Countries all over the world are experiencing a shortage of registered nurses (RNs). Therefore, some countries, including Sweden, have tried to solve this by recruiting internationally educated nurses (IENs). Countries offer bridging programs as educational support to qualify IENs for nursing work in the destination country. However, there is little research on IENs’ experiences of bridging programs in European countries and how these programs facilitate their integration into the world of work and their new society. The aim of this study is to explore the experiences of nurses, originally educated outside the EU (European Union)/EES, of the Swedish bridging program and of the program’s role in facilitating their integration into the nursing profession in Sweden.A qualitative descriptive design was used to explore the topic based on 11 informants’ perspectives and experiences. Purposive sampling was used to recruit participants at one university in Sweden. Data were collected by individual interviews using a semi- structured interview guide during the year 2019 and were analysed using an interpretative thematic approach.Two main themes emerged from the analysis: 1) Return to nursing, and 2) The bridging program as a tool for transition to nursing in Sweden. The first theme includes conditions and experiences such as personal motivation and determination, and support from others that the participants described as important in order to achieve the goal of re-establishing themselves as registered nurses in Sweden. Furthermore, the second theme describes the participants’ experiences of the bridging program as mostly positive because it led to new learning and achievements that were valuable for the transition to nursing in Sweden; however, the participants also emphasised the challenges of their transition into the nursing profession, which were related to instances of misrecognition of their professional competence and the uncertain outcome of the program.This study found that the bridging program facilitated integration into the nursing profession for nurses educated outside the EU/EES, especially knowledge gained in clinical-based training. Thus, it is important to recognise and value the IENs’ experience and previous knowledge and training when developing the bridging program’s curriculum.The online version contains supplementary material available at 10.1186/s12912-020-00525-8. The global shortage of registered nurses (RNs) has been shown to have negative consequences on healthcare, such as increased mortality, staff violence, accidents, cross-infection and adverse postoperative events. Therefore, some countries have tried to remedy shortfalls in the nursing workforce via the recruitment (including spontaneous migration) of internationally educated nurses (IENs) –3.From an international perspective, registered nurses differ in terms of knowledge base, regulations regarding what nurses are allowed to do, as well as differences in nursing education, national health care systems, nursing practice and cultural values. The bridging program is aimed at internationally educated nurses with a degree from a country outside the EU (European Union)/EES. After completing the bridging program, the IEN must show the knowledge and ability required to be able to apply for nursing license in Sweden . ConsequThere are literature reviews about IENs’ experiences related to migration and acculturation , migratiAs shown above, the significance of bridging programs for a successful transition to the nursing profession upon migration cannot be ignored. Yet our review revealed that research on IENs’ experiences of bridging programs in European countries and how these programs facilitate integration into the world of work as well as society in general is limited. This is an important area of study because nurses educated outside the EU are an under-used, under-appreciated human resource, and represent a means to remedy the nursing shortage. Knowledge about these programs and the experiences of participants is also vital to facilitate the transition into the labour market with the appropriate skill level . Our stuBridging education programs for internationally educated nurses have existed in Sweden since the beginning of the 1990s, . The aimThe bridging program is a one-year course and is presently offered at five universities in Sweden in accordance with Swedish law on Higher Education (2008: 1101). The Higher Education Law (2008: 1101) states that education must be planned to consider each student’s previous education and work experience. The bridging program includes different courses containing education about the nursing profession, nursing, pharmacology and pharmaceutical calculation as well as learning and leadership. In addition, the clinical training components are carried out in primary care, municipal care and nursing as well as in one of the specialties of medicine, surgery or geriatrics.After the bridging program, nurses educated outside the EU have to pass a so-called knowledge test, which is in Swedish and examines areas such as laws and regulations for the health care sector. It also includes a practical test showing the clinical skills nurses need before they can work as registered nurses in Swedish health care. Seventy-nine percent of nurses who completed the bridging program had acquired a good position in the labour market after 1 year .The aim of the study is to explore the experiences of nurses, originally educated outside the EU/EEES, of the Swedish bridging program and of the program’s role in their integration into the nursing profession in Sweden.A qualitative, interpretative and descriptive design was used to explore the topic based on the informants’ perspectives and experiences in order to capture a variety of understandings and to gain an in-depth knowledge of the studied phenomenon .Purposive sampling  was usedA total of 11 bridging program participants were included in the study, in order to ensure deep and rich information and better understanding about the phenomenon of interest . The parData were collected during 2019 through individual interviews using a semi-structured interview guide to allow for a conversational style of interviewing. The interview guide was developed specifically for this study and included three main areas covering the interviewees’ educational and professional experience before arrival in Sweden; educational experience of the bridging program and clinical training; and expectations of future working life. Each theme was supplemented with 5-12 open-ended questions. Examples of questions that were asked are: “Can you tell us how you came to be a nurse in the first place?”, “Can you tell us how come you applied for the bridging program?”, “Can you tell us about your experience of the bridging program?”, “What was different and what was familiar when working as a nurse compared to previous experience?”, and “How do you envision your near/distant future in regard to working and professional life?”. Furthermore, the researchers tried to stay responsive to the interviewees’ reflections and followed up with questions to expand on their different experiences or to clarify reasoning and details if needed. The interviews were conducted individually or in pairs by female authors EH, A-M SM and JS either face to face in a secluded room at the university or by telephone, depending on what the participant opted for. All authors had extensive experience in conducting qualitative research on migration issues. Eight interviews were conducted face to face in a secluded room at the university, and three by telephone. The interviews were held in Swedish and lasted 45–75 min. All interviews were audiotaped and transcribed verbatim by professional secretaries before analysis. Numbers are used to represent the IENs to ensure anonymity.The data was analysed using Ödman’s interpretative approach  as the sReturn to nursing and The bridging program as a tool for transition to nursing in Sweden  or “My goal was to get the licence [to work as an RN] as soon as possible” (P8). However, the path leading to the start of the program varied in length, from only a couple of years up to almost 15 years. Seven of the participants started the program within a five-year period after arrival in Sweden. The participants described personal as well as social conditions they deemed important for a successful transition to the world of work as a nurse. Motivation and determination in terms of a clear understanding of essential preconditions and how to acquire them were important personal conditions, while support from formal and informal relations were important social conditions.The participants presented themselves as persons with a strong will, who wanted to reach their goal to obtain Swedish registration as a nurse, and as persons who worked in a dedicated and purposeful way to achieve the goal. The participants described two basic conditions as important for reaching their goal: acquiring Swedish language competency and work experience from the Swedish health care sector.Several of the students did not regard the Swedish language as an obstacle in itself for their life and studies. However, they recognized the importance of acquiring language competencies to succeed in the world of work. Therefore, they tried to find ways to acquire the language skills and qualifications that were needed. They had, sometimes very intensively, studied Swedish language from the beginning by starting basic courses in Swedish for immigrants (SFI) and then had continued to meet the requirements for academic level studies. They also developed different strategies to learn Swedish which included e.g., reading books, watching TV and spending time with Swedish-speaking friends.You just have to keep trying and stay curious [ … ] and study like I do now. I’m not a person who says, ‘Okay I’m finished one with my education’ and close all books. No! I read every day, because I can read this paper today and then tomorrow [when I read it again] I will find new information that I didn’t find yesterday. [ … ] To learn a new language when you’re an adult is not easy, but we learn every day. I spend time with colleagues and Swedish people [to learn]. (P1).Formal certificates confirming appropriate levels of Swedish were obtained through language courses (SFI), often specifically targeting immigrants with experience of working in healthcare. The courses also included practical language training at different health care establishments. These courses were described as significant by the informants for assisting them in their endeavour to work as an RN in Sweden, as they not only provided formal competence in Swedish language but also gave essential knowledge and insights about the Swedish healthcare system. Moreover, many of the participants also took extra