Grant funding often drives innovative programming in efforts to enhance diversity in biomedical fields, yet strategies for sustainability of grant-funded biomedical intervention are not well understood. Additionally, as funding agencies shift toward supporting institutional change to biomedical training, less is known about the extent to which sustainability strategies can support long-term institutionalization of the original goals of the grant-funded initiative. The purpose of this study is twofold: to identify strategies used by grant-funded programs for promoting sustainability, and to examine the interrelations between the concepts of sustainability and institutionalization during early stages of grant-funded biomedical career training efforts.We employed a multiple case study design and cross-case analysis using interviews of program administrators and participants from 10 undergraduate institutions that received Building Infrastructure Leading to Diversity (BUILD) awards funded by the National Institutes of Health (NIH).BUILD sites engaged in the following strategies to develop program sustainability: 1) scaling and adapting to expand programmatic impact, 2) identifying additional funding and cost-cutting measures, 3) developing and maintaining infrastructure and structural operations, 4) leveraging relationships and with intra-and inter-institutional partners, and 5) and addressing hiring, policies, and reward systems at the institution. Senior administrative support supported program sustainability and early institutionalization, although we also identified situations where participants felt that they were on track for sustainable changes without administrative support or institutional change. Of the strategies identified, those that involve organizational and infrastructural changes contribute to early stages of institutionalization.This study contributes to literature on organizational change by providing evidence of distinctions and interrelations between program sustainability efforts and institutionalization of change efforts in that some sustainability strategies can overlap with strategies to move toward institutionalization. The findings indicate the importance of program administrators developing early sustainability plans that also lead to institutionalization, as well as an opportunity for funding agencies to develop technical assistance on sustainability, organizational change, and institutionalization as a resource to support program administrators’ efforts toward making lasting, structural change on their campuses.The online version contains supplementary material available at 10.1186/s12909-021-02663-2. Grant funding often drives innovation in higher education, allowing initial project planning, pilot testing, and implementation of science, technology, engineering, and mathematics (STEM) program interventions , 2. Yet,Several national grant-funded initiatives have been developed to support diversity, advance equity, and broaden participation in biomedical disciplines. For example, the National Institutes of Health (NIH), National Science Foundation (NSF), Association of American Colleges and Universities (AAC&U), and private foundations such as the Howard Hughes Medical Institute (HHMI) and the Robert Wood Johnson Foundation have allocated funds to support institutions in implementing science, technology, engineering, and mathematics (STEM) education innovations and institutional transformation. Sustainability, or continuing a program, is critical to maintaining momentum created by the brief infusion of external funds , 8.While plans for sustainability need to be made early, there are also distinctions between sustainability and institutionalization that are important to consider in order to achieve program goals once external funding ends. Sustainability involves maintaining desired outcomes of grant-funded innovations, which may rely on different sources of outside funding , whereasThe purpose of this study is to examine how educational institutions are actively building program sustainability (i.e. maintaining a program and/or desired program outcomes) and engaging in institutionalization efforts  during the early stages of program implementation. We identify how some institutions simultaneously approach the more complex process of institutionalization, requiring broader changes throughout the institution, and also probe how participants think about institutionalization as an aspect of broadening and sustaining change at their institution. We analyzed case study data from 10 Building Infrastructure Leading to Diversity (BUILD) sites during years three and four of a potential 10-year STEM program implementation. Funded by the National Institutes of Health (NIH), each undergraduate institution developed approaches intended to determine the most effective ways to engage students from diverse backgrounds in biomedical research, with the long-term goal of preparing an increased number of students to become potential future contributors to NIH-funded research . By instThe NIH has funded training programs to support the development of a diverse biomedical workforce for nearly 45 years, with most of the funding focused on students . The NIHThe concept of program sustainability comes primarily from health literature. Moore and colleagues  systematIn the health literature, sustainability of a grant-funded program is often modeled as the final stage of a program’s evolution. However, one study found sustainability processes in organizations (i.e. routinization) during early stages of program implementation , suggestInstitutionalization is defined as the processes that embed innovations into permanent parts of the organization  university-wide … we think that is good because students have liked it, their mentors have liked it, near-peer mentors have liked it, and now we have evaluation results... we want to make it a course so that it becomes sustainable regardless of large funding.While they had not yet reached the stage of actually scaling, they had a detailed plan that would easily make this next step toward sustainability a reality. Similarly, California State University, Long Beach (CSULB) was in the process of expanding curriculum through interdisciplinary efforts involving four STEM colleges on campus under an umbrella health-related curriculum that addresses health disparities, and is the first of its kind at CSULB to include faculty and students from such a wide range of departments. A senior administrator noted:Each college has their specific equipment, facilities and so forth … Often, those centers are geared toward supporting their own students and faculty. Now, because four colleges are working together, all those centers and institutes are open to, not only their own students, but students from other colleges as well. That's huge.Although CSULB reported bureaucratic challenges, they saw that their campus culture was shifting toward valuing the interdisciplinary, health-centered approach to achieve goals of increasing the number of underrepresented students in biomedical fields, and thus began trying to sustain this institutional shift by expanding efforts to impact all four colleges.A common strategy was to take a successful program element and looks for ways to scale up or adapt into larger campus programs and initiatives in the early implementation years (year 3–4). Almost all BUILD sites could identify at least one innovation on campus with evidence of success and enough resources on campus to either scale up and increase the number of students and/or faculty impacted, or adapt into a repackaged format that had the potential to achieve the same outcomes. Several sites were beginning to see success with summer research programs, research courses developed specifically for BUILD-affiliated students, and mentorship training sessions for biomedical faculty. In particular, some sites expressed that expanding exposure to undergraduate research opportunities was a major goal where efforts were being directed, but only a few were already at the stage of deciding how to make these opportunities sustainable. One of the administrators at Morgan State University (MSU) elaborated on the process and rationale to employ the strategy of expanding their entrepreneurial-focused research sequence:Another strategy was to focus on sustainability for every element of the BUILD program from the beginning. For example, one program administrator at University of Maryland, Baltimore County (UMBC) noted that their goal was to expand the program to become part of their usual way of operating, “One of our core PIs is constantly saying to us, ‘Think 500 not 50.’ I would say that we have really had sustainability and scalability in the forefront of everything that we’ve done since day one.” UMBC focused on making changes that could be financially sustainable, rather than the approach of using funds to pay for the operating expenses of new innovations. UMBC program coordinators reported that program elements such as the STEM living learning community (acquiring dorm space and adding a student affairs staff member), student advising model, and undergraduate research would be sustained because models for these already existed at the institution and/or required little investment to expand and adapt to reach more students.In the fourth year of funding, the NIH program officers asked sites to think about how to gradually reduce dependence on grant funds each year as the programs matured. Interviews with case study participants show how sites were strategizing around budgets. Strategies mainly focused on seeking new funding for student stipends and undergraduate research experiences, resources to run developed initiatives, as well as finding ways to run programs with reduced funding.We continue to try to solicit funding to continue  scholars to get into Oregon Health and Science University.” A senior administrator said the proposal focused on linking their undergraduates with graduate education to “make sure that we don’t let the momentum that has started from the [BUILD] grant” subside. While a lot of BUILD research experience initially occurred at research-intensive partner sites, grant-funded research projects obtained by a site’s faculty would allow for undergraduate research training and mentoring to continue on these campuses, in addition to providing career development and CV-building for the faculty involved in the grant-writing/awards. The challenge of this strategy is that additional efforts must also be invested in training faculty to submit grant proposals, in addition to having willing faculty who are interested in taking on the added responsibility of running a research project and mentoring student trainees. Participants mentioned the challenge of this goal, especially at primarily undergraduate teaching institutions where faculty have high teaching loads and are often evaluated on their teaching rather than their research. However, many of the sites were beginning to shift