Heart failure (HF) patients have difficulties in self-management after discharge. This study aimed to develop a discharge education program for HF patients using the teach-back method (TBM). As a methodological study to develop a program, we applied the analysis, design, development, implementation, and evaluation (ADDIE) model comprised of (1) analysis using EMR data, systematic review, and focus group interviews, (2) design and development of a program draft, (3) tests of program validity using 15 experts, 10 nurses, and 10 patients, and (4) development of the final program. The content validity index (CVI), and understandability and actionability of the educational material were used.The discharge education program provides definitions and information about medication, symptom/weight/diet management, physical activity, and other precautions. The educational method uses TBM. The overall CVI for the program was 0.96, and all item CVIs were greater than 0.8. The understandability and actionability were 90.2 and 91.3 % in patients, and 94.6 and 86.8 % in nurses. The contents and methods of the program were appropriate for patients and providers.We expect the discharge education program using TBM to enhance self-management among HF patients. The process we used to develop this program could guide researchers and clinical practice. Heart failure (HF) is a complex clinical syndrome resulting from structural and functional heart problems, such as impairment of ejection fraction in ventricles and a low level of tissue or organ perfusion . The gloIt is generally known that HF is a common disease in elderly patients , and thaEducational interventions using the teach-back method (TBM) for chronically ill patients who have difficulties in self-management have improved knowledge, adherence, self-efficacy, self-care skills , and reaTo our knowledge, no previous study used TBM in Korea. Several studies to improve self-management among HF patients were recently conducted in Korea, but they focused only on a health diary  and teleWe used a methodological study design to develop a discharge education program with TBM for HF patients and their caregivers.We developed our program by applying the analysis, design, development, implementation, and evaluation (ADDIE) model . The curThe analysis phase includes clarifying problems, determining goals, and confirming the intended population . In thisWe used EMR data to retrospectively analyze the 30-day readmission rate for 295 HF patients discharged from a tertiary hospital in Korea. The unplanned readmission rate of HF patients in that hospital was 19 % .A systematic review and meta-analysis were conducted to identify the effectiveness of discharge education using TBM. We found that discharge education with TBM reduced the 30-day readmission rate by 45 %. The detailed methods for the systematic review and meta-analysis are described in our previous work .Focus group interviews were conducted to explore the unmet needs for discharge education among cardiovascular disease patients and their nurses. Eighteen patients and five nurses participated in the interviews. Cardiovascular disease patients reported unmet needs of discharge education in terms of medication effects/side effects, detailed information on exercise/nutrition, and applying the right information at the right time. On the other side, nurses experienced unmet needs in the absence of a patient-oriented standard manual, insufficient time, and unified learning methods (pamphlet). Our program was developed based on these results.The design phase focuses on objectives, assessment instruments, and planning using a systematic and specific approach . The proWe designed the structure of the program by defining the target population, providers, and when and where to deliver the program. The target population is adult patients diagnosed with HF and scheduled to be discharged to their homes. The providers are nurses who provide discharge education to patients and their caregivers in a cardiology ward. The timepoint is the scheduled date of discharge or the afternoon before discharge. The place is a private patient room or consultation room.The process for the HEART program is based on the hospital’s discharge protocol, as shown in Fig. We reviewed assessment instruments to test the effects of the HEART program. Table The development phase is to generate and validate the program . We devevalid) divided by the total number of experts. The overall CVI was calculated as the proportion of items judged to be valid [We evaluated the content validity of the program using the content validity index (CVI) . The itebe valid . The expWe also evaluated the appropriateness of the education material using the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P), which contains items to evaluate understandability and actionability for users . The 17 This study was approved by our institutional review board (No. 4-2018-0788). All methods were carried out in accordance with relevant guidelines and regulations. We also received the agreement of cardiologists and the cardiology unit to conduct the study. All the participants were given information about the purpose, procedures, and possible benefits and risks of the study. Then, they were given time to consider their participation and took part in the study voluntarily.The HEART program contains seven topics for HF patients after discharge: definition of HF, medication, symptom management, weight management, dietary management, physical activity, and other precautions. The specific contents are summarized in Table The knowledge gap between a nurse and a patient or caregiver is assessed using pre-structured teach-back questions. We developed 15 questions that correspond to knowledge, attitude, and skills for each of the five major educational topics: medication, symptom management, weight management, dietary management, and physical activity Table .Table 3The overall CVI score for the contents of the HEART program was 0.96. The range of the item CVIs was 0.80 to 1.00. The validity of the educational content was confirmed because the CVI for all content items and for overall content were greater than 0.8.The understandability of the educational material among patients was 90.2 %, and the actionability was 91.3 %. The understandability and actionability of the educational material among nurses were 94.6 and 86.8 %, respectively. All but one of the scores evaluating the quality of the program exceeded 70 %, the cutoff point. The patients’ response to the actionability item “Provided instruction on how to perform calculations” was 66.7 % (Fig. Our main goal was to develop a discharge education program using TBM for HF patients. Our evaluation of the HEART program found that the content was valid, and the educational material was appropriate for both providers and patients.The TBM was designed to deliver a discharge education program. Growing evidence indicates that discharge education using TBM for HF patients effectively improves health outcomes compared with other educational methods –24. HowiWe used the ADDIE model to develop our discharge education program. ADDIE is a well-known instructional-systems design model that education technologists and instructional designers use for curriculum development . The strThe content validity and user validity of the HEART program were deemed suitable by patients and providers. In particular, patients rated the understandability as 90.2 % and the actionability as 91.3 %. Most previous studies did not report results from evaluation of the suitability of their patient educational materials –24 and tThere are several limitations that we should consider for the next steps. First, this program was developed for only one tertiary hospital in Korea, which means restriction of the generalizability. To test external validity, more discharge educational program using TBM should be implemented and evaluated as the experimental studies or the quality improvement project at various settings. Second, the outcome measurement for self-care was accounted for on the self-reported questionnaire, so we cannot assume the real change in behaviors. To overcome this limitation, monitoring objective health behaviors using internet of medical things devices could be one way.The contents of the HEART program were valid, and the educational material was appropriate for both patients and nurses. We expect our structured discharge education program using TBM to enhance the self-management of HF patients. Our study shows how HCPs and researchers can practically develop an intervention program using a methodological model and systematic approach. The detailed phases by which we developed the HEART program illustrate essential elements that HCPs need to consider during implementation. Also, the structure, process, and results of the program designed in this study could guide both research and practice and can be used in settings other than Korea. Finally, the teach-back questions we use to identify gaps between HCPs and HF patients in knowledge, skill, and attitude regarding self-management could be used in clinical practice.