measures to improve their knowledge and the chances of reaching their goal, either by working part-time in health care as assistant nurses and studying at the same time, or by taking complementary courses.I started a course in basic Swedish . After one month, in March, I started to work as an assistant nurse, employed by the hour, and studied at the same time. When I finished basic Swedish, I was employed. I continued to study SSL levels 1, 2 and 3 as distance learning courses while working 85% at a retirement home. (P2)The participants recognized that it was hard work, working and studying at the same time. But they were well aware that a successful transition demanded experience of working in Swedish health care and learning the Swedish language so they could manage the daily nursing practice. They reported the value of this hard work during the bridging program and subsequent transition to the world of work as it gave them not only language competence but also knowledge of the Swedish healthcare system. One of the participants described the experience she gained in Sweden before starting the bridging program as valuable because it made her aware that “[ …] I needed to develop my Swedish [ …] and I got an initial overview of the [Swedish] society and the differences in nursing compared to [country of origin]. (P3). However, the participants seldom explicitly described themselves as determined, but they often stated that “there is no other way, it just has to work out”.The participants described social relationships as significant for their experiences of the bridging program and their chances of a successful return to nursing. These contacts and relationships were both formal and informal in nature.The participants’ experiences of support from the authorities varied. In some cases, the participants felt the authorities had, hindered them from striving to get the education they needed, or that they needed to take matters into their own hands.They [officials at the Swedish public employment agency] asked me: ‘How did you manage to get a trainee position without our help?’ There were not pleased and wondered how I had managed to sidestep them. But I said, I’m here and I need your signature. I will not leave before I get the signature because I have found a trainee position. (P3)However, the participants also spoke about other persons, i.e., their managers or supervisors where they worked, who had encouraged them and informed them about the possibilities to get the Swedish registration. For some of the participants, it had also been possible to receive their education during a leave of absence from their workplace. Some of the participants, primarily newly arrived refugees or asylum-seekers, were also targeted to more general investments for competence by the local authorities, for example ‘fast-track’ courses for healthcare professionals.It was just a coincidence that I was accepted [to the language training program for newly arrived healthcare professionals]. I was playing football and a friend accidentally hit me over the ear, so I had to go to the district health care center. The nurse at the center knew I was a nurse and told me about the local project and she signed me up for it. [And later] I was accepted for the course. (P4)These formal relationships and acts of encouragement described by the participants were important drivers in learning about the possibilities to supplement one’s education and to set favourable conditions for the bridging program.Also, the informal networks and relationships helped the participants to manage the bridging program. Many of the participants had family responsibilities, material as well as emotional, that needed to be managed and fulfilled if they were to go back to school. During the education, several participants received their main support from their family members, especially from spouses or parents who took responsibility for the household tasks and childcare and shared economical expenses, so that the participants could devote all their time to their studies and pursue their goal.Interviewer: What was it like to attend the bridging program while having small children, what did that demand from you?Participant: Her [daughter’s] dad is with her all the time. If I need to relax and study, he’s with her. Sometimes, as a mother, I think that he is responsible for her and it is not my problem because I am a student. (P5)The value of this social support system in bridging program was highlighted in several accounts, especially by those with families and children. The support was important for creating the possibility to devote the necessary time to studies. Support from spouses was also important for sharing the emotional and care responsibilities in the families that are traditionally accepted by mothers, which is illustrated well in the excerpt above. For participants both with and without family responsibilities, the support from fellow students was highlighted. The participants described the strength of being part of a program where they all shared occupational experiences and a common goal, despite their differences in terms of national background, gender, age etc. The differences were even described as a resource:We all have different skills, experiences and capabilities but it was a really good student group because we worked together and helped each other. Some had worked for many years [as nurses] and others had not [ …] as a whole it was a really good group, we cooperated and assisted each other. [ …] We come from different countries and have different knowledge so of course we are different, but we give information, become friends and study together. (P6)The participants could make use of each other’s competencies and knowledge to advance in the program and to encourage each other to keep striving.The support from informal social relationships, such as family and friends and fellow students was emphasized as vital for encouraging and enabling their perseverance in the bridging program. For many participants the decision to enter a bridging program was a huge investment, both financially and emotionally, and the value they put on the support from near ones as a key to their success should not be understated. Formal social contacts and connections, such as public officials and authorities were mostly viewed as significant for learning about the formal requirements for working as an RN in Sweden and becoming familiar with the health care system.All participants considered that taking part in the bridging program was a more reliable option for reaching the goal of working as an RN in Sweden, compared to preparing on their own for the test that precedes nurse registration. The program thus provided a clear path toward their goal and a chance to fulfil the requirements, and to learn about the Swedish healthcare system and the role of RNs. The general perception expressed was positive in terms of the program as a tool for reaching one’s goal, nevertheless, the participants also reflected on obstacles and drawbacks.Attending the bridging program contributed more, according to the participants, to learning and understanding the differences in the scope of nursing practice in Sweden compared to their previous experiences. The main difference in nursing practice described by the participants concerned the relation between nurse and patient in daily practice. The autonomy of patients and the patient-centred care in Sweden were seen to differ greatly from what they had been used to.The difference is that you must consider the whole person, not just the disease. I must always ask the patient before I do anything, get consent if I wish to examine him and ask if he wants the treatment. The patients have a right to decline treatment. That was most important to learn, that I must ask the patient before I do anything. It is different in Syria, where the patient is treated without consent. He is there [at the hospital] and [therefore] accepts treatment. (P7)Many of the participants were not accustomed to the autonomy of the patients, and the need to confer with them before treating them. This was a new learning to handle, although they experienced it as positive. They recognized it to be important knowledge to acquire and that the bridging program contributed to the acquisition of that knowledge. Generally, the theoretical courses, which related to medical competencies and pharmacology, were seen by many as repetitive or affirmative of the knowledge they had already attained in their original nursing education and working life experience.I didn’t learn much new about the medical aspects [of nursing] but I learned a lot about the [organisation of the] medical system and routines, how to write in the journals etc., because that is different everywhere. The medical aspects are universal, so I didn’t learn new things because I had already done so. (P10)The participants regarded the practical courses as having a greater value for their learning and prospects of becoming a Swedish RN. The clinical training, which was part of the bridging program, was particularly appreciated. During clinical training the participants reported learning about the Swedish healthcare system, how healthcare care is organized in different establishments and how the forms of care differ, for example primary care, home care and hospital care. Clinical training also contributed to a deeper understanding of the scope of nursing, e.g., daily routines and assignments, relations to different professional groups that nurses collaborate with in daily practice, and work division between professional groups.Clinical training is difficult, but it gets easier once you know more about your role, when I know what my job assignments are and what assignments the doctor has. But it takes time, I need more time [in clinical training] to feel confident, or how to put it. [ …] You learn in daily practice. If a group needs support for example, who does that? Is it perhaps the doctor? Or the assistant nurse? Or me? (P4)The clinical training was described as challenging, but the participants still valued the learning that took place there rather than in classrooms. They had seen how the roles between doctors and nurses differed from their home countries, where the doctors had a more authoritarian role than in Sweden. To successfully adapt to the new role was time-consuming but was provided by the clinical training. The participants’ general stance was that this type of knowledge can only be acquired through experience of practical work and interaction at the different workplaces, as the scope of nursing and also the vocabulary varies between different hospital wards or healthcare establishments.Those who work in medical wards use their special concepts and those who work in surgery have theirs. That is why I have suggested that the