policies and reward systems to support faculty research projects, which we discuss further in the section on shifting hiring, policies, and rewards.Stipends provided to students engaged in the BUILD programs were often cited by participants as the most expensive part of program implementation, but a necessary part of recruitment and engagement. Many participants believed that these stipends were critical since underrepresented students’ capacity to engage in scientific skill-building engagement activities within BUILD programs depended on students’ financial resources. A few sites that were trying to sustain scholarship funding mentioned seeking private donors through campus development efforts. However, the level of ease of raising funds appears to vary by biomedical discipline and support of senior leadership. A college of engineering administrator at ReBUILD Detroit mentioned:Our Student Research Center … is something that definitely will stay on campus … but it's going to require funding. One of the things that I suggested is that they're going to have to raise funds, like any student organization. There needs to be funding raised in order to maintain some activities that the organization wants to do, and so I think that they have a plan to do some of that.We also found examples of how sites were simply trying to find ways to reduce costs to continue current programs without changing the structure of the program. UTEP had invested grant funding into developing research-driven courses (RDCs) for first year students, and planned to reduce future costs associated with the courses . As a faculty lead of one RDC at UTEP explained:I think the reality is these courses cost a heck of a lot more money up front to set up than they do to maintain...It won't cost that much to maintain four or five of these as long as we've paid those significant costs upfront to develop that infrastructure to run them … A traditional biology lab is given a TA already. The idea is that these RDCs ultimately will be replacing the traditional biology lab and they would get a TA.While the original RDCs involved initial funding to set up, and BUILD financial support for postdoctoral scholars and graduate students to support the effort, they can be converted to self-sustaining courses. The faculty lead also explained the plan to approach the Office of Research and Sponsored Projects and the Provost to step up and provide sustainable funding to pay for supplies for the RDCs.MSU invested BUILD funding into the development of the Student Research Center (SRC) and hiring a staff coordinator to support the initiative. The student-led and student-run center is open to all undergraduate full-time students with a grade point average of 2.75 or greater. The SRC has a dedicated renovated suite  in the science complex that is a student lounge and meeting space with state-of-the-art technology. Since the SRC is technically registered as a student organization, the salary for the coordinator of the Center will transition from grant funding to student fees. For other program costs, one administrator reported:We had a program called the graduate mentoring research associates … These were graduate students whose job was to directly work with research for undergraduates... It turned out that when we did the analysis on this, the return on investment, so to speak, was not all we had wanted … we were only getting three or four undergraduates per graduate student. [It] was much more effective to go to what we now call our [Research Advising and Mentoring Professionals] RAMPs. So we negotiated this with NIH and with our team and said, “Look, we're going to drop out these graduate mentorship programs in the future. Instead, we're going to put money into the RAMPs and we're going to put money into exporting RAMPs to these other institutions across the United States.Through re-evaluation of innovative practices while considering sustainability, UAF administrators ended up with a financially sustainable innovation that they believed enhanced the program’s impact, thus sustaining and even improving desired outcomes.For the University of Alaska, Fairbanks (UAF) BUILD site, the program evolved in response to evaluation data to build the sustainability of a mentoring component of their program. A program administrator shares the decision process that led to shifting from funding graduate students to developing a new position to mentor and support biomedical undergraduates:In sum, many BUILD sites began the process of securing funding from their institutions or via fundraising to maintain initiatives with promising outcomes, or explored ways to shift program elements and cut costs of the activities.When we first had BUILD, we had a Career Advancement Center for our Office of Career Services, we also in addition to the Center for Undergraduate Research we have a graduate placement office. It's almost like the parallel of a career services, but it's for students who want to go to graduate school. The Center for Undergraduate Research was separate from those two … When you really look at [the work of both centers], there's a lot of overlap … . We combined the Center for Undergraduate Research and Graduate Placement into one thing. It's now a huge name. It's the Center for Undergraduate Research and Graduate Opportunities. We're calling it CURGO. [Administrator] is the Senior Director of the whole thing.Rather than attempting to receive funding for multiple offices that support students that want to pursue graduate studies, they evaluated the duties of the different offices, addressed places where overlap existed, and consequently consolidated the offices to promote sustainability of services. The consolidation strategy not only appears to minimize the amount of overlap between different duties, but also promotes sustainability through limiting the amount of funding needed for personnel of different offices while continuing to achieve goals of serving students.Another strategy for sustainability focused on investing funding into permanent structures to serve biomedical training and research, or examining current organization and structures of programs and offices and restructuring in order to enhance student support. All sites invested grant funds toward building infrastructure such as active learning classrooms, research centers, and labs and lab equipment. Sites were finding ways to maintain staff support and/or coordination needed to operate newly-created centers, classrooms, and buildings. For example, one program staff member at Xavier University discussed the mid-grant strategy of restructuring their centers to maintain career development and other components of BUILD:My feeling is that all will stay in place once the funding is gone. The partnerships between the two institutions, UCSF and SFSU, those [relationships] are stronger. Those connections - once people have met collaborators and worked together on projects, that doesn't change. This year, actually, UCSF accepted more graduate students from San Francisco State than any prior year... The fact that these students are also entering these institutions with a background from San Francisco State, and the curriculum that the SF BUILD put out there, rolled out there, that goes with them wherever they go.Maintaining successful partnerships with pipeline institutions such as high schools and community colleges, as well as with research-intensive institutions where students could gain undergraduate research experience and potentially go to graduate school, were seen as important to sustaining the impacts of BUILD. Participants mentioned the importance of continuing work with community partners due to the synergy of sharing information/skills, resources, and connecting students. PSU developed unique partnerships with community colleges in the Pacific Rim in an effort to support Pacific Islander students’ biomedical career pathways by mitigating challenges to transferring to a four-year institution. For example, Xavier University developed partnerships with research institutions, such as X and Y, to connect their primarily Black biomedical undergraduate students in BUILD with biomedical research opportunities. Some participants shared that the relationships between faculty and staff, organized through the BUILD partnerships were valuable and sustainable beyond the grant. An administrator at SFSU elaborates:I think we have risen to the challenge with all of our various support structures. We actually have co-located our STEM initiative with the [BUILD] EXITO folks all on the same physical location that our office helped to do the renovations for in this minor way. We have a HHMI Howard Hughes Medical Institute grant in the same physical location ...We tried to put all of those types of things [together] ... and the McNair undergraduate program. We have multiple [STEM] programs relating to diversity in higher education in the same physical location.... I think that's going well. [BUILD] was kind of an instigator of [thinking], “how do we take all of these programs that we're doing together and basically have some efficiencies of space?” and try to give [people] opportunities to interact with others outside of their own program.Leveraging relationships with other on-campus programs fostered efficient use of physical resources and knowledge-sharing in order to sustain program goals for all involved. Additionally, newly-created partnerships may also be evidence of the institutionalization process, as structural changes in knowledge- and resource-sharing become embedded into the institutions.In addition to partnerships with other institutions, some campuses took the approach of building program sustainability through connecting STEM initiatives on campus to build networks and foster synergy between people, budgets, and events. A senior administrator at PSU shared how the BUILD grant was the catalyst to aligning all STEM programs on campus, and how they were trying to build sustainability of all efforts to support students in STEM by co-locating services and people, as well as pooling together space and financial resources:One of the things that we have to work on as an institution is our diversity of our faculty … there aren't many private institutions, particularly those who are Catholic and that have faculty unions … many people stay on a lot longer in their careers than they might in another situation. We want to bring in younger faculty members, we want to bring in more diverse faculty members … when we do hire, we hire and look for some of that diversity within our different departments. Students are attracted to institutions where they know that there is the same kind of diversity that they expect among the student body. That's going to be one of our challenges going forward and one that we have begun to work on.Commitment from leadership, in addition to precise insight of the challenges to hiring diverse faculty within UDM’s institution’s unique context are both critical to the development