Young women in the juvenile justice system have high rates of prior physical and sexual abuse, substance use and psychiatric disorders. Understandably services usually are based on a therapeutic model to address those needs. Positive Youth Development (PYD) is a complementary alternative format that aims to provide resilience, life competencies, and self efficacy for pro-social actions. We provide a narrative review of PYD programs with a focus on how those relate to youth in closed custody. Sleep and physical activity are two behaviors where incarcerated young women still have personal agency, and we present the additional relevance of those program aspects. We describe methods and findings from a feasibility trial of an existing evidence-based, peer-led program for young women high school athletes used with incarcerated young women. Findings are placed in the context of established models of behavior change. The program was feasible and acceptable, and in this small trial, results demonstrate the format’s potential efficacy. PYD may provide a trajectory of success and assets that could durably assist these young women following incarceration. Young women in the juvenile justice system are a high-risk, vulnerable population largely hidden from public view . Yet, thExisting services for young women in the juvenile justice system are not optimal. The 2015 report, Gender Injustice: System-Level Juvenile Justice Reforms for Girls, noted, “juvenile justice systems are routinely failing to modify promising system reforms for girls or even to collect data on how girls are affected by the problems systems seek to remedy” . EvidencAround 2000, a new paradigm of “Positive Youth Development” (PYD) entered the literature , where tThe Interagency Working Group on Youth Programs is a collaboration of 20 youth-supporting U.S. federal agencies, which defined PYD as an intentional, prosocial approach that respectfully engages youth to recognize, utilize, and enhance their strengths and that promotes positive outcomes , such asPYD programs assist adolescents’ reflection on existing behaviors, selecting personal goals, and pursuing healthy and/or prosocial actions by applying available resources . PYD’s gPYD originally was applied to universal programs for youth in community settings. Perhaps the best known and well-studied PYD format is the 4-H program. A longitudinal evaluation of local 4-H programs involving approximately 4,000 youth from nearly all states, concluded that youth consistently engaged in 4-H were at much lower risk of having personal, social, and behavioral problems than other youth . SubsequPYD programs also can target specific behaviors and actions. Reviews of PYD programs suggest that these efforts can positively impact actions relevant to justice involved youth, including reducing violence, harmful sexual practices and drug use –35. A syYoung women in the juvenile justice system might be especially appropriate candidates for a PYD program. Because of their high prevalence of abuse and risky sexual experiences, their childhoods end early, and the transition to autonomy is accelerated . AccordiIf a critical component of PYD programs is practicing healthy self-regulation, how is that possible in the tightly controlled setting of incarcerated youth? Both adequate restorative sleep and regular physical activity are behaviors amenable to goal setting, behavior change and positive reinforcement for achieving those goals while incarcerated. Each is an action that also may be especially beneficial for young women in the juvenile justice system.Chronic sleep deprivation is common among teenagers, especially young women . In a laGrowing evidence suggests that adequate sleep plays a crucial role in an adolescent’s healthy development, particularly in the regulation of behavior, emotion and attention. The ability to do different tasks simultaneously, such as combining cognitive and emotional tasks, may be particularly vulnerable to the effects of sleep loss. Dahl and Lewin have suggested that multi-tasking is one of the developmental milestones that adolescents encounter, and without adequate sleep that ability is impaired . ProspecSleep has been largely overlooked among researchers interested in adolescent delinquency. In a cross-sectional study using data from the National Longitudinal Study of Adolescent Health, youth who typically slept seven or fewer hours per night reported significantly more property delinquency than those achieving the recommended 8 to 10 hours per night. And those getting five hours or less reported significantly more violent behaviors. Overall getting inadequate sleep was associated with three times the level of adverse outcomes .Detention facilities often have a lights-out time established by staff. However, that does not mean that hours of sleep are established for these young women. They may have the option to read in their beds, and those with insomnia may not go to sleep at lights out. In other settings, improving sleep habits has helped in managing both depression ,54 and PPhysical activity is a second domain in which youth in closed custody can have some control. Participating in regular physical activity yields a wide range of well documented physical and psychological  benefits –62. ReguIn other contexts, physical activity has been a component of PYD programs. Positive Futures is a government-funded PYD physical activity-based intervention in England, where physical education is not part of the routine school curriculum. When assessed, that program favorably impacted at-risk youth by assisting in developing self-esteem, a sense of control, and decision-making skills . The PYDThe starting point for a trial of a PYD informed program among incarcerated young women was an existing evidence-based program for female high school athletes called, ATHENA . ATHENA is a gender specific, peer-led team-centered harm reduction/health promotion curriculum, which is integrated into a school sport team’s usual practice activities. In a randomized trial, it enhanced positive assets  and deterred drug use and other health-harming behaviors –75. SubsFor high school students in general, health or physical education is neither part of the educational “Common Core” nor required for high school graduation ,77, and Despite being designed for high school athletes, the ATHENA curriculum had features that facilitated its use at a correctional facility. Designed to be used by busy coaches during the sport season, it is explicitly scripted, which makes delivery easy for both counselors (filling the coach’s role) and peer-leaders. Both only required orientation to the leader manual and workbook format. Prior research demonstrated that the use of peer-leaders adds to the PYD component, as they provided more relevant examples, improved their communication skills, enhanced self-efficacy and better reinforced content through ongoing contact ,79. In aThe OYA conducted a pilot implementation of OYA ATHENA in one facility with 12 volunteer participants . The sessions used the original ATHENA program for high school athletes with minimal modifications, as this was staff’s preference in order to see how the format worked, while acknowledging the content’s limitations. As originally designed, ATHENA sessions run approximately 45-minutes, and one session is done each week of the sport season for 8 total sessions. Thus, the content could be easily worked into OYA usual activities, and it was completed at the facility in 10 weeks.The trial was designed to assess feasibility and acceptability. Sessions were observed, and participants and staff debriefed after the fourth and final sessions. In addition, before and following the program, participants completed a brief survey containing 27 items related to their knowledge, attitudes and behavioral intentions. The final survey also contained global ratings concerning the program. Individual items used a 7-point Likert agreement scale, and items were combined into risky and healthy attitudes/intentions constructs .Eight participants completed the program, with attrition due to release from the facility for four participants. Survey responses demonstrated a positive program impact. The risky behavior construct was significantly reduced, and a healthy behavior construct increased . Global The peer-led scripted format was acceptable to participants and feasible for delivery. Its focus on active learning and personal goal setting in the context of mutual support embody the structure of PYD programs. However, the ATHENA curriculum scope and sequence were developed from a cross-sectional study of the needs of young women high school athletes . IncarceIn 2016, Bonell and colleagues reviewed 16 PYD programs relating to substance abuse and violence, with the goal of identifying the theoretical underpinnings of programs’ positive outcomes . The synA hypothesized model of a PYD program for incarcerated young women is shown in In summary, although limited in its size and scope, the current feasibility study of the OYA-ATHENA program provides preliminary evidence of the feasibility of and likely value in implementing PYD programs focused on health behaviors within a correctional facility for young women. Others have advocated for applying PYD to the juvenile justice system, suggesting recasting it as “Positive Youth Justice” . Those a


In recent years, the application process for residency education has come under increased review. Step 1 scores will be pass/fail starting in 2022. There has been controversy about grade inflation or the lack of grades altogether at many medical schools. Faculty letters of recommendation have been criticized that they often exhibit implicit bias against women and under-represented minorities or simply are too vague or generic to be useful. Given this difficult landscape, the personal statement carries increased importance to highlight our applicants’ unique motivations and interests. We propose a model that residency and fellowship applicants may employ to craft their personal statements. From personal statement to mission statementIn recent years, the application process for residency education has come under increased review. Step 1 scores will be pass/fail starting in 2022, increasing the challenge for program directors to critically distinguish between talented applicants ,4. FaculWe believe the personal statement is a professional statement. It is your mission statement for why you seek further training. The application is not a prelude to a job interview; it is a request to be considered for further training. Simply put, if you cannot detail why you are applying for a particular residency or fellowship, then do not apply. Your mission statement gives a direction to your planned career. It is the why or the purpose to your direction. Program directors want to see evidence of premeditation, and that you have not arrived by chance or pushed by others. Do not fear any requirement to follow through with specific plans as detailed in your personal statement. All program directors are fully aware that you are likely to change your direction several times during the course of your training. While we do not believe there should be a standard form for the personal statement, we do offer general principles, born from decades of experience in reviewing applications for competitive residency programs in internal medicine, medicine-pediatrics, and specialty fellowships. We believe there are recurrent traps that snag bright and well-intentioned applicants:1. Be careful of the case vignette:  In our straw poll of last years’ applications, approximately two-thirds included a patient vignette. Much like a TV sitcom, there is a predictable pace with a satisfying end. A troubled patient with a difficult diagnosis is isolated from the healthcare team and has a profound impact on your professional trajectory. The experience inspires you to pursue medicine. Our own opinion is to do away with this trope altogether. Maybe this singular experience did move you, but medical education is complex and nuanced. And while this interaction should not be minimized, recounting it does not accomplish the goal of the personal statement. The personal statement is not the proper venue to teach clinical medicine, so even a unique patient presentation detracts from the importance of the central subject, you. As a thoughtful and mature developing professional, the epiphany from a single patient encounter is a worrisome signal of short-sighted thinking when offered as evidence of career selection.2. Avoid explaining the program director’s specialty to the specialty program director: A program director in nephrology knows all about nephrology. They live it. Details about the field in your personal statement does not further your intention of helping clarify your mission statement or make your application stand out. There is an assumption that you enjoy the material, or you would not be applying. Resist the urge to glorify the subject matter to those already convinced.3. No need to rehash your Curriculum Vitae (CV):  In the Electronic Residency Application Service (ERAS®) application, the CV is a clean, concise summary of your experience. There is no need to give a detailed description in your personal statement, as its purpose is not to be a narrative form of your CV. As you describe your mission statement, there will of course be elements of your story that appear in both places. Highlight these special accomplishments or milestones in terms of how they shaped your thinking and moved you towards your goal.4. Minimize your family’s medical history:  Wrapping your commitment to a life-long profession around the death of a loved one or care of a family member implies a poorly thought out emotionally-tainted decision. Certainly, personal experiences influence your decision, but program directors seek clarity that you have not stumbled your way into your decision to apply by happenstance. You are a professional, and this important decision should never be hurried or rash.5. Conclude with a powerful summary:  Never summarize that you are searching for “a supportive teaching program that provides a range of pathology and excellent patient care.” Are there programs that advertise unsupportive faculty with few, homogenous patients, with a narrow range of diseases that are poorly attended? You have done your homework. You would not apply if you think the program lacked essential elements to training. Conclude instead with a powerful and enthusiastic statement that conveys your excitement to begin the work you have outlined.6. Be grammatically correct: It goes without saying (but we will say it anyway), that the personal statement must be grammatically correct, with proper spelling and syntax. Simple errors imply disinterest and inattention. In the era of spell-check and grammar software, take the extra time to ensure there are no grammatical distractions from your message. Have trusted colleagues read and re-read your personal statement. The personal statement should clarify why you want to do what you want to do. Examples might include (and have) “I want to pursue pulmonary rehabilitation as it is overlooked as a mainstay of therapy.” Or “Basic neurosurgical techniques are absent in 70% of the hospitals in the United States. I want to work in a small community and help them to gain these advantages.” For a hepatology applicant, “I find great satisfaction in working with marginalized patients typically ignored and stigmatized. Hepatology permits me to help patients with alcohol abuse disorder and work towards preventing end-stage liver disease.” For Internal Medicine, “This is the field that best grapples with the epidemic of self-imposed disease. I want to affect a population with my work.”  Each of these statements, ideally, is informed by your CV. Highlighting salient aspects of work you have done strengthens the “why” of your application. The purposeful applicant emerges from the pack as grounded, oriented, displaying evidence of clarity and purpose. Convey more than your enjoyment of the field. In more competitive programs, of course, scholarship that fits with the mission statement enhances the application greatly.What do you want to talk about at your interview? The personal statement serves as the steppingstone for a high-stakes conversation. Typically, there are aspects of your life that do not pop on your CV that you amplify in the personal statement. What makes you interesting? What will you add to the program’s community? The application process is challenging for trainees and program directors alike. The personal statement is the only step in the ERAS application completely under your control. It can make the difference between getting lost in the pile of applications and standing out amongst a competitive group of deserving colleagues. Equally, it is a time to take a look at your professional direction and serve as a milestone for the next leg of your training.


The lack of a fully developed results-based financing model before implementation of a program in the health sector begins can lead to difficulty in communicating about the program to different actors involved and delay components of implementation. The intended incentive structure of results-based financing (RBF) makes it particularly important that program implementers communicate to beneficiaries of a program before implementation begins about the nature of the program and that RBF will be used.Improved decision making and communication about the requirements and expectations of an RBF program can enhance stakeholders' knowledge and perceptions of the program, and ultimately make implementation easier.The lack of a fully developed RBF model meant the program was more difficult to communicate to the different actors involved.The lack of knowledge of the RBF program and the existence of incentives raises doubts about whether the program incentivized actors for the intended targets.Program managers should recruit stakeholders from all governments and organizations involved in program financing and implementation to participate in the design of RBF schemes so that they can effectively communicate the structure and indicators to different levels of their respective organizations.Program implementers using RBF should have a flexible plan in place for the RBF model before implementation begins, even if the plan might change. In 2015, the Zambian government and the Swedish International Development Cooperation Agency (Sida) signed an agreement in which Sida committed to funding a program for Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH). The program includes a results-based financing (RBF) model that aims to reward Zambian districts for improved district-wide results on relevant indicators with additional funding. We aimed to describe stakeholders' knowledge of the RBF model and perceptions of the incentive structure during the first 18 months of the program's implementation. This study illuminates the possible pitfalls of implementing an RBF scheme without giving attention to all necessary steps of the process. A qualitative case study was used and included a review of documents, in-depth interviews, and observations. From February–April 2017, we conducted 37 in-depth interviews, representing the views of 12 development partner agencies, government departments, and health facility staff throughout Zambia. We used a qualitative framework analysis. Findings show that the Zambian government and Sida had different perceptions on what levels of the health system RBF will incentivize and that most districts and hospital administrators interviewed were unaware of the indicators that the RBF was part of the RMNCAH program at all. The lack of knowledge about the RBF scheme among respondents suggests the possibility that the model did not ultimately have the necessary preconditions to create an effective incentive structure. These results demonstrate the need for improved communication between stakeholders and the importance of sufficiently planning an RBF model before implementation. They outlined 7 characteristics that can differ between RBF,,,Still, past RBF schemes have suggested RBF can strengthen health systems and demonstrated key concepts that can help implementers optimize the characteristics of an RBF program for impact.,,Although some studies have attempted to analyze the results and impact of RBF, fewer have looked at the challenges involved in actually planning an RBF scheme  especially at the system level rather than individual level.Fewer studies have looked at the challenges involved in planning an RBF scheme, especially at the system level rather than individual level.,,Although the World Bank reclassified Zambia from a low-income country to a lower-middle-income country in 2011, foreign aid continues to be an important part of the Zambian health sector financing as it has for several decades.From 2012 to 2014, the World Bank supported a pilot RBF program in Zambian districts that used monetary incentives to motivate individual health care providers to improve and increase the provision of maternal and child health services.Based on some of the design features of the World Bank's RBF program, in 2015, the Swedish International Development Cooperation Agency (SidaThe fixed component involved each participating district receiving a portion of a fixed tranche of funds each year (70% of the entire grant) based on the allocation formula the government already uses to disburse money to districts. The Sida funds represented a significant increase in resources at the district level. For many districts, the Sida funds accounted for 20%–30% more on top of their usual government allocations for district-level health care operations, and some districts received an even larger share.Based on performance according to an RBF model, 30% of the grant money (€12.8 million) was released as a VT. While half of the VT was based on 5 indicators  chosen tBased on performance according to an RBF model, 30% of the grant money is released as a variable tranche.We used a case study approach, which “allows investigators to focus on a “case” and retain a holistic and real-world perspective”The main researcher was based in Lusaka, Zambia. That provided access to policy documents, representative stakeholders from the Ministry of Health (MOH), and cooperating partners (CPs)—international agencies and civil society groups that partner with the Zambian government—for conducting interviews and relevant policy meetings regarding the RMNCAH program and health sector overall. Data were also collected from government offices and health facilities in the Southern province and the Eastern province of Zambia.We defined incentive as something that creates motivation in an individual or among a collective entity to achieve a certain result, which can be specific RBF funding provided to districts through the RMNCAH program or the knowledge that results will be monitored for improvements. We defined program knowledge as including an individual's ability to convey the objective and indicators of the RMNCAH program, as well as his or her understanding that the RMNCAH program included an RBF component.The study was grounded in an in-depth review of Sida's agreement with the Government of the Republic of Zambia and the Appraisal of Intervention on the RMNCAH program, which provides insight into Sweden's objectives and intentions regarding the agreement. Other policy documents that were reviewed include the MOH's Joint Annual Review Reports from 2008–2012, work plans and budgets for the Eastern and Southern provincial health offices (PHOs), work plans and budgets for selected districts, and the 2016 Zambia Household Health Expenditure and Utilization Survey.In-depth, semistructured interviews were used to obtain information and perceptions on the RMNCAH program implementation from key stakeholders at organizations and agencies identified during a preliminary review of relevant policy documents and literature.We used purposive sampling to select respondents for interviews based on their ability to provide “intimate knowledge” of RMNCAH, all or parts of the RMNCAH program, or RBF.The researcher conducted nonparticipatory observations of 3 policy meetings in Lusaka, Chipata, and Eastern Province, as well as 3 RBF program meetings between Sida, MOH officials, and other key stakeholders. Observations were used to understand the process by which the RBF design was created and the perspectives and perceptions that stakeholders involved had about the process and design. These meetings also provided the researchers with a context for the Zambian health sector and the stakeholders involved and insight into how data is collected and analyzed at the district level. Furthermore, this allowed the researchers to identify key informants, such as district health directors and Sida-contracted employees at PHOs as sources for data.Participants provided verbal consent to the interviewer. The head of the Bilateral Development Cooperation at the Embassy of Sweden, at the time research was conducted, provided written consent for his quotes to be published under his title. A letter from the Permanent Secretary of the MOH endorsing the study was presented to an MOH staff member at the provincial levels. Interviews lasted 1–1.5 hours, and most were conducted within the respondents' place of work. We recorded 23 of the 38 interviews. During all interviews, the researcher took detailed notes, and transcriptions were made after recorded interviews.Anonymity was ensured to those participants that requested it. The researcher has enhanced anonymity by referring broadly to respondents as “MOH official,” “CP,” “facility administrator,” or “health worker” when appropriate. Program officers for the RMNCAH program, who did not request anonymity, were specifically identified when necessary. When relevant, the level of the health sector at which an MOH official works is specified by referring to them as “MOH Central official,” “PHO official,” or “DHO official.”,A key feature of a qualitative case study is that analysis is conducted throughout the process of data collection.Results indicate that during the first 18 months of implementation, many respondents responsible for carrying out the RMNCAH program lacked any knowledge that it included an RBF component for disbursing a portion of the grant and had different perceptions on the degree to which DHOs and facilities would be incentivized by the program's VT funding. Many also did not know which specific RMNCAH indicators had been chosen to measure performance. Respondents also revealed misunderstandings regarding the budget execution indicator. At the time of data collection, Sida had not yet dispersed any of the VTs.Most respondents agreed that funding from the RBF component is meant to target the service delivery points of RMNCAH and that the main purpose is to encourage the districts and facilities to work to improve indicator performance. However, there was less agreement regarding whether individual health workers might feel any extra incentive or motivation from funding received through the RBF component. The Appraisal of Intervention policy document broadly suggests that the RBF is not intended to incentivize individual health workers or facilities. Respondents who believed health workers were aware of the RBF, such as a hospital administrator interviewed, suggested that health workers would feel motivated to contribute and help the facility gain extra resources. In contrast and in line with the development partner's intention, a DHO official stated:Individual health workers wouldn't be motivated unless [the RBF] is well explained.Most respondents agreed that funding from the RBF component is meant to target the service delivery points of RMNCAH and that the main purpose is to encourage the districts and facilities to work to improve indicator performance.An MOH central official and 2 PHO officials asserted that the DHOs knew about the program's RBF and the intended monetary incentives directed toward them at the time research was conducted. An RMNCAH program coordinator within the MOH financed by Sida attended the RBF planning sessions with CHAI and Sida. The coordinator collaborated on the design and was responsible for communicating about the program and RBF scheme to the PHOs and DHOs through 1-on-1 meetings and policy meetings. One of 10 respondents interviewed at DHOs could provide any information that confirmed that they knew it would be used. The 3 respondents that admitted that they did not know that the program would use RBF were all district health directors .Additionally, several MOH officials expressed the perception that while the DHOs would feel motivated by receiving extra funds, the VT based on RMNCAH performance wouldn't serve as an “incentive” for them even though it could expand funding:The DHO doesn't have much incentive because we won't share it among ourselves…it's just extra resources to run programs. —MOH official“Facility staff” refers to hospital administrators and health workers at both hospitals and clinics. Two MOH officials and a hospital administrator stated that facilities and health workers were aware of the RBF, yet of 6 administrators and practitioners interviewed, the only respondent at a facility that knew about the RBF was the hospital administrator.The development partner's vision for the principles that should guide the RBF component of its support to Zambia for the RMNCAH program are outlined in the Appraisal of Intervention:When linking finance to performance it is very important that the indicators are relevant and measurable and that the measurements can be done in an objective and indisputable way.This policy document also states that the 5 RMNCAH indicators chosen to measure performance for the second VT were chosen from 29 coverage indicators “that can monitor real-time change” in data and are all regularly recorded in the national health management information system (HMIS). However, respondent interviews revealed that 3 of the 5 RMNCAH indicators initially chosen are not tracked in the government's HMIS, a system for collecting data from various levels of the health sector.According to an MOH central official, the indicators were changed to indicators that are included in regular data collection in facilities in June 2016, halfway through the first performance year, when the MOH wanted to start reporting indicator performance. At that point, facilities and districts should have started measuring the indicators for the first 2 quarters of the year.Most respondents directly involved with the RMNCAH program or Zambian health system—Sida and USAID staff, MOH officials, and health care workers or administrators—were asked if they could list the performance indicators used . Fewer tOne PHO official who could name the performance indicators ultimately used in 2016 and knew that 3 had been changed expressed uncertainty about which indicators would be used for 2017 stated:I hope that there's been revision of these indicators. They've been replaced for the annual report in 2016, but I don't know if they'll stay [for the rest of the program].The head of the Bilateral Development Cooperation at the Embassy of Sweden expressed the perspective that it was not a problem that most respondents involved in the program at the district and facility levels did not know the 5 key indicators used for reporting in 2016:[People] should [know]. But on the other hand, the incentive shouldn't be to achieve the indicators. The incentive should be to achieve certain results…I'm not saying it's not necessary [for people to know] – I'm sure there could have been advantages with that. But it's potentially also problematic – the reason we have many indicators is also that you shouldn't change your work in order to achieve 1 indicator.Before starting the program, CPs and MOH Central officials had not established a method for calculating how much of the VT each district would receive. At the time research was conducted, over a year into the program, meetings were held to determine the formula that would be used to calculate disbursement.Representatives from Sida, MOH Central, and CHAI took part in initial meetings about the disbursement formula, and USAID representatives joined for future meetings. Discussions revolved around how the program would measure improvement on the chosen indicators and the proportion of the VT a district would receive based on different levels of performance.During interviews separate from these meetings, Sida staff reasoned that it was an advantage not to have this aspect of the RBF model set before the start of the program because it allowed for those involved with the design to factor in lessons learned from the first year of the program's implementation.In answering a question about why the RMNCAH program was started even though the MOH had not implemented certain technical requirements that Sida had requested in the terms of the program, the head of the Bilateral Development Cooperation at the Embassy of Sweden shed light on why the RBF was launched without a complete design:We wanted the program to start, but we had also waited for years. And every year we wait, we either have to do nothing, which has consequences, or other things that we didn't necessarily fancy, like working through NGOs or other contractors outside the government…so of course we wanted to have everything in perfect order before we started. On the other hand, that's not going to happen, so we had to start something.This study reviewed the establishment of a program in the health sector in which RBF played a significant role 18 months after it started. We contacted a broad set of stakeholders to assess if there was a difference in knowledge between people working in high and low levels of the health sector and whether the knowledge cooperating partners had corresponded to actors within the high or low levels of the sector. We found that actors from top to bottom of the health system did not have the same perceptions or level of knowledge regarding the program's RBF scheme. Beyond gaps in knowledge, stakeholders also had perceptions about the RBF component that did not align with each other nor with the intended purpose of using the RBF tool as outlined in project documents. Here, we discuss the underlying reasons for these gaps in knowledge and differing perceptions, the possible impacts they have on the successful implementation of RBF in a health system, and potential ways to improve knowledge and alignment in perceptions in the future.We found that actors from top to bottom of the health system did not have the same perceptions or level of knowledge regarding the program's RBF scheme.Although data on the 5 selected indicators were collected in the first year of the program, details about the RBF model had not been communicated throughout the health system. Fewer than half of the 37 respondents expressed a complete lack of knowledge regarding the use of RBF, and almost all the respondents at the district level did not know RBF will be used or could not provide any details or information about how