Physical exercise programs are useful and necessary for the treatment of schizophrenia. The aim of this study was to assess the experiences of participants with schizophrenia in an out-of-hospital exercise program designed and supervised by qualified exercise professionals. Thirty-five individuals with schizophrenia from the intervention group of the CORTEX-SP study were interviewed. The interviews were transcribed verbatim and content analysis was performed using inductive coding. Two main categories emerged: the importance of the program being conducted out-of-hospital, and the individuals responsible for the program being qualified exercise professionals. The participants highlighted the importance of conducting the program outside the psychiatric center since it gave them greater satisfaction. They perceived greater seriousness and a greater number of resources and felt encouraged to repeat the program or prolong it. The success of the program, in addition to the space, was due to the personnel in charge of the program, i.e., the qualified exercise professionals, and the fact that the activities were designed and supervised. Participants emphasized the qualifications of the exercise professionals, key for this type of program, their social skills and the level of involvement with participants and their follow-up. Schizophrenia (SP) is the most common psychotic mental disorder  and affeFor this reason, the social insertion of individuals with SP, among other factors, is based on the control of the psychotic symptoms of the disease  and, to However, physical exercise programs for this population face a double challenge. Individuals with SP, in comparison to individuals without the disease, have worse cardiorespiratory fitness and ventilatory capacity, medium to high heart rates, worse physical, physiological, and biochemical profile, and overweight/obesity . TherefoPsychiatric hospitals provide a close and favorable environment for the initiation of physical exercise, offering a wide variety of exercise programs to their hospitalized patients . HoweverThis work is a part of a larger project in which different measurements were taken before and after the implementation of the program to evaluate clinical, psychiatric, psychological, physical, health, and social aspects. The qualitative methodology was used in the present study, specifically, the interview technique , which hAll those individuals who were participating in the CORTEX-SP intervention group at the time of the interviews were interviewed. The inclusion criteria for participating in the study were being a participant in the physical exercise program of the CORTEX-SP study and being of legal age. All the interviewees voluntarily participated in the present study and signed the appropriate informed consent form. The study was approved by the local Research Ethics Committee (PI2017044).Once the interviews were completed, they were transcribed verbatim and a content analysis was performed reading and analyzing the data obtained . The datSeveral participants expressed the importance of the program being out-of-hospital. In this way, the meaning attributed to it also differed and it was an opportunity to escape from routine, as stated by a participant: “it is also a way of escaping from the psychiatric hospital, which makes us crazier than we are” (William).Changing the space brought the participants more benefits, since some expressed that changing scenery was related to getting away from the negative feelings associated with the psychiatric hospital: “you are not in the same place, because the psychiatric ward is a bit sad” (William).Along the same line, the level of participation was related to the fact that the program was being conducted out of the psychiatric hospital. Some participants stated that their participation was conditional on the intervention being performed outside the psychiatric center, because they did not want to return to the past, as Isabella explained: “no, less in the psychiatric hospital, I would not have gone, no. I don’t like the psychiatric hospital. I don’t like those places and I’m screwed but I don’t like them. The less I go the better, you know”.These responses were given by patients that were no longer at the psychiatric center while participating in the program. This fact also allowed them to be closer to their homes rather than have to travel the distance to the psychiatric center: “in my case, I would have to come from the sheltered housing to the psychiatric hospital every day by bus; it’s much further away” (Thomas).Nevertheless, in some cases, some participants affirmed that they would have also participated if the program had been conducted in the psychiatric hospital. They also stated that the out-of-hospital program did not have as much influence when deciding to participate in it, since their addresses were in another community: “I tell you that I live in Logroño. There will be more people who have more difficulties. I don’t know the truth. I wouldn’t care” (Charles).Several aspects were highlighted by the participants during the conduction of the program, since it was beneficial in different aspects. First, the seriousness attributed to its implementation in sports facilities outside the hospital, as expressed by Reece: “when you come here to Mendizorroza, it’s sort of more serious, you know? You know what I mean? And you’re going to do it there in the hospital, it doesn’t seem funny, you know what I’m telling you, but it’s different. You see it and with this I make pam, pam. I don’t know what, but it’s not the same as coming here. You know you take it more seriously now”.In addition, as the participants affirmed, the sports facilities had more means to guarantee more attractive physical practice adapted to their needs. At the same time, having more resources was also a determining factor for the satisfaction associated with the participation of the participants and the importance attributed to the program: “realize that this is IVEF (Faculty of Education and Sport), this is a specialized center; it is a sports university or whatever; this is not the same as a center… it doesn’t have the same name, the same incentive, you know!” (Noah), and “I liked it better in Mendizorroza, because it was more like a cool gym, and I don’t know, you went there, with your own showers, history” (Reece).Other participants stated that leaving the hospital was very beneficial for individuals with SP. Therefore, differentiating the admission hospital and attending an out-of-hospital program helped create links with the outside world, which was a positive aspect according to the participants: “I think that if this continues this way, it would be very good for the individuals in there” (Max), and “being in the hospital I think it is very good to get out a bit and exercise” (Alexander).The continuation of the program and the need to continue promoting this type of proposal was highlighted by the majority of the participants. They perceived themselves benefited in different aspects thanks to their participation, showing the desire that the program had a long life: “it would have to be extended as if it were a municipal sports gym that would be prolonged in time” (Charles).Finally, there were those who stated that they wanted to do it again if that was possible. They felt very satisfied by having participated in the program, despite the fact that they initially did it for an altruistic cause such as helping by being part of the study: “ah! I would repeat it, if that’s what you mean. At first, it was to help the study, but I participated with pleasure during the program; I even had fun. It was good, a very good experience, come on, with the colleagues it was also good; we were all good; we didn’t have any conflicts between us, that is, there were no complaints” (Alexander).Practicing physical exercise with individuals specifically qualified in the field of physical activity and sports sciences was an aspect highlighted by the interviewees, since having personnel that did not come from the social and healthcare field―such as assistants, psychiatrists, or nurses―was valued by the majority. They emphasized that, without these professionals, they would not have been involved in the program and it would not have had the same approach: “with the auxiliaries and that can’t be done there, not at all, not at all, not at all, no, no” (Andrew), “no, no, no, neither. I don’t want anything. I don’t like it. I don’t like it. Psychiatrists and that stuff. No, no, no, no, no, no, no, I don’t like it” (Liam), and “I don’t know, I have an experience with you, and I think you did well, I think you also knew more about sports than nurses, right? I say that each one with respective functions” (Alexander).There were those who stated having had tense relationships with the staff of the psychiatric center: “uh, well it’s going to be worse, huh. I don’t see much of a future for attending the project with the personnel of the psychiatric hospital. I see it more as a tug-of-war, because for me the psychiatric hospital has been a tug-of-war, one tells you one thing, the other tells you another and the other another and all they do is make you dizzy, each one has their way of thinking and all they do is make you dizzy” (William).Regarding the closeness and bond created with the individuals in charge of the program, the participants agreed that the teachers were always attentive to their needs, the treatment was very pleasant, and this fact made them more motivated to make an effort. They positively valued the teachers’ behaviors, sharing positive memories related to the experience: “well, I prefer that the monitors had been there. Very nice, very friendly, and very nice” (Kyle), “they are nicer, more apprehensive, they care more, more affectionate. More cuddling and things like that ” (Amelia), and “yes, yes, yes, I have good memories of the exercise, yes, yes, yes, and also the responsible personnel were very friendly and very attentive, and always aware of whether or not something hurt, yes, yes, yes, always attentive” (James).There were those who highlighted that their experiences had been even more positive thanks to the qualities of the qualified exercise professionals, since it was a pleasant surprise for the participants and had effects in increasing their level of acceptance of the program: “I did not expect this; I did not expect the monitors as they were. I don’t know, I expected something else, well, more rigidity. […] yes, more rigid, and when I came across this, I accepted the program more” (Emily).On the one hand, the scheduling of the sessions and the way they were performed was positively valued by all the participants, highlighting their variability, as explained by William: “it is better designed, because they give us tasks and force us to do things, new things ehh… (which you don’t like doing on your own very much) no, I get more diverted, and I say again ‘one day I come and another day I don’t come’ and that is the problem”.In addition, as in the previous statement, performing scheduled activities helped the participants persevere and not give up while trying to perform the activities. This way, the activities promoted some adherence to physical exercises. Therefore, there were those who related having performed designed activities with less boredom, as in the case of William: “those from COTA (Counseling and addiction treatment center) were good, but do you know what happens? That it’s good because they form a group and perform activities all together, they tell us to run, they tell us to do things, but then, once you go to the gym alone, you don’t go with monitors who