Delivering self-management support to people with type 2 diabetes mellitus is essential to reduce the health system burden and to empower people with the skills, knowledge, and confidence needed to take an active role in managing their own health.Laura, designed to support diabetes self-management in the home setting over 12 months.This study aims to evaluate the adoption, use, and effectiveness of the My Diabetes Coach (MDC) program, an app-based interactive embodied conversational agent, 1c) and health-related quality of life (HRQoL). Data were assessed at baseline and at 6 and 12 months, and analyzed using linear mixed-effects regression models.This randomized controlled trial evaluated both the implementation and effectiveness of the MDC program. Adults with type 2 diabetes in Australia were recruited and randomized to the intervention arm (MDC) or the control arm . Program use was tracked over 12 months. Coprimary outcomes included changes in glycated hemoglobin  per person over 12 months. Compared with baseline, the mean estimated HbA1c decreased in both arms at 12 months (intervention: 0.33% and control: 0.20%), but the net differences between the two arms in change of HbA1c  was not statistically significant. At 12 months, HRQoL utility scores improved in the intervention arm, compared with the control arm .A total of 187 adults with type 2 diabetes  were recruited and randomly allocated to the intervention (n=93) and control (n=94) arms. MDC program users (92/93 participants) completed 1942 chats with 1c improvement.The MDC program was successfully adopted and used by individuals with type 2 diabetes and significantly improved the users’ HRQoL. These findings suggest the potential for wider implementation of technology-enabled conversation-based programs for supporting diabetes self-management. Future studies should focus on strategies to maintain program usage and HbAAustralia New Zealand Clinical Trials Registry (ACTRN) 12614001229662; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614001229662 Type 2 diabetes mellitus (T2DM) is a common chronic condition that places a significant burden on individuals and the health care system. The prevalence of diabetes has risen substantially over the past two decades worldwide . HoweverHealth coaching programs, incorporating continuous feedback and reinforcement  deliverereal world [Despite the increasing use of mobile apps for health purposes, reviews have found that existing digital health solutions are not generally able to meet the needs of people with diabetes, and more evidence is required before their wider scale-up ,11. Mostal world ,15-17.Laura, to provide more accessible and engaging self-management support, monitoring, and coaching to adults with T2DM in Australia. We undertook a hybrid effectiveness-implementation study [By adapting our team’s previous effective and cost-effective Telephone-Linked Care for Diabetes (TLC diabetes) program  to a moron study  with a rThis trial is a two-arm, open-label, randomized controlled trial with participants recruited between June 2016 and April 2017 in Australia. The trial was registered before recruitment . Full ethics approval was granted by the University of Melbourne’s Human Research Ethics Committee (Ethics ID 1442433). Participants provided written informed consent and returned the informed consent forms to the research team via email or fax, including permission for their general practitioners (GPs) to regularly share clinical data with the study team.Adults (aged ≥18 years) diagnosed with T2DM, registered with the National Diabetes Service Scheme (NDSS) for less than 10 years, with basic English language skills, who had access to an internet-enabled smart device with an up-to-date operating system (at least iOS 8.0 for Apple and 4.2 for Android) were eligible to participate in the study. Participants were ineligible if they were pregnant or planning to become pregnant, had severe comorbid conditions that would compromise their participation, or did not have stable doses of diabetes-related medication over the previous 4 weeks or more.To assist with recruitment, on behalf of the research team, the NDSS sent invitation letters to registered adults with T2DM living in the Australian states of Queensland, Victoria, and Western Australia. These 3 states comprise 54.5% of all Australians with diagnosed diabetes . RecruitParticipants were randomly allocated to the intervention or control arm using a 2x4 block randomization sequence, programmed into a Redcap data management system , with thParticipants allocated to the intervention arm received access to the MDC program for up to 12 months. The overall program comprises 5 components: the MDC app; a printed user guide; the MDC website; an optional blood glucose meter with Bluetooth capability ; and a small number of brief, structured interactions with a program coordinator, primarily for technical assistance. The MDC app was adapted from the previous TLC diabetes program  and was Laura, through a series of modules covering blood glucose monitoring, healthy eating, physical activity, medication taking, and foot care. The conversational scripts and algorithms guiding each individual’s progress were designed by applying behavior change theories and techniques, including the transtheoretical model [MDC delivers personalized support, monitoring, and motivational coaching via an embodied conversational agent, al model , social al model , gamifical model , and othal model . AlgoritLaura or touching buttons on the screen. Each appointment module with Laura began with a review of progress with feedback, education and counseling on the chosen topic, and incorporated tips on overcoming barriers, followed by a short quiz and closing remarks.Participants were encouraged to use the app weekly to complete online modules by chatting with In addition to the MDC app, participants were also encouraged to regularly access the user guide and the MDC website and to join the discussion forums on diabetes self-management topics posted fortnightly by the program coordinator on the website. The program coordinator, supported by a web-based user management portal, assisted participants in dealing with system-generated technical alerts by communicating with participants, their GPs, and Clevertar. The program coordinator also telephoned participants after 1, 4, 8, 12, and 24 weeks of program access to answer questions, to troubleshoot technical issues, and to encourage program use.Participants in the control arm were encouraged to continue their routine diabetes self-care, including access to health care services, resources accessed via NDSS, and the diabetes not-for-profit organizations in their states. They received a quarterly project newsletter to maintain their interest in the study. Following the 12-month data collection, participants in the control arm received access to the MDC program if they wished.We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the impact of the MDC intervention, which covered the 5 dimensions in terms of reach, effectiveness, adoption, implementation, and maintenance . This paLaura, the total duration of chats, and the number of blood glucose levels uploaded by participants. Other metrics included the number of technical and clinical alerts generated by the system for the project coordinator and the number of posts on the web-based discussion forum of the MDC website.Program adoption and use were tracked using the program management portal. The key metrics included the number of completed chats with 1c) and health-related quality of life (HRQoL), which were examined in terms of between-arm differences. The secondary time point of analysis examined the change between baseline and 6 month. HbA1c (reported as % and mmol/mol) was measured through a pathology blood test that each participant’s GP requested. HRQoL was assessed via participants’ completion of the Assessment of Quality of Life (AQoL)-8D scale, which is a 35-item multi-attribute utility instrument covering 8 dimensions focused on independent living, happiness, mental health, coping, relationships, self-worth, pain, and senses [Program effectiveness was measured by both clinical and psycho-behavioral outcomes. The coprimary outcomes were changes (12 months compared with baseline) in glycated hemoglobin  ; diabeteData were collected at 4 time points, including screening, baseline, 6 months, and 12 months post randomization. During the screening telephone calls, the research team contacted participants and recorded sociodemographic characteristics , clinical characteristics , and app use variables in the REDcap data collection system . Assessm1c of 0.4% between the 2 arms with three repeated measures based on a previous study. This estimation assumed a 20% loss to follow-up, a SD change of 1% in HbA1c, and an intraclass correlation coefficient of 0.6 within measurements from the same participant.On the basis of a previous study , we estiintention-to-treat analysis [t tests or chi-square tests were performed (as appropriate) to determine any differences in baseline characteristics between the 2 study arms. For indicators related to program use, mean with SD and range were reported for key metrics. A chat was included in the analysis of chat duration only if the whole appointment module with Laura was completed during the chat . Durations were truncated when the records showed extreme values (larger than two interquartile ranges above the third quartile of the distribution), as they were likely to represent cases when participants had forgotten to exit the app and duration had been tracked beyond the end of the actual chat.All enrolled participants who completed the baseline assessment were included in the analysis . DescripLaura. Posthoc subgroup analyses were conducted based on age, sex, baseline HbA1c, and NDSS registration duration by adding the subgroup variable and its interaction term with the variable of the interaction between intervention and assessment point as fixed effects to the mixed-effect models used for the main analysis. To further investigate the relationship between program use and effectiveness, mixed-effect models were fitted with a random intercept for the participant and fixed effect for levels of program use , assessment time point, and program use-by-time interaction. All analyses were conducted in Stata version 15.1 (Stata Corp) by EG and verified by a statistician (ML) who was blinded to the randomization allocation.The main effectiveness analysis followed the intention-to-treat principle . The ana1c was 7.3% . Individuals who were excluded were more likely to be females, have relatively lower education levels, be unemployed, and use mobile phones less or do not have access to a smartphone  from Victoria, 21 (16.5%) from New South Wales, and 21 (16.5%) from Queensland . The samartphone .P=.04) and had lower depression scores (P=.004) at baseline. Among the participants, 116 (62.0%) provided complete data for all 3 assessments . Incomplete assessments were due to active withdrawal, loss to follow-up, incomplete surveys, or refusal