The objective of this exploratory study was to investigate through a qualitative thematic analysis the reflections of six animal protection and wildlife conservation non-governmental organizations (NGOs) in Romania regarding the development of the first specialized master’s degree program in ethology and human-animal interaction in the country. The two research questions addressed in the study were (1) What are the needs of the participating NGOs that could be addressed by the first professional master’s program in ethology and human-animal interactions in Romania? (2) What are the expectations regarding the roles of the graduates of the program on the collaboration with the NGOs in addressing common problems in the area of human-animal interactions in Romania? The qualitative content analysis of the written reflections allowed the identification of two themes, which provided us valuable insights regarding the curriculum offerings and the pedagogical strategies that could respond to the expressed expectations. The first theme refers to the concerns expressed by the representatives of the NGOs over the animal welfare and human-animal interactions in Romania, which included seven categories of codes: concerns over stray animals, lack of education of general population on animal welfare and interactions with animals, maltreatment of animals, human-animal conflicts, lack of professional specializations in ethology and human-animal interactions, concerns over common global issues, and concerns over national nature conservation. The second identified theme refers to the expectations regarding the roles of the graduates of the master’s degree program, and it includes the following four categories: agents for change towards a responsible community, problem solvers, public policy-makers, and providers of competence-based expertise. This study aims to explore through a qualitative thematic analysis the reflections of six animal protection and wildlife conservation NGOs in Romania regarding the development of the first specialized master’s degree program in ethology and human-animal interaction (EHAI), in relation to the identified needs based on their experience in the field, as well as their expectations in terms of collaboration with the graduates of such a program in addressing the common problems in the areas of animal welfare and human-animal interactions (HAIs). The qualitative content analysis of the written reflections allowed the identification of two themes, which provided valuable insights regarding the curriculum offerings and the pedagogical strategies that could respond to the expressed needs and expectations. The first theme included seven categories of concerns expressed by the NGOs over the animal welfare and HAIs in Romania, i.e., concerns over stray animals, lack of education of general population on HAI and animal welfare, maltreatment of animals, human-animal conflicts, lack of professional specializations in HAI, concerns over common global issues, and concerns over national nature conservation. The second theme refers to the expectations regarding the roles of the graduates of the EHAI master’s program, and it includes four categories of codes: agents for change towards a responsible community, problem solvers, public policy-makers, and providers of competence-based expertise. The inclusion of Service-Learning as signature pedagogy in the EHAI program, in connection with the One Welfare approach, is discussed in relation to the needs expressed by the representatives of the NGOs. The development of academic interest in human-animal interactions (HAIs) is reflected in the increasing number of research publications in the field of anthrozoology, as well as by the number of Higher Education programs around the world. The diversity of the interactions shared between humans and animals  is reflected in the diversity of disciplines addressing aspects of these interactions not only within the field of anthrozoology but also within other fields, such as human and veterinary medicine, psychology, sciences of education, biology, geography, anthropology, political sciences, economic sciences, etc. ,2,3,4.In terms of competencies-based curricula, the Higher Education degree programs in the field of animal welfare, ethology, and anthrozoology that currently exist in the European space (and around the world) are usually highly connected with the professions of ethologists, conservation specialists, animal therapists, and animal behaviorists, which are framed within national and EU legislation (in the case of the EU countries), as well as regulations that are implemented by national boards of professionals. A recent synthesis of the current situation of university centers and programs for animal studies and human-animal interactions indicates that the interest of animal issues among university academics has risen in part because of the tremendous growth of the animal protection movement and the legislative frames and declarations at national, regional, and international levels . The collaboration between Higher Education Institutions (HEIs) and the representatives of the community, such as non-governmental associations (NGOs) and other institutions , can offer important insights on the community needs and on the applicability of research and education to real-world scenarios ,4,6,7. OOrganizations that have a central task in connecting humans to animals and the environment are expected to be familiar not only with the existent legislative frames in animal protection and wildlife conservation but also with the curricular offerings of the academic programs (including the emerging ones) in charge with the formation of specialists addressing the diversity of animal issues . AnthrozRomania is one of the EU countries with no specialized degree programs in anthrozoology, ethology, and animal welfare, although subjects such as ethology, ethopathology, and animal welfare  can be found in the curricular offerings of veterinary medicine, biology, and ecology, within the graduate and undergraduate programs. The animal-assisted interventions subject is currently offered at only one university in Romania (having a duration of one semester), within a master’s degree in Special Education, Faculty of Psychology and Sciences of Education, Babes-Bolyai University.For the first time in the academic history of the country, a master’s degree program in Ethology and Human-Animal Interactions (EHAI) is currently being developed in English language at the School of Animal Science and Biotechnology, University of Agricultural Sciences and Veterinary Medicine in Cluj-Napoca. The master’s degree program will have duration of 2-years, and it is expected to launch in July 2021. The university is one of the state HEIs in Romania, and it has been recently ranked on the 18th position among the 102 Romanian HEIs included in the Web Ranking of the World Universities in 2021 . FoundedInspired by the structure of similar successful degree’s programs existing in Europe and around the world, the team of the EHAI program is an interdisciplinary one, being composed of academic experts in from the School of Animal Science and Biotechnology, School of Veterinary Medicine , and the School of Psychology and Sciences of Education . The collaboration between the two HEIs in the field of human-animal studies was consolidated over the last 10 years through several research projects and educational ones, such as a distance learning postgraduate program in animal-assisted interventions (AAIs) for persons with special needs (the only existing academic training in the field of AAI in Romania) and by organizing community-oriented campaigns involving students for the promotion of the responsible ownership and optimal human-animal interactions.The planning of this specialized master’s degree in Romania in this particular moment is motivated by a series of favorable factors, as they follow: the constant signals coming from the animal protection and wildlife conservation NGOs in Romania regarding the crucial demand for academically trained experts in animal welfare and behavior, and the recent legislative changes in the area of animal welfare, including a law proposal for the profession of ethologist/animal behaviorist. Particularly, we consider that this law proposal opens tremendous opportunities of the HEIs in Romania to offer professional graduate and postgraduate degrees supporting the emergence of this profession at national level. Some examples of problematic human-animal interaction cases in Romania are presented below, which were highly reflected in the national and international media. In all these cases, several national NGOs in the field of animal protection and animal welfare manifested immediate reactions by direct implication in solving the problematic situations and by expressing the need for more efficient structures in charge with the reinforcement of the existing legislative frame in animal protection and cruelty prevention in Romania.Among other countries, Romania is often cited as a problematic country in global surveys and reports on the growing population of stray animals in urban areas, as well as negative human-animal interaction incidents ,18, suchAs already stated above, the particular timing of developing the EHAI master’s degree program is also marked by recent promising changes made by the Romanian Government in the area of animal welfare, particularly in the last 2 years (2019–2020). The first version of the national law on animal protection in Romania  dates from 2004, i.e., the same year in which Romania received the political confirmation of the EU accession negotiations, the accession taking place in 2007, January 1. Several modifications to the original version of the law in accordance to the EU legislations and existing treaties have been made ever since ,25. In aTaking into account the intensive participation in the last two decades of the NGOs in Romania in addressing problematic HAIs and the abovementioned promising legislative changes in the area of animal welfare, the objective of this study was to use a qualitative approach  to investigate the perceptions and the support of several animal protection and wildlife conservation NGOs in Romania regarding the opportunity of foundation, for the first time in the academic history of the country, of a specialized master’s degree in ethology and human-animal interactions. The NGOs included in this qualitative study have a history of collaboration in research and/or community-oriented events with the hosting HEI of the EHAI program, which is the University of Agricultural Sciences and Veterinary Medicine in Cluj-Napoca, Romania. We are fully aware that the number of the NGOs participating in the study is a small one and that the inclusion criteria are based on convenience, i.e., previous collaboration with the host university. However, the nature of this qualitative study is an exploratory one, aiming to generate data concerning the needs of community representatives in the fields of animal protection and wildlife conservation in Romania, as well as to identify potential ways to link these needs with the curricular content of the proposed master’s degree program and with the students educational and professional activities, in the direction of fostering their community engagement through collaboration with NGOs during the program and in the future. There is a growing recognition of the usefulness of the qualitative research  in many fields, including social and medical sciences, in providing valuable insights on the voices of individuals’ and organizations’ “life worlds” ,29. The two research questions addressed in this study are(1) What are the needs of the animal protection and wildlife conservation NGOs in Romania that could be addressed by the first professional master’s program in ethology and human-animal interactions?