As the overdose epidemic continues to worsen, nonfatal overdose calls for service represent a critical touchpoint for intervention. While most studies have focused on law enforcement led post-overdose follow-up, the current study describes the programmatic characteristics and outcomes of a non-law enforcement post overdose program comprised of peer specialists embedded within a local police department.We examined information on 341 follow-up responses occurring over a 16-month study period using administrative data. We assessed programmatic characteristics including demographic information on clients, referral source, engagement type, and goal completion.The results indicate that over 60% of client referrals ended in the goal of in-person contact. Of those, about 80% went on to complete an engagement goal with the peer specialist. We found no significant variation in client demographics and referral source or follow-up engagement (in-person or not); however, client referrals from law enforcement first responders, the most common source, are significantly less likely to result in an in-person contact, though, if contact is made, similarly likely to complete an engagement goal.Post overdose response programs that do not involve law enforcement are exceedingly rare. Given that some research has shown that police involvement in post overdose response can have unexpected, associated harms, it is important to assess the effectiveness of post overdose programs that do not involve the police. Findings here suggest that this type of program is successful at locating and engaging community members into recovery support services who have experienced an overdose. In the From a public health perspective, nonfatal overdose represents a critical touchpoint for intervention  to reducNational prevalence of post-overdose follow-up efforts suggests most programs include law enforcement during the follow-up, most often with EMS . ResearcIn this short report we describe such a program that is facilitated by peer recovery specialists. Importantly, the team is diverse in terms of substance use background , recovery experience, and race-ethnicity such that they are representative of the community they serve. We describe the characteristics of this program in detail and provide evidence of feasibility by exploring client characteristics and service engagement efforts to begin developing an evidence-base around post-overdose response efforts that address concerns expressed among those with lived nonfatal overdose experiences.1.1In February 2019, The Lake Superior Diversion and Substance Use Response Team (SURT) started working directly with clients following non-fatal overdose. The team is embedded within the Duluth Police Department which employs approximately 150 sworn officers. Duluth is in St. Louis County, Minnesota with a population of 86,700 in the city limits and 290,000 in the metro area which includes Superior, Wisconsin (Douglas County). While the overdose rates in Minnesota are generally lower than other US states, the overdose rates in St. Louis County are consistently higher than the state average and have closely mirrored the national trends, increasing dramatically over the past two decades over multiple waves shifting from prescription opioids, to heroin, and finally to illicitly manufactured fentanyl.The SURT consists of four peer recovery specialists and a licensed social worker (LSW) with alcohol and drug counseling certification, all of whom have physical workspace within the police department and are employed as civilian staff. The LSW is supervised by a contracted Licensed Independent Clinical Social Worker from the local drug and alcohol treatment center and three of peers are supervised are supervised by the SURT project manager, who is also a certified peer specialist, and who reports to law enforcement personnel. They coordinate regularly with an incident analyst , whose role is to identify overdose follow-up opportunities in the community. The incident analyst maintains a database with information from overdose calls for service where police were present. Peer specialists use this database to facilitate outreach through phone, social media , and in-person follow-up to either the individuals home address (if known) or the address where the overdose event occurred. As the SURT became established, peer specialists also cultivated direct law enforcement referrals , as well as referrals from community members and agencies. Regardless of referral source, SURT maintains a secured database, unavailable to others in the agency, that confidentially tracks client contact information.N = 341) to look at the rate and duration of follow-up. Records management also includes a measure of contact hours which includes efforts to contact the person and follow-up peer support which encompass time spent identifying available treatment and waiting at appointments. All data were collected as part of routine practice and deidentified for analysis as part of a program evaluation and non-human participant research. Variables were coded from administrative data with descriptive and bivariate analysis (Chi-square and t-tests) conducted in SPSS .In this short report, we are unable to assess program effectiveness but instead examine SURT administrative records to provide evidence of feasibility by exploring client characteristics and service engagement efforts. While the program peers have been working directly with clients since 2019, the present study focuses on data from 341 cases over 16-months  that were collected once a SURT records management system was established. Importantly, we were not able to access information on all overdose calls for service in the area during this period so we cannot establish a rate of overall referral but instead use all cases identified by the incident analyst and provide to the SURT peers as our denominator  were male, and the average age was 35.9 years. More than one-quarter were Indigenous or American Native persons (26.7%) and more than two-thirds were white (68.1%). Referrals came from a variety of sources with the most (43.7%) from law enforcement first responders, 24.9% from other criminal-legal agencies including courts and community supervision; and 16.1% through self-referral .Table 1Cχ2 = 55.9, Cramer's V = 0.405, p<.001) though, if contact was made, are statistically similar in likelihood to complete an engagement goal than those from other referral sources .In-person contact is the goal of the follow-up, and was accomplished with 60.7% of referrals , of which 80.2% went on to complete an engagement goal with the peer specialist. There was an average of 2 engagement goals per client, which resulted from an average of 4.6 contact hours (SD=6.9), with assessments (34.8%) as the most common goal followed by treatment engagement (28.6%) and entry into a detox facility (19.0%) . There w3In this short report we described and examined administrative records from a novel and innovative post-overdose follow-up response program led by peer recovery specialists who are embedded with the local city police department. Given that all of the published research to-date has focused on law enforcement led post-overdose follow-up, we present our findings as evidence of an alternative approach communities might consider. Peer recovery specialists are a paraprofessional workforce with an emerging evidence-base on the positive effects of incorporating these persons of lived experience as part of the recovery support process, particularly among those who are navigating criminal-legal systems involvement but also in overdose response efforts .While there are documented barriers to hiring peer specialists, specifically because of prior involvement in criminal-legal systems, the SURT sees this experience as an advantage as it gives peer staff shared experience with the people they serve. Given that more than one-quarter of clients were American Indian/Alaskan Native, this same philosophy guided SURT in bringing on a Native American male to focus on identifying effective means of engagement within this shared cultural context. The SURT peer specialists have autonomy over their work and leverage their embeddedness in a criminal-legal system to build trust by helping clients to address outstanding warrants and avoid arrest, sometimes by engaging directly with community supervision and agents of the court, to mitigate negative legal consequences. Moreover, with employment as civilian staff within the police department, the peer specialists are provided a more competitive salary, along with benefits that come from being a city employee , which can assist with recruiting diverse applicants, job retention, and long-term program sustainability.The SURT peer specialists recognize the stages of behavior change  and much4At a time when communities are questioning the role of police in the overdose epidemic, it is important to note that unannounced follow-up from law enforcement might be exacerbating overdose-related harms. Even well-intentioned officers might induce fear and trauma among overdose survivors and their family. Yet, nonfatal overdose does provide a critical opportunity to link people with health systems and social supports. The model described in this report is not driven by a law enforcement agency, but is facilitated through it, and run by persons with lived experience in recovery. The findings here suggest that this post-overdose response program is successful at locating and engaging community members who have had an overdose into recovery support services.Bradley Ray, Jessica McCarthy-Nickila, Nicholas Richardson, and Jeffrey Maahs. BR conceived of manuscript and wrote initial draft and incorporated feedback from JMN, NR, and JM. JM developed program data collection, JMN oversaw program and reviewed for accuracy of description, NR assisted with analysis and literature review. All authors contributed to the final written manuscript.10.13039/100005196Bureau of Justice Assistance’s Comprehensive Opioid, Stimulant, and Substance Abuse Program (2019-AR-BX-K053). They did not have any role in study design, data collection, analysis and interpretation of data, the writing of the report, or the decision to submit the article for publication.This work was supported by the No authors have any conflicts to declare but note that McCarthy-Nickila (co-author) was employed by the Duluth Police Department and oversaw program activities during the reported study period.


