Early career (EC) Earth system scientists in the Latin America and the Caribbean region (LAC) have been facing several issues, such as limited funding opportunities, substandard scientific facilities, lack of security of tenure, and unrepresented groups equality issues. On top of this, the worsening regional environmental and climatic crises call for the need for this new generation of scientists to help to tackle these crises by increasing public awareness and research. Realizing the need to converge and step up in making a collective action to be a part of the solution, the Latin America Early Career Earth System Scientist Network (LAECESS) was created in 2016. LAECESS’s primary goals are to promote regional networking, foster integrated and interdisciplinary science, organize soft skills courses and workshops, and empower Latin American EC researchers. This article is an initial step towards letting the global science community grasp the current situation and hear the early career LAC science community’s perspectives. The paper also presents a series of future steps needed for better scientific and social development in the LAC region. More specifically, LAC contributes 10% of the global CO2e emissions, where land use and change forestry is the major contributor4. This is mainly related to deforestation and forest fires due to agricultural, livestock and urbanization expansion processes, especially in the Amazon Forest5. In Central America significant warming trends between 0.2 °C and 0.3 °C per decade have been observed in the last 30 years. Long-term observed precipitation trends show an increase over south-eastern South America and a decrease in most tropical land regions. On the Atlantic coast of South America, the rate of sea-level rise is higher than the global mean (~3.6 mm yr−1) and is lower along the Pacific coast (2.94 mm yr−1). Similar results were observed on the Caribbean Sea/Gulf of Mexico side (3.7 mm yr−1) and the Pacific side (2.6 mm yr−1)3. CO2 absorption by the seawater also results in lower pH values, which is known as ocean acidification. In South America, ocean acidification is affecting the Humboldt Current, one of the world’s four major upwelling systems, provoking negative impacts on key ecosystems6. Moreover, recent studies showed that the rate of glacial mass loss in the entire Andes Mountains amounted to −0.72 ± 0.22 meters of water equivalent y−1 from 2000 to April 20187. As the Andes glacier volume loss and permafrost thawing increase, there will be significant reductions in river flow and potentially high-magnitude glacial lake outburst floods8. The coupling between Earth-Climate systems should also be considered, for example: it has been demonstrated that the Amazonian biomass burning reaches the Andean glaciers, which accelerate its melting9, and consequently raises sea-levels. This directly affects coastal areas like the Caribbean, Guatemala, Colombia, Venezuela, Brazil, Uruguay, Argentina, among others. All of these changes result in biodiversity losses10. In LAC, biodiversity hotspots and areas of high endemism are abundant. The LAC region contains about 60% of the global terrestrial life and diverse freshwater and marine species, 12% of the world’s mangrove forests, the most extensive wetlands, and 10% of the world’s coral reefs. However, there has been a decline in species abundance and a high risk of species extinction12.The impacts of climate change in the LAC region are observed in the atmosphere/hydroclimate, oceans, and cryosphere which directly impact the biosphere. They have been identified and quantified as altered precipitation regimes, higher atmospheric and sea-surface temperatures, higher risks of droughts, increasing aridity, glacier mass loss, relative sea-level rise, higher intensity of tropical cyclones, marine heatwaves and significant loss in biodiversity13. The socio-economic conditions of the region, characterized by poverty and high inequality, increased the vulnerability to these scenarios14. For example, considering the importance of the agricultural sector in LAC in producing food and ecosystem services for the entire planet16, the climate change impacts will affect food production, processing, storage, transport, and distribution, which could impoverish the regional economies17. In addition, populations located in the remote areas of LAC, indigenous people, and communities dependent on agricultural or coastal livelihoods will be especially at risk19. Additionally, climate change increases vector and viral diseases’ development and spread, resulting in worldwide consequences22.When combined and extended into the economic and social dimensions, all these impacts provide excellent conditions to exacerbate socio-economic distortions and inequalities in the LAC region23. Eighteen LAC countries highlight the importance of climate change for the population. On average, 83% of the people in these eighteen countries agree that anthropogenic activities are the leading cause of the impacts, and 70% agree that mitigation and adaptation should be a priority24. Most individuals in LAC see the issue of climate change as a serious threat25. This can result from local communities witnessing regional impacts, as described in Section 1.1. This awareness is dependent on the regional historical context and level of education24. Education is one of the main drivers of public engagement. However, in recent years the rise of the scientific scepticism movement as part of climate change denial is one of the reasons why science is not recognized as important by both the public and the governments24. A recent study by Soh (2019)26 notes that in LAC the relative distancing of the general public from the benefits of scientific discovery has made science and technology funding an easy political target for fiscal restraint in an economic downturn. Therefore, EC scientists have had to change their approaches to reach the public and change the perception of environmental and climatic issues. By enhancing EC networks like LAECESS, these new approaches can be addressed collectively.General public information and perception are essential to combat climate change, not only by changing their lifestyles but also by voting for decision-makers that can promote environmental protection policies. In the past five years, there has been increasing awareness (from 56 to 67%) of climate change as a threat25, the increasing perception of the severity of climate impacts needs to be aligned with concrete actions to minimize climate change impacts. Mitigation strategies can improve energy generation, urban transport, agriculture, food distribution, and population health with public support. The World Economic Forum27 highlighted the focus on expanded investments in research and innovation to allow new markets for the future, embracing diversity and inclusion. Thus, science should be transparent, easy to understand, and integrated into life.Although the local political context does not promote an environment to debate and shape new attitudes28. From 2010 to 2019 the number of students enrolled in higher education programs increased by 38%, while the amount of money spent for the same period was, on average, 1.3% of the gross domestic product29. Of the total number of graduates during 2019, 35.7% were from Education, Natural sciences, Technology, and Engineering, while 64.3% studied Arts, Humanities, Business, and Welfare courses related, considering the entire LAC29. Argentina and Puerto Rico are the countries with a higher percentage of graduates in the Natural science field.While many Latin America and Caribbean (LAC) region researchers aim for a high level of research, they are constrained due to lack of funding support, limited access to grant opportunities, substandard laboratory facilities and equipment, low salaries, and lack of tenure security30. The employment rate recovery occurs for informal jobs . In turn, brain drain takes place31. This type of migration, where highly skilled professionals leave their home countries seeking for better working conditions just increased over the years32. In average, 10 to 40% of the LAC brains went to the U.S. over the last five years33. Many researchers, especially EC scientists, decide to leave the region, looking for proper venues and adequate support34. Researchers find more freedom, stability, resources, and grants to implement their scientific endeavours in many developed countries abroad, especially if they have the chance to perform study or training during master’s or Ph.D. degree35.There are not enough research positions in LAC scientific institutions to absorb outstanding investigators. According to the International Labour Organization, millions of formal working positions were lost in Latin America during the last four years, with an impact on women and youth36. The number of graduates in LAC increased by 42% in one decade29, with the highest numbers from Chile, Uruguay, Brazil, and Argentina, respectively 37 37 Fig. . The num)37 Fig. . Over thDue to the immediate impacts caused by climate change in most areas in LAC, in this paper, we call for a comprehensive research system and more significant support for the EC of LAC researchers, which is crucial to ensure more robust scientific research and clear career paths for EC researchers.44. However, many studies have been conducted to disprove this idea and encourage gender equality policies to correct the imbalance between men and women in science45. Despite all these efforts, a considerable challenge for implementing equitable policies is the lack of information on the extent and magnitude of gender imbalance in science in nations with low research and development expenditure46.Historically, Science, Technology, Engineering, and Mathematics (STEM) has been traditionally patriarchal and has cultivated a false assumption that men are innately well-suited for scientific research while women are not47. It is important to note that these are total numbers for scientific publications and are not separated by gender. If gender disparity is considered among these five countries, only Argentina and Brazil have achieved gender parity in the number of women employed in research49. The ranking suggests that inequalities might be worse in countries where science suffers from a substantial lack of funding50, which might prevent the creation of programs that stimulate the increase of women in science.According to the Scimago Country Rankings, most of the scientific publications authored by researchers in the LAC region from 1996 to 2020 were produced by five countries - Brazil, Mexico, Argentina, Chile, and Colombia, covering 88.26% of all scientific topics and 86.56% of environmental science51. In general, the UIS numbers are based on headcounts, the total number of women employed in research and development, and therefore do not differentiate