Rare diseases affect > 400 million people globally with a disproportionate burden falling on children, resulting in high morbidity and mortality rates. Affected individuals in some under-resourced countries have limited access to expert care or treatments; moreover, they suffer long diagnostic journeys during which debilitating and life-threatening complications occur. Lysosomal storage disorders (LSD) are prototype rare diseases due, in the main, to inherited deficiencies of lysosomal enzymes/transporters that affect up to 1 in 5000 newborns. Recognizing the need to provide treatment access to people with LSDs everywhere, a collaborative partnership was pioneered and set up 30 years ago. Partnering with local authorities, non-government organizations across six continents, local as well as international experts, a robust, sustainable Humanitarian Program emerged that now represents the most enduring charitable access program for LSD treatment. Here we present the history, process, lasting beneficial effect of the program to develop healthcare systems and infrastructures, and the lessons learned from addressing major unmet needs for LSDs. Rare diseases affect > 400 million people globally, impacting more individuals than cancer and acquired immune deficiency syndrome (AIDS) combined . These iLysosomal storage disorders (LSDs) are prototype rare diseases that are, for the most part, due to deficiencies in one of the lysosomal enzymes/transporters , 4, withAlthough recombinant enzyme replacement therapies (ERT) are available for increasing numbers of these disorders, it is challenging for affected individuals in under-served populations to access treatment due to geographical location, local healthcare infrastructure, and prohibitive costs . Fig.  based onFig.  for the Fig. .Fig. 1GoThe Humanitarian Program is the longest-running charitable access program (CAP) for treatment of LSDs providing sustainable global access to therapies for affected people, regardless of local healthcare system infrastructures . To addrThe program was initiated in the United States (US) in 1991 through the launch of the CAP within 3 months of alglucerase (Ceredase®) approval, the first ERT for GD type 1 , 11. IndTo assess current perceptions of the program’s impact and challenges, information was collected through a series of qualitative web-based interviews with key individuals instrumental in the program roll-out and evolution. An online survey was also conducted to evaluate operational aspects , experience of the program, and suggestions for improvement. The survey was open to 320 physicians with experience in treating LSDs across 70 countries. The privacy and personal data of respondents were protected in accordance with the applicable laws and terms of Global Sanofi Privacy Policy. The insights gathered and reported herein represent the collective experience of > 50,000 patient-years of treating LSDs, spanning up to 40 years, and decades-long leadership in rare-disease patient advocacy.Successful program implementation requires an infrastructure supporting treatment access, coupled with concurrent development of healthcare ecosystems. Central to this are education, development of diagnostic technologies, disease monitoring, and building of expertise in local centers to eventually develop into destination centers where individuals with LSDs can receive diagnosis, therapy and monitoring of outcomes. Success was underpinned by striving to meet the needs of all stakeholders involving seamless partnership with members of the local treating communities, patient advocacy groups and organizations, and the healthcare system.Healthcare delivery for LSDs begins with a compassionate case-by-case response at the country level reaching far beyond simply shipping the drug. At its earliest beginnings Sanofi Genzyme recognized the essential need to build skill sets and infrastructure to support complex care for these people. Individual physician training rapidly evolved into medical advisory boards of enterprising local physicians, international expert physicians, and humanitarian initiative staff. These forums served as platforms for training and mentorship by international leaders, such that over time local physicians became thought leaders advancing the science and generating new knowledge in these rare diseases. The medical advisory boards collaboratively developed treatment guidelines, monitoring, and stratification of individuals based on disease pattern, severity, and genotypes. Over time, local expert physicians took increasing leadership in individuals’ selection, considering nuances of disease phenotypes, and treatment plans. Often, the phenotypes encountered had no prior counterpart in world literature, which is primarily European-centric. Technological developments included logistics of cold-chain transport of medication, advanced assessments to monitor the individuals, and transfer of knowledge and capabilities from a country with limited resources to a central laboratory in another country. For example, the development of dry-blood-spot technology for biochemical molecular analysis, and biomarkers studies in LSDs, advanced monitoring of individuals in remote locations without the need to ship whole blood samples to specialist laboratories. Partnership with rare-disease patient advocates and advocacy groups, renowned for their disease knowledge, was invaluable in ensuring free access to additional medical devices. Creation of such comprehensive healthcare systems supported by skilled providers is critical for improving the health of people with LSDs, and providing an established functional framework to elevate advocacy with local authorities to address the huge unmet needs of this underserved population. Achievement of these goals required overcoming disparate cultural, social, trade policy and political barriers.From its inception, the governance structure has ensured the program remains compliant with ethical standards, institutional policies, and external governmental requirements, and continues to meet the strategic goals and the foundational mission of the Humanitarian Program Fig. . It operPrioritization of individuals or countries is driven by the individuals’ need and is agnostic to the likelihood of government reimbursement or competitive market forces. Candidacy for treatment is primarily based on medical need in the following circumstances: when reimbursement is unavailable, until reimbursement is available, when reimbursement is available but the individual does not qualify, and when other local access or assistance programs are unavailable.The governance structure was tailored to individual country requirements to best serve that population Fig. . For exaTo evaluate the program and solicit opinions on future enhancements, 320 physicians with experience of treating LSDs were invited to take part in an online survey. Overall, 114 respondents from 42 countries completed the survey, of which 63% of physicians had individuals currently enrolled in the program. Respondents represented a broad range of specialties, including geneticists (27%), pediatricians (21%), and neurologists  reported that individuals under their care received the scheduled treatment regularly. The remaining 6% reported challenges to treatment access, including: government regulations, challenges with storage logistics, individuals unable to comply with all the monitoring guidelines, limited financial resources for logistics of getting infusion treatment/challenging environment, delays in receiving medication, and challenges in contacting individuals.Most physicians (92%) reported that they did not experience any problems when completing the required application forms or providing medical updates every 6 months, however, some suggestions for improvements to the program included digitizing the enrollment process, reducing the ongoing paperwork, and improving disease awareness and support.Country-specific examples of the successful implementation to build healthcare infrastructure serving LSDs in underserved populations illustrate how, the entire clinical spectrum of GD, for example, has been redefined to serve the individual’s unique needs. Figure The numbers of individuals with GD needing medical care became immediately evident upon inception of the program in 1999, when the number of individuals grew from 12 to 37. Project HOPE was a key partner, raising awareness of GD and assessing the gaps in treatment access. It was considered the most effective partner to manage the Gaucher Initiative, having operated in Egypt since 1975, and collaborating with the Ministry of Health and University Hospitals across the country for other healthcare initiatives. This collaboration with Project HOPE was critical in implementing many aspects of the program, including annual training for Egyptian doctors via international and national experts, and patient and family awareness activities. This initiative robustly models the key pillars of building healthcare systems, starting with affected individuals and their families, mentorship, and development of thought leaders within medical committees to achieve high-level expertise on how best to evaluate candidacy for treatment, assessing outcomes, and contributing gained knowledge to benefit the global community. To date, the program has supported > 250 individuals in Egypt with GD treated at centers of excellence established across the county, obviating the need to travel long distances for diagnosis, evaluation, and treatment.Initiated 20 years ago, the program in India has supported > 200 individuals across four LSDs. The program has resulted in improved awareness, diagnosis, and management of individuals with LSDs through the development of several centers of excellence and diagnostic capabilities, along with the implementation of medical-education initiatives for individuals with GD, FD, and PD –15. LocaThe China CAP has grown to support > 180 individuals with GD since its initiation in 1999. Since 2009, centers have spread across China, providing accurate diagnostic support and treatment for LSDs, and obviating the need to travel long distances. A growing number of provinces contribute toward costs through government medical insurance. The program’s flexibility allows for partial humanitarian support for > 50 individuals. The expert medical committee in China has developed treatment guidelines and provided country-wide clinical expertise.Since the late 1990s individuals severely affected with GD unable to receive treatment in Central and Eastern Europe have been treated via the Humanitarian Program. Individual European countries such as Albania, Belarus, Bosnia, North Macedonia and Serbia, rapidly adopted management of individuals with LSDs, propelled by powerful advocacy groups, which has transformed care. Early access to treatment in these countries has advanced physicians’ knowledge, shortening diagnostic journeys, and improving treatment outcomes.The impact on the lives of individuals with LSDs has been transformative. Thus far, the Humanitarian Program has provided treatment to > 3300 individuals across more than 100 countries, some for over 20 years, with the average treatment duration ranging from 3 years (for MPS type II) to 9.8 years (for GD; Fig. Experienced members of advisory boards have also played a pivotal role, with overseas experts mentoring local physicians in all aspects of LSDs. This mentorship has been central to the program, with local physicians emerging as experts contributing new knowledge to benefit the rest of the world , 15; locOperating a program of this magnitude and global reach is challenging. The lessons learned and the measures implemented to overcome obstacles at the local and global level are key to ensuring the resilience of the program.A hallmark of the program is providing access to treatment for affected individuals who meet the medical criteria, regardless of geography. This includes sanctioned markets such as Cuba, Iran, and Sudan, where treatment access has been provided through the program for 20 years. Other examples include supporting individuals with rare diseases in Palestine, and those displaced due to war or conflict in their countries of origin, for eg, Syrian and Iraqi refugees living in Turkey. In some of these geographies, the program enlists the help of NGO partners to ensure long-term therapy and overcome barriers to treatment access. The ethical underpinnings of the program were tested during a global supply shortage of agalsidase beta in 2009 and imiglucerase in 2010 that required dose-conservation guidelines to be implemented. However, doses were rationed equitably among the most critically affected individuals and Humanitarian Program recipients to ensure that the reduced product supply was distributed based solely on medical need . One of The Humanitarian Program is an exemplar of the rare-disease community coalescing with Sanofi Genzyme’s core mission to serve one person at a time, for individuals everywhere . It starThe Sanofi Genzyme Humanitarian Program, founded to address the unmet needs of individuals with LSDs who previously had no available treatment options, represents one of the longest-running CAPs for LSD treatment. Providing sustainable global access to therapy, it has paved the way for other manufacturers of ERTs to engage in humanitarian aid, and has helped to overcome the world’s fear of “new and unknown” orphan drugs. The program has seen the successful implementation of treatment for people with rare complex LSDs, as well as improving disease awareness and helping physicians to build local capabilities. Additionally, individuals enrolled in the program have been empowered to become advocates, building patient organizations with national and global reach.A key success has been maintaining an open-ended vision to provide treatment for rare diseases in underserved communities, which has resulted in its evolution from a charitable program for a single LSD to one that supports the provision of free treatment for five different LSDs to communities globally.