The purpose of the study was to investigate factors that influence vocational rehabilitation program enrollment and employment at discharge of veterans with psychiatric and co-occurring alcohol and other substance use disorders enrolled at a veteran health administration (VHA) medical center.A sample of 2,550 veteran patients referred for VHA vocational rehabilitation between 2016 and 2021 were examined for the current study. The current study was classified as quality improvement/assurance, thus resulting in exempt research by the U.S. Department of Veteran Affairs Institutional Review Board.Veterans with active alcohol use disorders (AUDs) and co-occurring depression, anxiety, post-traumatic stress disorder, or bipolar disorders were less likely to be enrolled for vocational rehabilitation program services compared to those without these co-occurring diagnoses. Veterans with AUD (active & in-remission status combined into one category) and a diagnosis of anxiety were less likely to be employed at discharge compared to veterans with AUDs and no anxiety diagnosis (anxiety diagnosis – 3.5% vs. no anxiety diagnosis – 5.8%).VHA vocational rehabilitation can be an effective intervention to assist veterans in reintegrating back into the community. Yet, there appears to be some disparities in the program enrollment and employment at discharge, depending on the nature of the psychiatric diagnosis. Investigating the factors contributing (mediating or moderating) to these discrepancies are needed. Although it appears access is not the issue in being referred for vocational rehabilitation services, other factors are likely contributing to program entry. The trajectory of substance use disorders (SUDs) is expected to rise in the United States (U.S.), and recent research examining 30 geographically-representative VA healthcare systems  demonstrated alcohol as the most commonly reported substance , followed by cannabis   veterans with serious mental illness or medical conditions ; and (2) veterans with significant employment issues as it relates to SUDs  are eligible for the SE program. Veterans enrolled in TW participate with work restoration services in actual work settings. The goal is to provide vocational supports and resources needed for successful transition to competitive employment. TW is for veterans that do not have a serious mental illness or medical condition as aforementioned but have significant employment related impairments. The Community Based Employment Services (CBES) program is optional for each VHA VR program, and accessible when made readily available. Veterans with mental health conditions or physical disabilities who have a history of sporadic employment, difficulty maintaining a job, or initiating and following through on their job search, or who require a range of supports to obtain or maintain competitive work, are eligible. However, veterans enrolled in these programs do not have the diagnoses as required to be eligible for SE, and have the knowledge, skills, and abilities to engage in competitive employment without the need of work restoration services (TW).VR is a crucial component of the comprehensive care provided to veterans with and without disabilities, and eligibility for VHA VR includes (a) medically cleared to work and participate in the program, and (b) goal of obtaining competitive employment . The effIn addition to improving employment outcomes, VR can also enhance the mental health and well-being of veterans. By providing a sense of purpose and accomplishment, employment can help veterans to rebuild their self-esteem and self-confidence, and to reduce symptoms of depression and anxiety. Furthermore, vocational rehabilitation can help veterans to develop social connections and establish a sense of belonging within their communities. As reflected upon by the U.S. , employmThe negative association between employment and psychiatric conditions and SUDs is well-documented, and research has shown that employment participation decreases as the symptoms of the conditions increase as psychiatric and SUD conditions can serve as a significant barrier. For example, after examining nearly 100,000 veterans, Zivin et al.  found thNational databases connected with VHA VR have been examined to evaluate its efficacy in employment and healthcare outcomes, and research findings have shown improvement in employment obtainment and retention  and loweDespite the evidence showing how psychiatric and SUD/AUD diagnoses can impact a veteran’s independent functioning and psychological well-being, the purpose of this study was to focus on the impact of having these diagnoses as they co-occur in terms of how it effects VHA vocational rehabilitation program enrollment and employment at discharge. Studies have shown that employment at discharge decreases when a veteran presents a SUD/AUD diagnosis or a mental health condition , 19, butThe Institutional Review Board (IRB) for the U.S. Department of Veteran Affairs indicated that this was a retrospective and quality assurance study, and therefore no approval (exempt) was needed if no identifying information was released for publication. The co-author’s university granted additional IRB endorsement  as exempt status to verify that institutional support was provided for the current study. The current study included data from a VHA VR program located within VISN-12 and accounted for veterans referred for services between 2016 and 2020. All veteran information was recorded by VR counselors in an access database that was used for programmatic evaluation . It is possible that this data were entered incorrectly (data input errors), and to verify the data’s accuracy, the primary author used the U.S. Department of Veteran Affairs’ Computerized Patient Record System (CPRS) and Joint Legacy Viewer (JLV) – includes data from medical care at other VA medical facilities across the country if applicable, and a search through CPRS progress notes and consults. The database used during the intake interview did not account for the durational period of last SUD/AUD usage  nor psychiatric diagnoses per the DSM 5 TR. Therefore, information was collected from CPRS and JLV to properly code the diagnoses . Lab testing was used to verify last usage per the urine drug screening criteria.The DSM 5-TR classifies SUD into three categories  to provide details on the severity of the disorder . ResearcAll veterans that had received a consult for VHA vocational rehabilitation were included in the data analysis. Oftentimes, veterans are not enrolled for services for several reasons such as (1) job obtainment prior to program start, (2) no longer wishing to work competitively, (3) having medical issues arise resulting in a cancellation until medical complications are no longer problematic, or (4) no longer interested in receiving services and seeking competitive employment. All veterans in the database were coded as 0 = not enrolled and 1 = enrolled. For veterans enrolled in the program and discharged, the coding was dichotomized: 0 = discharged without employment, 1 = discharged with employment. The outcome variables of VHA vocational rehabilitation program enrollment and employment at discharge, were evaluated by using a binary logistic regression analysis. In addition, the interaction between SUD and psychiatric disorder was utilized to examine the impact for veterans with both diagnoses on program enrollment and employment at discharge.n = 1,740, 87.92%), and had a mean age of 55.24 years (SD 13.16 years). Most of the participants had a high school diploma , and were Black or African American , followed by white non-Hispanic , Hispanic or Latino , and Asian or Other Pacific Islander . When considering the presence of clinical diagnosis, Major Depressive Disorder   and PTSD [F43.10]  had the highest frequencies, followed by Generalized Anxiety Disorder [F41.1] , and adjustment disorder [F43.20] . A total of 607 (27.96%) veterans reported that they were on the supplemental nutrition assistance program (SNAP), while 63 veterans (2.54%) were noted as being enrolled in the homeless program and were classified as homeless at program consult. The sample consisted of 2,550 veteran patients referred to VHA VR between 2016 and 2021. Of these, the majority of the sample were biologically male , AUDs , psychiatric diagnoses , and the co-occurrence of these diagnoses. As shown in p = 0.0031), anxiety , PTSD , and bipolar disorder  were less likely to be enrolled for program services compared to veterans without these diagnoses. Veterans with adjustment disorder  were more likely to be enrolled for program services.The alcohol and other substance use disorders diagnosis was split into active and inactive (in remission) to examine the influence  on program enrollment for veterans who additionally have co-occurring psychiatric diagnoses. A chi-square test was performed see  and findp = 0.0021) to be enrolled for program services compared to veterans without AUD. When including the interaction terms in the regression model (see p < 0.0001), anxiety (p = 0.0006), PTSD (p = 0.0011), and bipolar disorder (p = 0.0002). Specifically, active AUD veterans with depression , anxiety , PTSD , and bipolar disorder  were less likely to be enrolled for program services than those without these diagnoses.A logistic regression analysis see  comparinodel see , it was p = 0.4441). The same findings occurred when comparing veterans with (31.2%) and without (31.9%) an AUD diagnosis and employment rates at discharge. When only examining psychiatric diagnoses, veterans without an adjustment disorder had higher rates of employment at discharge, but no other psychiatric diagnosis comparisons yielded significant differences. The interaction between psychiatric diagnosis and SUD or AUD yielded significant findings for employment rates at discharge for veterans diagnosed with bipolar disorder and SUDs, where the SUD category was categorized into no diagnosis, SUD diagnosis. When examining veterans with and without AUD and psychiatric diagnosis, veterans with anxiety and AUD  had significant differences. SUD and AUD diagnosis were then split into three levels, including no diagnosis, active diagnosis, and in-remission diagnosis. A logistic regression analysis comparing the outcome variable of employment  demonstrated veterans with bipolar disorder were more likely  to be employed at discharge compared to veterans without this disorder . Research must (1) identify reasons why Veteran do not enroll in VHA VR after a referral is made, (2) impact of program engagement on VHA VR enrollment, and (3) the efficacy of providing concurrent vocational rehabilitation services while a Veteran is enrolled in mental health and/or substance use counseling services, rather than having a focus placed on vocational needs toward the end of their treatment regimen . State-federal (public) VR programs that are designed for civilians have shown higher SUD and or MH treatment compliance when employment is obtained, higher abstinence rates, and more successful vocational outcomes when treatment is concurrent , 33. EmpAs evident by prior research, employment improves self-esteem, recovery, less reliance on medical and psychiatric services, and lesser symptom impact for people with mental illness , 25. LikReasonable accommodations are any changes to the workplace, job functions, or to the procedures surrounding the job that make it possible for the person with a disability to perform the essential functions of the job. It is important to note that the accommodation is meant to limit or eliminate the impact of the disability so that workers can perform their jobs. A few examples include changing the location of task-related supplies, modifying a work schedule: acquiring new equipment, or granting access to a private space for breaks. Reasonable accommodations are integral to promote the effectiveness of VR programs and have an impact on independent functioning, job satisfaction and retention, and quality of life indicators –39.The Job Accommodation Network (JAN) provides a public resource for information about accommodations designed to support workers with disabilities and employers. Requests for accommodation ideas for individuals with mental health diagnoses are available. Some of the most common are flexible schedules, if there is required training this training may need to me modified, and a job coach . FurtherThere is significant psychological stress placed on an individual with severe mental illness and/or SUDs. Literature has found that it is hard for those diagnosed with MH disorders to request support or reasonable accommodations due to fear of retaliation and stigma –44. ThisThe current study had initial limitations that were addressed prior to analyzing the data. First, much of the data that were used in the current study was entered by VR counselors during the intake interview with the veteran. It is possible that this data were entered incorrectly into the database by VR counselors, therefore medical records in CPRS and JLV were used by the primary author to confirm that information was inputted correctly (the primary author made corrections if VR counselors inaccurately entered the information into the database – CPRS and JLV were deemed as more accurate than the database). However, it is still possible that data entry errors occurred, as information is manually inputted in CPRS and JLV systems. Another study limitation of the dataset was inaccuracy related to psychiatric diagnosis and past and current alcohol use and other substance use disorder. The database used during the intake interview did not account for the durational period of last SUD/AUD usage  nor psychiatric diagnoses per the DSM 5 TR (F-Code). Therefore, information was collected from CPRS and JLV to properly code the diagnoses . To account for stronger representation of access, enrollment, and efficacy of vocational rehabilitation services, a national study should be used to determine if the themes from the current study exist across the U.S.Prior research on VHA VR programs have primarily focused on outcomes. Current study findings have showed some disparities in program enrollment and employment at discharge when a veteran has a psychiatric diagnosis. With much focus of the VA related to access and outcomes, there is an apparent need for more research focus on how to increase program enrollment into VHA VR programs .https://www.research.va.gov/programs/orppe/vacentralirb/default.cfm.The data analyzed in this study is subject to the following licenses/restrictions: The U.S. Department of Veteran Affairs has strict guidelines on the release of Protected Health Information. Due to the policies governing the release or availability of data, we are unable to release the data associated with the current manuscript. Requests to access these datasets should be directed to Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants was not required to participate in this study in accordance with the national legislation and the institutional requirements.MS, FB, and HH contributed to the conception and design of the study. MS organized the database. MS completed the data analysis with the assistance of Y-SL. MS and Y-SL interpreted all data. HH, LR, FB, ZS, and AG wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.