tell us to perform activities and so on, they say ‘don’t come basketball, play basketball’ and we play basketball or you go to the machines, but it’s not like… (it’s not designed) it’s not designed exactly, and that’s more boring”.The professionalism of the qualified exercise professionals was evident in the experiences related by the interviewees, both when it came to scheduling sessions in accordance to the needs of the users and when trying to offer individualized services to each participant as far as possible.The participants of the CORTEX-SP program valued very positively the follow-up provided by the professionals and how it influenced them in increasing their motivation for being more involved in the program, as highlighted in the words of different interviewees: “well, I don’t know what I can tell you, I’m doing very well. You are giving them hope and we also have to consider the patients, the individuals who participate. Yes, illusion and such things. Maybe I don’t know because of X, I lacked that motivation, I don’t know, I had it at one point, but well, other times I didn’t, but it’s ok” (Robert), and “with great desire and not only for the program, the young man you have there, the entertainer, he is worth a lot, because he’s all the time cheering you up; it seems that he increases your strength when you don’t have it. . He is very human and generates a lot of positivity, joy, and everything, you start walking, it seems that you can’t and you can do it more (laughs)” (Poppy).The follow-up provided for continuing in the program was also valued very positively by a relative of a patient. This individual stated that the patient had never before achieved that level of involvement and commitment, showing gratitude for the progress of the relative in this adherence to physical exercise thanks to the qualified exercise professionals: “indeed, you know, that is, a very important part of the study is the daily follow-up, because she… you know, they obtained a commitment from her to come to the study that I had not achieved, you know, and the daily monitoring of ‘I’m not going today.’ Phone call, blah, blah, blah…, what’s up? How are you doing? Not today. Well, come on, see if you’ll come tomorrow; Joe called me, and their daily follow-up is the best part of the program. In other words, I have seen that he has managed to get something out of her, it has been them. (…) The commitment obtained by Michael and his partner, whose name I don’t remember exactly, is priceless” (Isla).Several qualitative ,33,34 anOn the one hand, the out-of-hospital nature of the physical exercise program was highly valued by the participants of the present study, since it could result in greater optimism and well-being ,39. AddiRegarding the feelings generated by the out-of-hospital program, the interviewees associated sadness and negative feelings with the hospital center and, on the contrary, declared that the change of scenery had generated greater positivity and greater benefits for them. This result is in line with other findings that observed that physical exercise improved feelings of depression, anxiety, and negative symptoms . In addiOn the other hand, several aspects of the out-of-hospital program were beneficial for the participants. Firstly, they highlighted the seriousness assigned to the intervention, which could be related to a decrease in unsafe, stressful, and tense situations experienced by the participants . SecondlThe qualified professionals in charge of designing and supervising the physical exercise program―i.e., the physical-sports education professionals―were very important for the participants, since the fact of being personnel outside their usual social and healthcare field (psychiatrists or psychologists) and having specific training in the field of physical-sports activities was very successful. The same result was obtained in other studies, which found that the dropout rates of the programs were lower when they were designed by qualified professionals . At the Regarding the skills of these professionals highlighted by the interviewees, the most positive were associated with the open, close, and friendly nature of the professionals. In turn, these characteristics contributed to greater motivation of the participants, greater involvement with respect to the program, and a more relaxed and pleasant atmosphere, as observed in other programs with similar characteristics ,18,42,48Participating in a programmed intervention, designed, and supervised by qualified professionals who were in charge of personalizing and adapting the activities to the characteristics, as well as the needs and interests of the participants, turned out to be very positive for them, as all the participants highlighted. This fact gives a more central role to qualified exercise professionals since they become the main axis of the program for the direction of physical exercise . FurtherThe participants of the present study highlighted two main characteristics of the CORTEX-SP program. On the one hand, the importance of the program being conducted out-of-hospital, and on the other hand, the fact that the individuals responsible for the program were qualified exercise professionals. They also highlighted the importance of conducting the program outside the psychiatric center. This fact led them to a higher level of satisfaction while the location provided them with greater seriousness and greater number of resources, and encouraged them to want to repeat the program or extend it. The personnel in charge of the program, i.e., the qualified exercise professionals, were also fundamental for the success of the program. The participants emphasized the qualifications of the personnel crucial for this type of program, their social skills, and the level of involvement with them, and the follow-up provided. They also highlighted the fact that the activities were programmed, designed, and supervised. These results are fundamental for the future implementation of physical exercise programs and the achievement of success for individuals diagnosed with SP. These programs will be vital for the prevention and treatment of cognitive dysfunctions, as well as the positive and negative symptoms caused by SP, aiming to help improve the quality of life of individuals affected by this pathology.


Two case studies of parenting programs, aiming to improve parenting practices and child development outcomes, and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and Boston College/University of Rwanda/FXB in Rwanda, respectively called Prescription to Play and Sugira Muryango, were conducted by an independent research and learning group. Implementation research focused on the workforce, a crucial but little-studied element determining the success of programs going to scale. Mixed methods were used to examine their training, workload, challenges, and quality of delivery. Health assistants in Bhutan and volunteers in Rwanda were trained for 10–11 days using demonstrations, role plays, and manuals outlining activities to deliver to groups of parents (Bhutan) or during home visits (Rwanda). Workers’ own assessments of their delivery quality, their confidence, and their motivations revealed that duty, confidence, and community respect were strong motivators. According to independent observations, the quality of their delivery was generally good, with an overall mean rating on 10 items of 2.36 (Bhutan) and 2.44 (Rwanda) out of 3. The facilitators of scaling for Bhutan included institutionalizing training and a knowledgeable workforce; the barrier was an overworked workforce. The facilitators of scaling for Rwanda included strong follow-up supervision; the barriers included high attrition among a volunteer workforce. Recent estimates suggest that over 43% of children under 5 years of age worldwide are not developing their mental capacities as expected for their age . EnergizA great deal has been written about the need for implementation data on parenting programs . LikewisAn effective parenting program has many critical inputs, but, like good theater, it must start with a riveting idea and subsequently be delivered in an engaging manner. A riveting idea delivered badly will not hold an audience to the end. A story with no plot, even if delivered well, will fall flat. So, an effective parenting program must have a curriculum with a compelling account of what parents must provide their children and why, and it must be delivered by a workforce that engages all the sensory, behavioral, social, and emotional brains of its audience. We start with a review of what is known and not known about preparing a workforce.Depending on the context, a parenting program’s workforce can involve health professionals, community health workers (CHWs), para-professionals, or volunteers. The workers delivering the service to parents are critical to its success ,11,12. HTomlinson  and otheCurrently, no common method exists to monitor the quality of delivery of a parenting program . HoweverBased on publications outlining features of the workforce that are critical to maintaining quality at scale ,14,15, wThe nature of a parenting program is as important as the workforce delivering it ,12. For The two parenting programs presented here are Prescription to Play (P2P) implemented by Save the Children/Ministry of Health/Khesar Gyalpo University of Medical Sciences in Bhutan (and based on their Building Brains Common Approach), and Sugira Muryango (SM) implemented by Boston College/University of Rwanda and its partner organization FXB Rwanda. Both are funded by the LEGO Foundation and began scaling their program in 2020 following successful evaluations ,23.Some information about the design of their programs helps to lay the groundwork for an understanding of their workforce. Each had created a parenting program for its respective country, built on existing programs, and had reasonable data showing that their program was effective. Both intended to scale it out over 3–4 years to include many more families—56,000 families in all 20 districts of Bhutan and 10,000 in 3 districts of Rwanda. Both had plans to engage the government by using an existing workforce: health assistants in Bhutan who are part of the Ministry of Health system, and Rwandan Friends of the Family (inshuti z’umuryango or IZUs) who are recruited by the Ministry of Gender and Family Promotion and regulated by the National Child Development Agency. Finally, both provided their workforce with a manual detailing activities for 12 sessions. In other respects, their initial designs were different . BhutaneFunding from the LEGO Foundation was related to the inclusion of play and nurturing care in their curriculum. The Bhutanese program included 12 monthly sessions delivered to groups of parents and their children; nine of these sessions emphasized play and communication, such that four games for different age groups were demonstrated and practiced at each, using household materials like cups, cloth, and pictures. The Rwandan program also included 12 home visits, but they were delivered weekly along with 3- and 6-month booster sessions that reviewed earlier topics. A total of 4 of the 12 included demonstrations of new ways to play and talk to children, though 15 min during each visit was devoted to parents showing how they played with their child while being coached by the worker. The themes of the non-play sessions in both programs included nutrition, hygiene, stress management, family conflict, and discipline, with some attention given to play at each session.An independent research partner, FHI360, was engaged and funded by the LEGO Foundation to collect data on the