Puppy raisers (PRs) are central to the raising and training of assistance dogs (ADs). They are members of the public who volunteer to help look after an AD puppy for the first year of its life, in partnership with an AD program provider. Research has established that experienced PRs likely raise more successful puppies. What remains unexplored is the motivations and experiences of PRs as volunteers, who may return to raise more puppies if their program experience is generally satisfactory. In this study, we invited university staff and students from two campuses in Victoria, Australia, affiliated with the same university, to participate in a PR program endorsed by the university. We interviewed 16 participants throughout the program  and analysed the data thematically to understand their experiences. We also considered our findings within a volunteer framework called the Functional Approach to Volunteerism. Our results supported past findings regarding the benefits PRs obtain from organisational and practical supports. We also identified four functional motivations for the PRs: altruism, egoism, interacting with others, and learning new skills. Future quantitative research is required to examine the relevance and influences of these motivations on PRs’ experiences and also on the training outcomes of their puppies.N = 16) from the same university-based program in different Australian regions . Semi-structured interviews were conducted and analysed both inductively and deductively. The inductive approach identified four major themes that helped to understand the PRs experiences throughout the program: expectations as a PR, organisational and environmental support and suitability, the intensity of PR workload, and practical support. The deductive analysis identified four functions of volunteerism relevant to PRs’ motivations: altruism , egoism (enhancement), interacting with others , and learning new skills (understanding). Overall, the results obtained from the two groups were consistent with past findings suggesting the benefits of organisational and practical support. These findings further develop our understanding of how to enhance puppy-raising experiences.Assistance dogs are beneficial; however, accessing one can be challenging due to the time, cost, and high failure rates associated with training. A major factor contributing to a high failure rate appears to be the competency of volunteer puppy raisers (PRs), with returning PRs typically more effective than first-time PRs. However, there remains a gap in the literature dedicated to examining PRs’ experiences and how they are affected by the raising programs. This study analysed two groups of PRs ( Assistance animals help their handlers with a disability mitigate the impacts of that disability on their lives ,2. The tTo keep costs down for handlers, AD organisations typically recruit volunteer puppy raisers (PR) from the community to help raise each puppy for the first year of life. These PRs perform a vital community service, often at some personal cost. The inconvenience of caring for a puppy may result in PRs relinquishing the puppy during the program or not returning as a PR once the first puppy is returned to the organisation. Sustainable solutions for the AD industry include effectively outsourcing puppy caring and training responsibilities to PRs, which, in turn, requires understanding the experiences of these volunteers so as to improve recruitment and retention.Raising puppies involves a long and demanding program that requires considerable sacrifice from volunteers. Volunteer PRs house puppies from around eight weeks of age to 12–16 months old ,12, takiN = 978) AD puppies’ behaviour at 6 and 12 months old. At 12 months, several aspects of the puppy-raising environment correlated with the puppies’ behaviour, as reported by their PRs. Those who had been a PR before were more likely to raise a puppy that demonstrated positive behavioural outcomes and who was more likely to continue into advanced training. In contrast, the opposite was true for first-time PRs [A recent critical literature review  proposedtime PRs . DeWitt time PRs  also foutime PRs ,14,21,22The high demands of being a PR, such as caring for and being with the puppies almost every day, can result in burnout ,23. MoreThe Functional Approach to Volunteerism (FAV) framework  posits tOf the six functional reasons, the understanding and social factors could help explain the experiences of PRs in recent research in the AD literature. Regarding understanding, Chur-Hansen et al.  found prA notable aspect of DeWitt’s  findingsThis study aimed to understand the experiences of PRs in the same raising program but located in two different parts of Victoria, Australia. One area was Bundoora, which is a suburb of Melbourne, a large city of 5 million people. The other area was Bendigo, a small city of 100,000 people about 150 km north of Melbourne. To achieve these aims, this study adopted an in-depth qualitative interview method to explore the impacts of the provision of support or the lack thereof during an AD puppy-raising program. Additionally, the specifics of the type of support that impacted the PRs are included in the analysis so future programs can begin to understand how to best support their PRs. Since the programs were implemented at two university campuses, a secondary aim of this study was to understand the suitability of campus environments for running AD-raising programs. The findings of this study will hopefully help future PR programs to improve their PRs’ overall program outcomes, with the long-term benefits for the AD industry including more satisfactory volunteer experiences and thus enticing them to raise further puppies.The data in this study were collected as part of a larger project, i.e., . The proWe recruited sixteen LTU members (twelve women and four men), eight from the Bundoora campus  and eight from the Bendigo campus . Eight were undergraduate or postgraduate students, and eight were staff members holding various academic and non-academic positions. Participation in the program was voluntary, and participants were recruited via convenience sampling. Inclusion criteria required participants to be continuing LTU students or staff members for at least the next 12 months, at least 18 years of age, and able to communicate in English. After expressing interest in the study, the program’s AD training provider assessed the individual as having suitable personal characteristics and home and work environments to raise a puppy. There were no explicit exclusion criteria. Some participants had prior experience raising dogs and other pets; however, none had raised an AD puppy.Although the recruitment of this study did not determine data saturation as a point of terminating data collection, our sample of 16 exceeded the recommended number of 12 for an exploratory qualitative study ,31.Participants were interviewed multiple times before, during, and following their involvement in the program. Semi-structured interview schedules were used with broad and non-leading questions, allowing conversations to unfold while staying on topic . The queThe overall procedure of this study adopted an extended fieldwork  design to enhance theoretical validity . A methoBecause implementing a puppy-raising program as part of the university’s approved activity was not widely known, the program was piloted at the smaller campus, i.e., Bendigo, before being rolled out to the Bundoora campus. The two programs followed the same puppy-raising protocols of the AD provider. However, the research designs varied slightly to reflect the piloting and normal implementation nature of the overall project; there were also different research ethics approvals for the two cohorts. Specifically, during the piloting phase, we conducted more frequent interviews (seven to ten interviews for the Bendigo PRs), while the program at the Bundoora campus followed a more common research design with interviews conducted at three time points. In terms of recruitment, the program was advertised to university students and staff through official LTU media and communication channels from December 2018 to March 2019 for the Bendigo campus and July 2019 and October 2019 for the Bundoora campus. Since this was the first official puppy-raising program between a university and an AD program provider in Australia, the roll-out of the same puppy-raising program at two campuses was planned at different stages to account for the availability of puppies and staffing of the program provider.Prospective participants received a participant information and consent form, and upon returning a signed copy, were asked to attend an initial interview before being admitted into the puppy-raising program by the program provider. Throughout the program, PRs attended several follow-up interviews over seven to fourteen months.Once they received an AD puppy from the program provider, PRs were responsible for caring for and implementing training programs for those puppies with support from the AD organisation. This was in the form of material help, such as providing food, toys, collars, leads, and harnesses, as well as informational and training support for the PRs and their puppies. There were weekly, hour-long training sessions on each campus run by the AD organisation. Additionally, each PR was assigned one or more puppy socialisers, volunteers who would help train, socialise, and look after PRs’ puppies. For instance, each week, a socialiser may oversee their assigned puppy for periods ranging between 30 min to an entire day, thereby allowing the PRs a break from their raising duties.As shown in The average number of days between Bundoora PRs receiving their puppy and attending their final interview was calculated to facilitate a comparison between campuses. The Bendigo interviews closest to this number were selected for analysis refer to . For insData analysis was conducted both inductively and deductively with the use of NVivo, a qualitative data analysis application .Inductive thematic analysis  involvesPhases one to four involved familiarisation with the dataset through repeated readings, and a series of free coding attempts were undertaken, during which themes began to emerge. The first author performed the