Frailty is a common geriatric syndrome, characterized by reduced physiologic reserve and increased vulnerability to stressors, due to cumulative decline in multiple physiological systems. We studied the feasibility of a community-delivered Baduanjin (BDJ) training program among pre-frail/frail community-dwelling older people. We examined (1) safety (adverse events) and physical and psychological effects; and (2) feasibility of recruitment, retention, adherence; recruitment efforts, and any program challenges, so as to inform future studies.Our study was a single arm pre-post study in a community setting. Sixteen-week group BDJ training (2×/week in the first 4 weeks and 3×/week thereafter) was co-designed and implemented by community-based providers in Singapore. Recruitment, attendance, and adverse events were recorded throughout the training. A participants’ survey was also administered after the training program. Effects of the intervention on physical and functional outcomes , Physiological Profile Assessment (PPA), 30-s Sit-to-Stand test, 6-m fast gait speed test), frailty outcomes (frailty score and status), and other outcomes (Maastricht Questionnaire (MQ), Fall Efficacy Scale (FES), Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale (GDS), and EQ-5D-5L) were examined before and after the program.n = 2) or maintained (n = 9) their frailty statuses. There post-training outcomes in hand grip strength, knee extension strength, TUG, MQ, FES, MoCA, GDS, and EQ-5D-5L index score appeared to be better. The reduction of frailty and PPA fall risk scores was of moderate-to-large effect size.Of 31 older adults screened to be frail, 15 met inclusion criteria and 3 refused participation, resulting in 12 older adults (9 women) enrolled into the program. During the program, one participant was hospitalized (unrelated to BDJ training) and the other 11  completed the program with average overall attendance of 89%. Most (89%) of the 44 training sessions had attendance > 80%. The program received positive feedback with no training-related adverse events. Participants either reversed (Community-delivered BDJ training program was safe and feasible for prefrail/frail older adults with the potential to improve physical and cognitive function, reduce fall risk, improve psychological well-being, and reverse frailty status. What uncertainties existed regarding the feasibility?There is no information on the safety, acceptability, and adherence of community-delivered BDJ training among prefrail/frail older adults.What are the key feasibility findings?The BDJ training was safe with very good attendance and acceptance among the prefrail/frail community dwelling older adults.What are the implications of the feasibility findings for the design of the main study?The results of this feasibility study can inform the design and development of randomized controlled study in terms of protocol feasibility, sample size calculation, and outcome selection.Frailty is a common geriatric syndrome, characterized by reduced physiologic reserve and increased vulnerability to stressors, due to cumulative decline in multiple physiological systems . The preDifferent interventions to reduce frailty have been studied –10. Recehttps://www.youtube.com/watch?v=3K-0JpiJu-o&t=75s). Compared with relatively more complex and lengthy exercise forms such as Tai Chi, BDJ is physically and cognitively less demanding and is easy to learn and practice with few limitations [Baduanjin (BDJ), also known as Eight-Section Brocades, is one common form of “mind-body” Qigong. “Mind” is understood as regulating thoughts to enhance the emotional and psychological processes. It involves eight simple movements with combinations of postures, meditation, slow relaxing movements, and breathing exercise in a harmonious manner which enhances respiratory function, improves holistic health, and achieves the integration of mind and body . A growiitations . Thus, iitations , 17 haveitations –20, mentitations , 22, anditations –25 in diitations , 26. HowThere are many factors to consider in translating the result of a successful clinical trial into real life settings . As suchThis feasibility study was designed as a single arm pre-post comparison. In partnership with a provider of senior community services (day care and community clinic), the study was implemented at a community center from September 2018 to April 2019, where the provider is based at the Whampoa housing estate in Singapore. A small convenience sample of older adults was recruited by the provider among the visitors of the community center, daycare center, and community clinic at the same locale near enough for participants to walk to the training venue. Wheelchair users were either assisted by their domestic helper or used a paid transport we provided. Participants were familiar with the venues since those venues were the activity centers within the communities.Researchers did initial frailty screening. Afterwards a licensed General Practitioner (GP) screened for program eligibility and excluded participants who did not meet the medical criteria. Since there was no previous study on BDJ frail older adults, we could not estimate sample size. Based on a maximum instructor to participant ratio of 1:10, we aimed to recruit a maximum of 20 participants.The inclusion criteria were (1) pre-frail (score 1–2) or frail (scored 3–5) according to FRAIL scale screening questionnaire ; (2) oldExclusion criteria were as follows: (1) participating in any other exercise program or interventional studies; (2) severe audio-visual impairment diagnosed by physicians ; (3) diagnosed with cognitive impairment and/or history of neurological disorder ; (4) unable to participate for the full duration of the study; (5) diagnosed with postural hypotension; (6) unable to come to community club by himself/herself or by the help of caregivers, (7) unable to get the medical clearance from the GP.The program was designed by the local Qigong association. The entire set of BDJ exercise comprises eight sections Fig. . ParticiAll participants cleared pre-exercise medical examination before recruitment into the study. Simple screening was performed by study coordinator before each training session. Participant with either one of the following did not participate for that training session: blood oxygen levels below 95% saturation, high resting heart rate (≥ 90 beats per minute) , abnormaSafety (adverse events) and physical and psychological effects.Feasibility of recruitment, retention, adherence; recruitment efforts and any program challenges.A survey was administered to the participants after the training program. The survey utilized a four-point Likert scale  and comprised nine questions on program acceptance, adherence satisfaction, engagement, and willingness for continued participation. Any adverse event during the program duration was recorded by a research coordinator who contacted the participants regularly. The coordinator also obtained the attendance record from the provider and is present at every training session.To examine the feasibility of the training program, the outcomes and process evaluated were :Safety To explore the potential effects of BDJ, we assessed a range of exploratory outcomes during the week before (pre) and the week after (post) the 16-week training program. All outcome measures were administered by assessors who were not involved as part of the research team nor BDJ instruction and demonstration.Physical and functional outcomes included knee extension strength, hand grip strength, 6-m fast gait speed test, Time Up and Go test (TUG), Physiological Profile Assessment (PPA), and 30-second Sit-to-Stand (30 s STS) test.To assess muscle strength, knee extension strength and hand grip strength were measured using a spring gage and hand-grip dynamometer respectively for the dominant leg or hand. Two trials were administered for knee extension strength, hand grip strength, and 6-m fast gait speed test and the mean values used for analyses.TUG, a test of basic functional mobility for frail elderly persons, required participants to stand up from a chair, walk a distance of 3 m at a comfortable pace, turn, walk back, and sit down . The tesPPA, which includes five measures of physiological functioning , was used as a systematic approach to explore the underlying causes of balance changes . The fivFor the 30 s STS, the number of successful stands within 30 s were recorded. The performance of 30 s STS has been suggested to be determined by balance, muscle strength, lower extremity endurance, and mobility .Frailty score of the participants was assessed using the Cardiovascular Health Study Frailty Phenotype (CHS Fried criteria) . The folWe also measured participants’ vital exhaustion using Maastricht Questionnaire (MQ)  and feard. Results of the post intervention interview was reported as the percentage of responses for each question. All analyses were conducted using Stata 14.0 .Descriptive statistics of demographic information and outcome measurements were presented as mean and standard deviation (SD) for continuous variables, and frequencies and percentages for categorical variables. Results from the outcome measurements were summarized, and effect size of each test was calculated using Cohen’s During the 3-month screening and recruitment in the community, 31 prefrail/frail older adults were identified using FRAIL scale. Of those, 16 who not meet inclusion criteria were excluded, and another three declined participation. In the end, twelve participants aged between 65 to 84 years old  were enrolled at baseline. The participants were all Chinese and had an average of 2.75 chronic illnesses—hypertension (91.7%), diabetes (50%), hyperlipidemia (41.7%), arthritis (33.3%), and heart disease (25%) were the top five comorbidities. Fifty percent of the participants used walking aids. According to CHS Fried criteria, 10 participants were prefrail, and two were frail (Table n = 10) had full attendance, 66% (n = 29) had an attendance of 80–100%, and only 11% (n = 5) had an attendance of lower than 80%  participants had an adherence of more than 80% throughout the training program  reversed to prefrail status , MoCA in 9 82%), GDS in 8 (73%), and FES in 7 (64%), respectively with a within-person change ranging from 8.1–44.2%  of ethnic Chinese. We did not manage to recruit other minority races—Malays or Indians. Program retention rate (91.7%) was high. We observed that the community provider arranged for snacks and drinks after each session, and the participants could socialize with the instructors and with each other after the sessions. There was also very good rapport between the instructors and participants which appeared to improve over the program. The social component  and abilProgram adherence is a significant challenge for exercise interventions in frail persons . Poor prA systematic review showed that the older people’s adherence to exercise programs was associated with the program characteristics and personal factors . It was Falls have