clinical training needs to last at least six months to give us a chance to see different wards. For example, I only spent ten days in home care and one month in primary care. That was not a lot of time [to learn]. (P4)Clinical training also placed the participants in challenging situations, and they faced difficult assignments. The advanced materials nurses had access to and worked with in Swedish health care, e.g., the digital solutions, such as journal systems, presented a challenge. Some of them regarded this as a problem, as their technological knowledge was not that good. Journaling and documentation were also described as difficult because it challenged the participants’ language competencies.I would put more focus on documentation. I think most of us have inadequate knowledge, not just me. [ …] When you sit down [to do it] you don’t know which box [to check] or what to write. It is difficult. I see how competent the nurses are. But I panic. It takes time for me and it stresses me out. [ …] Perhaps my colleagues will say ‘you have spelled this wrong or made a mistake here’. (P9)As illustrated in the excerpt, the participants expressed insecurity about language competencies related to documentation and journaling, which were often seen as new routines, although central to the nurses’ scope of practice. Due to experiences like this the participants valued clinical practice and described it as a means to improve their language competency, technical knowledge and familiarity with work routines, and therefore requested more clinical practice during the bridging program.As mentioned, the general experience of the bridging program amongst the participants taking part in this study was positive. The knowledge the participants gained throughout the course of the program, particularly during clinical practice, was identified as vital for a successful transition to the world of work and to re-establish oneself as an RN. Nonetheless, some participants also reported experiences of misunderstandings of their role and competencies during clinical practice. The participants described a lack of knowledge about the bridging program and the participants’ professional backgrounds among some of the supervisors.Sometimes they [supervisors of clinical practice] do not understand what the bridging program is and the [competency] level we have. I tried to explain to my supervisor that I was not there for language training but for the bridging program and that I was already an educated nurse. But for four weeks she only addressed me as a ‘language learner’ [språkpraktikant]. (P7)Not getting recognition for one’s professional competence while attending clinical practice due to the supervisor’s lack of knowledge is one example of the disappointing experiences the participants described.A second example related to the uncertainties of the outcome of the program as it did not guarantee acquisition of a nursing licence from The National Board of Health and Welfare. One participant described how the language competencies of some of the participants were perceived by the supervisors in clinical practice as problematic and as affecting the participant’s ability to work as an RN. One participant said: ‘there were some problems during the clinical practice where they complained about our language competency and said that we should work as assistant nurses instead’ (P2). The same participant continued to question why the risk of not passing the program was delivered late and wished that the program directors had made this clear earlier. Although she did not worry about her own future, she expressed compassion for her fellow students who had not managed to get through the education. They all had invested much time and energy in the education, and she empathized with those for whom it had not “paid off”. For most of the participants though, having managed the education and especially the clinical training was both a relief and an achievement that they were proud of:I was nervous up until the last day. When the examiner told me that I had passed [the program] I couldn’t believe what I’d heard so I had to ask her again. It was such an amazing feeling! I am proud and very glad that this was possible because it was a long journey, a really hard journey. (P3)The possibility to work as a registered nurse while waiting for the registration was appreciated and anticipated. However, for 9 of the 11 participants, the bridging program was not the final goal but instead it had made possible new goals for their future and working life. Most of them planned to work as an RN for a few years to gain experience and then continue their education and become a specialist nurse in an area of particular interest. Especially popular was the idea of becoming a district nurse, but other specializations were also of interest:In due time, I plan to continue my education and become a specialist nurse. [ …] Primarily to specialize as a district nurse, but it depends … perhaps specializing in diabetic care, asthmatic care or something like that. (P8)My idea is to work at the hospital for a couple of years and then if all goes as planned, I will continue my education. [ …] My main interest is to specialize as a nurse in intensive care. (P6)Overall, the study found that the participants expressed generally positive experiences of the bridging program and that it had a significant role in aiding their transition into nursing in Sweden, which is a finding consistent with previous research , 6, 14.The analysis highlighted conditions and prerequisites which the participants interpreted as important for achieving the goal of re-establishing themselves as registered nurses in Sweden. The importance of acquiring language proficiency and gaining experience from working in the Swedish health care sector which required personal motivation and determination to cope with various demands, was stated by all participants. This is a finding not previously described in European research on IENs. However, the struggles of integration into nursing for IENs in Canada and the importance of perseverance are discussed by Covell et al.  which leFurthermore, the participants also described receiving support from family, friends and fellow program participants as well as from public authorities and managers as important for facilitating the transition to nursing in Sweden. The importance of material and emotional support from close social relations such as family and friends was emphasised in all interviews. In this study, the participants continued social relationships from old networks and also developed relationships with new networks such as networks of fellow program students. An interesting finding from this study is that the support from formal organizational resources varied considerably. Most positively described was the support from managers at workplaces who offered encouragement, information on formal requirements for practicing nursing in Sweden and practical help, i.e., temporary training leave, which enabled the participants to attend the program. Participants who had received refugee status were also aided by formal programs targeting newly arrived professionals. However, there were examples where participants had experienced discouragement from public officials or difficulties in navigating and understanding the possibilities and demands of the system.These results highlight that more support is needed from formal organizational resources, i.e., information about the application process, the requirements for attending bridging programs, financial support available during this process  etc. ThiIn line with results from existing research our study revealed that attending the bridging program equipped the participants with valuable and practical new learning that facilitated the transition to work as an RN in Sweden , 6, 14. Experiences gained in clinical training were highly valued by the participants, who emphasised the importance of ‘learning-by-doing’ when they were about to make the transition into nursing in Sweden. Areas such as independent decision-making of nurses, teamwork and collaboration were described as skills that could not be taught in class but needed to be experienced first-hand, and the participants suggested they should be included to a greater extent in the bridging program. But clinical practice also brought out challenging experiences of misrecognition of professional competence and misunderstandings and insecurities due to language barriers. Language proficiency affected the performance in the bridging program, clinical practice, and the knowledge test to obtain a nursing license in Sweden. The study found that medical terminology, abbreviations and names of medication and equipment varied between countries and this complicated clinical work. Communication barriers have an impact on healthcare in areas such as patients’ satisfaction with the healthcare  and patiOur results differ to some degree compared to previous research. In our study the participants did not report being lonely and did not experience discrimination, in contrast to previous studies , 8, 10. A limitation of the study could be the recruitment procedure of the participants in the study. In the process of selecting participants for the study we contacted all program participants from two cohorts with the intention of capturing a variety of experiences. The participants who declined to partake in the study might have felt a threat to their independence, e.g., program participants who did not complete the program may have been afraid to express their views and this may have affected the results of the study . The nexThis study found that bridging program helped nurses educated outside the EU/EEES to achieve their goal, i.e. to obtain a nursing license in Sweden. However, achieving goals was also dependent on one’s personal characteristics such as strong will and knowledge, professional experience, and language proficiency, as well as development opportunities that were available such as formal and informal support. The findings from this study have implications: 1) for academy staff when developing the bridging programs’ curricula by recognising and valuing the IENs’ experience and previous knowledge and the importance of training and supporting supervisors in IENs clinical-based training, 2) for decision-makers and authorities when developing policies concerning: language programs, the information provided to applicants about the application process, the required bridging program and financial support available during this process to address IENs’ specific conditions and 3) for participants, due to the significance of being aware of the importance of material and emotional support from close social relations such as family and friends during the bridging program.Additional file 1. Interview guide.


