Paratuberculosis, or Johne’s Disease, occurs worldwide, causing a granulomatous enteritis in ruminants. Control programs, which operate mainly on a voluntary basis, have been established in several regions. In Thuringia, a federal state of Germany, a voluntary control program was firstly established in 2003 and revised in 2008 and 2015. This study aimed at evaluating the results achieved in voluntary Johne’s Disease control in Thuringia between 2015 and 2020. By the end of 2020, a total of 67 dairy herds with approximately 33,000 dairy cows and 87 suckler herds keeping approximately 6000 cows of beef breeds were enrolled, representing 35% or 16% of the population, respectively. In affected herds, the program focused on prevalence reduction by hygienic measures to break the infection cycle, annual testing for the detection of animals shedding the infectious agent and culling of these animals. A certification pathway was established based on a testing period of 3 years without positive results, and 58 herds were certified as ‘non-suspect’ with respect to Johne’s Disease. Analyzing the annual calf mortality rate in enrolled dairy farms revealed that herds that had been certified as ‘non-suspect’ regarding Johne’s Disease had a lower calf mortality rate than herds that were not enrolled in the program.The Thuringian Johne’s Disease (JD) Control Program provides a voluntary approach to JD control in Thuringia, a federal state of Germany. The program has three objectives: reduce the level of infection when present; reduce the spread of JD to uninfected herds; and facilitate the certification and protection of herds that are non-suspect with respect to JD. The program offers pathways for the management of affected herds and for certification of herds with continuing negative tests. After the control stage (CS), a certification stage of at least 3 consecutive years with continuing negative results in the annual whole-herd test has to be passed until a herd can be certified as ‘non-suspect’ with respect to JD. This study focused on calf mortality in relation to JD herd status. In a longitudinal study, the association of annual calf mortality rate of a total of 93 dairy herds  over 10 consecutive years with JD herd status was investigated using a generalized mixed linear model with repeated measures. Non-suspect herds had a lower calf mortality rate compared with other farms. We conclude that establishing JD control measures lowers the calf mortality rate. Mycobacterium avium subsp. paratuberculosis (MAP). The disease occurs worldwide, mainly in ruminants. Clinical signs are mostly nonspecific, unless intermittent diarrhea, oedema caused by protein deficiency and weight loss despite regular appetite occur frequently. The incubation period lasts up to ten years [Johne’s Disease (JD), or paratuberculosis, a chronic granulomatous enteritis in cattle, is caused by en years ,2. Decreen years ,4,5, whien years ,7. In oren years .Because of its impact on animal health, its untreatable nature and the zoonotic aspects, the strategic control of JD has a far-reaching history. Early programs to control JD were set up in France in the 1920s, followed by Great Britain and Iceland in the 1960s . OrdinanBased on the Regulation (EU) 2016/429 of the European Parliament and of the Council of 9 March 2016 on transmissible animal diseases and amending and repealing certain acts in the area of animal health , JD was a listed and, according to article 18, a notifiable disease in the European Union and a need for surveillance within the European Union was stated .The Thuringian program has three objectives: reduce the level of infection when present; reduce the spread of Johne’s Disease to uninfected herds; and facilitate certification and protection of herds that are non-suspect with respect to JD ,13. In aCryptosporidium parvum or Escherichia coli. Often these infectious agents cause more severe clinical signs and health risks in calves than JD and may enhance farmers’ willingness to improve suboptimal hygiene [As JD is only one of several infectious diseases which are associated with lack of hygiene, measures that improve hygiene in order to prevent infections with MAP will likely also have positive effects on the occurrence of fecal-orally transmitted infections such as Rota- and Coronavirus,  hygiene . A posit hygiene . In addi hygiene . The ann hygiene .The aim of this case study was (1) to evaluate the progress of the Thuringian JD control program during the phase from 2015 to 2020 and (2) to investigate a possible association between the annual calf mortality rate and JD herd status within the Thuringian JD control program. We hypothesized that the annual calf mortality rate was associated with JD herd status.At the end of the reference period 2015–2020), the cattle population in Thuringia consisted of 293,862 cattle with 91,041 dairy cows and 37,644 cows in beef suckler cow-calf herds. About 84% of the dairy cows were pedigree bred, mostly of the German Holstein breed with a minor proportion of Simmental, Jersey and Brown Swiss 15–2020, . The aveDairy farms in Thuringia were mainly cooperative farms. Large dairy herds with more than 500 cows are typical for the dairy industry in Thuringia. About 60% of the cows were kept in those herds. Herds with ≤200 cows represent 10% of the population, and herds with >200–500 cows represent about 30% of the population [Beef herds were mainly operated in a suckler cow-calf system, with an average herd size of 16 cows. Simmental was the most popular breed. Disregarding several large herds, hobby or part-time farmers operate the majority of beef herds. A relevant percentage was engaged in pedigree breeding with a long tradition for beef-type Simmental breeding.Until 1990, nearly no cases of JD were registered in Thuringia. The ‘iron curtain’ prohibited not only free travel for inhabitants but free animal trading as well. Although JD was widely spread in the (north-)western part of Germany, similar to all regions with a well-developed dairy sector, the eastern part of Germany (former German Democratic Republic) was well protected from the introduction of MAP. Cattle breeding was completely organized by state-owned operations in a way that genetics from abroad were imported only by bovine semen for artificial insemination and transferable embryos. The import of livestock by private farmers or cooperative farms was essentially prohibited. Triggered by a great market for Holstein cattle after the German reunification, a massive buy-in of livestock pushed the spread of JD into and within cattle herds in Thuringia and the other eastern federal states of Germany. The first clinical cases were confirmed several years later, during the late 1990s of the last century. Recently, a between-herd prevalence of about 50% was estimated for Thuringia as well as the whole eastern part of Germany ,22.The Thuringian JD Control Program is a collaboration between the Thuringian Ministry of Labor, Welfare, Health, Women and Family as the supreme veterinary authority in Thuringia, and the Thuringian Animal Health Service. This service is operated by the Thuringian Animal Disease Fund, a self-help organization of livestock farmers in Thuringia. Its original task is ensuring financial aid for animal disease control. The Ministry passed the program after consulting the Thuringian Farmers’ Association and Thuringian Cattle Breeders’ Association. The program is managed by the Thuringian Animal Health Service.On-farm veterinary risk assessment and tailored recommendations for improving hygiene management in order to break the infectious cycle between cows and calves;Identification and removal of MAP shedders by annual testing of fecal samples from all cows for MAP to reduce the infective pressure;Controlled buy-in of cattle in consideration of JD status of the herd of origin compared to the status of the own herd;Certification of herds as ‘non-suspect’ regarding JD and maintenance of status by testing every two years.After an initial program phase during the years 2003–2007, which was based on semiannual serological whole-herd testing and general rules for improving hygiene management, the Thuringian JD control program has been comprised of the following principles since 2008:–Level 1: improve hygiene management and monitoring at the herd level by semiannual environmental sampling;–Level 2: test and manage high-risk cows detected by annual individual testing for MAP-specific antibodies;–Level 3: test and manage or remove MAP shedders as detected by annual testing of fecal samples from each cow for MAP;–Level 4: test and remove MAP shedders in a timely fashion .The update of the control program in 2015 implemented the recommendations of the German Federal Ministry of Food and Agriculture that established different levels of control according to the diagnostic method used. In its present form, the program includes a control stage for MAP-positive herds, a certification stage for MAP-negative herds leading to certification with the status ‘non suspect’ regarding JD, and measures to maintain this status. The achievement of this status is described below. Due to the limited diagnostic sensitivity of animal-level tests ,24, thisAt enrollment, participating farmers can choose between levels 1 and 3 with respect to their