implementation process of each program as they began to scale up. This was done through a collaborative arrangement with the implementing partners (Save the Children and Boston College) so there would be no duplication of data collection. Scaling up is defined as “deliberate efforts to increase the impact of [parenting] innovations successfully tested in pilot or experimental projects so as to reach and benefit more individuals and to foster policy and programme development on a lasting basis” . The ExpDescribe the workforce training in terms of parenting topics covered, delivery skills addressed, and methods of teaching;Describe in quantitative form the training, supervision, workload, and parenting knowledge of the workforce in each country;Describe in qualitative form the workers’ understanding of the challenges they faced while facilitating parenting practices to promote child development, and how well prepared they felt after training and supervision;Evaluate the quality of delivery by the workforce in terms of the use of active learning methods and parent participation.The overall objective was to describe the training, supervision, and functioning of the workforce through surveys, in-depth interviews, and observations. Based on data from Year 2 (2021–2022) the research objectives were as follows:Suggested methods for assessing workforce competence and delivery quality were considered with the understanding that most are not standardized . The CARThe participants were the frontline workers who were trained and who delivered the parenting programs directly to parents with their children, namely health assistants in Bhutan and Inshuti z’Umuryango (IZU)/Friends of the Family volunteers in Rwanda. Informed consent was obtained from each worker  at the time they were interviewed or observed. Data were collected while providers were trained and then later in the midst of delivering the programs to parents, which started in early 2022 in Bhutan and 2021 in Rwanda—both delayed somewhat due to COVID-19 restrictions.The training was observed on multiple days during the 10–11 days of initial training of a cohort of the workforce. Training was conducted by Save the Children for the Prescription to Play program in Bhutan, and by FXB Rwanda for the Sugira Muryango program. The particular cohorts observed were selected based on convenience ahead of the program being implemented, and it was reasonably assumed that the same agenda and methods of teaching/learning would be used for other cohorts.Workers for the phone survey were chosen at random from the pool of recently trained providers. The sample constitutes a majority of recently trained workers in each country and was based on an expected improvement of 5 points out of 40 (1SD) in the knowledge test over time, leading to a required sample of 128.A purposive subsample of ten to twelve recently trained workers, who varied in gender and educational background, was selected to participate in in-depth interviews. Saturation was reached with this number and the intention was to follow up the same workers over time. Finally, observations were made of 60 different randomly selected providers in each country, using the phone survey as a sampling frame, as they conducted a group or home session. In Bhutan, providers were approximately 8 months into delivering their monthly program, whereas in Rwanda they were delivering the 3-month booster visit.A structured observation measure was used to identify the parenting topics covered, social skills practiced, and teaching/learning methods used by the trainers to help workers learn how to deliver a session to parents. To create the items to be observed, we consulted experts involved in training professionals, para-professionals, and volunteers for previously known and effective parenting programs. Because we were interested mainly in parenting for child development, topics related to play, communication, milestones of development, and father engagement were recorded, but not nutrition and health, though they also may have been taught. Skills for delivery included, among others, showing respect and empathy, listening and responding to parents, giving gentle feedback, and engaging parents. Methods of teaching included observation of a delivery enacted by a trainer or on video, role-playing delivery with other trainees, receiving feedback on delivery from the trainer or trainees, didactic teaching, and group reflection on one’s performance. These methods were rated during multiple 2–3 h blocks of time in order to determine their approximate frequency. Observers recorded their observations on the Kobo Collect app, and these were forwarded directly for analysis; if an item is recorded as observed, a space opens on the app for extra descriptive comments to be written. Observers were trained by an international and a local researcher over three days during which detailed descriptions were given for each item. Inter-rater reliability against the local researcher reached over 80% for the first training attended.The structured survey consists of 20 questions with sub-questions. It includes demographic variables ; workload for this program and for other duties; training and supervision; confidence in delivery; perspective on own work; and the 20-item Knowledge of Child Development Inventory assessing knowledge of child development with 10 items and ages for appropriate provision of stimulation with 10 items . The surThe semi-structured interview guide requests detailed information on providers’ understanding of what their work entails. Questions are open-ended and focus on issues that arose from the phone surveys. Items include parenting practices they attempt to change and how; workers’ understanding of the terms “early child development” and “responsive stimulation”; challenges they encounter in their work; most effective methods used in their own training; supervision and peer support; their motivation for work; and the perceived demand for their program in the community. Local researchers who are part of the research team conducted the interviews by phone. It took approximately 40 to 60 min per interview. The interviews were audio recorded, transcribed, and translated. Both the local researcher and the lead international researcher read through the transcripts and conducted a content analysis; the former wrote the first draft of a summary, including representative quotes.Based on previously published measures of delivery quality ,20, qualThe training of observers from the data firm was conducted over three or four 3 h sessions using written vignettes of hypothetical sessions based on the parenting program being delivered. Trainees were required to rate every instance they saw in the vignette that reflected one of the qualities to be observed. Over the course of three separate assignments, inter-rater reliability with the trainer reached 80% and above for all observers. During the first two days of observations, observers in pairs independently rated and submitted their data for the same session, then discussed the discrepancies to arrive at a consensus, and submitted the consensus ratings. These independent paired ratings also surpassed 80% agreement.Results for the four methods of data collection are presented in descriptive form. Data were collected by independent data firms and researchers in each country, and all analyses were conducted by independent analysts. Although the intention is not to statistically compare the two programs, similarities and differences are highlighted.Both Bhutan and Rwanda partners were observed to use a manual for training and delivery, with detailed descriptions of the activities to be performed in each session. These activities formed the basis of training. Two to three trainers conducted the training of 15 to 20 trainees lasting approximately 10 days—11 were observed in Bhutan and 10 in Rwanda. Not all days were devoted to parenting for child development: Bhutan had 9 out of 12 sessions on play and communication, developmental milestones, and respectful discipline; Rwanda had 4 out of 12 sessions on play and communication, with others devoted to family conflict and stress management. Both addressed hygiene and nutrition to an extent. Neither used video, but Bhutanese trainers had playthings and books for providers and caregivers to use with children during sessions along with illustrated play cards to take home. The Rwandan program emphasized the use of homemade playthings; trainees were shown how to make them and thereby engage caregivers to make their own playthings out of locally-sourced material.The delivery skills listed in According to the results presented in Days of training were similar, but follow-up support was stronger in Rwanda where most had received refresher training, recent face-to-face supervision, and peer support. Confidence in delivery was high, with an average quality rating between 7 and 8 out of 10, according to providers. Yet on a 40-point Knowledge Inventory, the means hovered around the midpoint, higher for health assistants, as expected. The mean for Turkish mothers who had no training in parenting was 19.2 . A commoData from the two countries are presented separately in order to convey the personal perspectives of the providers. Quotes from interviewees are included without identifying information because of the small sample.Bhutanese health assistants clearly understood the centrality of brain development and how it was related to mental capacity and behavior. They understood the term “stimulation” and the role of parents playing with their children, but most understood that children would be responsive to parents rather than vice versa. When asked: “What exactly do you tell parents that influences them to adopt new play practices? What exactly do you do?” they said by advising, showing, demonstrating, and talking about the benefits of play. Some talked about specific games and songs they teach, and they emphasized to parents the specific skills acquired with each activity.“….we tell them that playing at stacking cups helps develop motor skills, while singing “kuzuzangpo” song teaches them tunes, words and also to associate the words to greeting someone and bowing slightly when you meet.”Challenges in persuading parents included a lack of interest in the new play leading to a lack of attendance at group sessions and disinterest in practicing the games during sessions and at home. Fathers and grandparents were also said to express disinterest. Challenges in conducting sessions included finding time in their busy schedule along with a convenient space, and being called to attend health campaigns.Perspectives on their training revealed strong support for the materials received to help them deliver the program, including the step-by-step outline of activities presented in the structured manual. Sitting mats, toys, books, and visual charts were also helpful during training and delivery. Supervision by a District Health Officer was rare except perhaps on a national- or district-level social media platform where supervisors checked to see that sessions were being conducted and to offer advice. Especially in more remote areas, face-to-face monitoring did not occur. Planned meetings with other providers were infrequent, but those who met up spontaneously in a health center said the exchanges were useful.