initial analysis, and then all authors discussed the analysis in-depth to identify areas of agreement and disagreement. This process of analysis and discussion was repeated until the research team reached full agreement on the codes, which were subsequently categorised into five major themes with eighteen sub-themes. The involvement of multiple researchers to understand and discuss a dataset was additional to Braun and Clarke’s  procedurPhases five to six involved defining themes and selecting quotes that illustrate the essence of each sub-theme. As Braun and Clarke  suggesteDeductive qualitative analysis refers to using a theoretical framework to analyse a dataset, providing a more detailed analysis of some aspects of the data . Clary eThe qualitative data analysis revealed five themes: expectations as a PR, organisational and environmental support and suitability, intensity of PR’s workload, practical support, and motivations to participate. Each theme has two to five sub-themes. Summaries of the themes and sub-themes are in In the initial interviews, PRs from both campuses mentioned anticipating challenges in the program, namely that the puppies would make them emotionally and physically tired. However, they all expected the benefits of having a puppy to outweigh the costs of being a PR. All PRs expected the organisation to tell them what was expected of them , provide them with training techniques , and supply informational support . Additionally, most PRs expected support from their household members and work colleagues.In most interviews, PRs expressed how they had received, or not received, adequate support from the organisation. PRs mentioned more problems stemming from a lack of organisational support in their second interviews than in their third interviews. The expressed unmet expectations of organisational support might be due to higher demands for managing the puppies’ behaviours in the earlier stage (second interview) or it could be that the PRs had higher expectations of the organisational support which they might have re-calibrated as they gained more experience in this role (third interview). Most PRs often expressed disappointment with themselves and their puppies if the puppy misbehaved or their behaviour was not to the standard the PR wanted or expected. Training and everyday activities with the puppy were more enjoyable for the PR when the puppy behaved.The university environment was considered a suitable raising location, as many PRs stated how helpful it was to have a populous training environment nearby. However, a few PRs from both campuses reported not enjoying the extra attention the puppy brought them. Only one PR from the Bundoora campus reported having a substantially negative experience with a colleague due to the puppy. When the puppy brushed against their leg, they immediately began complaining to senior management instead of discussing it with the PR. While LTU senior administrators had released a memo of support for this program, the incident with the colleague caused the PR substantial distress.Regarding environmental suitability, the broader Bundoora and Bendigo communities predominantly welcomed the puppies. Misunderstanding AD laws were the cause of most problems; however, PRs could usually explain the puppies’ access rights and resolve the issues with minimal difficulty. Unfortunately, three PRs from the Bundoora and one from the Bendigo campus reported having problems with members of the public regarding their puppies’ access rights. For instance, one Bundoora PR reported being continually denied access by bus drivers despite explaining the AD puppies’ access rights.Although PRs from both campuses reported issues with the puppies being a time-consuming task on top of already busy lives, the Bundoora PRs reported this more often than their Bendigo counterparts. Additionally, most Bundoora PRs reported being too busy to dedicate the necessary time for training and caring for their puppies, while only a few Bendigo PRs mentioned this. The reasons for this discrepancy are not clear from the available data. However, PRs from both groups felt they needed more support from the organisation. PRs from both campuses noted that learning to accept that their puppies would misbehave was a relief, as it reduced worry and lessened the burden that they put on themselves to unrealistically raise the perfect puppy.Competent socialisers, a source of practical support, helped expose puppies to new environments and experiences regularly, allowing PRs from both campuses to take breaks from being PRs. In the current study, socialisers were recruited from the university community , who wished to be involved but did not have a suitable living environment to raise the puppy or simply could not provide long-term care for the puppy. They attended training with the PRs and were coordinated by staff from the AD provider to take over socialisation activities for the puppies around the campus for a couple of hours per week while the PRs were working or studying on campus. Most PRs found the socialisers very helpful. However, PRs reported less competent socialisers as becoming a hindrance. In this regard, the Bundoora PRs reported more frustration with managing their socialisers than the Bendigo PRs.PRs provided emotional support to each other by sharing their personal experiences and advice. These benefits extended to the training of the puppies, as they had more opportunities to interact and train together outside the weekly formal sessions with the raising organisation’s AD trainers. Furthermore, almost all PRs reported no issues with housemates and work colleagues. Instead, most PRs reported that individuals in their homes and workplaces often actively assisted in training, taking the puppy for walks and even caring for them when the PRs took some time off or visited places where they did not want to bring the puppies.In most interviews from both campuses, the PRs echoed similar sentiments regarding how they thought they were doing good by participating in the program. Some PRs from both groups shared how this helped keep them motivated.Most PRs from both campuses mentioned that being a PR made them feel good about themselves. However, these statements refer more to their altruistic intent and a sense of personal growth rather than acting as a protective process to reduce negative feelings resulting from guilt of being more fortunate than others. Most PRs from both groups shared how this helped maintain their motivation.PRs developed new relationships with other PRs and could engage with more individuals in their personal community  and broader community. PRs from the Bendigo campus reported considerably more social benefits from interacting with other PRs than the Bundoora PRs.In most interviews, PRs from both campuses expressed that learning new skills while raising their puppies made their experiences more enjoyable. However, when PRs felt they were denied these opportunities through a lack of organisational support, their motivation was negatively impacted.Only one PR mentioned their participation in a puppy-raising program as a way to advance their career, as it is an activity looked favourably on by others. Career advancement may be a motivational reason for joining the puppy-raising program in some cases.No PRs conveyed joining the program or receiving any benefits observed as acting as a protective process in a desire to protect their individual egos.This study analysed qualitative data to understand the experiences of puppy raisers (PR) in a university-based raising program, in partnership with an assistance dog (AD) training provider, at a suburban and a regional campus in Victoria, Australia.There were several benefits and challenges that PRs expected to experience; however, all PRs in the current study believed that the organisation would help them minimise the difficulty of being a PR. To overcome the challenges of raising a puppy, PRs expected the organisation to provide adequate raising support and informational advice. This is consistent with past research, suggesting PRs anticipated similar costs and benefits for raising an AD puppy and relied on the organisation to assist them . FurtherGenerally speaking, to increase PRs’ program satisfaction, the perceived benefits of organisational training and informational support need to outweigh the perceived costs of raising an AD puppy. However, the current findings revealed that for PRs to realise these benefits, the levels of organisational support must also exceed the PRs’ expectations. This added requirement of support was due to the first-time PRs’ tendency to underestimate the difficulty and complexity of raising an AD puppy. While this aligns with Chur-Hansen’s  findingsOur findings suggest that PRs wanted organisational support to increase their competency, which would reduce the difficulty of training and enable them to better manage their puppy’s behaviours. This supports DeWitt’s  finding In addition to organisational training and informational support, practical support was reported as beneficial, as it reduced the PR’s workload and helped them enjoy their experience in the program. In this study, practical support from household members, work colleagues, and volunteer socialisers helped reduce the intensity of raising an AD puppy. For instance, household members would often look after the puppy, allowing the PRs to relax and partake in leisure activities independent of their puppies. As shown by Moreno-Jiménez and Villodres , individHousehold help greatly assisted PRs in DeWitt’s  study, wIndividuals who shared their puppy-raising experience with fellow PRs benefitted from the emotional support and the enjoyment experienced from those interpersonal interactions. The emotional support PRs received from sharing their experiences with other PRs helped them deal with the challenges. Smith, Drennan  conducteThe benefits of having a shared understanding with others were more apparent during the current campus-based puppy-raising programs, especially when it came to the legal understanding of public access rights of the assistance animals and those in training. The PRs in the current study reported positive experiences when interacting with colleagues and the university community during