of solutions to achieve this goal. Some sites were already looking to the future by hiring faculty whose values aligned with BUILD goals. One campus, CSUN, was aiming to finalize the approval of a health sciences faculty cluster hire. The goal of the cluster hire was twofold: to invest in an interdisciplinary group of faculty who aligned with BUILD goals to increase the diversity of students entering the biomedical workforce, and second, to hire research-oriented faculty who would have a reduced teaching load in order to focus on obtaining grants in their first few years hired on campus. As explained by a program staff member at CSUN:There is a lot of evidence that cluster hiring does help support increasing diversity … before cluster hiring, our campus had a real push to diversify the faculty … the main goal of cluster hiring is to increase the research activity, so that's our focus. We want to bring in top-notch researchers …Thus, while the context at CSUN already had aspirational values that supported the hiring of diverse faculty, the sustainability of research training required that BUILD focus on hiring diverse faculty who would be able to support the research infrastructural development and training of underrepresented biomedical students.Hiring diverse biomedical faculty, policy changes, and rewarding faculty for shifting behaviors were also important for sustaining changes initiated by the BUILD program. A few campuses noted the importance of faculty recruitment and hiring as part of institutionalization or permanent changes to increase visibility of diverse faculty, and to have more faculty who can teach, mentor, and conduct research training in ways that align with the goals of the BUILD program. An administrator at UDM noted:Now, on the proposal clearance form that faculty have to use when they are doing a routing for their [research] proposals, there is a question that asks [the faculty member] if they have gone through mentor training. If they have put [a] budget in their grants for students, we expect them to go through mentor training because they need to serve as good mentors to these students.Strategies focused on changing policies to incentivize and reward behaviors that support biomedical training of underrepresented groups  are evidence of the institutionalization process. Over time, these practices can become typical expectations for faculty activity at the institution.Aside from goals to hire more diverse biomedical faculty who reflect student demographics, sites also focused on updating policies, evaluations for tenure and promotion, and creating rewards in order to reflect new shifts toward values of mentoring, improving pedagogy in biomedical disciplines, and conducting biomedical research. Many sites identified faculty mentor training programs as important to continue due to varying levels of success in shifting culture on their campuses. Some sites found funds to incentivize faculty to attend mentor and other training and made it required as part of new faculty orientation. Xavier took a unique approach by requiring mentor training for any faculty who apply for research grants with plans to include student researchers:Involvement of senior administrators  and faculty in leadership roles was critical to sustainability efforts because senior leaders were able to prioritize the program’s goals and redirect resources in order to sustain program elements and/or begin the process of embedding program goals into the institution’s operations.At a few of the institutions where senior administrators were part of obtaining the BUILD grant and were involved from the start led to additional investments to support BUILD efforts. For example, the president at WSU  strategically invested $400,000 in the BUILD program, making ReBUILD Detroit the only program where the research-intensive partner completely self-fund its commitments to BUILD. This funding enabled the campus to operate with greater autonomy and flexibility to achieve program goals. It is important to note that the WSU President had previous experience working at NIH (and as a former advisor to the Diversity Program Consortium (DPC) Steering Committee). Thus, the President’s work on diversity initiatives carried over into his leadership of WSU. At UAF, the paradigm that guides the BUILD program—the interdisciplinary One Health Model —is finanI meet regularly with the [campus administrator routinely], but also for BUILD because … he has the responsibility for that, too. In fact, it was interesting when they hired our new [campus administrator], in the (position) description, it was written that part of his new responsibility was the BUILD award.The administration’s responsibility to BUILD is further solidified by one of BUILD’s leaders who stepped out of her position as a campus administrator to work on BUILD initiatives full-time. As a part of her focused engagement, she brought her long-standing cross-campus connections, clout, and a practical understanding of the administrative processes in the institution to sustain program implementation.At other sites, PIs worked to involve senior administrators after they received funding. Challenges to this effort included changes in leadership over time at various institutions. However, what is important is that support from senior administrators was typically needed to obtain institutional funding, in addition to support for the other strategies that we identified for actively building sustainability. A program administrator at CSULB explains the involvement of the upper administration:While institutions with leadership support were able to more easily build and plan for sustainability and active institutionalization of innovations, campuses without institutional leadership support tried to infuse their program throughout the campus in other ways. At one institution a faculty member shared progress made with faculty Critical Race Theory (CRT) training, “As far as faculty go, we already have about a hundred faculty on board, out of the 650 full-time … through faculty affairs, that’s where we were planning to expand the idea of CRT through that mentor training that they do.” This strategy involves garnering wide-spread faculty involvement that will help to sustain initiatives through faculty development in mentor training.I would say it's sustainable because we have people like [faculty and staff colleagues] … who are willing to do the work and are doing the work anyway. Whether or not BUILD is here, they're going to be doing the work. Whether or not they're paid to do it, whether or not they're getting recognition … we are all very invested in these communities. We're not talking about abstract concepts or objects, this is our family … This is everything to us, so this is going to get done by these people whether or not it becomes institutionalized. I can only dream and imagine the work of [a BUILD colleague] and all these people could possibly do if they had the institutional support. If it came down from the president, from the provost saying, "Go for it. Let's do it."At this institution, key change agents were present and invested in STEM equity, however a challenge on their campus in the early stages was obtaining top level administrative support to formalize and institutionalize progress made with the current initiatives. This case underscores how conceptions of sustainability and institutionalization may differ. At this institution, sustainability might include changing faculty mindsets and behaviors from the ground up, resulting in sustained changes at the faculty level without formal institutionalization. Support from senior-level leadership may be include financial support and/or prioritization of faculty training that can further embed this program element into fully supported part of the institution.Another faculty member at the same institution alluded to how upper level administrative support could unleash the potential of dedicated faculty and staff to support underrepresented students in STEM:There was initiation of thinking about ways of creating a more welcoming environment … SF BUILD program then provided additional levels of training and awareness that then spread across the college … So it wasn't just in biology, but now these discussions were being held in math and psychology, and to some degree, chemistry and biochemistry.Whether or not there were tangible plans to continue offering the stereotype training, participants believed that changed values and behaviors would be self-sustaining. Another example of efforts focused on changing values of individuals involved in biomedical education comes from a faculty member at CSUN:Just thinking about training and trickle-down effects … junior faculty many times are looking for mentorship from senior faculty, and when we see senior faculty that are successful in terms of their program of research or that are offering guidance in terms of issues pertaining to [BUILD site’s theoretical framework], I think it creates that continuation of receiving that mentorship from above and then providing that mentorship to your own students. [Those are] aspects that I could see in terms of being able to sustain progress.The belief that changing values and mindsets “trickle down” as a way of sustaining progress of the BUILD program illustrates how some participants conceptualized sustainability without formal institutionalization. Similarly, a ReBUILD Detroit administrator shared:I think the advances that our faculty, the skills that they've learned, in terms of mentoring, in terms of doing research, they will have that now. That will help them for the rest of their career. So I think that that is there. We've learned things that don't have anything to do with continuing funding.A few participants believed that learning that occurred from even one-time offerings of training and workshops, regardless of whether they continued to be offered on campus to additional staff and faculty, was evidence of sustainability. These divergent approaches to sustainability hold promise if engaged faculty have actually changed their behaviors and are a stable part of an institution. A focus on development and training requires that faculty and administrators who have received training actually change their values and behaviors. Additionally, because faculty and staff members who have received training leave an institution sooner or later, it is less likely that the changes would be self-sustaining in the absence continued offerings of training and workshops for newly hired staff and to serve as a booster for already-trained staff.A few participants emphasized that cultural change was an intentional strategy that they believed was critical to long-term program sustainability . Specifically, they believed that espoused values embedded in BUILD initiatives could be passed onto faculty, administrators, and students in order to change behaviors, and ultimately shift the culture of the campus. Thus, even when grant funding ends and many of the