significant impacts on older adults including loss of mobility and confidence to maintain daily activities, leading to frequent hospitalizations and greater need for social care , 49. MusAll training and evaluation sessions were completed within the planned time period and within budget. Study did not record significant any personnel challenges or problems with respect to data collection.Program safety is vital for health promotion in the vulnerable population of frail older people. Our study intervention assessed BDJ exercise safety with close monitoring on blood pressure and blood oxygen levels before and after each training session. With no training-related adverse events, the current BDJ training protocol is safe for prefrail/frail older adults. The study exclusion criteria were adequate to ensure the safety for future trial. While intensive, the 44 training sessions within 4 months could maintain high adherence and retention rate. This showed that the BDJ training dose was acceptable in prefrail/frail older adults. In addition, the dose should be adequate to observe the physical and functional effectivity.d = − 0.59). There may be possible detection bias since the assessors could not be blinded. However, for future RCT design, assessors should be blinded to the group allocation.The participants appeared to have better post-training hand grip strength, lower limb strength, decrements in TUG and FES, better cognitive function (MoCA), psychological well-being (GDS), and quality of life (EQ-5D-5L index score). Frailty scores resulted in a marginal significant reduction of medium effect size  for maximizing both physical and mental well-being . MoreoveThis study was the first to demonstrate that a community-based BDJ intervention is safe, feasible, and acceptable among prefrail/frail older persons. The high adherence rate is important for the implementation of such a program in the real-world setting. The strength of the study is the implementation in a “real-world” housing site setting where the participants reside, close partnership with local community providers to engage participation and adherence and using simple equipment such as chairs. To explore the potential effects of BDJ, we assessed a broad range of explorative outcomes including physical and cognitive functions as well as psychological outcomes. As fall risk is an important concern for prefrail/frail persons, both subjective (FES) and objective assessments (TUG and PPA) were conducted to assess fall risk from different perspectives. Furthermore, we explored the Qi component of BDJ exercise using the validated MQ instrument. The results of these explorative outcomes provide information to design a RCT on the effectiveness of BDJ to reduce frailty and improve function. Based on an effect size of 0.7 for within-subject in knee extension strength, with a power of 90% and a 10% drop-out rate, the sample size for a two-arm RCT will be 60 participants.As a single-arm feasibility study, we could not make any assumptions on the effectiveness of the BDJ training program. The community provider also did not manage to recruit Malay or Indian participants. Future study in Singapore can include Malay and Indian participants to increase the generalizability. Although not a subject of investigation in this study, it is possible that BDJ Qigong is more appealing to the Chinese than Malay and Indians in Singapore due to its Chinese origin.Detection bias: as our assessors could not be blinded in this single arm study. In a RCT, assessors should be blinded to reduce detection bias.Performance bias: since our study was a physical intervention and participants could not be blinded in this nor a future RCT.Attrition bias: while attrition was low in this study, attrition may be higher in a control group of a RCT design.Our study highlights possible biases:The results provide some support to BDJ’s potential to be implemented as part of low-cost community health promotion program. As BDJ is an exercise which is easy-to-learn without any restrictions from specialized equipment or spaces, older adults can practice it at home, community activity centers, or nursing homes, through both group-based and self-practiced training. Furthermore, BDJ is a traditional Chinese exercise which is popular among Asian Chinese populations. However, to translate the research intervention into a real-world routine community program, efforts from service providers and community partners who have a good intervention fidelity are necessary for a successful implementation. More strategies are needed to maximize the program adherence and achieve the desirable outcomes.In summary, the study provides early evidence that the 16-week community-delivered BDJ intervention adapted to prefrail/frail older adults is feasible, safe, and acceptable. It may potentially benefit prefrail/frail older adults on physical, cognitive, and psychological health outcomes, and frailty reduction and status reversal. The findings provided information for the design and implementation of a randomized controlled study to investigate the efficacy of BDJ exercise among prefrail/frail older adults.


The present study focuses on an analysis of the efficacy of the online intervention program called “Hero” for promoting prosociality and other socioemotional variables related to prosocial behavior, such as empathy, positive emotions, and forgiveness, in two Latin American countries: Argentina and Uruguay. The final Argentinean sample consisted of 579 adolescents , and the Uruguayan sample consisted of 330 adolescents , aged 12 to 15 years old. The ‘Hero’ program provided evidence of efficacy for the promotion of prosociality, empathy, positive emotions, and attitudes of forgiveness. It impacted each of the dimensions comprising these variables differently depending on the country where it was applied. We discuss the differences found in each country. In recent years, the study of positive development in children and adolescents has gained great relevance. Positive development emphasizes the study and promotion of abilities, psychological resources, values and positive social relationships . NumerouThere are different prosociality intervention programs that have proven effective. However, the majority are lengthy, involve face-to-face implementation and have been implemented only in the country in which they were developed . It shouTo our knowledge, the Hero program is the only short program with a virtual modality whose usability and efficacy in promoting prosocial behaviors has been studied ; howeverWith an improved research design, the present study focused on analyzing the efficacy of the online intervention program called Hero for promoting prosociality and other socioemotional variables related to prosocial behavior, such as empathy, positive emotions , and forgiveness, in two Latin American countries: Argentina and Uruguay.The Hero program was developed in Argentina by Mesurado et al. in 2019  and targTo our knowledge, this is the first virtual intervention program aimed at promoting prosocial behavior and the socioemotional variables linked to it , 9. SeveHero is a self-administered program accessed from a Web page. To enter the program, adolescents must generate a username and choose an avatar, that is, they must select a virtual identity that represents them within the application. The program is guided by a Sensei who accompanies the adolescent throughout the application and presents the activities to be carried out through text and audio instruction, using the Spanish language with a neutral Latin American accent.The program is structured in five linked modules for promoting empathy  , gratituThe program is presented as an adventure that consists of a trip to five islands. The adolescent participates in the different phases in a sequential and predetermined way by visiting the island of empathy, the island of gratitude, the island of positive emotions, the island of forgiveness, and the island of prosocial behavior. The stay in each of the islands coincides with an intervention session, which lasts approximately 30 and 40 minutes. When the adolescent arrives on an island, he or she watches one episode of a psychoeducational video that deals with the behavior to be stimulated and then performs a series of activities. The videos narrate different conflictive situations in the daily lives of four adolescents . The conflict is resolved in each episode by exercising the socioemotional variable corresponding to the visited island. The videos offer a brief explanation of this variable and conclude with three brief suggestions from Sensei with exercises to stimulate it. The two or three activities that the adolescents then carry out are different on each island; some are playful, while others are reflective, relaxing, etc.  in Argentina, the 35.5% of those older than 25 years old completed primary education, 37.2% completed secondary education, and 20% completed Bachelor's or equivalent educations; and in Uruguay, 34.4% completed primary education, 43.5% completed secondary education, and 13.3% completed Bachelor's or equivalent educations . In 2018Regarding religious practice, Uruguay has the lowest percentage of Catholics 38%) and the highest percentage of atheists or nonreligious people in Latin America (41%) , 35. In % and theAccording to the World Values Survey (2010–2014), 87.3% of Argentineans and 86.3% of Uruguayans younger than 29 years old believe that family is very important in their lives. Similar patterns are found in both countries when analyzing the importance attributed to friendship, with percentages of 66% and 61% in Argentina and Uruguay, respectively. In contrast, there are important differences between the two countries when attitudes toward strangers are analyzed. In Argentina, approximately 57% of young people believe that it is important to show tolerance and respect for other people, while in Uruguay, 87% express this belief . MoreoveThe objectives of this new research can be summarized as follows: we propose to analyze the efficacy of the Hero program for the promotion of prosociality, empathy, positive emotions , and forgiveness. Specifically, the effect of the Hero program will be evaluated at a three-month follow-up period and compared to a control group in two Latin American countries: Argentina and Uruguay. The gender of the participants will be analyzed to determine whether gender had an effect on the efficacy of the program.The study and procedures were approved by the Institutional review board at Universidad Austral [CIE 19–031]. The data were analyzed anonymously.Five secondary schools with 31 classrooms in Argentina and four schools with 19 classrooms in Uruguay were intentionally selected to participate in the study. We carried out a cluster randomized trial at each school , 42. We The initial sample consisted of 778 participants from two important provinces in Argentina: Entre Ríos and Buenos Aires. The sample was collected from urban areas.The initial sample consisted of 396 participants