Dance is a mind-body activity of purposeful rhythmic movement to music. There is growing interest in using dance as a form of cognitive and physical rehabilitation. This manuscript describes the development of GERAS DANcing for Cognition and Exercise (DANCE) and evaluates its feasibility in older adults with cognitive and mobility impairments.The progressive dance curricula were delivered for 15 weeks . Participants were eligible if they were community-dwelling older adults aged 60+ with early cognitive or mobility impairment able to follow three-step commands and move independently. Feasibility outcomes included recruitment/retention, adherence, participant satisfaction, safety, and adverse events.SD]) age = 77.55 (6.10) years, range 68–90 years) with early cognitive  = 21.77 (4.05)) and mobility (92% were pre-frail/frail as indicated on the Fried Frailty Phenotype) impairments were recruited from a geriatric out-patient clinic or within the community. A total of 20/25 (80%) participants completed the study. Average class attendance was 72%, and self-reported homework adherence “most-days / every day” was 89%. A stepwise progression in the dance curricula was observed with increases in motor complexity and balance demands, and 95% of participants rated the program as a “just-right” challenge. Ninety percent of participants rated GERAS DANCE as excellent, and 100% would recommend the program to a friend or family member. Over 50% of participants connected outside of class time for a self-initiated coffee club. Adverse events of falls and fractures were reported for 2 participants, which occurred at home unrelated to the dance intervention during the study period. Pre-determined thresholds for feasibility were met for all outcomes.Twenty-five older adults  and motor complexity increases in agility, balance, and coordination appear appropriately tailored for this population. Future work will explore the feasibility of GERAS DANCE in new settings  and the mind-body-social benefits of dance.The online version contains supplementary material available at 10.1186/s40814-021-00956-3. What uncertainties existed regarding the feasibility? GERAS DANCE is a new program designed with rehabilitation and geriatric medicine expertise for older adults with early cognitive or mobility impairments. Prior to completing this study, the feasibility and resources required to implement the GERAS DANCE program and the recruitment were uncertain.What are the key feasibility findings? Pre-determined thresholds for feasibility were met for all outcomes. GERAS DANCE curriculum grading  and motor complexity increases in agility, balance, and coordination appear appropriately tailored for this population.What are the implications of the feasibility findings for the design of the main study? This study provides evidence that GERAS DANCE is a feasible and enjoyable program for older adults with early cognitive or mobility impairments. The next steps include testing the efficacy of GERAS DANCE in an RCT.Both mild cognitive impairment (MCI) 16–20%) .Given the importance of a clinical trial recruitment phase, it is critical to understand the feasibility, timelines, and best strategies to enroll participants . The stu32to reinforce/practice movements learned. Participants were able to participate in the classes without the support of a caregiver. One caregiver initially attended with their husband to ensure they were comfortable participating in the classes; however, after three classes, the caregiver started to use this as respite time to go to the library.GERAS DANCE programming aligns with recent evidence suggesting dance programs be organized to run twice per week, 1 to 2 h in length, for 3 months in duration to optimize social, physical, and cognitive benefits in neurological populations , 35. GERNinety-five percent of participants rated GERAS DANCE as a just-right challenge, and 100% would recommend the program to a friend or family member. Compared to the Baycrest Canada National School of Ballet Sharing Dance Seniors program , where pThe GERAS DANCE program has the potential to be implemented as community-based rehabilitation. This research study was supported by grant funding, which allowed participants to attend without any financial cost. If participants did not receive free memberships, the enrollment could have been lower than reported here. It is possible that dancing may not be an appealing exercise to men as a higher percentage of females were involved in the study. Future work should include a cost analysis and potential funding mechanisms to provide the dance program as a community-based program as a part of overall rehabilitation.GERAS DANCE is a promising therapeutic intervention and enjoyable for older adults with cognitive and mobility impairments. Future work should explore the feasibility of GERAS DANCE in new settings—i.e., virtually online, community centers, or retirement homes. GERAS DANCE efficacy will be studied in a randomized controlled trial to examine the mind-body-social benefits of dance.Additional file 1. CONSORT 2010 checklist of information to include when reporting a pilot or feasibility trial.Additional file 2. TIDieR (Template for Intervention Description and Replication) Checklist.


Reminders sent via SMS text messaging or email may improve the adherence to web-based programs and increase the probability of successful behavior change; however, it is unclear whether their efficiency is affected by the modality of the communication channel.A 2-armed randomized control trial was conducted to compare the effect of providing reminders via SMS text messaging versus email on the adherence to an eHealth program for smoking cessation and on the probability to initiate a quit attempt.Smokers were recruited via an internet-based advertisement. A total of 591 participants who diverted from intended use of the program  were automatically randomized to the experimental  or the active comparator  group.586=0.197, P=.84, and Cohen d=0.016), or the outcome, namely the quit smoking attempt rate . Secondary analyses showed that age, gender, and education had significant effects on program adherence and education on the outcome. Moreover, we found a significant interaction effect between the mode of reminder delivery and gender on program adherence, suggesting that the effectiveness of SMS text message reminders might be different for females and males. However, this particular finding should be treated with care as it was based on post hoc subgroup analysis.Unexpectedly, we found that the mode of reminder delivery did not significantly affect either the adherence, namely the number of completed program sessions, with the SMS text messaging reminder group showing a mean of 4.30 (SD 3.24) and the email reminder group showing a mean of 4.36 (SD 3.27) (tThis study indicates that the modality of user reminders to log on increased neither the program adherence nor the probability of quitting smoking. This suggests that program developers may save costs using emails instead of SMS text messaging reminders.ClinicalTrials.gov NCT03276767; https://clinicaltrials.gov/ct2/show/ NCT03276767 Interventions delivered through the internet may provide people with tailored and real-time suggestions  and alloThe efficacy of web-based interventions is closely associated with users’ adherence to them , making Therefore, the purpose of this study was to determine whether SMS text messaging would indeed be more effective in reminding the users to log onto the web application once they fail to log on as expected. Our point of departure was a web-based smoking cessation program (described below) that uses email invitations to notify the user of the release of new program modules. If the user does not log on as expected, the program will send out a reminder to prompt the user to log on. We conducted a randomized controlled trial (RCT) in which participants were randomized to receive these reminders either by SMS text messaging or email. We hypothesized that SMS text messaging reminders would have users logging onto the web application frequently  and possibly lead to an increased likelihood of an initiated attempt to quit smoking (due to increased program use).A 2-armed RCT was conducted. The 2 arms of the RCT differed only in the modality (SMS text messaging versus email) of the reminders that were issued to remind the smoker about the missed session (module). There were 4 different versions of this message, so that each user would never receive the same message twice in a row. The messages were very similar in content and form, for example, “Hi (name of user) I haven’t seen you for a while. You may have been busy? Hope to see you soon! (smart link to the web application) Best Andy (Andy is the English name of the intervention).” The study protocol was registered at ClinicalTrials.gov .The study sample consisted of Czech and Norwegian tobacco smokers using Andy, an eHealth smoking cessation program (described below). Czech participants were recruited through internet-based advertisements . Norwegian participants were recruited through internet-based advertisements  as well as through Healthy Life Centers. Participants needed to be over 18 years old, current tobacco smokers, willing to quit smoking, provide a valid email address and mobile phone number, provide consent to participation, complete the baseline questionnaire, and open the first session of the program. Additionally, only persons who qualified as nonadherers were included; nonadherence was defined as failing to log on to the program by noon on the day after a new session (module) was released. Overall, 584 of the 1175 recruited participants (49.7%) did not meet the inclusion criteria, resulting in a total of 591 participants. Baseline characteristics were collected through a web-based questionnaire, whereas program use information was recorded automatically. Program use information included the start and completion of a session, issuing of SMS text messaging/email reminders, and user-reported initiation of a quit attempt.The eHealth intervention named “Andy” is a fully automated web-based smoking cessation program that first prepares the user for quitting (preparation phase) and follows up once the user confirms having initiated a quit attempt (follow-up phase); however, this study focuses only on the preparation phase. During the preparation phase, the program releases 1 new session per day. The recommended/default length of the preparation phase is 11 days (which is the designated quit day), but users are free to advance or postpone at their own rate within certain limits. When a new session is released, an email invitation is sent to the user to prompt login (this happens at 5 AM). A reminder is due when a user fails to log onto an assigned session by