created programs will no longer exist, some participants expressed that knowledge left from any training and short-term efforts could maintain a culture that achieves the program goals of increasing diverse participation of researchers in the biomedical disciplines. For example, the SF BUILD site developed stereotype threat training modules in order to familiarize administrators, mentors, students, and faculty with a model that facilitates diversity in the biomedical sciences. One participant described the initiative spreading across campus:This study sought to understand how campuses were building program sustainability and early stages of institutionalization of initiatives that have promise in advancing program goals. We captured a snapshot of the state of BUILD sites, during their third and fourth years of program implementation, prior to knowing whether or not they would receive a five-year renewal of NIH funding. Although site participants often used terms like institutionalization, sustainability, and culture change interchangeably to explain their early efforts to build ways to sustain programs under development and implementation, their different approaches aligned with the concepts in the literature that support sustainability and characteristics of institutionalization as a process . We founOur analysis revealed lessons for moving grant-funded initiatives into regular campus programming and infrastructure. First, we found early evidence of institutionalization processes at many BUILD sites. Specifically, some BUILD sites were attempting to shift the organizational culture on their campuses, create structural and cultural changes, and consider which aspects of their program could be realistically sustained by examining financial, physical, and human resources unique to their contexts. Evidence of early steps towards institutionalization include infrastructure and organizational structural changes to increase biomedical research capacity, new support services for biomedical students, and enhanced biomedical curriculum. In particular, the literature on institutionalization highlights the importance of building organizational infrastructure in order to embed a new innovation . HoweverSecond, actively building sustainability and/or institutionalization is an iterative process, especially in the midst of implementation as program teams problem-solve issues that arise. Adapting and changing is necessary as an institution evaluates what works and how to best sustain the physical and cultural changes to a campus. For example, UAF’s original program that relied on graduate student mentors had to change when the evaluation showed that the model was not financially sustainable, resulting in a new, more flexible and fundable staff position (RAMPS). The intention of UAF to achieve and sustain goals, represents sustainability, but has yet to show institutionalization of these positions over the long term. Although, in combination with UAF’s financial support from senior leadership as a result of the One Health model, UAF began to extend initial research and curriculum initiatives across the institution that made infrastructure consistent with their context and rural/indigenous culture .Third, this analysis suggests that program sustainability may be possible without institutionalization, however, institutionalization may not be possible without program sustainability. For example, some sites were going to continue to support their initiatives with other new grants, rather than obtaining institutional funds. Thus, programs could be financially sustained, but not structurally supported by the institution via financial investment. While some BUILD sites discussed sustainability as the hope of changing the mindsets and behaviors of colleagues involved in biomedical research training, institutionalization requires wider institutional buy-in and accountability. The challenge of one-time training for faculty development aimed at changing practices is that change is unlikely to be sustained nor institutionalized due to turnover of faculty, staff, and leadership. Further, research indicates that those with a more extensive faculty development history show measurably larger changes in their behaviors (e.g. teaching methods) than faculty whose participation is slight, such as a single department workshop .Fourth, we found evidence to support prior findings regarding the importance of leadership  in orderOur research also provides clarity to the organizational change literature on sustainability and institutionalization processes and strategies employed by STEM program administrators; this is important insofar as we provide context for how these concepts interact in the field, something not extensive in prior research. Consequently, our research will provide grant-funded initiatives in STEM examples of how they can embed their program structures and values into the institution for advancing underrepresented student success.There are several limitations to this present study. First, the research team consisted of several members with changes in group membership during various phases of data collection and coding. As a result, various team members had different working knowledge and familiarity with each BUILD sites’ program elements and progress on program implementation. To address this issue, multiple meetings were held throughout the year between incoming and continuing team members in order to establish continuity of knowledge and team organization . Second,Overall, this study provides evidence of distinctions and interrelations between program sustainability efforts and institutionalization of change efforts. We found that program sustainability strategies can overlap with the process of institutionalization, especially strategies that focus on organizational and infrastructural change. When campuses enter the final years of this 10-year NIH initiative, research can assess how the early efforts in creating sustainable programs contributes to institutionalization of innovations to enhance diverse participation in biomedical education and career training. Researchers can also examine the sites that employed the sustainability strategies that overlapped with the concept of institutionalization to determine whether or not their strategies support or begin to modify theories about creating lasting institutional change. For example, CSUN provides an example in the form of attempting to change the culture via faculty mindsets  via raceFor principal investigators of STEM program grants and institutional leaders, findings indicate the importance of developing early sustainability plans that lead to institutionalization. Constant evaluation of both the efficacy of programs and efforts toward sustaining successful aspects of programs can support early institutionalization.For grant funders, including a sustainability plan along with their objectives for institutionalization in RFAs, and providing awardees with resources and suggestions to build sustainability can help mitigate barriers to institutionalization. This study begins to provide needed guidance for these projects. For example, funders can ask questions and provide guidelines for how institutions plan on embedding changes in culture and practices, (e.g. in HHMI’s new Driving Change initiative)  or simplAdditional file 1. Semi-structured Case Study Protocols.


Nigeria contributes the highest to the global burden of HIV/AIDS and also accounts for the largest proportion of new vertically transmitted HIV infections among children. The Mentor Mothers program in the Nigerian Department of Defense was introduced in accordance with the World Health Organization and its implementing partner guidelines to curb the high incidence of vertically acquired HIV infections. Understanding the experiences of participants could serve as a gateway to evaluating the effectiveness of the program to better provide quality services within targeted health facilities. This qualitative study employed key informant interviews with six healthcare workers as well as two focus group discussions with six mentor mothers and six prevention of mother-to-child transmission (PMTCT) patients in four selected hospitals in the Nigerian Department of Defense to explore their experiences of the Mentor Mothers program. A thematic analysis technique was used to analyze the collated data. As a result, four main themes emerged, with the program perceived by most participants as providing psychosocial support to the patients, a valuable educational resource for raising HIV awareness, a valuable resource for promoting exclusive breastfeeding and mitigating vertical transmission of the virus, and functioning as a link between patients and the healthcare system. The participants reported that the program had effectively decreased HIV infections in children, reduced child and maternal mortality, and supported the livelihood and development of women, families, and communities in and around the Nigerian Department of Defense health facilities. In 2017, the Joint United Nations Program on HIV/AIDS (UNAIDS) report revealed that out of the 180,000 new infections among children globally, about 159,000 occurred in sub-Saharan Africa, with Nigeria contributing the largest proportion of about 23% of new infections within the sub-Saharan region , and onlGiven the introduction of global targets and programs to end vertical transmissions of HIV among children and the current global aim to end the HIV epidemic by 2030 ,12,13,14As HIV-positive women who have gone through PMTCT services and are trained to mentor and support other HIV-positive mothers, mentor mothers (MMs) in the Mentor Mothers program of the Nigerian Department of Defense (DoD) provide services that range from HIV prevention, health education, counselling and promotion of HIV testing, tracking lost to follow-up patients, raising awareness, and community involvement to providing adherence counselling. These MMs offer these services through individual counselling as well as other activities in the community and health facilities where they work within the Nigerian DoD health facilities. However, studies that measure or evaluate healthcare workers, mentor mothers, and patients’ experiences of the MMs program targeting PMTCT care remain limited. Two studies assessing mentorship programs that specifically target PMTCT care suggested a reduction in vertical transmission ,19, but The aim of this study was to evaluate and present an analysis of the experiences of healthcare workers, mentor mothers, and patients in the Mentor Mothers program targeting PMTCT practices within the Nigerian DoD. The results of this study will not only be instrumental in improving the effectiveness of services rendered within the Nigerian DoD health facilities but will also form part of suggestions and resolutions to aid the development of a framework to facilitate implementation of the program in the rest of the health facilities that are not utilizing MMs program within