The liquid-phase exfoliation is an effective method to synthesize these metal hydride nanomaterials, and its efficiency is determined by the matching of surface energy between the solvent and the metal hydrides. The obtained TiH1.924 nanodots can produce reactive oxygen species (ROS) under ultrasound, presenting a highly efficient sono-sensitizing effect. Meanwhile, TiH1.924 nanodots with strong near-infrared (NIR) absorbance can serve as a robust photothermal agent. By using the mild photothermal effect to enhance intra-tumoral blood flow and improve tumor oxygenation, a remarkable synergistic therapeutic effect is achieved in the combined photothermal-sonodynamic therapy. Importantly, most of these TiH1.924 nanodots can be cleared out from the body. This work presents the promises of functional metal hydride nanomaterials for biomedical applications.Metal hydrides have been rarely used in biomedicine. Herein, we fabricate titanium hydride (TiH Dynamic therapy is attracting attention for cancer treatment. Here, the authors report that metal hydride nanodots can be used for sonodynamic therapy, which can be further enhanced by photothermal heating to increase tissue oxygenation. During SDT, sono-sensitizers are able to interact with surrounding oxygen and even water molecules to produce cytotoxic reactive oxygen species (ROS) to kill tumor cells7. However, the limitations of current sono-sensitizers have substantially hindered the extensive clinical applications of SDT. Traditional organic sono-sensitizers , which are often derived from photo-sensitizers, often show photo-toxicity toward the skin12. The most representative paradigm of inorganic sono-sensitizers is semiconductor titanium dioxide (TiO2)15, whose quantum yield of US-triggered ROS generation, however, is relatively low due to the fast combination of the electron (e−) and holes (h+) (50 ± 30 ns)17.Sonodynamic therapy (SDT) triggered by ultrasound (US) is a non-invasive therapeutic strategy that can be applied to treat deeply-seated tumors1.924) has been explored for applications in hydrogen storage19, and is frequently used as a foaming agent in the production of metallic foams 21, as well as a raw material for producing highly purified titanium and titanium alloys23. Considering the unique valence status of Ti  in TiH1.924,24 we hypothesize that it might be easily activated by external stimuli  for applications in photo-catalysis and sono-catalysis26. However, nano-structured TiH1.924 has not yet been synthesized to our best knowledge.Titanium hydride . Taking TiH1.924 nanodots for example, they have highly effective US-triggered ROS generation capability, which is superior to the sono-sensitizing effect of titanium dioxide (TiO2), the classical inorganic sono-sensitizer, likely owing to the reduced bandgap in TiH1.924. Moreover, these black TiH1.924 nanodots with strong near-infrared (NIR) absorption can also use as an excellent photothermal agent. Taking the advantage of mild photothermal effect to enhance intra-tumor blood flow and improve oxygen supply, a remarkably synergistic photothermal-sonodynamic therapeutic outcome has been achieved with TiH1.924 nanodots , DMSO, polyethylene glycol 200 (PEG 200), NMP, N,N-dimethylformamide (DMF)/NMP, pyridine, DMF, acetonitrile, tetrahydrofuran (THF), ethanol and acetone, 6 solvents of them  showed no exfoliation effects to the TiH1.924 powder, while the other 7 solvents  could efficiently exfoliate the TiH1.924 powder into small nanoparticles  or too low , TiH1.924 powder could not be effectively exfoliated. When the surface energy of the solvent  reaches a range of 41 ± 5 mJ m−2, successful exfoliation of the TiH1.924 powder into small nanoparticles could be achieved. Therefore, we proposed that the successful exfoliation might be owing to the matching of surface energy between the applied solvents and the TiH1.924 powder.Liquid-phase exfoliation technology has been widely reported for the preparation of mono- or few-layered two-dimensional nanosheetsnts Fig. . Taking nts Fig. . Among tles Fig. . The difles Fig. 27,31–33.1.924 nanodots showed very uniform sizes and morphology   spectrum also confirmed the existence of Ti elements , Ti2+ (39%), Ti3+ (23%), and Ti4+ (8%) were found in the obtained TiH1.924 nanodots , calcium hydride (CaH2), and hafnium hydride (HfH1.983) powder using the liquid-phase exfoliation technology with the assistance of NMP , CaH2 nanodots (2.1 ± 0.2 nm), and HfH1.983 nanoparticles (13.1 ± 3.5 nm) all showed uniform morphology, suggesting that the liquid-phase exfoliation technology could be a simple and universal method to prepare various types of metal hydrides nanomaterials.Among these 13 solvents, NMP offered excellent exfoliation efficiency and the obtained TiHogy Fig. . Thus, wNMP Fig. . The higNMP Fig. , which c82) Fig. 34. The eots Fig. 24. Apart1.924 nanodots indicates that they might be activated under US irradiation as a sono-sensitizer , a reactive oxide species (ROS) probe, was employed to detect the ROS generation by US-activated TiH1.924 nanodots. After mixing TiH1.924 nanodots with the DPBF probe, the UV-vis absorption spectrum of the mixture was monitored after different periods of ultrasound (US) irradiation  between TiH1.924 and TiO2 sono-sensitizer. . With a lower bandgap compared to that of TiO2, TiH1.924 nanodots thus could be easier to be activated to produce more ROS under US irradiation, useful for applications in SDT.To understand the mechanism of sono-sensitization effect of TiHred Fig. . Based ored Fig. 35,36, th1.924 nanodots. The as-made TiH1.924 nanodots showed black color and strong optical absorbance, which appeared to be independent to the wavelength and was extended to the second NIR (NIR-II) region . The extinction coefficient of TiH1.924 at 1064 nm was tested to be ~10.27 L g−1 cm−1 14, traditional graphene oxide 45, and carbon nanodots 46. Then, the photothermal performance of the TiH1.924 aqueous solution was further evaluated under 1064-nm NIR II laser. Significant concentration-dependent and laser-power-dependent photothermal heating effect was observed for these TiH1.924 nanodots  of TiH1.924 nanodots was calculated to be ~58.6%  nanocrystals (22%)48, copper sulfide (Cu9S5) nanocrystals (25.7%)49, and prussian blue (41.4%)50. In addition, there was almost no change of photothermal performance post five times ON/OFF laser cycles, showing the high photothermal stability of these TiH1.924 nanodots , which could stabilize TiH1.924 nanodots likely via the chelating-coordination between the O atoms of PVP and Ti atoms of TiH1.924  to be ~26.4%. Unlike as-made TiH1.924 nanodots which could be well dispersed in water but would aggregate in the presence of salt , TiH1.924-PVP nanodots showed great dispersity in both water, PBS, and cell culture medium for a week. Notably, the photothermal and sonodynamic performance of TiH1.924 nanodots did not change after surface modification with PVP or additional H2O2 treatments  toward 4T1 tumor cells . When further US irradiation was conducted , the 4T1 cell viabilities significantly decreased to ~10.6%, presenting increased cell killing compared to TiH1.924-PVP treated cells exposed to US alone without pre-treatment by the NIR-II laser. In addition, the excellent cancer cell killing effect of mild PTT-enhanced SDT using TiH1.924-PVP was also confirmed by live/dead co-staining   Fig. . This in1.924-PVP as a sono-sensitizer to kill cancer cells under ultrasound , all showed weak intracellular ROS-related fluorescence. In contrast, strong fluorescent signals were clearly observed in cells from the TiH1.924-PVP/US and TiH1.924-PVP/NIR/US groups, demonstrating the effective intracellular ROS generation by TiH1.924-PVP under US stimulation.Next, 2,7-dichlorofluorescein diacetate  and dihydroethidium  staining assays were also performed to determine intracellular ROS generation and verify the mechanism of TiHund Fig.  and 19541.924-PVP were studied using photoacoustic (PA) imaging and it could monitor the tumor uptake of NIR-absorbing TiH1.924-PVP nanodots. After intravenous (i.v.) injection of TiH1.924-PVP into 4T1-tumor-bearing balb/c mice for 8 h, much obvious PA signals were clearly appeared in the tumor site  effect. At the following time points, the PA signals gradually decrease, likely due to the clearance of the ultrasmall TiH1.924-PVP from the tumor. In addition, the biodistribution of nanodots in the tumor was then quantitatively studied by measuring the content of titanium ions through inductively coupled plasma optical emission spectrometry (ICP-OES) at 8 h post injection (p.i.). The tumor uptake of TiH1.924-PVP was determined to be ~5.2%ID g−1, further confirming the efficient tumor accumulation of these nanodots  thermal imaging. 