noon on the next day. In this study, a simple randomization procedure automatically took place when the first reminder was due, following which participants were randomized to either the SMS text messaging or the email condition. More information about the intervention program, how it is used, and its usability can be obtained elsewhere -16.Participants were asked about their age, gender, place of residence , education, employment, and income.Participant also reported their average consumption of cigarettes (self-reported number of cigarettes smoked per day). Following a standard procedure , we thenThe main outcome was whether the participants had initiated a quit attempt. Upon logging on to the program on the quit day, participants are asked whether they have in fact initiated a quit attempt as planned. Those who answer “no” are encouraged to quit the next day and will be asked the same question the day after (and on any subsequent day if they keep logging on to the program). Those who answer “yes” will be transferred to the follow-up phase of the program. Participants who dropped out from the program before they reached their quit day were considered treatment failures . Participants who continued to log on to the program until their quit day (or beyond) but did not report to have initiated a quit attempt within 6 weeks after accessing the first session of the program were also considered treatment failures.Program adherence was measured as the number of eHealth program sessions that participant had completed. It was possible to complete 0 to 10 sessions during the preparation phase of the eHealth program. A higher number of completed sessions indicated higher adherence to the eHealth program.t test for unequal variance to analyze the effect of SMS text messaging reminders on program adherence, namely the number of completed program sessions (secondary outcome). Next, we used the 2χ test of association for assessing the effect of SMS text messaging reminders on the initiation of a quit attempt (primary outcome). Moreover, 2 regression analyses were conducted to assess the effects of SMS text messaging reminders when controlling for the effects of all background variables  and the active control group (email reminders). Second, we used the Welch 2-tailed shown in  on the pThe study was approved by the Ethics Committee of the General University Hospital in Prague (no. 7/17GrantGACR-1.LFUK) and by the Norwegian Center for Research Data (no. 52874).Background characteristics of each group are reported in t586=0.197, P=.84, and Cohen d=0.02. Given the difference in the Czech/Norwegian participant ratio between the SMS text messaging and email groups, we conducted a regression analysis where we controlled for nationality (and other background variables) with the same result. Receiving SMS text messaging reminders (as compared with receiving email reminders) did not lead to a significantly higher number of completed sessions (P=.98). The number of completed sessions among all participants ranged from 0 to 10 . Contrary to our expectations, we did not find any statistically significant difference in the number of completed sessions between participants receiving SMS text messaging reminders  and those receiving email reminders ; Welch r=0.17, P<.001) and female participants showed a significantly higher number of completed sessions  compared to male participants ; Welch t513=2.98, P=.003, and Cohen d=0.25. Furthermore, participants with a university degree, namely Bachelor of Arts or Master of Arts, completed more sessions compared to those without high school graduation; the omnibus difference was significant  with Games-Howell post hoc t tests proving significant for differences between those without high school graduation and those with BA (P=.02) and MA (or higher) degrees (P=.02). The difference in the number of completed sessions between Czech  and Norwegian  participants was not significant (P=.27).Some background characteristics were found to be significant predictors of the number of completed sessions, namely age, nationality, gender, and education. Using separate analyses for each of these predictors, we found that higher age was positively associated with adherence  was 4.40 (SD 3.40), whereas for male users receiving SMS text messaging reminders (n=114), it was 4.14 (SD 2.98); further, for female users receiving email reminders (n=171), the average number of completed sessions was 4.91 (SD 3.22), and for male users receiving email reminders (n=116), it was 3.54 (SD 3.19)  .2χ1=0.4, P=.52). The frequency of quit attempts in the SMS text messaging group was 104 (34.2%) whereas it was 91 (31.7%) in the email group. We did not find any significant interaction between education, receiving SMS text message versus email reminders, and quit attempts. Regression analysis in which background variables were controlled for also showed that receiving SMS text messaging reminders instead of email reminders was not a significant predictor of initiating a quit attempt .In the whole sample comprising 591 participants, 195 (33%) participants initiated a quit attempt. Contrary to our hypothesis, there was no significant difference between the 2 randomized groups in initiating a quit attempt  or when controlled for all the background variables listed in P=.98). Similarly, we did not find differences in the proportion of reported quit attempts between SMS text messaging (quit attempt reported by 34.2% participants) and email (quit attempt reported by 31.7% participants) groups, either when measured separately (P=.52) or when controlled for all background variables (P=.45).This RCT tested the hypothesis that receiving SMS text messaging reminders (compared to receiving email reminders) increased (1) the adherence to the eHealth program for smoking cessation and (2) the initiation of an attempt to quit smoking. Randomization took place after the first sign of nonadherence to the eHealth program . There were no significant differences between the 2 groups in terms of their background characteristics, except for nationality. Norwegian participants were more often randomized to the SMS text messaging group as compared to Czech participants. The adherence to the eHealth program was measured as the number of completed sessions and the desired outcome was measured as self-reported initiation of a quit attempt. Surprisingly, we did not find any significant differences in the number of completed sessions between participants receiving SMS text messaging reminders (completed 4.30 sessions on average) and those receiving email reminders (completed 4.36 sessions on average), when tested separately (P=.04). In other words, the effect of replacing email reminders with SMS text messaging reminders on program adherence is heterogenous across genders. This effect suggests that SMS text messaging reminders are more beneficial for men, relative to women, in terms of program adherence  and the initiation of a quit attempt (education). None of these effects interacted significantly with the reminder modality (SMS text messaging versus email), except for gender, which is attributable to the modality interaction effect on program adherence , resulting in a short period for assessing the adherence. Moreover, the study focused on a smoking cessation eHealth program and may not be generalized for other types of eHealth interventions. Findings concerning the interaction between SMS text messaging reminders and gender are based on post hoc subgroup analysis, and as such, it should be treated with care . FurtherIn conclusion, and contrary to available literature, our data suggested that when it comes to reminding nonadherent eHealth users to log on to a web-based program, SMS text messaging reminders were not superior to email reminders, neither with respect to increasing program adherence nor in supporting a desired outcome . However, there may be gender differences affecting the preferred modality  that may be useful to pursue in further research. The results for both outcomes taken together suggest that there is very little to gain, if anything at all, by choosing SMS text messaging over email reminders for web-based behavior change interventions. Thus, our finding is important for developers and providers of eHealth interventions who may not need to allocate additional costs related to SMS text messaging reminders to enhance program adherence or outcomes, as reminders delivered via email seem to be equally effective.


DAS , IBCTQ , and ASPA-A  pre-treatment, posttreatment, and at a three-year follow up. Three of these couples were randomly assigned to the experimental group, in which they received five, 120-minute sessions of an IBCT-based conflict prevention program. The three remaining couples were assigned to a control group and received no treatment. Results indicated that the experimental couples grew in their acceptance of differences and significantly improved their level of empathic joining and unified detachment; they also manifested greater satisfaction in their total DAS score. At the three-year follow up, neither group showed significant changes with regard to their posttreatment scores. Although the data are based on a small number of couples and should be replicated, the results suggest that a program based on IBCT strategies can help prevent couple conflict up to three years after its application.Integrative Behavioral Couple Therapy (IBCT) has demonstrated its efficacy treating severe couple conflict. Nevertheless, its capacity to prevent such conflicts before they appear has not been analyzed. The following empirical study examines the effectiveness of a conflict prevention program based on IBCT’s main therapeutic strategies . A sample of 12 individuals (six couples) from the Community of Madrid completed the  Most couples seek therapy only when experiencing high levels of distress and numerous conflicts, with the corresponding risk of relationship dissolution ,2. This Couples Communication Program , that would be great”; “We tend to have big arguments from time to time and I would like to know what to do”; “Sometimes I’m badly affected when we fight”. By the second session, couples were starting to be more aware of their differences and the tendency to polarize: “This week, I’ve focused more on our differences”; “I’ve focused more on the differences that annoy me”; “I see that we have a lot of differences”; “In a discussion we had on Saturday, each of us became rigid in their point of view”; It’s difficult to get outside of your point of view when you’re emotionally altered, but having talked about it last session at least it makes you think”. The third session showed greater awareness of spontaneous conflict resolution techniques that were functional for the couple: “We complement each other well; each one knows how to calm the other”; “This week when my partner got angry, I went to give them a hug”; “I can’t deny him a hug when he’s altered, that’s how we resolve things”; “We looked at the most useful way in which we deal with conflict: humor”. In the fourth session, couples began to comment on the tendency to attack each other instead of expressing soft emotions and their efforts to implement empathic joining: “I used last week’s strategy without having to think about it”; “The psychologist told us that we could express ourselves without attacking each other”; “It’s difficult to not attack each other when we’re emotionally altered, but it’s true that it complicates things”; “The other day I saw how we got stuck in a vicious circle because of this”; “I became aware of how much we criticize each other underneath everything.” In the fifth session, couples mentioned the helpfulness of analyzing problems more objectively as a team through unified detachment: “We tend to try and see problems objectively”; “I really liked what you said, that if a one of us has a problem and it affects both of us, then it’s our problem together”; “It’s logical that if we look at problems as a team it will be easier to resolve them”; “Being a team is very important”; “We’ve stopped somewhat being [a team] since a while ago”; “I also [believe] that if you’re not [a team], then what are you?”