“It is very helpful as we share each other’s experience in group sessions and what one does when we encounter problems. That way we are exposed to new alternatives for solutions. This also helps in getting information on preparation.”When asked what motivates them to do this work, they mentioned the value of the program for parents and children, and its recognition as an important component of the health system. Health assistants were also paid workers.As part of a question on whether the program would be sustained once external funding finished, we asked about the demand for the program. The respondents felt that demand required effort to sustain at the community level. They suggested that the government might need to initially incentivize families to attend, by providing oil or rice, the way they had done with the immunization program, which now no longer requires incentives.Rwandan IZUs had a clear understanding of the phrase child development as encompassing cognitive, emotional, and social development and the brain. However, they were less clear about the term “responsive stimulation”, describing ways that parents could provide stimulation most of which were instructional rather than responsive. When asked: “What exactly do you tell parents that influences them to adopt new play practices? What exactly do you do?”, they listed a number of specific play activities along with verbal persuasion by citing the benefits for their child.“Play ensures that our bodies make movements, enhances sociability, creates bonds with parents; helps the brain to be active” and “The child does not become lonely… If the child is social, it is easy for a teacher to teach the child when he starts school.”Challenges in persuading parents to change their practices included not seeing the importance, being too occupied finding food and other material supplies, conflict between parents, and norms around fathers’ engaging with their children. “Parents do not see the importance of playing with a child. They see it as waste of time”. They solved this by working on trust, and being available to help families solve problems. Challenges in delivering the sessions included the lack of basic materials among poor families such as soap and materials to make playthings and having to delay the visit if the family was out working or otherwise occupied.Perspectives on training emphasized the value of their manual and its illustrations, which was used to prepare for each visit; preparation time varied between 20 and 60 min per family. They also referred to training in how to be humble with poor families.“The teaching manual was well prepared, like when teaching on a certain lesson I would check in the manual and understand well what to train about. The learning became concrete. Everyone should have this teaching manual in their homes.”Supervision took place weekly and often a supervisor watched a home visit and gave feedback. They also appreciated weekly meetings with other providers in order to exchange experiences and solutions to problems, and to arrange to fill in for a sick colleague.“We all needed to learn and refresh our minds. Because there were things I was doing wrong … We educated each other and corrected each other on how best to teach families.”Given that the Rwandan providers were volunteers, it was useful to hear what they said about their motivations to do this work. Some said that they were motivated by the changes they saw in families due to their influence: “to see families improve their lives… a sense of worthiness”. Others said the solutions they discussed with families were relevant to their own lives: “These courses are relevant to me and my life as well. I learn as I teach. I have improved and now able to solve my own problems as well”. Others said it was their duty as an IZU and because they had been trained and supported: “I accepted the responsibility because of the support I was given to do the activity”. They all agreed that they would continue with their work if the government decided to take over the program.A question regarding the demand for the parenting program was answered most often in terms of need. However, demand was reported to increase among families once they saw the benefits of the program, and among others who were in the second SES quintile and therefore did not receive the program. Local leaders were also reported to increasingly express a demand for the program.Delivery by health assistants in Bhutan received a mean of 2.36 out of 3 on the ten qualities related to active teaching/learning see . Only a Delivery by IZU volunteers in Rwanda received a mean rating of 2.44 on the ten qualities see . Once agHealth assistants in Bhutan delivered the 12 monthly sessions to groups of parents with their children, whereas the Rwandan volunteers delivered 12 weekly home visits to parents and children. The first challenge was that both were similarly unfamiliar with brain development and parenting for child development ahead of training for this parenting program. They also noted that parents initially did not see the benefits of responsive play and communication with children. However, they received similar 10–11-day training with a manual to guide them through delivery. Follow-up support was stronger for the Rwandan IZUs in terms of refresher training, supervision, monitoring of their visits, and peer exchanges. Yet, much of this support for delivering parenting visits would disappear once the 12-week program was over. Furthermore, as volunteers, they received little remuneration. Challenges for the Bhutanese health assistants included a lack of follow-up training, monitoring of their group delivery, peer exchanges, and a heavy workload, which is a common complaint among professionals. To accommodate their workload, the health assistants delivered two group sessions a month but long intervals between sessions and the need to send out reminders to parents made parent attendance challenging. Regardless, providers in the two countries received high ratings for the quality of their delivery, especially in terms of using techniques central to active learning for parents. Health assistants were insufficiently lively and engaging—a more difficult but much-needed skill when addressing groups—and this was reflected in less engagement in play activities on the part of parents. We caution against drawing strong causal or comparative conclusions as the study design was intended to be descriptive, and the modality of delivery and target beneficiary families differed in the two settings.These findings are now discussed in greater detail as they pertain to critical issues in preparing and supporting a workforce to deliver effective parenting programs at scale. Mixed method data from the two case studies reinforce previous guidance on scaling horizontally throughout a system and add new insights. They are based on the recognition that providers being used by most Ministries of Health in low- and middle-income countries, whether volunteer or professional, are unlikely to have experience or expertise around parenting for child development, much like the parents they are training. Professionals are conveniently part of the system, yet are already overburdened in attending to other duties, while volunteers who are trusted members of their communities will show higher attrition unless compensated. Going to scale requires that the workforce be continuously expanded while maintaining a consistently high level of quality, perhaps by institutionalizing the parenting program and training within the health system. As a program expands, different forms of monitoring for quality may be required. Going to scale also requires built-in feedback loops whereby implementation data are used to improve delivery.If “scaling” involves expanded reach and benefiting more individuals , there nBoth programs showed high quality both in terms of the ten critical activities needed to encourage behavior change among parents and in their delivery of social skills. The health assistants received little follow-up support after their initial training, while the Rwandan volunteers received strong supervision from mentors and peers. Maintaining quality as the program scales up across the country requires such supervision.In other respects, the programs in Bhutan and Rwanda both had two features that would facilitate consistent quality: one is the use of a detailed, structured curriculum manual highly appreciated by providers both during training and when preparing to deliver sessions to parents. Manuals are also essential for consistent scaling up across regions in a country . The secTo maintain quality, competence after training should be assessed. Of the multiple methods suggested for assessing competence , only anOnly the Rwanda program had an ongoing system for monitoring the quality of providers’ home visits. It required the volunteers’ supervisor to observe, rate, and provide feedback. The Bhutanese program has now put one in place using a local organization. Many parenting programs use such a system, including the Cuna Mas program in Peru . Others If scaling up requires “deliberate efforts” to expand the reach and improve the outcomes of a parenting program, then these efforts must be based on implementation evidence . In manyOne limitation is the lack of any statistical comparison of the two cases. Rather, we simply highlighted similarities and differences that were of interest. Statistical comparisons along with validation against endline changes in parental practices would be important. The methods for collecting quality data differed in that they were collected by an independent data firm in Bhutan and by potentially biased supervisors in Rwanda. Although supervisors’ reliability with a local research firm was high, supervisors might have deviated once the reliability test was finished. Potential biases in self-reports from the workforce when answering questions from the survey and in-depth interviews is a well-known limitation, but one that is acknowledged and accepted when one wants to understand the perspective of providers. The generalizability of the findings is limited by the nature of the workforce, their delivery modality, the families they intended to benefit, and more generally, the countries in which they lived and worked.This paper presented two case studies of parenting programs developed by organizations in Bhutan and Rwanda and studied by an independent research and learning group. The implementation research focused on the workforce, arguably the linchpin of a successful program. Expanding the workforce as the program scales horizontally and vertically requires a mechanism to institutionalize training and to build in continuous quality improvement and workforce skills development. Data on the quality of delivery, because they are known to be associated with parenting outcomes, are most likely to trigger changes in training and in continuous development through supervision. In recognition of the value of quality data, both programs described here instituted regular monitoring of program delivery using a robust quality tool, similar to the one applied here, early in the case of Rwanda and later in the case of Bhutan. In addition to independent assessments of training and delivery, new insights were gained from the perspectives of the workforce. Their own assessments of the quality of their delivery, their confidence, and their motivations revealed that duty, confidence, and community respect were strong motivators. These motivations can drive an existing workforce with minimal experience in early child development to manage workloads, share tasks, and deliver early childhood programs with quality. Continued support for the workforce in terms of refresher training, mentoring, and peer coaching is advisable to maintain quality implementation at scale. From the workers’ perspective, sustaining a quality program additionally requires financial and policy support from the government.


