The Indigenous Youth Mentorship Program (IYMP) is a 20-week communal, relationship-based afterschool healthy living program for Indigenous youth in Canada. IYMP embraces the Anishnaabe/Nehiyawak concepts of Mino-Bimaadiziwin/miyo-pimâtisiwin (“living in a good way”) via its core components of physical activities/games, healthy snacks, and relationship-building. A strength of IYMP is that it values autonomy, adaptability, and the school community context. However, this presents challenges when evaluating its implementation, given that traditional implementation science methods tend to oversimplify the process. In response, essential conditions for the implementation of school-based healthy living programs across diverse contexts have been developed. The purpose of this research was to understand the applicability of these essential conditions within the context of IYMP.n = 10 Young Adult Health Leaders; n = 5 coordinators) with experience implementing IYMP in the provinces of Alberta, Saskatchewan, Manitoba, and Quebec were purposefully sampled. Focused ethnography was the guiding method and one-on-one semi-structured interviews were used as the data generation strategy. The purpose of the interviews was to understand what conditions are needed to implement IYMP. The interview guide was based on previously established essential conditions developed by the research team. Interviews were audio-recorded and transcribed, and content analysis was used to identify patterns in the data.15 participants  to engage school community, community support, quality and use of evidence, and professional development) and four contextual conditions  were necessary, but made suggestions to modify two conditions (youth led and learning opportunities) to better reflect their experiences implementing IYMP. In addition, a new core condition, rooted in relationship, emerged as necessary for implementation.The overarching theme that emerged from the interviews was the applicability of the essential conditions when implementing IYMP. Participants felt the eight core conditions (This research adds to the literature by identifying and describing what is needed in practice to implement a communal, relationship-based afterschool healthy living program. The essential conditions may support other researchers and communities interested in implementing and rippling similar programs.The online version contains supplementary material available at 10.1186/s12889-021-12412-1. Hundreds of healthy living interventions for youth are implemented each year, however, few of these are tailored to the needs of Indigenous youth , 2. AmonCollecting information throughout implementation can reveal how and why interventions were successfully taken up and maintained by communities in diverse settings, which can guide future rippling . Two lanstudents as change agents, school/community-specific autonomy, demonstrated administrative leadership, higher-level support, dedicated champion(s) to engage school community, community support, quality and use of evidence, and professional development) and contextual conditions . Core conditions are those that are necessary for implementation whereas contextual conditions determine whether or not the core conditions can be achieved. These conditions have been adapted by schools across Canada and may be applicable to other school-based healthy living programs because of their focus on commonalities within the implementation process rather than commonalities within the intervention  about these are the different ways I’ve seen it run. I have a conversation guide that I made, framed around these essential conditions, to go through each one and kind of talk about what will you, what will work in your school (P6).More specifically, participants agreed that the eight core conditions were necessary to implement IYMP but had suggestions for how two of the conditions could be adapted to fit the context of IYMP. Additionally, a new core condition, rooted in relationships, emerged from the analysis as necessary for implementation and replaced the condition prior community connectivity . Indeed, youth engagement was identified as an indicator of successful implementation. One participant noted:If you can get a group of kids enthusiastic about it, and wanting to participate, and really just emphasize that the program is about showing their strengths and their knowledge, and doing what they want to do. That’s probably the biggest thing to run the program successfully is just getting youth engaged (P10).Similarly, youth leadership was identified as essential, and participants emphasized how youth serve as active leaders in IYMP. As one participant commented: “the students are the active leaders and planners in the program, especially those high school mentors” (P7). Another participant explained: “for me [the] standout would be the mentors, and their ability make decisions, and decide things” (P2). Participants expressed how youth leadership was especially important within the context of a peer mentorship program. As expressed by one participant: “if the goal is to bring grade four kids into a program, that mentorship program, then you want to surround them with the high [school] students who are – who would be good role models” (P11). Notably, participants prioritized voices from youth when planning and making changes to the program. One participant described engaging with youth in the program to learn: “how do they want to see the program” (P1). They believed that this approach enhanced engagement and passion for the program. Therefore, this condition was adapted to youth led to reflect the role of youth enthusiasm, leadership, and voice in shaping how the program is run.All participants agreed that students are the heart of IYMP – and are the reason communities run the program. YAHLs and coordinators wanted to be involved in IYMP because it prioritizes mentorship, empowers youth, and promotes healthy living. They also agreed that youth enthusiasm, leadership, and voice shaped how the program was run. As one participant stated: “was kinda required” (P10) because it meant that teachers could provide supervision during the IYMP program and youth could participate without needing to arrange for transportation after the program ended. Overall, it was described that IYMP is not a one-size-fits-all approach. As one participant explained:I think that’s what makes it appealing to communities that it can be so adaptive to their unique context because two communities right next door to each other will have totally different needs and parent involvement, and availability of resources, and equipment. So, I think the more that we can adapt it the more it can be taken up by other communities and actually be sustainable (P6).Participants also explained how school/community-specific autonomy promoted program relevance because any changes to how the program was implemented came from those directly involved based on their understanding of the school/community’s strengths and needs. As one participant indicated: “I also think just like working with the teachers and principals, and getting – being able to work with them to figure out what worked best, was super important, otherwise I just really think the program would not have happened here” (P7). This is echoed by another participant who stated:[community members] know your community better than anyone else does, and you know your kids better than anyone else does; ultimately this is about you guys serving your own kids, in your own community, and we just want to help you – encourage you in that (P8).School/community specific autonomy also enabled communities themselves to decide how best to incorporate local Indigenous cultural traditions and values. One participant recalled a conversation about how IYMP was adapted to align with “[their community’s] way of thinking about culture” (P2). In their community, relationship building within IYMP included “we’re sitting together, we’re eating together, and that’s one of the most important things that we do as [Indigenous] people is that every time we have a ceremony we sit and we eat together cause it’s about that sort of relationship building” (P2). In another community, games were adapted to include the local Indigenous language.All participants agreed that the delivery of IYMP must build on communities’ strengths and needs to be adaptable to the unique community context. Participants felt that it would not have been possible to run the program without autonomy. For example, in some communities, IYMP was adapted to run during school hours instead of afterschool. One participant explained how this modification “[IYMP] always seemed to be like a key focus [for our administrator], like we had that time blocked off no matter what” (P9). Administrators were also seen to play an important role in generating enthusiasm about the program, which made youth and staff more excited to get involved. As one participant explained:We always have the principal onboard, and I can’t imagine what it would have been like to do those other projects without the principal on board because they bring in the teachers, they bring in the time, the energy. They guide the energies that are needed to make it happen (P5).However, participants had differing views on administrators’ specific role. In some communities, participants felt that administrators needed to take an active role in the implementation of IYMP  whereas in other communities, participants felt that administrators needed to take a supportive role. Despite these differences, it was clear that active engagement from administrators could drive healthy changes within the school/community. For example, one participant illustrated how demonstrated administrative leadership in their school community made it possible to change the types of foods served not only for IYMP, but for all programs run out of their multi-use site. The participant explained:We also realized that the [program] may not – they were trying, but they may not always have like the healthiest snacks … and what we ended up doing is we were talking to the [program] about it and [the administrator] decided that they would adopt the nutrition policy for the [site] (P2).All participants agreed that support from administrators  was necessary to run IYMP. Participants identified administrators as leaders, and therefore, their support was considered vital to deliver the program. When administrators understood, valued, and prioritized IYMP, it supported implementation. Administrators also provided staff with space, resources, and time to run the program. One participant emphasized that the program ran well because higher-level support was described most often as provincial funding.Most participants valued provincial support to maintain and ripple the program. In the context of this study, higher-level support were notably different between YAHLs and coordinators. Thus their perspectives are described separately below. Among YAHLs, some believed that higher-level support was necessary to secure funding to maintain and ripple the program. Beyond financial support, participants felt as though securing funding meant that funders valued IYMP and prioritized the health and wellbeing of Indigenous youth. One YAHL stated that higher-level