individual goals and opportunities. Testing according to level 3 with negative results was a prerequisite to enter the certification pathway. Herds will enter the ‘certification phase’ if no MAP shedder has been identified in the respective year. A herd that had been tested accordingly with only negative results during three consecutive years will be certified as ‘non-suspect’. These herds were retested every two years for maintenance of the status.For MAP-positive herds having a low prevalence of MAP shedders (<3%) and striving for the status ‘non-suspect’, the program offers a special agreement that binds farmers to remove MAP shedders from the herd within one month after detection (level 4). In level 4, exceptions were only accepted for pregnant cows in dairy herds and suckler cows. The general recommendation for MAP-positive dairy cows was that calves had to be removed from the cow before the first feed, and the cows had to be removed from the herd within one month after calving. A MAP-positive suckler cow can remain on pasture for more than one month to ensure the feeding, health and welfare of their calf. In ideal circumstances, this cow, together with its calf, should be separated from the rest of the herd and not re-bred. The calf was not intended for breeding, and the cow had to be slaughtered when the herd was taken off pasture, at the latest after one month off pasture. A financial incentive from the Animal Disease Fund was offered for all animals that were removed according to the specific rules of that level. This level demands a written commitment of the farmer because these management measures required in-detail advice, and this goal required high aspiration from the farmer.Unless prompt culling of MAP shedders was recommended for each level, farmers in levels 1–3 could manage detected MAP shedders according to their pregnancy status, milk yield and hygiene management within the farm. The hygienic measures should have focused on calving hygiene and management of the calving pen, management of colostrum for the first feeding, feeding of unsaleable milk to calves, and staff hygiene in calf and youngstock units. An on-farm veterinary risk assessment was undertaken collaboratively by specialized veterinarians from the Animal Health Service and the farmer to systematically review the biosecurity risks of JD within the herd using a purpose-made questionnaire that served as a data record and the basis of discussing the herd-specific measures. Farmers were requested to agree to farm-specific management choices to reduce the likelihood of the introduction and spread of MAP and to adopt these measures in daily work.Farmers were advised to focus on the JD status of the herd of origin when purchasing animals. All buy-in cattle should originate from herds with the same or higher stage of control or should be certified as ‘non-suspect’.The program had the support of all involved stakeholders, recognizing it as having the capability to increase animal health and welfare in the enrolled herds. The program provides funded support for several activities. Costs of the whole-herd testing were shared by the farmer and the Thuringian Animals Disease Fund. For individual fecal sampling by a veterinarian, sampling assistance at the rate of EUR 2.00 per sampled animal was paid. For laboratory testing of the fecal samples, 50% of the testing costs were covered. For serological testing, testing assistance was provided at the rate of EUR 1.00 per tested animal and year. The Ministry paid the Animals Health Service to perform the veterinary risk assessment and counsel the farmers; additional expenses for improving farm hygiene were borne by the herd owner. There was no compensation for culling test-positive animals except for herds that joined level 4 by special agreement.The Thuringian State Office for Consumer Protection, which is the competent authority for research ethics approval in Thuringia, approved the sampling within the control program and declared an exclusion from approval by an ethics committee (2684-04-15-TSK-22-201).All tests regarding paratuberculosis were performed in the laboratory of the Thuringian Animal Health Service, which is accredited to DIN EN ISO/IEC 17025 for relevant tests.All results of the laboratory tests were reported as soon as possible to the farmer and his veterinarian in written form  and were electronically stored in the laboratory database of the Animal Health Service. Positive test results of fecal culture were reported to the competent veterinary authority as well because the detection of the infectious agent of paratuberculosis is notable in Germany.In level 1-herds, environmental samples were collected either by the farmer or the herd’s veterinarian using either conventional environmental fecal sampling as described ,26 or boIn level 2-herds, whole-blood samples were taken by the herds’ veterinarians using an EDTA-Kabevette  as provided by the laboratory. In most cases, aliquots of blood samples collected annually for animal disease monitoring  were used. These samples were provided by the Thuringian state laboratory, which was responsible for the animal disease monitoring.g  before being analyzed for MAP-specific antibodies using a commercial ELISA test kit accredited for MAP diagnostics in Germany by the FLI . ELISA tests were accomplished according to the manufacturers’ instructions with the use of cut-offs as recommended by the manufacturer.Blood samples were centrifuged for 5 min at 840× A fecal sample had to be taken from every cow to be tested in the framework of the control program, either to confirm clinical cases in level 1 and 2 herds or to perform the annual whole-herd tests in level 3 and 4 herds. Veterinarians were advised to take the samples rectally with an unused examination glove and wipe the feces off into a sterile plastic container supplied by the laboratory and equipped with a bar code. The samples were sent to the laboratory by a courier system provided by the Thuringian state laboratory within 24 to 48 h. The individual fecal samples were tested either by fecal culture or a commercial real-time PCR for the direct detection of MAP without a cultivation step. Because of comparable test performance, the test was chosen according to practical requirements. PCR was preferred in control stage farms for managing detected shedders because of the much quicker turnaround time, whereas for surveillance of ‘non-suspect’ farms, the fecal culture was preferred.Bacteriological cultivation was performed according to the official guidelines of diagnostic procedures published by the Friedrich–Loeffler Institut (FLI), the German Federal Research Institute for Animal Health  as descrFor direct real-time PCR testing, we used the commercial bactotype MAP PCR kit  after DNA extraction as recommended by the manufacturer. Samples with a Ct value less than or equal to 38 were considered MAP positive. Samples with a Ct value of 39–40 were considered inconclusive, and samples with no Ct value (>40) were considered negative.n = 39) and farms being not enrolled (n = 54) were gathered as described below. Enrollment in the animal health program included the permission of the farmer to retrieve the data from the database.In addition to the JD control program, some farms participated in a project regarding calf health performed by the Thuringian Animal Health Service  as described elsewhere . Study hData on calf mortality of 93 dairy farms included in this analysis were retrieved from the German database on animal identification and registration (HI-Tier) . German The JD status of the control program farms that were included in the analysis regarding the association between the annual calf mortality rate and JD herd status was defined according to the requirements of the control program as described in p ≤ 0.05 were considered significantly different from zero.Statistical analysis regarding calf mortality was performed using Microsoft Excel, version 2010  and R soAt the end of 2020, there were 163 cattle farms registered in the Thuringian JD control program. With respect to production type, there were 83 dairy farms with 38,842 dairy cows representing 43% of the dairy cow population and 89 beef herds with 7908 cows representing 21% of cows in beef cow-calf suckler herds. Some farms kept more than one dairy herd or a dairy and a beef herd.During the reference period, a mean number of 25,320 individual fecal samples per year were tested either by fecal culture or by direct real-time PCR; the latter test has been available for routine diagnosis since 2017. The higher mean proportion of MAP-positive samples tested by real-time PCR of 2.7% compared to the percentage of fecal culture-positive samples reflected its preferred use in control stage farms, whereas fecal culture was preferably applied for the surveillance of ‘non-suspect’ herds .Only a few farms had chosen level 2 of the control stage, which refers to managing high-risk cows detected by annual individual testing for MAP-specific antibodies. A mean number of 2855 blood samples were tested for MAP-specific antibodies with 3.0% positive test results and a decreasing tendency from 2015 to 2020 .By the end of 2020, 58 farms (35%) with 18,013 cows (14% of the population) were certified as ‘non-suspect’ with regard to JD, and 12 farms