Demographic and pre- and post-test evaluation data were collected. The training’s acceptability was measured after each module. Bivariate analysis was conducted using Wilcoxon signed-rank test to compare the CCPs’ competencies before and after the delivery of the STOP Program. Effect sizes were computed over time to assess the sustainability of the acquired competencies. Twenty-nine CCPs in Colombia and 24 CCPs in Peru completed the STOP Program . In both countries, 98.2% of the CCPs reported that the overall structure and organization of the program provided an excellent learning experience. The pre-post-test evaluations indicated that the CCPs significantly improved their knowledge, attitude, self-efficacy, and practices toward smoking, smoking prevention, and cessation services. We found that the CCPs’ self-efficacy and practices increased over time . The STOP Program was effective and well-received, demonstrating remarkable changes in CCPs’ competencies in providing smoking prevention and cessation services to cancer patients.We designed and tested the feasibility of the Smoking Cessation Training Program for Oncology Practice (STOP), a hybrid (face-to-face plus web-based) educational intervention to enhance Spanish-speaking cancer care professionals’ (CCPs’) ability to provide brief smoking prevention and cessation counseling to cancer patients and survivors. Changes in the CCPs’ competencies  were assessed post-training. Sixty CCPs from one major cancer center in Colombia ( Smoking prevention and cessation are one of the most effective ways to prevent cancer and is also essential after a cancer diagnosis to improve treatment outcomes . ContinuThe use of information technologies to deliver online educational programs and the widespread use of mobile health technology  are allowing for innovative ways to improve healthcare delivery . Few smoSmoking cessation can improve the overall health and quality of life of cancer patients, as well as reduce the risk of dying from cancer . Thus, pTherefore, in partnership with two major LA cancer centers located in Colombia and Peru, we developed, implemented, and evaluated STOP (Smoking Cessation Training for Oncology Practice) Program, a smoking prevention and cessation hybrid training program specifically designed for Spanish-speaking CCPs to safely and effectively provide brief smoking prevention and cessation counseling to cancer patients and survivors. In addition, we assessed the difference in the competencies  among the CCPs before and after their participation in the training program.In 2018, our team partnered with the National Cancer Institute (INC) in Colombia and the National Institute of Neoplastic Diseases (INEN) in Peru, two of the leading cancer centers in LA, to design, implement, and deliver the STOP Program.A convenience sample of sixty targeted CCPs (30 in each country) was invited to participate in the program. The inclusion criteria were (1) CCP working at one of the above centers; (2) ≥ 18 years old; (3) had direct contact with cancer patients; and (4) proficiency/access to internet with a computer, tablet, or smartphone.INC in Colombia (Cod INC-STOP Protocol/EX- 00812), the University of Texas MD Anderson Cancer Center Houston (Protocol No. PA17-0878), and the University of Texas Health Science Center Houston (Protocol No. HSC-SPH-20–1339) approved the protocol for the program. Protocol approval was not needed from the INEN in Peru as this was an educational program. Informed consent was obtained from all participating CCPs.The STOP Program, a hybrid (face-to-face plus web-based) training focused on different aspects of smoking prevention and cessation, was culturally and linguistically developed for LA oncology settings. The program consisted of 4 educational modules delivered within a month. Each module lasted 1 h, and after its delivery, STOP trainees were invited to complete a post-module evaluation to assess the module-content acceptability.Module I: historical overview and epidemiology of tobacco use in LAModule II: cancer and other chronic conditions associated with smokingModule III: behavioral-based smoking prevention and cessation interventionsModule IV: cessation medications and therapiesThe modules were as follows:Modules I, III, and IV were presented online, while Module II was in person. Once the 4-module course was delivered, trainees were invited to participate in 6 video conferencing sessions (one per month) where their experiences and challenges in providing smoking cessation services to their patients were discussed.T0 = baseline (before the hybrid course)T1 = 1 month (immediately after the hybrid course)T3 = 3 months (mid-point assessment of STOP training program)T6 = 6 months The STOP Program was delivered between April and October 2018 in Peru and January and July 2019 in Colombia. A pre-post-design was used to evaluate the STOP Program. There were four online assessments delivered at the following time points:The domains and questions included in the online assessments were adapted from the International Association for the Study of Lung Cancer Survey and the National Health Interview Survey , 12. REDThe retention rate was used as a key parameter for assessing the feasibility of the STOP Program. The retention rate at each training site was the proportion of recruited CCPs who remained in the training program and completed the 6-month assessment (T6). Descriptive statistics were used to characterize the sociodemographic information collected at T0. The responses to the acceptability questions were dichotomized, with proportions computed for each educational module.Gains in participants’ competencies in providing smoking prevention and cessation services to cancer patients were assessed by comparing responses to selected domain questions at each of the 4 assessment times. Each correct knowledge question response was assigned a score of 1; the incorrect answer was assigned 0. Attitude, self-efficacy, and practice domains had questions with responses on a 5-point Likert scale. Possible score ranges were 0–16 (knowledge), 6–30 (attitude and practice), and 7–35 (self-efficacy). The Wilcoxon signed-rank test was used to compare the scores obtained in the pre-test and post-test of the training program. Effect sizes were computed between the post-test  and baseline (T0) scores to assess the sustainability of the acquired competencies. Data analysis was conducted with STATA 17.0/SE.In Colombia, the post-test retention rate was 96.7%, whereas in Peru, it was 80.0%. The overall retention rate was 88.3%.The average age of the CCPs was 36 (± 8.5) years. There were 54 female CCPs and 6 male CCPs. All Peruvian CCPs were oncology nurses, while all except two of the Colombian CCPs were nurses. About 40% of the CCPs were specialists or had a master’s or doctorate degree. None of the CCPs were current smokers. However, 8.3% were former smokers. Most CCPs (83.3%) devoted more than 50% of their clinical time to patient care Table .Table 1SMost CCPs (> 98%) said that each module’s content was pertinent and informative. More than 96% of respondents said they would implement the modules’ teachings into their practice. More than 88% of the CCPs found the earlier readings, additional material, discussions, and group activities to be of immense help. The time allotted for the presentation, questions, responses, discussions, and group activities was deemed adequate by more than 90% of the CCPs. More than 98.2% of the CCPs concluded that the program’s overall organization provided an excellent learning experience.p = 0.0001), positive attitude toward smoking cessation (p = 0.0008), increased perceived self-efficacy to offer smoking prevention and cessation services to cancer patients (p < 0.0001), and engagement in smoking prevention and cessation practices for their patients compared to T0 . These outstanding rates set it apart from other training programs , 18. AltThe STOP Program is culturally appropriate to LA, a region that values some form of face-to-face interaction despite the tremendous growth of online communication. The training was also culturally adapted because the educational contents were LA-specific and country-specific. We believe this hybrid training program could be more cost-effective and advantageous than in-person or online training only. The STOP Program can offer a convenient alternative to receiving training on smoking prevention and cessation with little disruption to CCPs’ hectic clinical schedules providing care to cancer patients. In the program, more than 98% of the CCPs acknowledged and commended the training program’s overall organization as an excellent learning platform and said they would suggest the training to their other cancer provider colleagues. This further reinforces the high feasibility of the STOP Program’ success among CCPs in LA countries. The format and content of the program were highly accepted by the participating CCPs.The STOP Program was conceived and designed with the idea of increasing the engagement of the CCPs in prevention and cessation counseling for cancer patients. In addition to the module’s content and strategically selecting the speakers, there were post-training touch-base sessions to discuss the CCPs’ challenges and experiences while applying the knowledge they acquired to their daily clinical activities. These monthly touch-base sessions after T1 allowed for a two-way learning process in which participants shared with the rest of the cohort trainees their challenges in providing smoking prevention and cessation services and attempted to develop solutions. Other training programs in the region did not have such follow-up sessions with the participants after receiving the educational content, missing an opportunity to know the challenges the professionals encountered when attempting to apply the acquired knowledge to their clinical work.Our findings demonstrated that the STOP Program significantly improved the competencies of the participating CCPs in terms of knowledge, attitude, self-efficacy, and practices. Like the brief smoking prevention and cessation training effort among HCPs in Malta , the STOThere were some limitations to this training effort. To begin, the STOP Program was tested among a small sample of CCPs from only two LA countries, undermining the generalizability of our findings for the LA region. Second, the evaluation of the program was self-reported, which could have prompted response bias. Although all the online sessions went seamlessly, the internet services in Colombia and Peru constituted some technical difficulties in connecting and having all the equipment ready for the online meetings. Lastly, a third cohort of the STOP Program was planned in Brazil. However, due to the COVID-19 epidemic, the training was not fully implemented.Despite these limitations, the STOP training program is one of the first educational efforts to be developed and evaluated among CCPs in the LA region, with results demonstrating high feasibility and remarkable change in the CCPs’ competencies in providing smoking prevention and cessation services to cancer patients.The STOP Program was both effective and well-received. Its implementation showed sustained beneficial effects among CCPS in the oncology environment beyond the simple acquisition of tobacco use and nicotine addiction knowledge, with significant competency increase in providing smoking prevention and cessation services to cancer patients. Although preliminary, these results provide a justification for continued development and evaluation of this hybrid training program in other LA oncology settings.