. They also emphasized the importance of tolerance strategies such as self-care: “I also look to my needs”; “Yes, when we’ve had an argument, I know that things will be okay if I dedicate time to be with friends and practice a sport and calm myself”; “Maybe we’ve lost time for ourselves [as individuals].” All of these comments are coherent with IBCT strategies  and reveal progress in the program’s objectives. Not all couples responded equally to all program elements. Couples showed more interest in and benefited more from specific IBCT strategies as a function of their interaction profile. For example, Experimental Couple 1 (EC1) responded more to unified detachment. They were the youngest of the cohort, had been together the shortest period of time, did not live together, and were memorable because of each partner’s openness in expressing emotions and their attempts to attend to each other’s feelings during conflict. Perhaps this openness was the result of cultural influences given the greater gender equality lived by current Spanish youth. Nevertheless, they tended to become tied up in these emotions and suffer growing distress because of the guilt each felt for the emotional pain they were causing in the other. At the same time, they tended to fuse with the content of their conflict, blaming each other for their difficulties instead of seeing the conflict as an external pattern or event that they fall into together. This tended to erode their sense of facing their problems as a team, once again increasing their level of distress. Unified detachment, a more analytic IBCT technique, helps to increase intimacy and positive affect toward the partner by promoting psychological distance from the problem, thus avoiding the blame game and supporting a more detached, “us vs. the conflict” mentality, all of which helped this couple to better navigate conflict. Experimental Couple 2, on the other hand, responded better to empathic joining. They were a middle-aged couple that had been together longer than EC1 and lived together without any children. They tended to take a logical approach to the problems that occurred between them, and when they expressed emotions, they would accuse each other vehemently, resulting in numerous conflicts and emotional distance from their partner and from themselves. They even understood emotions as problems to be solved. Empathic joining, which also looks to increase intimacy and positive affect toward one’s partner, helped them to directly and assertively express both their surface and hidden emotions as well as learn how to interpret their partner’s emotions by taking into account their behavioral learning history. They began to stop seeing emotions as a problem that needed to be solved. Lastly, Experimental Couple 3 responded the most to tolerance strategies. They had been together for many years, had two children, and showed a manifest resistance to change. They were aware of this resistance and explained that their many years together and the prior unfruitful attempts that they had made to change each other were important reasons for it. Thus, they showed the greatest interest and inclination toward tolerance strategies, especially being able to see the positive aspects of each partner’s negative behavior and the emphasis on self-care, the latter of which they had tried before but out of resignation instead of seeing it as a way of tolerating and accepting the other.DAS and IBCTQ, and several of these improvements were maintained over three years. It could be concluded that IBCT contains diverse strategies that benefit each couple in keeping with their specific relationship characteristics, but that there are also common factors that seem to benefit most or all couples. These common factors include: (1) an open and uninterrupted expression of the unpleasant emotions experienced by each partner during and after a conflict; (2) active listening by each partner in response to the emotions of the other; (3) consciousness raising between partners regarding each one’s learning history; (4) a more careful and assertive use of language when revealing emotions, putting emphasis on expressing feelings instead of criticism; (5) achieving distance from problems, seeing them from a more objective perspective, and (6) greater introspection and critical reflection toward the behaviors used by each to manage unpleasant emotions.As can be seen through this qualitative analysis, each couple responded more to certain IBCT strategies in accordance with their personalities and relationship characteristics. Nevertheless, all showed quantifiable improvement on the DAS) also improve in couples post-intervention, although such changes only reach near-significance. We hypothesize that a longer training may favor clearer statistical results in these areas. The present investigation presents a new IBCT-based conflict prevention program for couples and conducts a pre-pilot test of its short-term and long-term efficacy with an experimental and control group. In contrast with previous marriage prevention programs, a single theoretical base (IBCT) was used to develop program content, and both quantitative and qualitative measures were used to investigate multiple intervention effects in line with that theory . The study’s follow-up period (three years) is also longer than that of most other marriage prevention investigations. Results reveal that the program can be efficacious in increasing relationship quality in the short-term and long-term , with the logical caution imposed by the small sample size. More specifically, the program contributes to increases in relationship satisfaction (mostly short-term) and affective expression (both short and long-term), which translates as a decrease in tension and an increase in intimate and sexual communication between partners. Other dimensions of relationship quality such as cohesion and consensus (IBCTQ). These results suggest that couples who complete the program are better able to conceive negative situations and actions (or inaction) by their partner as examples of differences that exist in the couple instead of personal attacks, just as the IBCT model posits [With regard to specific IBCT variables, this program helps couples develop a greater use of empathic joining and unified detachment  were observed, none were significant. One possible reason is that IBCT acceptance and tolerance strategies do not directly focus on couple communication types but rather approach them transversely.Although slight changes in communication types  and comparative analyses indicate the greatest change in e et al.  might haQualitative data tend to be more sensitive to subjective interpretation. Nevertheless, the results in this case are so clear and consistent among participants that there is little doubt concerning couples’ satisfaction with the program, that the intervention increased feelings of rapport and understanding between partners, and that participants perceived that they had acquired useful tools for managing future conflicts. Role-play practice of IBCT strategies and the therapists’ resulting feedback do not guarantee that empathic joining and other abilities were fully absorbed by couples. However, follow-up results seem promising, and the manifest satisfaction of the participants who learned them indicates their likely use.n = 12), this investigation should be considered as more pre-pilot than final. In addition, as previously mentioned, one of the experimental couples did not complete the three year-follow up data, expressing that they had separated. While this might seem worrisome, other marriage prevention studies indicate that a significant number of couples drop out or separate despite initial intervention gains [Although the results of this study are encouraging, limitations exist that suggest caution in generalizing the results. Due to the small sample size of the experimental and control groups  shows significant long-term positive effects, (2) possesses strict and well-defined content to help identify effective prevention components, and (3) is based on a single theoretically and experimentally sound model . Results reveal that the program is efficacious in increasing relationship quality in the short-term, with some long-term benefits, especially in the area of affectional expression. IBCT-related variables (empathic joining and unified detachment) showed significant short-term change, which were maintained at three-year follow-up. Associated measures of acceptance and tolerance also showed near-significant change. These data suggest that couples who complete the program are better able to view negative situations and actions (or inaction) by their partner as examples of differences that exist in the couple instead of personal attacks and gain a greater distance or separation from their problems, just as the IBCT model posits . Both exWhile only a pre-pilot study, we believe the present investigation demonstrates the potential that a purely IBCT-based model has for relationship prevention both short-term and long-term and recommend its testing in a larger sample. We hope that the divulgation of empirical studies such as this one will help alleviate the absence of long-term efficacious conflict prevention programs and help to better define the usefulness of specific intervention components  in avoiding the escalation of serious couple conflict and its grave repercussions.