were in the certification stage . PrevaleThe progress of Johne’s Disease control in the MAP-positive herds was demonstrated in Overall, 834 observations of 93 dairy farms were included in the data analysis. JD status was significantly associated with calf mortality, such that farms staying in the control stage as well as farms not enrolled in the program had significantly higher values for calf mortality compared with farms certified as ‘non-suspect’ . All fixIn both groups of farms enrolled in the control program, values for calf mortality decreased over time . InitialThis case study describes the progress of a control program for JD in Thuringia during the period 2015–2020, continuing the program review of the period 2008–2014 . Some isEnhance the number of farms that achieved the status ‘non-suspect’ with regard to JD;Reduce within-herd prevalence of MAP shedders in MAP-positive herds during the control stage by 50%;Advance control in registered herds to classify at least 75% of enrolled herds in level 3 or 4 of the control stage, certification stage or certified as ‘non-suspect’;Attain an enrollment rate of 50% of Thuringian dairy and beef cows in the program.The four objectives established for the Thuringian JD control program for the period 2015–2020 were to:Compared to the period 2008–2014, progress was made regarding the certification of farms as ‘non-suspect’. Overall, 70 farms reached that goal or at least the certification stage, and among them were several herds with an initial prevalence of MAP shedders above 15% a,c. Due By end of 2020, 43% of Thuringian dairy cows were enrolled in the program. This was in line with the level of participation achieved in other voluntary JD control programs, such as those in Ireland, Italy or Denmark ,37,38. NAn Irish study revealed that farmers’ decisions on whether to introduce control and preventive measures are not solely influenced by economic consequences. Rather the value that farmers associate with social relationships with others and with particular objectives and actions informed farmers’ decisions . Other sA reduction in the prevalence of MAP shedders was achieved in most of the participating herds. In most herds, prevalence reduced remarkably within the first five years after enrollment, as shown by the examples in Improvements in hygiene standards may result in a reduction in prevalence as well , assuminChanges in the management and structure of the maternity area of a cattle operation leading to a relevant improvement of calving and calf-rearing hygiene will be valuable for reducing the burden of JD and other infectious calf diseases . Besides omphalitis, diarrhea was the most common calf disorder in a recent German study and was most frequently found in dairy herds in the eastern part of Germany . A link Further development and continuation of the Thuringian JD Control program holds knowledge that may assist others running a JD control program. A permanent challenge was the continuation of the required testing schedule, particularly if the farm was certified as ‘non-suspect’ and testing was required to maintain this status. The owners of these farms demanded a remarkable reduction of the testing efforts. Ensuring a very low risk of having JD or high confidence of freedom from disease only by means of testing is hampered by the low sensitivity of easily available herd-level tests, such as repeated testing of pooled test day milk samples or bulk milk . Data onIn the context of commercial cattle farming, be it dairy or beef, a high technical standard of the control program was expected, but pragmatism will be needed at several points to retain the acceptance of the program. The strategic engagement of key stakeholders in agreeing on program updates and sharing responsibility for decision-making was a critical point. The involvement of pedigree breeders in the dairy sector and their associations was a challenge because they were afraid of restriction for the export of breeding cattle into third countries if their herd was deemed MAP-positive by the veterinary authority. This was the case if MAP was detected by bacterial cultivation because the detection of the infectious agent is noticeable to competent authority according to the European Animal Health Law. This may hamper export certification for several countries outside the EU. Pedigree breeders in the beef sector were more willing to join the program as they were selling at a regional or national market, and an official veterinary certification for the national or EU market is not mandated in the case of JD. Moreover, the Animal Health Law in its present form ‘guarantees’ the absence of veterinary trading restrictions regarding JD within the EU. At the EU level, there were no requirements regarding JD, and national measures shall not hinder the movement of animals and products between Member States. Thus far, when trading animals, only the buyer can prevent the introduction of MAP into his herd by infected animals in the subclinical stage of the disease.Future development of the Thuringian JD control program requires the improvement of communication strategies to reach the less innovative and ‘late-adopting’ herd owners. Some of them might be willing to register in the program, but they were sceptic regarding the benefit for their herd. A different communication strategy may be required to convince this group. Informative websites and social media channels may be helpful and should be developed in the near future. Changing the mind of ‘deniers’ would not succeed only by information campaigns. A mandatory surveillance system as established in Lower Saxony is expected to be more effective to motivate JD control in that group. Results of that monitoring, together with movement data, should inform an easy-to-use herd scoring system that provides information regarding the JD status of the respective herd for potential buyers of cattle. Ideally, such a system should be established as a market assurance program that is open for all cattle owners and not only for those who were enrolled in a voluntary control program. This would significantly reduce the risk of buy-in MAP together with cattle from other herds and limit the spread of JD between herds.We conclude that JD control was achievable at the herd level for years provided that veterinary advice, sufficient testing capacities and financial aid were available to the farmers and the re-introduction of MAP was prevented. Reduction of prevalence was feasible within several years, but reduction to a level where MAP was not detectable anymore takes a period of 10–15 years. Aiming at certification as ‘non-suspect’ regarding JD requires high aspiration and commitment from the farmer but was the aspiration of a relevant proportion of Thuringian cattle farmers. The annual calf mortality rate was reduced in dairy herds certified as ‘non-suspect’, reflecting an improved level of hygiene and calf health. Participation in this voluntary control program was limited to the more innovative and progressive farmers if not accompanied by a mandatory surveillance system. The involvement of the beef sector was worthwhile, as demonstrated by the enrollment of beef farmers in the Thuringian JD control program. Further development of the control program is required, particularly regarding the surveillance of ‘non-suspect’ herds and to establish an easy-to-use risk scoring system reflecting the potential herd-level risk of JD for potential buyers of cattle.


This study was designed to assess the effect of nonrigid connectors (NRCs) and their location in the success of tooth-and-implant-supported fixed prostheses in the maxillary anterior region by finite element analysis (FEA).  Three 3D FEA models were designed, presuming maxillary lateral incisor and canine to be extracted. Implant (replacing canine), abutment, bone , central incisor , periodontal ligament, and three three-unit cemented PFM prostheses (a rigid one and two nonrigid) were modeled. The NRC was once in the tooth side and once in the implant side. The prostheses were loaded twice: 250N to the incisal edges (0° to the long axis) and 200 N to the cingula (45° to the long axis). The von-Mises stress and vertical displacement were analyzed.  Under both vertical and oblique loadings, the rigid model presented the highest stress. Under vertical loading, the NRC caused a significant decrease in the applied stress to the prosthesis, bone, implant, and tooth. Locating the NRC in the tooth side decreased the applied stress to the prosthesis and NRC. Under oblique loading, prosthesis and implant tolerated less stress in the presence of an NRC. Placing the NRC in the tooth side resulted in the least stress in all of the components except for porcelain and patrix. Vertical displacement of the tooth apex was approximately equal in all models.  Using an NRC on the tooth side is the most efficient method in reducing the applied stress to prosthesis, implant, tooth, and bone. The amount of intrusion is not dependent on using an NRC or not. Implants have played an essential role in the edentulous patients' treatment since they were introduced by professor Brånemark . In receµm due to the presence of the periodontal ligament around it, and the ankylosed implant, which can only move 10 µm as a result of bone flexibility .