STEM from other sciences with higher women representativeness . Additionally, the total numbers lack an explanation for the larger gender disparities in senior levels, the large gap in authorship positions associated with seniority, the fewer women authors in prestigious journals, and the higher number of men to be invited by journals for paper submission52.In 2019, the UNESCO Institute for Statistics (UIS) presented data on the number of women employed in research and development. Although the rate of employed women in the LAC region (45.1%) represented relatively good performance in worldwide indexes of gender parity in science, especially when compared to the global rate (29.3%), women researchers in LAC still face many challenges as discrimination, unequal pay and funding disparities when pursuing a career in sciencehttps://www.thestemvillage.com) that offer a platform for improving LGTBIQA+ visibility, but it has not been found statistics that could provide a better perspective of this community within LAC scientists. In addition, other groups such as Black people, indigenous, and mestizos face consequences of inequalities within STEM in LAC. The racialized structure of STEM higher education perpetuates enormous disparities resulting from structural racism, which informs and is reinforced by discriminatory beliefs, policies, values, and resource distribution53. In LAC, in countries like Mexico and Brazil, mestizaje, or racial and cultural mixing, were projects advertised as the symbol of the nation and the hope of its future to offer an idea of high tolerance in LAC; however, behind this idea, the mestizaje had a role by encouraging mixing to further whitening, by denying Black and indigenous identities and cultures, and by homogenizing the racial and ethnic distinctions necessary for anti-racist mobilization54. These historical facts have certainly impacted the under representativeness of these groups within STEM in LAC, but the lack of studies prevents us from showing statistics for the whole LAC. This presents an acute symptom of the reality in LAC, in a sense that discussions on the representativeness of Black people, indigenous, and mestizos are still very preliminary within STEM in LAC and that scientific research on this topic is probably concentrated in humanities and social sciences.Other groups are underrepresented in STEM in LAC institutions. The LGTBIQA+ group is one of them. However, we have not found studies that directly tackled the representativeness of LGTBIQA+ within STEM in LAC. Our searches brought to us blogs and organizations  were the least affected, whereas Black women and mothers were the most impacted scientists49. These impacts are likely a consequence of the exacerbated unequal division of domestic labor during the pandemic, and that racism strongly persists in academia, especially against Black women; in addition, EC scientist women (regardless of race) might have been disproportionately affected since the early career period aligns with the reproductive age of these women58. Young children require much more attention and care, which was exacerbated during the period of social isolation. That can reduce the number of hours dedicated to research and likely to paper submission58. These recent studies suggest that the pandemic will have long-term effects on the career progression of these already underrepresented groups and that affirmative policies are urgently needed for reparation.Recently, the socio-economic crisis imposed by the COVID-19 pandemic has intensified the problems faced by underrepresented groups in LAC. Gender, race, parenthood, and intersectionality are essential factors in assessing how the pandemic has affected scientists. Recent studies have shown that women and mothers are the groups taking the strongest hit in academia in the US and Europe, with lower rates of paper submission and publication, as well as fewer grant proposal submissions during the pandemic59. Therefore, the combination of limited funding and poor working conditions promotes a reduction of women in science and can create a collateral brain drain, with Latinas moving to high-income or less-unequal countries to pursue a career in science. The contribution of other underrepresented groups—LGTBIQA+, Black people, indigenous, mestizos—within STEM in LAC and their intersectionality need to be further investigated to offer a deeper view of the current situation. Within the LAECESS network (see next section), we expect to boost discussions on how to increase the number of underrepresented groups in science, especially in Earth system sciences, including discussions on promoting their access to seniority positions within their countries. For the LAECESS network, it is imperative to increase the number of underrepresented groups as diversity is a keystone for building high-quality and innovative science61.In summary, despite recent progress, the gender disparity in LAC science is likely to persist for generations. Gender imbalance in the LAC region is deeply affected by Latino cultural stereotypes, notably contributing to Latinas leaving academia62 and IGAC 63. These two networks, hosting conferences every two years and plenty of webinars during the year, are global networks. iLEAPS has regional ECS groups whose goal is to provide opportunities to meet and engage with their interdisciplinary international broad community, where ECS can connect with established scientists through workshops, training events, and regional networks. On the other hand, IGAC has regional networks, such as IGAC Americas Working Group , which goal is to contribute to the development of a scientific community focused on building collective knowledge in/for the Americas including training and fostering the next generation of scientists64. Both groups often meet at conferences, and some members were or are part of both networks. In this sense, LAECESS founders felt the need to widen and join these two LAC ECs groups into a broader network. The networks above are still active, and LAECESS serves as a bridge between both ECS communities.The creation of the Latin America Early Career Earth System Science Network (LAECESS) was motivated by bringing ECs together, joining the members of two Latin American EC Groups: iLEAPS (integrated Land Ecosystem—Atmosphere Processes Study)Since its foundation in 2016, LAECESS has been an open platform for Earth system scientists with origin and/or research interests in Latin America to connect and share knowledge. LAECESS’s primary goals are to promote regional networking, foster integrated and interdisciplinary science, organize soft skills courses and workshops, and empower Latin American EC researchers.th 202165), periodic blog posts, where members share career advice, views on scientific topics with a communication outreach approach  and brief reports explaining our research to a broader audience. Additionally, LAECESS currently has social media accounts and hosts a permanent website, all interconnected and moderated by different steering committee members who frequently communicate with each other. This cooperative way of managing our social media brings different views and discussions to the table, always empowering and respecting our diversity of thoughts, cultures, and scientific limitations. Moreover, we use a mailing list to share job offers, funding opportunities, scientific studies, research questions, and a biannual newsletter.The LAECESS network has grown over time and currently holds 115 young scientists, including 25 on its steering committee. Over its six years of existence, LAECESS has organized multiple activities, including presentations at conferences, webinars, EC breakers in conferences and workshops 68, ILEAPS62, IGAC63, Fluxnet, Ameriflux, APECS (Association of Polar Early Career Scientists) or the Polar Science Early Career Community Office (PSECCO). Additionally the reason for not merging with other networks is the scope of the networks. LAECESS has a LAC-based scope, different from other networks. For instance, the network YESS (Young Earth System Scientists Community), which has a more worldwide scope, is an interactional EC network in climate and meteorology closely related to the World Meteorological Organization67. On the other hand, the networks APECS or PSECCO are very specific to the cryosphere. Nevertheless, we have LAECESS members in many networks who actively collaborate and have promoted internal communication regarding events, opportunities, and future projects.One key aspect of LAECESS is the networking diversity of its members who at the same time, are members of other important networks, enhancing LAECESS visibility and outreach. These networks are YESS (Young Earth System Scientists Community)After six years since its origin, LAECESS’s has become an active early career network. No matter where our members go, they keep strengthening our network, creating links with each other, and promoting the LAECESS goals. LAECESS’s biggest asset is its membership because even though members live in almost every time zone, we remain connected. LAECESS continues to invite everyone, regardless of gender, ethnicity, color, and origin. Our collective effort is our strength.LAECESS has identified priority actions to improve the LAC region’s scientific environment during these years. particularly for early careers. Namely, these are network sustainability over time, the need for a regional open-access information repository, improvement in scientific communication, early career involvement in decision-making, improved research funding opportunities, collaboration with other networks and initiatives, and increased representation for women in LAC earth science careers.Given the early career nature of LAECESS, as for any other early career network, there is a continuous flow of people in the network, and for it to be sustainable over time, a clear strategy must be established, such as mentoring activities from former chairs to new ones. In addition, communication among network peers is critical. In this regard, a monitoring plan is necessary always to include and engage incoming members. Some tools for achieving this purpose would be: (a) a clear description of the network’s purposes and expressing the need for this network for the Latin American Earth System Science community, and (b) training activities and an organizational structure for new members to follow.69. However, future and current challenges for earth system scientists in the region will require strong collaboration among research groups. LAECESS proposes an electronic LAC platform where the research groups could be listed and georeferenced. This platform would contain basic information about each group and observatory stations and modeling tools (including open data), and researchers can easily contact one another. This approach would significantly