from two cities in Uruguay -Salto and Belén- which belong to the Salto department (second most important department after Montevideo). The sample was collected from urban areas.We communicated with the authorities of the educational institutions to explain the objective of the Hero program and its characteristics . Once authorizations from the educational institutions were obtained, a letter was sent to each of the parents or guardians of the students aged 12 to 15 years telling them about the research project and asking for their authorization for their child to participate. The parents or guardians of the adolescents signed an informed consent form. Only adolescents who agreed to participate and who had the consent of their parents were included in the study.Once the authorizations were obtained, classes at each school were chosen randomly to participate in the experimental group or the waitlisted control group. The students used the computer room of the educational institution and participated in the eight sessions of the Hero program during school hours at the times granted by the authorities of the institution.Each session was directed by a psychologist trained in the use of the program, who ensured the proper functioning of the computer application and directed the adolescents on the tasks when necessary. Throughout the implementation of the program, the research team also had computer technical support.The participants in the experimental group participated in eight sessions: 1. Pretest evaluation; 2. Empathy session; 3. Gratitude session; 4. Positive emotions session; 5. Forgiveness session; 6. Prosocial behavior session; 7. Posttest evaluation; and 8. Follow-up evaluation. The control group participated in the pretest, posttest, and follow-up evaluations. Each session lasted approximately 30–40 minutes. The adolescents did not receive any compensation for participating in the research project.Participants from both countries in both the experimental group and the control group completed the following assessment tools during the pretest, posttest, and follow-up assessments. The instrument evaluation was blinded for the participants.To evaluate prosociality, a modified version of the Kindness and Generosity subscale extracted from the Values in Action Inventory of Strengths  by PadilThe questionnaire comprises 27 items, which the participants answered using a five-point scale ranging from 1  to 5 (“very much like me”). The items are distributed in three subscales, one for each target toward which the behavior is directed, namely, nine items to evaluate prosocial behavior toward strangers , nine items for prosocial behavior toward friends  and nine items for prosocial behavior toward the family . The score for each dimension is obtained from the average of the scores for each item.The instrument showed good psychometric properties of reliability and validity, both in its original version  and in tTo evaluate empathy, the Empathy Questionnaire by Richaud, Lemos  was usedPositive emotions are emotional experiences in which pleasure or well-being predominate. These emotions were evaluated using the Positive Emotions Questionnaire developed by Oros . The queExamples of the items are as follows: for the joy dimension, “I am almost always happy”; for the gratitude dimension, “I like to thank people”; for the serenity dimension, “I am almost always relaxed”; for the sympathy dimension, “I feel very badly if I see someone getting hurt”; and for the personal satisfaction dimension, “I feel like I am very valuable”.The capacity to forgive was evaluated with The Forgiveness Scale by Rye, Loiacono , which m“Think of how you have responded to the person who has wronged or mistreated you”. Two aspects of forgiveness are evaluated: the absence of negative emotions toward the aggressor  and the presence of positive emotions toward the aggressor . The items are rated on a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores on this scale reflect a greater degree of forgiveness toward the aggressor. Rye, Loiacono , friends , and family members  than the participants in the control group at the different evaluation times.In both countries, the adolescents who participated in the intervention program showed greater prosocial behavior toward strangers . Moreover, in Argentina, the experimental group showed higher levels of emotional awareness  and empathic action  than the control group participants at the different evaluation times, but no differences in emotional regulation and perspective taking were found. In Uruguay, the experimental group participants had higher levels of perspective taking than the control group participants did  at the different evaluation times, but no differences in emotional regulation, emotional awareness, and empathic action were found.The experimental group showed higher levels of emotional contagion than the control group participants in both countries , serenity  and satisfaction  than the participants in the control group did at the different evaluation times.In Argentina, the intervention increased participants’ serenity . Moreover, in Uruguay, the participants in the experimental group had higher levels of the absence of negative emotions toward an aggressor than the control group .The participants in the experimental group had higher levels of the presence of positive emotions toward an aggressor than the participants in the control group did in both countries [Argentina F = 4.16, p = .13); see p < .001) and the absence of negative emotions toward an aggressor remained stable (difference between follow-up and pretest Tukey’s post hoc test t p < .01); see In Argentina, the effect of the interventions on the presence of positive emotions toward an aggressor initially increased but then decreased in the follow-up evaluation  than males, we found no effect in the interaction between gender and the intervention, which indicates that the program was equally effective in females as in males.Given that empathy is a multidimensional construct that is intimately related to prosocial behavior, we analyzed the efficacy of the Hero program for promoting empathy in adolescents. The results indicated that the program was effective for promoting empathy in both countries. Specifically, when analyzing the interaction of the intervention and time, we found that, in Argentina, the adolescents in the experimental group reported higher levels of emotional contagion , empathic action (which refers to the emergence of helping behavior), and emotional awareness (referring to the ability to easily identify the emotions of others) than the control group. The adolescents in the Uruguayan experimental group reported higher levels of emotional contagion and perspective taking (the ability to understand the point of view of another) than the control group. These results provide evidence that the Hero program stimulates the two most important aspects of empathy: the emotional aspect  and more cognitive aspects . Finally, we found a gender effect on empathy in both countries that indicated that females have higher levels of emotional contagion, emotional awareness, perspective taking, and empathic action than males, while males experience a higher level of emotional regulation than females. However, we found no effect on the interaction of gender with the intervention, which indicates that the program was equally effective for females as for males.In relation to positive emotions, the Hero program was shown to be effective, although only for promoting serenity in the Argentina sample. In the Uruguayan sample, adolescents who participated in the program had higher levels of serenity, joy, and satisfaction than the adolescents in the control group. The results indicate that among the positive emotions evaluated in this study, the serenity dimension was the one most stimulated by Hero. These results may have occurred because serenity was directly stimulated in the virtual environment of Hero, while other dimensions, such as joy and satisfaction, were indirectly promoted. In comparison, it is surprising that the program was not effective for promoting gratitude since a specific module of the program is targeted at stimulating this positive emotion. This could be because the instrument we used to evaluate gratitude mainly operationalizes the feeling of enjoyment derived from returning favors  and reciprocity in the face of a supportive event  and does not evaluate broader attitudes of gratitude toward life or people, aspects that are probably more related to the activities promoted by Hero. Consequently, this fact will need to be studied in greater depth in future research.Finally, the Hero program was effective for promoting attitudes of forgiveness against an aggressor in Argentinian and Uruguayan adolescents. Specifically, when comparing the differences between the experimental and control groups, we found that, in the Uruguayan sample, the adolescents who participated in the program had higher levels of positive emotions and a greater absence of negative feelings toward the aggressor than the adolescents in the control group did. In the case of Argentina, in contrast, there was a difference in positive emotions between groups, but the effect of the intervention did not maintain stability in follow-up evaluations. There was a gender effect on forgiveness in both countries that indicated that girls have fewer negative emotions and more positive emotions toward an aggressor than boys. However, we found no effect on the interaction of gender with the intervention, which would suggest that the program was equally effective for females as for males. In conclusion, this research provided deep evidence for the Hero program’s effectiveness. Because Hero is a brief online program, is self-administered, has a low cost, and requires a simple infrastructure , it could be easily disseminated as a possible solution for the promotion of socioemotional variables. Consequently, Hero could be scaled up in several school contexts and other educational institutions in Latin America.In summary, while the Hero program provides evidence of efficacy for the promotion of prosociality, empathy, positive emotions, and attitudes of forgiveness, it impacts each of the dimensions comprising these variables differently depending on the sociocultural context in which it is applied. Consequently, it would be interesting to implement this program in a greater number of countries or cultural contexts to elucidate its efficacy with greater precision. On the other hand, it will also be important to include in future studies a more specific measurement of gratitude to allow a more detailed analysis of the effect of the program on different aspects of this variable.Finally, although the Hero program was initially developed for adolescents in the general population, in the future, it could be extremely interesting to analyze its effectiveness in contexts of violence, in adolescents with difficulties in social interactions, and/or in poverty contexts.