support, specifically funding, was very important for youth because:They get to see that there is people higher up caring for us. Just like we are the ones caring for the ones, the grade fours. You know and it’s just the ripple effect, once everything starts going and it just keeps going (P13).This was echoed by another YAHL when they stated: “what are we doing to support the Indigenous people of this province, country? There’s a responsibility of, for all stakeholders, and on whatever level it is to participate in that” (P1). Other YAHLs found it difficult to determine whether or not higher-level support was necessary because they felt as though their role within IYMP was focused on the day–to-day running of the program. A few recommended that we talk to coordinators and IYMP research partners to better understand the role of higher-level support within the context of IYMP.Interestingly, perceptions of “[Band Council is] welcoming this program to the community and to their people. Well you need that support from the community, for sure” (P14). In another community, local leadership included support from the school board, and a participant described the school board’s role as “… very important … ‘cause it just wouldn’t have been allowed to happen without that” (P7).While all coordinators agreed that provincial support was necessary to maintain and ripple the program, they also identified local leadership and support from Band Council, community advisory committees, and/or the school board as essential. One participant explained: higher-level support. One participant explained the role of the wider network as “Mentorship is transformative, but the unique benefit [of IYMP] is that there is a wider network. [Communities] aren’t starting from scratch.” (P6). Thus, a strength of IYMP is that communities are supported by the wider IYMP network, which includes direct support from coordinators in their region to take up and adapt the program. Similarly, coordinators described their role as building capacity within the community to implement IYMP. The wider IYMP network was also described as critical for providing learning opportunities, assisting with securing funding, and supporting research activities.Finally, YAHLs and coordinators included the wider IYMP network of youth, community leaders, Elders, scientists, and knowledge users within their descriptions of “I think one person needs to be the lead and feel like they have ownership over it; and they’re going to making sure that it’s getting done every week, and that things aren’t falling through the cracks” (P6). However, participants recognized that in order to promote the sustainability of IYMP, there needed to be multiple dedicated champions. One participant said: “I think there would be probably need a team of people if you wanted to make it flourish in your school or your community” (P14).All participants agreed that the project requires at least one person from the community to organize IYMP and connect IYMP team members. More specifically, participants felt that the program would not have happened if there was not at least one person advocating for and organizing IYMP. As one participant explained: planning activities with the students and helping to coordinate picking up the snack beforehand, and [they] played a huge role in the success of the program” (P9). Beyond supporting implementation, YAHLs played an essential role in mentoring youth. One YAHL described their role as “… trying to show them what mentorship can look like …” (P8). Another indicated:The little ones, they have little eyes, they already probably think about their lives' in high school and those are their role models. They interact with them in a way that is enjoyable, and the trust builds that way as well. And same for the mentors they look up to their YAHL. And that’s pretty cool to see. It’s like a full circle almost (P14).Importantly, most YAHLs held other positions in the school or community organization where IYMP ran. This meant that they often had pre-existing relationships with students, teachers, and administrators and understood the context of the community. This was described as important because it meant that the YAHL had an understanding of how to work with youth and run programs in their community. This was exemplified by a participant when they stated:Finding that right person you need to develop and implement the program and that wants to do it … Yeah because they’re the ones that create their program … I think it’s really important that you have that YAHL, that Young Adult Health Leader, who, you know, has those relationships with the high school mentors, is familiar with teachers and the system. That’s very valuable (P14).Participants also believed that it was important for youth to have Indigenous YAHLs supporting them. As one participant shared, “I am Métis myself, so [the primary researcher] thought that was like a good role for me to move into being a mentor for some of those high school students” (P9). Another participant described how comforting it was to have support from Indigenous coordinators because “… [they’re] there for support, and you know also being Indigenous being like is just really, really comforting” (P12).Unique to IYMP, participants identified the YAHL as an essential member of the team to plan and deliver the program. One participant described the role of the YAHL as “school community was essential to run the program, whereas only some participants felt that support from the broader community was essential for the successful delivery of the program. Participants indicated that support from the school/site where IYMP is delivered was needed to engage youth and gain the supports needed to run the program. One participant described how teachers’ active engagement in the program created “… a very positive environment for the students” (P9). Furthermore, participants highlighted the important contributions that their school community provided, which in turn made it possible to run the program. For example, one participant explained how it was easier to run a program when the school community was involved because “[if] they have a dedicated bus driver, and they have access to a space, nutrition staff is just going to buy the food, then like logistics are a slam dunk” (P6).All participants indicated that support from the “teachers were very supportive…So we didn’t have a lot of interaction in the community with community members outside of the school environment” (P9). Participants described hosting community events with parents to share information about IYMP. They also invited community members to plan activities with the students.In contrast, most participants indicated that relationships beyond the school/site could enhance the quality of the program, although these were not seen as essential. One participant expressed: “To keep it going in the long run, yes I think it’s important that the measurements are done in the beginning, and the end to show that there’s scientific proof that it is like helping us create stronger healthier children …” (P11). Another explained:[Communities] need to show families and council, and/or their board if they have an education board, um, they need to show them why this was worthwhile and so having those measurements throughout the year, and even like documenting it through photos and through videos; showing why this was worthwhile is really important for the sustainability of the program (P6).The above quotes also illustrate how participants wanted to balance different types of evidence. However, participants tended to prioritize conversations, experiences, and stories. As one participant stated: “If you hear it from the person who’s actually running it, or a high school mentor, then it becomes more alive … It’s all about bringing their voice. And they’re the best describers of [I] YMP in their community” (P14).Participants valued the research component of IYMP as a way to gain support for the program, grow the program, and promote sustainability. One participant indicated: “Trusting, empowering Indigenous ways of knowing” (P8). Participants described using evidence throughout the process to enhance the quality of the program. In one community, sharing circles were encouraged as a way to make the program responsive to the interests of youth and mentors. One participant explained:After every session with all the students, elementary, high school and the YAHLs, we would have a sharing circle at the end and just a reflection period, and we would hope – we would just talk, everyone would share what they thought went well, what they thought maybe we should improve on. Everyone sharing their feedback on how that session went (P9).Participants also felt that another way to strengthen the program would be to enhance the sharing of knowledge/evidence between communities. One participant suggested that IYMP record how it is being implement in each community. Then, if a community has questions on how to run the program, they can reach out and ask:… do you guys have any ideas of how to run a program … we have like 20 different communities that are trying the same exact thing, and they have – there’s 20 different ways that you could potentially run the program, so check out these (P8).Participants described using knowledge in the form of conversations, stories, and experience from YAHLs, coordinators, administrators, other school staff, and youth to adapt how the program was run. This was described by one participant as learning opportunities supported the delivery and refinement of IYMP within their local school community. Regional, national, and training gatherings were seen as a strength of IYMP as they provided opportunities to bring together IYMP communities, provincial organizations, and academics who are passionate about this work. Participants emphasized the importance of face-to-face meetings to strengthen relationships and share knowledge between communities. One participant described their experience at a National Gathering as:I think it was a great thing to have cause it kind of showed how communities across the country are running the programs, and every one kind of had different strategies and tips on how to facilitate the sessions, and just like great ideas of things you could do with the kids. And I don’t know, I thought they were – I thought they were very useful in just the fact that people were sharing ideas and things like that (P10).Participants also felt strongly that learning opportunities were needed for youth as a way to support them in becoming better mentors. Specifically, participants agreed that learning opportunities for youth should focus on relationship building and include opportunities to get to know each other. As one participant explained: “… we owe it to them to facilitate that, and so that is our goal, you know our first – our next meeting is just strictly building that community, the little community of mentors, and enjoying themselves, and having fun” (P1). In addition, hands-on activities for youth were described as critical to develop the skills and confidence needed to lead the program. For example, one participant felt as though learningopportunities for youth were necessary “… so that the kids feel confident planning it; identifying