to complete a clinical measure with blood tests. Participants without HbA1c measures provided by GPs at 6 months or 12 months were more likely to have lower baseline HRQoL (P=.01) and higher anxiety symptom scores (P=.03). Participants who had an incomplete survey without a valid AQoL-8D score were younger (P=.02) and more likely to be allocated to the intervention arm (P=.007).The intervention and control arms  were generally comparable, except that those in the intervention arm were slightly younger  uploaded their blood glucose levels at least once to the app. These 92 participants completed a total of 1942 chats over 12 months of program access and reached a mean of 243 (SD 212) min of chats per person. In general, the program use, including the number of chats and number of blood glucose uploads, reduced over time of the program access (m access . During P=.04) but not in HbA1c . This was maintained from the increase at 6 months . HRQoL remained stable for participants in the control arm between baseline and 12 months . The adjusted model showed consistent results. The per-protocol analysis yielded a slightly larger effect size, as the 12-month between-arm difference in the AQoL-8D score was 0.06 . Compared with baseline, the intervention resulted in an increase in the score of the physical health and mental health subscales . The results were consistent in the adjusted model. In the per-protocol model, a larger between-arm difference was observed at 12 months .Compared with baseline, the mean estimated HbALaura during program access had a significantly greater improvement in AQoL-8D utility score  at 12 months. There was no significant difference in HbA1c .There was a dose-response relationship between the number of chats and the change in the HRQoL score . Compare1c. There were greater between-arm differences at 6 and 12 months in the mean change in HbA1c for those with higher baseline HbA1c and those registered on the NDSS within the previous year (P=.04) was observed in the mean change in the HADS anxiety score at 6 months but not at 12 months or for other secondary outcomes reported here.Although this study was not powered for subgroup analyses, the results did show some statistically significant differences favoring the intervention for HbAous year . There w1c levels reduced during the trial, the between-arm difference was not statistically significant at 6 or 12 months.This study is among the very few randomized controlled trials that have evaluated the adoption, use, and effectiveness of a mobile app–based, interactive, embodied conversational agent to support diabetes self-management within home settings over a 12-month period. Our study adds new evidence to this emerging field by demonstrating the program use in a home setting and the effectiveness of app-based interactive conversational agents in supporting diabetes self-management. The MDC program was feasible and shown to be effective in improving participants’ HRQoL. Although HbALaura, with human-like characteristics who used a very conversational style of speech to provide people with T2DM with personalized coaching and support on a range of essential diabetes self-management activities in their home environment. The process evaluation that received response from 66 out of 93 participants at 6 months showed that more than 80% of them considered Laura as a helpful, friendly and competent assistant and 72% described Laura as trustworthy [Despite the growing number of studies using mobile technologies for diabetes management ,11,15, tstworthy .appointments with Laura) is very similar to the TLC diabetes program previously developed and evaluated by our team in Australia [The indicators for program use suggest successful uptake among individuals with T2DM, but maintaining long-term program use still remains a challenge. Interestingly, program exposure  at baseline. However, the significant difference by baseline HbA1c observed in the subgroup analysis suggests that the intervention may have significant benefits if the study had targeted only those individuals with HbA1c above target. Second, similar to some previous digital health trials [1c among participants in the control arm. This could be due to the Hawthorne effect with participants sufficiently motivated to be involved in the trial are likely to seek better self-management through other options when they were not allocated to the active intervention. Third, participants’ lack of maintenance in program use may have led to a relatively low dose of program exposure. The larger between-arm differences observed in the per-protocol analysis and the greater impact among people with higher program exposure indicates that the effect of the MDC program could have been larger with better fidelity to the study protocol.We observed a modest but statistically significant improvement in HRQoL at 6 months, which was maintained at 12 months. This finding is consistent with some previous research, which indicates a small but statistically significant benefit from mobile app–based interventions on HRQoL . The impprograms ,39, and h trials , there wThis study has several important strengths. First, study participants were recruited from across Australia, with broad inclusion criteria, and the program was delivered within participants’ home settings. Thus, the sample is broadly representative of Australians with T2DM, and the study findings are likely to be generalizable and scalable. Second, the study followed participants over 12 months, which is a relatively long term compared with many studies of this kind . Third, There were also some limitations. First, due to the nature of the intervention, we were not able to blind participants or their GPs  to the study arm allocation. Without being able to blind participants, self-report bias and Hawthorne effects may exist. Second, we observed a higher rate of completed assessments among participants in the control arm than in the intervention arm, possibly due to their interest in gaining program access or because of higher attrition in the intervention arm. Third, due to the relatively small sample size, the subgroup analyses should be interpreted with caution. Although the main analyses were fully powered, the subgroup analysis was underpowered and multiple testing would have increased the likelihood of false positives. Overall, the sample was not dissimilar from previous trials in this field .Laura over 12 months. The trial demonstrated benefits for HRQoL among individuals with T2DM in Australia, which remained apparent at 12 months. The lack of effect for HbA1c is likely due to the relatively low baseline HbA1c level and declining program use over time. Strategies that would increase the program engagement and maintenance in use and improve the effect on HbA1c are required before program scale-up.To summarize, this study presents findings concerning the effectiveness, adoption, and use of the MDC program, an app-based interactive embodied conversational agent, in supporting individuals with T2DM. Participants had good adoption of the program and completed a significant amount of chats with


SCI), prolonged nonactive sitting time and reduced physical activity—typically linked to this mode of mobility—contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton may be a promising physical activity intervention to counter these detrimental health effects.In wheelchair users with a chronic spinal cord injury  to determine the effects of a 16-week wearable robotic exoskeleton–assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors and (2) to determine self-reported satisfaction and perspectives with regard to the intervention and the device.SCI, who have had their injuries for more than 18 months, will complete an overground wearable robotic exoskeleton–assisted walking program  supervised by a physiotherapist over a 16-week period (one to three sessions/week). Data will be collected 1 month prior to the program, at the beginning, and at the end as well as 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia, and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users’ satisfaction levels and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures.A total of 20 WUThis study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in the spring of 2021.The results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based wearable robotic exoskeleton–assisted walking programs offered in the community, and to initiate a reflection regarding the use of wearable robotic exoskeletons during initial rehabilitation following a spinal cord injury.ClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752DERR1-10.2196/19251 Independent variables having reached a critical threshold (P≤.25) will then be confronted in a stepwise multiple linear regression analysis to identify the three best predictors for each dependent variable and the coefficient of determination (2R) of the model. To determine the factors for identifying the best responders to the program, analyses similar to the previous ones will be completed, except that the independent variables will be sociodemographic characteristics, anthropometric parameters, characteristics of the SCI, personal factors, and functional disability.For Hypotheses 2 and 3, Pearson or Spearman correlation coefficients will investigate the strength and direction of the relationships between the overall observed changes  will summarize the results of the satisfaction survey . Audio recordings of the interviews will be transcribed verbatim using Microsoft Word. A summer research intern will read the transcripts and generate initial codes or subthemes. A co-codification of the first transcript will be done manually on printed paper with the list of initial codes and subthemes; this will be done independently by three research collaborators . They will write codes directly in the margin of the printed transcripts. They will then meet via audio and video conferencing to compare and review coding, discuss discrepancies, and modify codes if necessary. This process will be done twice with the transcripts of the first two participants. To start the computerized qualitative analysis, all transcripts will be interpreted using thematic content analysis, where narrative data will be thematically coded and appraised using NVivo 10 . A final report, integrating findings from the MWESP-Q and the interviews, will be produced and recommendations will be incorporated in order to shape the development of a future home- or community-based adapted physical activity program.For Hypothesis 4Laboratoire de pathokinésiologie of the Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Québec, Canada, which is part of the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Ile-de-Montréal in Montreal, Canada, and at the Laboratoire du muscle et de sa fonction of the Université du Québec à Montréal. This project received ethical approval on March 14, 2019, from the CRIR ethics committee and was registered on June 7, 2019, with the US National Library of Medicine at ClinicalTrials.gov (NCT03989752). This study is expected to