enhance LAC region scientific collaborations and consequent development. The change of research workflows and practices toward Open Science approaches requires efforts beyond the individual initiative. Universities and research institutions are required to design Open Science strategies and to implement the necessary technology to improve the transition.The scientific LAC community would greatly benefit from public access to journal collections and data repositories. Some effort has been made in such regard with the SciELO initiative40. In this sense, LAECESS is getting closer to the general public and is becoming a critical scientific communication tool by maintaining a webpage (https://laearlycareer.wixsite.com/latinamericaecess), posting multilingual posts on social media, organizing webinars, and currently working on an Earth Science divulgation podcast channel. Since LAECCES has no direct access to funds, this initiative focuses on highlighting the EC researchers’ work, sharing different calls and job offers as a strategy not only to share and divulge knowledge but also to expand the reach of young scientists in LAC. A potential new field for LAECCES is to develop funding requirements from research bodies to support the network.Scientific communication is essential for generating impactful results and social engagement. EC scientists would greatly benefit from tools and techniques for effective communication. Scientists should be able to attractively engage with the general public by understanding the broad implications of their research, understanding their audience, and adapting their speech for non-technical audiences. One crucial step to improve scientific communication would be hiring scientific journalists to assist in science dissemination and outreach. Scientific journalists can also help train the LAC research body (including students), promoting public outreach via science fairs and exhibitions and multilingual scientific communication. We identified the need for funding opportunities for early career and established scientists that support these types of interdisciplinary interactions. Some efforts have already been made in the LAC region, such as RedLCC (by its acronymous in Spanish Red Latinoamericana de Cultura Científica), RedPop (Latin American and Caribbean Network for the Popularization of Science and Technology), the bilingual science communication portal Latin American Science and the Journal of Science and Communication (JCOM) América Latina41. However, the participation of EC scientists is scarce due to the limited space in decision-making combined with a lack of science policy and diplomacy training. Closer collaboration among mid-careers scientists, late-careers scientists, policy-makers, and diplomats could solve this scarce participation as well as encourage industries, companies and governments to link young career scientists considering the climate challenges for the next 10 years41 41. Governments, universities, and scientific institutions in LAC could adapt successful international programs to incorporate EC scientists into the science policy and science diplomacy areas. Two examples of these programs are the Colorado Science & Engineering Policy Fellowship (https://coscienceengineeringpolicyfellowship.com) and the Research Fellows at the European Commission (https://ec.europa.eu/jrc/en/working-with-us/jobs/vacancies/function-group-iv-researchers).There is a need to improve interactions with decision-makers. In the LAC region, there are great examples of opportunities to develop science policy and diplomacy skills, such as the Inter-American Institute for Global Change Research projects and initiatives such as the Science, Technology, Policy (STeP) fellowship program or the Latin America and the Caribbean Open Science Forum (CILAC in Spanish)Additionally, the participation of EC scientists in town hall meetings, policy brief developments, and decision-making platforms is crucial to sharing their knowledge with society. Here scientific communication, especially on social media, become essential by providing EC scientists with a flexible, dynamic, and direct option to share scientific knowledge with the general public.Research funding in the LAC region is needed for the technological and innovation development of the region, and in LAC, funding mainly comes from governments. Therefore, LAC-based funding opportunities are limited compared to other areas of the world where funding is expanded to private or independent research institutions. The collaboration with Europe has allowed for some advances, such as EURAXESS Latin America and the Caribbean (which links researchers in LAC countries with Europe) or the EU-CELAC platform . Additionally, LAC researchers are allowed to apply for Horizon Europe grants. However, these opportunities are not LAC-based, and progress into building LAC funding must be pursued. In this sense, the UNESCO-CEPAL, the Interamerican Development Bank, or Mercosul offer some funding opportunities for scientific research that are valuable but still scarce to fill the LAC research requirements.The LAC early career scientists would greatly benefit from creating an open-access database or search engine with potential available funding opportunities at all levels, including individual funding, collaborative funding, private funding, training opportunities, and guidelines for successful applications. LAECESS is currently working on implementing such a project. To achieve this, collaboration among local and regional research networks to help gather this database and to build a search engine is essential. Additionally, an important asset would be the involvement of senior scientists to share examples of previous funding opportunities and collaborative projects in the LAC region that received international funds.There is a need to include a wide range of stakeholders in the knowledge production process. In this regard, engaging in transdisciplinary initiatives is beneficial for both the academic and non-academic worlds. This endeavour requires early career networks, such as LAECESS, to advocate for improved research programs open to contributions from practitioners, the private sector and communities.LAECESS has collaborated with other early career and non-early career scientific networks to promote and organize seminars and is currently working to develop a podcast channel, webinars, and a resource database. An area of opportunity for LAECESS to increase the exposure of LAC research could be the collaboration with U.S.-based organizations with Hispanic and Latin-American branches. Examples are the American Meteorological Society Committee on Hispanic and Latinx Advancement (AMS CHALA), the Caribbean Institute for Meteorology and Hydrology, or the Society of Latinxs/Hispanics in Earth and Space Science (SOLESS). Some of these organizations have experience with collaborative efforts across academic institutions, scientific networks, and governmental agencies that could help LAECESS structure a path for establishing these types of connections in the future.As described in section 1.4, LAECESS recognizes the need to increase the representation of underrepresented groups in LAC. To that end, we are working on creating social media content to boost discussions on how to increase the number of women and other underrepresented groups in science, especially in Earth system sciences; this includes discussions on how to promote women’s access to seniority positions within their countries of origin.Tacking current environmental issues in LAC and the world requires joint international efforts and rethinking how scientific knowledge is fed into policymaking. Additionally, the inclusion of the whole society in the knowledge production process is vital to better understanding current problems and finding prompt and efficient solutions to them. The situation in the LAC region is of special importance due to current socio-economic conditions that prevent EC scientists from pursuing a career in the region. In this sense, the LAECESS network was created to promote regional networking, foster integrated and inter- and transdisciplinary science, organize soft skills courses and workshops and empower Latin American EC researchers. Yet, much work is still ahead of us. For better scientific and social development in the LAC region, we prioritize future steps to improve network sustainability over time, the need for a regional open-access information tool, the improvement of scientific communication, EC involvement in decision-making, and work towards enhanced research funding opportunities.


To ensure an adequate supply of N95 respirators in response to the global shortages caused by the COVID-19 pandemic, we evaluated and implemented hydrogen peroxide vapor (HPV) to reprocess disposable N95 respirators. Previous work performed by our team showed that HPV was effective in eradicating viable viruses from experimentally contaminated N95 respirators and that they retained their breathability and filtering efficiency for 3 cycles of HPV disinfection.A multidisciplinary team worked by performing experiments and PDSA cycles to develop the ultimate process. Key processes and stakeholders were identified and engaged in operations decisions.The respirator reprocessing program was successfully implemented. One of the critical components for its success was the implementation of a Personal Protective Equipment (PPE) liaison program which was developed to create a process and local, unit-level champion for the collection of used N95s and to educate the staff on the program and provide guidance per the hospitals’ PPE policy. A courier system was implemented for the collection, transport and delivery of bulk containers of respirators between facilities. Facility Services designed and constructed a centralized respirator reprocessing center to include a receiving location, a negative pressure decontamination area to sort and stage the respirators on racks, two HPV reprocessing rooms and a clean room to receive the reprocessed N95s and to repackage and label for distribution. Standard operating procedures, staff training and competencies, and logs for documentation were created.Within 18 weeks , nearly 32,000 N95 respirators were reprocessed and packaged for redistribution utilizing the 2 HPV disinfection rooms and 5 full time employees. As built, there was capacity to reprocess 5,000 respirators per day and evaluated by the U. S. Food and Drug Administration (FDA) led to the issue of an Emergency Use Authorization.This scalable program enabled YNHHS to ensure an adequate supply of respirators for the safety of staff during the COVID-19 pandemic and global shortages of PPE. A multidisciplinary team and leadership commitment to provide resources for space and personnel were critical for program success.All Authors: No reported disclosures.