games and snacks to include; basic classroom management; basic team building; so that they as a group feel good together” (P6). Thus, the condition was modified to focus wholistically on learning, as opposed to professional development opportunities.Participants agreed that prior community connectivity, was essential within the context of IYMP. One participant stated: “I think its foundational and I think it’s what makes it successful” (P5). Similarly, another participant explained: “it’s obviously important, so you feel like there’s trust … and people can feel safe” (P2). Participants embraced and prioritized relationships by carving out space to be present, to listen and learn from one another, and to laugh together. The importance of relationships was reinforced by many participants at the end of the interview when they identified trusting relationships as one of the key factors needed to implement IYMP. This was emphasized by one participant who explained that other communities could successfully implement IYMP if “[they have] that connectivity with the kids, high schooler [s]” (P13).YAHLs and coordinators emphasized how relationship building is a core component of IYMP, and therefore needed to be reflected within the essential conditions. This condition was developed, in part, based on participant feedback that the previously established contextual condition, “the relationships are the most important thing and that’s kind of – it’s very central to the program, so take the time to build those relationships first and then get the program started” (P7). During implementation, participants felt that trusting relationships between youth, mentors, and YAHLs were the foundation for delivering IYMP. For example, one participant explained: “I do think that, that’s why our program ran really smooth is that everyone started to feel so comfortable with each other and comfortable to share” (P9). It was also important for those involved in the delivery of IYMP to develop trusting relationships and open communication to ensure that all the different aspects of IYMP, including planning, organization, and implementation ran smoothly. The importance of clear communication was emphasized by one participant who shared: “I think the biggest thing for it to run was communication throughout the whole - like the higher up, all the way down” (P3).Indeed, participants prioritized relationship building prior to and during implementation. Prior to implementation, participants felt that relationship building between administrators, local leadership, and champions was needed to develop trust. This was exemplified by one participant who mentioned: time to run the program was also seen as important for sustainability. One participant felt as though IYMP was sustainable in their community because IYMP fit well within their mandate to support youth programming. Thus, they had dedicated time to run the program. They explained:I see a lot of programs where things start and one person starts it and tries to pass it off, and then it phases out. I really do believe that just under my mandate that, like as a team – with a teen mandate that I would, you know, definitely contribute to that sustainability (P3).All participants believed that sufficient time was needed to successfully implement IYMP. Specifically, participants emphasized the need for dedicated time to plan, organize, and run the program. Participants found it easier to dedicate time to IYMP when it was seen as their role and responsibility rather than an additional commitment. Dedicated “I think that’s definitely necessary, even just like paying for the food, and the buses, and all that kind of stuff I think it’s necessary to run the program in the way that we did run it” (P7).Similarly, all participants agreed that funding made it easier to run the program. In order to include all three components of IYMP, communities needed space to run the program, equipment and supplies, transportation, and food. While some of these resources were provided in-kind, participants indicated that community-level funding made it possible to provide transportation and healthy snacks. As one participant stated: [communities need to] see how this can fit in [their] current schedule; why [it’s] worthwhile, like how it’ll help with student engagement; it’ll actually make your teachers feel less burnt out, because they’ll feel more connected to the students than they do now (P6).In addition, communities felt that their understanding of the program and what was expected improved throughout implementation. As one participant explained:The second time we ran it, we ran the program we were definitely a lot more clear about what the program was and what we were going to be doing, and what the goals of it were; and why it was great. And I think that made everyone feel a lot more comfortable and a lot less confused, as we went along (P10).Participants agreed that having a clear understanding of IYMP and why it is important made it easier to run the program. Participants felt that developing a clear understanding of the goals and purpose of the program, as well as their role within IYMP was important. Prior to implementation:rooted in relationships, were needed to fit the context of IYMP. The materials developed from this study  to engage school community and learning opportunities. We learned how pre-existing relationships made it easier for YAHLs to deliver IYMP because they were not starting from scratch. Rather, those pre-existing relationships could serve as a foundation for the program. We also learned how relationship building between communities facilitated the sharing of knowledge, which enhanced implementation. Therefore, our data suggest that when rippling programs to multiple communities, it is important to identify key community partners with pre-existing relationships in each community. There also needs to be opportunities for relationship building across communities. Relationship building across communities has been shown to promote capacity building [Within IYMP, the non-hierarchical, mentorship model closely aligns with a key Indigenous approach of reciprocal multi-age mentoring . To our building . This maquality and use of evidence. Based on these findings, research in this area should prioritize youth voice to demonstrate the program and its impacts.Closely tied to relationship building was youth enthusiasm, voice, and leadership. Participants reported that implementation was successful when youth were enthusiastic and actively participating as leaders. This aligns with the core tenants of health promotion to enable: “people and communities to take control over their health and its determinants” . Previouschool/community-specific autonomy. Other healthy living programs for Indigenous youth, including Sandy Lake Health and Diabetes Prevention Project, Kahnawà:ke Schools Diabetes Prevention Project, Right to Play, and Healthy Buddies have identified the importance of autonomy for implementation to ensure sufficient tailoring to the local context considering local traditions and values, and community resources [Another finding from our study that is well-supported in the literature is the need for esources , 7, 11. higher-level support. Participants expressed how higher-level support might look different depending on what community you work with. Therefore, it was important to work with dedicated champion(s) in the community to identify local and provincial leaders to support implementation. An addition to the condition higher-level support was the inclusion of the wider IYMP network in supporting implementation. This network of youth, community leaders, Elders, scientists, and knowledge users provided support with implementation and evaluation, as well as learning opportunities. Taken together, IYMP appears to have been successful because it promotes autonomy and flexibility locally, while also developing a coordinated national network to connect and support communities. This aligns with the CSH approach [Participants also discussed the importance of approach . One conlearning opportunities for youth. Re-wording this condition was important to broaden the scope of these experiences to include everyone who is involved in implementation, especially youth. Learning opportunities are seen as ways to build capacity and enable individuals to become their own health promotion experts [Finally, participants in the study suggested a need for  experts . Within This research was limited in some ways by the geographic scope of the IYMP program. For example, it was not possible for the lead author to meet with each participant in-person, so some interviews were conducted by phone. Conducting interviews by phone may have impacted the lead author’s ability to develop a rapport with participants and capture non-verbal cues. Another limitation of phone interviews was that the lead author was not able to take part in IYMP programing in that community. In communities where this was possible, it added context to the interviews and provided further information on what implementation looked like in each community. However, despite the limitations of phone interviewing, the data generated from these interviews enabled us to include a diversity of perspectives that otherwise would not have been captured.A strength of the present research was the use of qualitative research methods. This approach provided a deeper understanding of how and why communities were able to successfully take up and implement IYMP in different settings. Indeed, traditional implementation science methods like program logs tend to oversimplify the implementation processes because they only identify what aspects of the intervention were implemented but not what conditions within the intervention process made it possible to implement or not implement the intervention . Importayouth led and learning opportunities, as well as the development of a new condition: rooted in relationships. Participants also shared concrete examples of what the essential conditions look like in practice and how these conditions can be used to support the implementation of IYMP. These findings give direction for IYMP as they represent a list of conditions that have been identified as necessary for implementation by those directly involved in the delivery of IYMP. Moving forward, we recommend the use of these essential conditions to support on-going implementation and rippling of IYMP to new communities.In conclusion, our study supports the applicability of the essential conditions to the experience of implementing IYMP in diverse contexts. Participants agreed that the eight core conditions and four contextual conditions were necessary. They provided suggestions that resulted in adaptations to two core conditions: More broadly, findings from this study may provide guidance to researchers and communities implementing and/or rippling similar communal, relationship-based healthy living programs for Indigenous youth in school-settings. Therefore, we suggest these essential conditions be used when planning, implementing, and rippling healthy living programs for Indigenous youth, as they support the implementation of programs that are autonomous and fit the unique context and needs of communities.Additional file 1.Additional file 2.