be completed by spring 2021, with results to follow shortly after.This study was recently initiated at the SCI who have a very poor prognosis for walking recovery [SCI are now requesting the democratization of accessibility to this technology during rehabilitation and in the community at a faster rate than evidence is generated and shared with physical activity and rehabilitation professionals, administrators, and policy makers. Strengthened evidence is urgently needed to fill this knowledge gap to some extent and to start informing the decision-making process of these stakeholders regarding the possibility of purchasing wearable robotic exoskeletons as well as developing, implementing, and evaluating activity-based and adapted physical activity programs with wearable robotic exoskeletons in clinical practice . Moreover, this evidence, once coupled with clients’ perspectives, may become key precursors to (1) develop and implement community- and/or home-based walking programs, (2) advocate for policy changes to broaden accessibility to wearable robotic exoskeletons, and (3) propel future larger-scale pragmatic or randomized controlled trials with an appropriate comparator targeting the effectiveness of walking programs with a wearable robotic exoskeleton. Of even greater relevance, it is expected that walking programs with a wearable robotic exoskeleton will reduce impairments  and optimize aptitudes, which are expected to positively influence psychosocial outcomes in WUSCI and potentially those with other sensorimotor impairments . In the long term, although not measured in the proposed study, we can hypothesize that indirect societal benefits may become tangible via reduced caregiver burden and reduced health care costs, for example. By optimizing their global health, especially as they age, WUSCI will also remain in a state of readiness to benefit from future advances in neural repair, recovery, or rehabilitation technology. Lastly, as some wearable robotic exoskeletons may become approved for home or community use by Health Canada, some WUSCI are now envisioning their use as personal neuroprostheses for ambulation in their daily lives as a complement to wheelchair mobility in the near future. Still, strengthened evidence is needed to support the prescription and reimbursement processes in order to accelerate uptake of wearable robotic exoskeletons in the community.This project innovates by being among the first studies to comprehensively, prospectively, and longitudinally investigate the effects of a wearable robotic exoskeleton–assisted walking program among long-term WUrecovery . This stSCI who have no or very limited walking ability, the walking program with the wearable robotic exoskeleton is not expected to have any reversal effect on their walking capacity without this novel mobility assistive technology. However, this project is relevant since it will generate the first evidence of the anticipated cardiorespiratory, musculoskeletal, and endocrine-metabolic health adaptations upon completion of a walking program with a wearable robotic exoskeleton. For the first time, the extent to which these adaptations translate into beneficial effects on functional capacity will also be verified, as will their effects on health-related quality of life and psychological health. This includes the psychological well-being domain, which was not specifically measured during the feasibility study but was mentioned by the majority of participants. Given the fact that the population of WUSCI continues to grow and that they now live longer, these potential beneficial effects are further warranted. The caregiver burden and the potentially costly long-term expenditures associated with adverse health events may also decrease. For rehabilitation professionals, the proposed project is relevant since strengthened evidence regarding the effects of the walking program and the characteristics of the best responders will be generated and will inform clinical decision-making processes or the development of a clinical algorithm for referring individuals with SCIs to a walking program. For rehabilitation program administrators and policy makers, the proposed study is relevant since the evidence generated may further confirm the need for publicly funded clinical and technological infrastructures to create structured programs incorporating walking technologies, such as the wearable robotic exoskeleton, and outcome measures into rehabilitation or adapted physical activity centers. Both program administrators and policy makers will need to work collaboratively and cohesively to develop creative solutions to address this current service gap and engage in transformative improvements. For the research community, this project provides a unique opportunity to create a strong multidisciplinary team of well-established scientists with diverse and complementary academic training as well as clinical and fundamental research expertise. For manufacturers with an interest in wearable robotic exoskeletons, among others, this project is relevant since the input from powered exoskeleton end users  will become available and may enrich the continuous quality improvement process. This process is imperative to further support and accelerate the development of wearable robotic exoskeletons and to reach key commercialization milestones for the technology to become personalized and accessible for WUSCI interested in home or community use  in the next decade.Many stakeholders may benefit from this interventional study. For WUA few potential challenges merit attention:Some potential participants will have insufficient passive range of motion at the lower extremities to engage with the project. These participants will be provided with a 4- to 6-week home-based stretching program, will be reassessed, and may become eligible later.SCI may be underrepresented. Efforts will be made for the sample to be representative of the SCI population and to have women make up 20% of the sample. However, since the minority of individuals affected by SCIs are female and the sample size is limited (n=20), it is unlikely that statistical analysis by subgroups  will be feasible in order to account for potential sex and gender differences. Nonetheless, descriptive statistics will present results separately for women and men whenever indicated.Female WU0, the equivalent of 1 year of vitamin D3 supplementation will be provided to all participants who are not currently taking supplements. Moreover, all participants will be instructed on healthy balanced diets.A small number of participants may demonstrate vitamin D deficiencies . To mitiSome participants may concurrently engage in extraneous physical activity or may seek cointerventions during the project. Participants will be asked to maintain their customary level of physical activity during the project and to avoid engaging in new cointerventions. Any unintended intervention  that may influence the results will be documented and its effect carefully verified by the research team and possibly considered as a dichotomous variable .Some participants may experience some lower extremity neurorecovery. In the event a participant was to experience neurorecovery , he or she would be withdrawn from the project and referred for a comprehensive neurological assessment and to an advanced locomotor training program.


Mentorship may offer protégés numerous benefits including improved self-esteem, increased interest in research, and/or enhanced productivity. Without proper planning, reflection, and evaluation, however, mentorship programs may result in undesirable consequences. In this paper we describe a mentorship program designed to improve psychosocial support and professional development for residents, that while initially successful, was terminated due to perceptions of inequity that led to strife among residents and ultimately created a toxic learning climate. Leader-member exchange theory provides a lens through which to view our program’s failure and to offer some potential solutions to mitigate such challenges for other programs. Leader-member exchange theory focuses on the importance of relationships, communication, and awareness of biases to optimize interactions between dyads such as a mentor and a protégé. We highlight opportunities during the stranger, acquaintance, and mature partnership phases that could have helped to save a residency mentorship program.The online version of this article (10.1007/s40037-020-00584-2) contains supplementary material, which is available to authorized users. Mentorship programs are an important part of health professions education. They are traditionally viewed as relationships in which there is a senior individual within an organization assisting the junior person’s personal and professional development . There aWhile one of us was working as the Associate Program Director for an Internal Medicine Residency Program, a lack of mentorship was observed as evidenced by only three of 26 first- and second-year residents (11.5%) reporting that they had a mentor. As such, a formal mentorship program was established to improve psychosocial support and professional development for the residents. All faculty members were offered the opportunity to participate via email and announcements. Faculty members interested in mentoring provided a PowerPoint slide with training background and academic and personal interests. All residents were invited to participate and were provided a presentation including the PowerPoint slides via email and in noon conference. Residents selected their top three choices for a mentor and were matched with a faculty member. All residents were assigned one mentor and were paired with one of their top two selections. All mentors were agreeable to the pairings. Residents were encouraged to seek additional mentors if desired or if they had interests or needs that were not being addressed. The residency leadership, which included the Program Director, two Associate Program Directors, and two Chief Residents, gave the mentors an introduction to mentoring packet, which included a first meeting tool and an article about academic mentoring . ResidenSix months after initiation of the mentorship program, residents and faculty participated in a workshop with four objectives: 1. Define mentorship, 2. Discuss traits of successful mentors and protégés, 3. Discuss obstacles to successful mentorship, 4. Compare and contrast responsibilities of mentors and protégés. The material presented at the workshop was generalized and was not based on survey results. Mentorship articles were sent to residents and faculty three times in the next six months .Resident opinions were queried via SurveyMonkey prior to the workshop and again 6 months later, a total of 12 months after the initiation of the mentorship program . The surveys were determined to be quality improvement and not research by the Institutional Review Board, there being no potential harm to respondents and as the anonymity of respondents was guaranteed. On the first survey, 39 first, second, and third-year residents