Improving the quality of care for a diverse population requires a diverse healthcare workforce which necessitates high educational attainment among underrepresented communities. Programs aimed to address healthcare workforce diversity gaps also serve as a public health intervention by offering avenues to improve the health of local communities by providing students with the knowledge and skills to promote healthy behaviors, foster scientific literacy, and inspire future public health professionals - who in turn serve their local communities to advance health outcomes. We interviewed alumni of the New York Presbyterian Hospital Lang Youth Medical Program (LYMP), a high school health sciences mentoring and enrichment program for underrepresented minority youth in Upper Manhattan, from graduating classes between 2012 and 2021 to explore their perspectives on what aspects of the program had the most impact on their academic and career paths.This is a qualitative study using in-depth, semi-structured individual interviews. All interviews were analyzed using the constant comparative method for developing grounded theory, following a convenience sampling method.106 codes were organized into 24 themes, which were further arranged into 4 topic areas: demonstrated program success, intangible program drivers, improvement opportunities, and barriers to program participation. Topic areas captured participants’ perspectives on how the program is designed to foster an environment of personal, academic, and professional development; ways aspects of the program organically worked together to provide unanticipated positive facilitators; opportunities for program improvements, and external factors that influenced decision-making.Through this study, we found that the LYMP had a positive influence in helping participants set and achieve personal, academic, and professional goals. Alumni reported activities and experiences offered by the program that foster key youth development constructs linked to healthier and more resilient communities. Importantly, the vast majority of participants described how the synergism between program features, staff support, family involvement, and professional development and networking created an environment of achievement that went beyond the scope of the program design. Findings from this study offer a blueprint for other organizations to craft a similarly successful enrichment program that improves health outcomes, reduces health disparities, and promotes overall population health. There is a need to increase the proportion of underrepresented minority groups in the healthcare workforce in order to provide high quality and accessible care for a diverse patient population , 2. DiffIn addition to increasing workforce diversity, healthcare pipeline programs have shown numerous positive effects for students, like increased standardized test scores , increasIn response to the rising need to improve diversity in the healthcare workforce and academic achievement in the local school district, NYPH-CUIMC founded the Lang Youth Medical Program (LYMP) in 2003 to provide students from those communities with the opportunity to nurture and explore their interest in the health sciences. Based under the umbrella of NYP’s Division of Community and Population Health, and led by Columbia faculty and NYP staff, the program provides high-quality health science, public health, and professional development programing to students in the Washington Heights and Inwood area through hospital-based mentorship and internship opportunities .With NYPH-CUIMC as a resource for mentorship and hands-on medical experience opportunities, students at the LYMP are provided with quality professional and personal development to help them achieve their goals and bridge the educational gap that students face. LYMP provides students who aspire to attend a four-year college the opportunity to explore careers in healthcare and become leaders in their community. While the LYMP aims to inspire students to achieve their academic and professional goals, the program also focuses on providing students with a rich and vibrant sense of community that creates life-long lasting relationships amongst peers, and between scholars and mentors.The Lang Program aims to educate young scholars by providing them with a tailored academic curriculum see , goal deEach LYMP cohort consists of 12 to 15 high-achieving seventh graders attending a middle school in the Washington Heights-Inwood school district. Students in sixth grade applying for the program must have a grade point average of 80% or greater in all subjects, an interest in exploring careers in healthcare, and the ability to make a six-year commitment to the program. Scholars attend program classes on Saturdays during the academic year and weekdays during the month of July. LYMP’s six-year curriculum is composed of five focus areas: health careers exploration, science enrichment, high school and college application, mentorship opportunities, and psychosocial support .As of 2021, 85 students are enrolled in the program. The male-to-female ratio is approximately 1:1, with 70% of students identifying as Latinx.The program’s first cohort of LYMP alumni graduated in 2009. Since that time, the alumni cohort has grown to 140 alumni. The LYMP alumni profile currently consists of 52 undergraduate students, 13 graduate students, and 40 professionals that work in a diverse range of fields including business, education, and healthcare. Eligible alumni may receive up to $6,000 in scholarships throughout their undergraduate careers for academic-related expenses, which is fully funded by LYMP.Scholars who graduate from the program are invited to attend two annual LYMP alumni reunions where they are able to connect with old and new peers, network with other alums and professionals, as well as become mentors to the newest class of high school program graduates. A newsletter is disseminated quarterly with details on employment, internship, and other resources for alumni to further advance their professional and career interests.Alumni have also returned as hospital volunteers, summer and academic per-diem LYMP advisors, and full-time employees of NYPH-CUIMC. Currently, there are five alumni working at NYPH-CUIMC within the Ambulatory Care Network, two of whom are registered nurses and one of whom was hired full-time as a coordinator for Lang.The importance of health profession pipeline programs for underrepresented students at the middle and high school level plays an important role in determining the future healthcare workforce. Research has shown that minority healthcare workers are more likely to practice in underserved communities . AdditioEvidence on career education and counseling, professional and research experiences, and meta-analysis on other educational strategies to improve academic outcomes among young students is generally positive . ServiceAmong minority students, health professions pipeline programs have demonstrated to increase the number of minority students who go on to pursue higher education in the sciences . ResearcPrograms that develop capacity building and empowerment have demonstrated an effect to increase the knowledge and skills youth need to succeed . The desYouth developmental models focus on developing the psychological, behavioral, and social characteristics needed for success, while also considering the structural supports needed to enhance the impact of external facilitators and reduce those of external barriers of achievement. Programs that integrate this model aim to provide opportunities to participate in meaningful activities with real-life applications, have high expectations, encourage deep positive relationships and connections with adults, peers, and the larger community, and have an environment of care and support , 29.The Development Assets framework provides further guidance on youth development by focusing on young people’s successes rather than failures, and viewing them as resources . The conThe constructs within these frameworks are cultivated throughout the program by design, such as courses in STEM, activities centered around interpersonal and professional skills, financial and family support, and providing an opportunity for scholars to develop deep, long-term, positive relationships with peers and professionals.This evaluation is an opportunity to further understand how a hospital-based youth mentoring and education program can influence the life trajectory of underrepresented minority students in pursuing academic and career paths in the health sciences. As a qualitative evaluation, we interviewed alumni to explore their perspectives on what aspects of the program had the most impact on their personal and professional choices and to offer areas of improvements.This study aims to answer the following research question: How has the Lang Youth Medical Program impacted the academic and career paths of its alumni?The Columbia University Irving Medical Center IRB approved this study’s procedures.N = 152). The LYMP administrator sent eligible alumni emails to participate in the study and register for an interview. Alumni from graduating classes in 2014, 2016, and 2019 had a slower rate of participation, thus, text messages from the LYMP administrator were also sent to these alumni to ensure participation from all graduating years. As eligible alumni volunteered to be interviewed on a rolling basis during the 5-month study period, this study followed a convenience sampling method.The setting for this research was NYPH-CUIMC, which provides funding for the Lang Youth Medical Program. Participants were determined to be eligible for recruitment if they graduated between 2012 and 2021  would influence alumni perspectives  for audio-recording and closed captioning. All participants were audio-recorded only. Transcripts were de-identified and loaded into Dedoose® (v.9.0.46) for coding and data analysis. Data files were stored in secure locations, accessible only to the research team per IRB protocol.Interviews began with questions about participants’ age, gender, and racial/ethnic identity. Next, interviewees were asked about their current academic and professional endeavors. Questions then focused on the alumni’s time in the program, with particular interest on the elements of the program that they found to be most impactful to their personal, professional, and academic growth. Additionally, part of the interview was dedicated to understanding the program’s impact on how alumni have been able to cope with the changes that had occurred in their life as a result of the COVID19 pandemic. Interview questions concluded with an opportunity for alumni to provide input on which parts of the program were the most useful and which could be improved.Throughout the data preparation and analysis process, principles from the constant comparative method of qualitative data analysis were applied to develop a grounded theory, whereby the uniqueness of each participant’s experience was carefully considered while exploring commonalities of experiences across all participants to craft codes, themes, and topic areas . To reacInterviews and data collection occurred over a 5-month period and were conducted by OK and ZW. RS supervised OK and ZW during the data collection and coding process. Transcripts