Strong cultures of mentorship and research remain underdeveloped at many African universities, threatening future knowledge generation essential for health and development on the continent. To address these challenges, a mentorship program was developed in 2018 at the University of Zambia with an aim to enhance the institutional culture of mentorship and to build institutional capacity through an innovative ‘train the trainer’ faculty development model. In this study, we documented perceptions of lived experiences related to mentorship culture by following trainers and trainees and their mentees over two years. We analyzed these perceptions to assess changes in institutional attributes regarding mentorship. We identified positive change in institutional culture towards mentorship, and this change appeared sustainable over time. However, a slight decrease in indicators for year two emphasizes the need for a continued culture of learning rather than assuming that one-off training will be sufficient to change culture. Organizational change (OC) has a profound impact on an organization’s performance, innovation, creativity, and strategy as well as employee engagement and performance 234567. W23456Yet institutional perspectives on change and learning recognize that institutions are not easily altered . Weber  refers tWithin this context, public universities are bound by regulations, policies, and legislation that differ from the private sector. Institutional learning in this context is constrained by the inflexibility of a large and complex system, and innovation can be considered risky. Literature has shown that some African universities remain inflexible, and the culture of mentorship and research remain underdeveloped, threatening future knowledge generation that will be essential for health and development in general 1314. Whi13As part of a training program to enhance the PhD programs at the University of Zambia (UNZA) , a needsThe program provided a structured approach to mentoring practices for senior and junior faculty to better support graduate students at UNZA. The needs assessment and a literature review of mentorship best practices informed the development of the program’s ten modules, which include topics on communication, conflict resolution, diversity, effective leadership, establishing goals, ethics, evaluating mentorship, fostering independence, professional responsibilities, and writing one’s mentorship philosophy. The modules are taught over five day-long workshops. In preparation for workshops, trainees read peer-reviewed articles on mentorship topics. During the workshop, they engage in small and large group discussions and analyze case studies on those topics. Trainees also craft their own mentorship philosophy to guide their practice. Since the program launch in 2018, 71 faculty members have been trained through this program, which has been replicated with a goal to train all health sciences faculty at UNZA.We conducted a program assessment using a standard ‘mentoring culture audit’ developed by Zachary . The aud18Mentoring as it is currently practiced clearly aligns with the organization’s values’ and ‘The organizational culture supports mentoring’ . These areas of growth indicate that participants noticed an increase in organizational support for mentorship activities.Overall, participants’ mean ratings of UNZA’s mentorship culture as measured by the 15 indicators increased by 3% two years post-program. The areas of greatest growth included ‘Mentoring results are measured over time,’ ‘Mentoring is linked to leadership development,’ ‘Mentoring as practiced in the organization incorporates best-practice models of adult learning,’ and ‘Organizational leaders actively promote individual and organizational learning’ . Similar to program participants, their mentees noted increased organizational support for mentorship. However, they also perceived increases in organizational support for leadership and learning. It appears that mentorship training and growth in the mentorship culture potentially had spillover effects to leadership and learning.Mentees’ mean ratings of the mentoring culture increased by 6% two years after the program. The largest areas of growth were in the indicators ‘Institutional mentorship culture is important for developing the next generation of researchers, scientists, and practitioners. While mentorship training programs exist globally, their impact on institutional culture beyond individual benefits has not been well described. In this study, we documented baseline culture of mentorship and institutional leadership and followed participants and their mentees over two years to assess changes in institutional attributes that support mentorship. Cultural change often occurs slowly over a long time period, and seemingly small shifts can be impactful in an organization. Although small, we identified positive changes in institutional culture towards mentorship, and this change appeared sustainable over time. The slight dip noted in year 2 indicators emphasizes the need for a continued culture of learning rather than assuming one-off training will be sufficient to change the culture. Incentives coupled with refresher courses and systems that reward mentorship will be needed to help continue cultural change.Two core principles guided this capacity strengthening approach. First, senior UNZA faculty directed and led the curriculum development process in consultation with Vanderbilt partners to facilitate context-appropriateness, ensure sustainability, enhance their knowledge, and hone their mentoring skills. Second, junior faculty participated in the program, developing their mentoring skills to guide the next generation of graduate students and future faculty. Because UNZA senior faculty led the curriculum development and implemented the program, such an approach could result in institutional change and reduce inflexibility that is known to exist in such institutions. We noted that at baseline, senior faculty did not recognize the gaps in mentorship and institutional cultures that existed at UNZA. This might have hindered real change. Instead of addressing these gaps through traditional avenues such as policy briefs and institutional surveys, the approach adopted here included development and implementation of a mentorship training guided by best practices in the field. The literature supports our results that culture can change but such change requires time and deliberate investment. Boss et al.  reportedSolving complex global challenges requires a broad cross-section of expertise in diverse fields. Formalized mentorship programs such as the UNZA Faculty Mentor Training Program help strengthen the human resource capacity needed to build the next generation of leaders, researchers, and practitioners to address local and global challenges. Such programs require buy-in and support from institutions, governments, and individuals for long-term sustainability. One of the UNZA senior mentors remarked, “I am now an advocate for structured mentorship at the school level.” This perspective speaks to the importance of viewing mentorship as an institutional value driven by both senior and junior leadership.The positive outcomes of mentorship for both the mentor and mentee, as noted in literature and now reported in our study, have prompted the attention of major research agencies like the United States National Institutes of Health to advocate for mentorship as part of institution capacity strengthening. We support these initiatives to promote institutional culture of mentorship as a catalyst to research and leadership development for the next generation of researchers and scientists in Africa and other regions.The additional file for this article can be found as follows:10.5334/aogh.4032.s1Trainee and mentee data set.Data and analyses from the 2018 and 2019 cohort trainees and their mentees.


Promoting residents’ wellbeing and decreasing burnout is a focus of Graduate Medical Education (GME). A supportive clinical learning environment is required to optimize residents’ wellness and learning.To determine if longitudinal assessments of burnout and learning environment as perceived by residents combined with applying continuous quality Model for Improvement and serial Plan, Do, Study, Act (PDSA) cycles to test interventions would improve residents’ burnout.From November 2017 to January 2020, 271 GME residents in internal medicine, general surgery, psychiatry, emergency medicine, family medicine and obstetrics and gynecology, were assessed over five cycles by Maslach Burnout Inventory (MBI), and by clinical learning environment factors . The results of the MBI and clinical learning environment factors were observed and analyzed to determine and develop indicated Institutional and individual program interventions using a Plan, Do, Study, Act process with each of the five cycles.p < 0.001), self-defined burnout (p = 0.013), program burn-out support (p = 0.002) and program back-up support (p = 0.028). For the Internal Medicine Residency program, there were statistically significant improvements in all three MBI factors (p < 0.001) and in clinical learning environment measures (p = 0.006 to < 0.001). Interventions introduced during the PDSA cycles included organization-directed interventions , and individual interventions .The response rate was 78.34%. MBI parameters for all GME residents improved over time but were not statistically significant. Residents’ positive perception of the clinical supervision by faculty was significantly and independently associated with improved MBI scores, while residents’ self-defined burnout; and impaired personal relations perceptions were independently significantly associated with adverse MBI scores on liner regression. For all GME, significant improvements improved over time in residents’ perception of impaired personal relationships (In our study, for all GME residents, clinical learning environment factors in contrast to MBI factors showed significant improvements. Residents’ positive perception of the clinical learning environment was associated with improved burnout measures. Residents in separate programs responded differently with one program reaching significance in all MBI and clinical learning environment factors measured. Continuous wellbeing assessment of all GME residents and introduction of Institutional and individual program interventions was accomplished.The online version contains supplementary material available at 10.1186/s12909-022-03366-y. Burnout has been described as a prolonged response to chronic emotional and interpersonal stressors on the job defined by three dimensions: emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment , 2. AccrIt has been suggested that the origins of burnout among residents are rooted in the learning environment. Vendeloo et al. found strong and consistent inverse association between the perceived quality of the learning environment and burnout among residents in a Dutch national study. They concluded that the learning environment is of key importance in preventing resident burnout . A studyIt is well documented that after entering training, residents’ burnout rates increase significantly compared to their peers , 6–8. A Drybe et al. noted that limited data are available regarding how to best address trainee burnout, but multi-pronged efforts, with attention to culture, the learning and work environment and individual behaviors, are needed to promote trainees’ wellness and to help those in distress . IndividTherefore, the objective of this study was to determine if longitudinal assessments of Maslach Burnout Inventory (MBI) scores and perceptions of the clinical learning environment by residents at approximately six months intervals as outcome measures over five cycles using principles of improvement science and a Plan Do Study Act process with the introduction of institutional and individual program interventions would be associated with improvements in the outcome measures. Our hypothesis was that using the Model for Improvement and serial Plan, Do, Study, Act cycles to test interventions would improve residents’ burnout.This is a report on a continuous quality improvement model utilized by GME to improve burnout and wellbeing perceptions of residents by burnout and program clinical learning environment surveys obtained from residents using time-series evaluation at 5 points from November 2017 to January 2020. Using a PDSA process, at each time point, residents’ survey results were analyzed by the GME analyst and Designated Institutional Officer (DIO), the data was reviewed with program directors, and interventions implemented by program or GME administrators as indicated.We used the PDSA continuous quality framework construct. The first step in the cycle is the Plan step which involves identifying an aim or purpose, formulating a theory, assembling the quality improvement team, defining process, outcome or balancing metrics, determining changes or interventions to be tested and putting a plan into action. This is followed by Do step in which the plan and interventions or changes are implemented, and relevant data are collected. In the Study step, the team monitors and reviews the outcomes to test the validity of the plan and interventions for signs of progress and success, or problems and areas for improvement. The Act step closes the cycle, integrating the new knowledge generated by the process, which can be used to adjust the goal, change methods, reformulate a theory altogether, or broaden the learning-which leads into the next PDSA cycle. These four steps can be repeated over and over as cycles of continual learning and improvement .The GME office at Arrowhead Regional Center includes ACGME accredited programs in Internal Medicine, Emergency Medicine, Family Medicine, Obstetrics & Gynecology, Psychiatry and General Surgery. The GME office initiated the conduction of a bi-annual well-being survey of all