socialisation and training of their puppies, even though they reported being denied access when conducting those activities in public places. Although public access for ADs in training varies by jurisdiction , in manyThe experiences of PRs in this study were relevant to four of Clary et al.’s  FAV funcRegarding the ‘social’ function, our findings revealed that some PRs were able to achieve some expected benefits, such as increased cohesion between families and partners, as they worked together in raising the puppy. Additionally, interacting with the public was enjoyable or tolerable for most PRs, but some from both the Bundoora and the Bendigo groups reportedly found that people stopping them so they could interact with their puppy became irritating. Furthermore, PRs in this study reported enjoying and benefitting from interacting with fellow PRs. Therefore, forming a community within the raising group, similar to DeWitt’s  findingsMost PRs were excited to learn and practise their puppy-raising skills for their own enjoyment and future use if they got their own puppy. This is consistent with the ‘understanding’ function of the FAV . HoweverIn short, the deductive thematic analysis revealed that individuals became PRs to raise a puppy for someone in need, presuming they could also benefit from the experience of doing so. These altruistic and positive egoistic motivating factors attracted PRs and helped maintain their motivation throughout the program. However, it was apparent that without adequate support, PRs struggled to meet their motivational goals for being PRs, decreasing their motivation and, potentially, their willingness to raise subsequent puppies.A potential limitation of the current study might have been interviewer bias, resulting in unfair prejudices that may have altered the interview’s outcome or the interviewees’ responses . SpecifiWe did not ask PRs about their intention to return to raise a subsequent puppy after completion of their first program, as this was beyond the scope of the current study. Future research should aim to ask returning PRs about the specific reasons for why they return; this will help AD organisations further optimise their programs, thus increasing their retention rates. Similarly, we were unable to compare the suitability of the Bendigo and Bundoora campuses as AD puppy-raising facilities, but future research should aim to determine whether regional or metropolitan campuses are preferable for programs of this kind. Finally, comparing the experiences of staff and students was beyond the scope of the current study, but it is a direction for further research.Using a phenomenological approach, the primary focus of this study was on the raisers’ experiences. Naturally, all volunteer raisers in the current study expected their puppy to successfully qualify as assistance dogs. Although puppy-training success is a common outcome measure in AD research, Mai et al.  referredAs explained previously, the aim of this study was specifically focused on the experiences of puppy raisers and did not investigate the welfare of the puppies or their behavioural development. The general public typically believes that assistance dogs experience good welfare , but thiWhilst this study did achieve its intended goal of understanding how the AD program impacts PRs’ experiences, future research may build upon our findings by employing a quantitative survey with appropriate statistical analyses to examine what types of support are helpful for PRs, depending on demographics , and how the wider community affects the PR experience. Ideally, this could show future organisations the kind of support that is most helpful for PRs, depending on their demographics, life circumstances, and competency levels. Although we found a range of social and psychological benefits from a campus-based puppy-raising program, they all came from the same program provider and the same higher education institution. Therefore, some of those benefits may be exclusive to puppy-raising programs at higher education settings or perhaps they are widely available in other private corporations. Future research is needed to evaluate the economic effectiveness as well as social and psychological outcomes of PR programs coming from those collaborations. By applying those quantitative measures to future AD programs in different settings  and regions, future research may be able to identify ideal candidates and locations for raising successful AD puppies.The current study aimed to explore what factors impact the experiences of puppy raisers (PR) in assistance dog (AD) puppy-raising programs. The results showed that organisational support substantially impacted PRs’ raising abilities, while the practical support they received helped ease the difficulty of raising a puppy independently. The findings from both campus groups indicated that fewer challenges were associated with higher PR competency and elevated levels of enjoyment, with altruistic and egoistic motivational reasons attracting PRs to the program. Furthermore, as long as enough of the PRs’ motivational reasons were satisfied, they maintained motivation, enjoyed their experiences and were willing to adapt to and overcome puppy-raising challenges. Our findings add to the small body of literature pertaining to PRs, potentially helping to inform future AD programs and researchers on how to optimise PR experiences, including what methods could be applied to ensure volunteers enjoy their experience as PRs.


Non-fungible tokens (NFTs) are cryptographic assets recorded on the blockchain that can certify authenticity and ownership, and they can be used to monetize health data, optimize the process of receiving a hematopoietic stem cell transplant, and improve the distribution of solid organs for transplantation. Blockchain technology, including NFTs, provides equitable access to wealth, increases transparency, eliminates personal or institutional biases of intermediaries, reduces inefficiencies, and ensures accountability. Blockchain architecture is ideal for ensuring security and privacy while granting individuals jurisdiction over their own information, making it a unique solution to the current limitations of existing health information systems. NFTs can be used to give patients the option to monetize their health data and provide valuable data to researchers. Wearable technology companies can also give their customers the option to monetize their data while providing data necessary to improve their products. Additionally, the process of receiving a hematopoietic stem cell transplant and the distribution of solid organs for transplantation could benefit from the integration of NFTs into the allocation process. However, there are limitations to the technology, including high energy consumption and the need for regulatory guidance. Further research is necessary to fully understand the potential of NFTs in healthcare and how it can be integrated with existing health information technology. Overall, NFTs have the potential to revolutionize the healthcare sector, providing benefits such as improved access to health information and increased efficiency in the distribution of organs for transplantation. Non-fungible tokens (NFTs) are cryptographic assets recorded on the blockchain. A blockchain is a digital ledger technology that securely and transparently records transactions across a decentralized network of computers, nodes, or servers, without the need for intermediaries. Unlike money, which is fungible, NFTs cannot be substituted, subdivided, or traded for equivalency. Their storage on an immutable blockchain provides certification of authenticity and ownership. Essentially, NFTs are digital certificates of ownership that can be bought and sold in online marketplaces. These unique features open doors for a myriad of uses in many sectors, including healthcare. Herein, we discuss blockchain and its use for promoting health equity, the potential applications of NFTs in healthcare, and the limitations of such technology.Blockchain is a decentralized immutable ledger that makes it easier to record transactions and track virtually any asset of value (including NFTs) . This teNFTs allow the tokenization of all types of data  and give individuals the option to monetize their data and receive royalties every time they are sold to a new buyer. When it comes to health data, NFTs have the capability of putting patients back in the driver’s seat as opposed to keeping health data vendors in total control of the fate and use of their data . One potMoreover, NFTs can help optimize the process of receiving a hematopoietic stem cell transplant . Booth aWhen it comes to research, NFTs can offer protection of intellectual property . For exaAs with any nascent technology, NFTs have raised several concerns , mainly In addition, the adoption of NFT technology in healthcare may face resistance from data vendors and insurance companies as it may result in a decrease in profit margins associated with the use of health data. However, in the era of big data and machine learning, NFTs for data can address the ethical concerns surrounding the use of publicly available patient data for AI algorithm development and monetization without providing financial compensation to the patients .The potential disadvantage of using NFTs as assets is the exacerbation of wealth disparities, where entities with more financial resources can acquire digital assets at the expense of smaller entities, thus validating the old adage “the rich get richer and the poor get poorer” . This coNFT technology is still in its infancy, and its extensive potential to improve healthcare delivery in the upcoming years remains to be explored. NFTs have a similar potential to revolutionize many sectors, including healthcare and medical research. Their unique features of being digital and non-fungible allow the tokenization and monetization of health data. Their storage on an immutable blockchain allows the democratization of the technology, making it available worldwide and eliminating roadblocks to current global markets. However, raising awareness of this technology and regulating NFT marketplaces that contain health data will be necessary to expand this technology and prevent malicious exploitation.