were coded in small batches and OK, ZW, and RS met regularly to revise, add, and delete codes, and ensure the final codebook contained codes that were applied uniformly. Once the codebook was finalized, codes were reviewed for their thematic application by all members of the team. JR and MMs led the organization of themes into the final topic areas. Development of the topic areas followed the same approach as the code and thematic process: use of multiple thematic perspectives to understand the data and reach a consensus on the perspective of each topic area. All members of the research team hold graduate or professional degrees, including training in qualitative research methods.N = 21 [78%]). Lang Program scholars graduating in 2018, 2019, and 2021 represented 52% (N = 14) of those interviewed. Of the 27 study participants, 67% (N = 18) were female, and 52% (N = 14) identified as Latinx.Twenty-seven alumni were interviewed, generating 106 codes. Following the constant comparative method, codes were organized into 25 themes, which were further arranged into four topic areas: demonstrated program success, intangible program drivers, improvement opportunities, and external facilitators and barriers to program participation . AlthougThemes within this topic area reflect program design features that reinforce the development of important constructs proven in the literature to have demonstrated success among other programs seeking to help young people achieve their academic and personal goals . ParticiAligned with the design of the program, participants provided specific examples of the types of training they received during their time in the program, which included academic, coping, interpersonal and professional skills. Participants also described receiving rigorous academic content and coursework, participating in extracurricular program activities, and developing short- and long-term goals.Participants recalled exercises in essay writing, health literacy, lab, scientific method, and test prep as important academic skills. Of the academic skills learned, health literacy skills had the most profound and long-lasting impact on participants. Health literacy skills are cultivated during the Lang Program by teaching health information and how that information can be used to make good health-related choices. Participants said that this was an important and useful experience:…for example…one of my friends in high school had…a pregnancy scare, she was super freaked out… [I said] …, “Well, you can get tested first before we freak out.” I knew this from Lang [sexual education class], so I was giving her counseling, and I told her not to freak out…I think having that knowledge was helpful for me to not only make good decisions myself, but also help other people make decisions that were right for them. …I think they prepared us very well for life. (P5)Scholar’s transition from childhood to adolescence to early adulthood during their time in the Lang Program. One participant recall discussing “life lessons” (P5), covering topics in “reproductive health, substance use, and other factors that affect adolescent life…,” which “helped [them] maintain [their] composure throughout adolescence.” (P5)Building resiliency and stress management skills are other coping mechanisms participants mentioned learning during their time in the program:We would meet up with our mentors and talk about any stresses that we had, any struggles we saw the [medical staff at their internship] had…and they would give us advice and we would have classes on stress relief. (P19)Lang really taught me…the best skills to use when feeling overwhelmed. They've really helped me figure out what works best for me and how to do things that work for me, but they also allowed me to understand that things are trial and error, and not everything is going to work out in the first shot. So, there's always different things to try out to see how they work. (P1)Practicing communication and empathy were important interpersonal skills training experienced by alumni:The program definitely helped [me] with communicating with…different types of people, since we were interacting not only with doctors and those within the medical field, we were also interacting with our peers daily, we were interacting with those in grades above us and below us, and we were speaking with our advisors. (P26)One thing I believe Lang really emphasized…and it was…key to the program was empathy. That's something that I never really thought about, prior to going into the program, but Lang made that really important and really emphasized it. So now, every time [I am] interacting with someone, I always try to look at things from their point of view. And that allows me to get a deeper understanding of their situation…and really understand that I am able to help the individual. So, I think Lang has really influenced how I interact with people in the sense that I have tried to look at their perspective first before I try to respond. (P24)Participants described professional skills, which are designed to meet the demands of professional and work settings, such as essay writing, interviewing, leadership, problem solving and critical thinking, setting boundaries, and other practical skills . One participant describes the professional expectations of the program:So, I remember every Saturday, we would have to go dressed up to program with slacks and a nice shirt. That was one way they helped us in our professional life because you know since we were young, they expected us to act a certain way at such a young age, to prepare us for the future. So, they helped us build character, act professionally… work, and organize our time. I remember having to do those classes [where] they would build a schedule for us. They would give us time to organize our days and that helped us grow into the professionals that we are today. (P19)Another participant described how the program went beyond academic training to cultivate professionalism:It’s an academic program where you’re learning about medicine… But it’s so much more than that…. You’re not just learning about medicine, you’re learning how to…talk to each other, you’re learning about how to show yourself off in a professional setting, you’re learning responsibility…You know, small little things like that, they help reinforce what you’re going to need in the future. And they don’t seem like they will, but they definitely will. (P18)Exercises in leadership skills were paramount in developing one participant’s professional abilities:…leadership skills that were very helpful having learned in Lang… for instance…not always being on top of the situation but rather more often listening and letting other people talk, instead of kind of me [being] a narcissistic leader… (P2)This alumni describes how the Lang Program motivated them to take initiative in their ability to communicate their thoughts as a leader:I think taking initiative, leadership, and…I would say…speaking your mind. I [now] feel like I’m never afraid to say what I need to say, or just say my opinion, and I think that’s one thing I feel like Lang has definitely prepared me for… I think speaking my mind. I’m never afraid to do that, and I think throughout college that has helped me, Lang has helped me develop that strength. (P26)Study participants listed case studies, exposure to health sciences courses, and dissections as impactful academic training. Program activities mentioned by alumni included class trips to colleges and healthcare expositions, panelist presentations, hands-on experience and internships in a hospital setting, and courses dedicated to college applications, SAT prep, and college readiness.During the interviews, participants described how the Lang Program provided structure and guidance to help them develop goals related to their academic and professional aspirations. One participant stated that being exposed to healthcare careers allowed them to “[understand] that the medical industry and the health field is not just having to pursue medicine. It can be things like public health, which we learned in the program” (Participant 25). Another participant shared that they “started to realize different things about the medical field and that’s what Lang was for, you know, to really open up that pathway for us to see the real medical field and for us to know what it’s like. So, it really helped me find what I wanted to do, which is psychology.” (P1).Participants also described how the program activities reinforced what major they would pursue in college or informed that decision. Eleven alumni pursued a STEM major at the undergraduate level. Another four alumni continued to pursue a graduate education across various academic fields. Additionally, four participants engaged in scientific research at the postsecondary or professional level after graduating from the program.N = 13), provided the foundation to pivot into an adjacent health career (N = 9), or gave them guidance on the best intermediate step(s) to achieve their LYMP career goals (N = 9).Alumni that chose to pursue a career in healthcare found that their time during the program helped them transition directly into a profession that was consistent with career goals they established during the program  alumni recalled receiving support from program staff or individuals associated with the program to help them through COVID19 related issues.A majority of study participants provided specific examples on how their perception of the health professions changed as a result of the various program activities. One respondent describes her time shadowing a nurse in a family health center as “getting a chance to see what those [nurses and doctors] actually do. I would see how they assessed the patients, what medications they give, [and] how they interact with patients. The program opened my eyes even more to what a day in their shoes … and … their profession is really like.” (P19) Another student spoke on how the program showcased “different areas of healthcare, and how they intersect with one another” (P20), and that “the program was really set on making sure to include the …business…and…research aspects of [healthcare]. That’s something I would not have realized if it wasn’t for the program. I did not even think of it as part of the healthcare [field] until I entered Lang.” (P20)23 alumni expressed their gratitude and satisfaction toward the Lang program as it gave them meaningful experiences and empowered them to pursue healthcare professions. Several participants believed the Lang program was an “eye-opening experience” (P3) and they “would definitely do it again.” (P7) One alumni found the Lang program to be a life-changing experience:It changed my life. Even though I don’t think that I’m going to work in a hospital, it definitely impacted my life for the better… (P12)Some participants made specific comments regarding the program’s academic and professional resources, such as resume building, essay writing, SAT prep, networking, and shadowing opportunities:I would not have known how to write a resume, I wouldn’t have been able to write my…college essay [without the Lang program] …they helped me so much…I definitely wouldn’t have been able to get into Hunter [College] without them. (P18)[Lang was] always introducing us to different doctors, to different health care professionals. And I think just because most of my childhood was in the hospital, that made the transition [to the clinical setting] a lot easier.” (P17)One alumni suggested that “the program made [her] think that it was a lot more attainable or just easier to break into or to dive into [the medical workforce]. That essentially [means] that if you wanted it, you could just do it.” (P10) The same idea was supported by another alumni by saying: “the program … shows you those opportunities at a young age and so you can visualize it and see [it].” (P12)The Lang program fostered strong relationships through its engaging program activities, including internships, curriculum, and workshops. 