In response to the COVID-19 pandemic, the Global Mental Health research group at Johns Hopkins School of Public Health worked with three local partner organizations in Myanmar to develop a psychosocial support (PSS) program that could be delivered by community-based focal points in internally displaced persons camps. This PSS program was designed to be delivered in communities with limited access to regional mental health services due to pandemic travel restrictions. The content of the PSS program was based on materials from an ongoing Common Elements Treatment Approach (CETA) mental health program; CETA counselors based in the three partner organizations were available to provide telephone-based CETA counseling. In April 2020, the partners organizations recruited and trained PSS focal points in 25 IDP camps to establish a multi-tiered system of MHPSS supports.via radio and loudspeaker, and were available to answer questions and provide access to a PSS program phones to connect with the CETA counselors. After 6 months of implementation, program monitoring logs were reviewed and a cross-sectional evaluation was conducted to assess the PSS program's reach, understanding, and perceived utility.The PSS program including psychoeducation handouts focused on stress and coping during COVID-19 and skills for cognitive restructuring  in simplified terms, audio recordings of the content of these handouts and referral opportunities for telephone-based services by CETA counselors located outside of the camps. PSS focal points distributed the handouts, had the recordings played n = 793 participants) found high levels of handout readership and perceived utility of the information, and good comprehension of the content and application of skills.Forty-one focal points implemented the PSS program in 25 IDP camps in Kachin and northern Shan States. From May to September 2020, the focal points distributed handouts to 5,725 households and reported 679 visits by IDPs, including facilitating 332 calls to a CETA counselor. Data from the program evaluation (via telephone, was feasible despite the constraints of the pandemic. Utilizing camp-based focal points was acceptable and successful in delivering basic psychosocial supports to a broad population while serving as points of contact for individuals who wanted and needed telephone-based counseling services.Findings suggest that provision of a multi-tiered MHPSS program, with PSS focal points providing direct information and linkages to further mental health services  Implementation of a multi-tiered mental health and psychosocial program is feasible, despite the constraints of the COVID-19 pandemic, when higher-tiered level services  are already established and accessible.Community-based programs utilizing locally recruited focal points was successful in delivering basic psychosocial supports to a broad population while serving as points of contact for individuals who wanted and needed more sustained telephone-based counseling services.This program can serve as a model for a multi-tiered MHPSS program.Program managers should consider empowering lay community members to play a role in a multi-tiered MHPSS program, particularly in areas where access to higher level service providers is limited.Program managers should consider lay community members as integral components of a responsive system that requires low levels of training and supervision yet allow linkages between community members and MHPSS services.During the COVID-19 pandemic, community-based delivery of mental health and psychosocial support information by lay community member focal points proved to be a feasible and acceptable approach for enhancing access to existing remote counseling services.COVID-19 significantly impacted provision of mental health and psychosocial support (MHPSS) services. A World Health Organization survey conducted in 2020 found that mental health services were stopped or disrupted in 93% of countries surveyed  has worked with Myanmar populations since 2008, initially on the Thailand-Myanmar border and then expanding to sites in Myanmar starting in 2015. During this time, JHU has provided training and technical support for five local partner organizations to implement an evidence-based mental health and psychosocial support intervention system, Common Elements Treatment Approach (CETA) . Table 1In response to the COVID-19 pandemic, starting in March 2020, JHU worked with the local partners to develop a new community-based PSS program to provide information and immediate supports to the IDPs living in communities that had, due to COVID-19 restrictions, lost in-person access to the available CETA services. Specifically, a community-based program was developed that trained individuals living in the IDP camps, PSS focal points, to deliver written PSS materials related to COVID-19 stress and worries. The materials were developed based on the CETA elements of Psychoeducation, Safety, and Cognitive Coping. Psychoeducation and Safety were included based on the need for foundational information and encouragement for participants and experience from CETA implementing partners that many populations experience challenges to their safety and need this to be confronted early on and during every contact. Cognitive Coping was selected based on evidence of its effectiveness and initial feedback from local CETA implementing partners that it is the most appreciated and most used element of CETA by both providers and clients .The specific content of the PSS materials was developed based on feedback from local partners who had informally collected information from IDP beneficiaries on the stresses they were facing at the beginning of the pandemic. JHU and local partners co-developed the handout information and discussed feasible options for dissemination and linking communities to the CETA counselors. In addition to being trained in the written materials, the focal points were trained to ask simple PSS questions and provide access to a project phone for IDPs who wanted to talk with one of the CETA counselors associated with the partner organizations. These CETA counselors were then able to conduct a structured, validated mental health assessment, and determine if the CETA intervention was appropriate. These counselors were located geographically close to the IDP camps (Laiza and Myikyina areas in Kachin State), had existing familiarity with the IDP camp communities based on previous service provision of CETA, and could provide services in the local languages of the IDP populations . The PSSIndividuals trained in the PSS focal point program were recruited by the three local partner organizations from among individual members living in the IDP camps. The selection criteria were: (1) ability to read and write the local language, (2) available time and interest to support their community during COVID-19, and (3) ability to use social media. PSS focal point backgrounds ranged from having experience with public health program community mobilization to being a school teacher or other community volunteer. The PSS focal points were not considered to be mental health service providers but, instead, were there to disseminate PSS materials in a variety of formats and to act as a conduit for the IDPs to access the CETA mental health counseling services by phone.The focal points received remote training due to COVID-related travel restrictions. Remote training (by KM) involved sending the PSS handouts and a procedures manual to each of the focal points (both electronic and print versions delivered by the partner organization to the camps) and having the review the materials on their own. This was followed by a training call  to review the materials, conduct role plays and review program implementation processes.via camp loudspeakers  general information on mental health during the pandemic , but proFor program implementation, the PSS focal points received a program kit that included multiple copies of each handout to be given to the IDPs and electronic copies of the 4-part video series and accompanying audio, and a project phone and phone credit to allow IDPs to call the CETA counselors. PSS focal points were trained to make private space in front of their home available for IDPs to choose to use when calling the CETA counselors. Face masks, hand sanitizer, and guidance on how to clean the phones before and after sharing with others were also provided for COVID-19 transmission prevention. The PSS focal points received monthly compensation based on the internal pay scales of their respective organization and in-line with compensation provided to similar positions.In each camp, the PSS focal points were given a “catchment” area to provide this program. The goal was for the PSS focal points to distribute the handouts to every household in their catchment area; first they distributed the “managing stress and coping” handout and then after 4 weeks, they returned to each household and distributed the “changing unhelpful thoughts” handout. The reason for the staggered distribution was to support multiple visits by the focal points to each household and ongoing presence in the area for individuals who had questions or wanted more support. The PSS focal points also posted the handouts in public areas, shared the videos on social media, and broadcast the audio files on local radio stations and loudspeakers.via telephone from a supervisor based with each of the partner organizations. During these calls, the supervisor reviewed how many households had been visited and handouts distributed, how many IDPs had talked with the focal point to get more information MHPSS and available supports, and how many IDPs had used the focal point's phone to call a CETA counselor. In addition, the supervisor solicited information from each focal point about any adjustments that needed to be made to the handouts or process for the program's implementation.During program implementation, the PSS focal points received weekly supervision The PSS focal point program was conducted in 25 IDP camps in Kachin