While health care payers are increasingly considering approaches that help support stable and affordable housing for their beneficiaries, experience with these initiatives is limited. Through its §1115 HealthChoice waiver, Maryland Medicaid has begun experimenting with programs designed to pay for housing and tenancy support/case management services. This study investigates barriers and facilitators to the success of Maryland’s pilot program initiative — Assistance in Community Integration Services (ACIS).The study focused on key stakeholders employed by the four Lead Entities that currently participate in the ACIS program. The stakeholders included members of each Lead Entity’s administration, direct service providers, state and local government officials, and case managers from local hospitals. The convenience sample was selected through an initial list of stakeholders and was supplemented using snowball sampling methods. Interviews were audio recorded and turned into transcripts via Otter.ai and then analyzed using NVivo by two independent reviewers.A total of 23 interviews were conducted between February 2022 and May 2022, representing a broad range of stakeholders across different Maryland geographies. A total of 4 themes were identified through the course of the interviews. Stakeholders identified difficulty finding housing for the target population in a tight housing market, challenges with communication within the program and with its clients, and problems with non-healthcare providers documenting services for reimbursement. At the same time, ACIS was seen as creating opportunities for organizations to work together across siloes in meeting client needs.The findings of this study helps to highlight Medicaid §1115 waivers as a novel approach to using Medicaid funds to support tenancy-based services, such as ACIS and to improve the lives of individuals while reducing healthcare costs. Implementation of the ACIS program in Maryland has been a resounding success in helping individuals obtain and sustain stable housing. However, continued efforts to align capacity with demand, streamline billing and reimbursement and improve communication with clients and across partners will need to be prioritized. The program also highlights the growing need to address root causes of housing insecurity including the limited supply of affordable housing. Although housing stability is increasingly being recognized as an important determinant of health outcomes, an estimated 380,657 individuals in the U.S. experienced unsheltered homelessness according to the 2021 point in time count –15.Policymakers have increasingly begun implementing initiatives designed to address housing instability as a means towards improving health and decreasing health care costs. In the Medicaid program, Sect. 1115 waivers provide states with an opportunity to introduce programs that are ‘budget neutral’ to the Federal government while better serving Medicaid populations . Six staIn their analysis of the first four states to implement housing supports via a Sect. 1115 waiver, including Maryland, Thompson et al. identified several challenges as states were beginning to implement their new initiatives. Their research highlighted concerns about the lack of affordable housing coupled with the limited supply of rental subsidies. Further, they identified a perceived stigma attached to homeless populations based on their social needs and often compounded by structural racism that creates difficulties in finding affordable housing . The staBuilding on this emerging literature, we sought to use qualitative interviews to identify the facilitators and barriers to program implementation within a single state. Since its start in 2017, Maryland’s Assistance in Community Integration Services (ACIS) program provides housing case management and tenancy support services to individuals who are homeless or at imminent risk of becoming homeless or institutionalized. The focus on the ACIS program provides an opportunity to examine the perspectives from a wide range of stakeholders, identify issues arising further along in the implementation process, and investigate differences in the approach and implementation of the ACIS across jurisdictions within the state.The ACIS program, as authorized under the state’s Sect. 1115 waiver, aims to serve “high risk, high utilizing Medicaid enrollees”. The ACIS program provides tenancy-based case management and support services, as well as housing case management , 20. ExaIndividuals are eligible if they meet at least one health and one housing criteria. Health criteria are defined as having either repeated incidences of emergency department visits or hospitalizations or two or more chronic conditions. Housing criterion is defined as individuals who are expected to experience homelessness upon release from certain settings or those at imminent risk of institutional placement. Based on the allocated funding, the program has grown to now include a maximum of 900 individuals who can be served by the housing tenancy services of the ACIS program within participating counties across the state.The program is designed to be overseen by lead local governmental entities  that are responsible for the organization of the care delivered in their city or county. Program managers employed by these Lead Entities work with direct service providers employed by community-based organizations  that deliver tenancy-based case management and support and receive Medicaid reimbursement. The program managers and direct service providers work in a broader ecosystem that includes health services and specialty mental health agencies, public agencies or departments, or other entities with significant experience serving the target population. The program started in 2017 with three organizations serving as Lead Entities and expanded to four in 2018.The study focused on key stakeholders employed by the four Lead Entities that currently participate in the ACIS program, as well as those working at the state level. The stakeholders included members of each Lead Entity’s administration, direct service providers, state and local government officials, and case managers from local hospitals. The convenience sample was selected through an initial list of stakeholders and was supplemented using snowball sampling methods. Potential interviewees were recruited via email and given the option to schedule an in-person, telephone, or video conference visit which was audio recorded.The interview guide was generated after a review of the literature and was iteratively revised before and during the interview process (see Appendix). The interview guide was designed to identify successes and challenges in the program design and implementation, targeting of beneficiaries, deployment of housing and tenancy services, coordination with healthcare services, and staffing and resources. Interviews lasted approximately one hour, and participants were offered a $40 gift card for their time. Interviews were conducted between February and June 2022.The interviews were conducted virtually using a video conferencing software and were recorded with the consent of the interviewee. The recorded interviews were transcribed verbatim using Otter.ai software. These transcripts were then reviewed by two members of the research team to correct any errors and then were entered into NVivo to identify major themes. Using a modified grounded theory approach, a codebook was created based on the research questions of interest. Two of the authors (RD and AA) independently coded each transcript and regularly met every two weeks once interviews were completed to compare their coded transcripts and identify emerging themes. After all transcripts were coded, a code book of major themes was created through an iterative process involving the independent coders with feedback from the other authors. These themes were further consolidated at the conclusion of the study to produce four major themes with each major theme having respective subsequent minor themes as well. The Johns Hopkins University and Maryland Department of Health institutional review boards both individually approved the study.A total of 23 interviews were conducted between February 2022 and May 2022, representing a broad range of stakeholders across different Maryland geographies  while the other half come from the federal government via Medicaid. In one of Maryland’s jurisdictions, local hospital systems contribute money for the local matching funds. To receive reimbursement from both the local and federal funds, direct service providers are required to provide and document a minimum number of services that were delivered to a client each month.A considerable proportion of interviewees worried that direct service providers—who often worked in community-based organizations and were not healthcare-based—were not as familiar with the documentation requirements Table . CompounDespite continued efforts to train direct service providers on appropriate documentation, this problem is further exacerbated by the continued staffing turnover. Discussions also focused on the difficulty using Excel as a manual data collection tool and cited differences in workflow between healthcare-based  and community-based organizations as potential contributing factors.Related to the need for data collection for billing, respondents also noted the challenges of data collection to demonstrate improved outcomes. Demonstrated improved outcomes was not a requirement of their receiving funding for the services they delivered but was seen as important for continued investment in the program. Conversations with hospital administrators acknowledged the desire to understand how services were being delivered and whether there was a return on their investment, given that they were contributing to the local matching funds in one Maryland jurisdiction. As one indicated, “….as stakeholders who are paying into this, we want to know that