20 participants talked about their peer, staff, and professional connections and their essential roles in “strengthening how youth contribute to the communities they live in” . One aluWe are also super close. One of our classmates had a baby a couple months ago and we all went to her baby shower…I texted [the Lang Medical Director] a month ago to let her know I have officially declared general surgery [as my specialty of interest]. Joey was the former alumni relations and I still chat with him.” (P17)I am still in touch with the dental internship [connection]…And I'm also in touch with the Lang coordinators. (P15)To better understand the program barriers, our research team specifically asked for trade-offs alumni made to participate in the Lang program. Many participants described time commitment as a major barrier: “It was a very long program; it was 6 years… a lot of our time was taken up” (P26). Time conflict is another common obstacle as students always have multiple commitments: “I was in middle school, and I was on the soccer team. I remember and there were some games that I wasn’t able to go to because of the commitment that I had with Lang” (Participant 24). Another alumni spoke about how they had less time to hang out with friends because “[on] Saturdays, we have to go to Lang and in the summer, it’s kind of intensive and it’s almost like school where you are going almost every day” (P27).While 21 out of 25 participants talked about the trade-offs they had to make, 12 of them also found the “sacrifice” to be worthy and “never thought it was too much of a tradeoff” (P6).The Lang program has focused on soft skill development by engaging students in a variety of social, academic, and professional activities. Some skills brought up by participants include networking skill, critical thinking skill, cultural competency, health communication skills, learning/cognitive skills, adaptability, organizational skills, presentation skills, public speaking skills, and time management skills.19 participants believe Lang taught them the essence of networking and encouraged them to never “be afraid to reach out” (P22):They pushed me to interact more with professors and teachers to have a better relationship with them because not only is it useful to you, but in the future, they could be the ones writing you a recommendation or telling you of certain opportunities that are there because you built a good relationship with them. (P13)Many participants believe they develop strong communication, public speaking, and presentation skills through Lang-related events:I have to mention the yearly expos… I think that definitely helped with my public speaking skills, and just speaking with different people. (P10)Those presentations [at the Expo] were the reasons why I became more confident in public speaking or even classroom presentations. (P20)12 participants mentioned becoming better at time management due to Lang projects, events, and courses, and they learned to “organize things properly [to] get everything done” (P23). Additionally, some alumni believe they developed critical thinking and learning/cognitive skills through the Lang curriculum and case studies:I think [Lang] really helped me to grow in my critical thinking [ability] and learning to connect information even if it didn't seem related, you know, pulling out meaningful information from experiences and other things that I know and relating it to what I'm learning. (P27)I guess other skills that I [learned was] cognitive thinking applications or being able to see parallels. And what does it mean to me or seeing my parallels and memorization. (P8)One participant believed the program helped them develop cultural competency: “if I wasn’t for Lang, it would be a little bit more difficult for me to give my patients culturally competent care” (P4).Adaptability was another important skill mentioned by participants where they became better at adapting to unexpected situations, such as the COVID pandemic:So, I'm very used to Lang, used to adapt in and make the best of the situation…I'm sure that definitely had an impact in how I approach the changes that were occurring during the pandemic. (P24)Attitude changes were defined as changes in attitude toward a specific career or health profession that may have led to a behavioral change, not just gaining new knowledge. This theme was coded 19 times across the interviews. Participants describe how their attitudes towards the medical field changed over time in the program:It got me interested [in] physician adjacent careers. Like research, because I never really thought about research, I never thought about becoming a scientist or anything like that, but through Lang and its affiliations with other programs, I was [exposed to] guest speakers [who are] doctors but they're also doing research… That was something that constantly came up where these people were doctors but they had so many other things going on and so many other things they were working on, and it really opened my eyes to different routes you can take even once you are a physician, and I think that also opened me up to getting my Master's in Public Health because I'm interested in the research side of medicine. (P5)I always wanted to be a nurse. [Lang] opened my eyes to maybe [not wanting to be] a nurse… [Lang] opened my eyes to [other careers], maybe I could do something else not as clinical and still make an impact, and still be in the community. (P11)Another intangible program driver found in the interviews was developing a sense of self. This was coded three times and defined as “Ways the program fostered participant intrinsic motivation for change and growth.” Participants describe how the program contributed to this development:[Participating in the program] motivated me to find a balance between work and play… We joked around and had fun, but at the end of the day we had to remain very professional, [Lang] helped me shape my professional and personal self. And then tie those together without being ingenuine in the professional setting, but also being myself. (P21)For some participants, a health career was not pursued for any number of reasons. Two participants in particular out of the 27 knew from the beginning that they were not interested in pursuing a career in medicine, but instead went through with the program for benefits such as scholarship money:I took what was interesting to me, what was gratifying rather an encyclopedia for how to become a medical student, or, you know, I wasn't on that line. I was kind of just like riding the wave for my scholarship money. (P2)While the majority of scholars had a genuine interest in medicine and health related careers, the resources and upward mobility associated with scholarships to pursue higher education was enticing to some.One of the most consistent intangible drivers of participant success was the internalization and enactment of specific values LYMP sought to distill onto students. Lang values were coded 9 times across the interviews and offered a rich perspective on how these values are passed from one generation to the next:Their values. The values that [Lang] taught me I still use to this day. Respect. Compassion. Patience. Professionalism. Those are things that they instilled in us. Those are things that you learn and are hard to let go because it’s very important for the future. For you and who you become as a person. I remember a few weeks ago, I was working, and we had a volunteer and ironically, she’s a part of the [program]. I started speaking to her and she was on the younger side. And I was giving her advice: “Listen you might not see it now because you’re young and you want to have fun but…you’re going to be super grateful for it in the future. So, stay still, do your studies, commit to the summertime here. And in a few years, you’ll see the outcome of it. (P11)While the Lang Youth Medical Program aims to foster an inclusive and supportive learning environment for all program participants, there are multiple areas that can be improved to enhance the program experience for future participants.A number of participants gave specific critiques regarding program support, time commitments, program diversity and inclusivity, college preparation, and career choice. Five participants believe the program provided inconsistent or insufficient support resulting in a lack of sense of community and belonging. Some participants mentioned they never felt engaged in the alumni network and hoped Lang could create more feasible opportunities for them to connect with their fellow alumni.Participants provided mixed comments on program academic content and parent engagement. While some participants believed the program should be more health-focused to prepare students for a pre-med track, others thought the program could incorporate more public health-relevant topics to broaden students’ perspectives and knowledge. In terms of parent engagement, one person believes the program has asked too much from parents, but another participant would like to see more parental involvement.The Lang program was also criticized because some alumni think the program failed to provide a comprehensive image of pursuing health as a career. Some alumni found such an environment gave them an optimistic image of pursuing medicine as a career. Once they enter college, they “realize how expensive and how hard it is to become a doctor and kind of lose that vision and that optimism” (P4).Other critiques include two alumni who expressed their disappointment towards the program because they were unable to secure a career through the Lang program to become Lang staff. While the program does not guarantee employment for participants post-graduation, these two participants felt disappointed as they were eager to make a contribution to the Lang community.Study participants provided a wide range of thoughtful program recommendations in their interviews. Some of the recommendations were made specifically on the program’s approach to addressing career choices, program activities, program selection criteria, and program outreach efforts.Several participants suggested that the program should be open to non-medicine-related career paths. They believe the program should consider “that not every student wants to be a doctor” (P21) and students “do not necessarily have to be a nurse or a doctor” (P11) to serve their community.Recommendations were also given concerning program activities. A few participants recommended having the retreat at a different time of the year to give students more time to make friends before any group activities. Additionally, some