and northern Shan States. Locations of the camps varied from within city and town centers to remote places in both government and non-government-controlled areas. Camp sizes ranged from 10 to 1,655 households. The total population in the 25 sites was ~34,323 .www.kobotoolbox.org) that changed based on the participant's answers. Questions gathered information on receipt of the handouts (yes/no), hearing the audio files (yes/no), use of the skills presented in the handouts, perceived utility of the content in the handouts, and comprehension of the PSS content. Use of skills was assessed by asking about frequency of use for each skill . Perceived utility for each handout was assessed on a 3-point scale . Separate sets of comprehension questions were developed for each handout. Comprehension of the “stress and coping” handout content was assessed by (1) number of signs of stress correctly recalled; (2) correctly identifying steps for supporting themselves or others that were described in the handout (the questionnaire including six correct and two incorrect steps) and (3) correctly identifying a sign that someone is experiencing stress from three scenarios included in the questionnaire. Comprehension of the “changing unhelpful thoughts” handout content was assessed by asking the respondent to create a more helpful thought in response to two example scenarios. To reduce participant burden, each evaluation participant was asked to report on their experience with only one of the handouts.A program evaluation was conducted after the PSS focal point program had been implemented in the 25 camps for 6 months; the evaluation focused on program reach  and utility  of the PSS materials. A cross-sectional study design was used to collect qualitative and quantitative information using an online-adaptive, phone-based data collection application  in Myanmar language. Data collectors were located in the IDP camps and were able to move freely within the camps to collect data during the program evaluation period. During data collection, study staff maintained daily contact with data collectors to answer questions and confirm the number of questionnaires completed.Data collectors were given a random start and skip number generated based on the number of houses in their assigned area. Data collectors used this random number to approach houses for participation in the study, alternating between questionnaires for every other house, until they completed their assigned number of interviews for both.n = 400 completed surveys in order to get 95% confidence with 5% error. Therefore, our aim was to survey 800 adults in order to get estimates for the two different questionnaires.Using standard sample size calculations for population estimates for our knowledge, attitudes and practice questions we calculated needing A total of 793 participants participated in the evaluation; 400 responded to the questionnaire on their experience with the “stress and coping” handout and 393 for the questionnaire on the “changing unhelpful thoughts” handout. Oral consent was obtained from all participants prior to their participation. Data collection took place from October 5, 2020 to October 31, 2020. This program evaluation was approved by the JHU IRB (IRB# 13256).Data from this data collection effort were analyzed together with process indicators collected as part of regular program monitoring. The PSS focal points kept program logs with information on the number of households visited each day to distribute handouts, the number of IDPs who approached the focal points for further information and support, and the number of times an IDP used the focal point's program phone to talk with a CETA counselor. These logs were reviewed with supervisors each week who entered data into the program monitoring data system.Forty-one focal points , ranging in age from 19 to 42 years old, implemented this PSS program in the 25 IDP camps. From May to September 2020, the PSS focal points distributed handouts to 5,725 households. The PSS focal points were active for an average of 15 non-consecutive weeks in this 5-month period.Analysis of focal point logs from weekly supervision data identified 679 visits by IDPs to the PSS focal points. During these visits, the PSS focal points reported reviewing the handouts with 521 (76.7%) people. In addition, 332 (48.9%) of the 679 visits resulted in a phone call to a CETA counselor.Evaluation respondents ranged in age from 18 to 85 years (mean age 42.5 years). For both questionnaires, there were more female than male respondents .Over 93% of respondents for both questionnaires reported receiving the handout with over 85% of these respondents reporting having read the handout (85.83% for the “stress and coping” handout and 86.38% the “changing unhelpful thoughts” handout).Frequency of using the skills and information in the “stress and coping” handout was reported by 29.28% of respondents to be daily or almost daily, 65.11% reported using the skills a few times a week or sometimes . For then = 321), 42.68% (n = 137) correctly recalled 3 or more signs of stress mentioned in the handout. An additional 44.24% (n = 142) correctly recalled 1 or 2 signs of stress. For the identifying correct steps for supporting self and others question, 64.80% (n = 208) of respondents correctly recalled one or more of the steps from the handout, with 33.64% (n = 108) only recalling steps not listed in the handout and 1.56% (n = 5) respondents being unable to recall any steps. For the question about identifying someone who is experiencing stress, 72.59% (n = 233) of the respondents were able to identify the correct scenario; 25.86% (n = 83) selected an incorrect scenario and 1.56% (n = 5) did not answer.Of the respondents who reported reading the managing “stress and coping” handout (n = 143) were able to respond with a more helpful thought to the first scenario, while 47.32% (n = 150) provided answers that were not considered to be more helpful or were unclear and 7.57% (n = 24) were unable to answer. For the second scenario, 63.09% (n = 200) were able to create a more helpful thought, while 29.34% (n = 93) responded with incorrect or unclear answers and 7.54% (n = 24) were unable to provide an answer.In the knowledge assessment, of the 317 respondents who reported reading the managing “changing unhelpful thoughts” handout, 45.11% (n = 232), somewhat useful by 27.10% (n = 87), and not at all useful by 0.31% (n = 1) of respondents who read the handout. This is similar to responses regarding the information in “changing unhelpful thoughts” handout, with 79.18% (n = 251) of the respondents who read the handout reporting that the information was very useful and 21.14% (n = 67) reporting it to be somewhat useful.The information in the “stress and coping” handout was reported to be very useful by 72.27% .n = 298), “somewhat useful” by 20.69% (n = 78), and “not at all useful” by 0.27% (n = 1) of respondents out of the 379 respondents who reported hearing the audio information. Again, this is very similar to responses regarding the changing unhelpful thoughts handout where 80.74% (n = 306) reported the audio information to be very useful and 19.26% reported it to be somewhat useful (n = 73), among those who reported hearing the information over loudspeaker and/or radio.The managing stress and coping information played on loudspeakers and/or the radio was reported to be “very useful” by 79.05%  PSS information, the PSS handouts have been revised to encompass more examples related to stress and trauma in general and address concerns related to the coup. This PSS focal point program, as part of the larger system of care, serves as a model for responding to MHPSS needs of communities in humanitarian and remote settings. To address sustainability in part, the model is currently being updated to include pre-recorded videos to enhance the remote training of PSS focal points, as well as modules for training organization-level supervisors. Further data will be collected on the implementation of this type of training, as well as ongoing implementation of the focal point system.Adaptations to the program described in this paper could be made in order to more appropriately match the context of new areas, including a review of individual access to personal phones. Because this study was conducted in IDP camps during COVID-19 lockdowns, more people used the available PSS phones compared to personal phones, however, other settings may find that people have more access to personal phones and choose to use these for calling counselors. In addition, the PSS focal points in this program lived in their respective IDP camps, however, implementing organizations in new settings would need to identify the most appropriate frontline workers. People on the community were selected for this study because of COVID-19 restrictions, however, it may be more appropriate to have focal points who are not neighbors, when possible, which is a decision each organization would need to make on a site-by-site basis.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was reviewed by the Johns Hopkins School of Public Health Institutional Review Board (IRB# 13256) and determined to be exempt.CL and MS led the writing of this manuscript with editorial support from JB. KM, GD, and LS contributed specific information for sections related to challenges and overcoming challenges. All authors read and approved the final manuscript and were involved in study planning and implementation and analysis and interpretation of the collected data.This study support for CL, MS, KM, and JB which was provided by the United States Agency for International Development (USAID) under grant number: AID-OAA-LA-15-00003. Funding support for implementation of the focal point system by local partners was provided by Development Alternatives Incorporated. Neither of the funding bodies had a direct role in the design of the program, nor the collection, analysis, and interpretation of data and in writing the manuscript.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.