Instagram provides an opportunity to deliver low cost, accessible and appealing physical activity content. This study evaluated the feasibility of delivering an exercise program for young women using Instagram.n = 16; M = 23 years), which prescribed running and body weight exercises to complete three times per week. Daily Instagram posts delivered the exercises, video demonstrations and motivational content. Feasibility was evaluated by examining exposure (Instagram posts viewed per week), engagement , and acceptability . Preliminary efficacy was evaluated by comparing baseline and 12-week self-reported physical activity (IPAQ short-form) and fitness  using the Exact sign test.A single-group pre- and post-intervention trial examined the feasibility and preliminary efficacy of a 12-week Instagram-delivered program with young inactive women (p = .06).On average, participants reported seeing six posts in their Instagram feed per week. Posts received an average of five likes (IQR = 3–6). A total of four comments and one tag were observed across all posts. On average, participants reported completing two exercise sessions per week. Retention was 88% at 6 weeks but dropped to 56% at 12 weeks. Participants reported increased motivation to exercise  and were satisfied with the program . Only self-reported cardiorespiratory fitness showed a meaningful, though nonsignificant, improvement . Future research could examine the use of behaviour change theory and provide information that enables participants to tailor the exercises to their interests and needs. Additionally, the use of objective assessments of physical activity and fitness among a larger participants sample is needed. Insufficient physical activity is a leading risk factor for non-communicable disease and premature death worldwide , 2. PhysOnline social media such as Facebook, Instagram, and Twitter is extremely popular, particularly amongst young adults. For example, almost 8 in 10 Australians report using social media, with rates of use among those aged 18 to 29 years at 99% . Social Celebrity fitness pages are popular on Instagram, with some hosting millions of followers. However, free content is often limited to individual workouts and lifestyle and motivational posts, with users required to pay a fee or sign up to an ongoing paid subscription to receive the full exercise program. Additionally, celebrity programs may not be based on the best available evidence and may not be effective and safe long term. Preventive health approaches could capitalise the popularity of such pages to provide appealing, evidence-based physical activity programs that could be delivered at low cost and freely accessed by users. Despite the potential to use Instagram to provide health programs to young adults, there is a dearth of research in this area. Previous quasi-experimental research has examined whether Saudi female college students would adhere better to a home exercise program delivered via a YouTube video if they were also provided with an Instagram page that delivered information about the benefits of exercise and reminders to exercise . AdherenEthics approval was provided by University of South Australia Human Research Ethics Committee. Participants provided written consent prior to enrolling in the study.The program and Instagram content were informed by three formative focus groups conducted with a convenience sample of 13 women aged 19 to 30, recruited through word of mouth, who were insufficiently active . Participants were asked a series of structured questions about the types of physical activity they would like to see in an Instagram-based program, and the types of Instagram posts they would find motivating. Three key messages from the focus groups informed the program: (1) running and body weight exercises would be preferred because they could be performed outdoors without requiring equipment; (2) Instagram posts should feature people with average body types, rather than fitness models; (3) simple infographics and inspirational quotes should be included.The 12-week program was developed in consultation with a clinical exercise physiologist , motivational quotes , and informational posts . Each post included a caption .Eligibility criteria were female, aged 18 to 30 years, insufficiently physically active , and currently use Instagram. Participants were a convenience sample from the greater Adelaide Metropolitan Region, who were invited word of mouth and snowball sampling to participate in a 12-week exercise program delivered via Instagram (July to August 2018). A sample size of 16 was considered sufficient to meet the primary aim of assessing feasibility of delivering an exercise program via Instagram  prior toThe study used a single-group pre- and post-intervention design. Participants joined the purpose-designed Instagram page entitled “Thrive”, which was set to private so that participants could remain anonymous to Instagram users who weren’t enrolled in the study. Participants were encouraged to turn on page notifications. Daily posts delivered the intervention content. The page delivered one post per day: the weekly exercise program on Sundays, video demonstrations of new exercises on Mondays, and motivational and informational content on other days. The posts were uploaded to scheduling software Later  prior to the commencement of the program and were automatically delivered for the duration of the program (August to November 2018). All participants began the intervention on the same day and received the same Instagram content.Participants undertook a series of telephone support calls of approximately 10 min duration aimed at identifying any feasibility issues and providing troubleshooting assistance . Calls were initially weekly weeks 1, 2, and 3), then bi-weekly (weeks 5 and 7) to reduce participant burden. Calls ceased at week 7 because responses had not indicated any issues with the program content or delivery that required addressing. Participants completed an online survey at baseline, 6 weeks (during the intervention) and 12 weeks , completion of vocational education and training qualification, currently enrolled in a university degree, completion of a university degree], which social media platforms they used , and how often they used Instagram .Participants reported the number of posts seen in the past week via the telephone support calls.The number of likes, comments and tags on each Instagram post were examined. Participants reported the number of exercise sessions completed in the past week via the telephone calls. Retention was defined as completion of the online survey at weeks 6 and 12.In the 12-week online survey, participants reported whether participating in the program had increased their motivation to exercise (1 = strongly disagree to 5 = strongly agree) and their overall satisfaction with the program (1 = not satisfied to 5 = very satisfied), using purpose designed items. Participants also provided open-ended responses to the items “What were the strengths of Thrive, in your opinion?” and “What were areas of improvement for Thrive, in your opinion?”Participants reported the number of days and average time per day (minutes) they spent doing vigorous physical activity, moderate physical activity and walking, using the International Physical Activity Questionnaire short form (IPAQ-s), which is freely available to use without license . Weekly p < .001 for all) [Participants rated their cardiorespiratory fitness and muscle strength relative to others their age using two items from the International Fitness Scale (IFIS), which is freely available to use . Particifor all) .The number of Instagram posts viewed per week is presented descriptively using medians and interquartile ranges.The average number of likes per Instagram post is presented descriptively using a median and interquartile range. The overall number of comments and tags were summed. The number of exercise sessions completed per week is presented descriptively using medians and interquartile ranges. Retention was defined as the percentage of participants who completed the online survey at weeks 6 and 12.Ratings for satisfaction and motivation are presented descriptively using medians and interquartile ranges. Open-ended responses for study strengths and recommended improvements were analysed using thematic analysis to identify common themes and are summarised as the number of participants that endorsed each reported strength or improvement.Twelve-week change in physical activity and fitness variables were examined using the Exact sign test  in SPSS 25.Participants were 16 females aged 18 to 28 years who reported regularly using Instagram .Daily posts received an average (median) of 5 likes (IQR = 3–6) across the 12-week period. Likes were highest in weeks 2 and 3 and declined over the study period  and were satisfied with the program .n = 9) provided open-ended responses, with some participants identifying multiple strengths  or suggestions for improvement . Responses were reasonably brief for both strengths  and suggestions for improvement . Themes were reflected in four main categories: 1) strengths of the Instagram content, 2) strengths of the exercise prescription, 3) criticism and suggestions for the Instagram content, and 4) criticism and suggestions for the exercise prescription. The most common strengths of the Instagram content were that it was easy to access (n = 3), informative (n = 3) and motivating . The most common strength of the exercise prescription was that the progression of difficulty of the exercises was appropriate . The most common criticism of the Instagram content was that it was repetitive . The most common recommendation of the exercise prescription was to reduce the amount of running  and the most common criticism was that the exercises were repetitive . Supplementary Table All participants who completed the week 12 survey  [Table ns/week) . There wThis novel study was the first to design and evaluate an exercise program for young women delivered entirely via Instagram. It was feasible to deliver an exercise program on Instagram, however, engagement with the program was modest. Additionally, there were trends for improvement in self-reported cardiorespiratory fitness, but not self-reported strength or self-reported physical activity. Results highlight some avenues for improving engagement with and efficacy of future exercise programs delivered via Instagram.Results suggest that an exercise program can be delivered to young women on Instagram using a cost-effective hands-off