4T1 tumors-bearing mice post i.v. injection of TiH1.924-PVP for 8 h were exposed to the 1064-nm laser irradiation   Fig. . Obvious57. Based on previous reports, the mild photothermal effect may increase intra-tumoral blood flow and then overcome tumor hypoxia60. To confirm this effect, immune-fluorescence hypoxia staining assay was conducted , and SDTted Fig. . Obvious1.924-PVP. All of the mice were divided into five groups: (1) Control; (2) TiH1.924-PVP ; (3) NIR  + US ; (4) TiH1.924-PVP + NIR; (5) TiH1.924-PVP + US; (6) TiH1.924-PVP + NIR + US. At 8 h post i.v. injection of TiH1.924-PVP, the tumors were treated with 1064 nm laser and subsequent US irradiation  was remarkably suppressed, suggesting the excellent SDT performance of TiH1.924-PVP. Interestingly, the TiH1.924-PVP/NIR/US group showed the most remarkable therapeutic outcome, and the tumor tissues were completely eradiated without recurrence during two months. The survival time of mice in the SDT group (TiH1.924-PVP/US) was prolonged compared to the other four groups   Fig. . More im1.924-PVP, NIR/US, and TiH1.924-PVP/NIR groups, the TiH1.924-PVP/US group showed obvious green fluorescence, and the strongest ROS-related fluorescence was observed in the combined laser plus US treatment group (TiH1.924-PVP/NIR/US). Our results indicated the mild PTT could overcome tumor hypoxia and facilitate the SDT-triggered ROS production. In addition, hematoxylin and eosin (H&E) staining were conducted at 24 h after different treatments. Tumor cells were severely damaged in the SDT group and mild PTT-enhanced SDT group, while the other four groups showed little cell dead , spleen (12.1 ± 1.5%ID g−1), and kidney (7.4 ± 0.5%ID g−1) at 24 h p.i. Importantly, rapid decrease of Ti levels in these organs was observed over time, indicating the efficient clearance of TiH1.924-PVP. After 14 days, the Ti retention in major organs drastically decreased to be <0.5%ID g−1, indicating the nearly complete clearance of TiH1.924-PVP. To further investigate the clearance pathway, the Ti concentrations in the urine and feces were also measured. High levels of Ti were observed in the urine, strongly evidencing the elimination of TiH1.924-PVP nanodots via the renal filtration pathway  were successfully exfoliated into small nanoparticles. With strong NIR-II absorbance and efficient US-triggered ROS production ability, TiH1.924 nanodots with PVP modification were further applied for the combined PTT-SDT therapy with great in vivo tumor destruction efficacy. Such TiH1.924 nanodots present the following advantages as therapeutic nano-agent. (1) These TiH1.924-PVP nanodots exhibit excellent sonodynamic performance in US-triggered ROS generation due to the reduced band-gap in TiH1.924 compared to that of TiO2. (2) The strong NIR absorption of TiH1.924-PVP could enable enhanced photothermal-sonodynamic therapy, in which the mild hyperthermia-induced tumor hypoxia relief would lead to improved sonodynamic tumor killing. (3) Containing biocompatible elements (Ti and H), TiH1.924-PVP nanodots with ultra-small sizes could allow their efficient body excretion without appreciable toxicity. Moreover, this work illustrates the promises of nano-structured metal hydrides nanomedicine platform against cancer and possibly other types of diseases.In summary, nano-structured TiH1.924), zirconium hydride (ZrH2), calcium hydride (CaH2), hafnium hydride (HfH1.983), and N-methyl pyrrolidone (NMP) were purchased from Aladdin reagent Co., Ltd. . 1,3-diphenylisobenzofuran (DPBF), Polyvinyl pyrrolidone , 2,2,6,6-tetramethylpiperidine (TEMP), and 5,5-dimethyl-pyrroline-N-oxide (DMPO) were obtained from Sigma-Aldrich. All chemicals were of analytical grade and used without further purification.Titanium hydride . After ultrasonic treatment for 20 min, TiH1.924 nanodots were obtained and further purified by centrifugation  and washing repeatedly with anhydrous ethanol. Via the same method, zirconium hydride (ZrH2) nanodots, calcium hydride (CaH2) nanodots, and hafnium hydride (HfH1.983) nanoparticles were also synthesized.100 mg commercial TiH1.924 nanodots were modified by polyvinylpyrrolidone (PVP)51. Briefly, 20 mg TiH1.924 and 200 mg PVP (MW 10 k) were dissolved in 50 mL anhydrous ethanol and refluxed at 50 °C for 8 h. After collecting by centrifugation  and washing with water and ethanol, the final TiH1.924-PVP nanodots were dispersed in deionized water, and stored at 4 °C for further use .The as-synthesized TiHλ = 0.15406 nm). XPS analysis was performed by the PHI Quantera SXM X-ray photoelectron spectrometer with an Al Ka monochromator source. ROS was quantified by an ESR spectrometer (Bruker EMXplus). UV-vis-NIR absorbance spectra were recorded by PerkinElmer Lambda 750 UV-vis-NIR spectrophotometer. The ultrasonic generator was made by Hainertec (Suzhou) Co., Ltd. The absolute Ti contents were determined by ICP-OES .Transmission electron microscope (TEM) imaging and elemental mapping were carried out by FEI Tecnai F20 TEM. Powder X-ray diffraction (XRD) measurement was conducted by a PANalytical X-ray diffractometer equipped with CuKα radiation (1.924 (20 µg mL−1) was mixed with 20 μL DPBF (1 mg mL−1). After different US  durations, the absorbance changes of DPBF at 420 nm were recorded to quantify the generation of ROS by US-activated TiH1.924. ESR technology combined with TEMP (for 1O2 detection) or DMPO (for ·OH detection) was employed to detect different types of the generated ROS. In this case, 1 mL TiH1.924 (20 µg mL−1) was mixed with 20 µL TEMP (1 M) or 10 µL DMPO (1 M) and exposed to US irradiation  for 1 min. The characteristic peak signals were detected by the ESR spectrometer. The settings for the EPR spectrometer were as follows: center field, 3520 G; sweep width, 100 G; microwave frequency, 9.77 GHz; modulation frequency, 100 kHz; power, 20.00 mW.1 mL TiH1.924 was analyzed by irradiating a glass cuvette containing a dispersion of TiH1.924 nanodots. The extinction coefficient and the photothermal conversion efficiency were calculated according to the previous studies44.The photothermal performance of TiH2. For the in vitro cytotoxicity test, 4T1 cells seeded in 96-well plates were incubated with different concentrations (0-400 µg mL−1) of TiH1.924-PVP for 12 h and 24 h. Relative cell viabilities were tested by the standard MTT assay.Murine breast cancer 4T1 cells were cultured in the standard cell culture medium at 37 °C under 5% CO1.924-PVP (50 µg·mL−1) for 8 h, followed by laser irradiation  or US irradiation . The cell viabilities were determined afterward by the MTT assay.For in vitro mild PTT-enhanced SDT, 4T1 cells were incubated with TiH1.924-PVP, NIR, US, NIR/US, TiH1.924-PVP/NIR, TiH1.924-PVP/US and TiH1.924-PVP/NIR/US) were stained with calcein AM  and propidium iodide . For ROS detection, the treated 4T1 cells were stained with DCFH-DA (20 μM) for 30 min. All the images were acquired by a confocal laser scanning microscope .For live/dead staining, 4T1 cells under different treatments  were used as the animal model in this work. Mice were housed in groups of 5 mice per individually ventilated cage in a 12-h light–dark cycle , with constant room temperature (21 ± 1 °C) and relative humidity (40-70%). All mice had access to food and water ad libitum.1.924-PVP (20 mg·kg−1). At 8 h p.i., tumors on these mice were exposed to the 1064-nm laser irradiation for 20 min with their temperature maintained at ~45 °C. Then immediately, tumors were surgically excised for hypoxia staining assay using the Hypoxyprobe-1 plus kit (Hypoxyprobe Inc) following the standard protocol62. Anti-pimonidazole mouse monoclonal antibody conjugated with FITC  and Alex 488-conjugated goat anti-mouse secondary antibody  for hypoxia staining. Rat anti-CD31 mouse monoclonal antibody  and Rhodamine-conjugated donkey anti-rat secondary antibody  for blood vessel staining.For immunohistochemistry analysis, 4T1 tumor-bearing mice were intravenously injected with TiH3) were divided into six groups (n = 5 per group): (1) control; (2) TiH1.924-PVP ; (3) NIR  + US ; (4) TiH1.924-PVP  + NIR ; (5) TiH1.924-PVP  + US ; (6) TiH1.924-PVP  + NIR  + US . At 8 h after i.v. injection, the tumors were treated with laser irradiation, or US irradiation, or laser irradiation + US exposure, sequentially. Tumor temperature and thermal images were monitored and recorded by an IR thermal camera (Infrared Cameras. Inc). Tumor sizes and body weight were monitored every two days. The tumor volumes were calculated by the formula: volume = length × width2/2. For in vivo H&E staining, tumors in different groups were collected on the second day post treatment.Mice bearing 4T1 tumors (~100 cm1.924-PVP (20 mg·kg−1) was sacrificed at 1, 3, 7, and 14 days, respectively. The major organs were collected, with one halves used for H&E staining, and the other halves used for detection of Ti levels by ICP-OES after these organs were solubilized by aqua regia. To study the excretion pathway, mice after i.v. injection with TiH1.924-PVP nanodots were kept in metabolic cages to collect their feces and urine at various time points, which were solubilized by aqua regia measured by ICP-OES to determine Ti levels.Healthy mice after i.v. injection with TiH1.924 was conducted by these instruments as indicated in the Characterization section.All statistical analyses were performed on Origin 8.5, Excel 2010 and GraphPad Prism 6. Fluorescent images were collected by Confocal Microscopy (Zeiss LSM 880) and analyzed by LAS AF Lite 3.2.0 Image J 1.74v. IR thermal images were collected by Infrared Camera (Fotric 255). Photoacoustic imaging data was processed by PA Tomography (Vevo LAZR). All other characterization of TiHFurther information on research design is available in the Supplementary InformationPeer Review FileReporting Summary