alumni wished there were more outdoor activities including trips and outdoor lessons as “being in that open environment really helps [when studying]” (P18).In terms of program selection criteria, a few participants indicated that they were never inclined to pursue medicine but were still accepted to the program. The program gave them a unique perspective but not necessarily an enjoyable experience throughout. One alumni mentioned that “at first, everything was really scary for me. And then it got scarier. And I think it stayed, it reminded me that I cannot work in the medical field because that is so scary for me. And it’s so much responsibility that I was not able to handle but it was so great to see it like a firsthand account” (P22).Additionally, some participants recommended the program improve its outreach effort by conducting it “more frequently” (P6) and providing more relevant messages to young students (P1).One key area of interest to this evaluation was participants’ ability to fully participate in the program. While plenty of support was provided by the program to ensure this, interviews showed that sometimes superseding conditions and external forces affected participants’ ability to succeed or struggle. This topic area of external facilitators and barriers to program participation is divided into two major topic areas: external drivers and financial hardship.External drivers were defined as “any external factors outside of the Lang program that had an influence on a participant’s personal and/or professional decision making .” This theme was divided into two sub themes which researchers used as codes when analyzing interviews. The first code, external influences, was coded 7 times across the interviews and the second code was parental support, which was coded 9 times across the 27 interviews.Oftentimes external influences provided a means of facilitating fuller participation in the program. For instance, having an older sibling who participated in the program was a major facilitator:I’d say it made it a lot easier for me to adjust to the way the program would work. [Because] I know that I probably had an easier time than some of my peers who were just going through the program kind of confused and not knowing what would happen throughout the year. So, with my sister, I’d be able to like, hey do you know what happened during this year of your time in the program, and she’d let me know, like, we covered this stuff, and then I’d have a little bit of input on how the year would go. So, I think that made it a lot more simple in my eyes. (P23)Others relied on parents who had experience in the medical field or who supported and pushed them to continue in the program:I’d say [I] developed [an interest in health careers] very significantly… I always had a view -- I guess an informed view of medicine and stuff because even though I was little, my parents worked -- like they operated a hospital in Pakistan. And I’d often visit them, so it wasn’t like a really foreign field to me…but like I was able to be exposed to [the medical field] way earlier on, and for a while and with consistent help from that was really nice. (P6)Yeah, definitely, it was—my mom probably helped out the most. My dad too, my dad would be there, um, he would come to like my expos and things like that, um, he would pick me up, he would stay late if he had to and things like that. And then my mom was like there in the morning, she’d be like, “Okay, get up, get your white coat on, get your gold pin, your ID and everything, make sure you have everything, let me make you breakfast,” things like that. And then if I ever was, like, doubting, like I said before, if I ever had any doubts about, like, going into medicine or things like that, she would just calmly, like, “Calm down, sit, let’s think about it, let’s talk about it,” things like that. (P18)Still others’ success in the program was driven by external teachers who had facilitated participation in the program:I was just…very lucky to always have had great teachers from kindergarten up until high school, and of course I have great professors as well, but I was really lucky to go to some schools that had teachers who really, really cared about the students. And so, my science teacher, she was the one who kind of like vetted who would go into the program or not--well, who would apply for the program. And she saw something within me, thinking that I would be a good candidate for the program. And I submitted an application and got the first few rounds of interviews, and I eventually got into the program. (P12)Financial hardship was defined as any “financial barriers that prevented a participant from participating in program activities or pursuing academic or professional goals.” This code was used four times across the interviews.While many students found facilitators to success in these external influences, others spoke about the external barriers they or others faced to being entirely successful in the program.Not all scholars lived within walking distance of the program. Most take the train and obviously your school pass only works Monday through Friday and so while I did not think it was a hardship at the time, I would imagine either based on my family income or whatever budgets there were, there always had to be some budget going towards transportation, clothes, and lunch. So, in retrospect, those were the things I thought about. (P10)Other students spoke about the financially daunting prospect of attending medical school -- something that was encouraged as an ideal outcome by the program, but not feasible in the eyes of participants:And I just knew, I guess I kind of knew from the outset that I probably wasn’t going to medical school, because it’s just, it’s way out there you know this commitment was enough for me. And also, financially, I wouldn’t have been able to afford it. (P2)The Lang Youth Medical Programs seeks to increase the number of minority students who successfully complete health sciences related academic tracks and go on to pursue a profession in healthcare. Recognizing how challenging these developmental years may be and understanding that there are external drivers that influence student decision-making, LYMP has also embedded in its logic model ways to support students’ psychosocial health and overall well-being. To this end, the program immerses scholars in activities that focus on academic content, interpersonal and professional skills, goal setting, and exposes students to a variety of healthcare professions. This study sought to examine how the Lang Youth Medical Program impacted the academic and career paths of graduating scholars.Participant responses demonstrate that the structure of the LYMP program is aligned with multiple youth development frameworks, such as the UNICEF Conceptual Framework for Measuring Outcomes of Adolescent Participation , and TheTo better serve prospective and enrolled students, evaluation of the program should occur more frequently to ensure student/alumni feedback is integrated into the evolution of program activities. Such efforts can lead to more timely improvements to address program weaknesses and reduce unnecessary barriers for students to participate in the Lang program. For example, in response to some study participants expressing that the inability to pay for transportation related costs had prevented them from attending certain activities, program leadership has secured transportation subsidies.Future research seeking to understand the impact the Lang Program has on scholars and alumni would be enhanced by qualitatively and quantitatively examining youth development constructs inherent in the program design, identifying a program enrollment time that would generate the greatest success, general educational and career outcomes of participants, and the perspectives of the professionals advancing the mission of the program by providing their time and expertise.Our study has several key strengths. First, this study makes an important contribution to the literature by documenting the perspectives of how a health science professions pipeline program for minority students impacts the personal and career trajectories of program graduates who are entering or in the workforce. The Lang Program has implemented a unique health professions pipeline model, with this study being the first of its kind illustrating the key components of the program that past scholars found to be most beneficial to achieving their goals. Further, our qualitative inquiry facilitated a more detailed and nuanced exploration of our research question than would be captured by quantitative methods. As a result, themes and topic areas were identified organically during data analysis. Additionally, this study presents invaluable information about the kinds of external factors faced by minority students in reaching their goals, providing a call to action for other institutions to address systemic barriers.There are a couple limitations to be noted. First, the interview tool was created from scratch by the research team and guided by the logic model. Development frameworks were used to consider what potential themes could arise, but the guide was not developed to test any specific development framework or construct. Second, given that many alumni graduated several years prior to the interview, responses could have been influenced by recall bias. However, this also allowed participants to provide feedback over a longer time period. Thirdly, selection bias may also be present, as the research team did not have accurate contact information for all eligible alumni. Participants whose information was up-to-date and participated in the study may be more engaged with the program than non-participants who could not be reached. Although the research team did not seek to generalize findings from this study to the entire student population, self-selection from this convenience sample may result in biased perspectives. Fourthly, 27 of the anticipated 30 interviews were completed, which may have left certain perspectives undiscovered. Although the research team found that data and thematic saturation was met for the collected sample, our sample is different from the program participant population in terms of race/ethnicity and gender. Not being able to interview more alumni could result in missing themes, but such limitation is not unexpected given this is a convenience sample. Lastly, alumni understand the mission of the program, and many have an interest in seeing the program succeed, therefore, it is possible that responses were primed by social desirability bias.Design principles from the program see  and findThe original contributions presented in the study are included in the article/The studies involving humans were approved by Columbia University Human Research Protection Office and IRBs. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.OK, ZW, and RS contributed to the conception and design of the study. The same three conducted the analysis and interpretation of the data, and draft of the initial manuscript. OK, ZW, RS, MM, and JR contributed to revisions of the paper. AN provided the finwal revisions and approved the submission of the paper. OK and ZW contributed equally to this work. All authors contributed to the article and approved the submitted version.