The changes to the standardized letter of evaluation (SLOE) in emergency medicine (EM) for the 2022–2023 academic year have concerning implications for our students.The standardized letter of recommendation (SLOR) has been used in EM since it was developed by a CORD task force in 1995.The final “global assessment” section of the previous SLOE included two questions that were particularly meaningful for SLOE reviewers. Question 1 read, “Compared to other EM residency candidates you have recommended in the last academic year, this candidate is in the:” with the writer to select top 10%, top 1/3, middle 1/3, or lower 1/3. Question 2b read, “How highly would you estimate the candidate will reside on your rank list?” with the same response options as above. Question 1  allowed for a more objective assessment of a student's performance, while the response to Question 2b (hereinafter referred to as “subjective program ranking”) has the potential to be influenced by a student's specific fit with a residency program's values, culture, or mission.For the 2022–2023 academic year, the SLOE has undergone revisions that warrant serious consideration and discussion.The change to the updated SLOE creates a number of challenges for students, SLOE writers, and SLOE reviewers. Primarily, despite a call for the initial iteration of the SLOR to provide “objective, comparative, and narrative information,” the newest version of the SLOE places greater reliance on a question that inherently is more subjective and prone to influence by factors external to the student.Consider a student who garnered outstanding workplace‐based assessments and scored highly on their end‐of‐clerkship assessment during their EM away rotation but is interested in a fellowship opportunity or serving a patient population unavailable at the site of their rotation. Alternatively, consider a student who performed well clinically on their EM away rotation but did not fit with a specific program's culture. Based on the revised SLOE, both of these students may be assessed lower on the subjective program ranking question despite having excellent potential as EM physicians. This change handicaps students. In circumstances such as these, SLOE writers, now more than ever, must provide more explicit narratives characterizing institution‐specific reasons why students may be assessed lower on this question. Similarly, selection committees must be willing to look past “lower 1/3” or “middle 1/3” assessments on the subjective program ranking item when narrative data suggests a student has potential to thrive within a specific type of training program or environment.We urge for substantive research to measure the influence the updated SLOE has had throughout this academic year on residency recruitment and selection. Specifically, investigation into how the new questions within the final section of the SLOE are perceived and utilized by SLOE writers and residency selection committees should be prioritized. While the newly integrated question about anticipated support and guidance may help fill the gap of the objective global assessment, research is needed to inform our interpretation of this data. Additionally, further research into discrepancies between narrative data and the subjective program ranking question on the revised SLOE is warranted.If, as a community, we continue with norm‐referenced assessment in the SLOE, we advocate reinstating the objective global assessment on future iterations as a more objective marker of a student's performance during their EM rotation. This fundamental change recaptures the essence of the SLOE, allowing programs to decide for themselves how a student will end up on their own rank list.


Adolescents from historically racial and ethnic minoritized and low-income communities have higher rates of early-life and chronic difficulties with anxiety and depression compared to non-Hispanic White youth. With mental health distress exacerbated during and in the wake of the COVID-19 pandemic, there is a need for accessible, equitable evidence-based programs that promote psychological well-being, strengthen one’s ability to adapt to adversity, and build self-efficacy prior to adolescence.An evidenced-based resiliency-focused health coaching intervention was adapted using a health equity implementation framework to meet the needs of a Title I elementary school in rural Alabama (AL) that serves over 80% Black and Hispanic students. To ensure that the program met local community needs while maintaining core program educational activities, all adaptations were documented utilizing a standard coding system.Leveraging an existing academic-community partnership with Auburn University and a local AL school district, a new program, Advocates 4-All Youth (ALLY), was created. Three major adaptations were required: (1) the use of local community volunteers (ALLYs) to deliver the program versus health coaches, (2) the modification of program materials to meet the challenge of varying levels of general and health-related literacy, and (3) the integration of the Empower Action Model to target protective factors in a culturally-tailored delivery to ensure key program outcomes are found equitable for all students.With continued increases in youth mental health distress, there is a need for the development of universal primary prevention interventions to promote mental well-being and to strengthen protective factors among youth from historically disadvantaged backgrounds. ALLY was created to meet these needs and may be an effective strategy if deemed efficacious in improving program outcomes. The program offered delivery flexibility in terms of the weekly, 30-min sessions to accommodate student/school schedules while minimizing missed sessions. As a universal program, Healthy Kids was designed with the intention that all students participate in the program and, to ensure buy-in from youth, parents, and the school community, the sessions have been incorporated into the existing school curriculum. Pilot data demonstrated improvements in symptoms of depression and anxiety among students who reported elevated symptoms at baseline, while improving resilience and self-efficacy among all students (Advocates 4-ALL Youth (ALLY) has been created using best practices and lessons learned from the pilot program, Building Resilience for Healthy Kids  –17. Healstudents .ALLY was created to extend the positive pilot findings of Healthy Kids by adapting program materials and delivery to meet needs of a new community of students. Specifically, ALLY has focused on utilizing tailored programming of materials to ensure program outcomes previously documented in one community were equitable among students in this new community which differed according to racial, ethnic, and cultural differences. Further, we focused on sustainability of the program within this new existing school systems with little to no financial or staff burden. ALLY utilizes community volunteers (ALLYs) with no previous health-related training required, compared to the certified health coaches used in Healthy Kids. The use of ALLYs to deliver evidenced-based mental health programs rather than mental health para-professionals has been suggested as a key approach to address mental health disparities for underserved populations . This apvia community and school support. Improving social connectedness is particularly vital for racially and ethnically minoritized and low-income youth as recent data  at the individual level. Increasing youth’s protective factors such as self-efficacy and resilience have been found to assist with prevention of worsening anxiety and depression , 27. SymWhen an individual’s school environment is focused on the interrelationship between the social setting and a youth’s well-being, youth tend to develop a strong foundation for positive development through adolescence and early adulthood . Early aThe program, Building Resilience for Healthy Kids , was developed using a community-based participatory research approach and served as a proof of concept and pilot-tested in Colorado –17. HealHere, a health equity implementation framework was used to document program adaptations in a new setting . SpecifiTo ensure our program met local community needs while maintaining core program educational activities, we documented all adaptations using the Rabin et al. adaptation framework and coding system . This prMultilevel stakeholder engagement , students, and researchers) provided feedback throughout the process. Feedback was documented at the level of each adaptation including a reason for the modification, identified person(s) that provided feedback, description of the modification, level of delivery of modification, content or context of modification, and the impact of the modification.An overview of the program modifications that occurred in the transition from Healthy Kids to ALLY are summarized in th grade students in this community remained in elementary school and attended classes with the 5th grade students. In partnership with the school and researchers, ALLY was modified at the level of the student to ensure that the content of program materials was age- and reading-level appropriate. The primary reason for this change was to ensure that the school could accommodate the individual sessions within their existing schedule for both 5th and 6th graders.The 6In Colorado, Healthy Kids was designed as an open communication format and followed a traditional motivational interviewing approach. Upon review of the program materials, the Alabama school teachers and researchers were concerned at the level of general reading literacy needed to comprehend the key messages. Specifically, terms such as bullying, depression, meditation, mindfulness, and self-care had different meanings and stigmatization in Alabama versus Colorado student communities. Due to these cultural differences, the content of the program materials was changed at the student level. The impact of this change was improved engagement from both teachers and school staff as the modified language was found to be more in line with their school culture.via a virtual platform over the course of five, two-hour sessions (10 h training). The training included an introduction to the program and review of the pilot results; description of the ALLY’s role including relationship and communication skills with a cultural humility focus (see description of Empower Action Model below); and general background on motivational interviewing, reflecting and summarizing a conversation to provide focus, changing mindset and behaviors, and delivering a program under the umbrella of ethical and effective research .Personnel modifications were also made to train local community members as program ALLYs. By utilizing an already-existing partnership between the school district and the local University, the aim was to increase the overall sustainability of the program. A total of eight ALLYs were trained To ensure that ALLYs delivered a consistent intervention, the ALLYs and researchers partnered to create a program workbook. The new program format was comprised of specific weekly topics that would be covered during the one-to-one, 30-min sessions between the student and the ALLY facilitators. This modification resulted in more focused sessions that were easier for the ALLYs to teach with little prior knowledge on the program materials. The ALLYs reported feeling more confident in their ability to deliver the intervention compared to the practice sessions using the previous materials developed for the pilot program.th and 6th grade students. The average reading level of the students was reported to be at a 3rd grade reading level. Thus, to ensure that students could understand and utilize our materials, we modified them from a 6th grade reading level to a 3rd grade level. Program facilitators found that students were able to read, comprehend, and