The aim of this study was to analyze the implementation of a sports-educational program in prisons where the Real Madrid Foundation’s Social-Sports Program is carried out. For that purpose, a survey of 468 inmates was conducted at 21 prisons in Spain where the Real Madrid Foundation implements its program (441 men (94.23%) and 27 women (5.77%)). Inmates stated that the program had had a favorable influence on their life in prison and considered that their participation in the program might have a significant influence on the likelihood of them continuing to play sports when they are released. In addition, inmates felt that they had learned a great deal about the contents relating to football and the values they had worked on, and that the program had had a very positive effect on their overall development as a person. The Spanish Prison Administration has clearly defined its purposes in Article 1 of the General Organic Law of the Penitentiary, which can be summarized as follows: Re-education and social reintegration of those sentenced to prison sentences and penal measures; retention and custody of detainees, prisoners, and convicts; and assistance and aid to inmates and released prisoners. The fundamental aim of this institution is the re-socialization of its inmates with the objective of reincorporating them into society by being genuinely free as citizens. To this end, there are many interventions and treatment programs that have been developed in prisons, including sports programs. These sports programs offered in prisons aim to “promote, through the practice of sport, attitudes, skills and behaviours that help to prevent high-risk social behaviour and favor insertion, trying to meet the existing demand and help to achieve physical, mental and social well-being” [In this sense, the importance of physical exercise and sport for prisoners’ reintegration has been noted in several studies. Special mention should be given to the publications by Ríos ; ChamarrIn short, it is clear that, when properly oriented, sport can aid in a person’s overall formation  because,In Spain, according to data from the General Secretariat of Penitentiary Institutions , the priIn this regard, few studies have evaluated the opinions of inmates regarding the implementation of sports programs in prisons. That is why the aim of this study was to analyze the implementation of a sports-educational program in prisons where the RMF’s Social-Sports Program is carried out.The research centered on 468 prisoners (441 men (94.23%) and 27 women (5.77%)), of which 14 were less than 20 years old, 230 were aged between 20 and 30, 154 were between 31 and 40, 63 were between 41 and 50, and 6 were over the age of 50. In addition, 185 had a Spanish nationality, 233 had a foreign nationality, 25 had both a Spanish and foreign nationality, and 25 had a dual foreign nationality. Of the respondents, 79 inmates had been sentenced to less than 2 years’ incarceration, 141 to between 2 and 5 years, 105 to between 5 and 8 years, 64 to between 8 and 11 years, and 79 to more than 11 years. As far as education is concerned, 67 had no schooling, 203 had a primary education, 50 had received vocational training, 105 had a secondary education, and 44 had university degrees. The survey was conducted at the end of the program in the third quarter of the 2018/19 season. The respondents were participants in the Social-Sports football program run by the RMF at the following penitentiary centers in Spain: Algeciras, Aranjuez, Ávila, Castellón, Estremera, Ibiza, León, Meco I, Meco II, Murcia, Navalcarnero, Ocaña I, Ocaña II, Palencia, Segovia, Sevilla II, Soto, Teixeiro, Topas, Valdemoro, Villabona, and Zuera. In total, 195 of the inmates were taking part in the program for the first time, 148 for the second time, 62 for the third time, and 60 for the fourth time.The instrument used was the questionnaire designed and validated by Ortega et al. , which cThe research was carried out in the third quarter of the 2018/19 season, after the necessary permits had been obtained from the various prison administrations. All ethical considerations involved in performing research with the participants were approved by the Training Committee of the Real Madrid Foundation, which also conformed to the recommendations of the Declaration of Helsinki. Additionally, all participants were informed about the research procedures and provided prior informed consent.The coordinators of the football program at the prisons distributed the questionnaires among the inmates, after explaining to them the reasons for developing it and what it hoped to achieve, and also that participating in the survey was completely voluntary and that they could quit it whenever they liked. In all cases, inmates signed an informed consent form. In the program, football is played for one hour once a week and tries to use the sport as an entertaining, recreational, and educational activity. It also attempts to promote values that can be transferred to inmates’ life both inside the prison and in their future re-entry into society. In parallel, promoting healthy sport routines and suitable ways of resolving conflicts is also an important objective of the activity. The Social-Sports Program concludes by holding an in-house competition that aims to reinforce everything that has been achieved in training.p < 0.05). In addition, the Mann-Whitney U test was used to determine whether significant differences based on gender existed. For intergroup comparisons , the Kruskal–Wallis test by ranks was used. In cases where the intergroup comparisons were significant (p < 0.05), a pairwise comparison was made with the Mann-Whitney U test and Bonferroni adjustment to correct the significance level, and the size of the effect was calculated [A descriptive analysis of the central tendency and dispersion of items that comprise the questionnaire was carried out. The results of Kolmogorov–Smirnov normality testing showed the need for non-parametric tests  and because they considered it was good for their health (M = 2.62 ± 0.597), although other reasons also stood out. On the other hand, less importance was given to reasons involving interrelating with people outside the prison (M = 1.86 ± 1.410) and getting prison benefits (M = 1.50 ± 1.163) see .p = 0.045, r = −0.09), and the size of the effect was small. Regarding the reasons why they continued to attend the sports program training session, it should be noted that, as before, most respondents stated that they did so mainly for health reasons (M = 2.63 ± 0.584) and because they liked playing sports (M = 2.74 ± 0.531)  than to men (M = 2.01 ± 0.898)  see .p = 0.035, r = −0.09), although the size of the effect was found to be small. On the other hand, significant differences  were detected in the importance of attending the sports program to get out of the pavilion between those who were taking part for the first time (M = 2.10 ± 0.961) and those who had been involved in the program for three seasons (M = 2.43 ± 0.921) , although the size of the effect was also seen to be small. Those who had been taking part in the sports program for longer attached a greater importance to getting out of the pavilion as a reason for attending the sessions.From the Mann-Whitney U test, significant differences were found in the importance that prisoners attached to attending the sports program because that led to prison benefits. This reason was more important for men (M = 1.54 ± 1.186) than for women (M = 1.04 ± 1.192) . It was also relevant that they expressed great satisfaction with the coach (M = 2.65 ± 0.573) and their playmates (M = 2.40 ± 0.628). However, they were less satisfied with how often the activity took place (M = 1.58 ± 0.875) and with how long the program lasted (M = 0.83 ± 0.489), so much so that the vast majority considered that the sports program should run for longer.Respondents stated they had learned between ‘quite a lot’ and ‘a lot’ from the contents relating to football (M = 2.33 ± 0.683) and also in regard to the values that the Real Madrid Foundation sports program works on see . Furtherp = 0.003, r = −0.13), self-esteem  , respect  , equality  , health  , motivation  , and autonomy  . In addition, inmates considered that their participation in the program was fairly or very influential on their physical condition (M = 2.37 ± 0.647), on their mental and emotional state (M = 2.37 ± 0.657), and on their relationships with other inmates (M = 2.29 ± 0.718). However, women (M = 3.78 ± 0.424) stated that their participation in the sports program had had a greater influence on their life in prison than for men (M = 3.36 ± 0.814) , on their mental and emotional state , on their relationships with other inmates , and on their relationships with the prison staff . The size of the effect in all cases was low. In addition, respondents considered that their participation in the football program had helped them to have fun, to be happier, and to learn to make an effort  considered that they had learnt more than men had (M = 2.36 ± 0.600) about the values of companionship , to respect others , to learn to make an effort , to appreciate their progress , to make decisions , to understand others better , not to use drugs and tobacco , and to have fun , with the size of the effect being slight in all cases. On the other hand, respondents considered that their participation in the football program could bear greatly on their continuing to play sports when they were released from prison and on their acquisition or learning of positive values, on their overall development as a person, and on their future integration into society  estimated that their participation in the sports program was of greater help for them than for men (M = 2.29 ± 0.650) to learn to accept and abide by the rules , in their overall development as a person , and in their acquisition or learning of positive values . When intergroup comparisons were made with the Kruskal−Wallis contrast test, significant differences were detected . A pairwise comparison using Mann-Whitney with Bonferroni adjustment