residents beginning in the Academic Year 2017/2018. The Mid-Year Well-Being Survey was conducted from November to January, while the End-of-Year Well-Being Survey was conducted from April to May. All residents were surveyed using longitudinal web-based survey instruments. The surveys for this report included the full MBI (22 items); and a program clinical learning environment survey which included sub-sets on: impaired personal/social relationships (3 items), self-defined burnout (1 item), program burnout support (2 items), program back-up support (3 items), clinical educational supervision (4 items), and sleep difficulties (1 item) .The learning environment survey was developed by the GME staff analyst based on a review of the literature and knowledge acquired from working with program directors and residents on wellness. Face validity was conducted by the DIO and program directors who evaluated, reviewed, modified, and finally determined that the surveys tested the intended themes.The results of each survey were compiled by a GME analyst and reviewed with the Designated Institutional Officer (DIO). The DIO used the wellbeing survey findings in combination with other data such as the ACGME survey results to strategize and implement institution-wide action plan and interventions. The unique data for each residency program was shared and reviewed with the program director and department leadership who likewise used the report in combination with ACGME survey findings as feedback to plan and develop appropriate interventions and strategies. Residents did not see the results of the surveys but participated in discussions, town hall meetings and focus groups but were not involved in executive decisions regarding interventions. The data and proposed interventions were also reviewed, deliberated with decisions made at the program directors meeting and the Graduate Medical Education Committee meetings.For the study, our outcome measures were: a) MBI items of emotional exhaustion (9 items), depersonalization (5 items), personal accomplishment (8 items); b) program clinical learning environment survey (14 items). Data was displayed in a run chart over time to monitor if implemented interventions or changes were leading to improvements.Interventions to achieve outcomes that were introduced in the PDSA process included both system wide and program specific interventions. Organization directed interventions that affected workflow and the learning environment that included leadership changes, faculty recruitment, administrative support and technological innovations were coordinated in collaboration with GME. GME advocated and acquired required financial support and resources allocation for program support and needs. GME further coordinated effectively between c-suite, medical staff, residency programs and other ancillary services to achieve desired wellbeing support for residents’ workflows concerns. Interventions that coincided with the desirable MBI trends included the provision of protected time for residents’ healthcare needs during working hours, regular wellness events sponsored by GME for all residents, and a yearlong focused wellness program for interns. Other Interventions involved successive strategies such as focus group meetings with residents with the development of strategies to address concerns. Changes in the operational leadership including Chief Medical Officer, Designated Institutional Officer, a departmental chair, and program directors facilitated a focus on the institutional academic mission, increased faculty, and ancillary staff (nurse practitioners and physician assistants) recruitment and workflow improvements in clinical service teams.p = 0. 0125 (0.05/4) was reported per test as significant for the Kruskal–Wallis test. Multivariate Analysis of Variance (MANOVA) analysis using General Linear Multivariate Model was used to test the statistical significance of the differences between groups. Linear regression was used to identify statistically significant independent associations. IBM SPSS Statistics for Windows, version 20 was used for statistical analysis. The study was approved by the institutional IRB.Kruskal–Wallis test was used to determine significant trends over time. Based on the five tests performed for the longitudinal trend, a Bonferroni-corrected alpha level of Overall, 271 residents from six residency programs were surveyed five times over three years with 1350 responses on surveys of MBI, and various clinical learning environment factors that could impact residents’ well-being. Residents’ completion of the surveys over the five points survey were: 82% (134/163); 81.6% (133/163); 76.8% (129/168); 78% (131/168) and, 73.3% (124/169) respectively (mean = 78.34%). Responses by specialty were as follows: Family Medicine = 360 (26.7%); Internal Medicine = 315 (23.3%), Emergency Medicine = 245 (18.1%), General Surgery = 180 (13.3%), Psychiatry = 155 (11.5%), and Obstetrics and Gynecology = 95 (7%),For all GME residents, emotional exhaustion scores decreased over time from 28.12 (categorized as high) to 24.35 (categorized as moderate) which was significant on initial analysis but became non-significant when corrected for multiple analysis. Depersonalization scores decreased from 12.48–10.65 (both categorized as moderate), and personal accomplishment scores increased from 38.51–40.05 (categorized as moderate to high) over time, but the trends did not reach significance (Table p < 0.001). Depersonalization scores decreased from 13.1 [categorized as high] to 9.5 [categorized as moderate] (p < 0.001); and personal accomplishment scores increased from 36.8 [categorized as moderate] to 41.7 [categorized as high] over time (p < 0.001).Kruskal–Wallis test for trends analyses of the MBI scores of each residency training program showed similar trends which reached significance only for the Internal Medicine residency training program. Figure p = 0.001); self-defined burnout scores decreased from 2.45 to 2.21 (p = 0.013); residents’ perception of program’s support for burnout increased from 3.37 to 3.71 (p = 0.002); residents’ perception of program’s support for back-up scores increased from 6.58 to 7.11 (0.028), clinical educational supervision scores increased from 9.10 to 9.44 (p = 0.613) and sleep difficulties decreased from 1.74 to 1.68 (p = 0.071).Figure p = 0.001); self-defined burnout scores decreased from 2.8 at the 2nd time-point to 2.0 (p = 0.001); residents’ perception of program’s support for burnout increased from 3.3 to 3.8 (p < 0.001); residents’ perception of program’s support for back-up scores increased from 6.6 to 7.2 (p = 0.002), favorable clinical education supervision scores increased from 9.2 to 10.5 (p = 0.006), and sleep difficulties decreased from 1.9 to 2.5 (p = 0.016).Analysis of the clinical learning environment of each residency training program showed similar trends which again reached significance for the Internal Medicine residency training program. Figure On linear regression analysis; self-defined burnout; and impaired personal relations were independently significantly associated with increasing depersonalization and emotional exhaustion scores but with decreasing personal accomplishment scores. Conversely, clinical supervision was independently significantly associated with decreasing depersonalization scores and emotional exhaustion but increasing personal accomplishment Table .Table 2LFigures After the first PDSA cycle, declining ACGME scores led to a review by the executive and GME leadership. Program leadership and hospital administration met with residents to listen to concerns and to develop strategies. As a result, in 2018, a new departmental chair who was contractually committed to the department was appointed as the indicated intervention. The new departmental chair worked with administration and a new chief medical officer, who was also a member of the department, on providing improved faculty supervision, and restructuring clinical workflows. The program instituted curricular changes, improved didactic education, increased faculty mentoring, support of residents and implemented a back-up system for the residents. In 2019, a new program director was appointed in PDSA cycle 3 who further strengthened the program and provided further support for the residents. In PDSA cycle 4, interventions introduced included residents receiving resilience training which included workshops such as emotional intelligence, imposter syndrome; and training to facilitate an inclusive, equitable and fair clinical environment such as implicit bias, and cultural humility. Residents’ planned social activities were increased and they were provided “wellness days” with protected time during work hours for self-care and healthcare visits  which is in concordance with the literature, with recent studies reporting physician burnout rates ranging up to 89% , 19–22. We used a time series evaluation which allows refining of the intervention and monitoring to determine evidence of effectiveness. Time series evaluation using PDSA cycles offer an advantage over simple before-after studies in that they allow teams to draw inferences about whether improvement occurred, as well as whether the intervention led to the observed improvement. 19 Use of PDSA to improve medical education has been reported. Arnstead et al. used PDSA cycles to improve the frequency of Competence by Design assessment in surgery residents in Canada . Dunbar p = 0.023) [The 22-item MBI regarded as the gold-standard self-reported questionnaire was utilized in our study to measure burnout, but some recent studies have used other measures. For example, Choi et al. used a one-item MBI scale and reported less burnout when measured twice from 2011 to 2013  . Mari et= 0.023) .The benefits of residency training maybe offset by rigorous educational demands, long working hours, lack of autonomy, work/home/life imbalance and a lack of supportive and nurturing environment. These learning environment factors may have detrimental effects on the mental health of residents and a substantial proportion of residents may experience burnout . Thus, aEven though this was a GME-wide approach, individual programs responded differently. Internal Medicine residency program achieved statistically significant improvement in all MBI and learning environment measures. This varying result is not unexpected since differing program-specific conditions, engagement, academic status, leadership, and learning environments would influence residents’ perceptions. Other investigators have also noted variations in individual residency program responses to wellness interventions. In contrast to our study in which we used organization level interventions, Aggarwal et al. using an individual intervention introduced a 12-week wellness curriculum to five residency training programs and noted that general surgery residents never implemented the booster sessions due to lack of protected time and change in program leadership, while anesthesiology residents had organizational challenges . It is aTo achieve residents’ wellness perceptions, we provided both organization-directed and individual interventions. This is in agreement with previous reports showing that organization directed interventions in comparison to individual interventions were associated with a meaningful reduction in emotional exhaustion and depersonalization scores , 28, 29.Globally more work is required in mitigating burnout and its sequalae such as depression and suicide amongst post graduate trainees. Naji et al. in a systemic review that spanned the past 2 decades noted a pooled prevalence of burnout involving 31 210 residents from 47 countries and reported that the prevalence of burnout remained unchanged over the past 2 decades. Burnout varied by region, with lowest level in European countries. They concluded that current wellness efforts and policies have not changed the prevalence of burnout worldwide and that future research should focus on understanding systemic factors and leveraging these findings to design interventions to combat burnout [There are many limitations to this study. The results are from a single county hospital located in an underserved minority community; thus, the results may not be generalizable to different locations. Since this is an observational study without control groups, the reported changes could be caused by other unobserved factors; thus, the reported associations cannot be interpreted as causative. Specifically, we did not focus on the role of ACGME surveys and citations on interventions and residents’ wellbeing perceptions. Though we used the validated MBI survey, our learning environment surveys were developed locally. There is always a concern of incomplete data and selection bias but the response rate of 73–82% would be classified as a high response rate. Other limitations were that each time point included residents from different graduate years and more time may be required for the interventions to be effective. Another potential limitation of this study is that clustering of data may have occurred since datapoints within training programs may be more similar than between training programs.To our knowledge, this is one of the few published reports on longitudinal burnout and learning environment assessments among GME trainees utilizing PDSA cycles. MBI parameters improved over time in all GME but were not statistically significant. Over time, all GME residents showed statistically significant improvements in self-defined burnout, personal/social relationships, and burnout support by the program. One residency program had statistically significantly desirable trends for all 3 MBI subscales and all learning environment measures including clinical education supervision and back up support by the program. This study suggests that GME-wide wellbeing assessments and interventions are feasible, and results may vary between residency training programs.Additional file 1.