complete the modified materials during the individual sessions.Three content modifications were made: (1) adjustment of reading level, (2) adjustment of length of the intervention period, and (3) integration of a new framework that represented our more diverse community. Upon review of our program materials, the teachers and school counselors shared a concern that the reading level was too high for their 5According to data from our Colorado pilot, the necessary number of program sessions completed to elicit the most improvement of program outcomes was five or more sessions. The program was originally designed to be delivered in six, 30-min sessions which occurred over a six-week time period. In partnership with school staff and researchers, a modification was made to extend the length of the intervention period from 6 weeks to up to 15 weeks, thus spanning the full semester. This modification resulted in more students completing the full program, i.e., six sessions.It was recognized that the majority of ALLYs did not represent the racial and ethnic background of the students . As a result, the research team along with the collaborators at Auburn University made a conscious effort to incorporate more cultural competency exercises and personal, self-assessments  including implicit bias recognition throughout the ALLYs training. Our cultural humility training was designed to prepare each ALLY for working within cross-cultural relationships including self-awareness, openness, and transcendence. This was taught using the ORCA-Stance framework including openness, respect, curiosity, and accountability. Each ALLY was required to complete the training and attend a group discussion for further learning and sharing of information. To guide the new training, a new framework was integrated into our program, the Empower Action Model (EAM) . The EAMTo improve health equity of our program, we created a curriculum that focused on fostering social connectedness and self-identity of each study using the EAM model. More opportunities were incorporated for students to feel connected in their communities both as they see themselves, their family, and their community. We were shown through this work, that to create this environment, curriculum needs to be focused on improving individual-level protective factors . By conducting individual sessions, ALLYs were able to empower each student to document supportive adult-child relationships, gain their own sense of perceived control within their lives, strengthen coping skills, and mobilize resources in their communities which were most personally meaningful to them . We created new activities focused on improving students’ social connectedness, self-view, individual growth and development, awareness regarding available school and community resources to meet their basic needs, and knowledge on how to form supportive relationships in their family structure, school, and wider community.The mental health of our nation’s youth has been slowly declining for years as suicidal behaviors and ideations continue to rise . The socALLY was created to combat these issues with little to no need for school resources by leveraging existing academic-community partnerships. This paper documents the various adaptations that our program implemented when it transitioned to a different state (Colorado to Alabama), community , and demographic composition . Although the format, one-to-one sessions for 30 min each week remained unchanged, several changes were noted. Major changes included: (1) the use of trusted, local community volunteers (ALLYs) to deliver program; (2) the challenge of varying levels of general and health-related literacy; and 3) the need to ensure programs are developed with program frameworks that focus on using an equity lens.via ALLYs after a short training. To eliminate the barrier of limited available time among ALLYs due to busy schedules, we chose to deliver the training on a virtual platform with both synchronous and asynchronous sessions. Due to this, we were able to elicit participation from a larger group of volunteers with varying schedules because they could complete the majority of the training at a time that was most convenient to them. As COVID-19 has streamlined and normalized teaching and meetings in the virtual world, our training can easily be accessed beyond Colorado and Alabama. We believe that this training model has improved our ability to train new ALLYs efficiently and effectively and will facilitate program expansion and reach anywhere in the U.S. and even beyond.As previously documented, developing sustainable mental health programs in schools very much relies on a strong academic-community partnership . We chosThe need to create program materials at appropriate levels for participants with a range of both general and health literacy is critical to the success of programs in high-needs communities . Our iniIn summary, ALLY is a universal, school-based, primary prevention intervention to promote mental well-being and to strengthen protective factors which has been adapted to meet the needs of a Title I elementary school in rural Alabama serving over 80% Black and Hispanic students. In this paper, we document the adaptations needed to deliver an existing program from an urban, middle-class, predominantly White community in Colorado to a rural, low-income, racially and ethnically diverse community in Alabama. A separate manuscript we will document pre-post changes in key mental health indicators to ensure that we can attain similar or superior program outcomes as in our Colorado pilot. Future work also needs to consider the level of supervision and ongoing training required to maintain effective ALLYs, including continued didactic training, case discussions, role-playing, as well as adherence ratings to the program using live or video observational fidelity measures .The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Colorado Institutional Review Board. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.JK wrote the first draft of the manuscript. AB, SS, AD, JC, RM, and MP contributed and approved the final manuscript. All authors agreed to be accountable for all aspects of the work.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Interview data were thematically analysed, and four main themes were identified: (1) the value of a peer-to-peer approach; (2) facing challenges and distress; (3) adopting self-care strategies; and (4) the development of valuable skills. Participants enjoyed the program content and learning. This involved self-care and communication strategies, boundary setting, service navigation, the concept of post-traumatic growth, the circles of control, and the stages of change model for families. Our findings strongly support the scaling up of the program in Darwin and other locations across the Northern Territory and future program adaptation for different vulnerable target audiences.While there has been a reduction in alcohol consumption among Australians aged 18 years and above, about 25% of people still drink above the recommended limit. The use of alcohol and other drugs is a substantial issue in the Northern Territory; however, there have been significant investments in alcohol reforms over the past few years. This paper reports on a pilot study that involved co-designing, implementing, and evaluating the Circles of Support consumer-led recovery and empowerment program for families and friends of individuals with alcohol and other drugs use issues. The evaluation comprised a mixed-methods approach; however, this article only presents the qualitative component ( In this paper, we introduce the Circles of Support program (hereafter program) and present evaluation findings from the recent ‘Supporting family members’ and friends’ individual recovery with a locally co-designed peer-led recovery program in Darwin’ pilot project. This program is a consumer-led recovery and empowerment program for families and friends (hereafter families) of individuals with alcohol and other drugs use (hereafter substance use), with the issues being co-designed by the Northern Territory Lived Experience Network (hereafter Network), which involves persons with lived experiences of substance use and related challenges. The program development and evaluation were funded through the Alcohol and Drug Foundation, Information Support Services Family and Friends Grants Program, from funding provided by the Australian Government Department of Health.The program is delivered by skilled peer facilitators affiliated with the Network who followed a stepped vocational pathway that was found to be the ideal pathway for the emerging local peer workforce . ParticiAccording to the Australian National Health and Medical Research Council guidelines, healthy men and women should drink no more than ten standard drinks a week and no more than four standard drinks on any one day . While tSubstance use issues rarely impact the individual only; they also significantly affect the whole family and even the broader social environment ,10. For Families of individuals with substance use issues often fulfil unique carer roles . They arMany families of persons with substance use issues withhold information from their social environment to avoid stigma and negative judgements . Indeed,Previous studies have shown that help-seeking among families is relatively low . They arThe evaluation primarily aimed to co-design, implement, and evaluate a local, consumer-led recovery and empowering program for families. The objectives were to assess the appropriateness and effectiveness of the program in terms of (1) exploring the main stressors and challenges faced by families on their journey of supporting someone with substance use issues; 2) assessing the families’ mental wellbeing; (3) investigating the families’ experiences with the program; and (4) considering the program’s impact on the families’ mental wellbeing. This article will only describe the families’ experiences with the program, which involved reflections on their learnings and the most helpful program elements. Further evaluation findings were published in the project report  because I have to support them …you always have to worry and…your priority is to help them.”(PP7)The families’ primary goals with the program was to connect with others and learn. They wanted to meet people with similar challenges and learn and understand more about the issues they face.“[I decided to] sign up to be a member of [the program] just to sort of keep in touch with what goes on in the world in regard to supporting people with lots of issues. My expectation was to learn and understand more about the issues…”(PP5)They were amazed by the power of the peer approach that created a safe, non-judgmental, and trusted environment where participants felt included, valued, eased, and understood.“The peer connection and support [were] the most important. You felt safe. You felt that you were not alone…you knew that you could trust them… no judgmental and all that…it was the best thing that I [could] do for myself.”(PP7)Families enjoyed the facilitation and liked the content, which exceeded their expectations. The facilitators introduced regular breaks with snacks and implemented various activities. This included open discussions, reflection, crafts, and activities for individuals and pairs. They also created the physical space in a purposeful way to be comfortable for everyone. For instance, many sensory objects were available to those needing them.“100% satisf[ied], the contents being fantastic. You know, [it] touched on some really, really good themes…I can learn from peer people with shared experience and from conversations with people who have similar backgrounds and are willing to be vulnerable and open about their backgrounds and share what they know from a deep place of understanding, [which] is really valuable. You don’t get that from professionals.”