revealed significant differences between the age groups of less than 20−30 years (M = 2.20 ± 0.828) and 41−50 years , with a low effect size. Younger inmates considered, to a greater extent, that their participation in the football program would have a considerable influence on their future re-entry in society.According to the Mann-Whitney U test, women (M = 2.52 ± 0.802) stated that their participation in the sports program had influenced them to a greater extent than men (M = 2.16 ± 0.839) in regard to their future re-entry into society (Z = −2.528, The aim of this study was to analyze the implementation of a sports-educational program in prisons where the WFR’s Social-Sports Program is carried out. In this sense, coinciding with data obtained by Castillo-Algarra  and PsycWith regard to the influence of the football program on personal affairs, the prisoners considered that their participation in the program could have a positive influence on their playing sports when they leave prison, on acquiring values in their development as individuals, and on helping them in their future integration into society . In thisPhysical exercise and sport can promote behavioral patterns related to healthier lifestyles for inmates and should occupy a prominent place in prisons . Among tOn the other hand, it is important to take into account the opinions of inmates regarding the implementation of physical activity and sport in prisons, in order to obtain better results ,23. TherIn general, society considers that sport builds values in those who play it . This isThe main limitation of our research refers to the scarcity of studies on inmate satisfaction with internal physical exercise and sport programs that reflect their opinions about how such programs are implemented. It should also be mentioned that, at the outset, there was some difficulty in distributing the questionnaire to people who did not fully understand Spanish, which was finally overcome by another inmate translating. Another limitation relates to the fact that no information was collected on the length of time that inmates had been in prison and its possible relationship to the results of the program. Therefore, more research on this aspect is needed. Besides, future research should focus on studying what type of physical exercise and which sports are most effective and most widely accepted in prisons. It would also be interesting to define, describe, and resolve the difficulties of implementing and operating sports programs and subsequently analysing them.In conclusion, according to the results of this study, it is significant that inmates considered that their participation in the program has had a favorable influence on their life in prison and has helped them, in particular, to have fun and be happier. It should also be noted that inmates estimated that their participation in the football program positively influences the creation of the habit of playing sports, the acquisition of educational values, and their future integration in society. Furthermore, inmates expressed great satisfaction with the work performed by the coach, which is decisive for the continuity of the program.These conclusions show that understanding what inmates think about doing physical exercise and sport is decisive when assessing the importance of this type of program in prisons. They also help to underline the importance of the proper planning and implementation of such programs and to recognize the need for further research on the subject.


In accordance with the provisions of the WHO Framework Convention on Tobacco Control (FCTC), each country shall promote and strengthen public awareness of tobacco control issues (Article 12). Many parties to the FCTC have adopted national tobacco control programs to organize their tobacco control activities. The aim of our study was to analyze the organization and funding of the Polish Tobacco Control Program in years 2000–2018. Document analysis of The Program and reports from its implementation were performed in accordance to the Agency for Health Technology Assessment in Poland (AHTAPol) recommendations and the WHO FCTC guidelines for Article 12 implementation. Spending was also analyzed. The study showed both inadequate planning of and funding for Polish Tobacco Control Program. The Program was developed without use of best practices detailed in the WHO FCTC guidelines as well as in national guidelines prepared by AHTAPol. The experience of Poland shows that although earmarking tobacco taxes has existed in the law, it has been largely ineffective due to the poor Tobacco Control Program design and insufficient funding resulting from a poor execution of the earmarking law. This may be a warning to other countries to strive to create law, compliance with which can be verified and controlled. In accordance with the provisions of the WHO Framework Convention on Tobacco Control (FCTC), each country shall promote and strengthen public awareness of tobacco control issues Article 12). The FCTC lists legislative, executive, administrative and other measures that each country shall adopt and implement in order to reach that goal. In accordance with the requirements of the treaty, many parties to the FCTC have adopted national tobacco control programs to organize their tobacco control activities. This was met with active resistance from the tobacco industry, the overcoming of which required joint efforts by governments with the support of civil society organizations 2. The FC,4.The guidelines for implementation of Article 12 describe how to design effective educational programs . Other rBeside organizational aspects of any program, one of the most important factors for the program’s success is its funding. Unfortunately, literature providing guidelines regarding proper funding for tobacco control programs is scarce. The FCTC Guidelines do not indicate the amount of funding sufficient to ensure program effectiveness. According to the Centers for Disease Control and Prevention (CDC), spending on tobacco programs should be: 3.99 USD to 6.75 USD per person, per year for community interventions, 0.65 USD to 1.95 USD per person, per year for mass-reach health communication interventions, 2.04 USD to 5.94 USD per adult, per year for cessation interventions, 10% of total program budget for surveillance and evaluation, and 5% of total program budget, or the cost of 25% to 100% of a full-time equivalent dedicated staff person, whichever is greater, for infrastructure, administration, and management . The funIn Poland, tobacco control program activities were based on the provisions described in the Act on the Protection of Public Health against the Effects of Tobacco Use of 9 November 1995 . This acThe Act of 27 August 2004 on health care benefits financed from public funds (Article 5), defines a health policy program as a set of planned and intentional healthcare interventions, designed, implemented, conducted and financed by the Minister or a local government agency, that is described as effective, safe and expected to achieve, in a designated time frame, goals of detecting and meeting healthcare needs and improving the health of a defined group of beneficiaries. According to this law, Ministers and local government agencies may design, implement, conduct and finance health policy programs (HPP). Another article (Article 48a) provides a detailed list of components required of an HPP and points to the procedures and criteria for assessing such programs by the Polish Agency for Health Technology Assessment and Tariff System (AHTAPol) .Globally, the economic cost of smoking in terms of health care-related expenses and the lost productivity of those sickened or killed by tobacco amounts to nearly 2 trillion USD (in 2016 PPP) each year, equivalent to almost 2% of the world’s total economic output . In PolaOn the one hand, Poland has had huge successes in reducing tobacco smoking. Data show that smoking prevalence in Poland declined between 1976 and 2014 from 73% to 28% among men and from 30% to 19% among women . During We have analyzed annual reports from the implementation of The Program for Reducing Health Consequences of Tobacco Smoking. Since 1997, there have been five editions of The Program. Additionally, the most recent Program for the years 2014–2018 [We have compared the Program with available national and international guidelines to see if the Program meets their criteria. We checked whether the key elements of the program were described and whether the descriptions were precise. The guidelines were: guidelines for effective health programs prepared by AHTAPol in 2010 and WHO FCTC Guidelines for Article 12.Description of the background;Description of the health problem;Program goals—description of the general goal, description of specific goals, whether the goals meet the SMART  criteria , and wheDescription of the beneficiaries of the Program;Program design—is the Program divided into phases of implementation, are the planned interventions clearly defined including the time frames of completion, is there any evidence for effectiveness of the interventions undertaken as part of the Program, are there EBM-based guidelines or standards of managing the defined healthcare problem;Costs/budget;Arguments regarding optimal usage of available resources; Description of monitoring and evaluation of the Program.AHTAPol has created the aforementioned model for health policy programs (HPP) to help central and local public institutions create effective health programs. It is an