An important part of biomedical research is the translation of discoveries into clinical or community applications that impact patient health. For a vast majority of clinical applications and sustainable community interventions, a time-tested way to get innovations to patients is through licensing of the technology and commercial development, often through startups. While biomedical scientists and trainees are schooled in discovery research, the processes of commercialization are foreign or intimidating. Further, many trainees will not aspire to a faculty position, and other avenues of advancement are desirable.At Case Western Reserve University, we developed and launched a Translational Fellows Program to provide such training for the community, focusing specifically on graduate students and postdoctoral fellows. The goals of this program include familiarizing our trainees with the principles of entrepreneurship, product development, and startups. This is accomplished through study of their laboratory’s technology to identify points of translational focus and to increase awareness to potentially move ideas and products toward societal impact. This program leverages much of our existing infrastructure and provides a mechanism for the prioritization of the translation of the technology as well as “release-time” to promote effort.Launched in summer 2020, our first cohort had 3 of the 12 fellows launching startups based on their technology and submitting an National Institutes of Health Small Business Innovation Research (SBIR) proposal. At least 80% reported increased knowledge and confidence in five of six key translational competencies.We are now continuing and improving the program and searching for sustainable support to stabilize the program for a long-term productive future. Twenty-one applications were submitted for seven advertised slots. All applications were reviewed by all members of the leadership team and scored on a five-point scale based on potential of the applicant, interest in a career in scientific translation, and (somewhat less important) the strength of their technology. With a last-minute awarding of an internal grant, we were able to onboard additional fellows, bringing our total to 12 fellows for year 1. In year 2, we had even greater interest in the program (25 applications) and we are currently supporting nine fellows.Our first 12 fellows represented much of the diversity that can be found here amongst our researchers. These 12 fellows brought technologies from novel therapeutics to medical devices to community-based healthcare. The stage of their careers ranged from graduate students to more senior research associates. Many fellows were interested in careers in startups and entrepreneurship, some in academic careers that had a translational focus, and some were still exploring career paths.In addition, our fellows had a diversity of demographics and backgrounds Table . Three oAs of 2 months post-completion of the first cohort, three of the fellows have started companies. All of these three have submitted an SBIR and one was successful on their first attempt. While ¼ of our trainees achieving a startup may seem modest compared to the MIT or StanfAn exit survey was conducted on the first cohort, with one follow-up reminder email. Ten of the 12 fellows completed the survey. The fellows felt their knowledge in the six key areas included in the survey were improved as a result of the program Table . Five ofOne of the goals of the TFP was to help to change the culture of our faculty to be more translational-oriented. Although we do not have objective data on this, anecdotal evidence from a couple of unsolicited feedback from the PIs do suggest that the fellows bring back their learning to their lab and/or that it has influenced how they think about their technology.As with all programs, this one is not without challenges. One of our metrics is diversity of our fellows. We have had some success but are still far from ideal, as a goal will be to have fellow representation from a cohort that is representative of our student body. In addition, our leadership team of six individuals is entirely White and has only one female, and there is a constant need to identify a sufficient number of minority and female mentors through CVMP. Although there is not one of our originally intended metrics, in our first cohort, only three of the fellows were in labs of women PIs. In year 2, none of the fellows are in labs with women PIs. Representation is important, and ensuring all PIs and students consider themselves potential innovators and entrepreneurs is necessary. Others have highlighted the need for programs like TFP and I-Corps to help bridge this lack of diverse talent in biotechnology .Another challenge is that fellows in this program come in with very different levels of experience and with very different needs. Thus, the program is, by design, very flexible to allow advanced students to explore beyond what is covered in the base program through mentoring and connecting with other resources. However, this remains a challenge and was one of the noted areas for improvement on the exit survey, as content will be basic for the more experienced fellows.Although much less cost-prohibitive compared to full-time fellowship programs, the TFP still requires a significant budget to operate. Salary support for each fellow as well as faculty effort and administrative support add up quickly. However, we believe that the returns well outweigh the investment. CWRU invested over 150K initially to get the program started. Having training grant-supported participants can help cover some of the salary. In fact, we have included this program as an option on at least two T32 applications submitted in 2021 (currently in review). We are also working with our development office to identify donor support for this program.There are many future plans to grow and expand this program. Not all students and postdocs are in labs where technology is ready for translation and/or have a PI who is translation-oriented. Conversely, not all labs with emerging technology have a lab member interested in a career path in translational science. We are considering a program for 100% supported postdoctoral fellows where, instead of devoting 20% entrepreneurial efforts on the research they are doing in their lab, they will be brought on to exclusively participate in the program and be assigned several technologies from the CWRU technology transfer office to work through the TFP.The large number of applications to the TFP highlights the demand and need for this program at CWRU. Although still a program is in development, outcomes from our initial cohort are very promising and we are confident that we will see a strong return on our investment. In addition, the deliberate training in a nonacademic career will help us attract strong doctoral students interested in translation and innovation.