the community members are being supported and what’s happening with the dollars.”Further, the hospital administrator’s comments noted concern in the current funding structure in which local governments may be relying too heavily on them as a permanent funding mechanism and the implications this may have for healthcare costs in general. As one hospital executive said, “Even if hospitals are investing in housing, but the government is not making an equal increase in housing, then we’re never going to move the needle on these big social determinants of health.”With a growing understanding of the ways that housing insecurity contributes to high healthcare costs, identifying payment mechanisms and developing best practices designed to address housing-related social needs has received increasing attention. Maryland’s ACIS program provides an important example of a Medicaid §1115 waiver focused on reducing the cost and burden of high healthcare spending among individuals who are insecurely housed. The results of the interviews with key informants underscore strategies that are contributing to the ongoing success of the program—including ways in which the program has leveraged existing community resources and improved coordination across these resources—as well as barriers to its implementation—including the tight housing market and difficulties with communication and data collection. These findings provide an important template as other states, payers, and health care systems move to meet patients’ social needs.This study reinforces the work by Thompson et al., showing that many of the challenges that existed during the early implementation of housing-focused programs persist in longer-term follow-up, hampering program efficiency and sustainability. While it is not surprising that issues related to the tight housing market continue, the difficulties with reimbursement and program sustainability remained salient for key informants. These findings highlight areas that would benefit from planning as states consider programs designed to utilize Medicaid funds to support housing and tenancy-based services.Program success stemmed from flexibility in leveraging existing resources across jurisdictions within the state. Stakeholders recognized that efficiently using the resources provided by the §1115 waiver—which required matching funds—necessitated coordination amongst stakeholders already working with the target population. Though not specifically discussed by stakeholders, this alignment of resources and matching of funds likely benefited from the state’s unique healthcare financing. Under Maryland’s previous model, the All-Payer Medicare Model Contract, hospitals received global budgets, which are largely based on historical hospital spending. These budgets, as opposed to more traditional fee-for-service models are designed to align hospital incentives to reduce expenditures and increase quality for the population it serves. Its successor program, the Total Cost of Care Model, came into effect in 2019 and seeks to limit per capita expenditures through population-based hospital payments, advances in primary care, and other avenues. The model established the Statewide Integrated Health Improvement Strategy through which state and industry stakeholders identified housing as the key social determinant of health that would drive success toward the population health goals . Also unMany interviewees described the broader difficulty in identifying safe and affordable housing generally, a problem made more challenging for individuals whom landlords may deem ‘risky’, including those with substance use or mental health disorders and prior evictions. The findings here suggest that some tenancy support services were useful in helping overcome barriers, for example, the development of a landlord risk mitigation fund to help address potential damage done to housing units. The size and funding model of risk mitigation funds varied across lead entities and was not discussed in detail by respondents.Other problems, however, such as the limited supply of affordable housing and limited rental assistance require more structural changes. Many of these issues are largely outside the traditional purview of healthcare (Medicaid funds are not permitted for the construction of housing units) and instead necessitate broader investments at the federal-, state-, and local-levels. For example, at the federal level, there has been policy attention towards increasing the supply of federal rental assistance which currently serves approximately a quarter of eligible households . States Maryland’s §1115 waiver did not permit Medicaid funds to be used to pay rent. The Centers for Medicare and Medicaid Services recently released guidance indicating that rent or temporary housing may be considered under §1115 waiver applications for individuals who meet certain criteria  . Given tData collection to support reimbursement and to determine program effectiveness was identified as a critical challenge to the continued funding and success of the ACIS program. Medicaid billing requires providers to document the delivered services in a manner fundamentally different from their routines. This challenge was compounded by using spreadsheets, which many direct service providers had limited experience with, and by ongoing staff turnover. The findings extend the work by Thompson and colleagues by suggesting that problems stem from not only setting up agreements and reimbursement mechanisms but also by how they play out in practice. Recognizing these challenges and working to design policies that align with community-based provider workflow is critical as these programs expand.Finally, communication was also noted to be a recurring theme. This aligns with prior work demonstrating the difficulties of working with a hard-to-reach population by virtue of their housing insecurity and limited financial resources. These challenges were exacerbated by the move to virtual communication strategies necessitated by the COVID-19 pandemic. Concerns over communication were not only limited to interactions with clients and stakeholders but also between health care organizations making referrals and service providers. Working to improve communication is important in continuing to generate referrals and developing on-going institutional support.This study had several limitations. First, while we sought to include a diverse range of perspectives to generate broad themes and achieved thematic saturation, the themes identified in this study might not capture the full range of perspectives across the state. Second, though individuals were speaking from their professional capacity, interviews may be subject to recall and social desirability bias. Third, the project does not capture the perspectives of individuals who were homeless or unstably housed. Their perspective on whether and to what extent the program addressed their needs and how it could be improved is a crucial next step. Further, the study was not able to recruit landlords, who may also have a unique and different perspective of the ACIS program. Understanding the perspectives of landlords in the low-income rental market is a growing area of inquiry and is necessary to address barriers. Finally, the study focused on a single state which expanded its Medicaid under the Affordable Care Act and has unique healthcare financing under the Total Cost of Care Model. In depth case studies of a single area are important in generating new knowledge which can be tested in other jurisdictions and settings.Medicaid §1115 waivers allow novel approaches to use Medicaid funds to support tenancy-based services, such as ACIS, to improve the lives of individuals while reducing healthcare costs. Implementation of the ACIS program in Maryland has been a resounding success in helping individuals obtain and sustain stable housing. However, continued efforts to align capacity with demand, streamline billing and reimbursement and improve communication with clients and across partners will need to be prioritized. The program also highlights the growing need to address root causes of housing insecurity including the limited supply of affordable housing.


Numerous studies have demonstrated that the increasing racial and ethnic diversity of the US population benefits from access to healthcare providers from similarly diverse backgrounds. Physician assistant (PA) education programs have striven to increase the diversity of the profession, which is predominantly non-Hispanic white, by focusing on admitting students from historically excluded populations. However, strategies such as holistic admissions are predicated on the existence of racially and ethnically diverse applicant pools. While studies have examined correlates of matriculation into a medical education program, this study looks earlier in the pipeline and investigates whether applicant – not matriculant – pool diversity varies among PA programs with different characteristics.Data were drawn from the 2017–2018 Central Application Service for PAs admissions cycle. Applications to programs with pre-professional tracks and applicants missing race/ethnicity data were excluded, resulting in data from 26,600 individuals who applied to 189 PA programs. We summarized the racial and ethnic diversity of each program’s applicant pools using: Simpson’sRegardless of the demographic diversity metric examined, we found that applicant diversity was higher among provisionally accredited programs and those receiving more applications. We also identified trends suggesting that programs in more metropolitan areas were able to attract more diverse applicants. Programs that did not require the GRE were also able to attract more diverse applicants when considering the URM and SDI metrics, though results for URiM were not statistically significant.Our findings provide insights into modifiable  and non-modifiable  program characteristics that are associated with more