(PP1)Families are highly stigmatised by alcohol and drug use. Thus, the perception of stigma and shame that prevent people from asking for help and participating in peer support programs, especially in small places like Darwin, needs to be considered.“Darwin’s a small place; you may know people that come along…day one we had people coming in…[and] there was a [person] that I used to work with… [this person] got up and went outside… I guess it is the stigma that [this person] might feel and also that confidentiality… [this person] had an issue with trusting… it was just unfortunate… shame or stigma or trust.”(PP5)Support programs aiming to empower families and improve their skills to maintain good mental health are critical since families face significant challenges while they support and care for their loved ones. As the participants expressed, they can get distressed, exhausted, isolated, and have negative feelings and experiences.“I felt incredibly isolated… and I didn’t really know where to turn for help…. I did not know what the future possibly could look like… And I think just probably like it an overall feeling of just being overwhelmed.”(PP4)Families shared that stigma, shame, and guilt were some of the most critical challenges they faced, which led them to have additional distress, withdraw from social interactions, and ask for help. This included informal support from the broader family and other friends. The situation was even worse for people with culturally and linguistically diverse backgrounds since cultural beliefs, norms, and values often exacerbated stigma.“…trying to explain it to family…this sort of shame and guilt and all the things that come around it… I just found it really difficult to talk to [them] about the situation… that was quite sort of distressing as well”(PP4)Additionally, some families developed confidence in this role and navigating the system over the years; however, some felt lost, unsupported, and doubtful. Many families also described various indicators and symptoms of stress. Among them, gagging, anxiety, and panic attacks were often mentioned. Sleeping problems, unhealthy eating, and inappropriate reactions to situations, such as being snappy and sharp when communicating with others, were also associated with distress.“In the beginning, I wasn’t confident I was actually scared.”(PP6)They agreed that self-awareness and breaks to maintain their own mental wellbeing and support their loved ones were critical. However, this was not always a possibility for some of them.“I try to [have a break], then some days there are no breaks because you have to [be] there as a carer.”(PP1)Not everyone had a solid self-care strategy at the program start; however, some families had already implemented self-care strategies before they joined the program. This often involved physical activity and other healthy lifestyle elements such as healthy eating, proper sleeping, and not consuming alcohol. In addition, reaching out for professional help if necessary and dedicating time for themselves were also mentioned. Others emphasised quieter activities that helped them calm down, such as a massage, relaxation, music, hot showers, and easy walking in nature. Many families mentioned friends and other social groups as significant parts of their self-care strategies.“No concept of [self-care] at all. And in fact, in the [Circles of Support] classes, we joke about how I’m learning about self-care now… Yeah, it was just the way life was. It was the way I was brought up. It’s the way things were. You just got on with it… I’ve learned that there are minor forms of self-care…That I’ve been practising, but nothing like I heard in the group from participants and the facilitators.”(PP3)Seeking help from professionals was also considered a critical self-care strategy which required self-reflection skills and knowledge about how and where to ask for help.“I’m engaging with…[an] employee assistance program… So, I reach out, I know [how] to reach out….”(PP2)They shared the most valuable skills and knowledge they learnt. One was the concept of post-traumatic growth , which w“The post-traumatic growth, which is something we all learned about in the Circle [of Support program], and everybody latched onto it. Wow, that’s fantastic. [one participant] was the only one who’s heard of it before because [they have] done classes with [the lived experience network]… And it’s something I knew intuitively and that it gives me the resilience that I have because I can keep taking the knocks and that they might knock me down for a day or two. However, then I’m back at it.”(PP3)Families also shared that the stages of change for families model , which i“Stages of change [for families]… as soon as I saw [it]..that is our family. That’s exactly…sort of what way we’re going through so…[it] was kind of revolutionary to me because it just suddenly very clearly mapped out the journey that we’ve been on, and I guess it’s comforting to know because it all just feels so chaotic when you’re in the middle of it. It was kind of comforting to know; Oh, there’s a psychology behind this as well. And that’s what we’ve all been through…”(PP4)Families highly rewarded the circles of control  model an“Articulating that what’s within our control and outside of our control, which is about our thinking, was certainly a fundamental piece for me—and reinforcing that about the ways to think about the person who is mentally ill or dependent on alcohol. A lot of what they’re doing is entirely out of our control. And therefore, where we can focus our energy and attention on what aligns with our values…”(PP1)As it was previously described, self-care was a significant part of the program that participants appreciated. The peer environment allowed participants to share and discuss their own strategies in a safe and trusted environment. They also learnt from each other, and many activities targeted improving these skills.“I get stuck on [with self-care activities]… what that looks like, and you think I just have a warm shower or go for a walk and just forgetting that… [however] there’s a lot of other things that you can do to nurture yourself so that looking at that list [we received in the program] and picking some of those things out and seeing what works on a daily basis…one size doesn’t fit all, so it’s just working out what will work for me.”(PP5)Communication with a person with substance use issues is often challenging. The program got participants to understand how inappropriate communication strategies could contribute to escalating heated and unpleasant situations, such as talking about the impact of substance use issues or trying to convince the person to seek help. However, learning about communication styles that help families to de-escalate these situations and better support the conversation with the person was powerful. Families described that using “I” statements, avoiding blame-focused discussions, and finding the right environment and time to address these issues were vital.“I have a really troubled way of communicating with one of my [children], and we seem to buttheads no matter what we do, it always ends in an argument… So I think, you know, really looking at that communication with [them] and how I could change that… stopping and reflecting and having a good look at myself and how I communicate, not just putting it all on [them] and [their] addiction, but you know how I possibly become part of the problem when trying to have this communication.”(PP5)Improving families’ boundary-setting skills was also a significant part of the program, with many participants having struggled with it previously. However, by the end of the program, they had learnt that they needed to practise these skills regularly and communicate these boundaries to maintain their own mental wellbeing, prevent exhaustion and emotional and financial burnout, and support their loved ones appropriately.“……if you are a rescuer, then…you blur the boundaries because you wanna fix…you wanna help, but actually you’re making it worse because you’re increasing the dependency. So, the work in boundary setting and communicating the boundaries [are very important] so that you get what you need out of life.. Every day, they need to be set and set and set.”(PP1)The families were given a comprehensive list, including local services and their contact details, which can help them to navigate the support system. They also appreciated the skills they learnt to respond to a crisis and advocate for their loved ones. After the program, they felt empowered and confident.“If times get tough again with my [child] that, I will know how to reach out…. Particularly to the lived experience network. I think that’s really that was a key learning I think… finding out that some people can support navigate the system…[and] understanding about rights and responsibilities and things like that within the system that we, we have to negotiate… I’ve felt a bit more empowered in that, and so when we were going through the [service] stuff recently, it was just incredibly, you know, people can be very patronising to [my child] and ignore [my child’s] right…. Advocating for [my child] and making sure that is [treated], you know, with respect.”(PP4)Exploring values and making families recognise how important it is to align them with their behaviour was another critical point of the program. Developing new self-care strategies based on families’ value systems and preferences was a new concept for many.“[the facilitators] worked hard on the values piece…and aligning our behaviours, oursel[ves], gratitude with our values…once you know that your values are aligned…[your] thinking blinds up. You experience that tension when you’re going away from values, so they worked hard with that, creating the boundaries.”(PP1)This study addressed a significant gap in the Territory’s service provision and evidence base by developing, implementing, and evaluating a local consumer-led recovery and empowerment program for families of persons with substance use issues. It also highlighted families’ reflections on their learnings, including the most valuable skills they had acquired to support their own mental wellbeing and recovery.Peer support groups, forums, and resources, including peer support for families, are commonplace in other jurisdictions of Australia ,34,35. HSimilar to previous studies ,52,53,54Some families had already practised self-care; however, some did not have solid strategies before the program participation. Since self-care was a significant part of the program, they learnt new techniques from each other and attempted to put them into practice. They enjoyed exploring their own value preferences and aligning their self-care activities with them, which may provide a long-term positive attitude when it comes to continuing practising them.Among the most valuable learnings and skills, families mentioned the concept of post-traumatic growth , the staWhile the pilot project was well-received and deemed successful in learning valuable skills and supporting families in recovery and empowerment , it had Families appreciated the availability of this local consumer-led course and enjoyed the skills they learnt. They liked the purposefully built program content. This included various concepts that families highly valued. This pilot project described a high demand for peer support among families in the Territory, which reflects the lack of available support for this vulnerable population in this jurisdiction. It also drew attention to further work that needs to be done to raise awareness about peer support and reduce the shame and stigma experienced by families in the local community. Our findings support the idea of scaling up the program in Darwin and other locations across the Territory and aid future program adaptation for different caregiver settings.