Comprehensive medicines reviews such as Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) can resolve medicines-related problems. Changes to Australia’s longstanding HMR and RMMR programs were implemented between 2011 and 2014. This study examined trends in HMR and RMMR provision among older Australians during 2009–2019 and determined the impact of program changes on service provision. Monthly rates of general medical practitioner (GP) HMR claims per 1000 people aged ≥65 years and RMMR claims per 1000 older residents of aged care facilities were determined using publicly available data. Interrupted time series analysis was conducted to examine changes coinciding with dates of program changes. In January 2009, monthly HMR and RMMR rates were 0.80/1000 older people and 20.17/1000 older residents, respectively. Small monthly increases occurred thereafter, with 1.89 HMRs/1000 and 34.73 RMMRs/1000 provided in February 2014. In March 2014, immediate decreases of –0.32 (95%CI –0.52 to –0.11) HMRs/1000 and –12.80 (95%CI –15.22 to –10.37) RMMRs/1000 were observed. There were 1.07 HMRs/1000 and 35.36 RMMRs/1000 provided in December 2019. In conclusion, HMR and RMMR program changes in March 2014 restricted access to subsidized medicines reviews and were associated with marked decreases in service provision. The low levels of HMR and RMMR provision observed do not represent a proactive approach to medicines safety and effectiveness among older Australians. Older people are at increased risk of medicines-related harm. Strategies are needed to address the harm arising from medicines use that contributes to an estimated 250,000 hospital admissions annually in Australia . ComprehMedication Without Harm and Australia’s new national health priority area ‘Quality Use of Medicines and Medicines Safety’ [The HMR and RMMR programs have operated for over 20 years, with major changes to program funding rules between 2011 and 2014. Examination of claims data suggests these program changes coincided with changes in service provision ,7,8 but  Safety’ ,9. This A repeated, cross-sectional study was conducted using publicly available Medicare Benefits Schedule (MBS) processing data, Australian Bureau of Statistics data, and Australian Institute of Health and Welfare (AIHW) GEN aged care data. MBS program rules require GPs to lodge HMR/RMMR claims after the medicines management plan is discussed with the patient. The total monthly number of GP claims processed for HMRs  and RMMRs  between January 2009 and December 2019 for individuals aged ≥65 years was extracted from the Services Australia website . Quarterauto.arima in R V4.0.2  [forecast in R.Trends were stratified by age group  and sex. Interrupted time series analysis was conducted using seasonal autoregressive integrated moving average (ARIMA) modelling . ProgramAustria) . Step  aged ≥65 years nationally, with 2292 GP claims for HMRs. There were 3073 GP claims for RMMRs in January 2009 and there were 152,376 older residents (71.8% women) included in the RACF denominator in 2009. The populations of interest increased to 4,107,641 individuals and 177,098 residents in December 2019, with 4405 HMRs and 6262 RMMRs provided. Monthly rates of HMRs and RMMRs per 1000 older people by age group and sex are shown in RMMR provision steadily increased across all age groups from January 2009; however, decreased provision was noted after March 2014 . ProvisiTrends in HMR provision in older people and counterfactual forecasting of HMR provision in the absence of 2014 program changes are shown in In January 2009, 0.80/1000 older people received HMRs, increasing to 1.46/1000 in September 2011. There was a small monthly gradual increase in HMR provision after October 2011 compared to the previous period  . There wComparison between observed and forecasted trends  suggested there were 41.3% fewer HMRs/1000 per month than predicted 12 months later  .In March 2015, there were 15.7% fewer RMMRs/1000 residents per month than predicted had the program rules not changed in March 2014 .RMMR and HMR provision is low in older Australians and was significantly impacted by policy changes during 2011–2014. Variation in HMR and RMMR provision by age and sex was observed. Our results are consistent with recent analyses showing significant national variation and overall low uptake of HMRs and RMMRs ,17,18,19Overall, GP claiming for HMRs and RMMRs continued to increase in older people following program changes in October 2011 that enabled referrals to be sent directly to accredited pharmacists and the removal of pharmacist-initiated RMMRs. While the changes in 2011 may have in part facilitated more collaborative medicines reviews, examination of crude pharmacist claims data suggest these changes led to an overall decrease in RMMR provision by pharmacists resulting from the removal of pharmacist-initiated RMMRs . PharmacOverall, program changes in 2014 were found to be a major barrier to HMR and RMMR provision in older Australians. More needs to be done to improve HMR/RMMR uptake, service delivery, and uptake of pharmacist recommendations. Strategies could include consumer and GP education, targeted feedback to GPs that identifies patients who may benefit from HMRs, standardized templates, peer assessment of reports, and better utilization of digital systems and decision support tools ,18,21,22We suggest the proposed changes need to incorporate evidence that good working relationships between health professionals, face-to-face discussions, and positive organizational culture are enablers to high-quality medicines reviews ,25,26. PThis nationally representative study captured all GP claims for HMRs and RMMRs processed via the MBS; however, individual-level information about recipients and service quality was not available. ARIMA modelling enabled us to account for non-stationarity, seasonality, and autocorrelation , but theChanges to HMR and RMMR program rules in March 2014 that restricted access were associated with marked decreases in the rates of GP HMR and RMMR claims for older Australians. Low rates of HMR provision persisted until 2019, while trends in RMMR provision recovered slowly between 2015 and 2019. Australia’s medicines review program is one of few subsidized, national services to support quality use of medicines in older people. Yet, the low levels of HMR and RMMR provision observed in this study do not represent a proactive approach to medicines safety and effectiveness. Systems changes are needed to address these gaps among older Australians and move the needle closer towards quality use of medicines.