Aboriginal and Torres Strait Islander Australians are disproportionately impacted by blood-borne viruses (BBVs) and sexually transmissible infections (STIs). Stigma remains one of the key barriers to testing and treatment for BBVs and STIs, particularly among Aboriginal and Torres Strait Islander people. The Deadly Liver Mob (DLM) is a peer-delivered incentivised health promotion program by and for Aboriginal and Torres Strait Islander Australians. The program aims to increase access to BBV and STI education, screening, treatment, and vaccination for Aboriginal and Torres Strait Islander Australians in recognition of the systemic barriers for First Nations people to primary care, including BBV- and STI-related stigma, and institutional racism. This paper presents routinely collected data across nine sites on the ‘cascade of care’ progression of Aboriginal and Torres Strait Islander clients through the DLM program: hepatitis C education, screening, returning for results, and recruitment of peers.Routinely collected data were collated from each of the DLM sites, including date of attendance, basic demographic characteristics, eligibility for the program, recruitment of others, and engagement in the cascade of care.Between 2013 and 2020, a total of 1787 Aboriginal and Torres Strait Islander clients were educated as part of DLM, of which 74% went on to be screened and 42% (or 57% of those screened) returned to receive their results. The total monetary investment of the cascade of care progression was approximately $56,220. Data highlight the positive impacts of the DLM program for engagement in screening, highlighting the need for culturally sensitive, and safe programs led by and for Aboriginal and Torres Strait Islander people. However, the data also indicate the points at which clients ‘fall off’ the cascade, underscoring the need to address any remaining barriers to care.The DLM program shows promise in acting as a ‘one stop shop’ in addressing the needs of Aboriginal and Torres Strait Islander people in relation to BBVs and STIs. Future implementation could focus on addressing any potential barriers to participation in the program, such as co-location of services and transportation. Although representing 3.2% of the Australian population , AborigiHowever, racism and BBV- and STI-related stigma can act as significant barriers to First Nations people seeking testing and treatment –10. FirsTo provide a culturally sensitive and safe space for Aboriginal and Torres Strait Islander people to engage in care for BBVs and STIs, the Deadly Liver Mob (DLM) program was first introduced as a pilot program in 2013 in one publicly funded needle and syringe program (NSP). DLM program is a peer-led health promotion program that aims to increase access to screening, treatment, and vaccination for BBVs and STIs for Aboriginal and Torres Strait Islander people through mainstream NSP and sexual health services. The program was initially modeled from the Safe Injecting Cwiz (SIC) conducted in western Sydney between 1998 and 2002, which targeted people under the age of 25 years who injected drugs . The SICIn the DLM program, Aboriginal and Torres Strait Islander clients who meet eligibility criteria are invited to a HCV education session with an Aboriginal and Torres Strait Islander worker and encouraged to refer their peers to the program. The presence of Aboriginal and Torres Strait Islander workers allows for culturally safe and appropriate introductions of clients to the health service . AlthougThe DLM program began as two pilot sites within western Sydney, NSW, in 2013 and 2015, respectively. In the first 12 months at the first pilot sites, more than 400 Aboriginal and Torres Strait Islander people received education, and over 300 people were referred to sexual health screening, resulting in a 1023% increase in access to sexual health services. Findings from an early mixed methods evaluation of the two pilot sites showed that the program was well-received by Aboriginal and Torres Strait Islander clients and resulted in increased attendance and engagement within the service . As partThe broader Partnership Project, led by the Centre for Social Research in Health, sought to evaluate the health outcomes and impacts of DLM, examine its acceptability, and develop a scale up and implementation toolkit that could be used at future DLM sites. This quantitative component includes analyses of routinely collected data by each of the DLM sites and shows clients’ engagement in the DLM program, including engagement in education, screening, and returning for results, and peer referral.Have ever injected drugs; ORCurrently inject drugs; ORAre classified as ‘at risk’ of injecting drug use and/or BBVs and/or STIs. ‘At risk’ was defined as having ever been in prison, having had an unsafe tattoo, or living with a person/people who inject drugs and/or has HCV. ‘At risk’ was a working definition, with the possibility of evolving based on any new knowledge.Aboriginal and Torres Strait Islander people who met eligibility criteria for the program were invited to a hepatitis C education session with a DLM Aboriginal and Torres Strait Islander health worker. Aboriginality is determined by the local Aboriginal DLM workers and in accordance with community principles. Due to the focus of the program on HCV screening and treatment, Aboriginal and Torres Strait Islander clients must:Non-Aboriginal or Torres Strait Islander romantic and/or sexual partners of Aboriginal and Torres Strait Islander clients are permitted to take part in the DLM program due to the importance of BBV and STI screening of sexual partners –22. HoweThe DLM program is designed to be a low-threshold service, with minimal client data collected in order to remove barriers to engagement in primary care. The evaluation attempts to mirror this approach with the research design, so as to ensure the research was not adding any barriers to clients engaging in the program. Routinely collected de-identified data were provided by each site to the evaluation team, rather than obtaining individual consent from clients to access these data. A waiver of consent was approved by the ethics committees overseeing the project. Ethics approval for the evaluation of the DLM program was obtained from South Eastern Sydney LHD and the Aboriginal Health and Medical Research Council Ethics Committees. Site-specific approvals were also obtained from each of the seven LHDs governing the nine sites involved in the study.Routinely collected data include the date the client attended the program, basic demographic characteristics , eligibility for the program or risk markers for injecting drug use or BBVs and STIs (defined above), recruitment of others to the program (maximum of three people recruited), and their engagement in the DLM program . Follow-up sexual health could include vaccination for HAV and HBV, and treatment for STIs if required . The provision of HCV treatment has changed significantly since the introduction of direct-acting antiviral therapy (DAAs), with the Australian Government subsidising treatment without restrictions from 2016. DAAs can now be prescribed in non-specialist and primary care settings including NSPs, sexual health, and by general practitioners . This haData from the introduction of DLM as a pilot site on April 29, 2013, up to June 30, 2020, where all nine sites were running are included in this paper. The program start dates for the nine sites were (1) April 29, 2013 (metro area); (2) February 12, 2015 (metro area); (3) and (4) February 8, 2017 ; (5) February 15, 2017 ; (6) and (7) September 11, 2017 ; (8) September 19, 2017 ; and (9) February 27, 2018 (metro area).Routine data recorded by the sites were originally collected on paper-based DLM intake forms and then entered into Microsoft Excel spreadsheets by DLM staff. The intake forms and spreadsheets were somewhat standardised across all the sites due to the information sharing that occurred at the beginning of the Partnership Project; however, there were some variations based on local requirements or preferences. The earliest pilot site which began in 2013 had incomplete demographic data due to differences in data recording at the beginning of program implementation. The spreadsheets were de-identified by DLM staff  and password protected, before being transferred to the evaluation research staff.The data were examined in relation to the notion of the ‘treatment cascade’ or ‘cascade of care’ . The ideComparisons in engagement in screening and returning for results between men and women were conducted using Chi-square analyses. Point biserial correlation was used to examine the relationship between age and engagement in screening and returning for results. These analyses were not conducted for engagement in education as all clients who enter DLM receive education. Analyses were conducted by the first author (EC), then workshopped with Aboriginal and Torres Strait Islander authors (KB and MB) and non-Aboriginal or Torres Strait Islander authors (CT and EC).n = 985) in 2016 up to the end of data collection in 2020 are presented in Table Demographic and risk factor data for a subset of DLM clients who entered the program since the introduction of the NHMRC Partnership Project . Although DLM staff made attempts to engage DLM clients to return for screening and results, these efforts were not always successful. We describe some of the individual and systemic barriers to engagement in DLM elsewhere, such as geographic spread of clients , travel cost, and parking difficulties, among others . Sites made efforts to address some of these challenges, such as by doing outreach to more regional and remote areas.n = 985). There were no differences in men and women’s engagement in screening or returning for results (p > 0.05). There was also no association between age and engagement in screening and returning for results (p > 0.05).We examined differences in engagement in screening and results according to age and gender. Given these data were only routinely collected after 2016, these analyses were limited to clients who entered the program between 2016 and 2020 (Over the life span over the project (from 2013 and 2020), an estimated $56,220 was spent in incentive payments to Aboriginal and Torres Strait Islander clients in the DLM program for engagement in the cascade of care. Of this amount, $35,640 was spent on incentive payments for HCV education of clients, $13,100 was spent on incentives for screening, and $7480 was spend on incentives for clients returning to receive their results.n = 985) in 2016. This was because early DLM sites allowed additional recruitment beyond three clients, and this was standardised in 2016 across all sites for up to three recruits per client. Since 2016, a total of 149 clients (15%) referred others to the program: of these, 106 (71%) recruited one person, 29 (20%) recruited two people, and 14 (9%) recruited three people. This comes to a total of $1596 in peer recruitment costs.Clients have the opportunity to refer up to three peers to the program for an additional $10 per recruit. For peer referral data, we focus on recruitment by any clients who entered the program since the introduction of the NHMRC Partnership Project , they could have recruited 1787–5361 clients. This would have come to a cost ranging from $17,870 to $53,610.The aim of this paper was to evaluate the ‘cascade of care’ progression of Aboriginal and Torres Strait Islander clients through the DLM program, and the estimated monetary investment required for clients’ progression through the core components of the program. Routine data collected by the sites where DLM was operating between 2013 and 2020 indicate that a total of 1787 Aboriginal and Torres Strait Islander people entered the DLM program and received HCV education, 1316 received BBV and STI screening (74%), and 753 returned to receive their results . The DLM program aims to overcome some of the systemic barriers to health-care engagement and retention for Aboriginal and Torres Strait Islander Australians. The data presented in this paper show that providing a culturally sensitive and safe space for Aboriginal and Torres Strait Islander people to engage in BBV and STI screening and treatment has positive impacts on engagement and retention, demonstrated through the progression through the cascade of care, requiring return visits from clients.As we have discussed elsewhere in relation to the two pilot sites , engagemThe data highlight multiple points at which people may ‘fall off’ the ‘cascade of care.’ Within some sites, the proportions of clients who go on to receive BBV and STI screening and return for their results may be lower than others as shown in the results. There may be multiple explanations for this. For example, not all DLM sites have sexual health services that are co-located to the delivery of the DLM education, which presents a barrier for clients progressing to screening. Sites typically rely on a single (or up to two) local Aboriginal or Torres Strait Islander DLM workers to deliver the program, which has been hailed as one of the key benefits in engaging community . Howeverhttps://www.deadlylivermob.org). An additional limitation of this data is the inability to capture further client data on treatment of HCV. This is because of the changing landscape of HCV treatment since the introduction of DAAs from March 2016, with treatment now able to be prescribed both in specialist and non-specialist settings, including NSPs, general practice, outreach clinics, sexual health, and liver clinics. Future DLM sites should consider how such data could be accurately captured prior to implementation while operating a low-threshold approach to service access .There are several study limitations that must be noted. This paper draws from routinely collected data from the DLM sites. This relies on DLM staff to consistently and accurately collect and record clients’ engagement in the program and the incentives distributed. Our experience indicates that this is not always the case. For example, the types of information initially collected by the two pilot sites differed from that collected later when new sites were introduced, and thus, we do not have complete demographic data for clients who entered the program between 2013 and 2015. Sites benefited from the funding provided by the Partnership Grant, which allowed for regular catch ups between all sites and research staff. Future DLM sites may not have access to these resources. However, to assist future DLM sites with implementation of the program, we have developed an implementation toolkit, containing a range of resources and templates to guide any potential future sites (see The DLM program sought to promote a culturally appropriate and welcoming service for Aboriginal and Torres Strait Islander people living with or at risk of HCV through re-design of the service, tackling stigma at multiple levels, including within the organisation and delivery of health services and via the provision of incentives, acknowledging the structural impact of material deprivation for First Nations people . The datThe findings presented here illustrate the positive impacts of the DLM program on Aboriginal and Torres Strait Islander peoples’ engagement in BBV and STI education and screening within primary care. The trust established between the Aboriginal and Torres Strait Islander DLM program staff and clients has been previously shown to be critical and accounts for much of the program’s success, in addition to the program’s partnership between NSP and sexual health . The pro


This study aimed to explore the experiences of older migrants’ (70+) access to and participation in different meeting places. Qualitative interviews were conducted with participants originating from Finland and four countries in the Western Balkans: Bosnia- Herzegovina, Croatia, Montenegro, and Serbia. The participants used everyday places in the neighborhood, which were not primarily meant to be meeting places, to create and uphold social contacts. These meeting places contributed to experiences of community and trust. Both everyday meeting places and organized meeting places were used to establish and develop relationships that could result in an exchange of both practical and emotional support. Perceptions of “not belonging”, limited proficiency in Swedish, and a strained financial situation created barriers to accessing some meeting places. The results of this study demonstrate the significance of meeting places that are not purposefully aimed at older people in general or older people from a specific country. This article focuses on older migrants in Sweden and their experiences of access to and participation in different meeting places. In Sweden, twelve percent of people aged 65 years and older have migrated to Sweden at some point during their lives, and this amount is presumed to double in size by the year 2030 . HoweverVarious definitions exist of what constitutes a meeting place. It can be defined as a place for social gatherings encompassing organized social venues such as associations, interest organizations, or senior centers arranged by Long-term care services. Furthermore, it can relate to spontaneous meeting places such as cafés, squares, and parks. Even though the physical environmental aspect of a meeting place is crucial, it can also be viewed as a social construction, as individuals create the meaning of a meeting place in their social interaction with others . PreviouFurthermore, negative perceptions of ageing can create barriers to participation in social meeting places explicitly aimed at older people , 10). Mo. Mo10]).For gerontological social work, it is essential to gain more profound knowledge about older migrants’ experiences of the significance of meeting places to promote social-inclusion. The knowledge sought is especially valuable to live up to the ethical values of social work, promote participation in society, and secure equal opportunities for all to access health and social care services. Furthermore, as older migrants are at risk of poorer health and since meeting places are essential to the wellbeing, the topic of older migrants experiences of meeting places can also be motivated from a health and wellbeing perspective , 16). In. In16]).The study was implemented in a district of a larger city in Sweden with a population of approximately 500,000, of whom 50,000 live in this district. The town is highly segregated, and the longevity between the wealthiest and most impoverished neighborhoods differs by about nine years. The inhabitants in the area come from over 100 countries. Half of all inhabitants in the urban community were born in non-Nordic and outer European countries. Regardless of the person’s age, the most common country of birth was in descending order: Iraq, Iran, Finland, Bosnia-Herzegovina, and the former Yugoslavia. The latter three were dominant countries of birth for persons 65 years or older. In the urban district 2012, residents’ general educational level and income level were lower, and the sickness rate was higher than in the rest of the city’s population. This qualitative interview study is nested within a more extensive health-promotion study:" Promoting Ageing Migrants ‘Capabilities” . The tarFor the present study, a strategic sample of ten participants reflecting heterogeneous migration backgrounds were drawn from the larger study. The only exclusion criterion is impaired cognition  below 80% of administered items. Five of the participants originated from the Western Balkans and five from Finland; half of them were men, and half of them were women. Five of the participants had migrated as labour migrants, four of the participants as refugees, and one participant for family reasons. Half of the participants had started a university or college education. Most participants had lived in Sweden for 21 years and rated their health good. Less than half of the participants were living alone. The ages of the participants ranged from 70 to 80 years. Data on the income level of the participants was not retrieved. However, half of the group had arrived in younger years as labour migrants, implying a more extended period in the labour market to accumulate enough years and pension rights to obtain a full base pension. The rest of the group had arrived during the financial crisis in Sweden during the 90´s . Most paBased on a thematic interview guide  qualitatThe analysis resulted in four code groups with nine subcategories: Everyday places become meeting places; Organized meeting places support social contacts; Meeting places as identity markers and Barriers to accessing meeting places. The four groups entailed nine subcategories see .Participants made new connections. It emerged that everyday meeting places, whose purpose was not primarily to provide a social meeting place, did have such a function. Social meetings could occur on a staircase in an apartment block, at a bus stop or on a bus, contributing to feelings of community and trust. Recurrent meetings between individuals at such places could gradually evolve into closer relationships where support was exchanged."I got to know a person from the same neighborhood at the bus stop. She has lived here for forty-three years: we became friends … a few days ago, I had to go to the medical center as she no longer knows where it is. She cannot find her way there on her own."The everyday places served as an intermediate step to deepen the relationships that could continue outside this context. Furthermore, the social interaction that occurred at these meeting places also appeared to have value in itself."These days, I take the public shuttle service where I socialize with other people; there are many people I can have a good laugh with…we talk to each other, and it is delightful."Some meeting places required membership to gain access and entailed a shared responsibility between the members. In addition to the "contract" in terms of membership, social support could be given at these meeting places that exceeded the required duties. One example of this was the condominium association. The joint responsibilities for the premises, gardening and other things that had to be done created a meeting place that allowed an exchange of support between the members that went beyond their duties, such as jointly celebrating birthdays or cooking for someone who had recently arrived home from the hospital:"The neighbor living across from me [member of the condominium association] brought me food when I came home from the hospital when I could not cook for myself. They thought that cooked food would come in handy."Also, a bridge club was found to provide a basis for the creation and maintenance of social contact. The responsibility toward each other was not mandatory in the same way as appeared to be the case in the condominium association; the tasks performed here were more voluntary. Everyone knew each other, but not on a deeper level, as became apparent in the interviews with the participants. However, an awareness of each other could emerge in such groups; for example, someone lonely could be given extra attention. Additionally, a gradual establishment of social contact was evident; weekly greetings could eventually lead to an exchange of support.