the Nigerian DoD.A qualitative descriptive study was conducted to explore the experiences of participants in the MMs program in the Nigerian DoD. This method was deemed appropriate because it is particularly valuable in examining healthcare and other issues related to nursing as it allows for in-depth interviews, questioning, and further probing of participants based on their responses in order to enable interviewers/researchers to understand their thoughts. Moreover, this study focused on gaining insights from categories of participants regarding their experience in the MMs program. To this end, in-depth interviews and focus group discussions were conducted to explore these experiences. As critical stakeholders contributing to PMTCT care and services, this approach is adequate to describe their experiences.The research was carried out in four selected health facilities of the three-armed forces of the Nigerian Army, Navy, and Airforce within Abuja, the Federal Capital Territory (FCT) where PMTCT care and services are provided. With an estimated total population of 3,277,740 in 2020, the FCT is home to 12 military barracks and health facilities. Although they all offer PMTCT services, only six of the 12 health facilities offer the MMs program’s services targeting PMTCT. These include the Guards Brigade Medical Centre, Mambila Barracks; 063 NAF Base Hospital, Airport Road Abuja; and the Defense Headquarters (DHQ) Medical Centre, Abuja. The others are the Lungi Barracks, Gado Nasko Barracks, and Aguyi Ironsi Barracks. The DHQ Medical Centre serves as the coordinating unit for all the Nigerian DoD MMs program in Nigeria. The choice of the selected facilities in Abuja was strategic as Abuja is the administrative headquarters of the Nigerian military medical corps, where the Nigerian DoD MMs program originated in 2014. Although these services were primarily targeted toward military personnel and their families, MMs services are also provided to nonmilitary personnel and their families. A purposeful sampling method was used to recruit participants, consisting of six key informants made up of three doctors and three nurses trained for PMTCT across the selected hospitals, six mentor mothers, and six PMTCT patients. These participants, especially the doctors and nurses, were purposely chosen by virtue of their training and vast knowledge in PMTCT practices. Participants were selected if they had been in the program for a minimum of six months. The inclusion criteria for the patients were that they were confirmed seropositive pregnant women registered and attending antenatal care (ANC)/PMTCT clinics in the selected health facilities with a minimum of four clinic visits and that they had been in the program for a minimum of six months. The table below  shows thNurse managers and hospital administrators were contacted for introduction of the research topic and to gain access to participants. Participants that met the criteria were purposely selected based on their direct involvement in the MMs program in the DoD health facilities. Written and verbal consent to voluntarily participate in the study was obtained from each participant.The research instrument was developed by the researcher after conducting literature review. This process was guided by the World Health Organization (WHO) health system responsiveness key informant questionnaire, key informant survey, and the health system performance assessment (HSPA) tool ,23,24. QEthical approval was obtained from the University of KwaZulu-Natal (UKZN) ethical committee (protocol number 00000186/2009) and the Ministry of Defense Health Research Ethics Committee (MODHREC) (reference number MOD/HIP/G3/230/09). Standard protocols as stipulated in the Helsinki declaration to ensure confidentiality and anonymity were also adhered to throughout the data collection and analysis processes.Interviews of the six key informants were conducted with doctors and nurses, while two focus group discussions were conducted with the MMs and PMTCT patients separately. The interviews were conducted in English language, lasted between 30 and 45 min each, and were sound recorded with the permission of participants. Data was collected between 5 and 14 February 2020.The audio recordings were transcribed verbatim and analyzed using a thematic analysis (TA) approach as described by Clarke and Braun and Rice and Ezzy ,26. The This was achieved by coding and comparing coded data and using thick descriptive data to define resultant themes, utilizing the purposive sampling strategy that also ensured an adequate spread of participants from each of the military health facilities selected for study, and describing the research processes in detail to enable its replication in other settings as required. Being part of a larger research project, the supervisor of the project provided oversight and ensured its dependability. Confirmability was ensured by rechecking the emergent themes generated from the data, using thick descriptive data to substantiate emergent themes, and comparing the data with previous research findings. In addition, the findings from this study were checked with the participants in a follow-up meeting to ensure that the results presented in this paper are a true reflection of the participants’ views. This also improved the trustworthiness of this study. Four main themes emerged from the dataset, as shown in Most of the participants perceived receiving and/or giving a diagnosis of HIV to be a life-altering experience for them because being HIV-positive is mostly associated with infidelity, promiscuity, and/or witchcraft, as reported by most of the participants. As a result, MMs were highly perceived to provide psychosocial support to other HIV-positive women, which helped in reducing the stigma and sense of alienation that these patients were initially faced with. Other participants associated their experiences with the MMs as motivating, encouraging, loving, selfless, compassionate, trusting, and giving them a sense of hope for improvement. As HIV-positive mothers, the MMs in the program understand and have deep empathy for the women they render their services to. They embody the Nigerian DoD MMs program goals and believe that positive change is possible in the country’s poorest communities. They know that if the right information, support, and tools are given, women have the strength within themselves to turn their lives around positively.The narratives below highlight the views of some of the MMs:“It’s all about trust … they really trust us, they believe whatever we tell them. Most of their husbands trust me because I am working with the knowledge I have … With the help of mentor mothers, these women can boldly breastfeed their babies even in the market, in the church, anywhere or even in front of family members who know they are HIV-positive”(mentor mother)“They believe us more than they do the nurses”(mentor mother)On their part, some of the patients related their experiences while appreciating the MMs and the benefits of the program:“When I met aunty C, she encouraged me … she brought me back to life so I am grateful for that … she is compassionate. Some people will look at you and say it is what you did; that’s the result of your bad character. They would be judgmental. It takes somebody who is compassionate to look at you and say there is still a way out without judging you irrespective of whatever thing you might have done”(patient)“Some other people would make you feel bad like ‘after all you are positive’. But she carries us all along. She gives us special treatment. That sense of belonging is one thing I have enjoyed so far”(patient)“She is so lovely. I feel loved … she gives me hope … mentor mothers are patient. They have this type of patience that I cannot describe. Even when you are crying for nothing they keep calming you down”(patient)“I am so loved. I don’t even know what to say”(patient)The healthcare providers also acknowledged the usefulness and success of the MMs program in promoting and cultivating effective PMTCT care and services:“The mentor mothers have the confidence, they can come out and say ‘yes, I am one of you and if you follow PMTCT guidelines, you will stay alive, you can live a positive life’. And people are really motivated by that … The Mentor Mothers program is good and should be sustained because the mentor mothers are doing a great job”“The patients would describe it as interesting because it has helped them gain confidence in themselves, in their marriages, and in life generally. Like there is this hope, you see. Suddenly the clients will move from being sad and unhappy to being interested and lively once again”The findings of this study also revealed that MMs were perceived as a key educational resource for raising awareness and educating women about HIV. Consequently, most of the participants considered the MMs program as an important channel of information and source of insight about HIV. Their experiences were reported as having access to the right information, educating mothers, acquiring knowledge, sensitizing patients, raising community awareness, and empowering patients. Therefore, by taking advantage of the MMs’ community involvement and expanding educational platforms, the Nigerian DoD MMs program focuses on raising awareness of HIV and reducing its prevalence and social stigma.“One of the primary things that we do is counselling. This counselling cuts across every aspect. The education of the patient about how the disease can be contracted, the prevention, the complications if they do not take their drug, and the side effects of the drugs”The findings from this study highlight that HIV-positive women who have used healthcare services to prevent vertical transmission of HIV have first-hand experience, which is instrumental to the facilitation and implementation of PMTCT in the Nigerian DoD health facilities. This places them in a position to better educate other HIV-positive women, acting as experienced peer “mentors” for women accessing PMTCT services and their families by providing emotional support, education, and advice . These r“We counsel them to the point that they are interested in helping others. They reach out to other positive mothers and talk with them, educate them, and give them enough knowledge for them to understand that it is possible to have an HIV-free baby even when the mother is positive”“We give them adherence counselling right from the day they are declared positive. This is followed by home visits. We visit them to know how they are taking their drugs … we follow them up and based on that they are doing very well”MMs were perceived by all the participants as a valuable asset in promoting exclusive breastfeeding, mitigating vertical transmission, and promoting healthy living among HIV-positive women. PMTCT patients within the Nigerian DoD MMs program are advised to breastfeed exclusively for six months and adhere to treatments and all the protocols required. The MMs and staff reinforce this