In an era of complex, multi-institutional, team-based science, there is little guidance for the successful creation of effective, collaborative, multisite training programs.We designed, implemented, and evaluated a multi-institutional Tobacco Regulatory Science (TRS) fellowship representing a scalable program that may be customized for other research areas.Using a mixed-methods approach, we analyzed program evaluations from trainees enrolled in the first 7 years of the American Heart Association (AHA) Tobacco Regulation and Addiction Center (A-TRAC) fellowship (2014–2021). We also reported the program outcomes, including published TRS manuscripts, independent grant funding, Food and Drug Administration (FDA) Docket comments submitted on TRS topics, TRS oral and poster presentations, research awards, and promotions in the TRS field.Thirty-five unique trainees  from eight institutions within the A-TRAC network participated in the fellowship since its inception. The trainees reported 74 TRS publications, 78 TRS oral or poster presentations, 25 FDA Docket comment submissions, and 13 funded grant awards. Participant evaluations indicated six areas of programmatic strength: 1) blended instruction medium with webinars and in-person meetings, 2) curricular emphasis on theories of experiential learning, 3) focus on career and professional development, 4) integrated mentorship model, 5) culture of feedback and feedforward to foster successful learning, and 6) focus on recruiting diverse participants. The A-TRAC model stresses experiential education, feedback and feedforward, and peer learning.Our resource-effective, needs-driven program is a reproducible model for institutions interested in developing multisite, virtual research education programs in the era of team science. With the emergence of new tobacco products in the market over the last two decades, Tobacco Regulatory Science (TRS) has become a vital discipline of fundamental importance to public health . In ordeIn an effort to successfully create an effective, collaborative, educational program, in 2014 we developed the American Heart Association (AHA) Tobacco Regulation and Addiction Center (A-TRAC) fellowship, a multisite, virtual program to train early-career biomedical and population researchers working across complex, interdisciplinary areas of TRS. We implemented a blended education model involving weekly webinars and annual in-person meetings, with a focus on experiential learning techniques, mentor network development, and the value of feedback for scientific excellence and career advancement.Given the broad educational requirements of TRS training and the geographically diffused network of TRS researchers , the A-TThe A-TRAC training program comprises three primary elements: 1) TRS core competencies ; 2) careUsing systematically collected program evaluation data from the first 7 years of the A-TRAC fellowship (2014–2021), we describe the program’s components and outcomes. Conceptually, the A-TRAC model need not be discipline specific; rather, it functions as a customizable archetype, providing translatable guidance for developing virtual fellowship programs that seek to combine specialized content knowledge, career and professional development, and intensive mentorship in a highly resource-effective manner.The Career Enhancement Core (CEC) is the training core within the A-TRAC grant, charged with leading the fellowship. It is the faculty team responsible for coordinating the fellowship’s educational activities. The CEC is comprised of A-TRAC investigators and administrative staff. For both iterations of the grant, A-TRAC 1.0 [2013–2018] and A-TRAC 2.0 [2018–2023], the CEC has been tasked with developing the next generation of basic, clinical, population, and translational investigators in tobacco-related cardiovascular health and policy and to accelerate TRS. Trainees gain expertise in both scientific investigation and public health to inform the FDA Center for Tobacco Products with relevant findings for regulation of the manufacture, distribution, and marketing of tobacco products. We leveraged the outstanding expertise, facilities, infrastructure, and research experience at participating institutions within the A-TRAC grant  to build a robust training curriculum. We also utilized the broad portfolio of these AHA-affiliated institutions’ research and training programs by providing opportunities in networking, research collaborations, and peer mentoring for the A-TRAC fellowship trainees.In addition, the CEC focused on research of the adverse consequences of cardiovascular disease from diverse tobacco products/uses. We worked with other TCORS sites to develop a rigorous, innovative multi-institutional career and research development program for trainees.The CEC accepted applications including project proposals for funded and alternatively funded candidates. Some candidates were funded directly through the grant in A-TRAC 1.0 or through CEC pilot awards in A-TRAC 2.0, whereas the alternatively funded candidates received independent funding from principal investigators within the A-TRAC grant. Both sets of trainees had the same expectations for participation and productivity. Successful applicant proposals were within the scope of A-TRAC 1.0 and 2.0 research goals and responsive to one or more of the FDA Center for Tobacco Products research priority areas ,15.Applications were evaluated based on the: 1) proposed project’s significance and innovation; 2) candidate’s demonstrated ability to carry out the proposed project; 3) applicability of research to A-TRAC’s mission and scientific scope; 4) compliance with FDA’s regulatory authority and alignment with FDA Center for Tobacco Products research priority areas; 5) strength of research and mentoring teams; and 6) inclusion of a clear and realistic timeline for investigating and publishing the project. All A-TRAC trainee pilot projects required FDA Center for Tobacco Products and NIH approval prior to project funding.In addition to pursuing a research project, A-TRAC trainees agreed to participate in the fellowship curriculum to learn about the scientific evidence around tobacco addiction, toxicity, health consequences, product diversity, product marketing, legislation, and economics. Institutional mentors of accepted trainees signed a mentoring commitment statement with their trainees. In addition, the trainees committed to attending 75% of the 90-minute weekly webinars and at least two in-person  annual meetings per year, one being the A-TRAC Annual Meeting with federal partners.Eligible applicants included current MPH, MD, or PHD candidates, post-doctoral fellows , early-career faculty, defined as investigators with less than 5 years’ experience in TRS. The applications received were from a wide array of disciplines, including toxicology, pharmacology, public health, nursing, medicine, and dentistry. The CEC required applicants’ institutional mentors to be A-TRAC grant principal investigators  working Wipfli et al. defined TRS competencies across six core domains and five specialized domains to guide emerging TRS curricula and training programs . Using t1.A needs assessment performed through an entrance survey at the beginning of each academic year also provided an opportunity to further understand trainees’ needs and interests relevant to TRS professional development skills. In addition, the needs assessment informed current and future expansion of our programming. Questions in the needs assessment are listed in Supplement We utilized a blended-learning, “flipped classroom”  approach to accelerate trainees’ career development  Table 11. ParticThe A-TRAC program elements align with the TRS training support provided by Center for coordination of Analytics, Science, Enhancement, and Logistics (CASEL) in TRS. The CASEL TRS Knowledge Center is a centralized online resource for over 1000 TRS investigators where they can access TRS-related events, announcements, learning materials, job postings, funding opportunities, data, and measure resources . CASEL pA recurrent feedback theme from the trainees over the last few years was the desire to closely collaborate with their peers across institutions. In 2020–2021 academic year, we piloted “collaboration pairs” among the cohort of trainees with the permission of their institutional mentors. The concept involved having an assigned partner from another institution who would be included as collaborator and potential middle author on a trainee’s project. Other ideas for collaboration included manuscript/grant writing and review.Another essential aspect of the curriculum is the face-to-face meetings during the academic year. Trainees committed to attend at least two in-person/virtual annual meetings over the course of the fellowship to enhance their ongoing learning and increase their exposure to professional efforts or networks in tobacco science. Pre-pandemic in-person/virtual meetings occurred during the AHA Scientific Sessions, Fall TCORS Grantee Meeting, and A-TRAC Annual Meeting.Russo et al.  reportedThe CEC mentors served as another level of mentorship. Our program provided biannual check-ins among mentors, mentees, and CEC personnel to scrutinize the strengths and opportunities to improve the mentoring relationship, the mentee’s productivity, and opportunities to improve the fellowship. Additionally, trainees served as peer mentors, providing accountability and feedback on the mentee’s progress, opportunities, and challenges.To evaluate the impact of our approach, we used mixed methods to conduct a robust educational and program evaluation. We employed the evaluation to promote continual improvement and innovation in TRS training while collaborating with the cross-TCORS training workgroups. Data from evaluations were analyzed and used in real time to facilitate ongoing CEC curriculum and programming quality improvement. The evaluation was designed to assess the curriculum’s efficacy, which was constructed based on TRS competencies. By evaluating the individual sessions, we indirectly evaluated the broader TRS competencies defined by Wipfli et al. .As part of the ongoing A-TRAC program evaluation, the training coordinator systematically distributed and collected evaluation materials. We conducted: 1) entrance surveys and needs assessments for new trainees; 2) weekly post-webinar evaluations to evaluate the effectiveness and value of weekly webinars; 3) mid-point and end-of-program satisfaction surveys to measure satisfaction related to overall CEC programming; 4) biannual trainee progress reports completed collaboratively by mentors and mentees to assess the progress of trainees; and 5) mid-point and end-of-program mentoring web-based check-ins between A-TRAC CEC mentors and trainees to assess the effectiveness of our mentorship structure.Trainees’ progress was assessed based on their stated goals, as well as in the following areas: published manuscripts, independent grant funding, FDA Docket comments submitted on TRS topics, TRS oral and poster presentations at conferences or educational venues, and research awards, recognition, or promotions in TRS field. Evaluations from 2014 through 2021 were reviewed and analyzed for relevant themes.We analyzed all qualitative evaluation materials using NVivo qualitative data analysis software . Using a grounded theory approach , one stuFrom 2014 to 2021 (A-TRAC 1.0 and A-TRAC 2.0), the fellowship accepted 35 trainees from eight institutions within the A-TRAC network .By analyzing trainees’ program evaluations and progress reports Table , we idenA key component of the A-TRAC training core involved the hybrid of video-enabled webinars and annual in-person  meetings. The requirement for all participants to use webcams enhanced focus and engagement, while the blended instruction approach allowed for geographically dispersed trainees to engage in experiential activities and facilitated networking with TRS faculty across the USA. One trainee noted: “Annual meeting and conferences were really valuable – Weekly meetings and frequent check-ins are helpful tool for accountability – Development of valuable expertise in TRS.” The virtual format allowed TRS experts nationwide to participate and present on their focus areas, thus broadening trainees’ TRS networks while providing focused training from leading scholars in the field. During the COVID-19 global pandemic, the virtual format of the fellowship