were queried. Twenty-seven residents responded to the survey for a response rate of 69%; 100% of these 27 responders reported having a mentor, and 21% reported having more than one mentor. Twenty-nine residents responded to the second survey 6 months later for a response rate of 74%: 96% reported having a mentor, and 48% reported having more than one. At this time, a majority of residents felt that mentor relationships were quite or extremely valuable, they were quite or extremely satisfied with the psychosocial support received, and they felt that mentors were quite to extremely important to their professional development. Of note, a larger percentage of residents responded not at all or slightly to these questions on the second survey than the first indicating that, while a majority of residents appreciated the program, a growing percentage was dissatisfied  provides one framework to prepare for, develop, reflect upon, and sustain a mentorship program. LMX focuses on the importance of relationships, communication, and awareness of biases to optimize interactions between dyads, such as a mentor and a protégé . By undeLMX describes three phases of relationship development: stranger, acquaintance, and mature partnership . FollowiDuring the stranger phase, the individuals in the dyad are assessing each other and the relationship. Mentors are offering opportunities, and protégés are communicating their needs. Improved leadership communication with the mentors and protégés at this stage may ensure that expectations are consistent within the dyads. This may assist with determinations of compatibility and allow for early identification of a mismatch. An educational plan during the stranger phase could increase buy-in for the program, assist with assessment of compatibility, improve communication skills, and provide strategies for bilateral feedback and conflict management. Education regarding identification of factors indicating dissatisfaction may also prove beneficial.During the acquaintance phase, dyads are informally negotiating the rules and boundaries of their partnership and forming mutual goals. At this time, the character of the relationship is becoming more developed, which enables clearer identification of successful and unsuccessful dyads. Applying LMX to the results of our survey during the acquaintance phase might have allowed us to identify and support struggling dyads. We unconsciously were focused on, and comforted by, the number of satisfied residents causing us to disregard the small but increasing number of dissatisfied residents. Three specific areas for improvement during this stage are increasing team building activities for dyads with potential for success, normalizing the need to terminate relationships in unsuccessful dyads, and dedicating appropriate attention and resources to on-going program evaluation and problem resolution.For satisfied dyads that reach the mature partnership phase, as was the overwhelming majority in this program, further skills training and education could have strengthened the relationships and the program. Relationship building skills such as improving communication, conflict management, and positivity in relationships may have improved the partnerships within the program .There are challenges in the development of mentorship programs that LMX does not address. It does not prescribe guidance for establishing an optimal level of structure or surveillance of a mentoring program. Additionally, it does not address how to identify individuals who are not interested in committing to mentorship or who will be dissatisfied regardless of the model created. While application of LMX suggests education, identification of dissatisfaction, increased communication, and team-building may have decreased the perceptions of favoritism, LMX does not offer a panacea for this problem.The moral of the story is that careful consideration and planning should be undertaken prior to the development of initiatives within educational programs, even seemingly benign interventions. Considering LMX during the planning and execution of the mentorship program could have increased the likelihood of success of our program and other mentoring initiatives. The residency leadership attempted to develop a program to increase psychosocial support, provide opportunities for professional development, and ensure satisfaction for all mentors and protégés. Instead, the result was significant discord within the residency program. Improved education during the stranger phase, continued education, ongoing evaluation, and more attention to suboptimal relationships during the acquaintance phase, and continuing support through the mature partnership phase would likely have led to more mutually beneficial relationships. Further, these efforts could have avoided the repercussions of a toxic climate that were suffered by this residency. We believe that LMX theory, and more specifically, application of principles in each of these three phases, could help educators seeking to introduce or enhance mentoring programs.Survey questions disseminated to the Internal Medicine Residents regarding the mentorship program.


Two large earthquakes in the Aleutian subduction zone provide unexpected evidence for low plate interface coupling. Mw) ≥8.0] earthquake. More recent geodetic data indicate that this region is weakly coupled, and the geologic record shows little evidence of past large events. From July to October 2020, a series of earthquakes occurred in this region, raising the possibility of greater coupling. The initial Mw 7.8 thrust faulting earthquake straddled the eastern edge of the Shumagin Gap and was followed by an Mw 7.6 strike-slip earthquake within the Shumagin Gap. Stress modeling indicates that this strike-slip earthquake is in fact favored if the Shumagin Gap has low coupling, whereas a highly coupled Shumagin Gap inhibits that type and location of earthquake. The initial thrust earthquake and its afterslip enhanced the strike-slip loading within the subducting slab, helping to trigger the October event.In the 1970s, the Shumagin Islands region of the Alaska subduction zone was identified as a seismic gap expected to host a future great [moment magnitude ( Mw) 8+] earthquakes and therefore having a high potential to host a great earthquake . These earthquakes reflect the recovery of elastic strain accumulated in the plates through this coupling. During the development of plate tectonics, a working model for earthquake potential within subduction zones was proposed in which the likelihood for upcoming great earthquakes along the margin could be simply related to the time since the last great earthquake at that location—the “seismic gap theory” (rthquake . AlthougMw 8.2 to 8.5) earthquake in 1946  is currently strongly coupled and accumulating slip deficit. In the Shumagin Gap itself, early triangulation surveys  generally aseismic between great earthquakes. The initial earthquake in the 2020 sequence was a subduction interface earthquake (Mw 7.8) subduction interface earthquake on 21 July  Comprehensive Catalog] (The July to October 2020 earthquake sequence began with a major ( 21 July . This evMw 7.6) intraplate strike-slip earthquake occurred 80 km southwest of the July epicenter, within the region identified in geodetic inversions to have low (30 to 40%) interseismic coupling  strain recovery associated with megathrust slip within pseudocoupled regions may not always produce a seismological signature even when occurring at earthquake strain rates, but such aseismic slip can be observed geodetically in the near field; (ii) although plate interfaces may be relatively stress free in uncoupled regions, the plate interiors in the transition zone between low and high coupling can become sufficiently stressed to host moderate-to-large earthquakes with faulting styles atypical for subduction zones; (iii) such an atypical intraplate earthquake can be triggered in response to stress changes caused by nearby, more common subduction interface thrust earthquakes; and (iv) likewise, aftershocks and afterslip can occur even in regions down-dip of a mostly decoupled plate interface when driven by adjacent earthquake slip.Mw 7.8 and 7.6) earthquakes within the Alaska-Aleutian subduction zone in the vicinity of the Shumagin Islands seismic gap thus provides a means to assess models and interpretations of (i) the spatial distribution of plate boundary coupling in this seismicity gap; (ii) the development of intraplate stress conditions that can generate large, nonsubduction interface earthquakes; and (iii) implications that non–plate interface earthquake sources can be damaging  within otherwise low earthquake-hazard subduction zone segments.We use a suite of numerical models to address these hypotheses by evaluating the spatial and temporal stress evolution in the vicinity of the Shumagin Gap. Specifically, we investigate the conditions that could lead the July plate interface thrust faulting earthquake to trigger the October intraplate strike-slip earthquake. This sequence of two major  asperities separated by a zone of free slip representing an uncoupled Shumagin Gap . Results from these models suggest that the transition from high coupling in the 1938 rupture zone to low coupling in the Shumagin Gap is needed to explain the faulting characteristics of the October large strike-slip earthquake. The intraslab stress field produced on the east side of the Shumagin Gap uncoupled zone during the 82 years of loading since the last great earthquake in the region strongly promotes right-lateral strike-slip failure on trench-perpendicular faults . This isMw 7.6 event , as indicated by the moment tensors determined by the USGS and Global Centroid Moment Tensor Project  modify the stress field. Using elastic half-space models, we estimate these stress changes along the top of the subducting Pacific slab, focusing particularly on the hypocentral region of the October er fault . If it i changes . These rOur interpretations of the plate coupling conditions and the sequence of events that led to this multicomponent earthquake sequence are shown in In most earthquake systems, there is a transition at depth along a fault where deformation switches from a brittle frictional (stick-slip) process to a stably sliding or ductile deformation regime. Beyond this depth, much of the relative plate motion is continuously accommodated aseismically, and little slip deficit accumulates. It is common in this transition region for both modes of plate boundary slip to occur in response to nearby larger events—a combination of earthquakes (coseismic slip or aftershocks) and relatively rapid aseismic afterslip. We refer to this section of the plate boundary simply as the “afterslip region” .Mw 7.8 thrust event and its apparent dual characteristics of seismic (in the coupled region) and aseismic (in the pseudocoupled region) slip is expected for an event on the edge of a well-coupled asperity , comes from the pseudocoupling framework (Our stress modeling results indicate that the distribution of asperities (coupled