advice and follow up feeding practices and treatment in the PMTCT patients’ homes. The findings from this study revealed that PMTCT patients were in general more positive toward early antenatal check-ups, and all the participants associated these positive outcomes to the influence of the MMs. The findings further revealed that MMs encouraged patients to adhere to their treatment plan and healthcare, test their children after delivery, return to the health facilities for their children’s test results, and adhere to postpartum PMTCT protocols. Thus, instilling hope in PMTCT patients by MMs was just as significant as giving practical advice on daily issues, which promotes or results in positive outcomes.This was corroborated by these participants:“…formally our children were turning out positive … before I became the focal person here there were lots of positive babies, but these days, hardly will you see any positive baby. Since this mentor mother came, we have not recorded any positive baby from our unit. Whenever patients come to the clinic, they always appreciate us, they appreciate the mentor mother in our facility”“PMTCT is functioning very well. Recently, people have the confidence, the belief that when they are adherent on their medication they are most nearly absolutely sure they are going to have a HIV negative baby. The tracking is reduced, they all just come by themselves. Maximum is a day or two they miss their appointment”“This program is okay… Mentor Mothers and PMTCT…. great job. I want the program to continue so we can achieve that zero transmission level”“The program has helped mothers live well … most mothers feel they will not give birth again…but with education by this mentor mother to live healthy, you can give birth to as many children as you like. Provided you keep to the rules, your children will come out healthy. The contribution of the mentor mothers to this program is very good”(patient)Distrust toward healthcare workers and treatment was common amongst most patients in the Nigerian DoD MMs program. Despite knowing that the treatments are reliable, many of the patients were at first reluctant to follow the protocols and instructions given to them. At the time of the study, the facilities’ ART pharmacies were separated from the rest of the hospital pharmacies, with most clinics having separate days or sections for HIV-positive patients for refilling and counselling, which most patients perceived as a reason for lack of confidentiality. However, with the help of MMs sharing their personal experiences with patients, they served as a link between the patients and the healthcare system. As a result, the MMs program in the Nigerian DoD functions as a bridge between patients and the healthcare system, thereby promoting a healthy environment for patients to have access to quality healthcare services in the facilities. It also fills the gap between patients in the community and healthcare services and focuses on HIV awareness and stigma reduction. In other words, the program focuses on advocacy, promoting patients’ rights, teamwork, healthy work relationships, and promoting access to quality care. Hence, most participants perceived MMs’ roles not only as filling the gaps that the healthcare system and the community could not fill but also as educating women on nutrition and feeding practices, facilitating healthy relationships, and providing referrals within the facilities when necessary. In addition, the MMs were perceived as a source of hope and encouragement by helping participants cope with their HIV status, something that some team members could barely provide for HIV-positive women. One of the MMs cited such an instance:“Even though they have been trained, some still have misconceptions about HIV. Some of them still believe that the child has traces of HIV, so in those kinds of doubt, they fall back to us, we that are positive and have had negative children”(mentor mother)Another MM substantiated the above:“I have been able to take away fear from our women by encouraging them. Some left school due to fear. I protect my women … many families depend on us as mentor mothers”(mentor mother)Again another MM validated the above narrative:“Because we have a good rapport with them, they trust us … we protect them in the various sites so they come to clinic with boldness knowing the mentor is there … No mentor mother, no PMTCT. It’s just that simple”(mentor mother)From the above narratives, it is implied that there is an expectation for professionalism within the organization to be maintained in order to build trust and good patient–provider relationship. Such a professional commitment was also verified by most of the participants as reported below: “Follow up, good result, encouraging them, and making sure that the confidentiality of these patients is maintained … those are the things that are encouraging the patients to fulfil good interpersonal relationship”“Those that access care here are very comfortable because they can walk in at any time and meet a particular set of persons and there is no breach in confidentiality”“They look out for the way you receive the patients, whether you maintain confidentiality or attend to them well”The findings of this study suggest that all participants credit the role of MMs as being effective and instrumental in achieving the goals of the MMs program within the Nigerian DoD PMTCT care and services. These findings not only portray MMs and the program as a key educational resource for educating women about HIV but also reveal that antenatal patients in MMs programs are more likely to return for testing compared to mothers not in the program; among those tested, mothers in a MMs program are more likely to return for their test results. This is largely because of the psychosocial support and HIV awareness that MMs provide to patients. This includes the facilitation of HIV education through community involvement and group health talks, referring clients to PMTCT, HIV care and treatments as needed, maternal and child health support, providing counselling to HIV-positive women and couples, and follow-up with clients who have missed clinic visits for PMTCT. Thus, the findings of this paper highlights that highly structured MMs program further improves uptake and successful completion of PMTCT services within the Nigerian DoD. Similarly, an analysis of mother support groups and MMs programs in countries like South Africa, Kenya, Mozambique, Nigeria, Ethiopia, Malawi, Zimbabwe, and Democratic Republic of the Congo (DRC) have revealed that support groups and MMs play a key role in ensuring a smooth continuum of care for HIV-positive mothers and their children, with MMs programs and/or mother support group participants having better PMTCT outcomes and reporting psychosocial wellbeing more often compared to others ,34,35,36The results of our study suggest a high level of satisfaction and positive outcomes from the MMs program orchestrated by the Nigerian DoD for facilitating PMTCT care and services. The participants considered the MMs program as an important medium of information and source of knowledge about HIV. They reported that access to the right information and education adequately equipped them with the right knowledge and sensitization to raise community awareness in the prevention of pediatric HIV infections. Therefore, the present evaluation of healthcare workers, mentor mothers, and patients’ experiences of the Nigerian DoD MMs program revealed that women in the MMs program report more self-efficacy and motivation, improved retention, empowerment, and increased disclosure of their HIV status, which is a positive sign that the program is achieving its goals. Due to the regimented nature of the Nigerian military, very limited information exists in the public domain on prevention of mother-to-child transmission of HIV using mentor mothers in the Nigerian DoD. In addition, research of this nature has not been conducted before now in the DoD, so researchers had limited literature on this subject in the DoD.Very few studies have previously addressed the experiences of healthcare workers, mentor mothers, and patients. The unavailability of adequate literature therefore limited extensive presentation of the discussion of findings in this study. The study was limited to Abuja, the Federal Capital City of Nigeria, which was chosen because it is the administrative headquarter of the Nigerian Military where the MMs program was implemented in 2014. However, due to the specific number of participants in this study, coupled with the fact that the study was conducted in one region of the country, the study findings cannot be generalized. It is suggested that further research be conducted in other DoD facilities to further explore the MMs strategy for PMTCT.The following were limitations of this study:Further research should also be conducted on the impact of the MMs program in the community. In addition, community awareness of MMs programs for PMTCT and its effectiveness should be investigated to measure the knowledge of women and mothers of childbearing age about PMTCT practices. This can provide insight on which areas and population groups to direct PMTCT care and services.


Healthy aging with dignity and aging in place are important for Taiwanese individuals. Although Taiwan did not experience COVID-19 outbreaks prior to May 2021, many older adults have been encouraged to stay at home since the beginning of the global pandemic in January 2020. Such shelter-in-place recommendations have resulted in significant lifestyle changes, limiting activities associated with aging with dignity such as exercise and community engagement. Few studies have explored how to promote or maintain holistic health practices and physical fitness in older adults residing in rural communities during the COVID-19 pandemic. This pilot study aimed to establish an interdisciplinary collaboration with community care workers (CCWs) and evaluate the impact of an innovative summer camp (ISC) program for older adults residing in rural areas.t-test was used to measure changes in physical biomarkers, pulmonary lung function, and health-related fitness changes.A quasi-experimental pre-post-test design with an interdisciplinary collaborative approach was implemented. The ISC program was based on a standardized protocol of modified Baduanjin exercise combined with three recreational breathing games. Participants were recruited from three community centers around the western coastal region of Yunlin County between June and August 2020. The ISC program was designed and executed by a nurse-led health promotion research team that collaborated with trained CCWs for 90 min per day, five days per week, for 12 weeks. Participants and CCWs wore facemasks during all activities. Paired in situ, and stand on one foot with eyes open. Most participants reported that they felt happy, satisfied, and hoped that this program would be continued in their community center.Sixty-eight participants completed