviewed and confirmed by the other authors. RESULTS/ANTICIPATED RESULTS: Two sets of themes emerged. The main themes that described positive aspects of the KL2 program by scholars included:


Hepatitis B infection is a major health concern in Myanmar. Hepatitis B birth dose vaccination to prevent mother-to-child transmission is not universal, especially in births outside of health care facilities. Little is documented about delivery of immunization programs in rural Myanmar or in conflict-affected regions. To address this gap, this study describes the implementation of a novel community delivered neonatal hepatitis B immunization program in rural Karenni State, Myanmar.A mixed-methods study assessed the effectiveness and feasibility of hepatitis B birth dose immunization program. 1000 pregnant women were screened for hepatitis B virus (HBV) infection using point of care testing. Neonates of HBV positive mothers were immunized with a three dose HBV vaccine schedule at birth, 1, and 6 months of age. HBV testing was completed for children at 9 months to assess for infection. Descriptive statistics were collected including demographic data of mothers, neonatal vaccination schedule completion, and child HBV positivity at 9 months. Qualitative data examining barriers to implementation were collected through semi-structured interviews, participant-observation, and analysis of program documents. Themes were codified and mapped onto the Consolidated Framework for Implementation Research.46 pregnant women tested HBV positive leading to 40 live births. 39 women-child dyads were followed until the 9-month age mark. With the exception of two neonates who received their birth dose past 24 hours, all children received their vaccines on time. None of the 39 children tested positive for HBV at nine months. Themes regarding barriers included adaptability of the program to the rural setting, friction with other stakeholders and not meeting all needs of the community. Identified strengths included good communication and leadership within the implementing ethnic health organization.A community delivered neonatal HBV vaccination program by ethnic health organizations is feasible and effective in rural Myanmar. The hepatitis B virus (HBV) is a blood-borne pathogen that infects the liver and is a cause of global morbidity and mortality with an estimated 257 million people living with chronic HBV infection in 2015 . There iThe prevention of mother to child transmission (PMTCT) of HBV is important as the likelihood of developing chronic hepatitis B is estimated to be as high as 90% among those infected at birth, and between 15 and 40% of those with chronic infections will progress to develop cirrhosis or hepatocellular carcinoma , 7. RateThe combination of hepatitis B immunoglobulin (HBIG), birth dose vaccine, and three dose vaccine series is estimated to reduce the vertical transmission rate to 3% . Within Little is documented about the factors that may influence HBV birth dose immunization program implementation in a rural, resource limited, and culturally variable Myanmar setting. Several studies illustrate HBV immunization programs in rural locales within surrounding Asian countries, but no studies have been conducted in Myanmar. A study on HBV immunization in rural South India described implementation and immunization rates , while aMyanmar presents a unique opportunity to proactively integrate context and implementation science into program design to create culturally aware and specific sustainable interventions that may grow with the health system over time and engage all stakeholders. Using the Myanmar context and existing definitions for evaluating program implementation, this study describes a targeted HBV vaccination program for PMTCT in a rural region and assesses the feasibility of such a program in a resource limited setting.A mixed methods analysis was completed. Based on the framework of Palinkas et al. (2011), a mixed method design in an implementation study  allows fIn 2016, a pragmatic field test case study in Karenni and Shan states, Myanmar implemented a targeted HBV vaccination program for PMTCT in rural areas. The HBV vaccination program was a collaboration between three partners: the Civil Health and Development Network (CHDN) of Karenni State, Myanmar, B.K.Kee Foundation, an American non-governmental organization operating out of Yangon, Myanmar, and Queen’s University in Kingston, Canada. CHDN is a network bringing together six ethnic health organizations to provide access to quality health care services for the communities in Karenni State. Its mission is to deliver healthcare services for populations where government services are limited or nonexistent. The vaccination program was funded by B.K.Kee Foundation, and technical and financial support for the monitoring and evaluation components was provided by Queen’s University.From January 2016 to February 2017, one thousand pregnant women were recruited sequentially and screened for HBV with the ABON Hepatitis B Surface Antigen Rapid Test Device. The relative sensitivity and specificity of these devices are 99.8% and 99.2% respectively . These vVaccines were stored in and delivered from the CHDN main office due to a lack of reliable electricity and/or refrigerators in rural clinics and the presence of a backup generator in the main office. Vaccine refrigerators were monitored with twice daily temperature checks for optimal temperatures between 2 to 8°C. CHWs at the clinics contacted the main office when vaccine was required and these vaccines were then delivered to each clinic. The cold chain was maintained during transport through cold boxes adapted following WHO recommendations .Training of clinic staff was completed in a two-day pre-implementation workshop, and monitoring of study progress and data collection was undertaken through field visits to each clinic one month prior to the start of recruitment and nine months into the program. Training included information