demographically diverse applicant pools. As the United States continues to become more racially and ethnically diverse, those from underrepresented minority (URM) and underrepresented in medicine (URiM) backgrounds make up a growing proportion of the population. As of 2019, 1.3% identify as American Indian or Alaskan Native, 5.9% identify as Asian, 13.4% identify as Black or African American, 0.2% identify as Native Hawaiian or Pacific Islander, 18% identify as Latino, Hispanic or of Spanish origin, and the remaining 60.1% identify as non-Hispanic white [The current medical education workforce, however, does not reflect national diversity. Among 2019 PA grads: 0.5% are American Indian or Alaskan Native, 8.6% are Asian, 3.2% are Black or African American, 1.0% are Native Hawaiian or Pacific Islander, and 71.7% are white. These data, however, do not include the ethnicity categories that are recognized by the census , and it is likely that the white group includes at least some Latino/a/x or Hispanic physician assistants (PAs) [To increase the diversity of the health care workforce, we must first increase the diversity of the student body and, before that, the diversity of the applicant pools from which programs choose future practitioners. While many programs, such as the University of Utah PA program, have made significant strides by increasing multiple dimensions of diversity  of the students in their program, the rate at which PA programs graduate students from historically excluded backgrounds remains unacceptably low , with a This is a secondary analysis of a data set including applicants to the 2017–2018 admissions cycle of the Central Application Service for Physician Assistants (CASPA), which is utilized by over 95% of accredited national PA programs. Students who did not list their race or ethnicity and programs with a pre-professional track were excluded, resulting in 26,600 applicants who applied to 189 PA programs. Access to the CASPA dataset was provided by the Physician Assistant Education Association (PAEA), and all participant identifying information was removed prior to PAEA providing the data for analysis. This research was determined to be exempt (non-human-subjects research) by the Institutional Review Board and all methods were carried out in accordance with relevant guidelines and regulations.Outcomes of interest included percent of applicants to a program with (1) URM background, (2) URiM background, and (3) program-specific Simpson’s Diversity Index (SDI) . ApplicaWe also calculated for each program the SDI. The SDI originated in biology and economics but has been used in education research as well, and is defined as the probability that two individuals taken at random from the dataset of interest represent different racial or ethnic groups . The ind2).SDI = 1 - , or multiracial. SDI scores for each program were then calculated by summing the squared proportions for each group and subtracting from 1. Possible SDI scores range from 0 to 1. For example, within a given university, if the proportion of racial/ethnic groupings were as follows: Native American (5%), Asian (7.5%), Black (10%), Native Hawaiian/Pacific Islander (12.5%), white (15%), Hispanic/Latino/a/x (17.5%) or multiracial (32.5%), then we can calculate the probability of two randomly selected individuals representing the same racial/ethnic group as ((0.05)2 + (0.075)2 + (0.10)2 + (0.125)2 + (0.15)2 + (0.175)2 + (0.32.5)2 ) = 0.1925, while the probability of two randomly selected individuals representing two different racial or ethnic groups would be calculated as 1-0.1925, or 0.8075. The SDI is particularly useful, as it accounts for the impact that individual or several categories with disproportionately large proportions have on reducing diversity [where Islander .5%, whita priori believed may be associated with increasing or decreasing diversity in the applicant pool. These included (1) Accreditation Status , (2) Academic Health Center Status (binary), (3) Public versus private institution (binary), (4) GRE required for admission (binary), (5) the number of applicants, (6) the number of matriculants, and (7) the Urbanicity of the institution as determined by its Rural-Urban Continuum Code .The primary predictors of interest included variables for which we a priori to 0.05. All statistical analyses were conducted with R version 3.6.1.We summarized data using descriptive statistics. We further employed individual multiple linear regression models for each of our outcomes of interest  to estimate associations between program characteristics and measures of program diversity. Effect estimates were presented as beta-coefficients and 95% confidence intervals, with the alpha value set Table Figure Figure Our study is the first to explore associations between PA program characteristics and applicant pool racial/ethnic diversity in a large national cohort of United States programs. We found that programs with a larger number of applicants, without a GRE requirement, and those with provisional accreditation status were associated with higher proportions of URM and URiM applicants, and with a larger SDI, indicating greater applicant diversity. Programs in smaller metropolitan areas  were associated with significantly smaller proportions of URM and URiM applicants, and smaller SDIs.Various insights and inferences can be drawn from the literature concordant with the study’s findings. The implications associated with these results are considerable as intentional medical education programs seek to diversify the applicant pool to achieve population parity with ever-evolving United States racial and ethnicity demographics. Achieving a more diverse health care workforce supports cultural humility as well as inclusive patient care for historically excluded populations. As the protectors of the public trust, health education programs have an opportunity to decrease health disparities, achieve reductions in health spending, and defray health systems waste , 14.Provisional programs attracting a more racially and ethnically diverse applicant pool may be explained by considering the program’s racial/ethnicity composition. In the case of a newly accredited PA program, URM/URiM applicants may view their chances for acceptance as more favorable as there are zero or few matriculated classes upon which to draw a conclusion regarding a program’s diversity priority. Past studies support that applicants from URM/URiM backgrounds assess a program’s current diversity , 15. ForPrograms that do not require the GRE are demonstrating inclusive excellence by removing systemic barriers and promoting equitable practices. Most PA programs require or recommend minimum GRE scores to qualify or disqualify applicants. This practice does not align with the test developer’s  formal guidance for use of scores . The GRELarger applicant pools seem to attract more diversity. The medical school literature supports that “a large diverse applicant pool is needed to ensure the appropriate candidates can be chosen. . .”  In orderMetropolitan and urban areas tend to have more diverse populations, though rural areas are currently experiencing growing racial/ethnicity diversity. However, historically, rural areas have been perceived to be less diverse and more homogenous regarding their respective populations. Previous studies support that when making college decisions, Black American and Hispanic American students prioritize both campus and neighboring community racial diversity . SimilarPA school applicants from historically excluded populations have related financial barriers in their pursuits for higher educational attainment. Thus, prior research has shown more URM/URiM applicants eventually enrolling in public-sponsored PA programs when compared to private-sponsored PA program enrollment . MissionUnderstanding factors that influence which programs prospective URM/URiM health care providers decide to apply to is paramount to increasing the diversity of medical providers. Though some contributors are not easily modified, PA programs can immediately begin to dismantle existing systemic barriers and re-visit their mission statements. PA programs can also begin to develop strategies that highlight their commitment to recruiting and retaining URM/URiM students while also inculcating an inclusive atmosphere of belonging and support.Our study has several important limitations that must be noted. First, while we analyzed national CASPA datasets which capture the vast majority of PA school applicants in the US, approximately 5% of US PA programs do not utilize the CASPA application system and as such our findings may not be universally generalizable. Second, the CASPA data is largely dependent upon applicant self-report of data. As such, it is possible that data on covariates may be reported in error or subject to reporting bias, resulting in residual confounding. Third, our study is cross-sectional and observational, factors which preclude causal interpretations. Fourth, we did not have information on other potential predictors of interest that likely impact the diversity of the applicant pool, such as program tuition [Increasing racial and ethnic diversity in the health workforce is an ongoing challenge. As the gatekeepers to the profession, these training programs have rightly focused on admitting students from historically underrepresented backgrounds. However, most recent endeavors and research have centered around the question of who gets in and less is known about who applies, to which programs, and why. We found that programs with provisional accreditation, that receive more applicants, and that don’t require the GRE, are associated with higher diversity among PA applicants, but only public schools maintain the increased diversity during matriculation. Additional research should explore why each of these associations exist to identify mechanisms that programs can implement to increase the diversity of their applicant pools.