the ISC program. The ISC program significantly improved the participants’ physiological biomarkers and health-related fitness, including reduced body weight, waistline, and systolic blood pressure, and increased forced vital capacity, biceps arm flexion, and ability to sit and stand from a chair, step with a knee up This interdisciplinary, collaborative ISC program improved physical biomarkers and health-related fitness in older adults. Despite limitations, results strongly suggested that primary healthcare providers and CCWs can employ the described ISC program to promote wellness in older adults. In Taiwan, the average life expectancy at birth is 81 years ; however, the healthy life expectancy at birth is 71 years , 4. FurtPrevious studies have indicated that adopting regular exercise has health benefits including improved lung function and reduced incidence of most non-communicable diseases, especially in the aging population –9. AgingDue to the global COVID-19 pandemic and subsequent shelter-in-place recommendations, many community-based activities have become limited, including group exercise and socialization. Related lifestyle changes have negatively impacted many individuals’ quality of life, including older adults. Although zero domestic COVID-19 cases were reported in Taiwan prior to May 2020 [A single-group, quasi-experimental, pre-post-test study design was applied in three rural villages in western coastal Yunlin County. Originally, we sought to evaluate the efficacy of the ISC program by comparing ISC participants (treatment group) with a group of older adults who were not offered ISC participation (control group). After the conclusion of the three-month study period and data collection, we planned to offer the ISC program to the control villages. However, community leaders in the participating communities objected to control group participation and requested ISC program administration for their communities as well. Thus, a designated control group was not included in this study.Participants were recruited from three rural community activity centers between June and August 2020. The nurse-led research team designed the ISC program and trained CCW collaborators prior to conducting the program. The ISC program comprised of a standardized protocol of modified Baduanjin exercise combined with three recreational breathing games. Typically, traditional Baduanjin consists of eight separate activities; however, due to the complexity three of these sections, we developed a modified Baduanjin exercise protocol that eliminated these sections and was shortened to five parts. In addition to participation in Baduanjin, older adults were provided with games, tools, and toys from their childhood and were offered recreational activities and lunch before returning home. Each week, the ISC program was designed and conducted by the research team. ISC programming lasted approximately 90 min, including 30 min of modified Baduanjin exercise, 30 min of table tennis, blowing games, and elephant-trunk paper flute (similar to a common pulmonary rehabilitation game), and 30 min of karaoke competition . Furthermore, we video recorded these sessions and shared ISC activities with other CCWs via YouTube in order to train them for the subsequent four days of activities each week. The inclusion criteria were as follows: (1) able to access the community center by walking or transportation (2) able to communicate in Mandarin or Taiwanese, and (3) agreed to participate in this study and signed the informed consent form.Demographic characteristics and health-related behaviors included age, sex, education level, occupation, and living arrangement. Based on the previous studies [ studies –3, partiLung function tests were performed by a certified respiratory therapist and experienced technician  using an automated flow-sensing spirometer  based on the American Thoracic Society recommendations [ndations . Three indations .Health-related fitness assessment was based on measures for the implementation of National Fitness Testing by the Ministry of Sports Education for older adults. The assessment checklist primarily focused on evaluation of the participants’ cardiopulmonary function and physical fitness using the following metrics: (a) upper limb muscle strength and endurance (duration times of biceps arm flexion for 30 s); (b) leg muscle strength and endurance (duration times of sitting and standing for 30 s); (c) cardiorespiratory endurance (duration times of raising the knee and stepping on the spot for 2 min); (d) shoulder softness (back grasp test); (e) lower limb softness (sitting on the chair and bending forward); (f) static balance ability (standing on single foot with the eyes open); (g) physical agility and dynamic balance ability . According to the standardized test by the Ministry of Sports Education [ducation , points  This study was performed in accordance with the Declaration of Helsinki and was approved by the institutional review board of the ethical committee of Chang Gung Memorial Hospital Foundation (IRB: 202000109B0). Participants who agreed to participate in the study provided informed consent in the form of a written consent form. Illiterate participants provided informed consent following oral presentation of the written consent form which was then signed by their guardian or companion following their permission to sign on their behalf. Before conducting the study, the research team  conducted a general health assessment via a checklist  to determine whether he/she was eligible to participate in this program. The checklist was recorded and continued by a CCW for another four days per week. The study’s purpose and procedures were explained to all participants, three village leaders, and all CCWs. The village leader sent messages regarding the information and invited individuals to participate in this study. Upon agreeing, one-to-one measurement was conducted at each community activity center before and after this study.The research team described the study procedures to all participants, including opening the windows, wearing surgical facemasks except when drinking water or participating in recreational breathing games, keeping social distance, the procedure of the lung function test, and health-related fitness , 22. Thet-test , the sample size was set at 55, which was calculated by the G*power 3.1.9.2 version, when the effect size = 0.4, α = 0.05, and power = 0.90. Due to the limited literature concerning similar interventions, we opted to use a medium effect size to calculate the sample size. Considering the 20% retraction rate, 82 participants were recruited for this study. The paired t-test was used to compare the mean difference in the physiological biomarkers . Data analyses were conducted using SPSS 20 .Based on a two-tailed p<.01). Regarding health-related behaviors before conducting the program, 26.5%, 44.2%, 41.2%, and 55.8% reported that they infrequently consumed enough servings of vegetables, fruit, or water, or participated in exercise regularly, respectively. In addition, 17.7% of participants indicated that they lived with cigarette smokers.The criteria were met by 85 older adults at the beginning of the study, of which 13 were excluded due to attending <70% of the program and four were excluded as they moved to a different county. Finally, 68 participants completed the study. The mean age of the participants was 73.9 years . Most participants were women (66.2%), 47.1% were illiterate, and 36.8% were living alone (Table p<.05), waist circumference , systolic blood pressure , forced vital capacity ; forced vital capacity predicted , and forced expiratory volume in 1 s predicted  significantly improved. As shown in Table p<.01), sit and standing from a chair , stepping with a knee up in situ , and standing on one foot with the eyes open  were significantly increased after the three-month intervention.Table n=66) of participants responded positively that they were happy and satisfied with the program . Only two participants complained, stating “I felt uncomfortable when wearing a facemask during exercise…” Furthermore, three CCWs also gave positive feedback, including “Thank you so much for teaching us how to handle the program… the recreational games are so funny and are not boring to the older individuals… so… they love coming here… I felt they were happier than before… hope your team continues to support our village…”. When we asked each participant the general question, “how do you feel/ are you satisfied with this program?,” 97.1% (This pilot study explored the effectiveness of an innovative, interdisciplinary ISC program that combined modified Baduanjin exercise and three recreational breathing games for older adults in rural communities. Although this study has some limitations with respect to the study design, the present findings indicate that after twelve weeks of participation in the ISC program, lung function parameters and health-related fitness were significantly improved. Thus, this pilot study suggests that similar programs may be effective in improving physical health and wellbeing in older adults residing in rural communities. However, due to the lack of a control group and the relatively small sample size, further studies are necessary confirm these results.The present findings are similar to results of previous studies that demonstrate that sequential movements of modified Baduanjin exercise, blowing games, and karaoke competition have beneficial health effects including reducing obesity, waist circumference, and systolic blood pressure, and improving lung function and feelings of happiness –19. PrevThe present findings were similar to those of a study conducted in Japan by Miyazaki and Mori  that fouAlthough some studies had challenged the safety and efficacy of wearing facemasks as a preventive measure for COVID-19 –25, all The present study had some limitations. First, the absence of a control group and the potential threats to the internal validity of the instrumentation must be considered, as these might limit the generalization of the findings. Thus, future studies must include a control group. Second, the sample size was small, and the population selection was not entirely random because all participants belonged to three communities from a single county. Third, the potential for a social desirability response bias also needs to be taken into consideration.This pilot study with an interdisciplinary collaborative approach supports the benefits of this simple, low-cost ISC program in improving physiological biomarkers, health-related fitness, subjective feeling of happiness, and satisfaction in older adults residing in rural communities. During the execution of the ISC program, no one was infected by COVID-19, suggesting these activities are appropriate despite modified safety precautions due to the COVID-19 pandemic. However, it is necessary to conduct further studies with both experimental and control groups to further evaluate these findings.