patches) typical in subduction zones produces an area within the asperities and extending into the adjacent pseudocoupled zone with sufficient slip deficit and stress conditions favorable for generating subduction zone thrust-faulting earthquakes (fig. S2) p region  (24). ThMw 7.6 earthquake in October 2020 is less expected, rupturing a high-angle (dipping ≥50°) strike-slip fault and located within the subducting Pacific plate  by down-dip slip in the brittle-to-ductile transition zone through a combination of aftershocks and aseismic afterslip . The July plate interface thrust faulting earthquake ruptured near the base of the seismogenic zone at 30-km depth, uplifting the seafloor up to ~70 cm. However, the depth of this event likely reduced its vertical displacement magnitudes. The October strike-slip event also can generate substantial vertical seafloor displacements, including ~40 cm of subsidence near the Shumagin Islands and ~50 cm of uplift closer to the trench, as it ruptured up the slab toward the trench. The moderate eastward dip of the fault (~50°) accentuated this seafloor motion compared with a steeply dipping strike-slip fault. Tsunami generation typically requires large vertical seafloor movements to displace the water column. Although this condition most frequently occurs in subduction zones during shallow plate interface thrust faulting earthquakes, any event that vertically displaces a sufficient region of the seafloor can be a tsunami source. Tsunamis can also be generated by large horizontal displacements of steep underwater topography, which might be important for this event or other strike-slip–generated tsunamis [e.g., the 1994 Mindoro, Philippines tsunami  on shallow (10 km) thrust faults (fig. S3D). The largest magnitude Coulomb stress changes occur south of the Mw 7.8 and east of the Mw 7.6 rupture zones, and shallow thrust faults have been positively loaded elsewhere throughout the Shumagin Gap. Although these splay faults may not be capable of great (Mw 8+) earthquakes as in a coupled megathrust region, a triggered Mw 7 to 8 earthquake on one of these faults could produce substantial seafloor displacements and therefore regional tsunamis.In the absence of plate interface thrust faulting earthquakes, slip on shallow splay faults in the upper plate can also generate tsunamis (Mw 7.6) strike-slip earthquake. We also find that although regions such as the Shumagin Gap have a low seismogenic potential for plate interface thrusting, so the seismic and tsunami hazard might be thought to be small, the existence of this decoupled region increases the potential for intraplate strike-slip faulting. Thus, other apparently uncoupled sections of subduction zones , which otherwise might be thought to have relatively low hazard potential, could still host earthquakes with the potential to produce strong shaking and regional tsunamis. Despite the additional evidence from this earthquake sequence for a decoupled Shumagin Gap, the cause of this low coupling here and in other global subduction zones remains enigmatic.The recent sequence of two large earthquakes (and their associated aftershocks) along the Alaska-Aleutian subduction zone provides strong evidence, perhaps paradoxically, for the decoupled nature of the Shumagin Seismic Gap. The sequence of events and, in particular, the triggering of an intraplate strike-slip earthquake within the gap are most consistent when the Shumagin Seismic Gap region is a decoupled segment of the subduction plate boundary, compatible with recent models from GPS data. If the plate interface is coupled in the gap, then it is hard to produce stress conditions within the subducting plate to produce a large , and μ is the effective coefficient of friction (set to 0.5 in this study). Stresses are variously resolved (as appropriate) on trench-perpendicular, right-lateral, strike-slip faults (simulated stress conditions for the October 2020 earthquake) and on thrust faults with the geometry of the plate interface.We monitor both the displacement and stress fields along the surface of the slab 1 km below the dipping plate interface. The displacement of the slab surface is plotted as arrows in Mw 7.8 mainshock and subsequent afterslip and aftershocks in triggering the October Mw 7.6 earthquake by calculating the Coulomb stress change , and strike = 355°, dip = 90°, and rake = 175° (a steeply dipping strike-slip fault).To assess the tsunamigenic potential for these earthquakes, we calculate the surface displacements produced by the events (fig. S4). We assume that the fault slip occurred in an elastic half-space with the same elastic parameters as described above and that the ruptures occur on rectangular faults with uniform slip. We use the equations of Okada (


Besides the evident positive effect on body development, physical activity has proven to boost executive functions, especially if the exercises are enriched with cognitive stimuli. Previous studies have shown that introducing challenging exercises in the physical activity routine can also enhance motivation. Therefore, enriching a physical education program with cognitively challenging exercises may also foster children’s motivation during physical education classes, where the motivation is high at the beginning of the school year and low at the end of it. Therefore, the purpose of this paper is to test if a sport program enriched by cognitive stimuli may improve kids’ motivation or take them out from a state of amotivation along the school year.A sample of 342 school children  took part in the study. Participants were asked to complete a battery of motivation and perceived social support questionnaires before and after they completed the ESA Program, a sport program enriched with cognitive stimuli. Moreover, parents of these children attended four seminars about the importance of supporting children for the practice of regular physical activity (PA). A control group consisting of children that attended the ordinary physical education school class was also included.A repeated measures MANOVA model showed that the ESA Program was able to improve children’s general motivation, in particular the intrinsic motivation. The program was not effective in social support, but, independently from the group, the family social support in sports activities decreased for females.Apart from cognitive improvement, the ESA Program can have beneficial effects on children’s sports motivation in physical education, but not on perceived social support. The practice of sport activities has undoubtedly positive effects on children’s physical fitness and psychological well-being. These benefits concern improved physical fitness, balance, and endurance jump as well as the decrease of obesity and type 2 diabetes . From thA review of A recent systematic review analyzed the effects of school-based PA interventions, such as PA components during school lessons or during morning, lunch and afternoon breaks, on a variety of motivational measures of PA in school-aged children and adolescents . ResultsNevertheless, children’s engagement in physical education class depends on their motivation . In partTo what concerns sport programs created for children, according to The current study hypothesizes a positive effect of an enriched school-based sport program, the ESA Program, on children’s motivation and social support. Enriched Sports Activity program (ESA program) is a sport program enriched through cognitive stimuli, experimented within the Erasmus + Project Enriched Sports Activity Program . The project aimed to enhance social inclusion, equal opportunity, and psycho-social well-being in children by stimulating their cognitive growth and motivational aspects . The proThe ESA Program session differ from a traditional physical education class in the standardization of the sessions, consisting in a warm-up phase and a stimulation phase, while a physical education class follows less rigid schemes. Moreover, children are encouraged to enhance their skills by increasing the exercise difficulty step-by-step. Finally, a cognitively engaging physical activity produces improvements in executive functions, while mere aerobic exercise does not produce the same enhancement .In the first phase (t1), data collection was conducted at the beginning of the school year, when children usually show high motivation, while the second data collection (t2) occurred at the end of the school year, when motivation is notably lower compared to the beginning. Therefore, we expect an overall decline in terms of motivation, and children attending the ESA Program should experience less reduction of motivation at t2 compared to those children who did not attend the program, showing a protective effect of the program on motivational decline. Concerning social support, since parents whose children attended ESA Program were also involved in seminars and informative days, we expect a general improvement of perceived social support along the school year.Finally, we will look for gender differences in motivation. In principle, it is expected a lower degree of internal and identified motivation and a higher degree in amotivation and external regulation in females, since sport is generally considered more suitable for men than for women . The sam1) and in May (t2) of the same school year. The study was implemented according to the Helsinki Declaration  and received permission from the Lithuanian Sports University’s Research Ethics Committee in Social Sciences with approval No 579661-EPP-1-2016-2-IT-SPO-SCP (2018-02-05).The sample consisted of 342 schoolchildren  coming from Italy, Germany, and Lithuania . Data weAfter parents’ signature of the consent form, children school classes were split in experimental and control group. Children from both experimental (ESA group) and control group completed two forms detecting sport motivation  and sociThe Youth Behavioral Regulation in Sport Questionnaire (YBRSQ) is an adaptation by Social support was assessed through the adaptation of the Social Support subscale from the Social Provisions Scale  made by ESA Program is a sport program conceived for children from 7 to 14 years, attending the physical education class in schools. The program’s strengths are the standardization of the warm-up phase and its enrichment with cognitive stimuli, attaining the three core executive functions, namely, inhibition, working memory, and task shifting. The implementation of the program lasted 14 weeks, running twice a week, for a total amount of 27 units. All the units lasted 25 min and were divided into a baseline phase and a stimulation phase. For the baseline phase, children were asked to perform an exercise, while in the stimulation phase, children were asked to follow some specific rules. The forecasted exercises were distinguished for cognitive stimulation and movement domain. The cognitive stimulation concerned the alternate enrichment of the activity with cognitive features that could involve inhibitory control, working memory and task switching stimuli. The inhibitory control stimulation consisted of replicating a gesture, previously