Adherence to medication and lifestyle changes are very important in the secondary prevention of cardiovascular disease. One of the ways is by doing a cardiac rehabilitation program.Cardiac rehabilitation program is divided into three phases. The cardiac rehabilitation program’s implementation, especially the second phase, center-based cardiac rehabilitation (CBCR), has many barriers not to participate optimally. Therefore, the third phase, known as home-based cardiac rehabilitation (HBCR), can become a substitute or addition to CBCR. On the other hand, this phase is also an essential part of the patients’ functional capacity. During the coronavirus disease-2019 pandemic, HBCR has become the leading solution in the cardiac rehabilitation program’s sustainability. Innovation is needed in its implementation, such as telerehabilitation. So, the cardiac rehabilitation program can be implemented by patients and monitored by health care providers continuously.Physicians play an essential role in motivating patients and encouraging their family members to commit to a sustainable CR program with telerehabilitation to facilitate its implementation. Cardiac rehabilitation (CR) is a comprehensive intervention for secondary prevention of cardiovascular disease (CVD) –3. The 2The cardiac rehabilitation program focuses on risk assessment and management . This prThis literature review aimed to promote telemedicine specifically in CR through telerehabilitation programs among physicians and encourage each family member to actively support the continuum of rehabilitation programs at home to maintain and improve patients’ quality of life.Cardiac rehabilitation is currently divided into three phases. The first phase is the acute phase, which starts from hospitalization following the heart attack up to the discharge, includes early mobilization programs. The second phase is the supervised rehabilitation phase initiated after complete healing and characterized by intense education and aerobic activities to achieve the desired exercise results. The third phase is the phase devoted to maintaining aerobic activities in phase II through a regular exercise program .The acute phase includes patient assessment, early mobilization, identification of CVD risk factors, and pre-discharge assessment. In this phase, outpatients are prepared to enter CR. Patients are given primary education on how to control risk factors and do self-care. The CR program is designed to make individuals mobilize from bed until they climb two stairs within 3–5 days. The types of activities commonly used in early mobilization are shown in Table Phase I’s primary goal is that patients are capable of performing activities up to 4 metabolic equivalent tasks (METs). This value represents the estimated number of daily activities at home after discharge. Before discharge, patients perform an exercise test to determine their functional capacity, and then they are educated about which activities can be performed at home .The second phase begins as soon as patients are allowed to be discharged. The phase II or center-based cardiac rehabilitation (CBCR) phase is a program that provides resources and an environment, i.e., a supportive community for patients to complete their comprehensive rehabilitation program . The CR In every risk category, direct supervision should be conducted. The supervision includes electrocardiogram (ECG) and hemodynamic examination. In this phase, a patient will undergo lung and neuromusculoskeletal examination, resting ECG, and risk profile to get a treadmill test .The third phase is the essential part of the program yet usually receives the least attention. The benefits gained from phase II (CBCR) will be subsided within a few weeks if they stop exercising . TherefoFrom the beginning of the CR program, sustaining an exercise program needs to be seriously emphasized. The exercises need to be integrated into patients’ actual lifestyles to facilitate compliance in this phase. Moderate-intensity exercises should be performed at the heart rate target for at least 30 min, three times/week, while low-intensity exercises should be performed five times/week .If peak heart rate (HR) is unknown, we can use Borg scale, either the Borg Rating of Perceived Exertion (RPE) scale  or the Borg Category-Ratio-10 scale (BORG-CR10) to guide exercise intensity. For moderate intensity which scores 12–13 on BORG RPE (4–6 on BORG-CR10), is in somewhat hard criteria or having a target as 40–59% of HR reserve, while low intensity which scores below 12 on BORG RPE (<3 on BORG-CR10) is in light criteria or having target as <40% of HR reserve. Heart rate reserve is the difference between a person’s measured heart rate (predicted maximum heart rate) and the resting heart rate . ECG monCardiac rehabilitation post-myocardial infarction (MI), post coronary artery bypass graft (CABG), and post percutaneous coronary intervention (PCI) are recommended (Class IA) by the American Heart Association (AHA)  and EuroThe rehabilitation program benefits are gained from the direct physiological effects of physical exercises and the indirect effects of risk factors control, lifestyle modification, and mood. Several studies had shown that patients who underwent CR programs following primary PCI had a lower mortality rate , 16.The CR programs are available in two forms: center-based cardiac rehabilitation (CBCR) and home-based cardiac rehabilitation (HBCR). The CBCR exercises are conducted in hospitals or specialized institutions, which is safer for cardiac disease patients because professionals supervise them. However, the CBCR program cost is quite expensive since it is a long-term program and may not be convenient for patients living in rural areas . TherefoThe CBCR program had a very high dropout rate (up to 24–50%), suggesting that the long-term exercises of CBCR were not continuously performed by most of the patients, whereas the progress been made after completing the program will not be maintained if the exercises are stopped , 18. MorBoth CBCR and HBCR programs effectively improved clinical outcomes and health-related quality of life (HRQoL) in patients with CAD, MI, or low-risk HF. The efficacy of HBCR was comparable to CBCR in terms of increased aerobic capacity, level of physical activity, exercise compliance, controlled BP, and cholesterol level. The HBCR effectively reduced cardiac mortality in patients with CAD, ranging between 27 and 31% , 18, 19.Patients frequently do not participate in CR due to their low perception of the program’s importance and necessity. The less optimal participation may lead to less optimal results in CR , 16.The primary strategy for improving adherence in rehabilitation works through a strong doctor-patient relationship and good communication skills, ensuring patient understanding of the impacts of non-adherence. Physician support indeed influences patient participation in CR programs. Patient characteristics may be the significant predictors when referring patients to join CR programs , 10.Of all patients who were referred to CR, only 30–34% participated . The lowThe HBCR program has proven to be safe, cost-effective, and acceptable to communities. In Indonesia, patients considered safe to do the HBCR program are commonly categorized as low-risk patients, do not require ECG monitoring, and can be monitored by daily reports via logbook or diary. Compared to CBCR, most patients can complete the HBCR program. Self-monitoring and self-management in HBCR will make a better transition from active interventions to lifelong independence of patients. The HBCR is considered safe because there are no reports or evidence of increased hospitalization or death risk. These findings support the HBCR program applied to HF patients as an alternative to conventional hospital-based rehabilitation , 18, 20.The HBCR program includes the core components of the CBCR program, which is delivered by a health care professional but may be delivered through telephone calls or cellular technologies. This program may expand the modalities of patient education, counseling, and monitoring because this service, which has been implemented in the USA, can be accessed 24 h a day and 7 days a week; therefore, making it easier to be accessed compared to contact professionals in the CBCR .The use of information and communication technology may be worth adjunctive to CR. It is known as telemedicine. Telemedicine is considered suitable, safe, and effective in increasing exercise capacity, controlling shortness of breath, maintaining physical activity, reducing disability, and improving quality of life in elderly patients with chronic obstructive pulmonary disease (COPD), CHF, and ischemic heart disease , 17, 18.The transition from conventional rehabilitation into virtual CR needs three main steps. In the first 6 weeks, CR should be done immediately by using available resources. Then in the next 6 months, the delivery should be standardized and optimized. The next step is the delivery should be developed and more innovative. The practical tips for establishing virtual CR can be seen in Fig. Access to health care professionals through a portal web of affiliated institutions may reduce costs and promote adherence to sustained healthy lifestyle changes. Interventions using mobile health had been proven effective for improving exercise outcomes in patients with cardiovascular diseases, controlling body weight and body mass index, and improving adherence to medical therapies. The HBCR using mobile health increased participation rates and compliance of participants. Text messaging and the internet are useful for increasing levels of physical activity. A short text message reminding exercises can be applied to increase the number of sessions attended. Figure Telerehabilitation appears to be at least as effective as conventional rehabilitation. This delivery model has been successfully trialed in patients with various cardiopulmonary diseases. In a study where HBCR was delivered via computer/tablet, all participants with COPD remained actively participating in the program after 1 year .The coronavirus disease-2019 (COVID-19) pandemic has a significant impact on health care globally, including acute and chronic cardiac care. The consequence is the global physical activity levels that dropped dramatically due to policies and the warning which encourage people to live and work at home and keep up physical distancing. Unfortunately, these recommendations do not emphasize the importance of maintaining a healthy lifestyle while staying at home , 26.Recent guidelines from the Centers for Disease Control and Prevention (CDC) recommend all high-risk individuals, including those with cardiovascular risk factors, stay at home to limit the potential exposure to COVID-19. Almost all hospital-based rehabilitation programs are closed, and many elective and outpatient health care activities are canceled or suspended during the COVID-19 pandemic. A consensus guideline from experts recommends limiting direct contact between rehabilitation therapists and patients due to the high transmission rates of COVID-19. The guideline suggests telemedicine as an option for screening and, if possible, for providing treatment to patients. Telemedicine may be considered as electronic personal protective equipment (PPE) by reducing the risk of exposure and contamination for both patients and practitioners .Permenkes No. 20 Tahun 2019. On the other side, the COVID-19 pandemic has led to a large-scale shift toward telemedicine  in the general population to deliver health care services while still implementing COVID-19 health protocols. It applies to rehabilitation programs that demand sustainability; therefore, new interventions are required to provide rehabilitation services, primarily through telerehabilitation [Telemedicine in Indonesia has already been applied and regulated by litation .A study suggests that in the shortened CR program, exercises are focused on the main core components  with an individualized approach based on residual cardiac risks, psychological symptoms, and lifestyle assessment. Face-to-face sessions can be replaced with remote assessment and monitoring/guiding through telerehabilitation. Patient assessment and risk stratification are generated by exercise tests whenever possible. Otherwise, other tools can assess cardiovascular risk and physical fitness to