BackgroundThe objective of this study was to assess the accessibility and content of the critical care fellowship websites provided on the Electronic Residency Application Services (ERAS) website.MethodsUsing the online information provided by ERAS, we compiled a list of Accreditation Council for Graduate Medical Education (ACGME)-accredited critical care fellowship programs. Each of the links provided by ERAS was evaluated by a standard search on Google as follows: the program name + “critical care fellowship”. After assembling the working links, those websites were subsequently evaluated based on the program description, application process, and educational content.ResultsWe reviewed 59 critical care fellowship programs that were obtained from ERAS. Of the 59 programs, one retracted its participation and was not included in the study, and six other programs were excluded due to repeated links on ERAS, nonworking links, and websites without any content. We analyzed the data collected from the remaining 52 programs. Our data shows a general lack of information being provided to prospective critical care candidates.ConclusionsERAS is a major source of information for prospective fellows looking for critical care fellowships in the current match. Unfortunately, the majority of the programs evaluated lack substantial information for prospective candidates. Despite many websites containing adequate information regarding program descriptions, there was a lack of information regarding the application process and educational activities. The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on critical care medicine, with approximately 5-20% of patients becoming critically ill and requiring intensive care monitoring [The COVID-19 pandemic has made a major impact in the critical care world, significantly changing the resident experience, teaching, and perception of medicine as a whole. According to the Journal of the American Medical Association (JAMA), internal medicine applications show a 6% increase from a 2.7% average, and unsurprisingly, fellowship numbers have also increased .Our culture has adapted to social distancing and virtual interviews so it is critical that these websites have working links, easy access, and sufficient information to provide prospective applicants applying for critical care medicine. There have been multiple studies describing the online content and presence of fellowship programs. A study by Ferre A et al. regarding surgical critical care fellowships revealed that 36 of the 90 programs reviewed 40%) had an inaccurate PD named on the website, and that “only 25% of programs had a website containing a program description, faculty list, curriculum, and current/past fellows list,” showing a surprising lack of information [0% had anhttps://services.aamc.org/eras/erasstats/par/display.cfm?NAV_ROW=PAR&SPEC_CD=142). The fellowship programs included in this study participated in the 2023 match. Out of the 59 programs on the ERAS website, one retracted from the Match and six did not have working links to websites for review, bringing the total number of programs to 52. The data to be reviewed was collected through the Google search engine  and through the links provided on ERAS.The current list of critical care programs participating in the Match was taken from the Electronic Residency Application Services (ERAS) website . Of the total links provided, 52 of the 58 (89.7%) programs were evaluated for program description, educational activities, and application process.Google links provided by ERAS worked for 84.62% of the programs. Using the standard search approach described above, we found critical care fellowship websites were the first available link on Google 90.3% of the time, with an average position for those websites on Google at 1.09.Program DescriptionThe overwhelming majority of programs provided a description of the program (94.23%) and the same number of those programs also included the program director (94.23%). Phones, addresses, and emails to contact the program were not as robust. The email address was most widely given 92.31%), but the address was only given by 40 of the 52 programs (76.92%), and phone numbers were only given by 46 (88.46%). With respect to current and past fellows, we found that programs provided information about their current fellows 65.38% of the time, but only 10 programs had information on past alumni (19.23%) or where their alumni work now (21.15%) . Only 25 programs provided information on journal clubs (48.08%) and 27 programs (51.92%) had information on the rotation schedule. Slightly more than half the programs, 28 total (53.85%), informed prospective fellows about ongoing research or clinical trials. Information about call responsibilities was the lowest in 13 programs (25%)  had information on their application process, and fewer, 35 (67.31%), programs had information on the number of recommendations required to apply. Nineteen of the 52 programs (36.54%) provided information on any special or additional requirements such as visa or research requirements. The deadline for when applications were reviewed was provided in only 21 programs (40.36%) and information on the salary was available in 13 programs (25%)  were evaluated; one program retracted from the match and six programs did not have working websites. Programs were evaluated for program description, educational activities, and application process. Google was the best way to find available programs (84.62%), and the average position of the google link to the program was 1.09. We were pleased to see that the overwhelming majority of programs included both the program director and program description (94.23%). Hospital information, such as an address, phone number, or email, was readily available, but in contrast, current fellows, past fellows, and alumni career information were not provided as readily .Similar studies from other specialties, including cardiovascular disease, surgical critical care, and orthopedic trauma surgery, also revealed their program websites' lack of content ,6,7. ThiOf the 90 surgical critical care fellowship programs listed on the Eastern Association for the Surgery of Trauma (EAST) or American Association for the Surgery of Trauma (AAST) site, 36 programs 40%) had an inaccurate program director in comparison to the 49 (94.23%) websites provided by critical care fellowships and only 25 (20%) surgical critical care fellowship websites contained a program description, faculty list, curriculum, and current/past fellows list 0% had an but was Critical care websites had poor access and provided minimal content regarding the application process and educational activities for prospective fellows. The application process was discussed by 86.54% of websites but only 19 of the 52 websites (67.31%) discussed special requirements for prospective applicants. Special requirements included sponsorships for J1 or H1 visas, which are extremely necessary for international applicants. Application deadlines were only provided by 40.38% of websites. Didactics, journal clubs, and rotation schedules were provided in less than 60% of the programs listed. Research meetings and conferences were provided by 53.85% of programs and only 32.69% of programs included current research/clinical trials.While our data appear to implicate a lack of general content provided by critical care fellowship websites, which as a whole appear to have less content when compared to other fellowships reviewed in this paper, this paper should not be used as a failing grade. Rather, we hope to shed light on the lack of content available for prospective critical care fellows. There is potential for improvement and better access to fast and reliable information in the application process. Critical care medicine, as a field, is gaining popularity and the number of prospective applicants is growing considerably. Given the internet has become more prevalent in the United States, both among average American and graduate medical students, it has become increasingly important to establish a strong online presence. A survey of 188 emergency medicine residency applicants found that nearly one-half chose not to apply to certain programs because those programs maintained poor websites .We compiled a list of recommendations, based on our analysis, to aid future programs when designing their websites to capture the attention and aid prospective fellows searching for their desired programs. First: This ensures that applicants can contact the program for additional information if necessary. This will ensure the applicants can contact the program for more information should they require it. Second: We recommend having clear tabs with designated pages for information instead of all the information on one page. This can increase page clutter and worsen loading times. Two websites in our study failed to load due to traffic congestion. As stated by Portnet on e-commercial retail "load speed for product category pages has the most impact on sales" . For theOur study does have limitations, the most important ones to consider are the subsections we reviewed. While it may be more obvious that applicants would want to see the program director on the fellowship website, it may be less obvious for other parameters. We may not have included some parameters that prospective applicants would want to see as well. The other limitation of the study was the innate risk of searching manually through each website for the information. If the information was well hidden we could mark the content missing.Our study was conducted to analyze the content of online information provided by critical care programs. COVID-19 has drastically changed how information is obtained and how important it has become for fellowships to have a strong online presence. Multiple studies in other specialties, including cardiology and surgical critical care, have also shown how important it is to have a strong online presence to recruit prospective fellows.