associated, and after the coach command, in the execution of another movement, before explained by the coach. For example, when the coach said “skip-ahead,” children had to perform the “kick-ahead” movement. The working memory stimulation occurred through the introduction of a series of exercises that children had to replicate in a reverse order. Finally, regarding task shifting stimulation, children created a circle of exercise, each of them performing one exercise. At the coach’s whistle, they had to change the exercise with the one that the kid ahead was performing. In this way, all the children performed one by one all the exercise of the circuit.The movement domain could relate to athletic drills, sport ball and smart circuits. Therefore, the program was articulated as follows: the first nine units were classified as beginner level (B), and alternatively concerned athletic drill, sport ball and smart circuits, alternatively enriched through inhibitory control, working memory and task shifting stimulation. An identical structure was replicated for the Intermediate level (I) and for the advanced level (A). The standardization of the protocol across the European Countries was guaranteed by a video-tutorial uploaded on an Internet platform. The ESA Program was implemented ensuring a safe environment for children.Parents whose children attended the ESA Program were involved in four seminars of 1 h each about the benefits of PA in children. Specifically, during the first seminar, the main objectives of the ESA Program were introduced. Moreover, parents participated in a group discussion about the sport motivation of their children. The second seminar focused on raising awareness about the importance of regular PA in children with a final group discussion on the topic. During the third seminar, parents were informed about the harmful effects of physical inactivity during adulthood and the benefits of PA in terms of cognitive functioning. The fourth and last seminar focused on the identification of parental support mode and support for children’s autonomy.post-hoc analysis with repeated measure ANOVA was performed to detect which aspects of motivation were affected the most. Concerning social support, since family and peers promote PA independently from one another, two distinct repeated measure ANOVA with Group , Time (pre-test vs. post-test condition), and Gender  were conducted to detect the effect of ESA Program on perceived social support and test for gender differences.First, descriptive statistics were calculated on the sample . A repeaW = 0.71, p < 0.001). Therefore, Wilks Lambda (Λ) was chosen as estimator of the test statistics for multivariate effect. First of all, gender did not produce any significant main effect and was hence excluded from subsequent analyses. The model thus became a 2 (intervention vs. control) × 2 (pre-test vs. post-test) × 5  design, with the first factor manipulated between participants. An interaction effect between Time x Motivation was detected  meaning that motivation has changed over time. A significant three-way interaction between Time, Motivation and Group emerged  meaning that the evolution of motivation over time depends on the participation into the ESA program.The repeated measure MANOVA revealed a violation of the sphericity assumption  = 4.15, p = 0.04; d = 0.28; F = 2.77, p = 0.09; d = −0.31), introjected regulation , and amotivation . Intrinsic motivation tends to decrease along the school year but only for children who did not take part in the ESA Program.The repeated measure ANOVA revealed that ESA Program had a protective effect on intrinsic motivation . Specifically, girls perceive less social support in sports activity from family than boys, independently from the participation to the ESA Program. Moreover, an interaction between Gender × Time emerged , and the program effect did not show gender differences .Concerning perceived social support from family, a significant effect of gender was observed , where girls perceive less support from friends than boys. The ESA Program did not produce any significant main effect  nor interactions with time  and gender .Concerning perceived social support from friends, a significant effect of gender emerged [Keeping children’s sport motivation high and supporting them throughout the sport practice can prevent their drop-out from the sport practice in the future. Within this perspective, the current paper aimed at assessing if a school-based sport program enriched by cognitive challenges could improve children’s sport motivation or, at least, limit motivational loss over the school year. From the analyses, we found that ESA Program has a general effect on children’s motivation in both boys and girls, compared to common physical education class. In particular, the program seems to have a protecting effect on children’s intrinsic motivational decline along the school year .Previous research has shown that intrinsic motivation is the main determinant of the engagement in PA over time . It’s laConsidering that parents involved in the program attended four seminars about the importance of supporting children in the practice of PA, we expected an enhancement in perceived social support from family in participants involved in the ESA program. Unexpectedly, ESA Program did not influence children perceived social support from family and friends. Perceived social support from family declined in girls over the school year. The same did not happen for boys who kept perceiving a support from their families all along the year. This result is in line with Social support coming from family is one of the strongest predictors of motivation and children’s future participation in sports . The difIn addition to the enrichment with challenging cognitive tasks, the strength point of this research is the delivery of ESA program in school context. Children spend a large amount of their day hours in school, so this is a perfect context to address all cohorts of students over prolonged periods of time. School revealed to be an increasing setting to implement accessible and effective programs to improve motivation to PA .Although the results of this study are encouraging, certain theoretical and methodological shortcomings must be acknowledged. First of all, we did not control for some variables that might influence the study outcome, such as socioeconomic status or motivational climate. Moreover, we did not control for the perception of self-competence and self-efficacy. The role of these variables on the intention to go on taking part in sport activities and sport programs will be investigated in future research. Finally, Germany did not carry out all the units the program, and spread some leaflet about the importance of sports activity instead of conducting seminars with parents. However, the results are encouraging even if the program was not entirely conducted there.Another relevant condition to control in the future is the relationship between the intensity of PA and the strength of the motivation. From a psycho-educational perspective, practitioners and families must be aware of the key role of PA to promote well-being and to impact on the whole child’s development. It is important that public health organizations address the primary aim to plan and implement evidence-based school programs to encourage sport motivation and the enjoyment in sport and PA practice. The results of the current study could be useful for physical education teachers in structuring classes able to foster children’s sport motivation. Moreover, school teachers should be aware of the gender differences in social support, for avoiding girls’ drop-out during adolescence.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by the Lithuanian Sports University’s Research Ethics Committee in Social Sciences with approval no. 579661-EPP-1-2016-2-IT-SPO-SCP (2018-02-05). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.AG, AB, and MA: conceptualization. AG, AB, and SB: data curation and formal analysis. AB and MA: funding acquisition and project administration. FS, ÖG, SP, YD, DS, MG-L, and IZ: investigation. AB, SB, and MA: methodology. DM, CB, IZ, and OD: resources. FS and DS: software. YD, SP, CB, and ÖG: supervision. MG-L and IZ: validation. AG and MA: visualization. AG, SB, AB, MA, and MG-L: roles/writing – original draft. FS, IZ, SP, YD, DS, CB, and ÖG: writing – review and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study aimed to develop a physical education fitness program for adolescents to counteract the declining physical activity levels caused by the COVID-19 pandemic, as well as to investigate the program’s effect. This mixed-methods study developed and implemented a five-component “Music Beeps” (MB) program to promote adolescents’ physical fitness. A total of 240 students from two high schools in South Korea—divided into experimental and control groups—participated in 32 sessions over 16 weeks. The changes in students’ fitness were analyzed, and the educational effects were examined via inductive analysis of the observation logs and group and in-depth interviews. The results demonstrated that, whereas the comparison group demonstrated no statistically significant changes in power, muscular strength and endurance, or cardiopulmonary endurance, the experimental group showed changes in all these variables, along with changes in flexibility. Further, the MB program had significant educational effects. First, students reported that musical cues enhanced their fitness motivation and sense of responsibility. Second, record-keeping and active participation contributed to self-led fitness management. Third, activity in a small space with few pieces of equipment led to the positive perception that the program was efficient and enabled regular exercise regardless of climate conditions. Improving physical fitness through frequent physical activity and regular exercise is important in adolescence. However, in recent years, adolescents worldwide have mostly been sedentary in school and have been spending most of their leisure time on their cell phones. Further, due to the increased amount of food consumption in addition to reduced physical activity, the obesity rate is on the rise. It was found that adolescents have reduced fitness due to the use of electronic media , and ActThe World Health Organization (WHO) recommends that children and youth aged between 5 and 17 years engage in at least an hour of moderate-to-vigorous-intensity physical activity (MVPA) daily for health benefits . To addrThe “Adolescents’ physique and health status” report from 2000 to 2015 indicates that, while the obesity rate is consistently on the rise, muscle strength, muscle endurance, flexibility, and power are on the decline overall  reportedAlong with reduced fitness, climate change has a diverse impact on school education and has induced various modifications. Physical education (PE) classes are limited because of fine dust, which is an emerging issue in the world; therefore, PE classes need to change due to environmental factors . PE has