Aboriginal and Torres Strait Islander women have access to and interest in mobile health , although few culturally relevant, evidence-based mHealth programs are available. We codeveloped an mHealth program in New South Wales with Aboriginal and Torres Strait Islander women, focusing on women’s and children's health and well-being.This study aims to assess the engagement with and acceptability of the Growin’ Up Healthy Jarjums program among mothers caring for Aboriginal and Torres Strait Islander children aged <5 years and assess the acceptability of the program among professionals.Women were given access to Growin’ Up Healthy Jarjums—a web-based application, a Facebook  page, and SMS text messages—for 4 weeks. Short videos of health professionals presenting health information were tested within the application and on the Facebook page. Engagement with the application was examined through the number of log-ins, page views, and links used on the application. Engagement with the Facebook page was examined through likes, follows, comments, and the reach of posts. Engagement with the SMS text messages was examined through the number of mothers who opted out, and engagement with the videos was examined through the number of plays and videos watched and duration of the video watched. The acceptability of the program was examined through posttest interviews with mothers and focus groups with professionals.A total of 47 participants joined the study . Interviews were completed by 78% (32/41) of the women and 100% (6/6) health professionals. Of the 41 mothers, 31 (76%) women accessed the application, 13 (42%) scrolled the main page only, and 18 (58%) clicked on other pages. There were 48 plays and 6 completions of the 12 videos. The Facebook page received 49 page likes and 51 followers. The post with the most reach was a supportive and affirming cultural post. No participants opted out of the SMS text messages. Almost all mothers  reported that Growin’ Up Healthy Jarjums was useful, and all mothers reported that the program was culturally appropriate and easy to use. Of the 32 mothers, 6 (19%) mothers reported technical problems with accessing the application. Moreover, 44% (14/32) of mothers suggested improvements to the application. All the women reported that they would recommend the program to other families.This study demonstrated that the Growin’ Up Healthy Jarjums program was perceived useful and culturally appropriate. SMS text messages had the highest engagement, followed by the Facebook page and then the application. This study identified areas for technical and engagement-related improvements to the application. A trial is needed to assess the effectiveness of the Growin’ Up Healthy Jarjums program at improving health outcomes. Aboriginal and Torres Strait Islander people are the oldest surviving culture in the world . The hea.Improving health literacy provides a foundation for individuals and communities to take action to improve their own health . There iAn array of mobile technologies is available to find, share, and generate health information . The majAvailable mHealth programs for Aboriginal and Torres Strait Islander mothers or their children are limited but growing, including an app, a website, and SMS text messaging on infant feeding ; SMS texIn 2019, we co-designed a multimodality mHealth program for Aboriginal and Torres Strait Islander women’s and children’s health . The aimFollowing a formative research phase, subsequent steps to develop and evaluate mHealth interventions include conducting a pilot study, a randomized control trial, and an evaluation of the implementation impact . The purThe aims of this study were (1) to assess the engagement with the Growin’ Up Healthy Jarjums program among mothers (or other women) caring for Aboriginal and Torres Strait Islander children aged ≤5 years; (2) to assess the acceptability of the Growin’ Up Healthy Jarjums program among mothers (or other women) caring for Aboriginal and Torres Strait Islander children aged ≤5 years; and (3) to assess the acceptability of the Growin’ Up Healthy Jarjums program among health professionals and early educators.A 4-week pilot study of the Growin’ Up Healthy Jarjums mHealth program was undertaken with Aboriginal and Torres Strait Islander women caring for children aged <5 years. Health professionals and early educators from the participating services provided feedback on the intervention in focus groups. Details on the development of the Growin’ Up Healthy Jarjums mHealth program can be found elsewhere . The AboAcknowledgments section) and coled by a Kuku Yalanji and Lama investigator (KH), as well as 2 non-Indigenous investigators (BB and JM). In total, 3 team members were Aboriginal women from (or connected to) the communities where the research took place: a Gumbaynggirr woman (NS), Gomeroi woman in the Kamilaroi Nation (BL), and Worimi woman working in the Awabakal community (BH). The cultural identities of the remaining team members are Macedonian-Australian (BB), German-Australian (JM), Pakeha or European-New Zealand (RD), and European-Australian (SJP). The team has various professional backgrounds: 4 women with Aboriginal lived experience , a behavioral scientist (BB), a pediatrician and academic (JM), a nurse and public health researcher (KH), an mHealth and public health researcher (RD), an early educator (BH), an Aboriginal health practitioner (NS and BL), and an occupational therapist and PhD candidate (SJP). All team members contributed to the conception of this study. Aboriginal researchers from the participating communities  led the implementation of the project to support cultural safety.This research was governed by an Aboriginal advisory board in partnership with Aboriginal organizations , owned or regularly used a smartphone, and had accessed a participating service  were eligible to participate. Health professionals from the participating health services and early educators from the participating preschools of all cultural identities who worked with women or children were eligible. . So it was helpful for me to learn new terminologies and stuff like that.Participant 3All the professionals reported that the program was culturally appropriate. A total of 33% (2/6) of the professionals commented on the cultural appropriateness of the language in a positive light. Overall, 17% (1/6) questioned whether the language would be difficult for some women to understand. She emphasized the need to ensure that representatives from each community that the program would be used in be involved in developing the content as well as to administer the Facebook page to ensure that the program continues to be relevant to women from different communities:You’ve got different lingos, different meanings, different sayings that’s going to grab attention [in different communities]. When I look through these text messages there are some words in here that I would think some of our women wouldn’t really understand. You actually need the women to do it, they’re very different to the workers. They’re the ones that are going to give you the right language.Participant 1It’s all culturally appropriate...the language is really nice. It’s really easy to read and interpret. It doesn’t have any of those big, yukky words that can be quite clinical.Professional 5All the women  reported that the content was easy to understand. They talked about the program being jargon free but not too simplified:It was spoken to you normally, not like all the medical jargon, do you know what I mean? It was understandable and relatable. I think if it’s too technical sometimes, it gets overwhelming.Participant 20It wasn’t dumbed-down. Like some things that we give to Aboriginal families that we get, some of them are so simplified that makes people think that we’re stupid, but this wasn’t. It was easy to understand, but it didn’t make me feel stupid, didn’t make me feel bad.Participant 27Most women  reported that the activities and information were appropriate. However, of the 32 women, 1 (3%) woman suggested that the language in the SMS text messages could have been more professional rather than colloquial:We followed what was on those messages each day. We made it a project with our kids because we thought we would see how it would go. My son likes looking at the pictures of it when they’ve had the Facebook competitions because it was all kids that he knew.Participant 27Most women  reported that the program was relevant to them and their family. They said that it was good having other mothers to relate to and access to reliable health information to talk to family about:Just sort of seeing other women with kids and stuff and sort of just having someone to relate to, somebody that’s a little bit more similar to me. So you don’t feel so alone in what you’re kind of going through. Things that you might think are silly or you’re a bit shamed to ask anyone. At least the messages address it and then you can see other women on the Facebook page.Participant 4I learnt some good stuff. I think the thing I like most about the program for us personally, it allowed me to have conversations with my partner about smoking. With the program I was able to say ‘hey I got a text about smoking,’ ‘do you know this’ it meant that it wasn’t just me making points. I sort of used the app as the conversation starter.Participant 18The women who did not find the content relevant to them  said that they already knew the information or felt that the information was targeted toward women caring for younger children. Of the 32 women, 2 (6%) women also made comments about some SMS text messages not always being relevant to their family:Some of them [SMS] might not be relevant to me personally, but I think as a community they are. The messaging was consistent, and I think that’s really important.Participant 6My little boy is older now, he’s two. So I felt like a lot of the messages and stuff like that, was more around the newborn stuff. But in saying that, if I had a newborn still, then it would have been more relevant.Participant 10Of the 31 women who commented on the overall positive impact of the program, 22 (71%) women reported that the program had an overall positive impact on themselves and their family. The favourite text of mine was the reminder that we all have rough days...And that it was okay, I thought you know what, yeah, I am going to take a breath right now, and it is all okay.Participant 10It was good to know that there was a service out there that did care I guess or had an interest in my son’s health.Participant 14Other positive impacts that the women discussed included getting their child’s ear health checked by a general practitioner, more play with children, spending time together as a family, taking children for hearing and vision tests, more exercise, taking care of themselves, talking to friends and family about quitting or reducing smoking, cooking with children, limiting alcohol, getting their child immunized, improved knowledge of contraception, and improved family eating:Usually I’m the type where I walk