Historically underrepresented groups in biomedical research have continued to experience low representation despite shifting demographics. Diversity fosters inclusive, higher quality, and innovative team science. One avenue for diversifying research teams is integrating diversity-focused initiatives into Clinical and Translational Science Award (CTSA) Programs, such as the integrated Translational Health Research Institute of Virginia (iTHRIV). In 2020, iTHRIV participated in Building Up, developed by the University of Pittsburgh CTSA, intended to increase representation and improve career support for underrepresented groups in the biomedical workforce. Drawing lessons from this study, iTHRIV implemented the “inspiring Diverse Researchers in Virginia” (iDRIV) program. This year-long program provided education, coaching, mentoring, and sponsorship for underrepresented early-career investigators in the biomedical workforce. To date, 24 participants have participated in the program across three cohorts. Participants have been predominantly female (92%), with 33% identifying as Hispanic/Latinx, 29% as Black, and 13% Asian. Notably, 38% of scholars have subsequently achieved at least one accomplishment, such as receiving a local research honor or award and an extramural funding award from a foundation or federal agency. The iTHRIV iDRIV program serves as a model for providing career support to developing investigators from underrepresented backgrounds, with the overall goal of improving patient health. The lack of diverse representation in the biomedical research workforce is a critical issue that requires urgent attention and immediate resolution. The National Institutes of Health (NIH) definition of populations underrepresented in biomedical research encompasses individuals from certain racial and ethnic groups, individuals with disabilities, and individuals from socioeconomically disadvantaged backgrounds . DespiteDiversity and research excellence are closely intertwined concepts. Diverse research teams are essential, as they bring together unique experiential backgrounds, perspectives, and problem-solving skills . The colThe impact of diversifying the biomedical research workforce extends far beyond the research itself; it also directly improves patient care ,13. A woImplementing comprehensive and proactive solutions to improve diversity in the field is essential. Solutions include actively recruiting individuals with unique and different perspectives and experiences from underrepresented groups, providing equitable opportunities for training and career development, and fostering inclusive and supportive environments that value diversity ,17. AddiOne avenue for implementing diversity-related initiatives focused on workforce development is to incorporate these into the existing framework of the NIH National Center for Advancing Translational Sciences (NCATS) Clinical and Translation Science Award (CTSA) Program. The CTSA program supports a national network of 62 academic health centers and institutions called “hubs.” These hubs provide resources and support to improve the translational research process, relying on a highly-skilled, creative, and diverse translational science workforce . The intDrawing inspiration from the Building Up study and the CEED program, we tailored and implemented iDRIV at a single academic health system (UVA), closely focusing on our workforce’s specific needs and characteristics. A fundamental pillar of the program was the delivery of guidance from a near-peer mentor per cohort. The near-peer mentor model was first implemented at the Walter Reed Army Institute of Research (WRAIR) for undergraduate research experiences for students in STEM . Near-peThe iDRIV program was designed for early-stage investigators committed to pursuing a career in clinical or translational research . EligibiApplicants were recruited through various approaches, including direct departmental invitations, email blasts, and postings on the iTHRIV website and the School of Medicine newsletter.Requests for Applications (RFA) were sent out, and applications were received annually. Applicants were required to submit an application form through the Research Electronic Data Capture tool (REDCap) along wiSelected iDRIV scholars participated in the yearlong program, with the first three cycles following the 2020–2021, 2021–2022, and 2022–2023 academic years. Each cycle began with individualized meetings between each scholar and the program near-peer mentor to identify and share resources that may have helped support the scholar. 1.5-hour collaborative sessions were held monthly via Zoom. The Building Up cohort started with 12 sessions that included topics such as the importance of mentorship, promoting research on social media, organizational skills, wellness, and work-life balance, among others . An addiAfter completion of the program, an annual optional iDRIV program evaluation survey was distributed to participants. The survey contained a total of 13 questions. The first five questions  evaluateAs metrics of the scholars’ and overall program success, we gathered information on scholars’ accomplishments and publications for up to three years after their participation. Program data were collected using Qualtrics  or REDCap . DescripCohort One of the iDRIV program was launched in collaboration with the University of Pittsburgh as part of the Building Up study between October 2020 and July 2021. UVA School of Medicine departments  subsequently supported Cohort Two (October 2021 to July 2022) and Cohort Three (October 2022 to July 2023).A total of 24 scholars were accepted into the three cohorts. Characteristics of iDRIV scholars are presented in The program sessions were well-received overall. Cohorts Two and Three had the opportunity to identify additional session needs, and extra sessions were added to their cohorts. For instance, Cohort Three participants expressed a need for research methods and statistical skills. As a result, a session with resources addressing those needs was provided in that cycle. Cohorts One and Two did not have sessions on Library Services and Resources, Microaggressions, or Biostatistics Resources. Cohort Three did not have sessions on Contract Negotiating in Academic Medicine, Wellness and work-life balance, or Scholar Presentations.The annual survey was distributed to Cohorts Two and Three (n=16), while the Building Up survey results will be presented separately by the University of Pittsburgh CTSA. In total, 50% (n=8) of iDRIV scholars responded to the annual survey .The respondents to the annual survey  overwhelIn summary, the open-ended questions revealed that the program was well-rounded, helpful, and provided the necessary resources for a future career in research. The iDRIV facilitators were commended for their outstanding performance, willingness to answer questions, and responsiveness. The panelists were praised for their relatability and unique perspectives on research. The networking sessions, where participants had the opportunity to meet with leadership, were found beneficial. However, one scholar recommended making the session format more informal to encourage open discussions, such as having small tables with food instead of one large conference room table.Regarding the program’s future, 25% of participants recommended in-person sessions to allow for more interactions among scholars. In response to a question about the most beneficial session of the program, participants commented that all the sessions were beneficial, and the most beneficial sessions were: ‘Orientation and Why Mentoring?’ (25%), ‘Giving Effective Presentations’ (25%), ‘Curriculum Vitae (CV), Biosketches, and Grant Submissions Process’ (13%), ‘Getting Organized’ (13%), and ‘Goal Setting’ (13%). Additionally, 88% of evaluation survey respondents expressed their intention to stay engaged in research in the future.iDRIV scholars’ accomplishments as of August 2023 are presented in Across all three cohorts, four iDRIV scholars have received federal and institutional funding totaling $1,932,280 after participating in iDRIV. Furthermore, we used the average number of publications per cohort scholar per year as another measure of success, with an average publication rate for early-stage investigators considered to be 1–3 papers per scholar per year [Diverse research teams bring forth new experiences and innovative ideas. However, biomedical research teams lack diversity, perpetuating a cycle of underrepresentation that continues to widen the gap. iTHRIV’s iDRIV program was developed to improve human health by diversifying the biomedical research workforce and providing career support to promising early career scholars who are historically underrepresented in research and translational science. We recognized the urgent need for such a program locally and successfully implemented it at UVA.Though we do not have a comparison cohort, the success of iDRIV is evident in the achievements and publications of its scholars during and after the program. These achievements align with the key outcomes analysis of the CEED program . The CEEiDRIV serves as a crucial pathway for our teams to reach the highest level of research excellence, ultimately leading to novel ideas for disease prevention, diagnosis, and treatment. We anticipate that iDRIV will lead to continued successes for our scholars, including but not limited to being provided with continued training opportunities such as the K12 scholars program or receiving an R01 or equivalent grant from the NIH or other governmental institutions. By fostering and graduating new investigators, the program has expanded the pool of diverse future research mentors and leaders, raising a more inclusive and representative biomedical workforce and, generating a more significant impact in our institution and beyond.Limitations of our work include that this is a new program, and our sample is small and lacks long-term outcomes. Additionally, not all of our scholars have provided feedback so our results may be biased by the limited respondents. We do not have a comparison cohort, and selection bias could contribute to our scholar’s success. Since we have accepted all applicants who meet the eligibility criteria, systematic selection bias seems unlikely. It is possible, however, that department leaders have introduced bias by suggesting that only the most successful candidates apply or that most successful scholars are more likely to apply. By continuing to refine our outcome measures and track the successes of our programs, we will improve our ability to accurately assess how participation in iDRIV impacts scholars’ future careers.One major limitation of this program is the lack of representation in the cohorts from specific groups such as American Indians or Alaska Natives (AIAN) and Native Hawaiians or other Pacific Islanders (NHOPI). As iDRIV directly recruits applicants from UVA, the cohorts roughly reflect UVA demographics. Thus, we are limited in our ability to recruit individuals who are underrepresented not just in NIH programs but who are underrepresented at this institution . NotablyAnother limitation pertains to our application process and data collection. Although we request applicants to self-identify as an underrepresented group (yes/no question), we do not collect data on the distribution of disability or socio-economic background of applicants. As a result, we cannot characterize scholars more specifically to determine if this program is effectively reaching individuals with diverse experiences. With this in mind, we are reviewing our process for potential improvement opportunities, such as expanding the self-identification questions. This will allow for a comprehensive view of diversity in our applicants and aid us in recruiting a more representative cohort.In response to the recent affirmative action ruling by the Supreme Court, our eligibility criteria have been revised . In the As we look to the future, we will continue to review our program design, implementation processes, sustainability plan, and impact to identify areas for improvement. We continue to capture input from our earlier cohorts and incorporate their feedback into plans. Programmatic development is ongoing, and we will establish an external advisory committee to enhance the educational programmatic rigor. We will incorporate in-person sessions to increase participant interaction. Recent additions include a complimentary leadership training program offered to iDRIV scholars. Additional funding sources will be identified to support and expand the program at UVA and extend the program to other iTHRIV partner institutions. Finally, the lessons learned from iDRIV about diversifying the biomedical research workforce will be implemented to address diversity needs across other professional branches of the research workforce, including Clinical Research Professionals and Research Administrators. Our application process will evolve to meet the legal requirements for all iTHRIV programs.Establishing career-building programs that support an outstanding group of early-career investigators with varied experiences is imperative for fostering biomedical research excellence. This can directly impact patient care and ensure a more representative and responsive workforce in alignment with our diverse population. The iTHRIV iDRIV program serves as just one model for such a program. Similar programs with novel approaches are warranted to improve diversity in biomedical research and the STEM workforce.