about the theory behind the program , standardized program rollout, and effective maintenance of data logbooks. The follow-up nine-month field visit assessed the implementation of the program through the collection of quantitative and qualitative data. All clinics were supported by the CHDN central office which also provided the day-to-day and field supervision during implementation.Quantitative data were collected using clinic logbooks and qualitative data were obtained through in depth interviews, analysis of textual data in the clinic logbooks and through field notes from participant observation.Demographic information and HBV screening results for mothers and children were collected by CHDN staff and recorded in a Microsoft Access Database. Data were analyzed with SAS Enterprise version 7.1. Descriptive statistics were completed for all screened pregnant women and their newborns.Qualitative data was collected through semi-structured interviews, examination of monitoring and evaluation documents, and the recording of field notes from participant-observation. The multi-modal approach allowed for methodological triangulation to increase the rigor of results. A theoretical approach of critical realism was used for the qualitative analysis. Critical realism describes how observed phenomena can approximate explanatory mechanisms through a lens of shared meaning making .Nine semi-structured interviews with CHDN and B.K.Kee staff were conducted nine months after implementation. Purposeful sampling was conducted selecting individuals involved in the intervention and study administration and implementation. Participants included CHDN front-line CHWs, CHDN central office staff including managers and supervisors, and B.K.Kee program management. An interview guide was used focusing on process, barriers and facilitators of implementation. A translator was used to conduct eight out of the nine interviews in Kayah and the ninth was conducted in English. Interviews were recorded and transcribed with direct translations to English where needed. Transcriptions were coded in NVivo version 11 using thematic analysis along the methodology outlined by Braune and Clarke .Focused participant-observation was also completed during the two field visits–the first just prior to implementation (during and immediately after training), and the second, nine months after initial implementation of the study. Two researchers took notes during the first field visit and developed consensus upon thematic areas, and one of the original researchers continued observations of clinics in the second field visit.a priori that observations and interviews would focus on mapping barriers and challenges in program implementation within the resource limited, conflict-affected setting rather than focusing on all aspects of the broader implementation experience. A focus on barriers and challenges allowed for resources to be dedicated towards understanding areas of program improvement. CFIR is a framework developed through consolidation of existing implementation theories which allows researchers to assess interventions across five major domains   can’t do it. We provided all 6 refrigerators. Yes, we provide already, but they can’t locate it [to the clinics]. And, they only use the transportation [of the vaccine] from the central office till [now] so far. And till now, so it is a it is not very much matched with the planned activities. “B.K.Kee Manager–Because of the lack of electricity and refrigeration, clinic CHWs had to arrange for vaccines to be delivered from the CHDN central office in the provincial capital on a case by case basis. Field visits confirmed the logistical challenges. Roads to even the closest clinic took two hours each way by truck with much of the road unpaved. All field visits were completed during the dry season, which meant that roads were still passable. But given that a majority of the roads were unpaved, it is very likely that many areas would be difficult to access during the rainy season. Continuous electricity was not available, although small solar panels were present and generators were occasionally used. As a result, none of the clinics were fully electrified meaning that it was not possible to maintain vaccine refrigeration on-site.Another theme in the CFIR outer setting domain (cosmopolitanism) was related to some noted tensions in relationships between CHDN, CHWs and other health care stakeholders. Given that Karenni State is a conflict-affected zone, local ethnic health organizations such as CHDN sometimes have tense relationships with the central Burmese government healthcare officials. Initially, limited communication between CHDN and B.K.Kee Foundation staff with the central government regarding the HBV vaccination program led to tense interactions between CHDN CHWs and governmental physicians and midwives. This created a problem in delivering HBV vaccines to governmental hospitals if women enrolled in the program delivered in those facilities instead of CHDN clinics. There was a purported lack of trust from Burmese officials in the ability of ethnic health organizations to provide the correct standard of care due to the limited communication about HBV vaccination protocols between ethnic health organizations and Burmese officials. Further dialogue with the governmental health workers after this barrier was uncovered helped smooth out these relationships.