The need to develop and implement more efficient fitness promotion programs for adolescents through school PE has been raised. The promotion of fitness programs that enable students to easily participate anywhere and anytime is necessary. Further, a program that can boost adolescents’ fitness within the areas available for PE at school needs to be developed and implemented ,9. Most The purpose of this study was to investigate the effect and educational meaning of an MB fitness promotion program and to generalize the results in order to improve health and fitness promotion for students. This study was conducted in South Korea; a “Music Beeps” (MB) fitness promotion program was developed, which involved the use of cues in music tailored to students’ capabilities. The MB fitness promotion program utilizes musical cues to substantiate the potential of a more efficient fitness promotion program and examine its educational significance. This study’s implications will help provide alternative programs to encourage self-directed fitness management in adolescents.We planned and developed the fitness promotion program from September to December 2018 and administered 32 sessions of the program over 16 weeks from March to June 2019. The MB program was run for 20 min during a 50-min class twice a week, which included the time for warmup exercise; the experimental group participated in our MB program, while the comparison group underwent the exercise on its own. In other words, we compared the differences between the group that underwent fitness exercise according to musical cues and the group that underwent existing fitness exercise on its terms and examined the educational significance. The remaining portion of the PE class focused on badminton and volleyball, involving cooperative learning for each school.This is a mixed-methods study, where the effects of the MB program were studied quantitatively, whereas its specific cases and educational significance were studied qualitatively. The use of this method is consistent with the emphasis on the need for qualitative research methodology in studies on adolescents’ health management ,11. SubsThis study was conducted following the principles stated in the Helsinki Declaration for studies with human subjects. Ethical approval from an institutional review board was approved by the Korea Ministry of Education and Korea Ministry of Culture, Sports, and Tourism , and informed consent was obtained from the participants.The participants were purposefully sampled from students in the tenth grade in one public and one national high school. From 240 students, 120 from each school, half  were non-randomly assigned to the experimental group and the rest to the comparison group. For the deep-focus interviews, four students  were selected from the experimental group. For both the deep-focus and group interviews, students who had indicated an interest and actively participated in PE class were selected. The reason for selecting only students who were active in PE was to identify the educational meaning of MB program participation for those who understood the purpose and content of the program well. The Physical Activity Promotion System (PAPS) is a mandatory evaluation performed once a year on all elementary, middle, and high school students in South Korea. Power (50 m run and standing long jump), muscle strength and endurance , flexibility (sitting trunk flexion), and cardiopulmonary endurance (shuttle run) are evaluated. Students are rated from 1 to 5  for each category. The Korea Ministry of Education recommends that each school plans and runs fitness promotion programs for students rated 4 or 5, and all schools run a fitness program based on the PAPS results. In this study, we measured the essential PAPS evaluation items: 50 m run (power), sit-up (muscular strength and endurance), sitting trunk flexion (flexibility), and shuttle run (cardiovascular endurance). We took two PAPS measurements before and after the program on the same day to ensure that the results were not affected by the weather.To examine in-depth the effects on students at each stage of the program described by Metz and Albers (2014), a semi-structured deep-focus interview was conducted . The deeWe performed reliability testing for power, muscular strength and endurance, flexibility, and cardiopulmonary endurance parameters to ensure the reliability of the study. Reliability was tested using Cronbach’s alpha (α), which tests internal consistency; the results demonstrated that the reliability was very high for power (0.999), muscular endurance (0.997), flexibility (0.999), and cardiopulmonary endurance (0.995) in the comparison group and power (0.997), muscular endurance (0.992), flexibility (0.992), and cardiopulmonary endurance (0.991) in the experimental group. Consent was obtained from all participants before beginning the program. To ensure the trustworthiness, validity, and reliability of the study, we utilized member checking, peer debriefing, and triangulation. First, we reviewed whether the validity and meanings were well conveyed through a process in which the participants frequently checked the transcriptions, including the deep-focus interview transcriptions and observation logs. Further, peer debriefing was performed, in which one sports education professor, one sports education researcher (with experience in research pertinent to program development), and two sports education researchers (with experience in running fitness promotion programs) verified whether the data were interpreted correctly and the analyses were pertinent to the study’s aim and questions to ensure the study’s reliability. Finally, triangulation was performed for a consistent and reliable interpretation of the array of collected data. Moreover, we reviewed the analytical processes and study outcomes based on the collected data to determine whether our study was similar to previous studies and whether the validity and reliability of our study had been established.In this study, the MB fitness promotion program was developed by adhering to the instructional design model based on the ADDIE model . This isIn the analysis phase—the first stage for developing a program—factors related to the program were analyzed. This phase involved analyzing the aims, techniques, and tasks of existing fitness promotion programs. We identified the need for a program that is both effective and fun for students as an alternative in response to the low motivation to participate in the existing fitness promotion programs and limited physical activity as a result of climate change. In the learner analysis, we analyzed the physical, cognitive, and affective domains of students; the students’ demands for a fitness promotion program were identified through interviews and a questionnaire. The tasks identified through the need and learner analyses were used to set the composition of the program, including goals, class plans, procedure, and evaluation. They were verified by one sports education professor, three individuals with research in educational programs, and five teachers who had run a fitness promotion program.In the design phase, the specific purpose and goals of the program were set, and the criteria to assess goal achievement and instructional strategies for the program were designed based on the analyses in the previous phase. We designed the program to be fun and efficient using the restricted space and devices based on the learner and task analyses. Further, to ensure student-centered classes, class environments were selected through task posters and activity journals as opposed to teachers’ involvement.In the development phase, the facility, device, and instructional materials for the program were developed according to the established goals. To secure instructional materials, class materials, facility, and the efficiency of the equipment to be utilized in the fitness program, we reviewed data, prepared the class environment, and examined learning experiences. The lesson plans and class model for each session of each program were finalized upon verification of their content validities by cooperating experts. Subsequently, a pilot 4-session program was administered to identify and address problems, based on which the program was finalized. We incorporated cues in music in stages to create a program tailored to the level of the learners and analyzed whether the cue for each stage was appropriate for the fitness of the students through a pilot experiment.Based on the analysis of prior research, students, and students’ needs, we developed the MB fitness promotion program as follows. First, to ensure a student-centered program, the teachers’ roles were reduced to simple guidance, assistance, and encouragement toward the students for an active participation in the program. Second, the latest music and cues appropriate to students’ fitness levels were utilized to maintain participation and rest throughout the program. Third, the teacher presented the task and the students resolved the problem at hand, in which they tried to solve their personal or shared task. Instead of making the teacher guide the students, we designed the program such that students were able to cultivate their problem-solving abilities through various tasks.The MB program developed in this study aimed to increase the fitness of adolescents and we established theoretical evidence for the purpose, contents, method, and evaluation of the program. In the development phase, we developed the contents for each session for the experimental and comparison groups and prepared instructional materials to be applied in each session. The program comprised 32 20-min sessions over 16 weeks (two sessions per week). Each component of the fitness promotion program was designed on the basis of the existing fitness programs verified in previous studies, and the reliability and validity of the program were established by fitness promotion program experts and the pilot test. As existing fitness promotion programs are perceived as uninteresting, we modified the music for the shuttle run and applied it to all programs to engage students and promote active participation. The shuttle run, also known as the 20 m Multi-stage Shuttle Run Test, is utilized to measure cardiopulmonary endurance in many countries . A runne2) at five stations (grade 1 to grade 5). Each session was equipped with minimal equipment, including a Bluetooth speaker (common), training ladder (power), yoga mat (muscular strength and endurance and flexibility), and jump rope (cardiopulmonary endurance). The students recorded their activities in a portfolio format in an activity log placed in the room and obtained feedback. To examine the efficiency of the cues in the music—the core component of the MB program—and its educational meaning, we used exercises that had been previously verified. To emphasize student-centered activity, teachers’ roles were minimized to guide students on the program and ensure safety. The fitness promotion program utilized musical cues for the participants to relieve stress from physical