Males are at higher risk of death by suicide than females in Australia, and among men, blue-collar males are at higher risk compared to other working males. In response, MATES in Construction developed a workplace suicide prevention program for the construction sector in 2007 that has been widely implemented in Australia. In the current project, this program is being adapted and trialled in the manufacturing sector. The common aims of MATES programs are to improve suicide prevention literacy, help-seeking intentions, and helping behaviours. The program will be evaluated using a cluster randomised-controlled trial design with waitlist controls across up to 12 manufacturing worksites in Australia. We hypothesise that after 8 months of the MATES in Manufacturing program, there will be significantly greater improvements in help-seeking intentions (primary outcome) compared to waitlist controls. The project is led by Deakin University in collaboration with the University of Melbourne, and in partnership with MATES in Construction and a joint labour-management Steering Group.Trial registration: The trial was registered retrospectively with the Australian New Zealand Clinical Trials Registry on 25 January 2022 (ACTRN12622000122752).Protocol version: 2.0, November 2022.The online version contains supplementary material available at 10.1186/s12888-022-04464-3. There are various work contexts where the workforce is predominantly male, particularly in manual, blue-collar work groups such as in construction, mining, energy and manufacturing. These are priority contexts for workplace suicide prevention for a number of reasons. Males are at higher risk of death by suicide than females: in Australia roughly three males die by suicide for every female; a pattern shared by many other developed countries . Males aProtective factors for mental health and suicidality have also been documented amongst blue-collar workers. Good mentorship and patient, skilful supervision are protective factors for blue-collar workers, particularly apprentices , 13, 14.Based on a reasonable assumption that the MATES program will be relevant and likely effective in other blue-collar, male-dominated industries, the MATES program has been extended beyond the construction, mining and energy sectors, and is now being adapted for rollout in the manufacturing sector. The impetus for this suicide prevention program has come from within the manufacturing industry in the Australian state of New South Wales (NSW). Both employers and unions identified an unmet need for workers to receive support for suicidal distress, and jointly petitioned MATES in Construction to adapt its program for the manufacturing sector. MATES in Construction agreed to oversee the creation and implementation of the MATES in Manufacturing program, and to roll out the program in collaboration with a joint labour-management Steering Group in NSW.Subsequent to the development of this initiative, funding was sought and obtained to evaluate the implementation and effectiveness of MATES in Manufacturing, hence leading to the development of this study protocol. This study will assess the implementation and effectiveness of the MATES program in the new context of manufacturing. Further, the proposed research employs a cluster-randomised controlled trial (cRCT) design, providing a much-needed complement to previously published observational evaluation evidence on MATES programs. If the results of this evaluation demonstrate the suitability and effectiveness of the MATES program in the NSW manufacturing sector, program reach could be further expanded to the broader Australian manufacturing sector and other blue-collar, male-dominated work contexts.Was the MATES in Manufacturing program implemented as designed?What were the barriers and facilitators to participation in, and implementation of, MATES in Manufacturing?What were participant and staff experiences of the program, including any noted outcomes arising ?Was suicide prevention literacy increased by the MATES in Manufacturing program relative to wait list controls? Did intentions to seek help increase in the MATES in Manufacturing program relative to wait list controls? (primary outcome)Did help seeking behaviour increase, and levels of distress and suicidal ideation decrease, in the MATES in Manufacturing program relative to wait list controls? (secondary outcomes)The following Research Questions (RQ) will be addressed using mixed methods for RQ 1–3 and quantitative methods for RQ 4–6:We also aim to evaluate the cost-effectiveness of the intervention if it is shown to have a significant positive effect on the primary outcome of help-seeking intentions.https://mates.org.au/). In brief, MATES is an industry-based community development approach to workplace mental health and suicide prevention. MATES does not provide clinical services but seeks to connect distressed workers to a range of clinical and non-clinical supports, as pictorially presented in Fig. MATES in Manufacturing is an adaptation of the MATES in Construction workplace suicide prevention program  is provided for all workers on a site. Volunteers for half-day Living Works’ SafeTalk ‘Connector’ training are recruited during the GAT, and subsequently trained as the persons on site who can ‘connect’ workers in need to appropriate sources of help. Distressed workers can either approach a Connector him- or herself, or a Connector might approach someone based on observation, or concerns expressed by a workmate. ‘Help’ in this context is for mental health or suicidality, or for any issues that could contribute to distress, such as financial stress, alcohol and drug use, or relationship concerns. Volunteers are fundamental to the implementation of the MATES program, and the program aims to have an average of 1 in 20 workers on-site trained as Connectors. In addition to Connector training, MATES also delivers LivingWorks’ Applied Suicide Intervention Skills Training (ASIST): a 2 day session that equips participants with the skills to co-develop a safety plan with an individual at immediate risk of suicide. The program aims to have one to two ASIST-trained workers on each worksite.Implementation of GAT on site is the starting point of the intervention. For those sites randomly assigned to intervention, the intervention will occur for 8 months during the study period, and then will continue beyond that timepoint at the discretion of the participating sites. Similarly, for sites randomly assigned to the wait-list control condition, the intervention will begin 8 months from the date of baseline assessment, and continue for at least 8 months thereafter. Participants in the trial will have indefinite access to MATES’ help line.The MATES program is introduced to sites by Field Officers, who are employed directly by MATES. Field Officers provide GAT and ongoing support to MATES sites through regular site visits, establish and maintain relationships with workers on-site, and support site-specific Connectors in their role. In addition, MATES has a national toll-free helpline, through which workers and their immediate family members can be connected to case management support. Case managers are qualified to assist distressed workers with a plan to address their problems and concerns. This could include connecting workers with such services as their employer’s or union’s Employee Assistance Program (EAP), financial counselling, mental health services, drug and alcohol services, grief counselling, or family and relationship counselling.The MATES in Manufacturing intervention will be delivered by the MATES in Construction NSW organisation.The MATES in Manufacturing intervention will be evaluated using a mixed methods implementation evaluation combined with a two-arm cluster-randomised trial design with wait-list controls for effectiveness evaluation. Implementation will be evaluated quantitatively by monitoring numbers and types of intervention activities and associated participation rates as well as suicide prevention literacy as a process evaluation measure. Qualitative implementation evaluation will entail characterising barriers and facilitators to implementation as well as participant experiences. Following SPIRIT Guidelines, the cRCT evaluation will assess help-seeking intentions as the primary outcomes, and help sought, suicidality, and psychological distress as secondary outcomes , led by Associate Investigators Lockwood, Cox, and Brimelow in collaboration with the joint labour-management Steering Group. The Steering Group includes representatives from MATES in Construction National, MATES in Construction NSW, the research team, interested manufacturing worksite employers, the Australian Industry Group (AIG) and unions representing workers at participating sites .nclusion criteria: 1) Employees or workers in the manufacturing industry who are working at participating sites of the MATES in Manufacturing program, including casual/temporary, contract, and continuing/permanent employees, and 2) Basic English proficiency for program activities (which will be conducted in English); however, surveys and some printed information on the program have also been translated into Vietnamese and Mandarin, and are available on an as-needed basis (some sites include a number of Vietnamese and Chinese workers). There is one exclusion criterion: Individuals aged under 18 years.All workers employed at each participating site will be eligible for the MATES program and all will be invited to participate in baseline and follow-up surveys (census sampling). We expect participants to be disproportionately male and blue-collar workers . There will be two irct_minim procedure in Stata. Balance will be sought for a single factor – site size – with sites of less than 150 workers classified as ‘small’ and sites of 150 or more workers classed as ‘large.’ Due to resource limitations, participating sites will be randomly assigned to intervention or wait-list control in small batches of up to four sites (further detail below). Allocations will then be revealed to the research team, MATES field staff and sites, as blinding beyond the baseline assessments will not be feasible.Allocation of sites (clusters) to intervention arms will be conducted by the project statistician (AM) using minimisation implemented with the MATES will be the direct contact for recruitment, intervention, and data collection. All data will be collected by MATES Field Officers and research staff directly from workers, with no survey responses or data being shared with companies/employers. MATES Field Officers have access to and have been trained to adhere to a structured data collection protocol. All are experienced with data collection and have administered surveys as part of previous evaluation research projects.Data collection will occur at each worksite, within work hours, at a date and time agreed with the company / site managers. Field Officers will deliver a brief preamble about the study purpose and aims. Workers will be informed that survey data collection and participation in MATES in Manufacturing as a program are separate processes: workers are welcome to participate in the program but are not compelled to participate in the surveys. There is no penalty for not completing a survey.Workers will be given a plain language statement, consent form, and survey form to peruse, and the consent process will be explained verbally. Interested workers will be asked to sign the consent form to confirm their willingness to participate, and Field Officers will answer any questions arising. Participants will be invited to seal their consent form and survey in a provided envelope (with or without responses) and place it into a data collection box. This will help ensure that those who do not wish to participate in surveys will not be readily identifiable. See Supplementary File At the end of the site visit, the data collection box will be removed from the site by MATES Field Staff. This box will then be transported, by courier, to the MATES Research Manager who is based in the Queensland office, where it will be entered into a secure electronic database. Survey responses will not be handled by or made available to employers.Data for the economic evaluation will be collected as a supplementary survey at time 