evidence-based model that emphasizes setting goals and measures of effectiveness . It was Apart from the AHTAPol recommendations, the WHO FCTC guidelines for Article 12 implementation present a checklist of elements that should be included in national tobacco control programs to ensure their effectiveness. The checklist includes: vision and mission statement, goals and objectives, strategies and expected results for each objective, budget, entities responsible for each activity, target dates and required resources, progress indicators, monitoring and evaluation of progress and outcomes, result dissemination. In addition to comparing the Program to available guidelines, we analyzed spending on the Program in years 2000–2018. We obtained data on funding from the annual reports on the implementation of the Program. We calculated the total spending for each year, and compared it with the sums related to the provisions described in the law (0.5% of tobacco excise tax). We also calculated the amount of money that should have been allocated to the the Program. Due to lack of relevant data, we could not analyze the effectiveness of the Program. Reports from the implementation of the Program did not contain information on whether the goals of the Program were achieved through the reported activities. There was also no data on the established measures of effectiveness.The Program included the following tasks: monitoring the situation in the field of use and cultivation of crop tobacco, effective protection from tobacco smoke, offering assistance in smoking cessation, information and warnings about the risks, health issues related to the use of tobacco, eliminating marketing practices violating the prohibition of advertising and promotion of tobacco, implementing economic and administrative stimuli limiting the consumption of tobacco products.We identified several instances in which the description of activities included in the Program were imprecise. The eligible population was not clearly defined, and simply stated that the Program was addressed to ‘‘the Polish society”. What is more, the detailed objectives of the Program did not precisely specify the effectiveness measures, and no initial and final values for the effectiveness measures were indicated, so no SMART criteria were applied. The tasks described in the document were not designed as the stages of Program implementation and had no deadlines. The entire document did not mention evaluation and monitoring. Only the requirement for the preparation of annual reports on the implementation of the tasks was listed. It is worth stating that in the last available annual report on the Program’s implementation from 2016, the following summary of the implemented activities can be found: “Due to the limited budget resources that could be used to finance Program tasks, their implementation in 2016 focused mainly on priority tasks, i.e., on the monitoring, educational and information activities directed to the people exposed to passive smoking, as well as on conducting education among various target groups” .The specific objectives of the Program are described for preventive measures  and actions from the level of intervention . For none of these specific objectives measurement methods or criteria were identified. When compared to the FCTC Article 12 guidelines , the TobAs no Program budget was planned and published ahead, we could not analyze spending on particular Program activities. Therefore, we concentrated our analysis on the comparison of spending on the Program with data on the portion of tobacco tax revenue that should have been spent on the Program according to the law, i.e., the 0.5% of the total tobacco tax revenue. The figures are presented in Our study showed both inadequate planning of and funding for the Polish Tobacco Control Program. The Program was developed without the use of best practices detailed in the WHO FCTC guidelines as well as in national guidelines prepared by AHTAPol. There can be several explanations for these situations. The lack of proper planning might be due to shortages of staff dedicated to the coordination of tobacco control activities. The preparation of the Program is the responsibility of the Ministry of Health, which has an agency for its execution (Chief Sanitary Inspectorate). However, within the Ministry, the Department of Public Health, which is responsible for tobacco control, has a very limited number of positions devoted specifically to tobacco control–this may also be a reason for the faults in the development of the Program. This situation could have been handled with the help of external experts from health agencies like the National Institute of Public Health, as well as from civil society organizations, which were very active at that time. To the authors knowledge, no cooperation was established with these institutions on planning the Program’s editions. Moreover, for several years, Poland was supported by the Bloomberg Initiative grants and many activists were sponsored to attend prestigious Global Tobacco Control Leadership Program in USA. However, it appears that the MoH never attempted to utilize this knowledge within the tobacco control programs. The lack of proper planning and execution of the Program was also noticed by the Polish Supreme Audit Office. In its report from 2013, the Office clearly stated that the Chief Sanitary Inspectorate, responsible for leading the Program from 2006 onwards, had never conducted a reliable monitoring and evaluation of the effects of its implementation. In general, a methodology allowing for an assessment of the implementation of the strategic aim and most of the detailed aims has never been developed: “The objectives of the Tobacco Control Program, which defined the directions of activities and priority tasks in combating health risks related to smoking, were not achieved, as the conditions for the implementation of the Program were not created: its budget was not separated, reliable monitoring and evaluation of the tasks specified therein was not carried out, and the management and coordination instruments provided for therein were not functioning” . The earmarking of tobacco tax for the tobacco control Program did not work either. Spending on tobacco control activities was miniscule compared to what had been agreed in the law, with the mean spending amounting to a mere 3% of what the law stipulated. It may seem that the Program was never prioritized, and that the support from the Bloomberg Initiative, which financed grants for the Chief Sanitary Inspectorate and a few civil society organization between 2007–2013  not onlyAlthough Poland achieved a significant reduction in daily smoking prevalence among people aged 15+ from 33% in 1999 to 24% in 2015 , there iOne of the biggest advantages of well-implemented tobacco control programs is their high cost-effectiveness. The cost of a life year saved through tobacco control is very low compared to other public health interventions. For example, it has been estimated that the Tips from Former Smokers, an anti-smoking media campaign prepared by the Centers for Disease Control and Prevention (CDC) cost only 393 USD per life year saved in the U.S., which by WHO standards makes the intervention very cost-effective . Unlike The analysis presented in this paper has several limitations. Due to the inconsistency in reporting as well as the lack of indicators of success we could not analyze the specific results of the Program. Analysis of reported activities did not allow us to draw any conclusions on the effectiveness of the Program. We could also not evaluate spending for the Program as no budget was planned ahead.Globally, countries do not give sufficient priority to tobacco control and Poland is a case in point. It seems necessary to put pressure on governments with the help of national and international NGOs. This activity can balance internal inertia and stop the negative impact of the tobacco industry. Governments should therefore support such organizations as they are their allies in the battle for public interest. They should also use experts in planning health programs and ensure legally sustainable funding for preventive activities. Otherwise, governments will always find “other urgent needs” worth funding. Creating overly general legal regulations, which omit the issues of verification/control of the implementation of statutory obligations, is another reason for the discussed failure of the Program’s financing. Legal obligations should be formulated with a clear and specific scope, as only in this way a law that is respected will be created. In such an important area of health protection, legal regulations should not give state authorities too much freedom in implementing the statutory obligations. The example of Poland may be a warning to other countries to strive to create law, compliance with which can be verified and controlled, i.e., certain entities have the competence to do so and certain entities are interested in proper law enforcement.Guidelines for the implementation of WHO FCTC Article 6 call countries to dedicate a portion of tobacco tax revenues to tobacco control programs. According to the latest WHO report on the global tobacco epidemic 2019, only a handful of countries do so. The experience of Poland shows that although earmarking of tobacco tax was provided for by the law, it has been largely ineffective due to the poor design of the Tobacco Control Program and insufficient funding resulting from a poor execution of the earmarking law.