(2) What are the expectations regarding the roles of the graduates of the EHAI program on the collaboration with the NGOs in addressing common problems in the area of human-animal interactions in Romania?Between October-November 2020, written reflections were collected by e-mail from six representatives of some of the most active NGOs in the areas of animal protection and wildlife conservation in Romania. The inclusion criteria consisted in previous collaborations with the host HEI in the field of student community engagement and/or in the field of participatory research. A number of 10 NGOs were initially contacted, but only 6 NGOs returned their written reflections in the timeframe provided, i.e., 3 weeks from the moment of receiving the message. The written reflections were collected in the form of support letters for the development and implementation of the EHAI master’s degree program in Romania). The representatives of the NGOs were asked to organize their support letters (one to two pages) in the following structure: (1) to provide a brief description of their main objectives and activities; (2) based on their own experience in the field, to provide a presentation of the problematic situations in Romania  and needs that could be addressed by the EHAI master’s degree; and (3) to reflect on how they envisage the collaboration with the future graduates of the EHAI program in addressing the identified needs. Along with the abovementioned instructions, an introductory text was sent to the NGOs’ representatives with a summary of the proposed curricular content (names and short descriptions of the subjects) of the master’s degree program for 2 academic years. Participants were informed that the support letters (with the names of the NGOs) would be used for qualitative analysis and official publications. The support letters were provided in Romanian language and translated in English by the authors. iCare is a local animal protection NGO with international connections, founded in 2014 in Cluj-Napoca, Romania. The iCare’s objectives are sheltering stray animals in a proper environment, ensuring that their basic needs are met, promoting of responsible pet ownership, conducting trap-neuter-return programs for community cats and informing the general public about the benefits of peaceful coexistence between humans and animals. Type of NGO: AP.Nuca is an animal protection NGO founded in 2012 in Cluj-Napoca, Romania (note: Nuca is note an acronym but a name chosen in the memory of the founder’s pet). Nuca’s activities consists in organizing sterilization and medical care campaigns for animals in community, in collaboration with veterinarians, by assuring accessible costs to low-income persons owning dogs and cats. Several awareness events are organized by Nuca NGO multiple times per year. Type of NGO: AP.Transylvania Animal Care  was founded in 2015 in Cluj-Napoca, Romania, set up both as an NGO and as a veterinary medicine business. As NGO, TAC social subsidizes spay and neuter surgery and veterinary care for animals brought in by their own volunteers, but also by other NGOs working for stray dogs and community cats, as well as for low-income pet owners. As a veterinary practice, TAC offers highly affordable veterinary services to animals (mainly dogs and cats) in Cluj-Napoca and around. Type of NGO: AP.Luana’s Dream Foundation (LDF) was founded in 2014 in Popesti-Leordeni, Romania. LDF is a non-profit organization that conducts medical care programs for injured wild animals, sterilization campaigns for controlling the reproduction of domestic animals with and without owners, as well as environment-oriented activities, such as planting and greening campaigns. LDF is hosting the Wildlife Rescue and Rehabilitation Centre, which, besides the veterinary medical care unit, is constantly offering volunteer openings and awareness education programs to community, especially to children and adolescents. Type of NGO: AP&E.Animal Society Romania (former Vierpfoten Romania) is active since 2003 in Bucharest, Romania. The activities comprise humane and sustainable management of dog and cat populations through sterilization campaigns, as well as information and awareness actions on the importance of sterilization, vaccination, and responsible adoption. In addition, the NGO includes a Centre for Animal Assisted Therapy and Activities with former community dogs, being the only center of this type in Romania. Volunteering openings and animal-assisted educational programs for children are regularly organized by the Animal Society Romania NGO. Type of NGO: AP.WWF Romania is active since 2006 in Romania, where it conducts several programs to protect the wild environment in the Carpathian Mountains and along the Danube: protected areas, forests, brown bears, bisons, Danube Delta, sturgeons etc. In addition, WWF Romania is involved in the stimulation of the transition to the green economy and in offering environmental education programs for young people in Romania. Type of NGO: E.A number of six directors of Romanian NGOs with local, national, and international activities participated in the qualitative study. All the participating NGOs are familiar with the academic profile of the host HEI, and they were involved over the years in joint community-oriented programs and participatory research projects. Below we present the short descriptions of the participating NGOs, such as year of foundation, location, representative activities, and the domain of activities: Animal Protection (AP), Environmental (E), or both.The qualitative data analysis of the raw data  was performed following the hands-on guide to doing thematic content analysis . AccordiAll the representatives of the NGOs participating in the study, including the two ones with focus on wildlife conservation and environment protection, indicated the problematic situation of community animal (dogs and cats) number and management in the urban and rural areas of Romania, as well as the high rate of abandonment and of adoption of animals from private and public shelters. The concerns over stray animals were presented by the respondents in connection to the other main codes, especially with the lack of education regarding human-animal interactions:“The high number of animals in the streets is influenced by the size of abandonment and the size of absorption of shelter animals in the population, both dimensions being determined by the level of education and understanding of human-animal relations.”The main code “lack of education” appeared associated with various attributes, such as “serious,” “problematic,” “with severe consequences,” etc. The lack of education regarding responsible ownership, treatment of companion, and wild animals, appeared in all the six written reflections with a frequency of 2–6 times, being associated with several categories of factors, such as age , statuses and roles , and locations .“Over the ten years of activity in the field, we have faced an overwhelming proportion of a very uneducated public on basic notions of animal behavior, a phenomenon transposed by a precarious understanding of the legal and moral aspects of abandonment and aggression toward animals…”“We are trying to achieve our goals by providing as much as we can educational campaigns in kindergartens and schools. Informing and educating the general population about human-animal interactions is essential in creating a society in which respect for all living beings and protection of the environment are core values.”“The Romanian society has, as a whole, a precarious relationship with animals, often marked by a serious lack of information, knowledge and contemporary skills, and, in many cases, by superstitions, beliefs and local traditions; all of these, plus the ignorance, affect not only animal welfare as an immediate reality, but also the human and community quality of life.”The codes identified within the maltreatment of community and companion animals’ category were reflected in the written reflections of five of the NGOs’ representatives. As stated above, the forms of cruelty towards animals, such as aggression, extreme violence, and the neglect, were always presented in association with the lack of adequate education in the area of HAIs and animal welfare legislation, but also with the ignorance of the existing local, national, and European legislative measures. The maltreatment of the community animals was placed by one respondent under the umbrella of human-animal conflict:“…This type of conflict situations, that usually ends with tragic consequences for animals (from abandonment to cases of extreme violence), occurs due to ignorance, disobedience and non-application of the laws.”The codes within this category referred to both domesticated animals  and wild animals. Particularly, the two NGOs with activities in the areas of wildlife conservation and rehabilitation indicated several conflicting situations between wild animals and humans, pointing out the potential causes, such as intensification of human activities, urbanization, and lack of information and educational program for the general public in regards to the impact of human activities on the wild animals, their habitats and the environment. “From the point of view of wildlife in Romania, over the last 5 years, we have noticed that, with the excessive urbanization, some wild species have managed to find an ecological niche in the anthropic environment. However, these animals often suffer from a lack of information of the citizens about the needs of these species and the appropriate ways to interact with them.”“…The number of wild-human animal problematic situations in Romania is constantly increasing, which amplifies the pressure on animals and often leads to radical measures against them.”The lack of professional specializations in human-animal interactions was mentioned in several forms by all of the participants, some of them even pointing the urge of providing modern programs to train specialists in the field in order to prevent and manage the negative HAIs. Affective reactions, such as sadness and disappointment associated with the pauperism of professionals in ethology and HAI, were reflected in most of the statements: “Unfortunately, the background of our national bad tradition of interacting with animals is based on two factors: the social and cultural habits of interactions between humans and animals and on the missing of authentic specialists to mentor these types of interactions. If the first factor can not be easily repaired, it is urgent to train specialists who can change the present and shape the future in this field like in other modern countries.”“…The lack of specialists and professional branches in Romania to understand in depth both the behavior and the vital needs of animals, especially in relation to the human presence, as well as aspects of legislative framework that should more efficiently protect animals, unfortunately creates many instances of conflict or ignorance, hence, animals often have suffered.”The content analysis of the written reflections provided by the six NGOs depicted a series of common concerns over common global issues , in some“According to the Living Planet Index, from 1970 to 2016, there was an average decrease of 68% in size at global level of the wild population of mammals, birds, amphibians and fish, which indicates that, on one hand, we do not know how to appreciate the value and importance of these species and on the other hand we do not have enough trained specialists to prevent these situations.”“In the context of the more frequent and severe zoonosis than can lead to pandemics, but also of climate change, human-animal interactions is expected to become an increasingly delicate but crucially important aspect.”The concerns over wildlife and nature conservation at national level were expressed by three of the NGOs, in two cases in association with national assets, such as the existence of numerous active NGOs that are in a constant state of readiness to intervene in solving problematic and crises situations  and the high natural diversity of Romania .“Often chaotic economic development, with projects that do not always and/or completely take into account the negative impact they may have on wildlife and environment, it is still a major and complex threat in Romania, given that our country is (still) among the richest in natural diversity of the European Union members.”“In the present year, there are dedicated public institutions and numerous NGOs in Romania with the best intentions in regulating the relations between humans, animals and the environment.”“National capacity building in the field of wildlife and environment conservation is a constant concern for us, without which we can not talk about viable long-term results and sustainability.”As indicated in “In the absence of a clear legislation framework on owning an animal and managing community animals, it is education that can provide agents for change for a responsible community and that can contribute to solving the inherent problems of community animals.”“We want the general public to have access to well trained specialists that can be a valuable source of local information in regards to the human-animal interactions and conflicts.”The two codes “problem solvers” and “public policy-makers” were mentioned either individually (5 times) or in the same statement (one time), always in association with concepts such as coexistence of humans with animals, education and attention to the needs of animals and the wellbeing of humans and of the society.“We believe that the graduates trained through this program will be able to contribute in the future in an essential way to solving current problems and that they will find sustainable solutions for a better coexistence with animals, which will increase the welfare of animals and the wellbeing of humans.”“The state of problems that our teams deals regularly in its veterinary medical work, advocacy and education of the people in the community, can only be changed by academically trained and certified specialists in ethology and human-animal interactions, who can become the competent educators of our civil and administrative communities, public policy makers and mentors of the school population at any level, which is currently deprived of structured and modern education in human-animal interactions.”The codes included in this category provided valuable information regarding the competencies and the learning outcomes that are expected by the representatives of the communities (NGOs) from the EHAI master’s degree program. Although the components of the One Health approach are mentioned by all the NGOs in their statements regarding the professional expectancies of the EHAI master’s graduates, the concept itself appears in one out of the six written reflections collected in this study.“We, as organization, are working for almost 20 years in the field of animal protection, and we support the development of programs to academically train professionals who can make an impact within the large concept of One Health, that underlines and strengthens the human-animal responsible interactions.”This study aimed to perform an exploratory qualitative analysis of the reflections of six animal protection and wildlife conservation NGOs in Romania regarding the development of the first specialized master’s degree program in ethology and human-animal interactions (EHAI) in the country. The reflections were expressed in relation to the identified needs based on each NGO’s experience in the field, as well as the expectations in terms of collaboration with the graduates of such a program in addressing the common problems in the areas of animal welfare and human-animal interactions.Following the qualitative content analysis of the written reflections, two themes were identified, which indicate that, although the participants did not provide explicit answers to the research questions, their reflections allow for interpretations and depiction of implicit meanings that can be further addressed either in the co-construction of the curricular content and/or in planning educational and service-based activities for students in partnership with the NGOs. concerns identified by the NGOs over the animal welfare and HAIs in Romania, and it includes seven categories: concerns over stray animals, lack of education of general population on HAIs and animal welfare, maltreatment of community and companion animals, negative human-animal interactions, lack of professional specializations in HAIs, concerns over common global issues, and concerns over national nature conservation. One way of dealing with the feedback regarding these categories of concerns is to address them through the curricular content of the disciplines included in the EHAI master’s degree program. It is important to mention that the curricular content of the EHAI program was planned after reviewing the structure of similar master’s degree programs in the European space and around the world, as well as based on consultation with international collaborators in the areas of animal behavior, anthrozoology, and wildlife conservation. The graduates of this program, through the disciplines included in the curriculum, are expected to gain in-depth knowledge of grounded theories and models that explain and support not only the investigation of the natural behaviors of animals, biological stress in various conditions of captivity, and HAIs but also skills on collection and analysis of behavioral and psych-physiological data. Another way of addressing the identified concerns in relation to the curricular content is to invite representatives of NGOs to present case studies and co-reflect with the students on the causes of the problematic situations and potential solutions of management and prevention. The first theme is represented by the A particular category is represented by the concern over the lack of education of general population on HAIs and animal welfare, which was pointed out by all the participants, and it was usually presented in a casual relation with a diverse array of negative human-animal interactions. This concern was interpreted in connection with the findings of the second research questions regarding the expected roles of the EHAI master’s degree graduates to be providers of education towards responsible and sustainable HAIs. We consider that this concern points towards the need to offer the students of the EHAI program the knowledge and the skills to educate others, especially children, as indicated by all the NGOs.The EHAI master’s degree program is proposed for use in tertiary education settings, meaning that it will include mature students that most likely have undergone a pre-service teacher training, which in Romania is usually offered at undergraduate level. The students that did not receive pre-service teaching training at undergraduate level can decide later on to enroll in didactic training modules during the master’s degree program. However, this decision is an individual one, so it does not guarantee that all the students will have the formal competencies to be involved in educational programs. This particular concern motivates us to foster the inclusion of educational theories and methods in the curricula of the disciplines addressing the animal welfare and HAIs in a variety of contexts. Cases of successful educational programs, particularly of those that involve students, will be presented as examples of good practice. Additionally, joint projects between the students of the EHAI master’s degree program and students of Educational Sciences will be encouraged, in which students can design together and exchange experiences regarding the ways of community education towards responsible and sustainable HAIs.the expectations regarding the roles of the graduates of the EHAI master’s program and it includes the following four categories: agents for change towards a responsible community, problem solvers, public policy-makers, and providers of competence-based expertise. As indicated in the second research question of this exploratory qualitative study, we aimed to identify the expectations of the participants regarding the roles of the graduates of the EHAI program on the collaboration with NGOs in addressing common problems in the area of human-animal interactions in Romania. Even though the findings reflect only the expected roles of the graduates, we decided to interpret them through the frame of the research question, i.e., how can the master program offer the ground to develop the expected roles of the EHAI students through collaboration with NGOs during the program and following their graduation.The second identified theme refers to the generation, use, application and exploitation of knowledge and other university capabilities outside academic environments” [The content analysis of the NGOs’ reflections indicated that the expected role that appeared first in the text of the support letters was the one referring to the graduates as agents for change towards a responsible community, followed by the role of problem solvers and public policy-makers. As recently indicated by international experts in Humane Education in Higher Education, an important part of capacity building is “training for change agents of those who will be responsible for facilitating change” not only in the organization but also in the community and in the society ,30. The onments” ,38. In lonments” , which aAnother aspect supporting our motivation to include SL in the structure of the EHAI master’s degree program, which is in line with the expectations of the roles of the graduates expressed by the six NGOs, is the positive impact that SL programs can have on the personal development of students, their prosocial attitudes, civic action propensity, political awareness, appreciation of diverse attitudes, and the feeling of being able to “make a difference” in the community ,40,41. IWe do acknowledge that a limitation of this qualitative exploratory study is the potential positive bias in the reflections collected from the representatives of the six participating NGOs, with whom the host institution had previously collaborated in community-oriented events and/or participatory research projects, as well as the fact that the four non-responses may reflect not only the lack of time of the representatives of those particular NGOs but also a neutral and/or non-supportive position toward the initiative of developing the EHAI master’s degree program.In conclusion, the content analysis of the letters of support provided by the six NGOs for the development of the first master program in Romania in ethology and human-animal interactions has offered valuable insights in the direction of finding meaningful ways for the co-construction of the curricular content and of the educational and professional activities of the students, which are expected to become educators of the community, problem solvers, and agents for change towards a responsible community in relation to animals, people, and environment. The solutions proposed by us to address the expressed concerns over the animal welfare, wildlife conservations and HAIs in Romania, as well as the expected roles of the EHAI graduates, were elaborated within the community engagement approach, thus interpreting the findings from the perspective of the formulated research questions. According to the last report of the Network of Experts Working on the Social Dimension of Education and Training , communi


This study describes the feasibility and patient satisfaction for an integrated treatment to address multiple health outcomes in a sample of older adults living in a low-income independent residence facility and their own homes in the community. Specifically, 30 older adults were offered the opportunity to participate in a feasibility study of different components of Activate for Life treatment targeting balance and physical strength (Otago Exercise Program), breathing retraining (Gentle Yoga and Yogic Breathing), and mental health . Three treatment combinations were compared in a randomized repeated measures design to determine if adding components to the existing Otago program were feasible and if this affected patient satisfaction. Arm1: the Otago strength and balance program alone (n = 10); Arm 2: Otago + Gentle Yoga and Yogic Breathing (n = 10); and Arm 3: Otago + Gentle Yoga and Yogic Breathing + Behavioral Activation (we named this combination ‘Activate for Life’ n = 10). Dependent measures included recruitment rate, session completion characteristics, and satisfaction with the program. Overall, study and treatment components proved feasible, and participants reported high satisfaction with all 3 Arms.


Retrograde popliteal access has long been established as an alternative to the antegrade approach to occlusive lesions in the superficial femoral artery (SFA). However, early reports with high complication rates  reduced enthusiasm for this technique. In recent years, with the development of thinner sheaths and low profile angioplasty devices, retrograde popliteal access has resurfaced as a viable technique, mostly in combination with or after failure of the more classical antegrade approach. In this retrospective study, we will report the safety and efficacy of the retrograde popliteal approach in the treatment of superficial femoral artery chronic total occlusions, in 13 consecutive patients between January 2017 and January 2021. The results showed 100% successful puncture of the popliteal artery and 100% successful recanalization and stenting of the superficial femoral artery with a total of 2 complications related to the puncture site and zero periprocedural mortality. In conclusion, the retrograde popliteal approach appears to be an effective and safe alternative to the common SFA complete total occlusion (CTO) treatment approach. Endovascular procedures are having an increased role in the treatment of peripheral arterial disease . InfrainVarious sophisticated devices have been developed for subintimal reentry, but their high costs have prohibited their widespread use . ConsequThe aim of this study is to assess the safety of retrograde popliteal access for SFA lesions, as well as rate the procedural success. This was defined as successfully puncturing the popliteal artery as well as angiographic success.This technique was first described years ago by Tønnesen et al., with results of 50 angioplasty procedures via the popliteal artery. It was described as especially suited for lesions close to the takeoff of the superficial femoral artery .Since then, it has diminished in popularity owing to complications, such as dissections, vessel ruptures, arteriovenous fistulas, pseudoaneurysm, and hematomas , 9.Trigaux et al. described the relationship between the popliteal artery (PA) and the popliteal vein, and the safest technique to puncture the PA. Several guidance methods for PA puncture have since then been reported, notably, by ultrasound (US) guidance and digital subtraction angiography (DSA) .This is a case series of 13 patients who underwent percutaneous retrograde popliteal access (RPA) for the recanalization of SFA occlusions.All patients gave written informed consent before undergoing the procedure. All procedures were done in a dedicated angiosuite under sterile conditions.At first, all patients had a trial of recanalization using the classical approach through the common femoral artery, using either the antegrade ipsilateral approach or the retrograde contralateral approach, and RPA was only used after failure of crossing the lesion.st attempted recanalization, while 7 (54%) were done in the supine position where femoral access and retrograde popliteal access were done.Recanalization using the RPA was done either at a separate scheduled procedure where the patient was put in a prone position to facilitate the popliteal puncture, or in the same setting and the patient was kept in the same supine position but with the knee slightly flexed and externally rotated. In our series, 6 patients (46%) had their procedure done in the prone position in a separate procedure than the 1Popliteal puncture was done under US guidance. The popliteal fossa was examined, and the popliteal artery and veins were identified using the color Doppler and compression maneuver.Local anesthesia was injected, followed by puncturing the popliteal artery in an area where the popliteal vein was not superimposing. Introducers used ranged in size between 4 F and 6 F depending on whether recanalization, angioplasty, and stenting were all done from the popliteal access or just the concomitant femoral access was used for stent deployment.All patients received 5000 IU of intravenous heparin.Recanalization was done using a hydrophilic guide wire and either a 4 F or a 5 F support catheter. Intraluminal recanalization was tried at first, but subintimal recanalization was used when inevitable.Prestenting balloon dilatation was done in all cases followed by deployment of nitinol self-expandable stents covering the entirety of the diseased vessel with at least 5 mm of disease-free vessel coverage at the proximal and distal vessels. When more than 1 stent was used, stents were overlapped by 10 mm. Poststenting balloon dilatation was done for full stent expansion.Completion angiography was done in all cases to control for adequate flow through the recanalized SFA and popliteal artery and to rule out any distal embolization.Postangioplasty, the popliteal access was managed with either a minimum of 15 minutes of manual compression followed by compressive dressing for 12 hours or the deployment of an extravascular closure device followed by 10 minutes of compression and a compressive dressing for 12 hours.Periprocedural dual antiplatelet therapy was initiated with aspirin and clopidogrel for at least 1 month, followed by aspirin alone indefinitely.Technically successful PA puncture was considered when the popliteal artery was punctured with retrograde passage of the guide wire. Technical success was defined as successful guidewire passage through the SFA occlusion  from the retrograde PA approach and <30% residual stenosis after the intervention.Complications, should they occur, were death, pseudoaneurysm, hematoma, AV shunt, neuropathy, and acute thrombosis.From January 2017 till January 2021, in a single center, 13 cases had chronic SFA occlusions that underwent angioplasty through a RPA.n = 13) had concomitant coronary arterial disease, 77% (n = 10) were smokers, 92% (n = 12) had diabetes mellitus type 2, 100% (n = 13) had dyslipidemia and hypertension, and 69% (n = 9) had chronic kidney disease.Of the 13 cases, 8 (61.5%) were males with an average age of 77.6 ± 7.5 years; 10 (77%) of the cases presented with critical limb ischemia with 9 (69%) of the patients already presenting with tissue loss; the remaining 3 patients had severe claudication limiting their daily lifestyle. The majority of the patients presented with extensive comorbidities that can be seen in ) and duplex ultrasound, as well as a diagnostic angiography to outline the anatomy of the vessels and define the characteristics of the lesions, seen in All patients had baseline physical examination followed by ankle-brachial index (ABI) measurements  and duplIn our series, all lesions were classified as TASC II C or D lesions, with an average lesion length of 247 mm ± 30 Figures .n = 11) having severe calcification.Lesion and procedural characteristics are summarized in n = 13) successful popliteal artery puncture and access, as well as 100% (n = 13) successful SFA recanalization and stenting  of the cases were done in the prone position after failure of recanalization through a femoral access in the supine position at a previous procedure, while 54% (n = 7) were done in the supine position, with concomitant femoral and retrograde popliteal access. Introducer size used for the popliteal access was at a mean of 5.6 F ± 0.7 with a labelled stent diameter at a mean of 6.125 mm ± 0.6.In our series, we had 100%  patients had deployment of a vascular closure device at the RPA with an extravascular plug placement.23% (n = 2) of patients developing a complication at the popliteal access site.Complications at the access site are summarized in In one case, a hematoma was seen on follow-up ultrasonography, with no sign of an AV shunt or pseudoaneurysm. This hematoma needed no further intervention except for serial US until resolution. In another case, the incorrect deployment of the vascular closure device led to the intravascular deployment of the extravascular plug. This caused an acute thrombosis of the vessel that was discovered postprocedure and promptly treated by a subsequent femoral-popliteal bypass.Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) can be useful for completing subintimal recanalization when there is failure to reenter the distal true lumen from an antegrade approach or when there is limited distal target artery available for reentry . In thisRecommendation for treatment of TransAtlantic Inter-Society Consensus (TASC) C and D lesions has been traditional bypass surgery , 13. HowIn our series, 13 patients had CTO of the SFA classified as TASC C and D lesions, of which 10 presented with critical limb ischemia. All of those patients failed endovascular treatment by femoral access, and no surgical treatment was done, due to either surgical contraindications or patient preference despite adequate explanation.Our results were encouraging with excellent technical success and significant improvement of ABI ; only onComplications at the access site can occur during the arterial access where puncture of the popliteal vein can result in an AV shunt or during hemostasis, at the end of the procedure, where failure of complete hemostasis can result in pseudoaneurysms or hematomas. To decrease the risk of complications related to the arterial puncture, all popliteal arterial access was done under ultrasound guidance. Both sonographic and fluoroscopic methods (roadmap technique after contrast medium injection) have been utilized successfully for popliteal artery puncture, with a recent predominance for puncturing the popliteal artery with the patient in the supine position , 23.In our case series, a vascular closure device (VCD) was used in 3 patients since closure devices were an attractive alternative to manual compression. We chose an entirely extravascular VCD because of the smaller size of the popliteal artery when compared to the common femoral artery and since the ExoSeal VCD has been found to be used successfully and with a low complication rate in puncture sites other than the CFA , 24, 25.In our experience, there is a big advantage in having the patient in the supine position during the popliteal puncture. Patients in the prone position tend to feel fatigue, more so in obese patients and patients with impaired respiratory function . The bidThis is a retrospective study with a small number of patients evaluated. Further research is needed with larger prospective studies.In conclusion, the development of thinner sheaths and low-profile angioplasty devices made retrograde popliteal access a safe and successful technique, which extends the ability to perform endovascular interventions in complex SFA lesions, where the antegrade approach has failed.We learned from our study that keeping the patient in the supine position and having a concomitant femoral and popliteal access is better than the prone position, with only a retrograde popliteal access, as it is more comfortable for the patient and easier for the physician, not to mention the ability to decrease the sheath size used at the popliteal access with the supine position as the popliteal artery access would be used for crossing the lesion only, and the remainder of the procedure, balloon dilatation and stent placement, would be continued from a femoral access.Randomized controlled trials which evaluate long-term patency after this specific type of approach have yet to be designed.


Significance was set at p < 0.05. Findings from the current study have implications for designing and conducting a process evaluation of complex healthy lifestyle programs with adolescents in schools. Additional training of peer educators may be needed to enhance program delivery. To date, there is limited published literature on process evaluation of adolescent health promotion programs. In this paper, we describe the methods and results of PAWS Club process evaluation over 2 years of implementation to compare the effectiveness of delivery by peer and adult leaders. PAWS (Peer-education About Weight Steadiness) Club was a 12-week healthy lifestyle program, delivered to 6th and 7th graders by peer and adult educators, using cluster randomized controlled design. Peer educators were 8th graders in the program schools and adult educators were staff/teachers in the program schools. Trained university students filled out fidelity logs at each session led by peer and adult educators to assess program delivery. The fidelity logs included questions to collect information about the number of participants, duration of the session, percent of activities completed, and if lessons started on time, lesson objectives were clearly stated, lesson objectives were emphasized, demonstrations were visible to participants, all activities were completed, the leader was familiar with lessons, the leader maintained an appropriate pace, the leader kept participants on track, and the leader asked if participants had any questions. Adult educators had a higher mean performance for all questions compared to peer leaders. Significant differences were observed for emphasizing lesson objectives ( Obesity in childhood and adolescence is a serious public health challenge due to its associated adverse health and social consequences ,2. DietaThe built environment and organizational, social, and communication frameworks of schools make them an ideal setting to deliver obesity prevention programs to school children and their families . In the Process evaluation allows researchers to assess whether interventions are delivered as intended, identify factors affecting implementation, and add context for interpretation of outcomes ,13. FideCommonly used tools for process evaluation include checklists or logbooks, interviews, focus groups, behavioral observation, and the use of administrative data including attendance or case records ,20. StudThis paper describes the results of a process evaluation undertaken to compare the fidelity of the PAWS (Peer-education About Weight Steadiness) Club intervention delivered by peer or adult educators over two years of implementation in four different schools in Eastern Illinois. The PAWS Club was a healthy lifestyle intervention implemented as an afterschool program in middle schools. The 12-week intervention focused on promoting healthy eating, physical activity, and cooking skills to prevent and reduce childhood obesity. The program was grounded in Stages of Change Learning Theory, guided by Social Cognitive Theory (SCT), and delivered by either peer or adult educators. Peer educators were 8th graders in schools, and adult educators were recruited from the staff/teachers in schools. Both peer and adult educators attended twelve sessions of training conducted by the program coordinator and practiced all teaching and hands-on activities at those sessions. The peer-led group of participants was taught by the peer educators and the adult-led group was taught by the adult educators. Outcome data were collected from participants at baseline, after the 12-week program, and 6 months later. Key outcome variables included changes in basic culinary skills, food, and physical activity behaviors, body weight, body mass index percentiles, blood pressure, and SCT mediators of behavior change . In addiThe aim of this paper is encompassed in three objectives for this study: (1) to present results of the PAWS Club process evaluation, demonstrating fidelity, quality, and completeness of delivery; (2) to compare process evaluation results between peer-led and adult-led groups; (3) to discuss PAWS Club outcome evaluation results in light of the process evaluation results.The PAWS Club study investigators developed separate fidelity logs for each of the 12 sessions of the program for collecting data regarding process evaluation. These logs were reviewed and assessed for face and construct validity by the PAWS Club research team. Fidelity logs were succinct and easy to comprehend to maximize completion. Each fidelity log had questions asking if: (1) Lesson started on time; (2) Lesson objectives were clearly stated; (3) Emphasized regular physical activity and healthy weight maintenance; (4) Demonstrations were clearly visible to participants; (5) All activities were completed; (6) Leader was familiar with lesson; (7) Leader maintained an appropriate pace; (8) Leader was able to keep participants on topic/task; (9) Leader asked if participants had any questions, and (10) Lesson ended on time. The response options for each of the 10 questions included yes, no, and open-ended comments ,13. In aUniversity students from the nutrition, kinesiology, and human development departments at the University of Illinois at Urbana-Champaign completed a 16-week rotation with the PAWS Club program to gain experience with program delivery. They assisted with process evaluation by completing fidelity logs for each session they observed. A total of 23 university students rotated with the PAWS Club program, such that 3–4 university students engaged with the project each fall–winter and spring–summer term. Upon recruitment, the university students were given the PAWS Club manual with lesson plans and fidelity logs for all 12 sessions. To ensure inter-rater reliability, the PAWS Club research coordinator reviewed the manual with the students and trained them regarding the completion of fidelity logs for each of the sessions they observed. The university students filled out the fidelity logs throughout each wave of the 12-week PAWS Club program intervention for peer- or adult-led groups separately from 2015 to 2017. Only one fidelity log was filled out for each group of participants led by either the peer or the adult educators. After completing the 12-week rotation, university students returned completed fidelity logs to the research coordinator. Information from the fidelity logs was entered into an excel spreadsheet and checked for accuracy and completeness. If a fidelity log had four or more missing responses, those logs were excluded from data analyses (<10% of fidelity logs).Fidelity logs were developed to assess the reach/dose (proportion of participants who received the intervention/amount of intervention delivered), fidelity (extent to which a complex intervention is implemented as intended by the developer), quality (program providers’ confidence and enthusiasm in delivering the program components), and context (aspects of the intervention setting and mode of delivery) of each of the program’s 12 sessions ,18,24. TWe used structured observations and prioritized collecting quantitative data, consistent with the MRC’s recommended steps for process evaluation of a randomized controlled trial . The PAWp < 0.05. For qualitative information from open-ended comments, summaries of responses for each question are compiled in Table 4 to capture the university students’ perceptions about each of the ten questions assessing fidelity and quality of program delivery. These brief summaries illustrate the impact of context on program delivery.For quantitative data, percentages were calculated separately for peer- and adult-led sessions for each of the 10 questions with yes/no response options and means calculated for the three questions assessing dose/reach (Tables 1 and 2). A Mann–Whitney U test was conducted to assess if there were significant differences between the peer-led and adult-led sessions for the 10 program fidelity and quality questions (Table 3). A summative score was calculated for each fidelity log for peer and adult educators for all 10 yes/no response option questions to determine overall fidelity and quality of implementation . For calA total of 23 university students completed fidelity logs for each of the 12 sessions of the PAWS Club program delivered to a total of 109 adolescents between 2015 and 2017. Each university student assessed program delivery by either peer or adult educators to a group of 4–6 adolescents. University students completed a total of 145 fidelity logs for peer-led sessions and 130 fidelity logs for adult-led sessions. On average, each of the 12 PAWS Club sessions was evaluated 23 times, 12 times for peer-led and 11 times for adult-led sessions congruent with the number of participant groups. Peer/adult educators, school staff, and research staff were not asked to complete fidelity logs to minimize the impact on intervention delivery. Process evaluation data are collated and enumerated in mutually exclusive tables for the peer-led and adult-led sessions .A percentage  was calculated for each evaluation indicator for each lesson and then an overall average percentage was calculated for each evaluation indicator for all 12 sessions. Process evaluation results of peer-led sessions are detailed in p = 0.005), making demonstrations visible to participants (p = 0.031), being familiar with the lesson plan (p = 0.000), maintaining an appropriate pace (p = 0.000), keeping participants on track (p = 0.000), and asking if participants had any questions (p = 0.000). Thus, all four quality scores and two fidelity scores were significantly different between the peer- vs. adult-led sessions. For the summative score, the average level of implementation for the peer-led sessions was 6.26 (medium) and adult-led sessions was 8.34 (high). For previous studies calculating a summative score, 8 and above was characterized as a high level of implementation and 6 as medium level [p = 0.000).For the three questions assessing dose/reach, duration was longer for adult-led sessions, and the ratio of leaders to participants was higher for the peer-led sessions . For theum level ,13. MannUniversity students’ notations on fidelity logs supported the quantitative results of process evaluation. For all six questions with significant differences between peer and adult educators, qualitative comments provided additional information about the contrast in program delivery by peer and adult educators . These cIn this paper, we have presented in detail the methods and results of process evaluation conducted throughout PAWS Club program implementation. Overall, the program achieved medium to high implementation, and 80% or more of the program activities were completed in both peer-led and adult-led sessions. The adult-led sessions scored higher for all 10 fidelity and quality evaluation indicators as compared to peer-led sessions. Significant differences were observed between the peer- and adult-led groups for all four quality indicators and two fidelity indicators. Another noteworthy finding was that for adult-led sessions, all 10 fidelity and quality indicators scored in the high implementation range; whereas for peer-led sessions, two were in the high category, seven in the medium range, and one in the low implementation category. Lastly, the summative score for adult-led sessions was in the high implementation range and for peer-led sessions in the medium implementation range. Previously published process evaluation studies suggest that training of program leaders, ongoing support from the research team, and access to a program manual promote compliance with program delivery plans ,22,26,27Many previous childhood obesity prevention trials have either not conducted comprehensive evaluations of program implementation or have not reported methods and results of process evaluation in detail . Even thThe MRC has delineated three core aims of process evaluation: (1) evaluation of quality and quantity of program implementation; (2) explanation of theoretical connections between the program delivered and its intended effects, and (3) assessment of the impact of contextual factors on the delivery and outcomes of the program . Within Our study results indicate that adult-led sessions scored higher than the peer-led sessions for all dimensions of fidelity and quality, with more significant differences with peer leaders for the quality constructs. Results of our study underscore the importance of conducting comparative process evaluation for both peer-led and adult-led groups to allow for interpretation of the intervention outcomes and for identifying best practices and barriers to implementation of such programs. Findings from the PAWS Club outcome effectiveness trial indicated that both the peer-led and adult-led groups showed significant changes in dietary intake by reducing caloric intake . The medWe collected process evaluation data for all 12 sessions of the PAWS Club program, for each wave of implementation from 2015 to 2017, for both peer-led and adult-led sessions in all four schools. Thus, a large sample of fidelity logs was available for analyses and inferences . To imprThe validity and reliability of fidelity logs were not assessed fully, as there is no current gold standard tool for fidelity assessment and most tools are intervention specific. However, we did establish face and construct validity of the log through confirmation with experts. Secondly, the peer and adult educators were aware that the university students were observing and completing implementation evaluation forms during the session, which may have influenced the delivery of sessions. However, the fidelity log results suggest that this did not happen, as the educators were not privy to any details on the fidelity log and the university students did not give any direct feedback to the educators. Thirdly, we used a single instrument, fidelity logs, to assess program fidelity and quality, which does not allow for data triangulation to confirm the findings. However, there was congruence between quantitative and qualitative data collected via fidelity logs. Process evaluation using high quality and multiple resources may not always be practical in real-world settings, as researchers need to balance the quality of measures used for process evaluation with participant and researcher burden . Lastly,Methods detailed in this paper will add to the process evaluation literature. The PAWS Club process evaluation strategy builds on the methods and findings of comparable interventions and assists with refining the methods and frameworks for future process evaluation efforts. Our study results indicate that both peer and adult leaders delivered the program with medium to high fidelity, but the quality of intervention delivered by adult leaders was significantly better than by peer leaders. As the program fidelity was maintained for both groups, the study effectiveness findings are a reflection of the program’s potential for positive changes. Moreover, our work highlights the importance of assessing the quality of program delivery, as some study effectiveness outcomes might have been influenced by the quality of intervention delivered. Future studies can assess if the quality and fidelity of programs can be improved by providing additional training to peer educators, providing more detailed lessons to peer educators, providing ongoing training, and allowing peer and adult educators to deliver the program together. To fill gaps in the literature, more studies need to be published to build the evidence base for valid, reliable, high quality, and feasible process evaluation tools and methods that can be used for obesity prevention programs. Such work will elucidate the relationship between program fidelity and program outcomes, which will aid in understanding the level of fidelity required for programs to be effective. Lastly, researchers need to adopt a multifaceted approach, encompassing outcome and process evaluation, to comprehensively evaluate complex obesity prevention programs.