To assess the impact of the COVID-19 pandemic on the academic and clinical processes of pediatric emergency medicine (PEM) fellowship training held by the Saudi Commission for Health Specialties (SCHS).A cross-sectional, nationwide, survey-based study was conducted between June and December 2020. PEM program directors as well as fellowship trainees were eligible. The collected data were under the following domains: (1) sociodemographic and work-related characteristics; (2) impact of the COVID-19 pandemic on patient flow and PEM procedures; (3) impact on emergency skills and competence; (4) impact on academic performance; and (5) attitudes toward PEM practice and potential solutions. Monthly reports of PEM visits and procedures were also collected from program directors.A total of 11 PEM program directors and 42 fellows responded. During the pandemic, the number of total ED visits decreased by 70.1%, ED inpatient admissions fell by 57.3%, and the number of intraosseous need insertion and lumbar puncture procedures fell by 76.7% and 62.3%, respectively; the temporal differences in the median frequencies were statistically significant. The pandemic has influenced the knowledge acquisition and leadership skills of one-third of program directors  and the skills and competence of fellows (31.0%). The majority of directors and fellows showed that online classes/webinars were useful , and there was no need to extend the current fellowship training to compensate for learning deficits . The importance of dedicated modalities to fill in the training gap increased by 62.5% of program directors and 35.7% of fellows.The COVID-19 pandemic had significant effects on clinical procedures and academic activities in the PEM fellowship program. The impact was consistently perceived across PEM program directors and fellows. Technology-driven solutions are warranted to mitigate the expected learning and clinical deficits due to reduced clinical exposure. The COVID-19 pandemic has dramatically influenced the behavior and actions of individuals, organizations, and communities worldwide, and health care organizations are no exception. Multiple operational changes have been made in hospitals, academic health centers, and medical practice institutions in response to the pandemic. For example, in Saudi Arabia, national authorities have undertaken measures to optimize health capacity and care for the surge in COVID-19 patients, extend services to private organizations, and instruct health care providers about the optimal use of personal protective equipment (PPE) . The MinAs a consequence, directors and leaders in academic medical education programs have adopted operational changes to respond to new clinical requirements and educational needs. Although scarce, data from Saudi Arabia revealed the effects of COVID-19 on residency and fellowship training programs for ophthalmology, internal medicine, and radiology –8. HowevThe study team at King Abdullah bin Abdul-Aziz University Hospital (KAAUH), which is located at Princess Nourah Bint Abdulrahman University (PNU), Riyadh, carried out a cross-sectional, survey-based study involving PEM program directors and fellows across the Kingdom of Saudi Arabia. The study was conducted between June and December 2020. The study protocol was approved by the institutional review board (IRB) of PNU [H-01-R-059#]. The collected data were kept confidential and were solely used for research purposes.The directors of the PEM program of the SCHS were eligible. In addition, first- and second-year PEM trainees who were enrolled during the post-pandemic period (from March to June 2020) were included. We excluded service PEM specialists who were not enrolled in the SCHS fellowship program and fellowship program trainees who were not enrolled in the post-pandemic period.Data collection was based on two main themes: (1) monthly reports of PEM visits and procedures as reported by program directors, and (2) survey-based data to collect self-perceptions of program directors and PEM fellows regarding the impact of COVID-19 on PEM fellowship training. Monthly PEM activities and procedures were collected for the period from March to June 2019 (the pre-pandemic reference period) and the same period in 2020 (during the pandemic) using dedicated data collection sheets on SurveyMonkey® (Momentive Inc.). These included the monthly number of PEM visits, the number of PEM inpatients admitted, and the number of the following PEM procedures: intubation, intraosseous needle insertion, and lumbar puncture. In addition, data on a number of resuscitation procedures were collected, including neonatal resuscitation, pediatric resuscitation, and major trauma resuscitation.Two structured questionnaires were created on the SurveyMonkey® platform (one for program directors and another for PEM fellows). Survey items were retrieved from validated investigations –13, and The program director questionnaire comprised five domains . The percent changes in ED visits between both pre- and post-pandemic periods were computed, and comparisons of numbers of ED visits were performed using the Mann–Whitney test. Statistical analysis was performed using the Statistical Package for Social Sciences version 26.0 .n = 7345 in 2019 to n = 3138 in 2020. The total number of emergent procedures performed at pediatric emergency departments has consistently dropped, with the largest decline for intraosseous needle access (76.7%), followed by intubation (62.7%) and lumbar puncture (62.3%). The differences between the pre- and post-pandemic periods were statistically significant for the median values of ED visits (p < 0.0001), ED admissions (p = 0.005), and two emergency procedures, including intraosseous needle access (p = 0.029) and lumbar puncture (p = 0.048). The number of resuscitation interventions showed modest reductions from March to June 2020, with no statistically significant temporal differences compared to the same month in 2019  or Jeddah (27.3%) and that the number of fellows enrolled in the programs ranged between 4 and 6 (54.5%) or less than 4 fellows (27.3%). Three program directors (27.3%) stated that their PEM departments had been converted to COVID-19 inpatient units to increase bed capacity. Furthermore, PEM fellows were redeployed from rotations to other PEM training centers or other planned pre-COVID-19 rotations, as indicated by 45.5% and 63.6% program directors, respectively.Regarding the impact of the COVID-19 pandemic on patient flow at PEM departments, the majority of program directors  underscored a significant reduction in the number of major pediatric trauma resuscitation cases 72.8%) and the average number of visits to the PEM department per shift  and negatively affecting PEM fellowship master plans (36.4%), whereas research activities were minimally affected . Interestingly, online classes and webinars held during the lockdown period were appreciated by all respondents. Only one respondent agreed that trainees would not be able to achieve the optimal technical competence as an independent practitioner, while three participants (27.3%) felt that it is important to extend the current training period of mentorship for PEM fellows. In addition, eight program directors (62.5%) acknowledged the role of these proposed modalities to fill the training gap, particularly for extending simulation sessions (100%) and providing multiple hands-on courses (62.5%).n = 42), there were 24 males (57.1%), 26 first-year fellows (61.9%), and 30 participants aged 31–35 years  indicated that the number of shifts/duties decreased during the COVID-19 pandemic. Approximately one-third of PEM fellows have an estimated a greater than 50% reduction in PEM visits (31.0%), and a more than 50% reduction in PEM procedures (35.7%) at the training centers.Approximately one-third of the PEM fellowship program trainees (31.0%) agreed that the pandemic has affected their PEM skills, competence, and performance. In addition, 19.0% of the trainees indicated that their teamwork, decision-making, and communication skills were affected.Concerning academic performance, 12 PEM fellows (28.6%) perceived negative effects on their academic activities in the post-pandemic period. Theoretical learning, PEM training, and educational rounds during shifts were the most negatively affected, as indicated by 56.1%, 47.6%, and 40.5% of the participants, respectively Fig. A. Among A large proportion of respondents agreed that online classes and webinars were useful during the lockdown period (95.2%) but indicated that there was no urgent need to extend the training period or the period of mentorship to compensate for the negative effects of COVID-19 on PEM training (78.6%). To fill the training gap, 15 PEM fellows (35.7%) corroborated the importance of conducting distinct modalities during the training. Of them, 13 (86.7%) and 9 (60.0%) participants acknowledged the impact of extensive simulation sessions and multiple hands-on courses to address the training gap  appreciated the role of alternative modalities to fill in the gap in fellows’ training.The findings of this study are generally in line with other findings in the literature regarding the negative effects on the learning process in fellowship programs. Indeed, approximately half of PEM fellows reported a significant impact on theoretical learning, PEM training, and educational rounds during shifts. In a recent study involving medical residents and fellows in Saudi Arabia, the majority of fellows 85.2%) and senior residents (81.8%) indicated a reduction in training activities during the pandemic 5.2% and . FurtherOf note, approximately one-third of PEM directors (36.4%) stated that knowledge acquisition has significantly reduced during the post-pandemic period. Furthermore, a considerable proportion of fellows indicated a 50% reduction in PEM training activities, which affect their skill development, competence, and performance. Similarly, the majority of ophthalmology trainees in multiple countries reported a 50% reduction in clinical activity and a more than 75% reduction in surgical activities .In this study, the importance of online classes and webinars was emphasized by all program directors and most fellows. Indeed, the pandemic has caused many training programs to modernize their educational content and update their method of delivery in a way that is familiar to residents and fellows. For example, in the USA, videoconferencing has been used as an alternative to on-site visits that had originally been utilized in selecting an otolaryngology fellow or fellowship programs . A workiImportantly, extensive simulation sessions and hands-on courses were suggested by approximately two-thirds of PEM directors and one-third of fellows as potential solutions to COVID-19-related learning deficits in the present analysis. Likewise, homemade and online simulation models, surgical videos, and webinars have been proposed as sources for important skill training for obstetrics and gynecology trainees, as indicated by a recent systematic review of the relevant literature . The posThe present study has some limitations. Variation in the perceptions of PEM program directors and fellows regarding different outcomes was not statistically assessed because the questions were not consistent in either the director or fellow questionnaires. For example, program directors were asked to rate their perceptions regarding the volume of PEM visits, whereas fellows responded to a question regarding a more than 50% reduction in PEM visits. The limited number of respondents might have also impacted the robustness and reliability of the data. Consequently, the implications of our results may not be generalizable to other regional settings. Finally, the cross-sectional nature of our study might have been affected by response bias in which some respondents may have accidentally or intentionally provided false responses.In conclusion, the COVID-19 pandemic had devastating effects on patient flow and the frequency of inpatient admission to PEM departments, with significant declines in distinct emergency procedures, including intraosseous needle access and lumbar puncture. Self-reported stress/anxiety levels were high among the majority of PEM fellows, indicating a need for psychological support via dedicated multidisciplinary health care teams that involve social workers, psychiatrists, and other mental health workers. PEM program directors and fellows reported similar patterns of self-perception regarding post-pandemic changes in patient volume at PEMs and knowledge and skills acquisition during shifts. Both groups equally appreciated the importance of online classes/webinars, and the majority of them showed no need to extend the training period to compensate for learning deficits. A higher proportion of program directors acknowledged the importance of implementing corrective modalities, especially extensive simulation sessions and hands-on courses, to fill training gaps. Future large-scale, longitudinal studies are required to corroborate the negative impact of reduced clinical exposure and academic activities during fellowship training. Smart technology should be widely adopted in national fellowship programs to account for the expected slowdown of PEM fellows’ learning curve in the post-pandemic period.