“This is one of the challenges involved because they haven’t done any advocacy [with] the government about this [Hepatitis B] vaccination program so they have to deal with the government also about giving awareness…”CHDN Manager–Observations during field visits also identified complex relationships between the different stakeholders as an important theme. Government clinics were present, but the buildings did not appear to be reliably staffed or in use. Despite supposed country-wide coverage delivered by the government, most of the infrastructure and governance in these remote regions were provided by CHDN and its affiliate organizations.An unintended consequence of this program, also relevant to the CFIR outer setting (needs and resources) domain, was the tensions caused by significant community awareness raising around HBV infection, but limited HBV screening and vaccination for the wider community. The funded HBV vaccination program was available only for newborns of HBV positive women. However, part of the objectives of the program was community education as evidenced by over 1900 people attending information sessions about HBV. Because of the increased awareness of HBV as a health issue, CHWs expressed concern about the lack of treatment options available for HBV positive mothers and the lack of screening and immunization for other community members.“Because the hepatitis program is targeted mainly [to] the pregnant woman, other age groups, [spouses] and other people they also want to be tested and want to be vaccinated, and they ask [us] whether they can get it or not…but we have to say no.”Clinic CHW–Awareness raising was successful in that community members were independently seeking information about screening for HBV. However, this may have also increased anxiety for community members, since there were no screening, treatment or vaccinations programs for those who could not afford to pay out-of-pocket for these services.Concerns about quality of monitoring and evaluation data were also identified as a CFIR process domain theme during the interviews. In addition to program implementation, another deliverable of this project was capacity building around appropriate program monitoring and evaluation. There were initial concerns with data accuracy, translation, and completion. The tools provided were used regularly, but with inconsistencies in the data when reassessed by CHDN managers.“So regarding the monitoring the 10 clinics what he is seeing is that there are some data inconsistencies between the self reporting so he is trying as much as he can he also calls them by phone and sees if the data is correct or not.”CHDN Manager–Field visits to the clinics nine months post-implementation confirmed variable record-keeping quality. Records were filled, but not all elements relevant to this project were necessarily completed. Yet extensive data was captured in medical visit logs regarding demographics, chief complaints, and routine treatments, providing evidence for ability and proficiency in maintaining records when deemed important.Suboptimal data quality likely resulted from a need for more training, reflecting a CFIR inner setting domain (readiness for implementation). The clinic CHWs stated that they would have appreciated more monitoring and evaluation training and refreshers throughout the program. They also wished that more clinic CHWs had attended the initial training instead of having only one lead CHW per clinic attend and then train other CHWs in the respective clinics.“There were no pamphlets for this program. She insists on giving refresher trainings if should they expand the program–refresher trainings/new trainings. Also invite all of these participants that is in charge of this and by all of them, not the focal person only. “Clinic CHW–This was supported by the initial field visits to several clinics whereby B.K.Kee staff had to review training again with CHDN clinic staff. The reasons and importance of good and complete data quality may not have been conveyed adequately during the training sessions.Although data collection was focused on barriers and challenges in implementation, several strengths were apparent in both observations and through the interviews. Themes were mostly grouped in the inner setting domains concerning networks and communication and readiness for implementation. Many interviewees commented on the support by the CHDN central office in implementation of the program. Despite the logistical challenges, communication within the organization was not a barrier as vaccines were able to be shipped to the remote clinics in a timely manner.“There is not much difficulty with this program. Because they are engaged with the central [CHDN] office in Loikaw. Should they need anything they can ask [the CHDN manager] for transportation, transportation of the vaccines and tests.”Clinic CHW–Interviewees identified the strong leadership of CHDN central office staff in providing support for the program in areas of re-training and troubleshooting any issues that arose. This was also apparent during observations during field visits whereby CHDN managers assisted in the data collection process and appeared to be responsive to clinic CHW needs.Our results indicate the feasibility of a vaccination program for remote, ethnic minority communities in a resource limited setting in Myanmar. The program was successful in preventing HBV vertical transmission in HBV positive mothers with no vaccinated infants testing positive for HBsAg. This is consistent with modelling that suggests that controlled temperature chain outreach strategy for delivery of HBV birth dose vaccine can reduce the burden of HBV associated with perinatal infection . This isIt is interesting that the HBV prevalence in the current study was lower compared to other studies. On the Thai-Burmese border, 8.5% of women were HBsAg positive whereas in this study only 4.6% were positive . FurtherIt is noteworthy that no vaccinated infants tested positive for HBV. Without vaccination, we expect 4–36 newborns to be positive for HBsAg, given a vertical transmission rate of 10–90% depending on relative HBsAg and HBeAg positivity in the mothers  thereforThis study’s qualitative results around implementation are a unique strength. To our knowledge, no current published studies describe the implementation factors and considerations in such a resource limited rural setting or in the context of Myanmar. A similar study describes barriers to immunization among Burmese migrant workers living in Thailand, but it does not