provided a framework for continued training with minimal disruptions.The A-TRAC training core designed the curriculum using adult-learning principles including the concepts of self-directed, project-based, and experiential learning . In our 3), including learning objectives, trainees’ preparatory work, session timeline, experiential learning methods, primary post-webinar individual commitments regarding new goals and/or behavior change based on the webinar, and ongoing learning opportunities. This is exemplified in a trainee’s comment: “I enjoyed having preparatory assignments each week that allowed us to start building knowledge and skills prior to each session.” The continued learning opportunities were sometimes formulated as takeaway assignments, such as tasks to finish after the session was complete, to extend the learning process as trainees incorporated training, techniques, or strategies learned during the webinars into daily life , we incorporated a rd model ,24. RathTrainees learned how to request, receive, and give both feedback and feedforward effectively throughout experiential webinars, during peer presentations, and while meeting with their mentors. We built time into the curriculum for regular interactions regarding trainees’ work, focusing on specific comments about behavioral actions rather than on critiquing personality traits: A trainee remarked: “The presentation sessions on the webinars help the trainees to develop presentation skills and an ability to provide constructive criticism - both useful characteristics in scientific careers.”A focus on diversity and inclusion has been an important facet of the A-TRAC fellowship from the program’s inception. Based on theories grounded in the strength of interdisciplinary groups ,26 and pParticipants also were geographically dispersed, with trainees at varied institutions across the USA, which provided opportunities to collaborate across institutions. The interdisciplinary, culturally diverse makeup of the fellowship cohort lent itself to cooperative learning , broadenIn our analysis of the ongoing evaluation activities of the A-TRAC fellowship, we report that the program effectively combined several important characteristics to support new scholars in TRS. The blended medium of webinars and annual in-person/virtual scientific meetings allowed for regular interaction among geographically dispersed trainees. Our experiential curriculum, based on adult-learning principles, engaged students to learn, practice, and incorporate the educational material into their research and lives. Intensive multilevel mentorship at the trainees’ home institutions, as well as across the broader field of TRS, helped to bond all project components to support trainees through critical stages of career and professional development. The focus on feedforward, including learning the value of giving and receiving helpful critiques, is vital to future professional development. Trainee diversity created a forum for multidisciplinary learning and teaching, providing opportunities for peer mentoring, as well as cross-disciplinary and cross-institutional collaborations. In examining the broader literature pertaining to multisite, multidisciplinary training and mentorship programs, we note that the A-TRAC program is unique in its focus on experiential learning, as well as the importance of feedback and feedforward for development and peer learning.Through seminars, presentations, collaboration pairs, and informal discussion opportunities, trainees developed group cohesion, discussed sensitive topics in career and professional development, and engaged in opportunities for broader TRS networking. A potential weakness of online learning and training programs may involve the lack of connection and communication with trainers and mentors. In-person meetings were particularly effective for discussing complex and/or personal topics, such as work-life integration, resilience, mentorship challenges, and difficult interpersonal conversations, as well as for practicing presentation skills.The focus on mentorship instilled a strong sense of accountability within the fellowship. Not only were trainees accountable for acquiring TRS knowledge and experiences, they also were expected to develop professionally by filing Docket comments with the FDA and submitting manuscripts and grant applications. Throughout the fellowship, participants reported on specific goals during one-on-one meetings and regularly communicated research progress during webinars to obtain feedback.Although our analysis was based on program evaluation materials regularly collected from trainees throughout the A-TRAC fellowship, we identified other overarching components of the program that render it an appealing model for adoption in other fields: resource effectiveness, customizability, and scalability; needs-driven programming; and operations-level organization.In our innovative model, A-TRAC trainees learned in a cohort structure, in which experienced research CEC mentors in the training core serve as secondary mentors in addition to the trainees’ institutional mentors. Our model was designed to capitalize on the resource-effectiveness of the blended instruction approach that allowed a set of diverse and geographically dispersed scholars to learn together. The costs of annual in-person meetings were offset by the negligible expense associated with weekly webinars, which trainees joined from any location with an internet connection. Since webinar presenters were located at research universities across the country, it would have been impractical and expensive to bring all these scholars on-site for weekly meetings in a traditional classroom format.We envisioned that similar models could be employed to facilitate team science for other areas of research focus at both domestic and international levels. The A-TRAC model has served as a foundation for several other multisite and multi-institutional training programs within the AHA Strategically Focused Research Network (SFRN). The training program has been adapted by AHA SFRN Center grants including research training areas in Atrial Fibrillation , CardiomThe second central component of the A-TRAC fellowship’s success involved its focus on being driven by the needs of participants. We regularly captured program evaluation feedback to improve the fellowship. Trainees completed online pre-fellowship needs assessments, satisfaction surveys at the mid-point and end of each program year, and session-specific feedback forms after each webinar and in-person meeting. The systematic, consistent participant feedback helped to improve the program through filling gaps in TRS competencies and career development needs and providing cogent suggestions for future iterations of the fellowship.The third major component related to the success of the A-TRAC fellowship involved the operations-level organization. A program with this level of intensity and training was enabled by a Director of Training and Education. Previous and current A-TRAC Directors have possessed doctoral- or master’s-level training in related areas, including program evaluation, adult education, and public health and have maintained responsibility for managing and facilitating all components of training and program evaluation. The Director devoted time to meeting with each facilitator in-person or via videoconferencing at least once prior to sessions to assist with the development of curricula focused on principles of adult learning and spent time carefully considering changes to the curricula. The Director also was available to trainees for regular check-ins to maintain productivity and troubleshoot challenges.Our analysis of the A-TRAC program has strengths and limitations. By analyzing ongoing program evaluations, we were able to observe areas of growth and development in both the program and the trainees – and to track how improvements in program implementation have been integrated over time.However, we acknowledge substantive limitations. First, this is a study of program evaluation materials from one TRS program, limiting our ability to generalize to other programs or fields. Second, the evaluation relies on qualitative data analysis, and although we followed standard qualitative data analysis procedures, there exists a possibility for bias and oversight. Additionally, the number of program participants was relatively small, as our data were limited to the number of trainees enrolled in the first 7 years of the fellowship. However, the sample was relatively heterogeneous, with broad experience and histories to speak to the program’s overall function. The data sources also were from static time points and often had been designed to serve other purposes within the broader program evaluation.As technology continues to develop, connecting across distance becomes easier and more vital. For institutions considering new training and mentorship programs, creating web-focused interactive/experiential programming is promising and provides a scalable, efficient, and resource-effective educational method for fostering team science. Future work should consider both short- and long-term outcomes of the A-TRAC fellowship and similar programs, including career trajectories, publications, and successful grant applications.


Background: Orthopedic surgery is considered among the highly competitive medical specialties to get in as a career in the United States. San Francisco Match (SF Match) is the matching service for orthopedic subspecialty fellowship programs, and the internet is the main source for applicants to obtain program information in the modern era. We aimed to determine and compare the accessibility, content, and accreditation details of the various orthopedic fellowship programs available at the Match website and alternative online resources.Methods: We studied eight subspecialties  in a cross-sectional design during August/September 2019 for programs starting in July/August 2021. We registered the available baseline information at the SF Match site under various categories. We tried to reach the program-specific webpage through SF Match hyperlink and categorized our results into successful (direct and indirect) links and unsuccessful links with subcategorization. We also analyzed the information available at sponsoring society, FREIDA (Fellowship and Residency Electronic Interactive Database), and ACGME  websites.Result: We analyzed 465 programs (874 positions) available through the SF Match website. A standardized program description was available for >80% of the programs in each subspecialty. The availability of a successful link for the program-specific webpage ranges from 35% (Pediatric Orthopedics) to 77% (Sports Medicine). Indirect links were almost twice as common as direct links. The success rates through the sponsoring society webpages vary from 3% (Shoulder and Elbow) to 53% (Pediatric Orthopedics). Failure rates after trying both (the Match and Society links) range from 10%  to 34% (Shoulder and Elbow). FREIDA provides comprehensive information but is limited to accredited programs. ACGME accreditation rate varied from 14.6% (Foot and Ankle) to 98.9% (Sports Medicine).Conclusion: The selection of a subspecialty fellowship program is crucial for most applicants. There are plenty of resources for the orthopedic fellowship programs' online presence after two decades since the first orthopedic fellowship match inception. Match website is the primary resource for the applicants. All parties could be benefited if both the programs and the sponsoring societies offer adequate online information to the Match, leading to ideal fellow-program matches and improved educational experiences. Our study may stand as a reference for future comparison possibly due to post-COVID evolution in the Match process. We recommend that consistent availability of direct functional program website links, point-based program description, and filter/comparison options may further improve online accessibility and quality of the content of the Match website. Orthopedic surgery is considered among the highly competitive medical specialties to get in as a career in the United States . OrthopeIn 2008, four orthopedic subspecialties started participating in SF Match for the first time. By 2016, a total of eight subspecialties were involved in the match as follows: (1) Adult Reconstruction (Hip and Knee Arthroplasty), (2) Musculoskeletal