PurposeThe purpose of this study was to quantify the number of surgical programs currently training osteopathic residents and to solicit advice for current osteopathic medical students who are interested in pursuing a surgical residency. MethodsA questionnaire was sent to all listed Electronic Residency Application Service® (ERAS®) email contacts for the following specialties: General Surgery, Neurological Surgery, Orthopedic Surgery, Otolaryngology, Urology, Integrated Vascular Surgery, Integrated Plastic Surgery, and Integrated Thoracic Surgery. The questionnaire was sent a total of three times.ResultsTwo hundred sixty-four of the 1,040 surgical residency programs responded to the questionnaire. Of these responses, 19% were formerly American Osteopathic Association (AOA) accredited programs. About 47.3% of responding programs indicated they are not currently training an osteopathic physician. One hundred thirteen programs provided additional comments on how osteopathic medical students may improve the competitiveness of their residency applications. These comments included increasing volumes of research activities, performing well on the United States Medical Licensing Exam (USMLE), and completing a sub-internship in the desired field or at a specific institution. ConclusionOsteopathic students still face many barriers to matching into surgical residencies. This study provides concrete steps students may take to increase the competitiveness of their application. As osteopathic medical schools have expanded, osteopathic medical students now make up greater than twenty-five percent of all matriculating medical students, naturally leading to an increase in osteopathic applicants to competitive residency programs . DespiteIt is important to note that the year 2020 marked the first year where all applicants to post-graduate medical and surgical training participated in a single match process. Prior to single accreditation, osteopathic graduates had the option of participating in either the NRMP or the American Osteopathic Association (AOA) match. It is unclear what the effects will be on osteopathic physicians applying for and matching into surgical specialties with single accreditation now being completed.The primary goal of this study was to characterize attitudes of surgical residency program decision makers toward osteopathic applicants by assessing the prevalence of osteopathic residents in their programs. A secondary goal was to provide recommendations for osteopathic applicants to increase the competitiveness of their eventual applications to surgical residency programs.This study was determined to be an IRB exempt study by the institutional review board at East Tennessee State University. In October 2020, as a part of the American College of Osteopathic Surgeons (ACOS) Strategic Planning efforts, the ACOS Medical Student Section sent a questionnaire to the listed email contact for each surgical residency program in the Electronic Residency Application Service® (ERAS®). Responses were requested via email from representatives of residency programs in General Surgery, Neurological Surgery, Orthopedic Surgery, Otolaryngology, Urology, Integrated Vascular Surgery, Integrated Plastic Surgery, and Integrated Thoracic Surgery. Emails were sent to the listed contacts separated out into respective specialty groups using the blind carbon copy feature. Three separate attempts were made by email each month from October to December 2020 to obtain the data. Responses were stored in Google Forms.The questionnaire requested answers to the following items: institution name, specialty, location, respondent name, and role. Participants were asked for responses to the following:(1) Do you have any osteopathic residents in your program? If yes, how many?(2) Do you find graduation from an osteopathic college of medicine a strength?(3) If the answer to either of the above questions is “no,” what can osteopathic medical students do to be more competitive for your program?Analysis was performed to determine if the program is currently training an osteopathic physician, and the percentage of responding programs without a current osteopathic resident was calculated. Microsoft Excel  was then used to generate a geographic heat map of the number of programs currently training osteopathic physicians by state. Additional comments given by the respondents were then assessed in order to appropriately categorize the responses.Overall results A response was received from 264 (25%) of the 1,040 surgical residency programs participating in the 2021 NRMP cycle across the aforementioned specialties. Program directors made up 28.3% of the responses, with the remaining responses being by program coordinators. Roughly 19% of responses (50 of 264) were from programs formerly accredited by the AOA. Overall, 47.3% of responses indicated their program is not currently training an osteopathic physician. Table Figure Of all the responses to the questionnaire, 38 programs 12.5%) suggested students should perform more research. Forty-five programs (18.9%) place emphasis on osteopathic students completing a sub-internship in their desired field or program to increase their competitiveness. Finally, 38 programs (14.4%) recommended that students complete and/or perform well on the United States Medical Licensing Exam (USMLE) in addition to the Comprehensive Osteopathic Medical Licensing Exam (COMLEX). Suggestions regarding how osteopathic students can become more competitive were not provided by 143 programs (54.1%). Figure .5% suggeGeneral surgeryA response was received from seventy-three of the 313 general surgery residency programs participating in the 2021 NRMP cycle, or approximately 23.3% of all programs in the United States. Roughly 27% of responses were from programs formerly accredited by the AOA. Eleven responses (15%) indicated that their program was not currently training an osteopathic physician. Michigan, New York, and Ohio are the states that currently have a larger number of programs training osteopathic physicians . Thirty-three percent of responses were from programs formerly accredited by the AOA. Seventeen (37.8%) of the responses indicated that their program was not currently training an osteopathic physician. A heat map  participating in the 2021 NRMP. Three of thirty-three responses (9%) were from programs formerly accredited by the AOA. Twenty-two (66.7%) of the responses indicated that their program was not currently training an osteopathic physician. The state identified as training the largest number of osteopathic physicians was Texas  Otolaryngology residency programs. Seven 20.6%) of thirty-four responses were from programs formerly accredited by AOA. Twenty-two (64.7%) of the responses indicated that their program was not currently training an osteopathic physician. Michigan, Ohio, and Pennsylvania have the largest number of programs currently training osteopathic physicians  of the 138 Urology residency programs. Six (14.6%) were from programs formerly accredited by the AOA. Twenty-three (56.1%) of the responses indicated their program was not currently training an osteopathic physician. The states identified as training the most osteopathic physicians were Michigan, Illinois, and Texas A response was received from 16 (26.6%) of the 60 Integrated Vascular Surgery residency programs. No programs were formerly accredited by the AOA. About 62.5% indicated that their program was not currently training an osteopathic physician. Analysis showed the states of California, Minnesota, Missouri, West Virginia, New York, and Massachusetts each have a single program that is currently training an osteopathic physician Figure .Plastic surgery (integrated)Seventeen (21.25%) of the 80 Integrated Plastic Surgery residency programs provided responses. No programs were formerly accredited by the AOA. Fourteen (82.3%) of the responses indicated that their program was not currently training osteopathic physicians. Minnesota, Indiana, Ohio, and Florida each have a single program that is currently training an osteopathic physician Figure .Thoracic surgery (integrated)Three (9%) of the 33 Integrated Thoracic Surgery residency programs responded. No programs were formerly accredited by the AOA. Two of the responses indicated that their program was not currently training an osteopathic physician. A heat map was not generated as only one program had given an affirmative response. Kentucky was the only state identified from respondents as having an osteopathic resident trainee.The goal of the current study was to provide specialty-specific advice to medical students directly from residency programs in regards to the residency application process. Both the literature and the NRMP outcomes data align closely with the responses to our questionnaire, as both matched osteopathic and allopathic medical students shared similar USMLE step 1 and 2 scores and volume of research experience ,6.Schlitzkus et al. (2012) highlight their study comparing the characteristics of allopathic and osteopathic applicants to an allopathic general surgery residency program. Interestingly, their results showed no significant differences between allopathic and osteopathic applicants, even noting that osteopathic applicants averaged a significantly higher USMLE step 1 score compared to their allopathic counterparts . These rIn a 2008 study, Melendez et al. determined that the most important factors for resident selection were the interview, USMLE step I scores, letters of recommendation, and alpha omega alpha (AΩA) membership . The resLikewise, fourth-year medical students also view the sub-internship, also known as an audition rotation, as an important piece of their residency application. According to Winterton et al., as many as 58.7% of fourth-year medical students completed an audition rotation in their 2016 study . JacobsoAs suggested by this study and multiple surgical specialty organizations, research is an important selection factor for residency programs. Upon review of the US News and World Report research rankings, osteopathic medical schools do not appear to have adequate research opportunities when compared to larger institutions, suggesting that osteopathic applicants have to look elsewhere for this experience . Though There are many components to a residency application packet, however, and the required board exams remain a significant factor in the decision to interview and rank applicants . AllopatWith the USMLE step 1 exam transitioning to pass/fail scoring in the near future, there are concerns that this change will have disproportionate impacts on osteopathic medical students and international medical graduates who aim for high step 1 scores to become competitive applicants . This chWhile some institutions do not currently have an osteopathic resident within their program, it was indicated that they had simply not had many osteopathic candidates. This may be due to a lack of osteopathic medical schools in the area, exposure to certain programs, or an applicants' held bias that a lack of an osteopathic resident is a red flag. Based on the feedback received in this questionnaire, we suggest that osteopathic medical students focus on applying to programs that they are truly interested in, rather than assume programs will not give their application a fair review. As of 2021, there are currently thirty-seven osteopathic medical schools in fifty-eight teaching locations in thirty-three states . Now thaTable LimitationsGiven the nature in which the data were recorded by a questionnaire, the results may not be completely applicable to the residency programs that did not respond or provide feedback for osteopathic medical students to increase the competitiveness of their applications. There are several potential limitations to consider that may have led to a suboptimal response. These possibilities include inaccurate contact information on the ERAS profile, inability to reach a program contact due to an institutional firewall, or declining to respond. Additionally, only 28.3% of all responses were received from program directors of their residency programs. Though program coordinators are likely knowledgeable on program policies and recruitment strategies, there may still be different perceptions on what makes an applicant competitive between program directors and coordinators.For those who intend to apply to a surgical specialty, this study produced several actionable items to improve the competitiveness of their application, including completion of and performing well on USMLE step exams, completion of a sub-internship in the desired specialty and/or at a specific institution, and an increase in research experience and publications. Osteopathic medical students applying to surgical specialties should utilize all of the resources at their disposal to best prepare for application to competitive surgical residency programs.