“I met an uncommunicative man at the bridge club I usually go to. He could have been more communicative; he did not talk to anyone. I told my wife I would help him to open up… One day, he came up to me … He said: "I trust you so that I will give you the keys to my apartment.…will you please check my mail while I am gone?" I said, "OK, I will." Then he said, "So, is there anything I can do for you?".Meeting places organized by the municipality, such as senior centers, also served the purpose of mutuality for the participants. An example of such a meeting place was the support group for carers."I feel free [when attending the support group for carers], and I do not think about my problems so much; I become happier, too.…they mean a great deal to me, so I assume that I mean a great deal to them too."Different meeting places also reflect the personal preferences of the interviewees. This was shown in the choice or avoidance of certain meeting places. The participants chose meeting places they identified themselves with. Some interviewees were, for example, involved in various associations and fellowships, viewing themselves as "fellowship people". Others regarded themselves as "dog people", for whom the daily walks with the dog were a meeting place for new acquaintances. Furthermore, they also described exploring their identity in different meeting places."I am not in a retirement club. I was for a while, but I did not think I got anything from it, so …I thought it was better to walk the dog… that gave me the opportunity to meet other people."Some meeting places were avoided because they reminded me of lost identities and no longer belonging. It could be the former workplace, a retirement club or somewhere else. "When I quit my job, I was anxious about leaving it; later, when I met my former colleagues, they said they missed me. I said I miss you too, but I can do nothing about it… I have not returned once since I retired due to anxiety over the separation I experienced." For others, feelings of affiliation emerged in experiences of how they maintained contact with old colleagues. By meeting former colleagues once a month at a local pub, participants could maintain a sense of identity-related to the former workplace. These meetings rekindled the feeling of being a part of the past community. The affiliation experience could also emerge when meeting former classmates from the country of origin at class reunions. The home country was a place that made them reflect upon how their own life had turned out compared to those who had stayed in their home country."I now keep in touch with my former high school classmates in my country of birth… In these meetings, we get insight into what has happened and how we have aged. It is interesting to see how they are doing and what they do in their spare time. For some interviewees, their homes represented the central venue and meeting place in their lives, which was used for maintaining contact with family and friends. Thus, more public meeting places such as associations and fellowships did not appeal to these participants."Some aspects of meeting places were described as obstacles to participation. Barriers were perceptions of not belonging, strained financial situations, and limited Swedish proficiency.Perceptions of not belonging as a barrier mainly occurred as perceptions of feeling too old and functionally limited or too young and healthy to go to. Only a few participants associated barriers to participation with their previous migration.“You stand on a bridge with half the body on one side and half the body on the other. Mm, ok, in two worlds all the time, I can tell you… If I’m not mistaken, almost everyone feels that way.”The interviewees reported how they associated certain meeting places with decline and frailty for older adults, which made them reluctant to go there. However, some interviewees challenged these notions and attended meeting places that others associated with negative aspects of ageing.A strained financial situation could also be experienced as an obstacle to participation in particular meeting places. Being unable to travel due to friends or not having the necessary financial means could lead to difficulties in maintaining or establishing social contacts.I don’t know; maybe they are afraid. For the most part, due to economic problems.“Women born in the forties had low-paid jobs and had no money to spend except on the most essentials."Language was also found to be a barrier to participation in meeting places where most participants spoke Swedish. At such meeting places, participation was therefore experienced as more difficult. Where the workplace no longer represented a possible social contact arena, several interviewees mentioned its importance for learning the language. Others stressed how the lack of a workplace as a meeting place affected their present possibilities to establish contacts with Swedish-speaking people in later life and to participate in Swedish-speaking meeting places." I would like to have the opportunity to meet someone who is native Swedish."I want to be able to talk to them. I am now of an age at which I do not work, and I will not work again since I am retired. The workplace creates a network of people to talk to, providing an opportunity to practice Swedish. "The findings show that the participants attended various meeting places to establish and maintain social contacts. Previous literature on older migrants’ participation in meeting places, in the Swedish context, has focused on meeting places targeting older people from a specific country –15). How. How15])Furthermore, the participants’ self-identification and identification with others emerged as gate openers and gatekeepers in accessing various meeting places. Perceptions of not belonging to certain meeting places could form barriers preventing participation in some meeting places. As shown before, self-identification and identification with others could contribute to a sense of belonging . These pIn line with previous research, we argue that senior centers need to adapt to the diverse and changing needs of the older population , 11). St. St11]).Finally, in qualitative research, external validation concerns whether or not the results can be applied in other settings , 34). Th. Th34]).This study provides valuable insights, especially regarding gerontological social work promoting social participation in society for all older adults and meeting places where they can contribute to or limit such opportunities for older migrants. The results of this study point to the importance of creating environments, so-called everyday meeting places, which can naturally enable meetings between older people. This is particularly important for people who suffer financial constraints. Creating everyday meeting places is of fundamental importance in health promotion for older people in Sweden, especially those with financial vulnerability who are also at greater risk of poor health. Since everyday places that were not designed or intended as meeting places proved to be of great importance, we argue that there is a need to move toward a more comprehensive definition of meeting places for older adults. Our findings on older migrants’ perceptions of not belonging to certain meeting places should urge policymakers and practitioners working with older people to find ways of promoting social participation that reflect the increased heterogeneity of the older population. Moreover, as our study reveals different barriers to older migrants’ social participation in some meeting places, we need to analyze further how social exclusion and inclusion processes are used.


Transbronchial lung biopsy guided by radial probe endobronchial ultrasonography with a guide sheath (EBUS-GS-TBLB) is becoming a significant approach for diagnosing peripheral pulmonary lesions (PPLs). We aimed to explore the clinical value of the resistance of the probe to pass through the lesion in the diagnosis of PPLs when performing EBUS-GS-TBLB, and to determine the optimum number of EBUS-GS-TBLB.We performed a prospective, single-center study of 126 consecutive patients who underwent EBUS-GS-TBLB for solid and positive-bronchus-sign PPLs where the probe was located within the lesion from September 2019 to May 2022. The classification of probe resistance for each lesion was carried out by two bronchoscopists independently, and the final result depended on the bronchoscopist responsible for the procedures. The primary endpoint was the diagnostic yield according with the resistance pattern. The secondary endpoints were the optimum number of EBUS-GS-TBLB and factors affecting diagnostic yield. Procedural complications were also recorded.The total diagnostic yield of EBUS-GS-TBLB was 77.8%, including 83.8% malignant and 67.4% benign diseases (P=0.033). Probe resistance type II displayed the highest diagnostic yield (87.5%), followed by type III (81.0%) and type I (61.1%). A significant difference between the diagnostic yield of malignant and benign diseases was detected in type II (P = 0.008), whereas others did not. Although most of the malignant PPLs with a definitive diagnosis using EBUS-GS-TBLB in type II or type III could be diagnosed in the first biopsy, the fourth biopsy contributed the most sufficient biopsy samples. In contrast, considerably limited tissue specimens could be obtained for each biopsy in type I. The inter-observer agreement of the two blinded bronchoscopists for the classification of probe resistance was excellent (κ = 0.84).The probe resistance is a useful predictive factor for successful EBUS-GS-TBLB diagnosis of solid and positive-bronchus-sign