All the individuals who applied for a marriage license during the years 2009 and 2020 were covered by the program. A network of four reception centers in the Ministry of Health facilities and one Premarital Diagnostic Laboratory (PDL) in Maternity Hospital were involved in performing all investigations for hemoglobinopathies. The total number of individuals identified with β-thal trait was 5861 (2.12%), while 22 individuals (0.008%) were diagnosed with β-thal disease. A total of 5003 subjects (1.81%) were carrying the Sickle cell trait, while 172 subjects (0.062%) had Sickle cell disease including Sickle cell anemia (SCA). Results showed that the program succeeded indeed in preventing the marriage of 50.4% of risky couples by issuing unsafe marriage certificates. Yet more efforts are needed to improve the program’s main objective of decreasing high-risk marriages. In particular, health care systems should be ameliorated in a way to intensify the counselling mechanism for the high-risk couples, strengthen the awareness of the general population and induce earlier age screening policies.This study aims to estimate the prevalence rates of β-thalassemia and Sickle cell disorders in the adult population screened ( Hemoglobinopathies are one of the most common monogenic inherited blood disorders affecting the structure, function or production of hemoglobin molecule. Hemoglobin disorders such as β-thalassemia and Sickle cell disease (SCD) affect millions of individuals worldwide. They are characterized by severe clinical heterogeneity, complicating patients’ management and treatment. β-thalassemias are clinically often associated with profound anemia, jaundice, expanded bone marrow volume, siderosis, cardiomegaly and splenomegaly. A thalassemia patient requires multiple repeated blood transfusions and hence subjected to peroxidative tissue injury due to secondary iron overload . Sickle Preventive screening programs such as PMS have been implemented in several countries worldwide, and aim to identify carriers of the hemoglobin disorders in the population to assess the risk of having children with a severe form of disease and reduce the prevalence of β-thal and SCD . CountriIn Kuwait, a mandatory premarital screening program was initiated in 2009 and involves screening individuals intending to get married for β-thal, SCD, Human Immunodeficiency Virus (HIV), Syphilis and Hepatitis B and C. In this study, we present the findings of eleven years of PMS in Kuwait regarding β-thal and SCD, resulting in an estimation of the prevalence of hemoglobinopathies in the entire adult population as well as the effect of the program among high-risk couples. The prevalence rates for β-thal and SCD trait among premarital couples was found to be 2.12% and 1.81%, respectively, indicating a great need to reduce the burden of these hemoglobinopathies in Kuwait by successful and efficient premarital screening program.In September 2009, H.H. the former Emir (Sabah Al-Ahmad Al-Jabeer Al-Sabah) passed the decree of the Premarital Screening Law No.31/2008 which involves mandatory screening of Kuwaiti individuals intending to get married. This article reports the impact of eleven years of premarital screening on the prevalence of hemoglobinopathies in Kuwait. The screening program offers free testing/counseling for local couples applying for a marriage license in Kuwait and aims to reduce the number of marriages between couples who are found to be affected or carriers of the aforementioned diseases.The first step of the PMS program was the referral by the Legal Authentications Administration (Ministry of Justice). Prospective couples were directed to one of the four Ministry of Health (MOH) designated Premarital Reception Centers: Sabah area (Main Center), Ahmadi PMS , Farwaniya PMS  and Jahra PMS . Demographic information  was collected by these centers which were equipped with medical personnel and supplies. Blood samples were collected in tubes containing EDTA anticoagulant and plain tube without additives/anticoagulant to be sent to the Premarital Diagnostic Laboratory (PDL) in Maternity Hospital, which is the only center authorized by MOH to perform all investigations for hemoglobinopathies and syphilis. The screening protocol (screening cascade is shown in All the couples found to have a low risk were issued compatibility certificates (“Safe marriage”). On the other hand, when both partners were found to be positive for Sickle cell trait/disease and/or thalassemia trait/disease and/or other hemoglobin variant trait/disease they were designated as high risk couples and referred to a genetic counseling clinic. There, the counselor would explain the situation to both partners and issue a certificate of incompatibility (“Unsafe marriage”). Although the primary aim of counseling was to avoid high-risk marriages, the couples were free to marry regardless of their test results as long as the female was above 21 years old age.The study was approved by the MOH ethical committee with the code of 2019/1151. The privacy and rights of the individuals were protected by appropriate protocols; no patient identifiers were used in any part of the study.p value ˂ 0.05 was accepted as statistically significant.The dataset was thoroughly examined for integrity, inaccuracies, inconsistencies and invalid entries. Necessary changes were made to correct data errors and recode variables as needed. Subjects’ data were recorded in a questionnaire and analyzed using SPSS v25 for Windows . Continuous variables were summarized with descriptive statistics . Categorical variables were summarized with frequency counts and percentages within each category, or between levels of a category as appropriate. The prevalence rates were calculated separately for disease and carrier statues within each condition and estimated as the number of affected individuals divided by the number of tested individuals per 1000 population. A During the 11-year reporting period (August 2009–August 2020), a total of 275,819 individuals were screened within the program, with the majority (58.96%) of program attendees in the 25–34 year-age group. Almost 90% of the individuals were holding Kuwaiti nationality (KN). The female:male ratio was 51.0%:49.0% and 76.32% of the candidates applied to the premarital program for their first marriage. Most of the participants (53.06%) had a university degree or above. The overall study population of 275,819 individuals approached the four different premarital screening centers. The highest proportion of screened KN individuals was from the Ahmadi region (35.62%), followed by Sabah (25.09%), Farwaniya (17.51%) and Jahra (11.60%) . On the The total number of individuals identified with β-thal trait was 5861 (2.12%), while 22 individuals (0.008%) were identified with β-thal disease. β-thalassemia prevalence varied by region; 17.97% and 16.84% of β-thalassemia trait cases were from Sabah and Ahmadi regions, respectively, followed by Farwaniya (8.12%) and Jahra (5.65%) regions. Regarding Sickle cell hemoglobinopathies, 5003 subjects (1.81%) were carrying the Sickle cell trait, while 172 subjects (0.062%) had Sickle cell disease including Sickle cell anemia (SCA). The rates of Sickle cell trait were highest in the Sabah region (16.45%) followed by Ahmadi (13.52%), Farwaniya (6.22%) and Jahra (1.04%) regions .In the 11-year program period, the average prevalence rate per 1000 for β-thal and Sickle cell trait was 21.1 and 18.1, respectively. As shown in Following β-thal and Sickle cell traits, 747 cases of Hb D trait (0.27%), 145 cases of Hb E trait (0.053%) and 49 cases of Hb C trait (0.018%) were the most prevalent ones. The overall prevalence rate of Hb H disease during the 11-year period was 70 cases (0.025%), which are identified by the presence of Hb H inclusion and Hb H peak in HPLC that most likely represent a deletional type of Hb H disease followed by Hb D disease (0.010%) and Hb C disease (0.001%). Almost 0.1% of the screened samples showed an unknown peak in HPLC analysis, or a band with altered mobility in alkaline electrophoresis analysis; some of these samples were referred to the Molecular Genetics Unit.All abnormal cases of hemoglobin variants recorded during the screening program in the different PMS centers are shown in Our program also involved screening all the samples with low MCV and MCH values to be tested for serum ferritin; 7.86% of the total screened individuals were diagnosed with iron deficiency anemia. Of these, 94.6% were females; a gender distribution of the total cases is shown in Of all couples, 137,744 (98%) were issued a safe marriage certificate, 1485 (1%) were issued an unsafe marriage certificate and 1064 (1%) were not issued a marriage certificate and their marriage was stopped; of these who were issued unsafe certificates, 358 (24%) were due to hemoglobinopathies in both partners.The other group with no marriage certificate (1064 couples) can be divided into three groups. First, for 387 cases (36%) the female was under 21 years of age; out of those, 144 were diagnosed with a blood disease. Second, for 510 cases (48%) there was a disagreement between couples for unsafe marriage; of these, 168 disagreed to proceed due to the risk of hemoglobinopathy. The remaining third group, 167 cases (16%) involved other non-hematological causes. Overall, it was noticed that there is an increasing trend towards disagreement between couples over the 11 years of the screening program .In order to study the effect of Kuwait Premarital Screening (KPMS) program on the future prevalence of hemoglobinopathies and whether it has a preventive and discouraging effect, from the available data the total unsafe results due to hemoglobinopathies in both parties in couples during the last 11 years was found to be around 670 couples with unsafe results. This included the following group: A total of 358 couples issued unsafe certificates, of which 332 couples (49.6%) proceeded to marriage despite the risk and 26 (3.8%) couples decided to stop the marriage; data supplied by the Ministry of Justice. A second group included 312 couples (46.5%) who stopped their marriage because of hemoglobinopathies either by law (144 couple) or disagreement (168 couple). Thus, the KPMS program succeeded to prevent and discourage around 50.4% of those couples with unsafe hemoglobinopathies results to proceed with the marriage, as shown in Here we present the first published data from Kuwait Premarital Screening and Genetic Counseling Program (PMSGC) of hemoglobinopathies, reporting the prevalence and distribution of β-thal, SCD and other hemoglobinopathies in Kuwait in the period August 2009–August 2020. One strength of the Kuwaiti PMSGC program is the fact that it was made mandatory. This claim is derived by the cultural behavior of the population when adapting to new rules and changes to the habits that have been practiced or passed on from one generation to the next. Marriage is a culturally sensitive subject that follows traditions and cultural/religious rules, thus unless a mandate on inserting science in the process is put in place the society would have never adhered to the new rules on pre-testing. Additionally, the program offers free pre-testing for all local individuals (both partners are screened even if only one is Kuwaiti) seeking to get married. The program has a wide coverage involving around 2% of the total population every year, and provides valuable data that contributes to a more accurate assessment of the prevalence of hemoglobinopathy disorders in Kuwait. The results reveal a prevalence of β-thalassemia (2.12%) and Sickle cell trait 1.81%), comparable to those reported in a study conducted in the Gulf Cooperation Council 1%, compa. RegardiOne of the important observations of this study is that 22 cases of β-thal major applied for PMS testing, which reflects a good standard of management of the β-thal major program in Kuwait for pediatric and early adulthood. On the other hand, it is worth mentioning that those 22 cases probably are not reflecting the actual number of adult patients with β-thal major in Kuwait.The Kuwait PMSGC program was successful in preventing and discouraging at-risk marriages which will contribute to reducing the prevalence of affected offspring, especially with the newly implemented program of preimplantation genetic diagnosis (PGD) to be offered for free for high-risk marriages that received an un-safe marriage certificate and planned to continue proceed with their marriage. One of the primary goals of the Kuwait PMSGC program is to identify couples at risk of having a hemoglobinopathy-affected child and to reduce or even eliminate the presence of β-thal and SCD in newborns. However, achieving this goal is complicated and dependent on the presence of other preventive programs such as national prenatal screening and abortion, the implementation of which is restricted by ethical, religious, and societal values ,13. EvalIn addition to screening programs, health education is of great importance to achieve the set goals and should be focused on younger age groups. Studies among university students showed that knowledge of the PMS program, even though they were aware of the program, was low ,15. OrgaOn the other hand, we found many factors play a major role in limiting the success of PMSGC in decreasing marriage among at-risk couples. One of the important risk factors affecting the occurrence of β-thal and SCD disorders is consanguineous marriages, in such cases the recessive genes will be able to survive and concentrate and retain the related diseases for generations. Consanguineous marriages have been described as the major reason for the higher prevalence of autosomal recessive disorders in populations of the Middle East and North Africa (MENA) region . Indeed,Together, the results show that education in the hemoglobinopathy prevention program and genetic counseling are still to be evaluated in detail. Knowledge and awareness of the PMSGC can be improved through relevant educational programs in schools and universities, as well as by governmental campaigns, especially on social media and the internet—the most efficient communication platforms nowadays. For example, using educational videos employing thalassemia patients might increase the awareness of the disease. With the collaboration of the government and non-government organizations, leaders in the community, religious leaders, parent organizations at schools and local health personnel, the program will develop community awareness of hemoglobinopathy diseases, which will increase its efficacy. The high morbidity related to hemoglobinopathies, chronic transfusion requirements, the high cost of chelating, organ damage, painful crisis, as well as the limited availability of stem cell therapies underline the importance of premarital screening programs.Population screening programs for hemoglobinopathies have been implemented in many countries ,25,26 foGenetic methods are in constant development, and preimplantation genetic diagnosis (PGD), carried out on embryos, could be an efficient tool in screening programs. PGD allows (at-risk) couples to exclude affected embryos and use only the healthy ones, and in this way, help decrease the prevalence of genetic disorders and their associated diseases. With PGD, couples avoid the trauma of leaving their partner as well as the ethical dilemma of terminating an affected pregnancy . In this light, it is important to develop public health campaigns to highlight the different options. The resulting awareness may also promote a change in the governing laws of some countries, allowing at-risk couples to have children as they now have a viable, safe, successful, and cost-effective option to have unaffected offspring. Several studies have shown that integration of prenatal diagnosis options, such as PGD in prevention programs for hemoglobinopathies, are well established and successfully decrease Sickle cell and β-thalassemia prevalence ,28,29. KStudies on Thalassemia and Sickle cell diseases have been covered in the literature since decades. Despite the existing efficient diagnostic and medical treatment strategies, lessening the burden of the diseases will always critically depend on prevention. There are several important components to evaluate a screening program, such as feasibility, access, cost, and, most importantly, measuring the effectiveness on the outcome of the diseases. Since Kuwait has a relatively small population (around 1.5 million inhabitants) to be screened through a PMS program, we preferred to have a centralized laboratory in order to maintain accuracy, reliability and validity as good as possible. Our study represents around 20% of the population and has new implemented strategies specific to the Kuwaiti people. In particular, we wanted to investigate the effect of the marriage prevention law for females less than 21 years old who got involved in an unsafe marriage. Our current study reveals the areas of weakness in the Kuwaiti PMS program and offers guidelines to health care providers to improve the primary aim of counseling: to prevent diseases by avoiding high-risk marriages. We believe the results and conclusions from our study will help involved parties to set up effective disease management strategies.In conclusion, this study provides an update on recent trends in the occurrence of β-thal and SCD over a 11-year period in Kuwait (2009–2020). The obtained data will set the stage for continued monitoring of hemoglobinopathy disorders and will facilitate future evaluation of the effectiveness of existing preventive programs. Moreover, it will enable decision makers to prioritize new programs and implement policy changes. In order to better determine the genetic consequences, the Kuwait PMSGC program will require a longer timeframe, and would benefit greatly from following couples that proceed to marriage as well as following their offspring.