Based on the demonstrated benefits of physical activity (PA) practice for chronic health disease, PA resumption programs have come alive in France. However, their effectiveness has not been scientifically tested. The PERSISTE project  compare the effectiveness on PA practice and its determinants of an hospital led and a community led resumptions programs.A mixed-methods QUAN study assessed PA practice and its determinants, both quantitatively through the IPAQ questionnaire and qualitatively  during semi-structured interviews. Data were collected among 69 patients  at three time point: enrolment in the program, end of the program and 3-5 months post program. Data analysis included multivariate data analysis for quantitative data and thematic coding for qualitative data. Data integration considered quantitative data on PA levels as drivers for qualitative data analysis.Quantitative results have shown no difference of PA levels between the two programs at each measurement time point. Moreover, a significant difference was found on PA levels for both program between before and directly after the resumption program, but not between before and 3-5 months post program. Qualitative findings suggest key factors to consider to sustain PA practice, like the short duration not allowing behaviour change. Difference in challenges between programs have been found. A request for more supervised support in patient orientation after the hospital led program can be noticed. Organizational problems, such as unavailability of infrastructure or costs have been highlighted in the community program. Specific leverage arms were identified for each program, such as follow-up appointments after the hospital program or the practice offer in a very similar context for the community program.This study compared two resumption programs in different context and showed no significant difference on PA levels, but difference in intervention mechanisms supporting PA sustainability. Practical implications on strengths and weakness of each type of program, as well as challenges for both can be derived from this study, to enhance program quality.PERSISTE project is funded by the “Comité Départemental Olympique Sportif de Seine-Saint-Denis”.


The African American (AA) population is disproportionately impacted by chronic disease as well as many of the leading causes of preventable death, including hypertension, obesity, heart disease, stroke, and type 2 diabetes. In the AA community of Kane County, Illinois, the incidence of chronic disease is particularly high. A standardized Zoom-based group program that gives participants the knowledge, skills, and support to adopt a whole-food plant-based diet has been shown to rapidly improve health. The results of a cohort analysis were analyzed to assess the effectiveness of this program within an AA community characterized by a high burden of chronic illnesses.t-tests for the normally distributed measures, and a Wilcoxon signed rank test for measures that were not normally distributed.Participants were recruited from a network of 12 AA churches in Illinois to participate in Rochester Lifestyle Medicine Institute’s “15-Day Whole-Food Plant-Based (WFPB) Jumpstart” program. The medically-facilitated 15-Day Jumpstart program provided WFPB nutrition education, coaching, and cooking demonstrations during seven 1 and 2-h Zoom sessions. Participants underwent pre- and post- metabolic screenings to assess for changes in their weight, vital signs, blood sugar, and cholesterol measurements. Changes in diet, biometrics, and patient-centered outcomes from baseline to the end of the program were assessed via paired p < 0.05 for each comparison). Participants reported significantly better energy , sleep (7 vs. 8.5), and mood (8 vs. 9). Average weight loss was 5.8 pounds , systolic blood pressure dropped from 129.7 to 119.9 (p = 0.02), and total cholesterol dropped from 185.1 to 147.9 (p < 0.001). All participants who provided data reported an intent to continue eating at least a partially WFPB diet following the program.Twenty-one AA adults participated. Ten of 16 who provided results had hypertension, 5 had diabetes, 5 had pre-diabetes, and 5 had hyperlipidemia. Participants ate more vegetables (median 2 servings at baseline vs. 3 during the program), greens (1 vs. 3), fruit (2 vs. 3), whole grains (1 vs. 2), and legumes (1 vs. 2). They decreased their consumption of meat, eggs and dairy, added fat, processed foods, and high-fat plant foods (The 15-Day WFPB Jumpstart program led to significant changes in diet, resulting in improvement in several chronic disease measures in this AA community. This rapid improvement can reinforce behavior change. Further large-scale implementation is needed to confirm these preliminary results and to understand whether behaviors and outcomes are sustained. Chronic disease, exacerbated by obesity, impacts African Americans (AAs) disproportionately . The NatAfrican Americans have a distinct cuisine which encompasses a diverse array of food choices and flavors. The African American Heritage Diet maintains that traditional AA cuisine is primarily plant-based, grown from gardens, with substantial quantities of fruits, vegetables, and whole foods . HoweverPrevious reports of outcomes in a primarily Caucasian population have demonstrated that the Jumpstart program rapidly gives people the knowledge, skills, and experience of a WFPB diet. By doing so, participants realize significant improvements in weight, blood pressure, cholesterol, and blood sugar in 15 days . This piThe AA participants were recruited from 12 AA churches in Kane County, Illinois. The clergy from the 12 churches were invited to participate in an informational webinar prior to the start of the program. At the webinar, they learned about the prevalence of chronic disease in Kane County AAs and received an overview of the 15-Day WFPB Jumpstart program and its potential benefits for their at-risk parishioners. Afterward, they were asked to distribute program recruitment flyers at their churches.Overweight and obese parishioners were recruited to participate in the program. Most had at least one other chronic disease indicator. They underwent metabolic testing pre- and post- the 15-Day WFPB Jumpstart program to observe its effects on weight, blood pressure, cholesterol, blood sugar, and mood. The metabolic testing was done at an Ascension community health clinic. The medically-facilitated 15-Day WFPB Jumpstart programming was administered virtually.The 15-Day program components consisted of an informational Zoom session that explained the program structure and the WFPB eating regimen. It also encouraged participants to forward the program information to their medical providers, as incorporating these healthy eating changes could reduce the need for prescription medications. Before beginning the program, the participants had completed a pre-Jumpstart questionnaire regarding their nutrition, the state of their health, and the results of their metabolic testing blood work. During the program, the participants had access to 7 medically-facilitated Zoom-based nutrition education and support sessions.The program equipped participants with a comprehensive nutrition guide that included shopping lists and recipes for a WFPB diet. Additional nutrition resources were available in a Google Classroom. Between-session communication occurred in the Google Classroom where participants could ask RLMI staff questions about their health, the program, and the WFPB eating pattern. The 15-Day Jumpstart WFPB diet focuses on fruits, vegetables, whole grains and legumes. As has been previously described, “animal products are excluded. High-fat plant foods  are excluded, as are processed foods and foods with added oil or sugar. Foods that provide a concentrated source of natural sugars, such as dried fruits and maple syrup, are limited to 1 tablespoon per day. Patients are advised to eat 1 tablespoon per day of ground flax seeds to provide omega-3 fatty acids. Patients are not advised to count calories or control portions. In fact, they are encouraged to eat whenever they are hungry—as long as the food is compliant with the program”  Institutional Review Board to use the data collected from the program participants as part of the QI program. The program was deemed exempt.t-test was used to evaluate outcomes for the normally distributed measures, and a Wilcoxon signed rank test was used to evaluate the change in waist measure. Several of the dietary components and the self-reported outcomes did not meet the cutoff (p < 0.05) for normality. Differences in diet and self-reported outcomes were therefore assessed using the non-parametric Wilcoxon signed rank test. Analysis was completed using IBM SPSS Statistics for Windows, version 29.0 .One hundred and eight AA adults were invited to participate in the program via email outreach; out of 108 invitees, 21 (19.4%) agreed to participate. The program took place in May and August of 2022. Descriptive statistics were used to characterize the participants at baseline and at the end of the program. Since this was a small pilot study (<20 participants who provided pre-post data), a Shapiro–Wilk test was completed for all the variables, to test for normality. All the biometric measures were normally distributed except for the baseline waist measure. A paired Participants ranged in age from 21 to 74, with an average age of 58 . 