The potential for disaster in an area is based on the geographical characteristics of a place and the living factors of the surrounding community. Community preparedness must be implemented to minimise the impact of an earthquake. This study aimed to determine the level of community preparedness in facing earthquakes in Cisarua District, Indonesia, based on the results of earthquake hazard mapping. The research used the quantitative Analytical Hierarchy Process (AHP) for earthquake hazard mapping and disaster preparedness using questionnaires. The AHP parameters include earthquake acceleration, distance from the Lembang fault, rock type, soil type, land use, slope and population density. The sample for this study comprised 80 respondents from six villages with a relatively high level of vulnerability, namely the villages of Jambupida, Padaasih, Pasirhalang, Pasirlangu, Kertawangi and Tugumukti. Data collection was carried out through interviews and site surveys based on a questionnaire consisting of variables like knowledge and attitudes, policies, emergency response plans, disaster warning systems and resource mobilisation with a total of 80 respondents. The study results concluded that community preparedness was included in the unprepared category with a total score of 211. Aspects of kinship and kinship relations between residents greatly influenced community preparedness, and knowledge and attitudes were considered sufficient with a weight of 4.4. Increased public awareness of the potential for earthquake disasters must routinely be carried out through disaster emergency response outreach and training activities in addition to improving residents’ emergency response facilities.The study findings highlight the village community’s earthquake disaster preparedness with the support of integrated spatial mapping of disaster vulnerability. The lack of awareness of the village community in earthquake disaster mitigation increases the level of disaster risk in their area. Starting from 17 goals of Sustainable Development as well as global and national commitments shown in The sustainable development goal concerned with natural disaster preparedness is Sustainable Development Goal number 11, namely ‘Building Inclusive, Safe, Disaster-Resilient and Sustainable Cities and Settlements’. This goal focuses on building cities and storage that can withstand the risks of natural hazards, protect residents from the effects of disasters and ensure access to basic facilities such as safe and sustainable air sanitation, sanitation and transportation. Other policies related to increasing disaster and climate resilience are implemented by strengthening the convergence between disaster risk reduction and climate change adaptation through disaster management strategies and increasing climate resilience. There is a need to create institutional mechanisms that are adaptable and amendable to meet the targets of Sustainable Development Goals at local levels  so that it effectively is an urgency to select respondents from the community from high to medium-referenced location area maps to be taken and used as samples, according to the needs. For reference, the questionnaire from LIPI-UNESCO/ISDR was modified as a Likert scale to facilitate field interview surveys. The research objective was to determine the level of community preparedness for earthquake disasters. The research also aimed to compare the level of community preparedness in various regions to assist policy-making in increasing community preparedness for earthquake disasters in West Java.The research method used quantitative methods along with the AHP for earthquake hazard mapping. Analytical Hierarchy Process is used to eliminate and select the area’s most vulnerable location from the disaster vulnerability distribution map, which has a category value from high to low. Disaster preparedness using questionnaires uses statistical analysis. Data collection is carried out by distributing questionnaires to several respondents selected through the area categories of the AHP model disaster hazard map selected from the population of the village area that is the focus of the research. The validity and reliability of the data were tested in the study to ensure that the sample used was sufficiently representative of the population to be studied.The earthquake hazard zoning map variable uses the following indicators: administrative boundaries, Lembang fault, land use, rock types, soil types, earthquake intensity, earthquake acceleration, slope and population density. Earthquake hazard mapping using the AHP method is largely determined by the weighting classification of each indicator  = 80 of 0.220. Referring final validity test, it was found that all instruments ranging from knowledge and attitude variables, policies, emergency response plans, disaster warning systems and resource mobilisation consisting of 46 statements all resulted in the value of r arithmetic > r table and the significance value <0.05 so that the instrument data are valid.Data collection was carried out by testing the validity of the Pearson Product Moment to determine the validity or suitability of the questionnaire used when measuring and obtaining research data. The results of observations in the The validated instrument used in the study is reliable first using the Cronbach Alpha reliability test Cronbach , which aThe results for the knowledge and attitude variables with a total of 10 statements and the reliability value of Cronbach’s Alpha is 0.868. In the second variable, namely the policy with a total of five statements, the reliability value of Cronbach’s Alpha is 0.784. While the emergency response plan variable with a total of 17 statements, with the acquisition of Cronbach’s Alpha reliability value of 0.896. The fourth variable is the disaster warning system, with a total of six statements as the number of indicators, and the reliability value of Cronbach’s Alpha is 0.775. Moreover, the fifth variable is resource mobilisation, with eight statements. The reliability value of Cronbach’s Alpha is 0.817. So, the data are categorised as reliable because the value is >0.6 (Sujerweni The indicators used to assess community preparedness come from the main parameters sourced from LIPIUNESCO/ISDR . The intThe variable characteristics of the respondents that can be seen in K = 1 + 3.3 Log (100) = 7.6, and the number of classes is rounded up to 8. While looking for the width of the interval class, the equation: I = (R/K), where I is the width of the interval, R is the range  and K is the number of classes. So, from the equation, we get the width of the interval class I = (100−0)/8 = 12.5%. We can classify classes with the criteria and weight values as indicated in Class division and weighting were assessed from all indicators of each variable with a range of values from 0 to 100. The class division uses the Sturgess formula with the following equation: The assessment per indicator of community preparedness refers to the 2006 LIPI-UNESCO/ISDR instrument  for 80 respondents is 400.The lowest value is 80. Using the Sturgess formula, we recalculate the class interval whereInterpreting intervals from the value of earthquake preparedness is carried out using the Sturgess formula based on the sum of each earthquake preparedness indicator score. From K = 1 + 3.3 Log (N) so that K = 1 + 3.3 Log (46) = 6.4 is rounded to six classes. For the width of the interval, I = (R/K) = ((400−80)/6) = 53. The percentage value is obtained by comparing the total value of each indicator in one variable to the maximum value of 400.The framework model for community preparedness for earthquake disasters carried out in this study includes the initial stages of mapping earthquake hazards, followed by the data-collection stage of questionnaire interviews with village residents as samples and continued at the stage of interpretation analysis to determine disaster preparedness scores. Mapping the distribution of disaster vulnerability in the Cisarua District area is very important. It helps to determine which villages need priority as samples and local government anticipation of increasing community capacity in dealing with disasters in six villages comprising Jambudipa, Padaasih, Pasirhalang, Pasirlangu, Kertawangi and Tugumukti with moderate to high vulnerability levels. This has never been done before in the early stages of selective and detailed sampling of area data. Meanwhile, the results of the disaster preparedness score from Based on the results of the study, it can be concluded that earthquake hazard mapping helps to determine the location of areas that are of concern to the government in the preparedness of the people of Cisarua District for earthquake disasters, especially the distance of settlements with medium and high levels of vulnerability whose radius is close to the Lembang fault. The preparedness of the people of Cisarua District who deal with earthquake disasters is included in the criteria of ‘not pretty ready’ with enough criteria for aspects of knowledge and attitudes. Although enough, aspects such as emergency response plans and disaster warning systems also require serious attention, because results tend to be not good. The kinship and closeness of relatives is a substantial factor in community cooperation. Local and central governments need to provide equipment for early detection of earthquakes, such as sirens, and ensure evacuation routes, disaster posts, and other emergency equipment to deal with disaster emergencies. Socialisation and training activities are critical in increasing awareness in the community regarding earthquake disaster preparedness and need to be carried out regularly, especially in areas prone to earthquake disasters.