Since the emergence of COVID-19, health care workers and first responders have been at a high risk for mental health symptoms owing to their exposure to the virus and increased work stress during the pandemic. Although interventions exist to address mental health issues following exposure to disasters, emergencies, and humanitarian crises, considerably less is known about web-based unguided interventions to help mitigate the negative impacts of such events. Additionally, in contexts in which emergencies reduce access to in-person care, remote forms of support are critical, yet there are limited studies on the use of such interventions. Evidence-based, easy-to-use, scalable interventions are direly needed for this population.This study aimed to develop and test the feasibility of an unguided electronic mental health program, COVID-19 Anxiety and Stress Resilience Training (COAST), tailored to first responders and health care personnel, based on scientific evidence and empirically based techniques.We developed COVID-19–specific training modules focusing on several domains that are previously reported as key to resilience and stress recovery: self-efficacy, mindfulness, sleep quality, and positive thinking. The program was made available to 702 first responders between May and August 2020, during the COVID-19 pandemic. Sociodemographic, work-, and COVID-19–related information was collected, and psychometric questionnaires were completed. We examined user acceptance and user activity, including module choice and participant feedback.P>.39). First responders who had tested positive and those who had been quarantined were more likely to engage in the program. A click count analysis per module showed that participants used the self-efficacy and mindfulness modules most often, with 382 and 122 clicks, respectively, over 15 weeks. Overall, first responders expressed satisfaction with the program.In total, 52 of 702 (7%) first responders to whom we reached out used the program at least once. COAST use was independent of age, sex, or baseline levels of self-efficacy, mindful awareness, sleep quality, and positive thinking (for all, Engagement of first responders in the multimodule web-based COAST program was feasible and the first responder cohort expressed overall satisfaction with the program. Those in more difficult circumstances, including those in quarantine and those who tested positive, may be more likely to engage in such programs. Further controlled studies could pave the way for efficacy studies and the development of additional modules, including just-in-time interventions or blended interventions combining individual use of an unguided self-help intervention, such as COAST, with subsequent individual psychotherapy for those who continue to experience stress and psychological symptoms. Since early 2020, COVID-19 began to severely impact the daily lives of a majority of the world’s population after a cluster of infections was first identified in China as early as December 2019 . Health With physical distancing and other restrictions in place and a decreased mental health system capacity, calls for increased investment in telehealth and telepsychiatry, as well as other digital mental health solutions, have emerged -11. DigiThis study was designed as single-cohort feasibility study to evaluate a COVID-19 Anxiety and Stress Resilience Training (COAST) program and receive user feedback for future adaptation of our modules. The study was approved by the ethics committee of the philosophical faculty of the University of Zurich. We included first responders who were offered free and unlimited access to the program. The first users and study participants joined COAST in May 2020, and final questionnaires were completed in July 2020. Our analyses encompass an overall period of 15 weeks, during which participants were followed-up during their individual use of the program.COAST comprises 4 intervention modules to increase resilience to stress due to the COVID-19 pandemic. These modules were made available on a website for free and self-paced perusal by our participants. The self-paced option appeared relevant to adapt to the busy schedule of health care workers during the pandemic. All 4 modules are standalone modules, targeting (1) self-efficacy, (2) sleep quality, (3) mindfulness, and (4) gratitude and positive reframing. The choice of these module topics was based on previous reports that identified them as useful targets to improve resilience to stress and adversity -28 and oEach module contained explanations and mini-interventions that users could engage with in their daily lives, based on previous results and protocols and adapted for web-based use. The self-efficacy module was based on the findings that activating autobiographic memories of perceived self-efficacy can help strengthen clinically relevant factors for tolerating distress  and promDecisions in favor of shorter interventions and questionnaires were taken considering previous reports highlighting the occasional low participation rates of health care workers and first responders and their high workload .We recruited first responders from Schutz & Rettung Zürich, an urban first responder organization that provides first aid services in the Greater Zurich Region. For our study, all 702 first responders in the service, mostly including ambulance workers and fire fighters, were invited to use COAST via email. In total, 52 of them used COAST at least once and were included in the study. The emails contained an invitation to take part in the study, with the purpose of evaluating COAST, and a link to the first set of study questionnaires (baseline) immediately after registration. Furthermore, users were asked to fill in a short questionnaire on the website and were sent reminders to do so. Inclusion criteria were being a first responder at the abovementioned institution, providing consent to participate in the study, and signing up for the COAST program. Participants in the study were offered to enter a raffle and win 1 of multiple vouchers by entering a draw at the end of each external questionnaire. Owing to the exploratory nature of the study and our interest in feasibility indices that are largely independent of sample size, power analysis was not conducted.Participants chose an anonymous username, as the privacy of e-mental health interventions had been previously raised as an important issue pertaining first-responder interventions . They weFirst responder personnel in Zurich, who were interested in engaging with the COAST program, were sent a log-in code for the program via email. The program was delivered via a custom-built university website. For those participating in the study, the code was also used to match program-based data (including user indices and questionnaire items on the website) from the COAST website, with other questionnaires that were sent to participants via a link to their browser, and completed on the internet to ensure anonymity. The users agreed to the use of their data for research purposes when entering their code prior to their engagement with the COAST program and at the beginning of each questionnaire that was filled in outside of the program. All questionnaires were filled in on the internet. A total of 3 reminder emails were sent for questionnaire completion.Participants filled in items embedded in the COAST program as well as separate questionnaires at baseline and at 2 and 4 weeks’ follow-up. Questionnaire completion was not mandatory for participating in the program, and the number of users who completed questionnaires varied. We thus report on different subsamples.α=.95), the 9-item Patient Health Questionnaire [α=.83), the 7-item Generalized Anxiety Disorder Scale [α=.89), the General Self-Efficacy Scale [α=.76), and the Posttraumatic Stress Disorder Checklist of the Diagnostic and Statistical Manual of Mental Disorders (5th edition) [α=.95). An adapted version of the 8-item Client Satisfaction Questionnaire (CSQ-8) [α=.94). We also employed an open question on potential further suggestions to optimize the program .We used standardized, validated, self-reported measures at baseline (questionnaire 1) and follow-up (questionnaires 2 and 3), including the Perceived Stress Scale    (Cronbac (CSQ-8)  was usedWithin the COAST program, sociodemographic, work-, and COVID-19-related questions were completed by the participants. We also included key questions corresponding to each of the target modules obtained from the validated questionnaires. Users were asked to fill in the questions when they started using the program. The questions measured stress (“How nervous or stressed do you feel today?”), perceived self-efficacy (“How much do you currently believe in being able to change things in your life?”), mindfulness (“I am in contact with my experiences here and now”), sleep quality , and optimism or positive thinking (“I have a positive outlook on the future”). Users answered the questions on a scale of 0-10 for stress, self-efficacy, and optimism and 0-3 for sleep quality and mindfulness.Activity scores were calculated over 15 weeks on the basis of the users’ activity in the program, reflecting the number of times individual pages of the program were accessed, including repeated access to the same page.P value of .05 to indicate significance.All statistical analyses were conducted in RStudio (version 1.3.959) for Mac OS . We calcSociodemographic information and scores for in-program questions are displayed in COAST participants were representative in terms of age and sex, for the overall population of first responders from the aforementioned first responder organization, one of the largest urban first responder units in Switzerland, and there were no significant differences between the 2 populations in these variables. However, the proportion of positive COVID-19 tests was higher among COAST participants than among the total sample of 702 first responders in the organization , and 26% of COAST participants reported having been in quarantine at some time, while this number was at less than 1% in the overall first responder population.We found no significant correlations between user activity  and sociodemographic, COVID-19–, or work-related items . Perceived stress and self-reported scores relating to module targets  were also unrelated to user activity scores .Analysis of the click count per module indicated that the self-efficacy module was used the most (amounting to 382 clicks), followed by the mindfulness (122 clicks), sleep (103 clicks), and gratitude (47 clicks) modules. The mean activity score of all users was 15 (SD 11.11) clicks in the program, assessed over a period of 15 weeks. Activity scores ranged 0-54 clicks, while the time spent on the pages was not measured. We detected 3 outliers through visual analysis of the boxplot and excluded them from the activity scores.On average, users were satisfied with the program, as indicated by a mean score of 21.42  on the CSQ-8, representing “mild satisfaction.” Some participants reported difficulties using a web-based format or wanted more visualization of the content. One user was concerned about confidentiality, specifically with regard to work-related answers.We developed an evidence-based, multimodule, web-based COAST program to increase resilience to stress among health care workers and first responders during the COVID-19 pandemic. Here we report data from a feasibility study. COAST was actively used by 52 first responders, which accounts for 7% of the overall first responder group targeted and invited to participate during the COVID-19 pandemic. COAST use was independent of age, sex, and perceived stress, as well as scores mapping on the content of the module target of the respective intervention . First responders who had tested positive for COVID-19 and those who had been quarantined were more likely to engage with the program. This suggests that we indeed may have reached those who are more and directly affected by the COVID-19 pandemic and are potentially in need of an intervention; however, a decreased workload during quarantine may also have contributed to this. Individual users mostly engaged in the self-efficacy memory module, followed by the mindfulness, sleep quality, and gratitude modules. Overall, first responders expressed satisfaction with the program.The use of web-based technology is gaining popularity in mental health care, and these technologies have become increasingly available and affordable, thus lending themselves to implementation in the current first responder setting. Owing to their busy and challenging work environment, we expected to face challenges with regard to the engagement of this population with our program. Previous studies have indeed confirmed that first responders  and mediThe second-most frequently used module was mindfulness. This is in line with recent efforts and success of implementing mindfulness interventions for mental health and other health workers ,54. PrevOnly a subgroup of participants provided feedback through questionnaires, however this could potentially be of use for further program development. Among the points raised by the participants were privacy concerns, which is commonly reported in such populations ,29 and sOur sample was representative of the targeted population of first responders, but the health care system in Switzerland may not be comparable with those in other countries; hence, our findings may not be generalizable to other health care professionals during the COVID-19 pandemic. A country’s economy and socioeconomic differences and the severity of the outbreak in the country have been shown to influence the impact of the COVID-19 pandemic on a population ,18,57. AOur study is not without its limitations. First, while we noted significant interest in COAST among our study participants and subsequent activity in the program among those who registered, the response rate to the external questionnaires (questionnaires 1-3), which we administered to our participants for program evaluation, was low and these could therefore not be evaluated. Future programs should make module use conditional on completion of a core set of questionnaire items. Second, all questions were self-reported questionnaire items and were thus associated with known challenges, including a retrospective response bias, social desirability , and beiDespite these limitations, our study has practical and clinical implications for prevention and intervention science. We reached a small, albeit significant subgroup of first responders who actively used the program and provided feedback. Advantages of such e-mental health interventions include their application and use without physical contact and their scalability, as we can reach more clients than would be possible face-to-face. These are critical features during crises, such as the current pandemic. More controlled studies on developing and adapting web-based interventions tailored to the preferences and needs of health care workers and first responders during the COVID-19 pandemic are needed. Such studies could also pave the way for additional novel interventions, such as just-in-time interventions or blended interventions combining individual use of a self-paced intervention with subsequent individual psychotherapy for those who continue to experience stress and psychological symptoms.