discuss the in-country Myanmar context nor does it use an implementation framework . This stCFIR has been used in the past to analyze implementation of immunization programs both in developed and developing countries , 30. SimIdentified barriers emphasized the importance of process and understanding the outer setting. There were various barriers associated with the planning and execution phases of the process such as issues with adapting training materials to local needs and the monitoring and evaluation requirements of the program. These barriers could be easily mitigated through longer term development of the tools as well as early involvement of stakeholders and end users to ensure that the tools are appropriate and useful. The overall program was designed and implemented quickly over a few months and would have benefitted from a longer planning phase and training period to overcome these process barriers. Unforeseen issues such as consent not being part of normal health care could then have been identified and addressed in advance. In future partnerships, a longer planning phase and earlier engagement with the local stakeholders is recommended.The outer setting barriers echo the complex environment of Karenni state and the importance of adapting programs to the local context. The friction between governmental and non-governmental stakeholders was not fully anticipated by project leads. Additionally, further pre-planning would have been useful to assess the needs of the community and to address unintended consequences such as increasing stress in the community about HBV without the ability to offer broader testing and treatment. A needs assessment would have been beneficial to both mitigate the unintended consequences and to set priorities in such a resource limited setting , 33.The program in Karenni State provides a model for collaborative efforts in vaccination program implementation in a resource limited setting. The incorporation of the local ethnic health organization, CHDN, likely explains the success of this program. Mapping data onto the CFIR, it became apparent that the inner setting domains were sources of strength that moderated implementation barriers. There were positive structural characteristics with a combination of stability and resources in the partnership between CHDN and B.K.Kee. CHDN also had effective internal processes that fostered positive communications and readiness for implementation. It appeared that most of the barriers identified were able to be overcome due to the commitment and capacity of CHDN. Despite the complex environment, CHDN was also able to adapt to the changing circumstances and to support their staff throughout implementation. Issues such as the lack of electricity to power vaccine refrigerators and complicated relationship issues between CHDN and the government were overcome. Having local stakeholder involvement allowed for a community based participatory approach to implementation, which is associated with more effective and sustainable interventions .The successful implementation of this program is also a hopeful step in this conflict-affected setting. CHDN was able to navigate the relationship between Burmese government officials and overcome this barrier to improve overall health in the region. At the time of this study, it was hoped that the ability to work parallel to the Myanmar government might provide a roadmap of peace through health in the region. Obviously, the landscape has changed dramatically since the military coup of February 2021. Nevertheless, it may be that further, potentially collaborative, efforts centred around health and led more by Burman and ethnic health workers rather than governmental agents or policy could enhance the relationship leading to beneficial effects to the local population. Reaching an understanding about superordinate health goals can be a mechanism that is further developed to achieve lasting peace .Strengths of this study include the multiple modalities of capturing the implementation experience and contextual factors. The mixed methodology incorporating multiple data collection and analytical approaches allowed for increased credibility of the results and increased depth of analysis into barriers. This approach enabled analysis on both the process and the outcome, which are key to implementation success.Limitations of this study include the lack of a control group to reliably assess vaccine effectiveness. The before-after nature of the study only allowed estimation of vaccine effectiveness based on assumptions of baseline HBV positivity. Furthermore, exact maternal HBV status with viral loads and HBeAg testing was unable to be completed due to the resource limited setting therefore clouding understanding of possible reasons of why this regimen was effective. Additionally, monitoring was only done at discrete time points by the study team without continuous embedment during the study period. With already existing issues in data management, data collection inaccuracies could have affected the results. Language and cultural barriers were a significant issue in interpretation of the findings. However, the incorporation of multiple perspectives mitigated potential problems through triangulation of the themes.9. This vaccination campaign was successful in preventing HBV vertical transmission, with no infants testing positive for HBsAg. Further longitudinal research is needed to assess the sustainability of this intervention and its potential expansion to other immunizing agents.Taken together, the results show that a complicated vaccination program is feasible and effective in a resource limited rural region in Myanmar without government health system involvement. Despite the complexities of the setting, which have only increased recently barriers were able to be overcome. Ethnic health organizations have demonstrated their innovation and creativity for decades in the context of waxing and waning conflict with the central government