2 (8 months) for both intervention and wait-list control sites. Following administration of the paper ‘core’ survey, participants will be invited to scan a QR code and complete a brief health service use questionnaire.Field Officers will observe participants throughout survey administration. Anyone who appears to be uncomfortable or upset will be offered immediate support. All Field Officers have completed Applied Suicide Intervention Skills Training, and all are experienced with supporting individuals in distress;At the end of their survey (tick box question on survey) or by direct in-person request, participants will be able to indicate that they would like a follow-up support call from MATES. This is a mechanism that all MATES programs use during training and in survey administration for other program evaluation projects . All requests for follow up calls will be addressed immediately;As soon as surveys are returned, the Research Manager will review responses for any indications that a participant is in distress, or has recently been in distress . This too will trigger immediate follow up via phone, and referral to MATES case management staff.Because respondents will be asked sensitive questions , we prepared a safety protocol for data collection and intervention activities. We have three mechanisms in place for following up with participants who indicate  that they are upset or in distress at the time of data collection or during program activities, and for following up with participants who indicate through their survey responses that they have recently experienced psychological distress:Intervention sites will participate in baseline surveys then 8 months of the MATES in Manufacturing program from the first GAT on site, with follow-up surveys administered 8 months after intervention initiation. Wait-list control sites will participate in baseline surveys (month 0) then follow-up surveys 8 months later. At wait-list control sites, the MATES program will commence following the 8 month surveys, then continue for at least 8 months. See Fig. Volunteers for Connector and ASIST roles at participating sites will be recruited through posters with information provided for contacting the research team (phone numbers and QR codes). Program participants (including those recruited to be Connectors and ASIST workers) and Field Officers will be interviewed in separate focus groups or individual interviews, as is feasible for scheduling. We will aim to conduct focus groups in person, but depending on the state of COVID-19 restrictions at the time, we may conduct individual or focus group interviews by Zoom.Informed consent will be provided on recruitment and scheduling of interviews. The same safety protocol described for the surveys will be applied in the context of focus group interviews.extremely unlikely to extremely likely on a 7-point scale [Help-seeking intentions will be measured using the General Help-seeking Behaviour Questionnaire (GHSQ). GSHQ questions will be modified to present 12 different sources of help seeking (including a MATES worker or Connector and an open-ended option for ‘other’), and participants will be asked to rank their help-seeking intentions prefaced by “if you were feeling overwhelmed and unable to cope.” This phrasing was derived from a qualitative study on how blue-collar male workers conceptualise emotional and suicidal distress, with the results indicating that blue collar male workers are inclined to emphasise a loss of agency . Intentint scale . A singlAmong those who report having felt overwhelmed or unable to cope at any point in the preceding 6 months (yes/no), forms of help sought during the preceding 8 months will be measured using the General Help-seeking Behaviour Questionnaire (GHSQ). GSHQ questions will list the same 12 sources of help as detailed in the primary outcome of help-seeking intentions, except in this case asking whether help has been sought, and how frequently . A single summary measure across all the 12 options will be computed by summing the responses (reverse coding the ‘no one’ option).Suicidal behaviour will be measured using 2-items from the 4-item version of the Suicidal Behaviour Questionnaire-Revised (SBQ-R) . The firnone of the time) to 4 . The six items will be summed to give a score ranging from 0 to 24.Psychological distress will be measured using the Kessler-6 instrument (K6) . ParticiHealth service use will be assessed using a modified version of the self-report measure of the Resource Use Questionnaire  developeName & mobile telephone contact number , company/site name (for cluster identification), age, gender, occupation, Aboriginal and Torres Strait Islander status, Australian-born versus born outside Australia, history of previous training in MATES programs .We will monitor and record the number of program activities and participation levels in program activities . In addition, we will measure suicide prevention literacy as a process/implementation measure using the literacy of suicide scale short form (LOSS). Each of the items on the LOSS is responded to on a 3-point scale , with correct responses allocated a score of 1 and incorrect or “I don’t know” responses assigned a score of 0 . Total scale scores are calculated by summing item scores, yielding a total literacy score (per cent correct). The LOSS has been validated by using Item Response Theory to identify items that had the strongest discrimination of the underlying literacy construct .The primary analysis will be undertaken on an intention-to-treat basis: including all participants as randomised, regardless of treatment received or withdrawal from the study. Mixed-model Repeated Measures (MMRM) analyses will be used because of the ability of this approach to include participants with missing data. Cluster effects will be modelled using a random site effect. An unstructured residual variance-covariance matrix will accommodate within-participant dependency. The statistical significance of the primary outcome will be evaluated in a planned comparison of change from baseline to 8 months post-initiation of intervention in the active arm compared to 8-month change in the waitlist group. Tests of significance will use appropriate degrees of freedom adjustment where necessary . Where necessary, transformation of the outcome variable will be undertaken to ensure distributional assumptions of the model are met.For binary outcomes  and other non-continuous outcomes , comparable generalized mixed models will be used with population average effects of intervention being compared.We based our power and sample size calculations on the primary outcomes: intentions to seek help from formal sources. From a previous MATES trial in construction workers  [In addition, we will conduct exploratory analyses to investigate whether intervention-associated changes differ by gender or by manual blue-collar versus white-collar.Descriptive analyses will be reported on frequencies of program intervention activities relative to plans, and participation levels in program activities.Was the MATES in Manufacturing program implemented as designed?What were the barriers and facilitators to participation in, and implementation of, MATES in Manufacturing?What were participant and staff experiences of the program, including any noted outcomes arising ?Interview transcripts will be analysed using descriptive thematic analysis  to answe4)Was suicide prevention literacy increased by the MATES in Manufacturing program relative to wait list controls? The suicide prevention literacy process measures collected by survey will be analysed as above for the quantitative effectiveness evaluation, Research Question 4:If the trial achieves significant positive improvements in the primary outcome of help-seeking intentions, a trial-based economic evaluation will be conducted based on the help-seeking intention scores, the intervention costs, and mental health-related services costs. Intervention costs include the intervention development costs . Mental health services cost will be calculated by applying standard Australian unit costs , with approval for the qualitative implementation evaluation on 30 September 2022 from the Western Sydney University Human Research Ethics Committee (protocol number H14506). See Supplementary File Site recruitment commenced in December of 2021, but has been hampered by the COVID-19 pandemic and the associated restrictions and impacts on businesses. As sites were recruited, they were grouped and randomly assigned as soon as feasible, such that data collection and intervention implementation could be spread out over time and managed with the small implementation and research teams available. Two groups of four sites have been recruited and baseline data collection completed before random assignment by the procedure detailed above . Intervention activities have been initiated at most sites assigned to the intervention condition. A third and final group of sites awaits completion of baseline surveys and random assignment. The 8 sites recruited to date vary widely in size, ranging from 25 up to 440 workers, corresponding to an estimated study population of 1573 workers in total. Survey participation to date has been relatively high, with an overall average of 74% and a range of 60–92% over the 8 sites.Though few in number, distressed workers have been identified and followed up while piloting the survey, and at both intervention and wait-list control sites during the conduct of baseline surveys; the frequency and nature of these events will be captured from Field Officer notes. While strictly speaking, this would constitute ‘contamination’ of wait-list control sites, this is a limitation that is ethically imperative and is not likely to affect the overall results of the trial.For study participants, the final results of the trial RCT will be presented to the joint labour-management Steering Group, and we will provide a plain English lay summary for distribution to program participants by management and union steering group members. For the research, policy, and practice communities, we will publish peer-reviewed journal articles and deliver presentations at national and international research conferences. We will also deliver other presentations on findings to mental health and suicide prevention practitioners and policymakers.This project represents a strong partnership bringing together practitioners at the coalface of suicide prevention (MATES), industry partners , and suicide prevention researchers. Further, the trial addresses an urgent need for experimental evidence on the effectiveness of workplace suicide prevention programs, both for MATES in particular as well as for workplace suicide prevention in general . The quaWhile the cRCT design provides strong internal validity, our study may be limited with respect to external validity, or generalisability. Worksites that have engaged with the labour-management steering committee and are willing to accept the terms of an experimental study may be a select group that is not representative of all manufacturing worksites. Within sites, however, we expect that the potential for selection bias is limited, given the relatively high participation rates in the baseline surveys (average = 74%), which we will hope to retain at follow-up.In addition to contributing to the international literature on workplace suicide prevention, the trial will generate evidence-based policy and practice insights for the partners involved. The MATES intervention is being implemented under real world conditions by an established workplace suicide prevention charity, driven by a need identified by industry partners; hence the potential for translation of this research to policy and practice is high. The project partners are well positioned to adapt and disseminate findings to a wide range of workplace mental health and suicide prevention stakeholders. The MATES workplace suicide prevention strategy under evaluation could also be adapted to other settings nationally and internationally if the findings are positive, and at a minimum will provide implementation and effectiveness insights for future research, policy and practice.Additional file 1. SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents*Additional file 2.Additional file 3.