approach. Instagram content was uploaded to scheduling software Later, which delivered the Instagram posts each day with no further action from the research team. Although smartphone apps have become a popular method of disseminating health programs and have been shown to be moderately effective in increasing physical activity , 18, theSimilar to the use of algorithms to determine content in a user’s Facebook feed , 20, InsParticipants reported completing two out of the three prescribed sessions per week on average. Over 40% of participants dropped out of the program by week 12. Additionally, engagement with the Instagram content was low, with approximately 30% of participants liking each post, and most participants never commenting or tagging. Maintaining participant interest over time has been a major challenge for internet-delivered health interventions  were included in 7 weeks of the program. We note that we were likely underpowered for these analyses. Only nine participants could be included in this analysis, and patterns of change may have been clearer in larger sample.p < .05 for all Bonferroni-adjusted pairwise comparisons) [Participants also did not show statistically significant improvements in self-reported strength or cardiorespiratory fitness. The World Health Organisation recommends that, to improve cardiorespiratory and muscular fitness, adults aged 18–64 years should do at least 150 min of moderate-intensity aerobic physical activity or 75 min of vigorous-intensity aerobic physical activity per week, as well as muscle-strengthening activities on at least 2 days per week . If partarisons) .To our knowledge, this study is the first to evaluate an exercise program delivered via Instagram. The program was developed in consultation with exercise experts and formative research with end users, and contrasts with current Instagram offerings ; however, limitations must be noted. The pilot sample was small, highly educated, and non-representative. Additionally, two participants were classified as highly active according to the IPAQ-s at baseline, suggesting either the screening item did not accurately identify those participants as active or the participants overestimated their activity at baseline on the IPAQ-s. All measures were self-reported except for the examination of likes, comments and tags on the Instagram posts, which were observed on the Instagram page. Although the IFIS has shown significant associations with objective measures of fitness , objectiOnly 56% of participants completed the 12-week survey. This data should therefore be treated with caution. Results may have been different if all participants had completed the final questionnaire. Retention may have been low because 50% of participants were currently enrolled in University, and 12-week assessments coincided with end-of-semester examinations. A rigorous reminder or follow-up procedure should be employed in future to reduce missing data.The video demonstrations used in the program included a variety of women in different settings . This may have influenced feelings of continuity and impacted participant engagement. Additionally, we selected videos by fitness trainers that provided detail about how to ensure the correct form while performing the exercises. Although no videos depicted ‘extreme’ body types , most had a body type that would be considered thinner than average. Therefore, we were not always able to follow the recommendation from the focus groups to depict average body types in the program. Future iterations of the program could overcome this limitation by purpose-designing the videos. It is also important to note that the program was run as a private Instagram group, for research ethics reasons. A major advantage of using social media for health promotion is the potential for health information to spread rapidly through online social networks. Although running the program as a private group maintained participants’ privacy, running the program as a public page would likely extend the reach of the program and improve effectiveness. Future research should aim to use a larger representative sample and objective measures of physical activity and fitness, and evaluate the reach of the program through a public, rather than private, Instagram page.This study showed there is potential to use Instagram to deliver an exercise program for young women, but further research and development is needed before the program would be suitable for delivery on a large scale. The program was feasible to provide; it was low-cost, accessible and provided participants with sufficient information to enable them to perform the exercises. Generally, participants were satisfied with the program. However, the program did not show feasibility in terms of promoting a high level of engagement  or preliminary efficacy in terms of increasing physical activity and fitness. Future research should aim to identify methods of maximising engagement with physical activity content on Instagram, and examine how increased engagement affects exercise adherence. Engagement with the program might be improved through incorporating behaviour change theory and enabling participants to tailor the exercise program to their needs. The use of objective assessments of physical activity and fitness among a larger participants sample is also required to more accurately assess the efficacy of the program.Additional file 1: Table S1. Thrive 12-week exercise program, to be completed three times per week.Additional file 2: Table S2. Survey items. A list of all survey items that were used in this study, indicating response options and data collection timepoints.Additional file 3: Table S3. Results from open-ended survey items at week 12.


Connect for Health is an evidence-based weight management program with clinical- and family-facing components for delivery in pediatric primary care for families of children ages 2 to 12 years. We used the Consolidated Framework for Implementation Research (CFIR) to guide formative work prior to national implementation. The purpose of this study was to describe the process and results of stakeholder engagement and program adaptation.We used mixed qualitative and quantitative methods to iteratively adapt and optimize the program by assessing needs and perspectives of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. We conducted interviews with primary care clinicians from four health care organizations in Boston, MA; Denver, CO; and Greenville, SC, and used principles of immersion-crystallization for qualitative analyses. We also conducted surveys of parents of children with a body mass index ≥ 85th percentile.n = 400), approximately 50% were Spanish-speaking and over 75% reported an annual income < $50,000. Parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and offering multiple methods for resource delivery. Decisions about program modifications were made at the program and healthcare-system level and based on stakeholder engagement findings. Modifications included cultural, geographic, and target audience adaptations, as well as varied resource delivery options.We reached thematic saturation after 52 clinician interviews. Emergent themes representing the CFIR domains of intervention characteristics, outer and inner setting, and process included (1) importance of evidence-based clinical decision support tools that integrate into the workflow and do not extend visit time, (2) developing resources that respond to family’s needs, (3) using multimodal delivery options for family resources, (4) addressing childhood obesity while balancing competing demands, (5) emphasizing patient care rather than documentation and establishing sustainability plans, and (6) offering multiple training methods that incorporate performance feedback. Of the parents surveyed (Connect for Health program and national implementation settings, adaptations were systematically made through engagement of clinician and parent stakeholders to support adoption, sustainability, and health outcomes.To ensure the fit between the NCT04042493 Contributions to the literatureFew evidence-based, scalable childhood obesity interventions have been implemented in the pediatric primary care setting.By engaging clinician and parent stakeholders during the pre-implementation phase, we identified needs, perspectives, and preferences for the clinical- and family-facing program components, contextual barriers and facilitators, and organizational readiness, which allowed us to adapt and refine the intervention tools and implementation strategies to fit the contextual needs of the implementation sites.This study adds evidence about contextual factors based on stakeholder engagement that need to be evaluated prior to implementation and illustrates real-world solutions to addressing those factors.Connect for Health is a proven-effective PWMP intended for delivery in primary care to improve body mass index (BMI) and family-centered outcomes that leverages clinical and community resources [Despite national obesity prevention efforts, the prevalence of childhood obesity remains high and continues to disproportionately affect low income and racial/ethnic minority children –3. Primaesources , 9; the The pre-implementation phase provides an opportunity to assess contextual factors that influence implementation by engaging key stakeholders, thereby increasing the likelihood of successful translation from research to practice. The Consolidated Framework for Implementation Research (CFIR) is a meta-theoretical framework that represents constructs across five domains  to assist in the understanding of what works and why . CFIR haConnect for Health pediatric weight management program across four healthcare organizations in the USA, we aimed to engage stakeholders, iteratively adapt and optimize the program to fit the implementation contexts, and ultimately improve the adoption of the program nationally. The purpose of this study is to describe the process and results of stakeholder engagement and program adaptation.In preparation for national implementation of the Connect for Health is a weight management program for families of children ages 2 to 12 years with a BMI ≥ 85th percentile that leverages clinical and community resources [esources . In a raConnect for Health program by assessing needs, perspectives, and preferences of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. In preparation for implementation, we engaged pediatric clinicians and parents across four healthcare organizations through interviews and surveys consistent with the Patient Centered Outcomes Research Institute’s guidelines for stakeholder engagement [clinicaltrials.gov (NCT04042493).We used mixed qualitative and quantitative methods to iteratively adapt and optimize the gagement . In addiConnect for Health is being implemented in four healthcare organizations across the USA: Boston Medical Center and Massachusetts General Hospital in Boston, Massachusetts; Denver Health in Denver [n Denver , 22, ColPediatric clinicians and support staff were identified by research study staff and stakeholders at each site and were sent an email if they were interested in participating in an interview. Research study staff with experience conducting qualitative interviews at each site conducted interviews by phone or in-person using a semi-structured interview guide. Interviews were approximately 30–45 min in length and were audio-recorded. Participants were provided with $50 for compensation. Participants were enrolled until thematic saturation was reached and no new concepts emerged.The interview guide was developed to understand clinicians’ needs and preferences for the clinician and family-facing program components, implementation strategies, contextual barriers and facilitators, and culture and readiness for implementation . Surveys took approximately 10 min to complete and participants received a $10 gift card as compensation.The survey questions aligned with the CFIR domains and were intended to assist with program adaptations and implementation to ensure we met the needs of families , and workflow across the sites, we found thematic saturation after 52 clinician interviews. The findings from the engagement we completed with other key stakeholders  were similar to the clinician interview findings in regards to EHR tools, workflows, and aligning with healthcare organizations’ priorities. The findings from the interviews represented the CFIR domains and resulted in six emergent themes. Table clinicians wanted evidence-based clinical decision support tools for screening and management that are actionable, integrate into their workflow, and do not detract from patient care or extend visit time. This theme provided important information regarding the CFIR constructs of intervention adaptability and complexity and allowed us to make modifications to the clinical-facing tools to be responsive to clinicians’ needs and preferences while increasing best evidence-based practice for screening and management of childhood obesity.We asked questions about the CFIR domain of intervention characteristics regarding preferences and needs of EHR flagging and clinical decision support tools and found family resources should be responsive to the needs of families by being concrete, culturally sensitive, available in multiple languages, and include local resources; and (2) the delivery of the resources should be multimodal to suit the needs of families, clinicians, and staff. These themes highlighted patient needs and resources across the four healthcare organizations and the need to ensure the family-facing tools would be responsive to their needs.Two themes emerged when exploring the CFIR domain of outer setting by asking questions regarding needs and preferences for family-facing tools. The themes included (1) childhood obesity is an important issue and clinicians are open to implementing new programs, but they are aware that competing priorities may detract from this program; and (2) for successful adoption, the program should highlight the importance of improving patient care rather than documentation, and sustainability plans should be addressed early as clinicians have seen other programs fade out. The first theme represented the CFIR constructs of implementation climate and organizational readiness, while the second theme represented the CFIR constructs of implementation climate and culture.We asked clinicians questions about implementation readiness and their organization’s culture representing the CFIR domain of inner setting and two themes emerged (1) clinicians prefer a combination of in-person, individual, and online trainings that are concise, interactive, and case-based that are offered throughout the program duration and provide feedback to clinicians and practice. This theme illustrated the CFIR constructs of engaging, champions, and reflecting and evaluating, and helped elucidate ways to engage clinicians in program adoption, identify key implementation leaders, and understand the role clinician champions should play in the implementation process.We explored the CFIR domain of process by asking questions about training and implementation strategies and we found We completed 400 parent surveys (220 in English and 180 in Spanish) in the Boston, Denver, and Greenville area see Fig. . ParentsFollowing the mixed methods assessments, we made several adaptations to the core program components and to the implementation strategies. We found the results of the engagement across all stakeholders converged which strengthened our modification decisions. As a research team across all four organizations, we collectively reviewed results of the clinician interviews, parent surveys, and other stakeholder engagement activities. Based on the findings, we made modifications at the program level and then each healthcare organization identified additional changes for their setting. During the pre-implementation phase, the research team met monthly via video conferencing, as well as an in-person meeting to review and discuss program adaptations. Across the core components, we identified cultural and geographic, mode of delivery, and target audience adaptations that were necessary due to differences in geographic location and patient populations as compared to the original trial, differences in organizational culture and clinical workflow, and in consideration of future program scalability . Table 4Based on the interviews, we learned each of the healthcare organizations had their own unique practice workflow and had customized EHR instances; therefore, each site modified the flagging of children with an elevated BMI to fit their needs. For example, changes included creating a non-interruptive best practice alert and having medical assistants receive alerts rather than the physician. Changes to the clinical decision support tools included housing family-facing tools within the EHR and creating an order to enroll patients in the text messaging program that would support future program sustainability. We aligned changes to the best practice alert and clinical decision support tools with performance metrics at the healthcare organizations to incentivize the usage of the EHR tools and for sustainability purposes.Modifications to the family-facing tools  included translation of materials into languages spoken by the healthcare organizations’ patient populations, revision to the materials to meet the needs of patients in urban and rural settings and geographic locations across the USA, and consolidation of educational materials for ease of delivery. Additional changes included a handout focused on creating a balanced nutrition plan and modifying the text messages to be unidirectional rather than bidirectional. Several of these modifications  were made at the program-level in consideration of program sustainability and scalability.Modifications to the implementation strategies included selecting a clinician who was embedded within the clinical practices to engage other clinicians and champion the program, adding a practice coach to provide technical assistance, and inviting all staff to in-person trainings and extending them throughout the implementation phase. Based on the interest in on-demand trainings, we also added a virtual learning community for capacity building of childhood obesity screening and management. For the in-person trainings and virtual learning community, we intend to offer continuing educational units and quality improvement bonuses  to incentive participation and increase the likelihood that clinicians will be familiar with the program. Modifications to the implementation strategies were made at the program level, but each of the healthcare organizations were encouraged to customize as needed.Connect for Health pediatric weight management program, six themes emerged that informed adaptations to the clinical- and family-facing components of the program that mapped to the CFIR domains of intervention characteristics, outer setting, inner setting, and process. Additionally, parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and delivering resources using a variety of methods. We leveraged the stakeholder feedback to then iteratively modify the program in preparation for national implementation. A key component of program implementation has been maintaining the core components of the evidence-based intervention while adapting it to each site’s workflow, needs, and culture. This approach makes the program generalizable to a broad variety of medical homes that serve children, including hospital-based clinic systems, federally qualified health centers, and other clinic-based systems. The approach also serves as a model for disseminating and implementing other clinical practice innovations.In this mixed methods study involving stakeholder engagement to adapt the The high prevalence of childhood obesity necessitates the translation of evidence-based interventions into routine clinical care to improve child health outcomes. Effective pediatric weight management interventions are being implemented in school-systems, community programs, and child-care programs –30, but Connect for Health program, the outer setting, the inner setting at the four healthcare organizations, and the implementation process. Clinicians discussed that complexity and adaptability of the intervention would impact their adoption of this program. For example, if the EHR tools did not integrate into their existing workflow or if the tools added additional time or “clicks” to the visit, clinicians reported they would be reluctant to use the program. These contextual factors have been previously identified, but through our engagement, we could probe for solutions and make adaptations to the EHR tools and implementation strategies [Using the CFIR, we explored characteristics of the rategies . Severalrategies . These iEngaging parents helped us to understand their needs and refine the program and our implementation plans. Findings from the clinician interviews and parent surveys aligned, including multimodal delivery methods of materials, parent’s interest in discussing and developing plans for weight management, and providing referrals and resources. In addition, clinicians discussed the importance of family-facing resources and materials being responsive to family’s needs, culture, and geographic location. This information and the resultant modifications ensured that our materials were family-centered. Interventions that are family-centered have been shown to improve child health outcomes , but manConnect for Health program, clinician champions will encourage reflection and evaluation, but other strategies will be employed, including practice coaching and learning communities to promote adoption through other mechanisms of action [Understanding culture, implementation climate, and organizational readiness assisted with planning and developing implementation strategies. Clinicians discussed methods of how they wanted to be engaged in adopting this program. Methods included in-person and on-demand educational trainings that were offered both individually and as a group. Clinicians also recognized the importance of receiving feedback throughout the implementation phase to improve their performance. To meet this need, we will have clinician champions deliver feedback and encourage reflection and evaluation. A systematic review found that champions were associated with implementation success, although the findings suggest that it was champions in conjunction with other strategies that promoted change . For impf action . We haveConnect for Health in four healthcare organizations; this work, though, does present with limitations. In the clinician interviews, we did not include questions pertaining to the CFIR domain of characteristics of individuals. Although this domain may offer insights into the uptake of the program, we felt that during this phase, other domains were more critical for planning and we choose to omit these questions in the interview guide. Additionally, we were not able to interview all of the unit chiefs of the health centers or practices. To ensure buy-in and that we understood the needs and culture of the individual health centers and practices, we attended meetings with unit chiefs, both individually and as a group. The four healthcare organizations whom will be implementing Connect for Health have several differences , but also share commonalities including being large university-affiliated medical centers and having the same EHR vendor. Therefore, some of the findings from the parent surveys and clinician interviews may not pertain to other healthcare settings.This formative work during the pre-implementation phase represents an important step in the implementation of Connect for Health program in the pediatric primary care setting stands to improve the health and family-centered outcomes of children throughout the USA. In preparation for national implementation of the Connect for Health pediatric weight management program, we engaged clinician and parent stakeholders through a mixed methods assessment. This approach during the pre-implementation phase was useful in adapting and refining the program and implementation strategies to fit the contextual needs of the four healthcare organizations. Through engagement, we identified needs and preferences for the clinical- and family-facing program components, contextual barriers and facilitators, and organizational readiness, which resulted in cultural, mode of delivery, and target audience adaptations at the program and healthcare system level. During the implementation phase, we will evaluate the effectiveness of our implementation strategies to increase the uptake of this program in the pediatric primary care setting.Given the high prevalence of childhood obesity and its disproportionate impact on racial and ethnic minority, low-income populations, the adoption of the evidence-based Additional File 1: Connect for Health Clinician Interview Guide. Description of data: This supplemental file contains questions used to guide interviews with clinicians prior to program implementation across sites.Additional File 2: Connect for Health Parent Feedback Survey. Description of data: This additional file contains survey questions used across implementation sites to solicit feedback from parents regarding the Connect for Health pediatric weight management program.


In the Canadian context, the Association of Faculties of Medicine of Canada (AFMC) announced in May that all interviews of medical students applying for 2021 Canadian Resident Matching Service (CaRMS) positions will be in a virtual format. At the AFMC board meeting on June 18, it was decided that there will be no visiting electives for the medical students in the Class of 2021 for the duration of the 2020–2021 academic year.2 As a result of the changes made in response to the COVID-19 pandemic, the class of 2021 will not have the same opportunity to gather this knowledge about residency programs. Students already report that the residency application process is frustrating and too subjective,3 and the pandemic-related changes and uncertainty could make this worse.4Medical students use both visiting electives and interviews to gather information about different residency programs and to demonstrate their interest in particular residency programs. Students use these visits to meet program directors and faculty members, get to know residents, and visit the program training sites.5 The COVID-19 pandemic has made it impossible to visit cities during electives and interviews and very difficult at other times.Students also use electives and interviews as a unique opportunity to experience the city itself, independently of the academic program at a given university. This may be of particular importance in a nation the size of Canada. CaRMS data have shown that the number one most important factor for program location choice is the “impression of the town/city.”6 For students who matched to Neurology, it was 79%. The published literature on selection of residency programs provides further support to the idea that in-person contact with a residency program is a critical factor in medical students’ decision-making.8How important is it for a medical student to visit residency programs in person? In 2020, approximately 55% of Canadian medical graduates who matched to a residency program in Canada had previously completed an elective in that discipline at the school to which they matched.9 provides advice to medical students applying to adult and pediatric neurology programs. Rather than asking factual questions about research or elective opportunities, the answers to which are often readily available on the CaRMS or program websites, Mirian and colleagues make a strong case for students to develop an “actionable plan” for their evaluation of residency programs. They encourage students to ask residency programs more in-depth questions about the structure and culture of the program. These include how the program’s selection committee will address inequalities in the selection process (such as the advantage that students from a “home school” may have); the adaptability of the program in terms of clinical structure, wellness, safety, and research opportunities in the pandemic era; and the availability of guidance in the form of mentorship and career planning.How can medical students in the class of 2021 learn about and evaluate the strengths of different residency programs? The article by Mirian and colleagues in this issue of the Journal10 and included additional suggestions such as virtual social gatherings, an enhanced social media presence, testimonials from former residents, and resident-led blogs.11 Importantly, these strategies are not only a means to inform students but they also provide opportunities for programs to showcase their strengths and recruit students.Mirian and colleagues also provide advice to residency programs about how to inform students about their program in the absence of in-person electives and interviews. Strategies include improving program websites, allowing applicants to attend virtual academic half-days, hosting virtual meetings with the program director or residents, posting informative videos, hosting virtual tours or information sessions, and connecting applicants with existing residents. Other authors have echoed these suggestions9 However, one could argue that the opposite may be true. While the response of a program to a stressor can reflect where it started, it can also illustrate where it is planning to go. Ideally, all programs should be making continuous efforts toward improvement, and the current pandemic provides an opportunity for all programs to innovate.Mirian and colleagues suggest that programs which successfully adapt their educational strategies to COVID-19 “likely have a well-established foundation in clinical and teaching excellence.”The article by Mirian and colleagues does not address how residency programs can best gather information about students in the absence of visiting electives and in-person interviews. They suggest that applicants should find answers to fact-based questions about the program on the CaRMS or program websites and focus their virtual face time with the program on more specific details. Perhaps a similar suggestion could be made to the programs. For instance, the answer to traditional interview questions such as “why do you want to be a neurologist” can often be found in the applicant’s written personal statement. With less in-person time with medical students available to residency programs, focusing on interview questions that could help get to know the applicant as a person, team member, and learner could be a more effective use of time.3 The COVID-19 pandemic may offer residency programs the opportunity to critically review this selection process,12 increase objectivity, and reduce the emphasis on perceived “fit”13 and familiarity with the program.14 The use of a defined set of criteria to select applicants for interviews,13 more structured interview formats,12 and greater transparency about the selection process used3 are potential strategies for improvement.Mirian and colleagues also do not address the process that residency programs use to select residents. The CaRMS application process has been criticized for its bias and lack of objectivity.There is no question that the COVID-19 pandemic has provided many challenges for medical education. However, as Mirian and colleagues have shown in their thoughtful article, the pandemic is also an opportunity for both medical students and residency programs to improve the residency selection process.