provide personalized exercise advice and guide telerehabilitation. For CVD patients who are positive for COVID-19, the exercise program may be postponed if COVID-19’s signs and symptoms are still present. Evaluate exercise resumption is on an individual basis. In general, patients with mild-to-moderate symptoms can gradually restart the exercise program after no fever in a week and no symptoms in 48 h. Whenever possible, all components of the CR program are not suspended but provided remotely .Fifty-two percent of rehabilitation centers in Belgium already provided cardiac rehabilitation programs by implementing telerehabilitation . The remWhile at least 35 centers reported delivering CR programs using telerehabilitation in Canada. The remote program reported were using telerehabilitation to deliver exercise program (32% of the programs) and education program (43.5%). Exercise was delivered using telephone, e-mail, mailing forms/resources by post, and web-based platform resources. These methods were significantly increased .The other differences in conducting the CR program during COVID-19 were that the eligibility criteria have shifted to lower risk and less complex patients. The services also are limited, such as initial assessments, consultation, stress management, and group-based education for nutrition .Things that need to be considered in carrying out telerehabilitation are the right staff, the ability to use technology, and other methods of implementing telerehabilitation if the patient does not have access to technology. Developing strategies to admit high-risk/vulnerable populations into the CR program should be concerned . The criDuring lockdown, telemedicine can provide many benefits, so it can be a useful intervention to avoid stress and boost the immune system by applying the exercises recommended by CR. It has a real impact on elderly patients with CVD .Patients can still exercise without any equipment during pandemics, such as gymnastic movements of muscular strengthening , balance or stretching training, and online relaxation sessions. These exercises can be easily described and explained to the patient by using videos. Moreover, it can be illustrated in a physical activity notebook .An important note that the particular HBCR exercise prescription (more than 30 min of moderate-intensity exercise and 3-5 sessions per week) should have to be modified for individuals who used to walk/run outside. Other forms of physical activity, such as chair-based exercises, calisthenics, resistance, and balance exercises, should be explored. The yoga trends in CR could be a prospect to be used among patients with CVD .By using a logbook, patients can follow the practice of regular training during quarantine. Fifteen minutes per day, every day may be enough to fight against muscle deconditioning and avoid the harmful impacts of strict confinement. However, a precise individualized prescription for each patient is still needed to assure their safety. To increase adherence, coaching by phone seems to be potential and reduces harmful impacts on psychological and physical health, especially in the elderly population .To ensuring patient safety, trackers may be used to quantify physical activity. The equipment is expected to record and send variables  measured via sensors to a web platform accessible to the physician, nurses, and the centers. Simultaneously, real-time monitoring, such as ECG and BP measurement during exercise, is still a challenge to be solved .The cardiac rehabilitation (CR) program is a sustainable and multidisciplinary intervention where patients are encouraged to continuously implement a healthy lifestyle and regular exercise after starting the program. This program should include physical training, risk factor modification, education, stress management, and psychological support. The CR programs are available in two forms: center-based cardiac rehabilitation (CBCR) and home-based cardiac rehabilitation (HBCR).The progress made after completing the CBCR program is often not well-maintained for many reasons; therefore, HBCR is highly recommended since patients’ training and participation can be done independently at home. Moreover, long-term adherence to medication and a healthy lifestyle is crucial since they are associated with a lower risk of death and recurrence.Using multiple technology modalities may be superior to using a single modality. Implementing information and communications technology in medicine, known as telemedicine, maybe a worth alternative to CR. There were already some countries that have been applied telerehabilitation. Moreover, it is highly recommended in the current COVID-19 pandemic, where patients are advised to perform remote consultations unless in urgent conditions. Thus, physicians play an essential role in motivating patients and encouraging their family members to commit to a sustainable CR program with telerehabilitation to facilitate its implementation. It is essential for rehabilitation physicians and family doctors to regularly monitor patients in primary health care facilities.


Current obesity management strategies are failing to achieve sustainable and favorable long-term results. We propose a more personalized, dynamic, and systemic perspective on the interactions of key determinants and coaching advice on obesity. The aim of this study was to use a systems view on overweight, complexity science, and a transdisciplinary process to develop a five-year personalized integrative obesity-coaching and research program. Managers, medical specialists, clinical psychologists, dieticians, physical- and psychomotor therapists, and lifestyle coaches aligned their perspectives and objectives with experts in systems thinking and systems biology. A systems health model of obesity was used to identify the causal relations of variables with the most influence on obesity. The model helped to align and design a personalized integrative obesity-coaching program and to identify the key variables to monitor the progress and to adjust the personalized program, depending on the goals and needs of the participant. It was decided to use subtyping of participants by a systems biologist, based on traditional Chinese medicine symptoms, as a novel method to personalize the intervention. The collaborative transdisciplinary approach based upon a systems view on obesity was successful in developing a personalized and adaptive five-year obesity-coaching and research program.  Overweight and obesity have become the most important public health concerns due to their association with non-communicable diseases , COVID-19, and related economic consequences . It is eLifestyle-related factors are the dominant causes of becoming overweight or obese, besides ageing of the population, genetic predisposition, and medical treatment ,7. Both To date, current healthcare strategies have not resulted in a reduction in the number of people with overweight and obesity in society. This is presumably the result of a general conception that overweight and obesity are (mainly) the result of the imbalance between calorie intake and calories burned . This coComplexity science in health (care) is the study of dynamic processes of a large number of biological, psychological, social and behavioral determinants, which fits very well with such a systems view on overweight. These determinants contribute to unhealthy behavior and physiology causing overweight and obesity. The key determinants may be different for each individual, and there are many interactions between these determinants with various strengths and speeds over time ,20. OverInterestingly, such a systems view on health has been developed and practiced for thousands of years in China . ChineseIn short, to develop a long-term effective and personalized integrative obesity-coaching program, we argue that a systems approach to obesity is needed. This paper presents a description of the development of a long-term personalized integrative obesity-coaching program with a highly adaptive character, targeting adults, which is based on a theory-driven group modelling approach involving the potential target group of patients and involved professionals. In follow-up studies, the adaptive program will be evaluated. We expect that a more personalized integrative coaching of obesity improves compliance and effectiveness, resulting in a sustainable long-term lifestyle change.The systems view on health was ‘translated’ into a multidisciplinary treatment plan for people with overweight . In ordeThe systems health model was a semi-quantitative CLD built with the TNO proprietary software MARVEL 3.2.11.4 ,32. BetwThe model was then used to simulate various chronic stress- and overweight-related scenarios using the MARVEL software. Simulations revealed the variables with the most influence on health, which then supported the development of the lifestyle program. Then, a pragmatic set of measurements and instruments for all of those variables were identified by the experts.The initiative to develop a multidisciplinary obesity coaching program started with the assumption that a center of rehabilitation medicine is a suitable organization for the development of a new comprehensive treatment of obesity. Medical specialists in physical medicine and rehabilitation (PM&R) (working at the rehabilitation center from a holistic concept) are experts in designing comprehensive, patient-centered treatment programs and are ultimately responsible for this program. They utilize time-tested treatments to maximize function and quality of life for their patients. Treatments aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. A center of rehabilitation medicine provides an infrastructure for implementation and execution of treatment programs.The CEO of Vogellanden, Center of Rehabilitation Medicine & Special Dentistry (Vogellanden) and a Physical Medicine and Rehabilitation physician (PM&R physician) of Vogellanden and the Isala Hospital  increasingly realized that a healthy lifestyle is important to reduce the medical consequences of overweight and obesity. They also recognized the limitations of existing monodisciplinary strategies and comprehensive treatments in the management of obesity in the long run. Therefore, they contacted the Department of Systems Biology of The Netherlands Organisation for applied scientific research (TNO) in 2014, well known for its extensive knowledge of complex systems, systems thinking, and both Chinese and Western medicine ,21,24,29Subsequently, based on the Dutch guidelines of obesity treatment ,34 and tIn- and exclusion criteria and recruitment of the potential participants, informed consent form, format of the intervention, and outcome measures with a time schedule were determined. Furthermore, the role of the professionals, treatment frequency, and treatment duration, individual and/or group sessions, and conditions (which the program must meet) were discussed. It was also discussed how the participants and their environment  could be actively involved in the program. Finally, the team agreed that the program would start in 2015 and that it would be further developed and adapted based on the experiences of healthcare professionals and participants, and new (scientific) insights.The group modelling revealed six main domains of obesity, i.e., mental, emotional, physical, metabolic, nutrition, and social, which all determine the overall health status of an individual. These six domains are visualized in our systems health model of obesity, as presented in According to the experts and literature, chronic stress and motivation appeared to be key factors in the development of obesity and thus a reason to include a systems biologist and psychologist in the program. The model also showed that for each domain , a healthcare professional should join the program design.The choice of the healthcare professionals participating in the program was based upon the system health model. The design team decided that the program should consist of a multidisciplinary team, working under supervision of a PM&R physician. The PM&R physician will supervise the inclusion, the medical aspects of the treatment, the monitoring of parameters, and external communication. After initial assessment of a potential participant, the PM&R physician and a clinical psychologist will decide whether the potential participant can participate in the