4.8% reParticipants increased their intake of vegetables, greens, fruits, whole grains, and legumes during the Jumpstart program . They deThe participants decreased their intake of high fat and sugary foods by focusing on increasing vegetables, leafy greens, fruits, whole grains, and legumes. The session with two cooking demonstrations was pivotal in helping participants understand the “how” of incorporating more plant foods into their diet. During the 2-h virtual session, they were educated on the technique of sautéing vegetables without oil, batch cooking, and meal prep. The session four virtual potluck was instrumental in helping participants understand that eating a whole-food, plant-based diet was not only doable but a delicious way to eat. The virtual potluck required all participants to share their favorite WFPB recipe and a meal photograph, which was incorporated into a participant cookbook. During this session the participants did virtual presentations of their dish, shared preparation tips and answered questions. The virtual, weekly check-in sessions allowed participants to address their barriers to implementing the WFPB diet and assess if they were correctly adhering to the outlined eating regimen. Participants realized that they had preconceived notions on the meaning of eating healthy and that their perceptions did not always correlate with the 15-Day Jumpstart’s literal meaning of fruits, vegetables, whole grains, and legumes. In the 15-Day WFPB Jumpstart, they learned practical and easy-to-implement tips on how to make sustainable lifestyle changes. Because of this education, the participants addressed potential nutritional deficiencies—such as a lack of fiber, and high calorie foods with low nutrient density– that often lead to chronic diseases. In addition, the Rochester staff, due to their willingness to tailor the dietary recommendations to the participants’ cultural preferences, were able to overcome perceived cultural barriers and successfully implement the principles of the 15-Day WFPB Jumpstart in this AA study population.In addition to improvements in energy, sleep and mood, participants lost weight, had a reduction in abdominal girth, and decreased systolic blood pressure, total cholesterol, LDL and HDL. Except for HDL, all of these changes have been shown to be beneficial to heart health and reducing cardiac risk. Long-term adoption of a very low fat whole-food, plant-based diet has been shown to be effective in reversing heart disease . The chaSince some of the 15-Day Jumpstart participants missed multiple sessions, this may have led to less than a full experience of the program. Seventeen of the 21 participants (81%) attended 4 or more sessions, which is the organization’s definition of participation in the program, as it represents at least 5 h of program content, and significant time to interact with program staff. In this population, there are various stressors that may have impacted the participants. Several of the participants were seniors who were primary caregivers to their elementary school-aged grandchildren. Session attendance could have been made more convenient for busy participants by recording sessions for later viewing. It should be noted that sessions should not conflict with church meetings, like mid-week Bible Study or Sunday services, as occurred during this study. For some, in-person meetings tied to these activities might help to boost participation.Future efforts should focus on motivating the participants to attend all of the sessions and to complete post-Jumpstart questionnaires. Increasing attendance will also give participants more opportunity to develop the skills and obtain the resources needed to make sustainable changes. Faith leaders spend a considerable amount of time attending to the health needs of their parishioners by praying for the sick, visiting patients in the hospital, and planning and conducting funerals. Launching such interventions in faith-based organizations necessitates forming collaborations with clergy and establishing the shared goal of health promotion in their congregations. Clergy can play a vital role by incorporating spirituality into this health intervention  and can highlight the biblical imperative of pursuing a healthy lifestyle. As a trusted source of information, clergy can encourage participants to regularly attend the sessions. This would lead to a greater likelihood of following the recommendations, which in turn could increase success.A WFPB diet can be used as a conduit to help AAs lower their chronic disease risk and reduce obesity . AccordiParticipant recruitment was challenging because many individuals who could have benefitted from this nutritional program did not feel they could implement it. Individuals voiced concerns about eliminating meat and dairy from their diets. They perceived that a WFPB diet would not be satisfying or palatable. A recruitment event that showcased the medical benefits of a WFPB diet coupled with a live cooking demonstration that allowed participants to taste the food can be utilized to increase interest and participation and assuage participants’ concerns.One of the biggest limitations of the study was its small sample size: 21 participants. However, this was designed as a pilot program to serve as “proof of concept.” Participants made significant changes in eating patterns, and as a result, both experienced improvements in health and expressed an intention to continue at least a partially WFPB diet. A larger, randomized prospective trial would provide more precise estimates of the impact of this program on an African American community. The results seen in this study suggest that a larger study is warranted. Approximately 19% of the individuals who were invited participated in the program, and it is feasible that with increased awareness of the outcomes, the enthusiasm of the participants, and ongoing collaboration with the clergy, the interest in the program could increase.Not all of the people who signed up participated fully. Some of the program’s sessions had a scheduling conflict with Sunday church services, which created a barrier to regular attendance. Many participants did not thoroughly understand the 15-Day Jumpstart principles which resulted in mistakes in their choices of meal ingredients. This constraint can be addressed by including a component that would evaluate the participants’ understanding of the program’s dietary instructions. For example, including a simple quiz or a hypothetical scenario could confirm that the participants understand the Jumpstart guidelines. This could be done early in the program, to correct any misunderstanding, and enable full participation.Self-reported outcomes, such as mood, energy, and sleep, were assessed as part of a QI program. As a result, the team used single-question queries rather than more extensive validated tools, in order to maximize response rate. A prospective study using validated tools would help to confirm these preliminary findings. Self-reported measures are subject to reporting bias. Participants are aware of the desired responses, namely, improvement in these measures. However, participants also experienced improvements in objective measures, such as weight, vital signs, and lipids.This pilot program was initiated to evaluate whether an AA population with a high burden of chronic disease could be identified, who would be interested in participating in a program to educate them about the benefits of a WFPB diet. Furthermore, it was important to know whether they would make the dietary changes recommended by the program, and whether they would experience positive health outcomes from moving to a WFPB diet.A nutrition intervention can be utilized to mitigate the disproportionate chronic disease health disparities that plague AAs. This medically-facilitated, 15-Day WFPB Jumpstart program provides the support, education and the practical tools to incorporate increased fruit, vegetable, whole grain and legume intake while eliminating meat, dairy and foods that are processed, contain increased sugar, or are high in fat. This study also highlighted the need to include AA clergy in community health partnerships as they are highly vested in health promotion that benefits their congregants. Their influence as respected faith leaders can be utilized to encourage participation in the 15-Day WFPB Jumpstart program, thereby realizing the shared goal of improving health and decreasing chronic disease.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.FN assumed multiple responsibilities, including participant recruitment, supervising pre- and post-metabolic screenings, maintaining communication with Frontier journal throughout the submission, peer review, and publication process, ensuring compliance with all specified journal submission guidelines, addressing post-publication correspondence, and serving as the principal investigator. TB was the lead educator for all of the virtual training sessions. BG and MD served as research managers and assisted in conceptualizing and coordinating the health and nutrition intervention in an African American faith-based setting. BP assumed the role of the data coordinator and prepped all data for the statistician. SF was the co-investigator and performed statistical analyses; analyzed and summarized all data; and assisted FN in writing and revising the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by Vegfund (15-Day Jumpstart registration fees) and Ascension Mercy (metabolic fitness testing for each participant). The American College of Lifestyle Medicine paid the access publication fees.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.