to the park and then watch her play. When I read the messages, I’m like, I should actually try with her more, and be more active with her at the park.Participant 24I was drinking far too much, it was just a stress handling thing, because we did have a lot of problems, and it was difficult the first couple years. And so, getting that information, that really helped me to kind of kick that habit and to look at my own lifestyle and stuff.Participant 9Other women experienced stressful life situations at the time and had competing priorities, limiting the potential impacts of the program.The most common suggestion for improving the program was to make changes to the application to overcome technical challenges. Of 32 women, at least 6 (19%) experienced technical problems. Difficulty in downloading and saving the web-based application, rather than accessing an Android or iOS (Apple Inc) app, was the main difficulty. Almost half of the women  suggested improvements to the application, including making the web-based application an Android or iOS app so that it “looks” like an app, removing the step of saving to the application to home screen, implementing single log in, making navigation simpler, making the application accessible on all phone types, localizing the application to specific communities, and making the application more interactive:I had to log back in and it would take me to the web page. It kept wanting me to resave it to my home screen, but it was already saved to my home screen. I wasn’t too sure what was going on there.Participant 30The next most common suggestion is related to the SMS text messages. A total of 59% (19/32) of the women reported that there was just the right number of SMS text messages, but 38% (12/32) of the women reported that the SMS text messages were too frequent. The women indicated the preferred timing of SMS text messages to be earlier in the day and a preference to have SMS text messages from the same sender phone number for ease of reviewing.Other suggestions to improve the program overall included suggestion to ensure better tailoring to the child’s age as well as suggestions for alternate topics , suggestion to provide less content about smoking, suggestion to provide more links to further information , and suggestion to provide to make the program more interactive:If it is targeting under five, some of the information could be more around toilet training, difficulties with separation, entry to preschool, advice on services and stuff, like Koori stuff around.Participant 9In total, 6% (2/32) of the women talked about web-based groups: 1 woman suggested a Facebook group (rather than a Facebook page) and another suggested a chat group within the application (to discuss specific topics). Moreover, 6% (2/32) of other women talked about the importance of the continuation of the program and the longevity of Aboriginal and Torres Strait Islander health programs in general, as Aboriginal health programs often have short funding cycles and the community is left with a gap:I would have benefited more with the Facebook group if it was an actual group created, because normally you get notifications and stuff when you’re in the group and it tells you who’s posted what. I probably would have had more interaction with that if that was a constant notification coming up.Participant 13Keep it going. We find sometimes that programs are really good and then they stop. When the funding runs out or it doesn’t get approved or whatever it stops and then that’s a gap.Participant 27The professionals suggested several ways to improve the program, including continued involvement of women in the development of the program to ensure that the language and content remain relevant and appropriate, including for families living in regional and remote areas. Another professional suggested that the content should be current and tailored to the age of the child. Another suggested a “search” feature in the application so that families could easily search for the health issue or topic that they are interested in . Another suggested more specific steps about how to manage certain illnesses and to include more common childhood illnesses. Another suggested that the application needs to be more interactive, for example, tailored specifically to the child’s age, with notifications for activities for that age group or milestones. One other professional suggested forums or private group chats so that discussions are not public, whereas another suggested providing grandparents and other family members access to the program.Overall, the Growin’ Up Healthy Jarjums program was found to have high acceptability. The results indicate that women found the program to be useful, culturally appropriate, and easy to use, and most women reported positive impacts. None of the participants withdrew from the SMS text message portion of the program, which indicated the high acceptability of and engagement with this component. Engagement with the Facebook page was found to be higher than that with the application. Individual users preferred different modes , indicating that a multimodal intervention increases reach. Importantly, this pilot study showed several ways to improve the program, including technical changes to the app.Similar to other studies with Aboriginal and Torres Strait Islander people, the SMS text message component of this program appeared to have high acceptability and engagement -14. ThisThe women reported that they liked having a choice of topics for SMS text messages, as this increased relevance. Some women commented on the core (requisite) topics, indicating (1) breathing well and (2) smoke-free families as being irrelevant to them and their families. SMS text messages on smoking cessation and child lung health were requisite based on the original focus of the intervention to promote child lung health, including smoking cessation. The focus on child lung health was based on the call for more culturally appropriate information on childhood coughs . In addiMany participants experienced technical challenges in accessing the app, with nearly one-fourth 10/41, 24%) having been unable to access it. The prototype application used in the pilot study was a web-based application. A web-based application is accessed through an internet browser, such as Google Chrome (Google LLC) or Firefox (Mozilla Foundation), and is essentially a website designed to look like an Android or iOS app. Android or iOS apps are downloaded from an app store and saved on the phone . The ben, 24% havIn addition to considering the technical barriers to accessing applications, careful consideration must be given to long-term engagement . In a loOne such delivery mode is social media. It has been established that Aboriginal and Torres Strait Islander people are avid users of social media, Facebook in particular -11, whicA limitation of this study was the need to conduct all recruitment and instruction of the program remotely using SMS text messages, links, and phone calls owing to COVID-19 restrictions. In the initial protocol, we proposed recruiting women, setting up the app, and providing instructions on how to use the application in person to reduce technical problems. Unfortunately, this was not possible, and women experienced a high number of technical problems. With a large proportion of women having had difficulty accessing the application, most of the feedback on the application was centered on the technical challenges, and there was limited feedback on the content; however, it was useful to discover during this early phase that a web-based application is not feasible. An initial in-person setup would be considered important for further use of the program.Another limitation of this study is that generalization to other communities is limited. Aboriginal and Torres Strait Islander communities are made up of many diverse cultural and language groups . Each coThis study demonstrates that the Growin’ Up Healthy Jarjums program was perceived as useful and culturally appropriate by users and health professionals. The SMS text messages had the highest engagement, followed by the Facebook page and then the application. This study identified suggestions for improving the application. A trial is needed to assess the effectiveness of the Growin’ Up Healthy Jarjums program at improving health outcomes.


BCR::ABL1 tyrosine kinase domain (KDM) and of which the majority of which occur at seven codons within this region. A case of CML is described in which presence of a rare D363G BCR::ABL1 KDM resulted in a suboptimal response to frontline imatinib. Switching to dasatinib resulted in achieving a sustained major molecular response that was maintained after a subsequent switch to bosutinib due to the side effects. Reporting of such cases is important for the future management of any CML patients with this rare mutation.Acquired resistance to tyrosine kinase inhibitors (TKIs) remains a therapeutic challenge in the treatment of chronic myeloid leukemia (CML). The most studied reason for TKI resistance is the acquisition of mutations within the  BCR::ABL1 kinase domain mutations (KDM) extensively investigated. Mutations associated with TKI resistance have been described throughout the gene encoding, the BCR::ABL1 kinase domain, with approximately 20 mutations recurrently observed. In vitro TKI activity profiles of this common BCR::ABL1 KDM facilitate appropriate selection of subsequent TKI therapy [BCR::ABL1 KDM. More recently, next-generation sequencing (NGS) approaches have demonstrated improved limits of detection and are becoming increasingly adopted [Despite extensive advances in the therapy of chronic myeloid leukemia (CML) over the last twenty years due to the introduction of tyrosine kinase inhibitors (TKIs), a small but appreciable number of patients are either refractory or resistant to these inhibitors. The causes of resistance are myriad with acquired mutations of the  adopted . Uncommo adopted –7.9/L, and platelet count of 278 × 109/L. Bone marrow aspirate and trephine biopsy showed trilineage hematopoiesis and myeloid hyperplasia with immunophenotyping demonstrating 1% myeloblasts. Cytogenetics detected the t  translocation in 181/200 metaphases analysed. Quantitative reverse-transcription polymerase chain reaction detected e13/14a2 BCR::ABL1 transcripts at a high level, all consistent with a diagnosis of low-risk , chronic phase CML; the patient commenced imatinib 400 mg twice daily which was well tolerated and achieved a BCR::ABL1 transcript level of 11.7% at three months approximating a warning as per European LeukemiaNet recommendations [BCR::ABL1 transcript level was 2.9%  in achieving MMR in this setting. Reporting of such cases is necessary for the future, real-world management of BCR::ABL1-positive leukemia patients. The increasing application of NGS approaches is likely to improve BCR::ABL1 KDM detection allowing a timelier reconsideration of TKI therapy.The D363G mutation is exceedingly rare with only sporadic cases reported in imatinib-resistant chronic phase CML patients , 10. In