program. It was decided that every participant would be assigned one of the lifestyle coaches as a case manager. Lifestyle coaches will be responsible for their own expertise  but will collaborate intensively with each other.A systems biologist will be responsible for subtyping the participants in one out of five Chinese diagnostic symptom patterns, primarily intended to recognize these different subtypes, which will possibly help to further personalize the intervention. To be able to determine the subtype, participants will complete a questionnaire prior to consultation see . Optiona2). Potential participants with pulmonary-, cardiovascular-, internal- and/or psychologic disorders that may interfere with the intervention will be excluded from the program. Prior to the start of the program, some participants will be selected for a maximum performance test in cases of: age > 40 years, proven pulmonary of cardiovascular risk factors, and/or serious doubt about physical capacities. Healthcare providers located in Zwolle and surroundings  will be informed about the program. They will recruit potential participants and refer them to the Vogellanden center of rehabilitation medicine, special dentistry, and prevention .The design team decided that the obesity-coaching program will be developed for people aged 18 years or above with obesity  reviewed the evaluation protocol of the program (METC number: 15.0224). They concluded that further ethical approval within the scope of the Dutch Medical Research Involving Human Subjects Act ) is not needed. All participants will sign an informed consent prior the start of the program.The coaching program will be a highly adaptive long-term personalized lifestyle intervention for obese adults based upon the system health model for overweight. The aim of the program is to achieve, within a timeframe of five years, a sustainable healthier lifestyle of the participants by modifying behavior focusing on nutrition, physical activity, sleep and stress, while taking into account the changing needs and possibilities of the participant in his/her environment . Major goals are personal growth  and meaning of life . Concrete additional goals of the program are improvements in quality-of-life scores, 5–10% sustainable weight loss, and subsequent improvement of general health. To achieve these goals individual coaching sessions, group meetings and social events will be organized. In a plenary session prior to the start of the program, the participant and a representative of our rehab center will both sign a covenant in which they commit themselves to the principles of the program and intended results. During the first twelve weeks after the start of the program, information based on individual goals, -needs, questionnaires and biomedical- and anthropometric characteristics will be put together and will be used to develop a personal (coaching) strategy for each participant. Therefore, the content of the intervention and coaching frequency may vary amongst participants. For example, completed food diaries will be used to provide dietary advice appropriate to the needs of the participants. The TCM subtype can also be taken into account when giving nutritional advice .In addition, participants will participate in at least 27 theme-sessions in the first three years of the program. During these group sessions, topics related to a healthy lifestyle will be discussed. These group sessions were divided into five blocks, and it was decided that the following main themes will be discussed: dietary behaviors and nutrition, sustainable behavior change, body experience and physical activity, sleep and stress, and mindful eating. In preparation for the meetings, participants will be asked to read the offered documents and complete homework assignments . Furthermore, workshops will be organized in which what is learned will be applied in practice . Finally, a book club will be founded for those who are interested. During informal meetings, books about health and healthy lifestyle will be discussed. Participants can propose the title of a book themselves. Family and friends of the participants are regularly invited to these meetings and workshops in order to involve them in the program. Furthermore, participants will use a Vogellanden proprietary smartphone app  in which recipes and informative videos will be shared. The app will also be used by participants to view their own progress by recording outcomes as measured by coaches  and determined in a hospital laboratory , and personal goals. The app will also include an agenda (with upcoming sessions and meetings) as well as a forum for discussions and sharing of experiences. An important feature of the program is the buddy system, in which all participants will voluntarily be linked to another participant, a so-called ‘buddy’ . Both ‘bChanges towards a healthier lifestyle will be achieved by setting small goals and, when these goals are achieved, setting new small goals . ProgresThe procedure of running the program and the progress of each participant will be evaluated and discussed every 6–8 weeks with the entire team. In between these evaluations, coaches will be allowed to fine-tune their approach daily. As long as participants participate in the program, progress will be monitored at pre-arranged times. Depending on these evaluations and the measurements (including questionnaires), the treatment strategy will be determined. For example, for one participant, the emphasis will be on psychologist support, while for another participant, improving the diet will be the most important part of the program.The monitoring plan was also based on the results of the systems health model of obesity . The modThe most important (yellow) variables for measuring the effects of the lifestyle program were: energy intake, energy expenditure, basal metabolic rate, body fat, weight, Hba1C, triglycerides, lipid profile, physical activity, physical overload, physical capacity, cognitive function, sleep debt, motivation, food quality, social competence, and self-esteem. Measurement instruments for each of those variables were assessed for possible application in practice during the lifestyle program. 2-max) will be predicted based on the submaximal cycle ergometer aerobic fitness test according to the protocol of Åstrand (mL/kg/min) [To gain insight into the changes in biomedical-, anthropometric-, and physical fitness, a standardized set of clinimetrics will be administered at pre-arranged times. A lipid profile  and HbA1c will be determined in the nearby hospital laboratory and registered in mmol/L. Weight (kg) and  fat percentage will be measured with a four-point bioelectrical impedance device of Tanita RD-545 (Tanita Europe BV). Waist- and hip circumferences will be measured with a measuring tape in centimeters . Maximal/kg/min) . The ave/kg/min) , Rosenbe/kg/min) , the Che/kg/min) , Utrecht/kg/min) , and Sym/kg/min) . To dete/kg/min) ,28. As lThe first group of ten individuals will participate in an adaptive pilot study. The feasibility of this pilot study and the experiences of healthcare professionals and participants will be studied. The results of this pilot study, which will be one year ahead of the program, will be used develop the personalized integrative obesity-coaching program.In order to determine the effectiveness of the personalized integrative coaching program, the collected data will be analyzed at the level of the individual participants. First, we will investigate the effect of the different measures with a linear mixed-effects model. This model can be used per outcome measure to represent the differences between the time points per participant in a one-dimensional way. The effect of the various interventions is also taken into account. To show the effect on different scales, we will look at a visual representation on some scales on a spider-plot and on a three-dimensional axis. This will be compiled with a combination of analysis methods such as factor analysis/main component analysis, as well as the created content models. This makes it possible to visualize the displacement and to quantify the change on these axes. The axes are composed of categories identified by experts as important and validated scales on questionnaires. It is also important to map out the mutual relationships. Using the systems health model of obesity with the relationships according to the experts, we can use the questionnaires and measurements to convey what the relationships are within the data. We will use the questionnaires and measurements as a starting point to draw up two network models: one per coaching moment, and one that shows the effects over time. This will provide insights into the mutual relationships between the various risk factors and outcome measures.This paper presents a description of the development of a long-term personalized integrative obesity-coaching and research program with a highly adaptive character, targeting adults with obesity based on a systems dynamic model of health. The growing interest in interventions that take into account the multifactorial drivers of overweight and obesity was recently reported in a systematic review . In receDue to the multifactorial drivers of obesity, a strength of the study is the integration of systems thinking and a transdisciplinary approach via the use of a systems health model of obesity to identify the causal relations of variables with the most influence on obesity. This helped to select and align all professionals towards collaboratively developing the adaptive obesity-coaching program. The model was used to identify the key variables to monitor the progress of the participants, which then supports further fine-tuning of the program. The second strength is that this program, in addition to the usual goals of lifestyle interventions , focuses on personal transformation and personal growth towards improvements to become a ‘better version of the individual’.For each participant, the meaning of life plays an important role in this program. The third strength is the active (participatory) role of participants, their family, and their social environment, which will all be involved in the program.Besides strengths, some limitations can also be identified. The design of the program is highly personalized and adaptive. Each individual is unique and will follow its own path. Therefore, the heterogeneous nature of the resulting data will not allow a standard experimental controlled design. However, whilst the outcomes of the described program can be compared with outcomes of other lifestyle interventions, direct comparison with a group control group  will not be possible.Actually, a longitudinal N = 1 study design will be followed. In addition, the personalized integrative approach makes the study very laborious, and in the first two years, a group of only 10 participants per year will be included. Information on the healthcare professionals, participants, and measurements will be used to develop the program continuously, taking into account the efficiency  and costs . Only when the program is fully evolved can we foresee that after 3 years of experience two or even more groups of participants can be included each year. Therefore, the recruitment of sufficient participants for a substantial evaluation of the effectiveness of the program will take some time.Despite these limitations, the personalized integrative obesity-coaching program described in this paper has a unique and added value in its personalized approach and the 5 year period in which participants will be coached and monitored. In addition, due to the adaptive nature of the coaching program, participants will receive coaching when there is a need, instead of at fixed points in time. Finally, our coaching program will act as a learning community and will be continuously improved based on the experiences of participants, professionals, and the newest scientific knowledge.This collaborative transdisciplinary approach based upon a systems view on obesity was successful and led to a new intervention for individuals with obesity. The result was a personalized and adaptive five-year obesity-coaching and research program. The project has been in progress since 2015. Eleven groups with approximately ten participants each have started the program so far. Dissemination of the first results is planned for early 2022.