As measures, the NRC subscale of the Brief RCOPE, the Experiences in Close Relationships-Revised questionnaire, and the Childhood Trauma Questionnaire-Short Form (CTQ-SF) were used. From the whole sample, 23.7% respondents reported higher NRC. Respondents with higher anxiety in close relationships were more likely to use negative coping strategies, with an odds ratios (OR) of 1.27 . Similarly, avoidance was associated with negative coping OR = 1.41 (1.13–1.75). Moreover, each subscale of the CTQ-SF revealed a significant association with high summary NRC. Respondents who reported physical neglect scored highest on summary NRC with OR = 1.50 (1.23–1.83) after controlling for sociodemographic variables, but also for anxiety and depression. Our findings support the idea that childhood trauma experience and adult attachment style are associated with higher use of NRC strategies.Religion as a coping strategy is mostly connected with positive health outcomes. Yet, negative religious coping (NRC) has been associated with rather negative outcomes that affect one’s health. The aim of this study was to explore whether insecure adult attachment and childhood trauma are associated with higher NRC. A sample of Czech adults ( Religion belongs among well-documented coping strategies, through which one can understand and deal with stressors . When asAs a multidimensional construct, religious coping has both positive and negative associations with health . PRC hasThe first reason people use NRC may lie in their attachment strategies. One’s beliefs about and relationship towards God have been found to be similar to human attachment relationships ,17. For The second explanation could be that the inclination to draw on PRC or NRC strategies in crises could be associated with one’s image of God . WhereasAs a robust predictor of poor health-related outcomes, NRC has been separately assessed in some studies ,30,31. ATherefore, the aim of this study is to explore the association of adult attachment and childhood trauma with NRC in a highly secular environment. We wanted to assess NRC, using both a total score and a more detailed analysis of individual items, to see which of these items showed the strongest association with our observed variables.The sample in our research was created by selecting from the original representative sample only the respondents who identified themselves as religious. The original sample of the Czech population aged fifteen years and older was obtained by using a two-step procedure. In the first step, the questionnaire and all further procedures were piloted among 206 participants. This led to the final version of the survey. In the second step, another 2184 participants were randomly chosen with the help of quota sampling and asked to participate in a study on health, life experiences, attitudes, and lifestyle. Quota sampling is a technique often used in research to imitate the known characteristics of the population in the sample, allowing relationships between subgroups to be observed. In this case the criteria that allowed the construction of a representative sample corresponding to the adult Czech population were used. Of these respondents, 384 (17.6%) refused to participate mainly due to their lack of time or no interest in the topic. The remaining sample consisted of 1800 respondents. Among whom only some reported themselves as religious; therefore, the final sample consisted of 531 participants.Data was collected by professionally trained administrators in September and October 2016 during a standardized face-to face interview with the respondents. Participation in the survey was anonymous and voluntary and respondents did not receive compensation for their participation in the survey. Participants signed an informed consent form prior to the study; this stressed the possibility of leaving the study at any time without giving reasons. The study design was approved by the Ethics Committee of the Olomouc University Social Health Institute, Palacky University in Olomouc (No. 03/2016).All instruments were available in the Czech language. Religious background was obtained using self-developed questions on religiosity: ‘At present, would you call yourself a believer?’ with possible answers: yes, I am a member of a church or religious society; yes, but I am not a member of a church or religious society; no; no, I am a convinced atheist. The question assessed whether respondents consider themselves religious and whether they are affiliated to a specific religion or religious practice.Religious attendance was measured as the frequency of attending church or religious sessions using the question: “How often do you go to church or to religious sessions?” Possible answers were: never, occasionally; often, but not every week; once a week; more than once a week. Those who reported attending religious sessions at least once a week were considered attending. Prayer frequency was assessed by the question: “How much time do you devote to personal prayer (excluding religious gatherings)?” with possible answers: at least half an hour a day; approximately 10 min every day; approximately 10 min together per week; I pray only occasionally, I don’t pray.Religious coping was assessed using the negative religious coping subscale (NRC) of the Brief RCOPE . It is cExperience in close relationships was assessed using the shortened version of the Experiences in Close Relationships-Revised (ECR-R-16) questionnaire , which wTo assess childhood trauma, the Childhood Trauma Questionnaire-Short Form (CTQ-SF)  was usedAnxiety and depression were assessed by Anxiety and Depression subscales of the Brief Symptom Inventory (BSI-53) ,44. The In the first step, we described the background characteristics of the sample and the distribution of NRC item responses. Nonparametric methods were used to compare different sociodemographic groups. The Wilcoxon sign-rank test was used to compare gender; in other cases, when more than two groups were compared, we used the Kruskal-Wallis test. We then assessed the associations of two attachment dimensions, anxiety and avoidance, and the five types of childhood trauma experiences with negative religious coping  using a binary logistic regression model that was crude at first (Model 1), adjusted for gender, age, marital status, and education (Model 2). Finally, above that to establish whether the positive relationship between negative coping and recollected trauma and attachment insecurity are not only a spurious effect of general anxiety and/or depression we assessed the third group (Model 3) adjusted also for background levels of depression and general anxiety to compare groups of people already showing general negativism. Each of the independent variables was assessed in a separate model. All analyses were performed using the statistical software package IBM SPSS version 21 .p = 0.012). However, a comparison of the groups according religious practice  did not reveal any significant differences.The background characteristics of the sample  are presented in The results of binary logistic regression assessing the associations of childhood trauma with negative religious coping and its separate items, crude and adjusted (Models 1–3) are presented in The aim of this study was to assess the associations of adult attachment and childhood trauma with negative religious coping. We found that almost a quarter of religious population showed signs of NRC and we also observed higher NRC within the group of elderly respondents. Furthermore, we found that NRC was associated with both anxiety and avoidance in close relationship and with all five types of childhood trauma experience.The finding of higher NRC within the group of the elders is in line with results of other studies e.g.,  and mighWe also found that respondents who reported anxiety in adult relationships were more likely to report higher NRC. These findings are consistent with those of other studies ,35. An eAdditionally, we found that attachment avoidance was associated with NRC, which corresponds to the findings of Schottenbauer et al. , who repFurthermore, we found that all subscales of the CTQ were associated with NRC. These results are consistent with the findings of other studies which have reported a negative impact of childhood trauma on religiosity ,27,28. VIn addition, we found no significant association between emotional and sexual abuse and some NRC items. Although respondents wondered what they had done that God would punish them, questioned God’s love, or felt abandoned by the religious community, they did not feel abandoned or punished by God for their lack of devotion. These findings contrast to those of other authors, who found strong associations between sexual and physical mistreatment and a concept of God as distant  and an aFinally, the comparison of the three models showed the differences between crude and adjusted data. Whereas the difference between crude model and model adjusted for age, gender, marital status and education was only slight, comparing these models to the model adjusted also for background levels of general anxiety and depression revealed differences. After checking for a spurious effect of general negativism in Model 3, the results showed no associations between anxiety in close relationship and NRC items except for the feelings of punishment from God and NRC summary. The comparison of groups in this model showed that association between NRC and childhood trauma and attachment avoidance and anxiety can be related to general negativism. Moreover, it is possible that adverse childhood experiences and attachment insecurity can be associated with higher adult anxiety and/or depression in general, which can consequently negatively influence one’s religious coping.Our findings of an association between the feelings of being punished by God and negative religious coping support the idea of Pollard  that insThis study has several important strengths. The most important is its response rate. It is also one of the few studies that assesses the associations of negative religious coping with adult attachment and childhood trauma experience in a secular environment. However, the high rate of religiously unaffiliated respondents in the original sample limited the sample size for this study. Another limitation is the cross-sectional design of the study, which does not allow us to make causal inferences. The third limitation may involve cultural awareness, as our study does not reflect a particular cultural context. Furthermore, the last limitation concerns information bias, as our data were based on self-reports of respondents, which might be influenced by social desirability as religiously affiliated respondents might have responded according to their images of God and religiosity. These limitations should be included in a follow-up study in order to achieve a better and more precise understanding of underlying processes that affect the tendency to use maladaptive religious coping.Our findings suggest that attachment avoidance and anxiety as well as childhood experience of maltreatment may affect NRC. Framed within a multidisciplinary approach toward dealing with the history of childhood trauma or with the attachment insecurity, NRC might be worth considering for professional counselling interventions in the area of spirituality aimed at lowering the use of NRC. The counsellor or spiritual guide can obtain information about patient’s religious background or whether the patient uses religion to cope with his or her trauma. This can contribute to the culturally sensitive awareness of a counsellor.At the same time, using NRC strategies can serve as a sign of attachment insecurity and distress, and could therefore be informative for professionals in other areas. Further research is needed to explore the role of religiosity in both one’s partner and one’s parents in the development of individual religiosity and one’s image of God. The role of a perpetrator of violence should be further considered. Moreover, further research should focus on unravelling the causal pathways.Our findings suggest that adult attachment and childhood trauma are associated with negative religious coping. Attachment anxiety and avoidance may be transmitted to the relationship to God and lead to increased use of NRC strategies. Similarly, individuals who suffered any form of childhood trauma may tend to view God as rather distant and unloving, and they might be more likely to use NRC. Thus, this study offers a deeper understanding of the factors that might contribute to the use of maladaptive NRC.