Commercializing biomedical discoveries is a challenging process for many reasons. However, Academic Medical Centers (AMC) that have teaching, patient care, research, and service engrained in their mission are well poised to host these discoveries. These academic discoveries can lead to improvement in patient health and economic development if supported to cross the “valley of death” through institutional assistance, by providing guidance, gap funding and product development expertise. Colorado has a vibrant local startup ecosystem, state support for commercialization and entrepreneurship as well as critical mass of product development expertise. University of Colorado Anschutz Medical Campus, as a major AMC, is an engine for growth for the region. This article discusses innovation efforts at the University of Colorado Anschutz Medical Campus as a case study, which is built around two major efforts: the CCTSI and CU Innovations. I-Corps at CCTSI and the SPARK|REACH program of CU Innovations have been instrumental in fostering innovation, commercialization, and entrepreneurship on the campus. Academic medical centers (AMCs) have a well-established multipronged mission: patient care, education, research and engagement, and service to their communities which are intertwined in sophisticated ways. Faculty at AMCs produce scholarly products that report on biomedical and healthcare advances upon which scientific progress and education is built . The funThe University of Colorado (CU) Anschutz Medical Campus is the largest AMC in the Rocky Mountain region. Since its opening in 2004, the two-hundred and thirty acre campus now includes more than eleven million square feet of state-of-the-art facilities where world class biomedical research, clinical care, and educational programs are delivered. Each year more than two-million patients receive care on the campus, at one of the three co-located health systems. The campus consistently receives over a half billion dollars of extramural funding for research, has 5,000 faculty, 300 post-doctoral fellows and 1,500 professional research associates actively working to contribute to scientific endeavors [Conducting and excelling in basic and fundamental research is a prerequisite. Crossing the VoD by learning industry’s needs and driving inventions at least past the pre-NPD [New Product Development] stage, until the industry can pick them up, is also paramount. The typical pre-NPD includes four steps: 1. Affirming the technical viability of the invention as a product or service; 2. Formalizing the product concept; 3. Validating the concept with market research; 4. Developing a business case to gain commercial support, again using consumer research and marketing .Commercialization of academic discoveries is challenging. There are numerous barriers that prevent rapid translation of discoveries into products. First is the skills gap. Academic investigators are trained in hypothesis-driven research and are not experienced in identifying commercial potential nor commercialization pathway. They lack the knowledge and understanding about how new technologies are brought to market. Second is lack of access to technology development expertise or commercialization resources required for early stage product development. Access to regulatory, reimbursement, and product development experts among others is vital for success but quite difficult to find at AMCs. Third, moving from basic research discoveries to scientific proof of feasibility or validation studies is typically not supported by traditional NIH grants and thus requires gap funding. In many instances, investigators do not have access to such funds . The infand the market. In turn, this requires interdisciplinary teams working together both assessing the viability of the invention and developing it as a product. Technology transfer officials generally have IP knowledge with a scientific background and do not have the human capital to deliver in all these domains. Hence, universities have been building innovation offices and programs to bring critical commercialization and business development expertise in house [The University and Small Business Patent Procedures Act of 1980, or what is commonly known as the Bayh-Dole Act, “designed to accelerate the commercialization of technologies, gave universities the right to claim ownership to inventions within their institutions that were supported by federal funds” . A majorBuilding on its strengths in performing cutting edge basic research, deep understanding of biology, disease modeling, and clinical mechanistic studies over the years, CU Anschutz has invested in talent and infrastructure for translational research, while cultivating a proentrepreneurial culture. Catalyzing this transformation has been the awarding of numerous grants and philanthropic donations to support translational research, including the creation of the Colorado Clinical and Translational Sciences Institute (CCTSI) in 2008 funded by the CTSA Program of the National Center for Advancing Translational Sciences (NCATS), CU Comprehensive Cancer Center grants from the National Cancer Institute, and the CU Gates Center for Regenerative Medicine, to name a few. A number of groundbreaking CU Anschutz discoveries led to major improvements in patient care and public health. Two vaccines for shingles, Zostavax and Shingrix, are examples of blockbuster drug discoveries that were discovered at CU Anschutz, similar to Kineret for rheumatoid arthritis and Botox for hyperactive bladder. Myogen, Synergen, Taligen, GlobeImmune, and miRagen are examples of start-ups that underwent major acquisitions, the first two being acquired by two major pharma companies for $2.5 billion and $1.1 billion, respectively. Despite these successes, certain challenges prevail. Acknowledging and eliminating roadblocks to innovation and commercialization, the university restructured its technology transfer office, now called CU Innovations, in 2016 to adopt a fresh comprehensive perspective enriched with best practices.th Industrial Revolution to make a change in the US healthcare system by collaborating with startups to multinational industry partners.CU Innovations has been working in collaboration with academic and administrative offices of the university to identify unique barriers for translation and find creative ways to partner with industry and fill in skills gap for commercialization. At its core lies the traditional patent licensing and patent management. However, in recent years, greater emphasis has been placed on industry collaborations, providing gap funding, making technology development experts accessible to faculty, and offering training programs. Technology development, startup formation, business development, and venture development are also within the remit of CU Innovations. The office hired accomplished Entrepreneurs in Residence to help faculty in maturing their commercialization ideas and setting up ventures. Finally, what might not exist in many other innovation offices is the close collaboration with hospital partners on the campus for healthcare innovations through codevelopment of technologies emerging both from within the campus and outside. This partnership utilizes the offerings of the 4Acknowledging the importance of gap funding, CU Innovations set up various funding mechanisms Fig. . Two accThe CCTSI has been a major partner of CU Innovations as it is designed to improve and streamline the translational research process and to catalyze innovation in the training of translational scientists and the development of new research tools . Its worThe trained clinician or translational research scientist often has little knowledge about how to advance solutions from concept to commercial value. To support this workforce development need, Colorado was one of the 10 CTSAs selected nationally by NCATS to adopt the Innovation Corps™ (I-Corps™) program for clinical and translational researchers . I-CorpsLocally identified as I-Corps@CCTSI, the program has established a clear path for CU AMC scholars to translate research innovation and discoveries into commercially viable products or services. This team-based experiential three-week training is taught by faculty with entrepreneurial experience. The objectives of the I-Corps program are to a) develop the workforce by catalyzing an academic entrepreneurial culture and skillset; b) develop discoveries and commercialization potential, and, c) demonstrate impact by connecting researchers to resources for commercialization, domain expertise, and accelerator funding.A defining feature of the I-Corps program is the customer discovery process ,14; a cuParticipating faculty and students use a business model canvas framework to conduct customer discovery, gather market force data, and gain a clear understanding of the value of their invention to the marketplace. From 2016 to fall of 2019, I-Corps@CCTSI has trained 8 cohorts, with 68 teams and 191 participants from diverse backgrounds  Research Evaluation and Commercialization Hub (REACH) Award in 2019. REACH at CU-Anschutz is built on the previous SPARK Colorado program that has been engaging with local ecosystem partners in creative ways and helping faculty translate their discoveries.In 2018, the campus initiated a pilot accelerator program in collaboration with Stanford University, called SPARK Colorado. CU Anschutz preferred to adopt the proven model of Stanford for supporting faculty innovations and maturing inventions through the next inflection point where industry partners or investor groups would be willing to engage. SPARK Stanford was founded in 2006 around the time when the concept of accelerators was emerging in industry and has recorded a success rate of 51% of projects either licensed or entered the clinic. The program is built on three pillars: moderate funding, industry mentorship and, curriculum-based training on product development and commercialization.The chief novelty of SPARK has been helping to bridge the cultural divide between academia and industry by creating venues for interaction and mutual learning. It has been derisking drug development, medical device, and diagnostic projects for outside companies, investors, and even for federal grant agencies. Many SPARK projects were not only licensed to outside companies with access to larger, needed funding but also were able to receive funding from NIH or Defense Advanced Research Projects (DARPA), after generating initial data supporting their hypothesis . AnotherSPARK Colorado announced its call for applications on February 1, 2018, for its inaugural year. There were three major project selection criteria: scope of unmet medical need, novelty of the approach, and feasibility in terms of time and financial cost to move a project forward. SPARK Colorado, unlike Stanford’s single focus on drug development, accepts projects in drug development, medical devices, and diagnostics. It is a cohort-based program in which about 10 admitted teams per year meet on a bi-weekly cadence with voluntary mentors and other teams. They discuss progess in their programs or host a guest speaker on key topics such as regulatory affairs, reimbursement, intellectual property (IP), medicinal chemistry, or venture development. Most of these training sessions are open to everyone on campus. During its first two years of the program, over 1,000 individuals participated in the 45 SPARK Colorado seminars.Startup Communities: How to Build an Entrepreneurial Ecosystem in Your City describes in detail how the Boulder ecosystem was established in the 1990s and potentially how it can be replicated elsewhere and what would be the minimum requirements. In that sense, Colorado is relatively better off in tackling the challenges of entrepreneurial space as it has established components of an innovation ecosystem supporting