Facilitated learning approaches are increasingly being used as a means to enhance climate and sustainability collaborations working across disciplines, regions, and scales. With investments into promoting and supporting inter- and transdisciplinary learning in major programs on complex global challenges like climate change on the rise, scholars and practitioners are calling for a more grounded and empirical understanding of learning processes and their outcomes. Yet, methodologies for studying the interplay between learning and change in these initiatives remain scarce, owing to both the “hard to measure” nature of learning and the complexity of large-scale program implementation and evaluation. This paper proposes a new method for studying social learning in the context of large research programs. It aims to analyze the social learning of researchers and practitioners engaged in these programs and assess the contributions of this learning to the resilience of the natural and social systems that these programs seek to influence. We detail the theoretical basis for this new approach and set out six steps for developing multi-layered contribution pathways and contribution stories with stakeholders to document both the process and outcomes of social learning. The proposed method, we argue, can strengthen our analytical capacity to uncover the structural drivers and barriers to social learning that are often masked by the complexity of large-scale programs. An illustrative example, drawn from a large-scale climate adaptation research program, provides evidence on how this method might advance our methodological strategies for studying learning in these programs. We conclude by highlighting two key methodological contributions brought about through this approach, and by reflecting on opportunities for further methodological development. Enriching our understanding of learning and change processes, we argue, is an important avenue for understanding how we can pursue transformations for sustainability. Global challenges such as climate change and sustainable development are characterized by their complexity. Addressing them requires collective coordination and action to deal with the interrelated social, environmental, and economic dimensions of the challenge and their associated nonlinear feedback systems. This recognition has led to a push for new modes of collaboration, coordination, and learning within international research programs, with a view to enhancing collaboration across disciplines, regions, and scales . Social changes in understanding occurring at the level of individuals lead to changes in practice within wider networks and systems, is also said to be a powerful tool in navigating complex challenges like climate change  Multi-dimensional constructs, processes and outcomes (such as SL) are often intangible, making it difficult to identify representative indicators and appropriate instruments data collection;(2) Challenging settings with many actors and fast-changing contexts yield external factors which are likely to significantly influence processes and outcomes;(3) Multiple, uncertain pathways of change make causal inferences unreliable, as they introduce non-linear changes and confounding variables that are difficult to account for; and(4) Diverse interests and aspirations characterize these partnerships, often with competing rationales and priorities for what should be studied and how.Effectively documenting SL processes to assess their influences on large-scale programs presents challenges on several fronts. These dimensions feature in recent studies of climate change and SL, with authors highlighting the non-linear nature of the processes , the unpThe research within which this method was developed and tested examined the role of SL processes in two climate change adaptation research programs implemented in Africa and Asia.The present study builds on earlier reflections conducted in both programs, which observed that facilitated SL was an important contributor to effective collaboration . We exten = 4) and, in the case of the FCFA program, a survey of program members (n = 72). A further 15 semi-structured interviews were conducted for the contribution analyses of the selected cases. Participants were identified through snowball sampling based on the set of cases identified. The analyses were then validated with interviewees in line with the methodological steps we describe below. The methodological description that follows reflects the learning from those five cases. We have then selected one illustrative case to describe the process .For the development of this method, we selected five cases of change for analysis from the two programs using the steps set out below. Cases were identified and prioritized through a series of interviews  assess the extent to which SL is a necessarycontributory cause of the observed programmatic outcomes and impacts, and 4) build causal narratives of why and how SL has contributed to the wider program influence  reveal the learning dynamics in large program processes over time, 2) demonstrate the nfluence .The original contribution analysis approach set out by An Emerging Method to Assess Learning Contributions section, reconceptualizes the method’s original theory-based underpinnings by modifying the second and third steps of the original procedure  program implementation, and 2) the SL processes and outcomes that shape that implementation, participation is needed from actors who can speak to both processes. In many cases there may be considerable overlap in these roles, with program managers promoting SL processes as a means of supporting collective reflection and action, for instance. This reduced the overall number of participants needed to meet these various information needs.The types of participants required may also vary according to the stage of the contribution analysis process. The early steps of case identification and contribution pathways call for participants with a good overall knowledge of program activities, the assumptions behind the program design, as well as overall program governance. Later steps of co-constructing detailed narratives of the cases under study, conversely, requires participants with detailed first-hand knowledge of how these processes unfolded, both formally and informally. Their perspectives on the programs’ outcomes and impacts are particularly important in documenting the reality of how program processes unfolded in practice, and for drawing connections between learning and wider development and sustainability outcomes. All participants contributed to the process of constructing the change narratives through interviews or group discussions.This section provides a stepwise description of the methodological approach  taken toThe first step of Once a list of candidate cases has been developed these are scored using two criteria to ensure they are aligned with the objectives of the contribution analysis: 1) relevance of the change to program objectives, and 2) perceived contribution of SL to the change in question. Again, this scoring involves the participation of program members who score candidate cases according to these criteria, sometimes making suggestions on how the framing of the cases could be clarified, or where individual candidate cases should be combined to produce a larger, more coherent example of change. Early engagement with the intended audience  in problem framing and focusing can improve accessibility and perceived usefulness of the findings being communicated . Once thThe second step of To address this challenge, we modified the step by developing contribution pathways that are divided into two layers . The firThe objective of this second step is to generate a tentative description of the change process under study, which can guide the interviews and participant validation in the subsequent steps. The contribution pathways are developed through a combination of document analysis and preliminary interviews with participants to document their change narratives. In the pilot case described below, the documents studied included annual reports, partner reflections and stories (such as blogs), academic publications, evaluations, and learning reviews. While constructing a contribution pathway with two layers allows us to begin illustrating the dynamics between SL and program processes, it is worth noting that the learning-centered pathway tends to be absent or highly fragmented at this early stage because evidence on SL is rarely systematically documented throughout the program period. There may also be multiple explanations about the causal links between change events, program outputs and outcomes in the documents because they are recorded by different actors, from different standpoints, at different stages of the program process. These issues are addressed in the subsequent steps.Narrative evidence on SL processes and their outcomes are crucial for this constructivist approach to contribution analysis, especially when there are gaps in documentary evidence. However, perspectives on learning processes and their contributions to change are strongly tied to participants’ own vantage points within these processes, their personal assumptions, and the depth of their engagement in the processes. Therefore, the contribution pathways developed in the previous stage must be further co-developed and tested in order to strengthen the robustness and perceived credibility of their contribution claims. To this end, participants with in-depth knowledge of the change cases are invited to contribute their own change narratives and aid in co-constructing the contribution pathway and story. This participatory process responds to concerns that contribution analysis, as a theory-based evaluation method, tends to overly privilege the views of researchers and evaluators . It alsoIn the five case studies used to pilot this method, the authors carried out 3-8 individual or small group interviews with key actors from each change case, either face-to-face or virtually. In these interviews, participants are invited to review the draft contribution pathway diagram that is crafted as an editable timeline of events and processes. Participants are also asked to share their own change narrative, identifying aspects of the pathway diagram that are incomplete, unclear or inconsistent with their recollection or interpretation of the events. Emphasis is placed on having participants describe the drivers and impacts of particular stages in the change process through the use of probing questions such as: “What led that to happen?” and “why do you think that moment was significant?” Importantly, participants are invited to challenge the authors’ causal inferences concerning the influence of SL on the change processes in order to enhance the credibility of the contribution claims set out in the pathway. The revised contribution pathway diagram and