PPLs where the probe was located within the lesion. Four serial biopsies are appropriate for both probe resistance type II and type III, and additional diagnostic procedures are needed for type I. There have been an increasing number of patients with lung nodules that are being detected owing to the increase of lung cancer screening by chest computed tomography (CT) scans, especially low-dose CT , 2. Of tThe factors affecting the diagnostic yield of EBUS-GS have been evaluated in a considerable amount of researches, most of which remains unclear with variations among studies –15; howeTherefore, the present article was designed to confirm whether the probe resistance can influence the diagnostic yield of TBLB guided by EBUS-GS (EBUS-GS-TBLB) for PPLs. Also, we investigated the relationship between the yield of bronchoscopic biopsy specimens and serial biopsies, with the intention of presenting a strategy for sampling via EBUS-GS-TBLB in the clinical field, resolving the clinical contradiction corresponding to the yield of EBUS-GS-TBLB and prolongation of the intervention.We performed a prospective, single-center study investigation at a tertiary care academic medical center. All patients with PPLs who received EBUS-GS-TBLB were examined between 1 September 2019 and 31 May 2022 at the First Affiliated Hospital of Naval Medical University. Eligible and recruited patients must meet the following criteria: (1) the lesion is between 10 mm and 30 mm in diameter; (2) the nodule is solid; (3) the probe is located within the PPLs on a basis of the EBUS image; (4) CT scan shows the bronchus can be detected in connection with the lesion. Exclusion criteria: (1) the lesion can be seen directly under bronchoscopy; (2) fail to reach to the lesion using EBUS-GS; (3) absence of 1-year follow-up data after transbronchial procedure. The study protocol was approved by the Institutional Review Board of Shanghai Changhai Hospital, Naval Medical University (protocol code: CHCE2021-049). Written informed consent was obtained from all participants involved in the study.The size of the lesion measured on the axial lung window setting of chest CT, and the distribution of peripheral bronchus identified by 3 experienced bronchoscopists using chest CT, were utilized to determine the type of flexible bronchoscopes  prior to operation. All procedures throughout the study period were performed by the same interventional pulmonologist with more than 20 years of experience in the absence of any assistance from bronchoscopic navigation techniques. A 20-MHz radial-type EBUS probe with an external diameter of 1.4 mm  inserted through the working channel of the bronchoscope was applied in all patients. A guide sheath (GS)  with an outer diameter of 1.95 mm was inserted together with the EBUS probe. Anesthesia was administered as previously described  and EBUSAt least 6 successive biopsies were performed during EBUS-GS-TBLB, followed by bronchial brush cytology and bronchoalveolar lavage. Each biopsy was instantly presented onto a numbered glass slide and immediately evaluated by an experienced cytopathologist using rapid on-site evaluation (ROSE). Whether TBLB sampling ended was eventually determined by the bronchoscopist in the light of the feedback from ROSE.The primary endpoint was the diagnostic yield according with the resistance pattern. The secondary endpoints were the optimum number of EBUS-GS-TBLB, factors affecting diagnostic yield, and incidence of procedural complications. In all cases, pathological examinations were performed by two experienced pathologists who analyzed the specimens obtained by EBUS-GS-TBLB. Diagnostic yield was calculated as the number of PPLs achieving successful diagnosis by EBUS-GS-TBLB divided by the total number of PPLs. The EBUS-GS-TBLB procedure was regarded as a definite diagnosis if the pathological assessment revealed malignant neoplasms, specific benign characteristics and/or positive microbiological results. For PPLs with nonspecific inflammation, only if the lesions decreased or disappeared were they considered to be successfully diagnosed by EBUS-GS-TBLB. For those non-diagnostic patients, additional diagnostic procedures, such as surgical biopsy and CT-TTNB, were required to further clarify. The final diagnoses were established on the basis of the pathological evidence, microbiologic evaluation, or clinical follow-up .The statistical analyses were carried out using SPSS Version 26.0 and GraphPad Prism Version 9.3.0. The continuous variables were presented as mean ± standard deviation (SD) unless otherwise stated. The Chi-square (χ2) test or Fisher’s exact test for the case of very small counts (≤5) was used to evaluate the differences in proportions. Every biopsy was reported and recorded separately with ROSE to build a quadratic function indicating incremental yield to plateau with serial biopsies and create a heatmap regarding to count of malignant cells for serial biopsies with different types of probe resistance. Inter-observer agreement was assessed using the weighted kappa (κ) coefficient. All analyses were two-tailed and a P value of <0.05 was considered significant.In total 237 consecutive patients with PPLs who underwent EBUS-GS-TBLB between September 2019 and May 2022 in our institution were obtained from the medical records and after screening, 126 eligible patients were ultimately included in our study Figure 2The overall agreement of the two blinded bronchoscopists for the classification of the resistance of the probe to pass through the lesion was excellent . Ultimately, we determined the type of probe resistance of every lesion: I , II , and III  Table 1.In general, a definitive diagnosis of PPLs was obtained in 98 (77.8%) patients using EBUS-GS-TBLB and majority were adenocarcinoma. The diagnostic yield of malignant diseases was 83.8% (67/80), while benign diseases was 67.4% (31/46), with a significant difference (P = 0.033) Table 3.For both size of lesion on CT and lobar location, no statistically significant differences in diagnostic yield were observed in any group. As shown in 2= 0.989)  cases that were controllable with topical application of cold saline solution with epinephrine. There were no pneumothorax or other severe complications associated with procedure occurring during the study period.In the few decades, interventional pulmonology has evolved rapidly and revolutionized the analysis of PPLs as it enables the one-stop ambulatory bronchoscopic diagnosis and treatment of PPLs , 22; wheIn the present study, the diagnostic yield of EBUS-GS-TBLB was 77.8%, which was in accordance with that of previous published reports , 24–27. Our results have indicated that the resistance of the probe to pass through the lesion is a significant predictive marker for successful EBUS-GS-TBLB diagnosis of PPLs. In detail, a probe resistance type II or type III is well correlated with the excellent diagnostic yield; for PPLs patients with which, EBUS-GS-TBLB examination is encouraged. On the contrary, an alternative or combined diagnostic procedure such as virtual bronchoscopic navigation  or electFurther analysis found this difference in diagnostic yield between malignant and benign PPLs is significant; the former is more likely to be successfully diagnosed than the latter. With respect to these observed results, possible reasons are listed as follows: malignant lesions invading the bronchial mucosa and resulting in propulsion resistance of the probe can be detected more easily. Moreover, when sampling for type III (the lesion in relation to high resistance), the forceps tips are often difficult to open the narrow lumen, thereby leading to its relatively inferior diagnostic yield in comparison with type II.It is without dispute that this novel classification of contribution may provide useful reference for interventional pulmonologists when encountering PPLs to be determined. Surprisingly, the classification of probe resistance was identified with excellent inter-observer agreement. Whilst these are encouraging and promising, it is worthwhile noting that the classifications with regard to different types of probe resistance in all patients are assessed by the same bronchoscopist with more than 20 years of experience, and operator and expertise dependent factors in varying degrees may affect the classified types, as previously mentioned , 34. ConThe ideal number of EBUS-GS-TBLB has not attracted considerable attention all the time, which may be attributed to high false negative rate of EBUS-GS-TBLB due to a variety of causes (e.g. unsatisfactory sample preparation and inadequate specimen collection) –37 and pThis study carried certain limitations. First, this was an observational design with relatively small sample size in a single center. Because these results may vary among institutions, they should be interpreted with caution. Yet, as far as we are aware, this report is, for the first time, a tentative exploration on the usefulness of the probe resistance and the ideal number of EBUS-GS-TBLB. Hopefully, more multicenter prospective researches with larger patient cohort will be encouraged to have broader practice patterns, to reduce unnecessary bias and to improve the statistical power of our study. Second, the same bronchoscopist with more than 20 years of experience performed all procedures and clarified the probe resistance in our study; hence, universal adaptability of the clarification of the probe resistance remained to be established. Last, it was noted that the determination of the optimum number of EBUS-GS-TBLB was based on the ROSE examination; but ROSE could not take place of the final histopathologic evaluation. Furthermore, the evaluation concerning the sufficiency of EBUS-GS-TBLB specimens for molecular analysis was unavailable in the present study. Future studies are needed to be assured of the reliability of the conclusions.Taken together, this observational study has demonstrated that the resistance of the probe to pass through the lesion has the potential to serve as a predictive factor for successful EBUS-GS-TBLB diagnosis of solid and positive-bronchus-sign PPLs where the probe was located within the lesion. Further, performing serial four biopsies is recommended for the probe resistance type II or type III, whereas additional diagnostic sampling methods are warranted for the probe resistance type I.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Institutional Review Board of Shanghai Changhai Hospital, Naval Medical University (protocol code: CHCE2021-049). The patients/participants provided their written informed consent to participate in this study.Conceptualization: ZH, ST, CB and HH. Methodology: ZH, ST, XW and QW. Investigation: XW, QW, LG, YT, WZ and YD. Analysis: ZH, ST, XW and XL. Funding acquisition: CB and HH. Project administration: WZ, YD and CB. Supervision: CB and HH. Writing original draft: ZH and ST. Writing-review and editing: CB and HH. All authors contributed to the article and approved the submitted version.