startups. Yet, Colorado shares a restrain that many other inland states face, which is access to capital. Particularly many of the biotech companies move to east or west coast after or for raising funds from venture capital.A major challenge for the entrepreneurial space is the availability of small business concerns with the appropriate expertise, organizational structure, and competence in commercialization. Colorado has a unique ecosystem for startups, which is to the advantage of the University of Colorado. Boulder, Colorado is a nationally renowned startup hub that has built a unique ecosystem particularly for technology companies. A major global accelerator program, Techstars, based in Boulder, was successful in building a tight-knit network of entrepreneurs and consultants for small businesses. They have been also successful in recruiting talent from across the nation. Bred Feld in his book Initiation of the SPARK program at CU Anschutz has enabled the campus to better engage with the local innovation ecosystem Fig. . The proMentors come from diverse backgrounds including former executives in large drug development and medical device companies or entreporenurs who successfully launched and exited startups. The program has 30 mentors that engage with the teams at different levels and cadence. They assist faculty in developing and providing the information essential for externalizing their technology, such as defining a clear clinical indication, understanding the market and competitive landscape, navigating FDA regulations, developing a roadmap for first-in-human studies, and understanding the reimbursement landscape. All of these taken together build the economic value proposition for the product under development.A critical component of SPARK Colorado is active project management to help teams establish project plans and ensure they follow timelines and deliverables. A project manager with the requisite experience in drug, device, or diagnostic development is assigned to each project to oversee the research effort and to assure that the project is tracking toward milestones that will increase the likelihood of creating a viable start-up company or partnering opportunity. SPARK project managers meet with teams on a regular basis and plug in resources such as regulatory consultants or Contract Research Organizations when necessary; they work with teams to identify commercialization strategy gaps and analyze the competitive landscape.SPARK Colorado has a call for applications annually. Faculty apply through a digital platform to which external reviewers have access. This external review board is composed of the mentors of the program. Once written reviews are completed, in a second review phase, selected faculty are invited to a live pitch session. Project managers of the program work closely with faculty to hone their applications and their pitches. A major challenge for this kind of program at an academic institution is to identify the best projects as well as the teams that are most likely to execute on their ideas. SPARK Colorado has continued to work on improving its process for team and project selection with room still to grow.The program has been experimenting with various models to cover costs. For the first year, funding for selected projects came from the faculty members’ departments, whereas programmatical expenses were covered by CU Innovations. In the second year, the program merged with the Advanced Industries Accelerator (AIA) funding of the State of Colorado, Office of Economic Development and International Trade (OEDIT). The State of Colorado has been funding innovation through technology transfer offices of research institutions including CU Anschutz by awarding grants for proof of concept projects. Universities are expected to provide matching funds in order to receive state dollars.A major challenge for Colorado startups, similar to many other companies founded in inland states, is access to capital. Colorado does not have any restrictions in its law, unlike some other states, that hinder state dollars being spent to support private industries. Indeed, the State of Colorado has been instrumental in filling a major gap as it provides direct support to private industries through grants and tax credits. A major venue for this is the AIA program run by OEDIT, funded by tax revenues. This is a grant mechanism to support proof of concept work conducted within universities as well as early-stage companies in advanced manufacturing, aerospace, biosciences, electronics, energy and natural resources, infrastructure engineering, technology, and information. The state provides early-stage capital, collaborative infrastructure, and export grants as well as investment tax credit. All these are governed by the Procurement Code of the State of Colorado, which does not hinder the state in providing funding for private industries. The AIA program is funded through 2024 and has been critical in advancing life science innovations. This required collaboration between the Colorado Bioscience Association, the Office of the Governor of Colorado, and the research institutions.NIH has been reflecting on ways to translate basic research discoveries conducted with federal dollars to products to have broader impact of taxpayers’ money. With this goal in mind, NIH established the REACH program in 2013 Fig. . InitialThe Colorado REACH hub has three major goals: identifying the most promising technologies and providing funding for product definition studies; promoting commercialization of selected products by enabling access to technology development resources and facilitating formation of strong spin out companies; and expanding educational, experiential, and networking opportunities Fig. . ColoradA crucial component of biomedical innovation is navigating FDA regulations. As already mentioned, SPARK investigator teams are paired with mentors who generally have high-level knowledge of the regulatory process as many of them are accomplished entrepreneurs that have taken products to market. However, the program also requires the teams to work with a paid consultant to provide specific input pertaining to their projects. The funding that comes from the State of Colorado enabled teams to budget consultants for their projects. But most recently, the NIH REACH grant also allowed the program to set aside dedicated funds for consultants who are regulatory and reimbursement experts that work with teams as they start to define milestones to achieve during the program and afterwards. Finally, the university also has an office that facilitates investigator-initiated INDs on behalf of the university. However, since it has limited human resources, the office is generally quite selective in deciding which project to support.Apart from grant dollars, REACH has provided the SPARK program with new resources provided by the proof of concept network. All of the projects that are selected for advancement after the initial review at CU Anschutz are also reviewed by a Technology Guidance Committee (TGC) consisting of experts assembled by the NIH, including an entpreneur-in-residence, a regulatory expert and representatives from the FDA, USPTO, CMS, Kaiser Permanente, and a liaison from the relevant institute at NIH. The TGC provides invaluable early input from key experts. The extra grant dollars also enabled the campus to put aside dedicated funds for paid consultants not only to serve the selected projects but also to the whole campus through office hours. REACH also provided a broader umbrella to build new partnerships between campuses of CU and beyond. Projects are encouraged to make use of expertise and resources available from our collaborating partners including the UC Cancer Center Developmental Therapeutics Program, Department of Bioengineering, CU Denver School of Business, School of Pharmaceutical Sciences, Colorado Office of Economic Development and International Trade (OEDIT), Rockies Venture Club, Small Business Development Centers (SMDC), and the Colorado Biosciences Association (CBSA).A major pillar of REACH, similar to SPARK, is education and culture change. During the application process for the first REACH cohort, CU Anschutz worked with the CU Denver Business School in organizing a “Bio Bootcamp” to introduce fundamental concepts of business and product development. Similarly, MBA students engage with project teams in helping with market research or preparing commercialization plans. The CU Anschutz REACH team is working to build a robust educational component that is developing targeted and easily accessible material while also incorporating existing resources on the campus including the Bio-Design course in the Department of Biomedical Engineering, the Drug Development course in the School of Pharmacy, I-Corps program provided by the CCTSI, and the Colorado SPARK curriculum around commercialization to provide broader visibility and access.In certain cases there can be challenges working with health systems in terms of distribution of faculty time between clinical activities and entrepreneurial activities. In the Anschutz case, UCHealth, Children’s Hospital Colorado and the University of Colorado are separate legal entities. Clinicians working at UCHealth and the Children’s Hospital are the faculty of the university and they work for the medical school. Therefore, the decisions about allocation of faculty effort and time dedicated to innovation and entrepreneurship is up to the departments and division chairs, and not to the hospital systems. Having said that, if faculty have extensive hours in clinic it might be challenging to dedicate extra time for their innovation and entrepreneurship related efforts. In these cases, faculty can buy out their clinical time through grants. The campus is currenlty engaged in a process to standardize institutional support for innovation and entrepreneurship for faculty through a committee working on revising tenure and promotion criteria. In its current form, there exists divergence between departments and divisions’ support for such activities.The University of Colorado, Anschutz Medical Campus as the largest academic healthcare center in the Rocky Mountain region has been investing in fostering innovation on multiple fronts. Having an innovation friendly and supportive leadership is essential to enable organizational culture change that will embrace innovation at various layers of the organization. Leadership must acknowledge that returns from such programs may take years to fully become realized. Restructuring the technology transfer office in 2016 and tasking it to identify institutional roadblocks for product development and interaction with industry was a major step forward. The close collaboration between CU Innovations and the CCTSI with a shared mission of supporting translation of discoveries had led to major successes, one of which is the NIH REACH award. SPARK Colorado and later REACH has enabled a growing community of innovators. The collective efforts of these disparate groups and the continued commitment of campus toward cultivating a culture of innovation have empowered faculty and students to make a direct impact to improve human health and created new venues for the campus to engage with the local ecosystem partners and broader community.During the three years of SPARK| REACH program, in total it has received 155 applications, of which 28 projects were admitted to the program. In total, SPARK teams generated $11.1 million follow on funding as well as $2.9 million in investments. As a result of the program, 6 new patents were filed, 6 new startups were formed. But most importantly, SPARK| REACH in collaboration with the CCTSI has accelerated the change of culture on the campus, raising awareness and interest among faculty and students for commercialization and entrepreneurship.