Oncology (MSK Onco.), (3) Foot and Ankle (F&A), (4) Pediatric Orthopedics (Peds Ortho.), (5) Shoulder and Elbow (S&E), (6) Orthopedic Spine Surgery, (7) Sports Medicine (Arthroscopy), and (8) Trauma. In 2018, application deadlines, interview deadlines, and match result days for all the orthopedic subspecialties were made uniform like National Residency Match Program (NRMP). There have been various studies in the past to determine the online accessibility and scarcity of content in orthopedic fellowship program-specific websites for individual subspecialty sponsor websites and discuss its impact on the fellow-program selection process . HoweverWe studied all eight orthopedic subspecialties available through the SF Match website Figure .Adult Reconstruction (Hip and Knee) and MSK Oncology were considered as a single subspecialty in the SF Match. However, we have studied them separately as they have different affiliated societies and involve the treatment of different pathologies. We did not include the orthopedic hand surgery fellowship program as it participates in the NRMP instead of the SF Match, and it is open for general surgery and plastic surgery residents along with orthopedic residents.www.sfmatch.org) from August 5, 2019, to September 4, 2019, for the Orthopedic Fellowship Programs starting in July/August 2021. The period selected for online data collection was a typical application window for the upcoming match cycle. We used the Google Chrome® search engine (v. 76.0.3809), and we registered the baseline information of the SF Match website, which is uniform for all the fellowship programs irrespective of subspecialty. Afterward, we went through various subspecialties to collect data under different information headings. Besides primary program information , we extended our search for program descriptions and functionality of available program-specific website links. We reviewed the Match program description for each program to get a subjective idea about the program. We also analyzed relevant information like the percentage of programs where application deadline/interview dates were missing and whether research opportunity was available besides clinical training.We explored the Match website  no link, (2) non-functional link , (3) departmental link only (without any extension toward full program description), (4) link back to the SF Match (SF Match link/webpage), and (5) link to the sponsoring society (sponsoring society web page that required further search). Another reviewer also checked the unsuccessful departmental links before declaring them as a departmental link only without extension toward the desired web page. Irrespective of the category of such an unsuccessful attempt, we extended our search via the sponsoring society webpage and tried to reach up to the desired page. We recorded whether the sponsoring society webpage helps to reach up to the desired page if the attempt was failed or was unsuccessful through the Match website. We did not perform any random Google search with program names for the unsuccessful category or did not analyze program-specific web page contents.assn.org), ACGME website (apps.acgme.org), and sponsoring society website. We again registered uniform baseline information from these resources. We compared the current ACGME accreditation rate of programs in various subspecialties with the results published in 2014 by Daniels et al.  and Arthroscopy Association of North America [AANA]) and Orthopaedic Trauma Association (OTA) were having some missing programs. All other subspecialty society websites listed all the programs available for the match (except one missing program). Thus, sponsoring society’s website proved to be the second-best option after the Match web page for full program description search.The Match website provided a standardized program description window for each program Table .It always consisted of basic program details , contact details , personnel information , and timelines (application deadline and interview dates). The program description was available for most of the programs (>80%) in each subspecialty. The program descriptions were highly variable. It usually had information regarding the fellowship curriculum, current ACGME accreditation status, and eligibility criteria. The program description available on the Match webpage ranges from 81% (Adult Reconstruction) to 100% (Foot and Ankle). The availability of described research opportunities  ranges from 25% (MSK Oncology) to 95.3% (Spine Surgery).The results of a three-step sequential search for the desired program-specific webpage for each subspecialty are shown in Table The availability of a successful link for the desired page at the Match webpage ranges from 35% (Pediatric Orthopedics) to 77% (Sports Medicine). For most subspecialties, the availability of successful indirect links was almost twice as common as the direct links except for Pediatric Orthopedics for which it was almost equal. The success rate of sponsoring society webpage to reach out for the desired webpage in the unsuccessful category was quite variable, ranging from 3% (Shoulder and Elbow) to 53% (Pediatric Orthopedics) among the various subspecialties. The failure rate of reaching the desired webpage despite trying both (the Match and the Society) websites ranges from 10% (MSK Oncology) to 34% (Shoulder and Elbow).FREIDA website has the facility to filter programs by geographic region (or state), program type , qualification , visa sponsorship (H1B/J-1), salary, and working hours to narrow the search. FREIDA was uniform to provide three types of information. (1) Overview includes program location, positions, timelines, website, etc. (2) Faculty and fellow information includes exam/score requirements (USMLE/COMLEX), faculties (fulltime/part-time and physician/non-physician), fellows  and work and call schedules. (3) Program environment includes educational benefits , insurance benefits , time-off , employment benefits , and evaluation information (for fellow and program). The ACGME accreditation analysis of various subspecialties is shown in Table The highest percentage of fellowship programs accredited by the ACGME was in Orthopedic Sports Medicine (98.9%), compared to the lowest 14.6%) in Foot and Ankle. There are very handful of ACGME-accredited programs available for reconstruction/sports for the upper extremity. All Shoulder and Elbow subspecialty programs listed for the match are non-accredited. The ACGME accreditation rate of seven out of eight subspecialties has decreased (up to 18.6%) in the last five years (2014-2019) when compared with a study published in 2014 [.6% in FoThe selection of a subspecialty fellowship program is crucial for most applicants. Several factors play a vital role in the selection such as the applicant’s personal interest, geographic location, financial impact, and the program itself . Easy onFREIDA provides comprehensive information regarding programs but is only limited to ACGME-accredited programs. ACGME accreditation does standardize the programs for a minimum requirement and is considered one of the important factors in deciding the program selection. However, many orthopedic fellowship programs that are not ACGME accredited are available in the match. ACGME website is the most reliable source to confirm ACGME accreditation status because it provides up-to-date information, accreditation history, and withdrawal details if any. Except for Sports Medicine, the ACGME accreditation rate is not more than 60% for most subspecialties. The Shoulder and Elbow subspecialty is still not widely recognized as a subspecialty by ACGME. Moreover, there have been many programs for which ACGME accreditation has been withdrawn in the last few years. Spine Surgery, Sports Medicine, and Pediatric Orthopedics were among the top three subspecialties with decreasing overall ACGME accreditation rate when compared to a study by Daniels et al. in 2014 [After the Match, the sponsoring society’s website seems to be the second-best place to find the program information. However, a detailed program description was available only for half of the subspecialties at sponsoring society websites: (1) the American Orthopaedic Foot & Ankle Society (AOFAS), (2) Pediatric Orthopaedic Society of North America (POSNA), (3) North American Spine Society (NASS), and (4) Orthopaedic Trauma Association (OTA). The remaining four sponsoring society websites contain very limited or basic information. OTA has covered the trauma program description in a precise and meticulous way. However, international medical graduate (IMG) acceptance details were missing, which are covered by AOFAS and POSNA. Moreover, OTA covers 82% of programs, and NASS includes only 76% of programs of all participating in the Match. Thus, there is no option left but to look for the institutional website's program description for the remaining programs. SF Match webpage provides a successful link for 35%-77% of various orthopedic subspecialties. Again, almost two-third of successful links were indirect links. We found that search for the following terms was helpful to reach the desired page via the indirect link: ‘Education’, ‘Graduate Medical Education (GME)’, ‘Fellowship’, ‘Orthopedic Fellowship’, ‘Career’, ‘Residency training’, and ‘Other’. Among the unsuccessful/broken links, most of the time, there was no link or non-functional link. Links reaching up to department webpage can be time-consuming without end-result if proper search terms are not used. Rarely, there is just the SF Match homepage link (Pediatric Orthopedics and Sports Medicine) or the sponsoring society homepage link (Trauma) available instead of the program-specific webpage link. Overall, a failure rate of 10%-34% to reach out to the desired program webpage indicates the scope for improvisation.Besides, as per our knowledge, there are more than 10 orthopedic fellowship programs available across the United States, which are not participating in the match mainly because of the atypical nature of the subspecialty including but not limited to Hip Preservation, Limb Deformity Correction, Metabolic Bone Disease, and Geriatric Trauma. For such programs, the program-specific institutional webpage is mostly the only available option to get the program information.There were some limitations to this study. The accessibility evaluation was based on the SF Match, FREIDA, ACGME, and sponsoring society websites. We did not explore ABOS, AAOS, and direct search for program-specific webpages to limit our dataset. The online evaluations were performed during a fixed period. There is a chance of human or server error during website content review during the study. The Match program description section was not comparable because of discrete information instead of point-based attributes.To conclude, there are plenty of resources for the orthopedic fellowship programs' online presence after two decades since the first orthopedic fellowship match inception. Both parties (applicant and the program) could be benefited from adequate online information, leading to ideal fellow-program matches and improved educational experiences. Considering the organizational limitation of FREIDA, ACGME, and sponsoring societies, we believe that the Match website is the primary resource for the applicants. However, further coordination between participating programs and the sponsoring organizations may still improve online accessibility. Moreover, keeping the information up to date is also equally important. While this study pertained to orthopedic fellowships, the information obtained may be relevant for subspecialties outside of orthopedics. Our study may also stand as a reference for future comparison, possibly due to post-COVID evolution in the Match process. We recommend the following suggestions for the Match website that may further improve the online accessibility and quality of content: (1) Consistent availability of direct and a functional program website link as there is no alternative to it for complete authentic information; (2) point-based program description for important information; (3) addition of filters for important program attributes  besides currently available filters of state and application deadline; (4) provision of fellowship program comparison option within the subspecialty; and (5) direct video link for the program introduction if made available by the program.