the model will work.The purpose of the RBF model, as described in both documents and discussions with CPs and MOH officials, is to incentivize better performance and service delivery, although stakeholders had differing perceptions on whether money should go to the DHOs or the facilities. By definition, an incentive provides individuals or groups with motivation for a certain course of action or behavior.Importantly, the RBF model is also meant to incentivize the health workers and health facility staff. Lack of communication may be the reason stakeholders had different perceptions on who should be incentivized, which in turn can have implications on the program outcomes. If individuals at these levels had known about RBF from the start of the grant period, they may have felt motivated to ensure that their performance was measured based on accurate data from regularly reported indicators and may have realized the issue earlier during the implementation process.Beyond stakeholders' doubts that the incentives are effective, Paul et al. noted that performance-based financing programs can weaken health systems in cases when recipients do not have a clear understanding of how and why they get RBF bonuses.When individuals on the ground lack knowledge about RBF, those most influenced by the policy cannot offer feedback and help improve it.,The low numbers of individuals at the district and facility levels who could name the performance indicators and that the initial indicators were not all tracked in HMIS also demonstrate that the indicators have not been internalized in the health system. Literature suggests that a national government should be fully aware of the indicators used and feel a sense of power over them to optimize the impact of RBF.,,,The head of Bilateral Development Cooperation at the Swedish Embassy in Lusaka indicated the perception that although people should know what indicators are used, they do not need this knowledge for the RBF to work. Sida wants the health sector to achieve improvements in RMNCAH overall rather than just on specific indicators. The perception of the head of the Bilateral Development Cooperation reflects a worry that RBF recipients will neglect unrewarded activities that are not measured and distort other health outcomes.The use of indicators to measure results is an inherent characteristic of an RBF scheme, and thus respondents' lack of knowledge about them implies a lack of communication within the health system.Sida staff reasoned that the lack of a finalized RBF formula that would be used to calculate dispersals of the VT was advantageous. This standpoint is supported by frameworks that promote concepts of iterative learning to design development programs. In their problem-driven iterative adaptation approach to development interventions, Andrews et al. (2012) proposed that a key element of system reform is active learning through experimentation of design and implementation. In low-resource settings like Zambia, implementing interventions should allow for the context to shape the design on a continuous basis and incorporate lessons learned from what works and what does not work on the ground.Still, to use a process of iterative learning, a program must be planned at least to the extent that it can be implemented and experimented in actual practice. The RMNCAH program started with an incomplete RBF design. Sida and the MOH waited for feedback about the chosen indicators and information from the lower levels of the health system that might help them develop the RBF component's design, but the lower levels of the system lacked knowledge about the program that would allow them to provide feedback because they were waiting for instructions about the RBF component and what the program actually included. Both waited for communication and additional knowledge about the program from each other, which meant that initial implementation and experimentation never occurred and information could not be gathered about the functionality of RBF in the Zambian context. Communicating about an initial plan, even if it will be revised, necessitates creating a process of information dissemination that can help gather feedback about the initial design from participants and can help clarify channels of communication for disseminating any changes to the plan or additional information in the future.,Previous literatureWhile this study achieved its aims, it did suffer from certain limitations. Due to a limit of time and resources, the researcher could not interview more individuals in remote districts, which could have provided a broader range of perceptions regarding RBF and the intended incentive structure, as well as a larger pool of respondents to better understand communication between various levels of the health system. The researcher could not contact some of the stakeholders in the RMNCAH agreement and implementation that stakeholders mentioned in interviews. It was also difficult to return to respondents for a second interview, so some information gathered in the process of data collection could not be triangulated by all types of stakeholders. The limit of times and resources also meant that the research was designed to only focus on the initial phase of implementation and did not follow the RMNCAH program through its completion. Ideally, further studies would be conducted to look at implementation after a longer period has passed since the program's initiation. Additionally, during fieldwork in Southern province, the researcher was largely subject to supervision from the PHO. A driver was provided for transportation and PHO staff introduced the researcher to relevant staff at the DHOs and facilities. The researcher accepted this supervision as a way of adhering to MOH protocol and for convenience in accessing respondents. These introductions, however, may have altered the respondents' perceptions of the researcher and limited the scope of possible informants sought by the researcher.This study illuminates important considerations for planning and implementing an RBF scheme throughout an entire sector. Stakeholders interviewed displayed limited knowledge about the RBF model, the results that would be rewarded, and how the rewards would be calculated. Although an RBF scheme might benefit from being iterated throughout the implementation period, it is recommended that a flexible plan is in place for a program during the initial phase of implementation so that all actors have at least basic knowledge and understanding from the onset on its intended results and incentive structure. We recommend that all relevant stakeholders from each government or organization participate in the design of the RBF scheme so that they can effectively communicate the structure and indicators to the different levels of their respective organizations. While these recommendations apply to RBF schemes, preparation and a shared understanding of programmatic details among stakeholders is important for any reforms to the health sector.A follow-up to this study could examine if the challenges experienced during implementation impacted performance and the ability of Zambian districts to make improvements on the chosen RMNCAH indicators. More broadly, research could examine the minimum knowledge RBF recipients need about an RBF model implemented in LMICs to create an effective incentive structure and determine the preconditions for a viable scheme.


Although considerable attention has been paid to the application of leadership in virtual communities, the field of live streaming has not been involved. This exploratory study aimed to explore how different broadcaster leadership traits  influence audiences’ loyalty (cognitive and conative). And audience self-construal was chosen as a key moderator. The top 15 broadcasters from the regional rankings were selected from each of the two popular live streaming platforms, Douyu and YouTube, for the study. And we used snowball sampling with a link to an online questionnaire as a recruitment procedure. 310 audiences with live streaming experience from the Chinese Mainland and Taiwan participated. Hierarchical linear modeling was adopted for the analysis. This study found that broadcasters with servant and charismatic leadership traits positively affected cognitive loyalty. Broadcasters with servant leadership traits also had a positive effect on conative loyalty. Additionally, independent self-construal negatively moderated the relationship between servant leadership and cognitive loyalty. Independent self-construal positively moderated the relationship between authoritarian leadership and conative loyalty. Furthermore, interdependent self-construal negatively moderated the relationship between charismatic leadership and conative loyalty. Interdependent self-construal positively moderated the relationship between authoritarian leadership and conative loyalty. These conclusions extend the understanding of broadcasters’ traits and audiences’ psychology concerning the booming phenomenon of live streaming and can help platform managers motivate audiences’ loyalty on these platforms. Such platforms, YouTube, as a new internet trend, live streaming, which involves high interactivity to meet the needs of consumers by presenting current real-time situations to end-users through Internet media, has gained great popularity . Live-stIt is noteworthy that both audiences and broadcasters have important, active roles in live streaming platforms. With the increase in the number of broadcasters available, the audience’s adherence to specific broadcasters gradually declines. If a broadcaster cannot obtain the audience’s continuous loyalty, it will be difficult for the broadcaster to increase the retention rate of the audience and form its own fan group . TherefoAdditionally, broadcasters facilitate audience-broadcaster relationships by providing quasi-social experiences  with theThis study aims to investigate and gain a better understanding of the traits of broadcaster leadership and consumers’ cognitive and conative loyalty with self-construal as a moderating factor. This study has three potential contributions. First, rather than considering broadcasters as an indiscriminate group , this stPrevious studies of charismatic leadership have mainly focused on the leaders of enterprises or government organizations  and haveAuthoritarian leadership is based on the absolute obedience of followers to those in power, which means unconditional obedience and dependence . In addiAuthoritarian broadcasters are usually highly professional in their field and content and often express their own opinions to convince the audience to accept their views, thus achieving didactic leadership. In addition, to establish an unattainable image or lofty status, these broadcasters define themselves as key opinion leaders who do not allow others to question their opinions or who even attack audience members with different opinions, thus arousing the audience’s emotional reaction. When there is strong emotion in comments, the results of viral spread will be added to the content . These sServant leaders take the needs of their subordinates as their primary consideration. To enable subordinates to exert their full potential to achieve organizational goals and self-realization, service leaders try their best to support their subordinates’ accomplishments . The motAudiences tend to seek information directly related to their own interests and then consider the newsreader’s identity . BroadcaScholars have discussed many aspects of customer loyalty. One of the most important indicators of customer loyalty is whether customers have repeated purchases of a product or service. Through this indicator, customers can be divided into four groups: undivided, divided, unstable, no loyalty . In addiPrevious research has shown that when audiences watch TV, they will want to interact with other audiences , which iIn addition, when customers participate in virtual interaction related to brand advertising, they can create brand loyalty and purchase intention through social presence  and commWith the development of science and technology, users no longer need to interact with each other on two screens. Mobile terminals allow broadcasters to contact audiences through any channel at any time and place during live streaming and to respond to audiences in real-time. The benefits of social TV engagement can be applied to consolidate or enhance audience loyalty. In addition, brand loyalty is highly correlated with brand characteristics. The broadcasters of live streaming are similar to brands. In the face of fierce competition, it is necessary to have unique brand characteristics and distinct leadership characteristics. However, regardless of the leadership traits a broadcaster has, his ultimate goal is to attract more viewers and increase their stickiness and loyalty . TherefoIn combination with the characteristics of live streaming and the definition of loyalty , in thisAudiences, as passive recipients of information, are vulnerable to the subjective opinions of broadcasters, who can influence antagonistic relations between different groups . ChangesCharismatic leaders are highly contagious and can quickly influence the audience’s preferences and psychological state. In addition, charismatic leaders can quickly integrate into the group, shorten the distance and become popular with the public . GeneralThe servant leadership qualities of a broadcaster have a strong moral sense. The moral foundation of these broadcasters is based on service motivation . They arThrough these acts, service leaders can instill a sense of moral integrity and obligation into the organization, increasing normative commitment . TherefoThus, we suggest the following hypotheses:H1:Different leadership traits of broadcaster have significant impact on audiences’ cognitive loyalty.H1a:BCL has a significant impact on audiences’ cognitive loyalty.H1b:BAL has a significant impact on audiences’ cognitive loyalty.H1c:BSL has a significant impact on audiences’ cognitive loyalty.Conative loyalty refers to the willingness of customers to purchase a product or service again . InterneBroadcasters with charismatic leadership traits can connect followers and give meaning to joint efforts and goals . They prH2:Different leadership traits of broadcaster have significant impact on audiences’ conative loyalty.H2a:BCL has a significant impact on audiences’ conative loyalty.H2b:BAL has a significant impact on audiences’ conative loyalty.H2c:BSL has a significant impact on audiences’ conative loyalty.Prior research has demonstrated that followers’ personal characteristics, emotions and attitudes influence their perceptions of or preferences for certain traits of relationships with superiors and their propensity to follow a particular trait of a leader . Kim et The social cognitive theory of mass communication  has deveIndependent people tend to be self-interested when working in a team. They often welcome anyone who can contribute to their need for personal development and are motivated by useful people . TherefoH3:ID moderates the relationship between different leadership traits of broadcaster and audiences’ cognitive loyalty.H3a:ID moderates the relationship between BCL and audiences’ cognitive loyalty.H3b:ID moderates the relationship between BAL and audiences’ cognitive loyalty.H3c:ID moderates the relationship between BSL and audiences’ cognitive loyalty.H4:ID moderates the relationship between different leadership traits of broadcaster and audiences’ conative loyalty.H4a:ID moderates the relationship between BCL and audiences’ conative loyalty.H4b:ID moderates the relationship between BAL and audiences’ conative loyalty.H4c:ID moderates the relationship between BSL and audiences’ conative loyalty.Interdependent people are expected to readily identify with their superiors’ goals or the common goals of the group. An interdependent self-construal (ITD) is conceptualized as an individual’s perception of themselves as having a variable, flexible self. With the increase in the cognition of broadcasters and the increase in interaction time, the feelings of an interdependent audience toward the characteristics of broadcasters and the resulting loyalty relationship may change. For example, in the early stage, a dependent audience may develop cognitive loyalty because of considerate service broadcasters. However, because this kind of audience tends to follow instead of leading, the audience performs better when working with those they feel to be superior to themselves rather than those on a similar level . TherefoH5:ITD moderates the relationship between different leadership traits of broadcaster and audiences’ cognitive loyalty.H5a:ITD moderates the relationship between BCL and audiences’ cognitive loyalty.H5b:ITD moderates the relationship between BAL and audiences’ cognitive loyalty.H5c:ITD moderates the relationship between BSL and audiences’ cognitive loyalty.H6:ITD moderates the relationship between different leadership traits of broadcaster and audiences’ conative loyalty.H6a:ITD moderates the relationship between BCL and audiences’ conative loyalty.H6b:ITD moderates the relationship between BAL and audiences’ conative loyalty.H6c:ITD moderates the relationship between BSL and audiences’ conative loyalty.A web-based survey was used to collect data for quantitative testing of the study model in Chinese Mainland and Taiwan. Specifically, the selection of popular platforms refers to T-test analysis. We also compared the first quarter with the last quarter of the questionnaire and the difference is still not significant. The male-to-female ratio was approximately 55.73 to 44.27. Most of the respondents were aged 18–34 years old (85.1%), young people account for a larger proportion of the total population. A majority of respondents (60.9%) were students, followed by service employees (15.1%). More than 73.1% of respondents have been watching live streaming for more than half a year and more than 70.4% of respondents watched the broadcast more than twice a week. We pretest the valence of questioner of 66 respondents. The questionnaire was revised based on the results of the pretest.The survey was conducted from April 20 to Jun 30, 2020. Of the 310 electronic questionnaires, 262 were completed and returned. Forty-eight questionnaires were incomplete and not used, leaving the number of valid questionnaires at 262 (Response rate = 84.51%). There is no significant difference in usage time and willingness to participate between two platforms after The questionnaire includes five parts. Participants were asked to choose their favorite broadcasters in Part 1. Appendix A show the list of broadcasters we provided to participants to choose from. Part 2 is based on the constructs of BCL, BAL, and BSL. We adapted In this study, because participants provided data at the team level (level-2 – leadership trait of broadcaster) and the individual level , our hypotheses were examined by cross-level techniques. Since HLM can deal with non-independence issues and estimate the influences of the different level factors on the dependent variables , HLM wasThe convergent validity of scale items was calculated on the basis of reliability, composite reliability, and average variance extracted (AVE) . Only thFor GFI, in addition to BCL, BAL, ITD, ID below the standard value of 0.9, other variables were in line with the standard. However, according to the evaluation standard of In terms of NFI, BSL, CGL, and CAL were above the standard value of 0.9. But according to the evaluation standard of In terms of AGFI, although the values for all variables were range from 0.8 to 0.9, according to the research of In terms of RMR, BAL, ITD and ID were all above the standard value of 0.05. However, according to the evaluation standard of We estimated discriminant validity by comparing the common variance between factors with the AVE among the six factors . Table 4rwg values of leadership traits of broadcaster (level 2 – broadcaster level) to examine the inter-rater agreement. The results showed that the large values for charismatic, authoritarian, and servant leadership were 0.95, 0.89, and 0.93. The rwg values were higher than 0.7 (the accepted level) (To examine the appropriateness of the data aggregation of the level 1 (audience level), we computed d level) ; therefo2[32] = 44.759, p = 0.001) for cognitive loyalty. Also, the results revealed significant between-group variance  for conative loyalty. Therefore, a multilevel analysis was appropriate for the data.At first, in order to assess the appropriateness of the multilevel analysis, the current study estimated a null model, which means no predictors in the audience level (level 1) and the broadcaster level (level 2), to estimate the significance level of the group level. The results revealed significant between-group variance . And BSL was positively related to CGL . However, CAL had not significant effect on CGL . Thus, the result supported H1. Specifically, the result supported H1a and H1c, but not H1b. Additionally, the result revealed that only BSL was positively related to CAL . BCL had not significant effect on CAL . Meanwhile, BAL had not significant effect on CAL . Thus, the result supported H2. Specifically, the result supported H2c, but not H2a, H2b.p = 0.004; see M8). In other words, when facing the broadcasters with a high quality of servant leadership, the audience with a low quality of independent self-construal will have a high level of cognitive loyalty . Also, independent self-construal did not moderate the relationship between BAL and CGL . Thus, the result supported H3. Specifically, the result supported H3c, but not H3a and H3b.But independent self-construal did not moderate the relationship between BCL and CGL . In other words, when confronted with the broadcasters with high authoritarian leadership, the audience with high independent self-construal would have higher conative loyalty . Also, ID did not moderate the relationship between BSL and CGL . Thus, the result supported H4. Specifically, the result supported H4b, but not H4a and H4c.But ID did not moderate the relationship between BCL and CAL . Also, we investigated the same effect on BAL  and BSL . Thus, the result did not support H5 .p = 0.014; see M14). In other words, when facing the broadcasters with high charismatic leadership, the audience with low independent self-construal will have high conative loyalty . When faced with a broadcaster with high authoritarian leadership, the audience with high interdependent self-construal would have a higher level of conative loyalty . Thus, the result supported H6. Specifically, the result supported H6a, H6b, but not H6  film clips and contents of specific emotions or themes; (ii) specific broadcasters and network celebrities; and (iii) the gender, appearance, content and behavior of broadcasters and network celebrities, which influence the audience . LeadersSecond, the core of enterprise marketing activities often lies in the development, maintenance, or improvement of customers’ loyalty to products or services . Loyal cThird, this study contributes important insights to the literature on self-construal. Although existing research has attempted to propose different reasons why social media activities may affect consumers’ choice at the theoretical level , little Based on the findings of this study, we recommend that broadcasters should adjust their content and method of live streaming according to their own leadership characteristics to gain more loyal audiences. For authoritarian broadcasters, they should introduce the characteristics of service-oriented leadership as much as possible and know how to listen to the audience’s feelings and needs. The tone of live streaming can still be tough, but the audience should feel the broadcasters’ kindness. Charismatic broadcasters should attach importance to establishing a long-term trust relationship with the audience to promote the audience’s behaviors of active subscription and donation. Although the enthusiasm of charismatic broadcasters is very appealing, the content of the live streaming often abandons the old and establishes the new, demonstrating a new style. It is difficult for an audience to internalize new ideas in a short time and generate identification. Therefore, in the process of delivering consultation, these broadcasters should pay attention to good guidance and to the needs of most people.Moreover, live streaming fosters authenticity, visualization, and interactivity in online shopping. Taking note of the power of live streaming, international brands such as Guess, Clarks, and Anna Sui  have used e-commerce live to reach their customers. The way broadcasters present products and brands become the key to determining sales performance in live streaming. If the brand style is consistent with the spokesperson style, the credibility of advertising information transmission can be increased, and then the brand attitude of consumers can be affected . When brAlso, operator of live streaming platforms should change their marketing strategy. Most operators usually recommend broadcasters to audiences based on the subscription number, without considering the individual characteristics of the audiences. Instead, operators can predict the personality characteristics of customers by collecting their behavioral data (such as the number of interactions and duration of stay) in the live broadcast, so as to recommend more accurate broadcasters. If the audience seldom speaks after entering the chat room but they pay attention for a long time, they can be classified as an audience with a low degree of independence. On this basis, more service broadcasters can be recommended. However, if the audience is eager to express their opinions after entering the studio and they often have the intention to attract others’ attention (such as rewarding the broadcaster before and after the speech to attract the attention of the broadcaster), they can be classified as an audience with low interdependence traits. On this basis, more charismatic broadcasters can be recommended.The personality of the audience is also worthy of the broadcaster’s attention. In combination with the leadership characteristics of the broadcasters themselves, corresponding responses are given to audiences with different characteristics. Usually, audiences with independent self-construal are not afraid to speak out actively and present themselves generously. What they hope to gain is the recognition and affirmation of the broadcasters rather than material satisfaction. They will also attach great importance to whether broadcasters have their own opinions. If broadcasters blindly follow a trend, it will be difficult for them to gain the attention and respect of this type of audience. We suggest that broadcasters should first listen more to understand what the audience is trying to express and then combine this with the speech they are going to make to give the audience timely recognition. After accumulating certain feelings and credibility, audience members will naturally have the opportunity to actively subscribe and donate. Audiences with interdependent self-construal will attach excessive importance to the atmosphere of the chat room and the harmony of the whole process of living conditions. They also value the connection among audience members. When broadcasters show the characteristics of being responsible and reliable, this will help to build a sense of belonging to the group and meet the needs of a dependent audience to promote the behaviors of active subscription and donation.First, this study did not consider the role of another important group in live streaming, namely, the influence of other audiences who interact with each other. Specifically, the entirety of live streaming content is not just provided by broadcasters. Contributions from multiple audiences complement the overall experience of watching live streaming content and distinguish it from the consumption of traditional TV programs . Thus, wThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the National Central University. The patients/participants provided their written informed consent to participate in this study.YH and YL contributed to the improvement of the initial idea. YH and GW designed the study and collected the data. GC and YH conducted the analysis. GC, YH, and JM worked on the first draft. JM and YH revised the conceptualizations and the final manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


OBJECTIVES/GOALS: Regardless of their career choices, today’s biomedical researchers need to blend great science with core skills ininnovation and entrepreneurship (I&E). The objective of this NIH-funded education program was to develop and test a pragmatic training program to teach relevant I&E skills. METHODS/STUDY POPULATION: We used a modified Delphi approach to identify 15 relevant competencies for I&E and the essential topics to include in the program. Learner interviews identified preferences for online training programs . The inaugural program included 7 short, online courses that addressed how to identify and validate opportunities for innovation, sell your innovation to diverse audiences, assess its ethical consequences, work in teams, and develop resilience as an innovator. It also included mentor support, a team-based capstone project, and an optional in-person boot camp. RESULTS/ANTICIPATED RESULTS: 51 students enrolled and 41 participants from 9 institutions completed the program, including pre- and post-doctoral students and junior faculty. They organized into 10 teams to complete the capstone project, with 6 teams pitching their innovation to fellow students and mentors at the boot camp. Students rated satisfaction with courses highly overall, with 79% stating they would be disappointed if the program was no longer available. Preliminary results suggest participants increased their knowledge about and ability to perform tasks taught throughout the program. Suggestions for improvement included providing more practical advice and real-world examples to complement educational videos. DISCUSSION/SIGNIFICANCE OF IMPACT: The inaugural E4B program was well received and effective in increasing I&E skills. Improvements will include increased opportunity for mentor interactions and for advanced entrepreneurial training. The program is open for biomedical research trainees from all institutions with a CTSA award.


UPnGO with ParticipACTION (UPnGO) was a commercialized 12-month workplace physical activity intervention, aimed at encouraging employees to sit less and move more at work. Its design took advantage of the ubiquitous nature of mobile fitness trackers and aimed to be implemented in any office-based workplace in Canada. The program was available at cost from June 2017 to April 2020. The objectives of this study are to evaluate the program and identify key lessons from the commercialization of UPnGO.Reach was defined as the number and percentage of employees who registered for UPnGO and the number and percentage of sedentary participants registered. Effectiveness was assessed through average daily step count. Adoption was determined by workplace champion and senior leadership responses to the off-platform survey. Implementation was assessed as the percentage of participants who engaged with specific program elements at the 3-evaluation time points. Maintenance was assessed by the number of companies who renewed their contracts for UPnGO.Using a quasi-experimental design over 3 time points: baseline, 6 months, 12 months, five evaluation indicators were measured as guided by the RE-AIM framework. Reach across 17 organizations, 1980 employees participated in UPnGO, with 27% of participants identified as sedentary at baseline. Effectiveness Daily step count declined from 7,116 ± 3,558 steps at baseline to 6,969 ± 6,702 (p = <0.001) at 12 months. Adoption Workplace champion and senior leadership engagement declined from 189 to 21 and 106 to 5 from baseline to 12 months, respectively. Maintenance Two companies renewed their contracts beyond the first year.The commercialization of UPnGO was an ambitious initiative that met with limited success; however, some key lessons can be generated from the attempt. The workplace remains an important environment for PA interventions but effective mHealth PA programs may be difficult to implement and sustain long-term. Being physically inactive, defined as not meeting physical activity (PA) guidelines , is a maIncreases in physical inactivity may be related to changes to the nature of work throughout the twentieth and twenty-first century. In the 1970s, 2 in 10 Americans had sedentary jobs; however, by the 2000s, this number had increased to >4 in 10 adults , the worTo address changes in these health behaviors, ParticipACTION, a Canadian non-profit which promotes PA nationally, developed a mHealth intervention named UPnGO with ParticipACTION (UPnGO). The intervention was designed to take advantage of the ubiquitous nature of mobile fitness trackers and mHealth applications so that it could be delivered at a population level to any workplace in Canada. UPnGO began as a 6-week workplace PA initiative aiming to increase habitual PA (steps) during the workday. Higher step counts have been associated with lower risk of all-cause mortality, and lower risk of cardiovascular morbidity and mortality . InterveWith the initial success of the UPnGO program, ParticipACTION then scaled-up the program. Scaling-up is defined as deliberate efforts to increase the impact of successfully tested health interventions to benefit more people and to foster policy and program development on a sustainable and lasting basis . There iThis manuscript describes the changes made to UPnGO with ParticipACTION for the purpose of commercialization. The specific objectives are to (1) evaluate the commercialized UPnGO program using the RE-AIM framework; and (2) identify key lessons to inform future considerations in the commercialization of PA programs.The commercialized UPnGO program was a 12-month workplace PA intervention that evolved from the initial piloted 6-week intervention . DevelopThe initial UPnGO pilot phase study was a 6-week program, which consisted of three essential elements across two levels of intervention : (1) education and training on PA behavior change skills ; (2) real-world PA opportunities ; and (3) leadership support of engagement in the UPnGO program and PA participation in the workplace . These elements were delivered both on- and off-platform the UPnGO web/mobile app. The on-platform program component includes an UPnGO web-based and mobile application that could be synched with wearable PA trackers . The off-platform components included weekly themes, walking activities and opportunities for participants to interact within the workplace. Workplace champions supported both on- and off-platform activities.Reboot your Commute which challenged participants to engage in PA during their commute. Additionally, UPnGO participants were no longer provided devices to monitor PA as in the pilot program and were expected to use their own device (wearable technology or phone) to monitor activity. Participants who did not have access to these devices were able to manually record PA, but not their daily step count through the web-based platform. A summary of the differences between the 6-week and 12-month program can be found in The decision to extend the time-line of the program from 6 weeks to 1 year was based on feedback that Canadian companies would be less interested in paying for a short-term program. The 12-month program followed the same principles as the 6-week program, however overall monthly themes were added to the program with supporting weekly themes where appropriate. A 1-month long challenge was included every quarter (4/year), such as The individual-level components aimed to enhance an individual's capability in self-regulating their PA behaviors. This was primarily delivered through the on-platform component of the UPnGO program. It included a web-based and mobile application that contained (1) educational content, delivered via blogs, notifications, stream posts, and videos, related to behavior change skills, including goal-setting, action planning, barrier identification/problem solving, and self-monitoring; (2) a platform for self-monitoring (tracking) steps by using a wearable device; and (3) a platform for self-monitoring activities related to action planning, such as planning a walking meeting, or setting standing reminders. The application also provided participants with a set of interactive tools to increase program engagement. This included emails, prompts and notifications to support individuals in achieving their PA goals and an incentive system to promote and sustain program engagement throughout the intervention. There was also a stream post function for individuals to seek and provide peer support, a group/company calendar for creating and promoting social PA events, and a leaderboard that ranked participant activity levels in order to foster positive inter- and intra-departmental competitions.The organizational-level components aimed to provide organizational support to make PA a socially acceptable choice. These activities were mostly operated outside the UPnGO platform. Leadership support was reflected by three aspects of UPnGO: communication of support, role modeling, and permission. Senior leadership at each participating worksite was expected to provide a formal communication of support to their employees, such as through company-wide email/official announcements about UPnGO. Senior management was expected to serve as a role model to their employees by actively engaging in at least 50% of the UPnGO events. They were also recommended to work closely with their managers on every monthly theme to ensure that employees were allowed to have a flexible work schedule  to engage in the UPnGO activities.Action Plan It, focusing on developing action planning skills, Unite to Ignite, focusing on increasing social support for PA, and Pump It Up, aiming at increasing physical activity intensity.Monthly real-world PA activities were organized at the worksite by UPnGO workplace champions and related to the monthly theme. Examples of the most popular monthly themes included Optional organizational-level components included environmental prompts  and engaging organizational champions to organize weekly PA opportunities and program emails.A similar sampling frame was used for the commercialization of UPnGO as with the pilot phase of the study as described by Lau and Faulkner . CompaniA total of 17 companies enrolled in the commercialized UPnGO program from June 2017 until April 2019. Similar to the pilot, the characteristics of the companies varied in terms of organization size. This included 11 companies with <100 employees, 3 companies with 101–200 employees, 2 companies with 201–300 employees, and 3 companies with >301 employees. The companies also covered various sectors including public administration (5), financial (4), management (3), professional, scientific and technical services (2), agriculture (1), energy (1), and telecommunications (1). Employee eligibility was determined by the individual company as the funding model required employers to pay per participant.Program implementation proceeded as described by Lau and Faulkner . In brieUPnGO with ParticipACTION was launched in April 2017 and was concluded in April 2020. To evaluate the program, a quasi-experimental design with no control group was employed. Three time points were included in the evaluation: program initiation (baseline), 6 months post-baseline (6 months), and 12 months post-baseline (12 months). The RE-AIM framework was selected to guide the evaluation of the commercialized UPnGO program . The fraReach was assessed by two primary metrics: number and percentage of employees who registered for UPnGO at registered organizations, and the number and percentage of physically inactive participants registered. The number and size of the companies who registered for UPnGO influenced these metrics significantly. However, taken together, these metrics assess the various levels of reach required for the successful commercialization of an intervention: organizational, individual, and targeted population. As physically inactive office workers were the target demographic for the UPnGO program; 3 separate metrics were used to determine the successful recruitment of inactive participants at baseline; participants (1) with a step count <5,000 steps per day at baseline , based oEffectiveness was assessed through average daily step count as the program aimed to increase physical activity (as measured by steps). Participants' de-identified daily step counts were automatically synched to the UPnGO platform through their personal activity tracking devices . As such, each individual's device is subject to its own internal logic for calculating steps; however, for the purpose of our analysis all recorded steps through devices were considered the same. A valid day was defined as any day with step counts between 1,000 and 40,000 . Averagep < 0.05.All analyses were conducted using SPSS version 26.0. Descriptive characteristics were extracted from the implementation specialist records and PA metrics (steps and activity tracking) were extracted from the on-platform database where applicable. Of the 1,980 registered users, 667 (33.7%) had valid step data at baseline, 517 (26.1%) had valid step data at 6-months and 193 (9.7%) had valid step data at 12 months. As such, we used a conservative intent-to-treat (ITT) approach, whereby participants are only required to have valid step data at baseline to be included in the analysis. For participants who did not provide complete step data at later intervention time points (6 and 12 months), we conservatively assumed no change in outcomes by carrying forward baseline values. We also performed a sub-analysis on users who had complete step count data . The step count data is extracted from the online platform, completely de-identified, as such it is not possible to assess whether the demographic characteristics of users with step count data differ from users without step count data. One-way repeated measures ANOVA were used to assess differences between the 3 time points. Changes in step count over the 3 time points was also compared between active and inactive users at baseline using mixed two-way repeated measures ANOVAs and reported using simple main effects with Bonferroni correction for multiple comparisons to assess interactions between the groups. Statistical significance was set at Adoption was determined by two metrics: the number of workplaces who were willing to implement the program, and workplace champion and senior leadership responses to the off-platform survey to assess the number of agents willing to implement the program (change agents). The pilot program of UPnGO revealed that engagement of senior leadership and workplace champions were integral to success by creating a workplace that supports PA . We tracA total of 17 organizations with 6,913 employees were eligible for at least 1 year of UPnGO. Of the employees, 1980 (29%) registered for the program. At baseline, 27% of participants recorded <5,000 steps per day, while 36% of survey respondents reported that they performed <150 min of MVPA/week, and 82% of respondents reported sitting for >6 h/day.p < 0.001). By 12 months there appears to be a rebound in steps ; though this number is still significantly lower than baseline (vs. baseline p = 0.010). When we looked at only the participants who had step data at all 3 time points, we observed a decline in step count at 12 months . When we compared inactive vs. active participants at baseline over the 3 time points, we observed no significant change in the step count of the inactive participants  . However, active users appear to be driving the observed rebound in step count from baseline to 12 months .UPnGO aimed to increase daily step count, however, there was a modest decline in step count between baseline and 6 months in the ITT analyses , step tracking , activity tracking , and healthy habit tracking .Only 2 (12%) out of the 17 companies renewed their contract, both of these companies were recruited in the first year of UPnGO and renewed their contracts for both year 2 and 3 of UPnGO. This suggests limited maintenance of the UPnGO program based on our criteria. We are unable to present results on the maintenance of the UPnGO program at the individual level as step data was not collected following the 1-year program.The intent of the commercialization of UPnGO was to create a sustainable and financially viable workplace intervention. The commercialized UPnGO program demonstrated limited success. A total of 17 organizations with almost 7,000 employees purchased the commercialized UPnGO program suggesting organizational interest in such programs. However, only ~30% of those employees registered for UPnGO and even fewer of those registered users were considered inactive at baseline, based on the study metrics. Program engagement significantly and steadily declined over the 1-year program, with limited effectiveness, adoption, and implementation of the UPnGO program. Only two organizations renewed their UPnGO contracts beyond the first year, suggesting a lack of sustainability of the program. UPnGO with ParticipACTION has now been retired and key learnings from the program are being adopted into future ParticipACTION initiatives. UPnGO's commercialization process may provide significant insight into some of the challenges in implementing a national workplace physical activity mHealth intervention.Sufficient program engagement is necessary for any digital health intervention to have an effect . DecliniHowever, declining engagement with long-term mHealth interventions is not unprecedented. Hermsen et al.  demonstrAssociated with declining engagement, the 6-week pilot study Lau and Faulkner  revealedLike many PA interventions, UPnGO failed to recruit participants who would benefit most for the program—inactive adults. Inactive adults or participants who took <5,000 steps at baseline  accounteRecruitment and training were provided to workplace champions to help them recruit inactive participants in their worksite. Due to the scaling-up design we have no way of determining what additional recruitment strategies were employed at each site. Little is known about the most effective recruitment strategies for PA and specifically walking interventions. A systematic review of 47 studies examining recruitment in walking interventions identified the most effective recruitment strategies to be time and resource intensive, and require skilled research and recruitment staff . TherefoThe nature of the UPnGO program lent itself to commercialization as it was designed to be implemented in office-based workplaces by companies that may have limited capacity to provide access or resources for PA promotion. This study demonstrated the feasibility of commercializing a workplace PA intervention with 17 companies participating. The 6-week pilot program was adapted to a product that consumers would want to purchase at a price point that was appealing and that was feasible for ParticipACTION to deliver. Several key features were changed to accomplish this goal: (1) the timeline was lengthened to 12 months, (2) participants were no longer provided with devices to track their steps and were asked to use their own device (wearable trackers or phone apps), (3) the longer timeline resulted in less frequent contact between the implementation specialists and the workplace champions and the champions had more autonomy within the UPnGO program. These changes resulted in a different UPnGO program delivered to participants in the 1-year program compared to the 6-week program, so much so that it rendered the real-world trial included in Lau and Faulkner's  hybrid eCommercializing UPnGO led to unforeseen pressures on ParticipACTION compared to the 6-week pilot program which may have hindered its success. This includes the expectations of a company paying for a commercialized PA program. Companies looking to purchase a workplace wellness program may not have the same level of commitment/expectation to supporting the implementation of the program. As such, there may be a perception of “Isn't that what we are paying you to do?” instead of an organizational internalization of the program principles. Additionally, as a non-profit, ParticipACTION did not have the resources to devote to the level of support required for company success to the extent required with the new model. The intent of the entire scaling-up process was to create a sustainable, income generating program that would increase PA in participants with minimal support from ParticipACTION.In a commentary by Holtermann et al. , the autAs stated by Lau and Faulkner , UPnGO hIt is possible to increase PA long-term (>12 months) through behavior changes interventions. A systemic review of 9 RCTs by Wahlich et al.  demonstrIn addition to program changes for commercialization, variability in company size may have also significantly impacted the success of UPnGO. The smallest company had just 22 employees while the largest had over 4,000. In an evaluation of the organizational-level determinants of participation in workplace health promotion programs, Lier and colleagues found that organizational size was negatively correlated with participation . They alOverall, commercializing the program resulted in changes to the “active ingredients” that drove the success of the 6-week pilot program : senior There are several limitations to this study. The primary limitations being the limited recruitment and declining engagement of participants (~30% of eligible employees), and the lack of recruitment of the target group, physically inactive individuals. This led to a small and likely biased sample included in the effectiveness analysis. Additionally, as a result of commercialization, the companies were charged for use of the program which may have contributed to selection bias in terms of participating companies. The use of personal tracking devices to derive device-recorded data resulted in the grouping of step data from a variety of different tracking devices, each with their own internal logic, reliability, and validity. Also, the use of self-reported physical activity and sitting time is also subject to recall bias. Finally, there was no follow-up with the companies following the 12 months of the program to qualitatively explore perceptions of the program.The commercialization of UPnGO was an ambitious goal in moving from a successful pilot program to a commercially available mHealth PA intervention. Although ultimately unsuccessful some key lessons can be generated from the attempt. The workplace remains an important environment for PA interventions, but effective PA programs are difficult to implement and sustain. Commercialization adds an additional level of complexity to the scaling-up process of PA programs and may influence participant expectations. While interest in mHealth research related to PA and sedentary behavior has grown rapidly, sustaining sufficient engagement necessary for long-term behavior change remains elusive. More research is needed in understanding how to sustain engagement and in identifying the optimal length of PA mHealth interventions for the workplace.guy.faulkner@ubc.ca.The data analyzed in this study is subject to the following licenses/restrictions: This study involved the secondary data analysis of the process and outcome evaluation of the UPnGO with ParticipACTION evaluation. The data is owned by ParticipACTION and was provided to the research team as third party evaluators. Requests to access these datasets should be directed to The studies involving human participants were reviewed and approved by the University of British Columbia Behavioral Research Ethics Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.KD and GF conceived of the manuscript and wrote the manuscript. KD, EL, and GF developed the manuscript idea. KD and LY collected the data. KD analyzed the data. All authors revised and approved of the final manuscript.UPnGO with ParticipACTION was supported by a multi-sectoral partnership grant from the Public Health Agency of Canada, ParticipACTION, Public Inc., the British Columbia Ministry of Health, and the Ontario Trillium Foundation and AstraZeneca. KD and LY received funding for their work through Mitacs Accelerate Awards in collaboration with ParticipACTION.KD and LY received funding through Mitacs Accelerate Awards in partnership with ParticipACTION. GF was a member of the ParticipACTION Research Advisory Group. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In motor control studies, the 90% thresholding of variance accounted for (VAF) is the classical way of selecting the number of muscle synergies expressed during a motor task. However, the adoption of an arbitrary cut-off has evident drawbacks. The aim of this work is to describe and validate an algorithm for choosing the optimal number of muscle synergies (ChoOSyn), which can overcome the limitations of VAF-based methods. The proposed algorithm is built considering the following principles: (1) muscle synergies should be highly consistent during the various motor task epochs , (2) muscle synergies should constitute a base with low intra-level similarity . The algorithm performances were evaluated against traditional approaches , using both a simulated dataset and a real dataset of 20 subjects. The performance evaluation was carried out by analyzing muscle synergies extracted from surface electromyographic (sEMG) signals collected during walking tasks lasting 5 min. On the simulated dataset, ChoOSyn showed comparable performances compared to VAF-based methods, while, in the real dataset, it clearly outperformed the other methods, in terms of the fraction of correct classifications, mean error (ME), and root mean square error (RMSE). The proposed approach may be beneficial to standardize the selection of the number of muscle synergies between different research laboratories, independent of arbitrary thresholds. Muscle synergies are a valuable tool to understand the mechanisms behind motor control in a quantitative and non-invasive way. Applications range from the medical field  is able to manage a highly complex system with many muscles and joints. Indeed, the basis of this hypothesis is the ability of the CNS to reduce a large number of degrees of freedom of the movement thanks to the combination of a few discrete elements . In othen) as an input, which is not known a priori. Therefore, the factorization is typically run several times, considering different numbers of synergies . The only constraint is that the number of synergies must not exceed the number of muscles (m) considered in the sEMG acquisition (maxn ≤ m); otherwise, the meaning of “synergy” itself would be lost. Afterward, in post-processing, one has to choose the “correct” number of synergies cn (with minn ≤ cn ≤ maxn), i.e., the input that feeds the factorization algorithm providing “good” results, with a “small-enough” reconstruction error. In recent years, the correct number of muscle synergies (cn) has been proposed as a meaningful feature for the analysis of motor control strategies in pathological populations  de dek-meanThe approach proposed in this work was validated both on a simulated and on a real dataset, considering an overground walking task. The performance of ChoOSyn was directly compared against VAF-based methods, in terms of the fraction of correct classification, mean error (ME), and root mean square error (RMSE).Analyzing the simulated dataset, we found that ChoOSyn correctly identified the number of synergies in almost all cases with very small errors. E-VAF and P-VAF methods showed overall performances similar to ChoOSyn. On the contrary, the T-VAF method fails to identify the correct number of muscle synergies. This is probably due to the nature of the dataset: the simulated signals are less complex to factorize, and the VAF assumes higher values already at small numbers of synergies. Indeed, the ME values show that the T-VAF always goes wrong by defect.When tested on the real dataset, ChoOSyn achieved the best performance, with a marked difference compared to the other methods. The ME and RMSE values of ChoOSyn are also much lower than those of the other VAF-based methods. The worst performing methods were T-VAF and P-VAF, which are based on arbitrary thresholds, further highlighting the problem mentioned above. E-VAF, which does not require thresholds, has the best performance of the VAF-based methods.Therefore, we proved that ChoOSyn shows equal (simulated dataset) or even higher  performance in the correct identification of the number of synergies with respect to the methods currently available in the literature. Indeed, the misclassifications are limited and the number of synergies obtained is close to the correct number, with ME and RMSE values comparable (simulated dataset) or smaller  than those obtained with VAF-based methods. Moreover, ChoOSyn operates without thresholds.The number of muscle synergies can also be strongly influenced by other steps of the muscle synergy extraction process, such as the sEMG pre-processing   and the The proposed method was tested on 20 healthy subjects. It would be interesting to test.ChoOSyn both on a larger population and on different cohorts . The need for long-lasting sEMG acquisitions to properly select the number of muscle synergies does not limit the feasibility and applicability of the proposed approach to pathological populations. Indeed, gait analysis is commonly used only in those patients that can independently walk, for at least some minutes, without external supports or walking aids. In the past, several studies demonstrated the feasibility of long-lasting gait data acquisition in patients suffering from different neurological conditions, such as normal pressure hydrocephalus , mild atWe described and validated an algorithm (ChoOSyn) to select the optimal number of synergies expressed during gait, which overcomes the limitations of VAF thresholding methods. The proposed approach may support the standardization of reports, in motor control studies, among different research laboratories. Moreover, ChoOSyn may be applied to different repetitive motor tasks  without any specific need for adaptation to the motor task considered.