activity; their PAPS ratings were measured before and after the study to verify their improvement. To generalize the developed music and identify the amount of exercise from the name of the music file, the files were named according to the standard illustrated in Based on the pre-study survey, we developed a five-stage program that corresponds to PAPS grades 1 to 5 with music files modified using Sound forge 8.0  and Corel VideoStudio X3 . A total of 20 music files were used for the MB program. They were applied from stage 1; with the advancement to the next stage, its effectiveness was verified, and the level of improvement was examined via PAPS. The exercise program comprised power-muscular strength and endurance–flexibility–cardiopulmonary endurance components in order, with five minutes in each component in an indoor space . Changes in the mean pre- and post-test scores within each group were analyzed using the paired sample In this study, the educational significance of the MB program was explored via an inductive analysis of the data, involving transcription, coding, and categorization of expert discussions, observational logs, deep-focus interviews, and group interviews. First, we transcribed all collected data; then, while repeatedly reading and interpreting the transcriptions, we coded the data by their themes and recurring contents as related to the study question, conceptualizing the messages and meanings in the text.We divided the students into the experimental and comparison groups. We checked the experimental group’s power, muscular strength and endurance, flexibility, and cardiopulmonary endurance before the MB program (pre-test) and after the MB program (post-test) and analyzed whether they had statistically significant changes. The comparison group autonomously performed exercises for each component of the MB program, and their average changes were analyzed on the basis of pre- and post-test measurements. The results are illustrated in PAPS is a national evaluation system of student health and fitness that scores strength, muscular endurance, flexibility, cardiorespiratory endurance, and power. There was no statistically significant difference between the groups in the pre-tests for the dependent variables. In the comparison group, there were no statistically significant changes in power, muscular strength, or endurance and cardiopulmonary endurance, but there was a statistically significant change in flexibility. In the experimental group, there were significant changes in power at a 99% confidence level, with 9.041 in the pre-test and 8.886 in the post-test. There was also a statistically significant increase of mean muscular strength and endurance from 41.016 in the pre-test to 45.550 in the post-test. Further, there was a statistically significant increase in mean flexibility, from 8.764 in the pre-test to 9.595 in the post-test. Finally, there was a statistically significant increase in mean cardiopulmonary endurance, from 41.800 in the pre-test to 45.250 in the post-test.This study utilized fitness programs that have been validated in previous studies and added a modified version of the Shuttle Run music and cues to each program. Whereas existing fitness programs have involved the monotonous repetition of exercise or exercise while listening to music, musical cues used in the MB program prompt students to complete the given tasks with a sense of responsibility. Music enhanced the students’ interest and motivation and the beeper influenced them to be responsible for their fitness level.This fitness program was really helpful for me to exercise consistently because the cues in the music like the ones in the Shuttle Run signal me to do the target exercise and to rest.(Deep-focus interview with student B)It was definitely different from other fitness programs, where I exercised while listening to music. I think having to achieve the goal on cue gave me a sense of responsibility and set a clear goal to improve my fitness.(Deep-focus interview with student C)Students participated in programs for grades 1–5 in each fitness component station. The goals for each grade, set depending on the level of improvement, gave students a sense of responsibility and motivation, which, in turn, served as an important factor that boosted students’ physical fitness.Throughout the study, the students who participated in the MB program attempted to foster an ability to manage their health. Setting specific goals and keeping a record of their progress throughout the MB program provided them with a sense of responsibility and helped them practice self-led health management. This was one of the factors that actively engaged the students in the program. Setting goals according to the cues and keeping specific records to advance to the next stage allowed them to record their progress and difficulties, based on the feedback provided. Thus, the students could participate in the class and MB program more enthusiastically. The students could verify their fitness grades, and while continuously participating in the program, they learned about their level of fitness and improvement and attempted to achieve the goals they had set.I’m not very physically fit, and keeping a health practice report during this program gave me an opportunity to look at myself and learn the values of health. I became confident as I watched my records improve slowly.(Deep-focus interview with student A)I think adjusting the health learning goals that my teacher set for me to a level I can handle helped me a lot.(Deep-focus interview with student B)I really put myself into the program to achieve the fitness goals even without my teachers’ pushing me, and I think I developed good workout habits.During the MB fitness promotion program, students developed an interest, as opposed to fear, in participating in an exercise to improve their health and actively participated in the program, without being bored, to achieve the shared goal of improving their fitness. As they experienced a new level of fitness and body images through various fitness promotion programs, they developed confidence, which, in turn, had a positive impact on their participation in other classes as well.2 with only limited and simple equipment. In each station, we placed a Bluetooth speaker (common), training ladder (power), yoga mat (muscular strength and endurance and flexibility), and jump rope (cardiopulmonary endurance). The participants also perceived the efficiency of a small space that was not influenced by climate conditions and the use of only a few pieces of equipment as an advantage of the program:During our study period from March to June, fine dust, yellow dust, and heatwaves hit South Korea, and consequently normal schools had restricted PE classes. To overcome these climate conditions, we designed our program to utilize a small indoor space of about 100 mLast year, fine dust concentrations were high every day, so when we had combined classes with other classes in the auditorium, we were only able to do some simple warmups and couldn’t even play a single game. I had a hard time not being able to relieve stress because of the restricted PE classes, but I loved the idea of exercising efficiently in a small space with little time we have.(Deep-focus interview with student A)During the last year’s fitness program, we didn’t have enough squat equipment, and we had to move around all the time, so it was difficult to participate. But this time, no large equipment was involved, so it wasn’t hard preparing, and I was able to enjoy participating in the program.(Deep-focus interview with student C)This program, which is not restricted by climate conditions or facilities, prompted students to participate in the MB program regularly, and with continuous participation, the students were able to see an improvement in their fitness.This study aimed to develop and implement a program to promote the physical fitness of adolescents through school PE classes to overcome the fact that adolescents are becoming less physically fit due to reduced physical activity worldwide. To this end, we utilized validated fitness programs to design an MB program that involved musical cues and compared them with self-directed fitness exercise. Ultimately, we attempted to verify the feasibility of an efficient fitness promotion program and examine its educational meaning.The results demonstrated that the comparison group only showed statistically significant improvements in flexibility, whereas no significant changes were identified in power, muscular strength and endurance, or cardiopulmonary endurance. Conversely, the experimental group demonstrated statistically significant changes in power, muscular strength and endurance, flexibility, and cardiopulmonary endurance. In other words, the MB program improved power, muscular strength and endurance, flexibility, and cardiopulmonary endurance compared to existing fitness programs. This demonstrates the limitations of a fitness promotion program that relies on students’ autonomy. A teacher’s support has a great effect on a student’s psychological satisfaction and motivation and the music and beeps provided by the teacher to the students in this study were the results of students’ autonomous participation and responsibility . As anotAs previous research revealed, the most important factor in fitness promotion to students is the utilization of a specific motivation strategy, this MB program differentiates itself from existing student fitness-related studies by being based on student autonomy and responsibility, which helped motivate students to participate in exercise . The MB First, in this study, we have demonstrated the value of a program that can motivate students. Although the music and cues employed in this study were used only in fitness promotion programs, our findings suggest the possibility of applying them in a variety of other circumstances, such as regular PE classes or sports training. Utilizing music and cues in regular PE classes would motivate students and give them a sense of responsibility during class. This is because things that can motivate students within the limited time of the PE class help them become more deeply engaged in class and invest more effort.Second, applications and programs that allow easy editing of music and cues for fitness promotion need to be developed. To ensure the efficiency of our program, support is required to help teachers manage music and cues more conveniently and utilize them in various educational environments.Third, in this study, we separated the power, muscular strength and endurance, flexibility, and cardiopulmonary endurance stations. Examining the implementation of a mixed workout for circuit training would contribute to diversifying fitness promotion programs.Fourth, this study was limited to general high school students in South Korea; thus, geographic location, environment, and socio-economic status of students’ families were not considered. It is expected that the MB program in this study will be applied in demographic experiments in other countries to add diversity.