interview transcripts provide the authors with the basis for developing the contribution story.A key part of the researcher’s role in developing the contribution story is continual checking, questioning, and confirming the emerging details and contribution claims as they are identified. This strengthens the results, and thus the rigor, or trustworthiness  of a study . To thisCredibility refers to the confidence of the truth of the contribution story. It is first enhanced through an ongoing and trusting engagement with the program members and study participants. Its effect can be observed in the first step of the method where only a small set of the change cases in each program are seen influenced by SL, and thus selected for further investigation. This process involves recognizing that some candidate cases did not lead to significant outcomes, or were not the product of SL interactions (based on the insights of participants with first-hand knowledge of how events unfolded).The authors also seek to strengthen the credibility and dependability of the contribution story through an iterative process of assembling evidence and reassessing the contribution claims . The focTriangulation of claims across multiple sources of evidence can also be used to resolve any contradictions. In some cases, parts of a contribution story may differ across documents and interviews. When this occurs, the authors ensure that competing interpretations are kept, and interviewees are invited to comment on them. Through multiple rounds of data collection and comparison, we seek to establish the most plausible explanation supported by robust evidence and multiple actors’ interpretation of events. Importantly, final outputs of the research analysis  are shared back to the participants for validation and member-checking to ensure credibility and dependability of the study findings.Confirmability is concerned with the degree to which the study findings could be confirmed by other researchers. This is addressed, in part, through process of member-checking described above. The authors also establish confirmability by transparently describing the research steps taken from the start of a research project to the development and reporting of the findings, as shown in the illustrative example below.Finally, transferability is the degree to which the contribution claims can be transferred to other contexts or settings with other program members. While it is impossible to draw direct comparisons from one context-specific case experience to another in another setting—as one might do in more experimental designs—the use of existing scientific theories or frameworks can be used to test contribution claims within the story to further strengthen the confirmability and transferability of insights from the study. For example, To illustrate the use of this approach in practice, we present our analysis of a change case from the Collaborative Adaptation Research Initiative in Africa and Asia (CARIAA). The CARIAA program (2012–2018) was jointly funded by the United Kingdom’s Department for International Development (DFID) and Canada’s International Development Research Centre (IDRC) to support applied climate change research in 17 countries of Africa and Asia. CARIAA was composed of four research consortia, one of which was the Adaptation at Scale in Semi-Arid Regions (ASSAR) consortium, led by the University of Cape Town, which is the focus of this specific example. IDRC was the primary organization convening SL activities across the CARIAA program. Key members of IDRC who have professional interests in SL and transdisciplinary collaborations were thus invited to participate in the case study.At the outset of the study, IDRC created a list of significant program impacts (or changes to which the program contributed), generated through a review of the four CARIAA consortia’s final progress reports. This list served as the start point for selecting cases of study for CARIAA.An Emerging Method to Assess Learning Contributions section discussed above. We reviewed the scoring table through one-on-one and group discussions with seven CARIAA members  who had either a broad overview understanding of the entire program and its activities, or deep knowledge of one of the four specific research consortia within CARIAA. We ensured that the set of participants included at least one person with detailed knowledge of each consortium. Through this process, three out of 28 cases were selected for development from the CARIAA program, one of which we will focus on below. This case, drawn from the work of the ASSAR consortium, is described as: University of Botswana, Oxfam and University of Cape Town contributed to the District Development Plan for Botswana’s Central District. The authors began the first step by developing a table for scoring options and asked participants to score the significance of each of the changes listed as described in the Having identified the case, we then used a combination of document search and interviews to narrow down a set of documents as a starting point for developing the initial contribution pathway. In total, 73 documents were collected and screened, yielding eleven documents with content related to the case were retained. These served as the primary data for constructing the initial contribution pathway, presented in Once a preliminary outline of the case had been developed through document analysis, we gathered change narratives through interviews with five participants who were integral to the case. The participants were identified through our document analysis and conversation with the CARIAA members. Each of them had different roles in ASSAR  and a different institutional affiliation, so we were particularly interested in their perspectives on how the collaboration and SL processes took shape, and how their sustained partnership led to the ultimate policy impacts described above. This use of multiple data sources allowed for triangulation, and thus strengthened the credibility of the contribution claims.During the interviews, participants were invited to comment on the draft contribution pathway diagram (shared using GoogleDocs and the draw.io diagramming plugin). Attention was also given to understanding participants’ perceptions of the role of SL in the program implementation process. The authors then revised the contribution pathway diagram based on the interview transcripts see .4 As MAn Emerging Method to Assess Learning Contributions section, all case materials were sent back to the participants for member-checking, which allowed for enhancing credibility and dependability of the study findings.As a relevant output of the analysis, the finalized contribution pathway illustrates the added level of detail and complexity that emerge from the co-production process. The additional details provided much greater insight on the contribution of SL on program processes, as can be seen in the lower half of Looking at the dynamics between SL and program processes in the case, the method serves to generate evidence supporting the assertion that careful program design and its associated learning spaces are key factors in creating the enabling conditions for SL . For exaOne important trend in contemporary research on global challenges like climate change is a growing focus on the real-world impacts in the near term . TransdiThe novelty of this emerging method is twofold. First, its constructivist orientation to contribution analysis disrupts the primacy of the evaluator’s role in interpreting the evidence available in favor of a more participatory mode of knowledge creation . The bouSecondly, the inclusion of multi-layered contribution pathways helps to distinguish and illustrate the dynamics between overlapping processes of SL and program implementation. This methodological strategy provides a much more nuanced picture of SL in complex settings where problems are “wicked” and transdisciplinary collaborations are needed. It also provides a way to generate robust evidence on the effects of SL within networks and systems, the scales that sustainability research and practice often seek to influence. As illustrated through our case study, analysis across the two layers of contribution pathways can provide a much clearer understanding of how a particular learning process shapes the dynamics of program implementation. This clarity can help program managers, researchers, and evaluators to distill evidence-informed lessons that are transferable for future program design. The modification of contribution analysis also helps us better detect the underlying factors, such as structural barriers and existing norms, that foster or inhibit the processes and outcomes of SL. It can therefore be invaluable when assessing the drivers of success or failure in large-scale programs. Finally, given the perceived link between learning and transformation, this method may also provide insights on how we can better embed the processes, structures, and ways of learning into programs in ways that allow us to move away from incremental forms of change.ex-post analysis of the learning outcomes rather than active documentation as the process unfolded. This practice often leaves out the vital reflexive component of qualitative analysis. As adult education theorist Griff (1) Collecting real-time program data: In their synthesis review, : Based on our experience, searching and synthesizing relevant documentations was especially time consuming because information about the processes and outcomes of SL in large-scale programs were not systematically documented throughout the program period. This issue can be a particular challenge when dealing with the interventions that hold broad working definitions or ambiguous conceptual boundaries, such as SL.(2) Considering the time and costs required(3) Multimedia data collection, analysis and communication of findings: Given the growing demands for knowledge mobilization, there exists a large amount of multimedia information  produced and shared by program stakeholders and partners. Integrating tools and methods to analyze these sources could represent an opportunity to gain added insights into the members’ SL experiences, or to compare and aggregate insights in novel ways. New technologies can also be used for developing and revising the contribution pathways and contribution stories with participants in real-time, allowing for more open dialogues and negotiation in a knowledge co-production process. The approaches described here begin to use these kinds of collaborative technologies, but there is further room to innovate. To maximize their reach and influence, exploring ways to use multiple formats to share the contribution stories is also needed.With this said, no approach is without limitations. Reflecting on our experience, we conclude with a few considerations to stimulate further improvement and discussion on this emerging method: