To enhance cancer prevention and survivorship care by local health care providers, a school of public health introduced an innovative telelearning continuing education program using the Extension for Community Healthcare Outcomes (ECHO) model. In ECHO’s hub and spoke structure, synchronous videoconferencing connects frontline health professionals at various locations (“spokes”) with experts at the facilitation center (“hub”). Sessions include experts’ didactic presentations and case discussions led by spoke site participants. The objective of this study was to gain a better understanding of the reasons individuals choose or decline to participate in the Cancer ECHO program and to identify incentives and barriers to doing so.Study participants were recruited from the hub team, spoke site participants, and providers who attended another ECHO program but not this one. Participants chose to take a survey or be interviewed. The Consolidated Framework for Implementation Research guided qualitative data coding and analysis.We conducted 22 semistructured interviews and collected 30 surveys. Incentives identified included the program’s high-quality design, supportive learning climate, and access to information. Barriers included a lack of external incentives to participate and limited time available. Participants wanted more adaptability in program timing to fit providers’ busy schedules.Although the merits of the Cancer ECHO program were widely acknowledged, adaptations to facilitate participation and emphasize the program’s benefits may help overcome barriers to attending. As the number of telelearning programs grows, the results of this study point to ways to expand participation and spread health benefits more widely. Cancer remains the second leading cause of death in the United States, and new methods are needed to support health care professionals in providing both prevention and survivorship care for their patients. To that end, a school of public health introduced an innovative telelearning program to use technology to link frontline health professionals at their locations with experts at the school for regularly scheduled learning sessions. These sessions on a range of cancer prevention and survivorship care topics take place twice a month and feature presentation of current information and discussion of cases. After the program’s pilot year, this study sought input from both participants and nonparticipants to identify incentives and barriers to participation. Input was collected via interviews and a survey. Incentives to participate included the program’s high-quality design, supportive learning climate, and access to information. Barriers included a lack of external incentives to participate and limited time available. Participants also wanted more adaptability in program timing to fit busy health care provider schedules. The results will be used to expand and improve the program in the future with the aim of enhancing providers’ use of cancer prevention strategies and care for survivors. The didactic content covers a broad spectrum of cancer-related topics, ranging from lifestyle and vaccination prevention measures to motivational interviewing and smoking cessation to postradiation oncology surveillance, and repeats so participants can enroll at any time during the year. Hub team members are from oncology and its subspecialties, primary care, social work, psychology, and public and community health. In the pilot year (2019–2020), 22 sessions were held, and 147 spoke site individuals participated; 16 of those were primary care providers (PCPs). Sessions had an average of 14.5 spoke participants each, with an average of 2.5 PCPs (17.2%).As the Cancer ECHO program transitions from the pilot stage to wider adoption and a routine operation, we want to expand spoke site participation. The objective of this study was therefore to gain a better understanding of the reasons individuals choose or decline to participate in the Cancer ECHO program and to identify incentives and barriers to doing so. Prior studies of ECHO programs suggest the model has high feasibility and promising educational effectiveness in new contexts,Participants for this mixed-methods study were recruited based on purposeful sampling . Recruitment emails were sent to three groups: (1) the hub team ; (2) spoke site members who attended at least one Cancer ECHO session and may or may not have attended other Project ECHO programs; and (3) providers who attended one or more of the other Project ECHO programs but did not participate in the Cancer ECHO despite being invited, so we designated them potential spoke participants. All participants were asked to choose whether they would complete a survey or participate in an interview. The nonhub participants were provided with compensation of $10 to $40.Both the survey and the interviews explored individuals’ reasons for participation or nonparticipation in the Cancer ECHO program and their perceptions of the program. The anonymous survey was administered on IU Qualtrics, a secure web-based survey tool . In thisTo organize and analyze data from the interviews, we chose to use a well-established conceptual framework: the Consolidated Framework for Implementation Research (CFIR). The CFIR synthesizes constructs from multiple theories into a robust framework and has been found effective for guiding the successful implementation of programmatic innovations in numerous health care domains.http://www.wiki.cfirwiki.net/).Three research team members  independently coded the transcripts using CFIR constructs . Each trWe conducted 22 semistructured interviews and received 30 anonymous surveys between May and September 2020. These participants’ gender, setting, and relationship to the program are shown in Hub providers are specialist physicians and primary care providers. N/A: not applicable.Among the survey respondents, 10–15% chose the program’s length, scheduled time, priority, or content as their primary reason for nonparticipation . The resThe consensus was that 13 of the CFIR constructs were salient influences on participation in the Cancer ECHO program. Six constructs had a positive impact, and six had a negative impact; one was equally positive and negative . The folBoth PCP and non-PCP spoke and potential spoke interviewees spoke highly about the relative advantages of the ECHO model compared to other educational activities. They like that it is virtual, conversational, interactive, and interdisciplinary in nature. One interviewee  said that, in other online continuing medical education (CME) programs, for “a lot of the activities you’re just in front of the computer screen doing some multiple choice or reading articles. I think [the ECHO program’s] real benefit is that with other people you have a community of support; you have feedback. So I feel like it can be a lot more fruitful than a lot of the other CME activities.”The Cancer ECHO has a broad range of audiences, but some of the PCPs said they would prefer the program include further conversations within a smaller group or provide an asynchronous option to fit their schedules—suggesting they perceived it as not being adaptable to their needs. Current ECHO sessions are live-streamed with an option to replay a recording of the didactics part only but without asynchronous interactions. This construct refers only to the adaptability of the information exchange, not of the shared knowledge. This finding relates to the fact that the scheduled time was said in the interviews to be a major reason for nonparticipation and was the most selected aspect that needed to be changed on the survey .The program assembled a dedicated hub panel who developed didactics topics with a holistic view of care. The hub team, with its broad range of expertise, also offered engagement and mentorship in the case-based learning, which enabled a collaborative model of education. The interviewees spoke highly of the program quality, especially the case discussion. “It’s been good to hear the [didactic] presentations, which is what I initially thought was [going to be] the most helpful,” said one interviewee . “But actually, the case presentation and discussion component, where you have a question and answer, has been surprisingly more beneficial … at times and helps create change to my practice.”This construct was especially important to PCPs. They considered the external policy and reimbursement for providing cancer control services at the point of care a significant negative factor for adopting the Cancer ECHO program and implementing its changes in their practices. Health professionals can earn CE credits by attending. However, not only potential spoke but also spoke PCPs expressed extensively that cancer control is a poorly incentivized field, which makes it a barrier for their participation in the program. One interviewee  noted, “I think one of the … major hassles that we find is that … the productivity requirements [for PCPs] are incredibly high…. You want to reach the agile clinicians, but you have to give them some kind of a carrot, and just increasing knowledge doesn’t do it.” Another  said, “It sounds bad, but people just come out and say that there’s no billable code for talking about smoking cessation.”The interviewees agreed cancer control is an important topic that needs clear improvement, and they desired a change in the current performance of cancer control services. They mentioned many aspects impeding them from successfully delivering services to the needed population, such as insurance coverage and the difficulty of navigating the system and connecting to resources. “We have to improve cancer screening and prevention,” emphasized one interviewee . Another  said, “A lot of my burnout is also often related to system barriers and knowing our health care systems are very hard to navigate, even when you’re within the system.”The interviewees, especially the potential spoke group, talked extensively about their patient population, the role of their specialty and services in cancer patient care, and the Cancer ECHO program’s perceived relevance and fit to their careers. Some said the pediatrics topics did not apply to their geriatric-dominant patient population. Others said they were not playing a big role in cancer survivorship care or were comfortable with their collaboration with specialists and felt the current content would be more meaningful to new care providers who do not yet have a niche in their practices. A dentist  emphasized that he believes in dentists’ role in cancer control, but said that an unexpected conversation about cancer with patients “freaks them out sometimes.”In general, spokes and potential spokes interviewees held a moderately negative attitude towards the relative priority of the program. “I think that I probably wouldn’t be able to allocate that much time [for the Cancer ECHO],” said one interviewee . “The Hepatitis C [ECHO] is a little bit unique because … to be a primary care physician that prescribes medication for Hepatitis C, you’re legally required to attend the ECHO, so that sort of gives me and my organization a little bit more [incentive]… It’s a lot harder to kind of see that the value [of Cancer ECHO] adds to the cost of not seeing patients.” Another  noted that, as busy care providers with many competing tasks, their choice of how to spend learning time “probably would be very topic-based.” On the survey, 10.9% of respondents reported the program’s not being a priority was their primary reason for nonparticipation. Asynchronous participation was proposed by some as a possible solution.The spokes interviewees regarded highly the learning climate in the ECHO program, and the potential spokes interviewees who knew about IU ECHO programs also had confidence in the Cancer ECHO’s learning climate. A spoke participant  said, “I think it’s empowering to feel like you’re a part of a team that is very broad and very large, that we are all working towards mutual goals, even in different specialties, in different roles, with different clinical backgrounds and different educational backgrounds. So that’s really neat to learn from other providers in other parts of the country potentially.”Comments in this construct primarily addressed the Physical Space and Time subconstruct. Thanks to the multipoint videoconferencing technology utilized, program participants were able to join without limitation in physical space resources, even during the pandemic shutdown. However, all subgroups of interviewees and survey respondents  perceiveA multidisciplinary hub team acted as the knowledge and information source and was dedicated to live-streaming support during sessions. An online resource library was also provided for individuals to review session recordings, didactic materials, and other resources mentioned during the session. Both spoke and potential spoke interviewees saw this access as a positive motivator. “I love the fact that they have the resources that they apply,” said one . Another  commented, “If you have a situation that you’re worried about, you can bring that up to the panel and they can also do a session on that.”This construct had mixed data. Interviewees said they believed they could gain cancer-related knowledge from participating in the program, but PCPs perceived that complex systemic issues are what prevent patients from receiving optimal cancer preventive care, not care providers’ awareness or knowledge of best practices. The potential spokes and some spokes PCPs expressed uncertain beliefs in improving the issues in cancer control by mentoring PCPs, given the lack of incentives and worsening productivity requirements for care providers as well as unaffordability of preventive services. One PCP said that improving the operational side of health services would be more effective, while others expressed their belief in the ECHO model. One interviewee  who is a medical director in an underserved area said, “I’m not interested in what are the ideal or best practices. I’m interested in what can we do for people with the resources that are available to us right now.” Another  said, “I think ECHO is right on target. You have to start somewhere.” Although some survey participants reported the ECHO content contributed to nonparticipation, only a few thought content change was the primary change needed .Engaging PCPs to participate and present cases were perceived as a challenge. Although spokes interviewees said that they benefited the most from case discussions, the richness and the topics of that part of the sessions were not advertised to the target audience. Since case discussion is led by spokes PCPs, engaging them to actively present cases was limited by a relatively low PCP participation, despite frequent email communications between the program and its spokes and target audiences. Hub interviewees in particular pointed out concerns with this. “I don’t think we are capturing primary care providers, physicians in our ECHO participants,” said one . Another  noted, “I think the thing that’s been the toughest challenge is that we’re having a tougher time getting spoke sites to find good cases to present.”N = 14) reported the program met or exceeded their expectations.The hub team and spokes participants reported thinking the pilot year of the Cancer ECHO program went very well overall in terms of content quality, progress, and organization, provided useful resources and knowledge, and held stimulating discussions. One interviewee  summarized this perspective by saying, “The organization of it [Cancer ECHO] and the layout of it were really impressive.” Although the hub team had difficulty obtaining real-time feedback from postsession surveys, a one-time survey found that 100% of spoke survey respondents . The Cancer Prevention, Survivorship and Prevention ECHO, a program of the IUPUI ECHO Center at the Indiana University Richard M. Fairbanks School of Public Health, described in this study received funding or in-kind support from the Indiana Department of Health (Contract #18938 “Cancer Prevention and Control Project ECHO plan”), specifically the Division of Chronic Disease, Primary Care, Rural Health, the Indiana Immunization Coalition (Contract #173640), Riley Children’s Hospital, American Cancer Society, Indiana Cancer Consortium, and the Indiana Clinical and Translational Sciences Institute. We also acknowledge the support from the Indiana Clinical and Translational Sciences Institute funded, in part by Grant Number (UL1TR002529) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Library of Medicine, the United States government, or any of the listed organizations or programs.All authors listed meet the ICMJE criteria for authorship for this manuscript. ZM, EM, JD, BD, AC, TS, and TV contributed to initial study design, and the development of protocol and interview and survey questions. All authors contributed to research strategy development. ZM collected the interview and survey data. EM, JD, BD, AC, and AJ supervised or assisted data collection. ZM, EM, TS, BD, TV, and JB contributed to the qualitative analysis strategies. ZM, TS, CS, and EM contributed to the qualitative analysis of coding and grade assignment. ZM, EM, TS, CS, JD, and BD contributed to the data interpretation. ZM wrote the initial draft, which was revised by all authors. All authors have approved the final manuscript to be published.JAMIA Open online.ooac004_Supplementary_DataClick here for additional data file.


NIH offers multiple mentored career development award mechanisms. By building on the UC Davis Clinical and Translational Science Center (CTSC) from its initial NIH funding in 2006, we created an institution-wide K scholar resource. We investigated subsequent NIH funding for K scholars and to what extent CTSC research resources were used. Using NIH RePORTER, we created a database of UC Davis investigators who obtained K01, K08, K23, K25, or K99, as well as institutional KL2 or K12 awards and tracked CTSC research resource use and subsequent funding success. Overall, 94 scholars completed K training between 2007 and 2020, of which 70 participated in one of four institutional, NIH-funded K programs. An additional 103 scholars completed a mentored clinical research training program. Of 94 K awardees, 61 (65%) later achieved NIH funding, with the majority receiving a subsequent individual K award. A higher proportion (73%) of funded scholars used CTSC resources compared to unfunded (48%). Biostatistics and Biomedical Informatics were most commonly used and 55% of scholars used one or more CTSC resource. We conclude that institutional commitment to create a K scholar platform and use of CTSC research resources is associated with high NIH funding rates for early career investigators. The success of the national scientific enterprise is intrinsically linked to the development of a well-trained cadre of junior investigators . This neBeyond the NIH, individual universities and academic health centers are important stakeholders in ensuring the successful transition of trainees to independence in a highly competitive environment. Recognizing the challenging nature of this path, many institutions have developed support mechanisms such as protected research time, active mentoring training, peer groups, and assistance with grant writing. Notably, the Clinical and Translational Science Award (CTSA) program, funded by NIH’s National Center for Advancing Translational Sciences, provides institutions with resources to support infrastructure, training, career development, and research and educational resources to catalyze translational research and develop a workforce of biomedical science researchers . While tUC Davis received one of the 12 inaugural CTSA awards in 2006 that established the Clinical and Translational Science Center (CTSC) ,8. At thSince its inception, the UC Davis CTSC, including its associated TL1 and KL2 awards, has been continuously NIH funded. With a 15-year history of serving investigators, the CTSC has had the potential to influence the research trajectory of many UC Davis scientists, including early career investigators. In this report, we summarize the impact of the CTSC on the UC Davis training and mentoring environment and the subsequently funded NIH grants received by trainees. Beyond its impact on the number of institutional career development grants awarded, we also sought to determine the role of specific CTSC or affiliated institutional resources on K awardee success rates in obtaining subsequent NIH funding. Although the R01 grant has traditionally been the benchmark for independence, in this age of team science, scientists may also maintain active research programs through funding from different grant mechanisms or as co-investigators or core leaders of another PI’s grant. Thus, in addition to K and R01 funding, we also tracked other “R-type” funding  as assessment of whether institutional or individual K award funding leads to subsequent NIH funding of any type, providing a relevant metric of K awardee success.We constructed a data set of UC Davis K awardees, both those with individual and institutional K awards, to assess their subsequent funding success in obtaining NIH funding. Using NIH RePORTER, we entered “Davis” in the Organization field, “2007–2020” in the Fiscal Year field, and “Research Career Awards” for the Activity Code. The start year of 2007 was selected as this was the inaugural year for the first scholars entering the CTSA KL2 program. Awardees were included whether they initially received their K award at UC Davis or transferred the award from another institution. In addition, we included scholars who successfully competed for funding through four institutional KL2 or K12 awards  as well as scholars who entered our K30 . Attainment of subsequent grant funding was determined from NIH RePORTER and defined as being the Contact PI/Project Leader for any funded grant regardless of grantee organization. R00 awards, which are coupled to K99 awards and contingent upon obtaining a tenure-track equivalent position, were not counted as subsequent funding. Grants in the R, P, or U mechanisms were considered subsequent funding and included irrespective of whether the Contact PI/Project Leader had transferred to another institution. Subsequent funding of R awards was categorized as either R01 or R-type, defined as any non-R01 (including R03 and R21), P or U award.Scholar use of CTSC resources, defined as scholars having one or more records in the CTSC’s Application for Resource Use (AFRU) on any date after receiving a K award, was captured starting in 2007. Both type of service  and frequency of use were captured and included. Grant writing assistance and subsequent leadership positions and honors/awards were also recorded. Leadership positions and honors/awards were self-reported as part of annual scholar surveys.To correlate subsequent NIH funding with use of UC Davis CTSC resources, we excluded individuals whose K awards were still active in 2020. Individuals were also excluded if they transferred to another institution either during the K award funding period or immediately afterwards, as assessed by online search or NIH RePORTER data of the grantee organization. For the remaining scholars, we determined subsequent funding success rates by calculating, within each category of K award, the percentages of individuals who were awarded any type of NIH research grant following the K award. As these data represent a census that describes the trajectory of funding for K awardees at UC Davis between 2007 and 2020 and are not a sample from a larger population, no inferential statistical tests were conducted.1, a number of KL2 and K30/MCRTP graduates have, during the 15-year CTSA funding period, been successful in competing for such leadership positions, many of those at UC Davis.At the initiation of the NIH CTSA program, UC Davis had one institutional K program and a few individual K awards. The existing K program, funded a year earlier, was an NIH K30 award with an associated Master’s in Advanced Science degree that provided no salary support and was integrated into the CTSC upon funding of the latter in 2006. As part of the CTSC, the K30 program transitioned into a Mentored Clinical Research Training Program (MCRTP) as one component of the CTSC Research Education and Career Development (RECD) Program. From the beginning of the CTSC program, both the CTSC and School of Medicine leadership realized the opportunity to utilize the center as a platform to create a strong institutional training and mentoring program. This process was facilitated by the K30 Director assuming an overarching role in directing the CTSC RECD Program. By enhancing the resources available through the CTSA with institutional funds and bringing the MCRTP, the CTSC TL1  and the CTSC KL2 (junior faculty training) programs administratively together, a widely recognized institutional platform and centralized mentoring resource emerged. Another advantage in creating a unified administrative home for the three training programs was the wide recognition by School of Medicine and departmental leadership, that these programs represented a unique opportunity to develop a strong cadre of early-career investigators, ready to take on new leadership roles. Throughout the CTSA funding period, having KL2 or MCRTP scholars as faculty members has been a source of pride and recognition for departments, a sense reinforced by the many successful careers launched through these programs. As detailed in Supplemental Table 2). Regular meetings for this community included, in addition to “Works-in-Progress” research presentations by the scholars, presentations from directors of the various CTSC programs to promote awareness of CTSC resources and provide easy access for their use. A particularly well-embraced innovation was the establishment of an Annual Scholar Symposium attended by an external Education Advisory Board, which served to strengthen scholar presentation skills and enable valuable extramural mentoring advice. To date, these scholar symposia have been held for 16 years. With scholars from multiple training programs, these joint sessions have resulted in novel collaborations, some of which have led to interdisciplinary research programs. Examples include collaborations of veterinary and medical school trainees, resulting in coclinical trials in human and animal (mostly canine) patients. Other ongoing programs include partnerships between pulmonologists, epidemiologists, and biomedical engineers to analyze breath exhalates to characterize disease severity and exposure, most recently applied to patients exposed to wildfire smoke and to diagnose COVID-19 infections.When the first CTSC KL2 scholar cohort was selected in 2007, several individuals had already graduated from the K30/MCRTP program, providing a source of qualified applicants. Although the CTSC program funded a limited number of K scholars per year due to the relatively small initial size of the NIH award, once established, many features of the program were modeled and leveraged by other subsequent UC Davis institutional K applications. In addition, all UC Davis K scholars, including those not directly funded by the CTSA, were invited to be part of a “K community.” Since inception of the CTSC, 70 K scholars have participated in the four institutional K programs and were joined by 24 scholars receiving individual Ks. In addition, more than 100 scholars have completed MCRTP training  Program, and the Emergency Medicine Training Program. In addition, the CTSC has brought infrastructure and administrative support to a number of individual mentored K awardees. In 2020, compared to 17 K scholars at the time of the first year of the CTSC KL2 in 2007, there were 36 K scholars at UC Davis . As the CTSC Director assumed this institutional leadership position a few years after NIH funding, this grant writing resource was functionally closely integrated and streamlined with the CTSC RECD program, albeit remaining fiscally separate. The GF program has, over the years, consistently had three staff members, of which one position was mainly responsible for assistance with career development awards, ensuring strong continuity and familiarity with the scholars and their research areas. They give orientation and information sessions to K and MCRTP scholars and any junior investigator at UC Davis preparing a K or a R submission are encouraged to seek their assistance, frequently by mentors or program leadership. The CTSC director meets weekly with GF program staff and the KL2 directors refer scholars to the GF program when they have generated enough preliminary data to begin developing a grant application. The value of the GF program was recognized such that a similar resource was subsequently created in the NCI-funded UC Davis Comprehensive Cancer Center to facilitate cancer-related grants including career development and early career investigator proposals.To further enhance the skill sets of K scholars, an institutionally funded Grants Facilitation (GF) program was created, reporting to the Associate Dean for Research in the School of Medicine . In addition, activities and services managed by or affiliated with the CTSC are also available, including K scholar cohort activities and grant writing assistance. An institutional initiative to create a UC Davis Health Mentoring Academy, led by CTSC faculty, was launched in 2010. The academy included training for department and center faculty with mentoring responsibilities. It was open to mentees at all stages and every UC Davis K scholar was required to participate. As seen in Table We next examined whether utilization of CTSC resources was associated with subsequent grant funding success. As is common for CTSA programs, the UC Davis CTSC offers multiple services to advance translational research, including Informatics, Biostatistics, Clinical Research support, Community Engagement, and Regulatory Knowledge Support . Scholars who utilized the CTSC often accessed more than one program, with 109 scholars (55%) using one or more services. Biostatistics and Informatics were most commonly used. Notably, there was similar usage of Grant Writing Assistance.To examine how K and MCRTP scholars used CTSC resources, we extracted data on the distribution of resource use by scholars across the various programs   program, scholars are referred to the GF program well in advance of training completion to allow adequate time to plan, strategize, and review proposal drafts. In addition, the GF program makes scholars aware of special funding opportunities . By guiding scholars through every step of what is typically their first NIH application, the resource serves as an additional layer of hands-on mentorship in grant writing and submission. The existence of a K community provides a means to collectively learn from both successful and unsuccessful applications. Use of CTSA and affiliated institutional resources, such as grant writing assistance, was more common among scholars who received subsequent NIH funding, with the exception of individual K scholars.An important factor to consider is length of the mentored training period. Among the four institutional K programs at UC Davis, the BIRCWH program has offered a full 5-year funding period, while the other programs have limited the funding period to 2 or 3 years. In some cases, the third year was institutionally funded. It is therefore not surprising that the success rate for subsequent grant funding following the institutional K award was highest for BIRCWH scholars. The average time on grant for BIRCWH scholars was ∼3.5 years, with nearly half  exiting the program before 5 years. Nevertheless, subsequent funding success was comparable between those who exited early and those who did not. Although not all scholars needed the 5 years, those who required additional time to generate preliminary data or resubmit grant applications were able to maintain continuity in their research. This is also likely contributing to the higher success rate of individual K scholars, who also received 5 years of funding . These tAs biomedical research, particularly in clinical and translational science, is becoming more complex and increasingly requires a team science approach, it is relevant for trainees to consider opportunities to contribute as part of a larger grant team. Although R01 funding largely remains a standard measure of research independence and success, an equally important measure may be a role as collaborators, multi-PI or project or core leaders of P or U grants. In addition, smaller research project awards such as R03 or R21 grants represent important mechanisms for maintaining research productivity. It was notable that such types of non-R01 research grant funding were more common as the next step for both institutional and individual K awardees than R01 funding. This is likely to become even more commonplace in the future. Several of these larger P or U grants represented long-running, continuously funded grants. Given the firm institutional anchoring of K scholars in the four institutional K programs, these scholars provided a well-trained cadre for succession in leadership of large, established research programs.We acknowledge some limitations of our study. As our focus was primarily on NIH funding, we did not take funding from other agencies into account. We also did not consider payline fluctuations over time, differences across institutes, or that paylines for K and R awards may differ.In conclusion, our results demonstrate a trajectory of growth for mentored career development awards at our institution. UC Davis rapidly recognized the importance of a CTSA award and used this as a springboard to build a training platform that has generated a cadre of NIH-funded investigators as well as individuals who have assumed various leadership positions. These data further indicate an advantage for scholars who used CTSC services and provide important insight into the effect of a CTSA on scholar career trajectories. The competitiveness of NIH grants makes starting with a K award as a springboard a good strategy for obtaining any type of subsequent NIH funding. While an R01 award is an indicator of research independence, it is not the only benchmark of success or continued contribution in research. Our data also point to the importance of having a strategic institutional plan to ensure that trainees participating in institutional K programs receive the full training period in order to optimize their career trajectories. Our experience to date has informed institutional leadership, program leaders, and not least future trainees positioning UC Davis in a strong position to continue to build on this foundation.


Plasmodium vivax. Recently, a novel panel of P. vivax proteins were identified and validated as serological markers for detecting recent exposure to P. vivax within the last 9 months. In order to improve the sensitivity and specificity of these markers, immunoglobulin M (IgM) in addition to immunoglobulin G (IgG) antibody responses were compared with a down-selected panel of 20 P. vivax proteins. IgM was tested using archival plasma samples from observational cohort studies conducted in malaria-endemic regions of Thailand and Brazil. IgM responses to these proteins generally had poorer classification performance than IgG.To achieve malaria elimination, new tools are required to explicitly target  Plasmodium vivax are a major challenge for malaria elimination. This is due to unique biological features of P. vivax parasites, including an arrested stage in the liver (hypnozoites) that can reactivate weeks to months later, causing relapses of clinical disease. Individuals with hypnozoites are major reservoirs of transmission and are responsible for >80% of blood-stage P. vivax infections ), performed well with IgM in both the Thai and Brazilian cohorts, with AUC values of 0.74 and 0.71, respectively. In the Thai cohort, the protein PVX_082670 (merozoite surface protein 7 putative [MSP7]) also performed reasonably well for IgM . The AUCs for IgM responses against RBP2b (the top-performing marker for IgG) were much lower at 0.63 and 0.56 , we hypothesized that IgM responses may be better markers of very recent exposure. We therefore tested the ability of IgM antibody responses to our 18–20 Our original results showed that IgG antibody responses to combinations of proteins were better at classifying individuals as infected within the last 9 months compared with individual proteins alone. We therefore tested the classification ability, using the 9-month time frame, of each IgM antibody response combined with IgG responses against the top protein RBP2b. IgM from any of the proteins tested when combined with IgG responses against RBP2b had better classification than IgM alone against any protein, as determined by AUC values . In the P. vivax infections could play an important role in malaria elimination by delineating areas of ongoing transmission and identifying individuals with a high chance of carrying hypnozoites in their livers. We note that in our cohort studies the recent blood-stage infections could have been caused by hypnozoites relapsing or by new mosquito-bite derived infections. The fact they have had a recent blood-stage infection means that it is highly likely they are harboring hypnozoites (if they have not received liver-stage drug treatment) and could go on to have future relapses. In this study, we aimed to improve upon an existing set of serological exposure markers by incorporating IgM, in addition to IgG, responses against these proteins. We demonstrate that 2 proteins in particular, PVX_087885 (RAMA) and PVX_082735 (TRAP), induce IgM responses reflective of recent exposure to P. vivax within the past 9 months in endemic regions of Thailand and Brazil. They have similar accuracy as compared with these same antigens using IgG . However, the accuracy of these classifications overall is poorer than for the top-performing serological marker (RBP2b) when using IgG, and generally the IgM AUC values for each antigen were lower than the corresponding IgG AUC values . Another contributing factor is likely the high background of IgM in the non-malaria-exposed controls  is unlikely to yield better results.When we combined each of the IgM responses against the 18–20 Finally, we ultimately aim to develop a point-of-contact test to be used in the field. It would be a more complicated and costly test if both IgG and IgM responses were required to be measured. We will therefore not be pursuing IgM responses in our optimization of our novel panel of serological exposure markers, and will instead focus on other avenues for improved performance of the signals we can obtain from the IgG responses.Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at ofab228_suppl_Supplementary_MaterialsClick here for additional data file.


For the HAC Reduction Program, “if data from January 1, 2020 - March 31, 2020 (Q1) is submitted, it will be used for scoring in the program.”2In the above mentioned published article by Stevens et al


We evaluated a large-scale pilot program in Shaanxi Province, western rural China, which integrated prenatal screening interventions for congenital abnormalities into routine antenatal programs.We surveyed 1,597 mothers who gave birth between 2009 and 2016. Adopting the interrupted time-series design, we evaluated the program's impact on awareness, coverage, and cost, by comparing two counties with only supply-side policies, and two counties from the neighbouring province with no policies; and among the two counties with both supply- and demand-side policies and the two counties with only supply-side policies. We adjusted the sampling procedure and women's background characteristics. We conducted subgroup analyses by women's education.After one year of implementation, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose by 25.0% and 23.5%. The program's supply-side policies attributed to 17.2 percentage points (90%CI 7.8–26.6%) and 27.3 percentage points (90%CI 16.2–38.5%) in coverage, and contributed to a higher median cost of 796.5RMB (90%CI 595.5–997.5). These significantly affected women with secondary education and above. However, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions, which raised awareness, and increased coverage of prenatal foetal aneuploidies screening by 28.6 percentage points (90%CI 13.4–43.8%), while not increasing costs. These significantly affected women with primary education and below. Education-related inequalities widened post-program in counties with only supply-side policies, but no inequalities existed in counties with demand-side policies.Shaanxi's program made a pilot study to other provinces of China to integrate antenatal services. Government subsidies might be more effective in targeting specific geographic locations and people with primary education and lower. Evidence before this studyThe global health community is calling for integrated maternal, new-born, and child health care. However, two latest systematic reviews from low- and middle-income countries (LMICs) concluded that there was still a striking lack of evidence on integration and delivery strategies. Prenatal screening of congenital abnormalities, that is, serum screening for foetal aneuploidies and B-ultrasound screening for structural malformation, is an important prophylaxis intervention. Our systematic search of the literature showed that no study has investigated the coverage and inequality of prenatal screening in rural China, particularly for the western part that encountered great challenges in promoting maternal, neonatal, and child health. Vouchers have been widely considered by policymakers and program managers in many LMICs to promote equity for antenatal care. However, systematic reviews revealed important literature gaps for implementation. First, no study has explored whether and how vouchers can help to facilitate the integration of other interventions into routine care. Second, no study has explored the mechanisms of how vouchers work, considering contextual factors.Added value of this studyThis study examined the first pilot program from rural China that attempted to integrate congenital abnormalities’ screening interventions into routine antenatal care. We found that after one year of implementation of this program, the coverage of the extended interventions increased substantially, which was independent of women's geographic access to health care, demographic factors, and socioeconomic status. On the one hand, the program's supply-side efforts increased the coverage of the extended interventions and contributed to a rising median cost. These significantly affected women with secondary education and above. On the other hand, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions and increased coverage of the extended interventions, while not increasing costs. These significantly affected women with primary education and below. In addition, education-related inequalities widened after one year's implementation in counties with only supply-side policies. However, in counties with demand-side policies, no inequalities existed.Implications of all the available evidenceOther regions in China and Western Pacific may learn from this case to promote integrated antenatal care that built constructive accountabilities that link families, communities, and health providers. The Chinese government should also pay careful attention to the varied contexts while designing and tailoring voucher-based programs. It might be more effective to target specific geographic locations and people with primary education and lower.Alt-text: Unlabelled box1There has been a strong global commitment to universal health coverage, and the extension of essential preventive services is one of its central features Demand-side financing consists of a group of innovative tools to promote equity in essential health services st, 2015, aimed at integrating the two types of interventions that screen congenital abnormalities into routine antenatal care: prenatal foetal aneuploidies screening and prenatal B-ultrasound screening.China has been scaling up its National Essential Public Health Program, which has been providing five free routine antenatal visits since 2009 Specifically, Shaanxi Province implemented two types of managerial measures. Appendix Table 1 describes the policies in detail. Briefly, on the supply side, the government advocated universal uptake of prenatal screening services and established mechanisms to coordinate health providers and guide service procedures. Whereas on the demand side, the government directly subsidized families who used the extended interventions through the existing vouchers-based system within the National Essential Public Health Program. Notably, supply-side measures were universally introduced in Shaanxi, while demand-side measures  for the new integrated services were piloted in only about one quarter of the counties predetermined by the provincial government, prioritizing poor counties and those having maternal mortality above the provincial average.In this study, we evaluated the impact of the Program on coverage and equity. Comparing between counties, we tried to differentiate the impacts of the Program's supply- and demand-side managerial measures. By considering the contextual factors, we draw lessons for the Chinese government on how to proceed with integration and promote equity in similar settings.22.1According to data from China's national surveillance Using survey data, we conducted an observational study that compared between counties that had policies and similar counties that did not. First, to evaluate the impact of the Program's supply-side integration measures, we compared between two counties in Shaanxi Province where only supply-side measures were conducted, and two counties in Ningxia Province where integration had not yet commenced. We chose Ningxia because it is a neighbouring province of Shaanxi, and vouchers were used in both of the two provinces to deliver routine antenatal care. Second, to evaluate the impact of the Program's demand-side measures, we compared four counties within Shaanxi Province, where supply-side measures were universally carried out, but demand-side measures were only conducted in two of them, as a means to promote integration. In addition, the four counties within Shaanxi came out from two different contexts, where two neighbouring counties were from the mountainous regions and the other two neighbours were from the plain regions. For each pair, one had demand-side policies for integration and the other did not. .2.2We surveyed mothers who gave birth during the 2009–2016 period in the six counties from July to August 2016 using a stratified, clustered sampling procedure. First, to define the stratum, we ranked all the townships in each county based on their travel time (distance) to the county hospital using Baidu Maps. We then classified the townships into three groups based on this travel time, where each group was a sampling stratum. Second, we sampled 3–4 townships within each stratum. The number of townships that were selected ranged from 10 to 12 for each county. For each township that was selected, we considered the distance of each village from the township maternal and child health doctor who was in charge of the National Essential Public Health Program. We then sampled at least two villages - one far from, and one near the township hospital. Third, we obtained lists of names of all the mothers living in the sampled villages from the local maternal and child health doctor. The lists of names contained the basic information - including name, address, date of birth, and telephone number - of all the mothers and children that were recorded in the annual report system. We investigated all the families on this list that were at home during the survey. Fourth, we defined seven age groups according to the mothers’ date of delivery before the survey: 0–6 months, 6 months to 1 year, 1 to 2 years, 2 to 3 years, 3 to 4 years, 4 to 5 years, and 6 to 7 years. The sample size was determined by the time window of the study. For each age group, we selected a minimum number of mothers for the study. For the 0–6 months’ age group, we surveyed at least 100 women, while for the other age groups, we surveyed at least 20 women in each group. We recruited and trained students from the author's institute, to interview the mothers using a structured questionnaire. Verbal informed consent was obtained from the participants of the study. The study was approved by Peking University (IRB00001052–14070).In total, we approached 1615 mothers of which 16 (1.0%) refused to participate in the study, and the other 170 (10.5%) participants had important missing values. For the 170 participants, our student interviewers contacted them at least three times through phone calls to complement the missing questions, of which we excluded 18 questionnaires. We finally had 1597 (98.9%) valid questionnaires for this analysis. We input the data using the EpiData software version 3.0. Each questionnaire was double-entry and checked for inconsistencies. Data were then exported to Stata 13.1 for further recoding and analysis.The first author designed the survey and developed the questionnaire with consultations to statisticians and epidemiologists in the author's institution. One section of the questionnaire requested the mothers to recollect the frequency, contents, and total costs of the antenatal care received. We built the following coverage indicators, defined as the proportions of women who declared having used such services: prenatal foetal aneuploidies screening, prenatal B-ultrasound screening, and at least five routine antenatal visits. We ascertained 2 cost-related indicators, i.e. the total medical and non-medical costs associated with antenatal care. Medical costs referred to the out-of-pocket payments to health providers to receive antenatal care, while non-medical costs referred to the costs of travel and accommodation that were directly related to the activities in seeking antenatal care.In addition, the questionnaire investigated the respondents’ awareness of the government program and their benefit from it. These data comprised four indicators in this analysis: 1) knowing about the five free routine antenatal care visits; 2) having used antenatal care vouchers; 3) knowing about the Extended Antenatal Care Program; 4) having used the extended interventions free of charge. We also collected information on the following covariates: mothers’ education, households’ income per capita, mothers' health insurance, distance, parity, and age.2.3We described women's characteristics by types of interventions and regions. We analysed trends in awareness and coverage, adjusting confounding factors using Poisson regression with sandwich robust standard errors. We reported 90% confidence intervals (CIs) that accommodate higher type I errors because this is a pilot study with relatively small sample sizes. We adopted the interrupted time series approach to model the Program's impact 2.4The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and all authors shared the responsibility for the decision to submit for publication.3st, 2015. Correspondingly, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose from 44.5% and 52.1% to 69.5% and 75.6%, respectively. In Ningxia, however, there were no obvious trends in coverage of these two types of interventions , coverage of five routine antenatal visits , prenatal foetal aneuploidies screening , and prenatal B-ultrasound screening  rose faster in the control group rather than in the intervention group. P = 0.3106 and 0.7857 testing differences). In terms of coverage as well, there were no education-related inequities before the Program (P = 0.5638 and 0.4277 respectively). However, after the Program, women with secondary education and above had 45.2 (P<0.0001) and 26.5 (P = 0.0002) percentage points higher coverage of prenatal foetal aneuploidies screening and B-ultrasound screening, respectively, compared to those with primary education and below. In addition, persistent education-related inequalities were observed for at least five routine antenatal visits during the study period .P = 0.0030, 2.3 percentage points, P = 0.7049 before and after the program, respectively). Similar patterns were observed in the coverage of routine antenatal care and the two types of extended interventions.4The Sustainable Development Goals (SDGs) and the Global Strategy for Women's, Children's, and Adolescents’ Health are calling for countries to deliver integrated care for maternal, neonatal, and child health Prenatal screening of congenital abnormalities, including serum screening for foetal aneuploidies and B-ultrasound screening for structural malformation, are important secondary prophylaxis interventions. To date, we identified only two studies in urban China that analysed women's uptake of services Our survey shows that the coverage of both types of prenatal screening interventions had already been rising with a faster speed in the counties that were to receive demand-side interventions (vouchers) in plain regions of Shaanxi, which explains why we found an “inverse” impact of vouchers in this setting. Coverage of B-ultrasound screening rose fast in the mountainous regions of Shaanxi before the Program as well. Foetal aneuploidies screening services were newly introduced technologies in rural China, whilst the B-ultrasound scanning service  was already available before the program. This helps to explain the differences across interventions. Hospitals may have incentives to import new technologies to attract more patients. However, whether the government chose counties with higher coverage to put forward subsidies is unknown. Further research is warranted to understand how technology infusion per se may affect coverage in rural settings.,While integration did play a role in improving coverage, our data showed that supply-side integration efforts alone might come at costs that undermine equity, consistent with experiences from other settings [3]Importantly, we found that women with higher educational achievement, that is, more knowledgeable women, were more likely to uptake the new interventions. The effects of vouchers varied across contexts and women's education as well, which were independent of women's wealth level, location, and other socio-demographic characteristics. These findings question the mechanism of how the voucher works in this specific context. In fact, in the plain regions, we found that vouchers had no effect on women's knowledge, that is, women from the county that had only supply-side policies had similar level and trends in awareness of the government program; whilst in the mountainous settings, where one-third of women had to travel more than an hour and a half to reach the county hospital, vouchers took a substantial effect in promoting knowledge of the government program. In the Program, the county maternal and child hospital took the responsibility to advertise the new interventions. Information was released in public media, such as TV, newspapers, and radios, or in the form of posters and booklets that were distributed in the location of county maternal and child hospital. Women living far might have found it harder to access these channels but the process of distributing vouchers make a chance for them to receive such information directly. This might explain why the impact of vouchers in the mountainous areas was greater among women with primary education and below, compared to those with secondary education and above, because the latter might be more likely informed by the public media. Taken together, vouchers’ effectiveness may stem from targeted acknowledging the recipients of the services rather than removing financial barriers. Global debates continue on whether and how to target while implementing demand-side measures, where means-test for the poor are costly and often ineffective in LMICs This study has several important limitations. First, this was an observational study that was based on a natural experiment from a government pilot program, we are not able to draw causal conclusions. We intentionally chose counties for the investigation. Although geographic factors were considered in the design and the comparisons were made between neighbours, these counties may still vary in background and baseline characteristics. To tease out the policies’ impact, we used an interrupted time-series approach that further adjusted demographic and socioeconomic factors, which might help to reduce biases The other provinces in China could learn from Shaanxi's pilot program that intended to deliver integrated antenatal care to women living in rural settings. This program has made good progresses to build constructive accountabilities Xing Lin Feng designed the research, organised the survey, analysed the data and wrote the paper. Other authors participated in the critical interpretation of the findings.Newton Advanced Fellowship jointly supported by the 10.13039/501100000691Academy of Medical Sciences and 10.13039/501100001809China National Natural Science Foundation (71761130083), and China National Natural Science Foundation Excellent Young Scientist Program (71422009). Both are fellowship projects that support the PI to do basic research in China. The funders played no role in this study.The evaluation study is funded by Individual participant data that underlie the results reported in this article will be available, with researchers who provide a methodologically sound proposal, beginning 9 months and ending 36 months following article publication. Please contact the corresponding author at fxl@bjmu.edu.cn.Xing Lin Feng declared no conflicts of interests.Chunmei Wen works in the Health Commission of the Shaanxi Province. She is the department head in charge of maternal and child health of Shaanxi Province. She led her team in designing and implementing the Extended Antenatal Care Program in Shaanxi.


Finally, based on the diving beetle's hind-leg movement pattern, a kinematic model was constructed, and according to this model and the motion data of the joint angles, the motion trajectories of the hind legs were obtained by using MATLAB. Since the advantages of this propulsion method, it may become a new bionic propulsion method, and the motion data and kinematic model of the hind legs will be helpful in the design of bionic underwater unmanned vehicles.The fast swimming speed, flexible cornering, and high propulsion efficiency of diving beetles are primarily achieved by their two powerful hind legs. Unlike other aquatic organisms, such as turtle, jellyfish, fish and frog et al., the diving beetle could complete retreating motion without turning around, and the turning radius is small for this kind of propulsion mode. However, most bionic vehicles have not contained these advantages, the study about this propulsion method is useful for the design of bionic robots. In this paper, the swimming videos of the diving beetle, including forwarding, turning and retreating, were captured by two synchronized high-speed cameras, and were analyzed via SIMI Motion. The analysis results revealed that the swimming speed initially increased quickly to a maximum at 60% of the power stroke, and then decreased. During the power stroke, the diving beetle stretched its tibias and tarsi, the bristles on both sides of which were shaped like paddles, to maximize the cross-sectional areas against the water to achieve the maximum thrust. During the recovery stroke, the diving beetle rotated its tarsi and folded the bristles to minimize the cross-sectional areas to reduce the drag force. For one turning motion (turn right about 90 degrees), it takes only one motion cycle for the diving beetle to complete it. During the retreating motion, the average acceleration was close to 9.8 m/s In particular, the excellent maneuverability of diving beetles in water, including their rapid propulsion, flexible turning, and rapid retreating, have attracted extensive research interest7. Compared with other aquatic organisms, such as turtle8, jellyfish9, fish11 and frog12, the diving beetles are more flexible, for which they could complete retreating motion without turning around, and the turning radius is small for this kind of propulsion mode13, whereas the mentioned creatures can usually move in only one direction and have a larger turning radius. Their streamlined body shapes contribute to the reduction of the resistance of water and the improvement of stability while swimming14. As the major propulsion organ, the oar-like tarsus with neatly arranged bristles provides the main propulsive force for swimming18. During the recovery stroke, the drag force generated by diving beetles is only 1/40 of the thrust force generated by diving beetles during the power stroke3, and the principle of drag-powered swimming allows the swimming efficiency of diving beetles to reach 84%19. Furthermore, the movements of the two hind legs are synchronous during forwarding or retreating. Synchronized-leg-swimming kinematics are more hydro-dynamically efficient than alternating-leg-swimming kinematics20. These features of diving beetles can potentially be used to design miniature underwater robots, and, as such, the swimming patterns of diving beetles have been analyzed from the perspective of robotics25. However, due to the lack of detailed data on the movement process of the diving beetle's hind legs and the hind legs were simplified as a two-link mechanism, the biomimetic robots retreated during the recovery stroke of swimming motion and the turning efficiency was low. At present, the underwater propulsion flexibility of most bionic underwater unmanned vehicles is not as good as that of diving beetles29. When multi-link mechanism moves underwater, the torques corresponding to different link attitudes are different due to the existence of the potential flow along the direction of the link30, the change characteristics of the joint angle of the hind legs may affect the energy consumption during this process. For the design of underwater robots that mimic diving beetles, the variable law of joint angles among the components of the hind legs requires further study. The present paper focuses on the joint angle changes of the hind leg components of diving beetles, and provides a kinematic model for the design of bionic unmanned underwater vehicles that mimic the diving beetle.Diving beetles can swim rapidly due to their streamlined body shape, two flattened hind legs, and special mode of marine propulsion. They are good swimmers16. The result of the tip of the femur moving at an angle to the ventral body surface found in this research is different from the findings of Hughes31. During the recovery stroke, the femur was found to move along the abdominal surface and the tarsus rotated to the original position . In addition, the hairs were found to fold up passively. These adaptations may reduce the resistance of the water during the recovery stroke to some degrees.As depicted in Fig. Conversely, the two hind legs were found to move unsymmetrically during the turning motion, and the time sequence diagram of the right-turning motion is illustrated in Fig. As presented in Fig. Only the movement joints on one leg were analyzed during the forward and retreating motion due to the symmetry of the movements of the two hind legs. However, the change characteristics of the joint angle of both hind legs during the turning motion were analyzed.τ increased greatly. At the end stage of the power stroke, the femur swung forwards slowly, and the angle τ began to decrease. During this part of the movement, the maximum joint angle τ was 145°. During the recovery stroke, the angle τ first decreased and then began to increase at the end. The swinging range of the femur was between 87° and 146° during the entire process  of the left and right hind legs exhibited opposite trends, excluding the joint angle α. During the right-turning motion, the joint angle range of the right hind leg was less than that of the left leg. During the power stroke, the angle τ of the left hind leg increased rapidly while the angle τ of the right leg decreased slowly. During the recovery stroke, the angle τ of the left leg decreased greatly, and the angle τ of the right leg increased slightly Supplementary Table 38, and the transformation matrices between different links are shown in Supplementary Equations:The general expression of the transformation matrix is as followss represents the sine function and c represents the cosine function.Finally, the coordinates of joint 2 areFinally, the motion trajectories of the hind legs of the diving beetle in different motion modes were obtained by inputting the trajectory equations and angle values of each joint into MATLAB software and calculating with it, and then drawing the trajectories at different points of time. As is presented in Supplementary Fig. Similarly, the motion trajectories of the right and left hind leg of a diving beetle were also symmetrical during the retreating motion . The changes of joint angle In the three motion modes, the maximum velocity occurs at about 60% of the power stroke. The speed first increases quickly to a maximum value and then rapidly decreases. It takes only one motion cycle for the diving beetle to complete the turning motion. All of these indicate that the movement of the diving beetle is sufficiently flexible.The kinematic model of the diving beetle was established and the motion trajectories of the hind legs of the diving beetle in different motion modes were also obtained, which may contribute to research on miniature unmanned underwater robots, especially their paddle propulsion systems.Cybister bengalensis, a species of diving beetle, belongs to the class Insect, order Coleoptera, family Dytiscidae, and genus Cybister Curtis, and was the research subject of this study. All the diving beetles used in this study, which were obtained from Foshan City , were adults, and their average body length was 36.3 mm with a standard deviation of 0.67 mm. The body of the diving beetle comprises a head, chest, abdomen, two pairs of wings, three pairs of legs, and a pair of antennae. The pair of forelegs is used primarily for feeding and grabbing objects, the pair of middle legs can be used to stabilize the body during the recovery stroke while swimming, and the hind legs generate thrust for movement39. The main swimming organs of the diving beetle are their hind legs. Studies have shown that the hind legs are able to propel the beetle farther than the middle legs, and can generate a larger angular velocity than the middle legs40. The physical parameters of the hind legs of the diving beetle are displayed in Supplementary Table 41. The femur is curved with a smooth outer surface, while the inner surface is distributed with pit structures. The surface of the tibia is non-smooth with some pits, in which burrs grow. The tarsus is comprised of 5 sub-sections that gradually narrow from the base to the end. The inner and outer edges of the tarsus have bristles with diameters of 5–20 μm (Supplementary Fig. 31. The flattened femur, tibia, tarsus, and numerous swimming hairs assist with swimming42, and the change characteristics of the joint angle of the hind legs may affect the energy consumption of the diving beetle during this process30. When two articulated links rotate underwater, the torques corresponding to different link attitudes are different due to the existence of the potential flow along the direction of the link. As an aquatic creature, the diving beetle may adapt to the influence of this potential flow, and the kinematic model of its hind legs may improve the energy efficiency of paddle-driven robots to some extent. Therefore, the motions of the hind legs are of primary focus in the present study.A motion capture system with two high-speed cameras was constructed, which was used to capture the motions of the hind legs of the diving beetles. The system is illustrated in Supplementary Fig. The main swimming modes of the diving beetle are forwarding, turning, and retreating, which were recorded in the experiments. Interestingly, the diving beetles could retreat without turning around, which was found to be realized by the forward swing of the hind legs, just like a car in reverse gear. In this paper, the feature points (white points in Supplementary Fig. Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.


Specifically, depressive symptoms, anxiety, contamination obsessions, family well-being challenges, and behavioral concerns have emerged globally for children during the pandemic. Without treatment or prevention, such concerns may hinder positive development, personal life trajectory, academic success, and inhibit children from meeting their potential. A school-based resiliency program for children (DREAM) for children was developed, and the goal of this study was to collaborate with stakeholders to translate it into an online-live hybrid. Our team developed a methodology to do this based on Knowledge Translation-Integration (KTI), which incorporates stakeholder engagement throughout the entire research to action process. KTI aims to ensure that programs are acceptable, sustainable, feasible, and credible. Through collaboration with parents and school board members, qualitative themes of concerns, recommendations and validation were established, aiding in meaningful online-live translation. Even though the original program was developed for intellectually gifted children, who are at greater risk for mental health concerns, stakeholders suggested using the program for both gifted and non-gifted children, given the universal applicability of the tools, particularly during this pandemic time period when mental health promotion is most relevant. An online-live approach would allow students studying at home and those studying in the classroom to participate in the program. Broader implications of this study include critical recommendations for the development of both online-live school programs in general, as well as social-emotional literacy programs for children.In standard times, approximately 20% of children and youth experience significant emotional, behavioral, or social challenges. During COVID-19, however, over  The DREAM Program has two main goals: the first is to support the community, including the children, their families, and schools, with an evidence-based sustainable toolkit, giving children skills they can use throughout their life. The second goal is to increase a sense of meaning, social skills, and agency over thoughts and behaviors to improve overall mental health . “MeaninOne PP2.0 theory is called REAL  could be ensured because of the automation, running costs of the programs were lower, ability to monitor program processes and outcomes were easier through online programs, the interactive visual nature of online programs was more appealing for children, and there was a reduced need for train the trainer . This reThere was a great need for a mental health prevention program for children, and the COVID-19 pandemic has heightened this need. The translation of the DREAM program to an online-live hybrid should hopefully fill this need if the program enhances meaning and mental health. How can DREAM be adapted to an online-live hybrid so that it optimizes the feasibility, credibility, sustainability, and acceptability of the program using recommendations from key stakeholders?Using the KTI framework, it was important to the authors that the essence of the stakeholder’s comments was captured in the results. The authors decided that integrating grounded theory and thematic analysis was the best way to systematically clean the varied data sources and keep the meaning being the stakeholder’s comments. The thematic analysis outlined by This study took place in a Canadian Metropolitan city with the following demographic characteristics of participants:The mean age of the parent participants was 40 years, with a highly educated population (45% of the population reported having a university certificate or higher) compared to the national average of 28.5% of the population having a university certificate or higher . The larRegarding school board participants, their age and ethnicity were not reported. Further details about school board staff are presented below.Three retired elementary school teachers  were presented with the materials for the program.Although a child psychologist and her team developed this program, two psychologists were consulted throughout the process of program development. One of these psychologists was academic, who further consulted families with lived experience of child mental illness to provide recommendations, and the other was the former executive director of well-known child mental health organizations.The present study uses secondary data from two research projects, under the Principle Research of Dr. Armstrong and her Ph.D. student Emmalyne Watt. Dr. Armstrong and Dr. Watt had previous funding for DREAM research projects. Dr. Watt was conducting research to create a Wait-list program for children waiting for mental health resources, using the DREAM program’s principles. Dr. Armstrong was doing research to expand the accessibility of the DREAM program. Due to the In total, there were seven different data sets. See the Ethics Approval in The first four data sets include French and English school board staff members in both the Public and Catholic domains who live in a Canadian metropolitan city. Each focus group had three school board stakeholders present at each, and the focus group duration was 1 h at each board. These are school board staff who oversee the gifted, mental health, and special education programming in their school boards, including psychologists and learning support teachers. These participants were recruited through contact via phone, email, or in person. The focus group sizes are supported in research, indicating that very small focus groups increase participation and depth of responses . Toner . Data sePsychology Reading Circle, or through a local gifted program Facebook page. This focus group had seven parents and six children present, and the focus group duration was 3 h.The fifth data set includes parents and children invited to participate in a focus group for the DREAM program targeting families on mental health waitlists. The participants were parents and children recruited either through local City therapists, notified about the program through the online platform Psychology Reading Circle, local gifted program Facebook page, and through the waitlist focus group. In total, there were seven families present for the live administration, which included four gifted children, one child on the autism spectrum, two children with learning disabilities/ADHD, and the rest were non-identified.The sixth data set included the seven families who completed the questionnaire and participated in a previous live administration of DREAM. A questionnaire was distributed after completion, with a portion assessing the participants’ recommendations for the program’s online adaptation. The families for this administration of the program were recruited through local therapists, who were notified about the program through the online platform The seventh data set includes feedback received from retired teachers and mental health experts involved in an interactive reviewing process with an outline of the online-live DREAM program. The online-live DREAM program provided to these stakeholders was a version of the program that had been adapted with the results from the first six data sets. The review process took place after the initial results were obtained and the development of the videos and scripts occurred. The data collection for this data set included notes made on a Microsoft Word document.DREAM includes ten units, each with an original song, discussion, and activities associated with the unit topic. In the online-live hybrid version, the song is going to be made into a music video and will provide the content for each unit. The live portion of the unit includes the discussion led by the facilitator, the games, and activities . There are suggestions within the units for take-home or in-class activities. These activities can be used as reinforcement in between units if the facilitator does not deem homework appropriate. As a part of the program, an evaluation would be distributed to the students after they completed the program. Below are the topics for each unit. For more details of the units and content, see Online-live DREAM Outline.•Unit 1: Mental Health and Gifted Literacy.•Unit 2: Emotion Recognition and Social-Emotional Literacy.•Unit 3: Relaxation.•Unit 4: More Calm Down Activities: Worry Time, Imagery, Humor.•Unit 5: Avoidance and Obsessive Behaviors.•Unit 6: Enjoyable Distraction.•Unit 7: Meaningful Living.•Unit 8: Connection Between Thoughts and Feelings.•Unit 9: Choosing to Think Differently.•Unit 10: “Act as If,” Helpful Problem-Solving, and Putting it All Together.In the satisfaction survey seen in No names were included in the focus groups’ transcription or recorded on DREAM participants’ questionnaires to ensure confidentiality. The questions asked in the focus groups and questionnaire pertained to the acceptability, credibility, sustainability, and feasibility of the proposed online-live implementation and more open-ended questions regarding suggestions for online delivery to facilitate knowledge translation. See The Family Waitlist focus group provided verbal and written consent , a variety of themes emerged. Below are the definitions of each of the themes. Find the quotes and field notes that support these themes in –Implementation: Describes factors of incorporating the online-live version of the DREAM program into schools.–Technology: Considerations surrounding technological requirements.–Duration: Considerations about the program’s length.–Curriculum: Factors considering the incorporating of the program into the existing curriculum.–Facilitator: Considerations of who would be facilitating the program.Within the three sub-categories of credibility, a variety of themes emerged. Find the quotes and field notes that support these themes in –Online-Live Viability: The perceived ability and impact of the program being an online-live hybrid.–Implementation: Describes factors of incorporating the online-live version of the DREAM program into schools.–Unit Specifics: Data that directly comments on parts of specific units.–Goals: Quotes and field note that directly comment on the goals of the program.Within the three sub-categories of sustainability, a variety of themes emerged. Find the quotes and field notes that support these themes in –Overview: Quotes and field notes that pertain to the overall program and not one specific factor.–Memory Aid: Data that mentions using various memory aids.–Unit Specifics: Data that directly comments on parts of specific units.–Movement and Engagement: Quotes and field notes that discuss physical activity and engagement.Within the three sub-categories of acceptability, a variety of themes emerged. Find the quotes and field notes that support these themes in –Online-Live Viability: The perceived ability and impact of the program being an online-live hybrid.–Language: Comments on the level of language used in the program.–Duration: Considerations about the program’s length.–Technology: Considerations surrounding technological requirements.–Facilitator: Considerations of who would be facilitating the program.Content: Data that pertains to the content of the overall program.–Games and Creative Activities: Quotes and field notes about games and creative activities used in the program.2. See Following the interpretation and application of the above qualitative data, a proposed live-hybrid model was constructed in further collaboration with school board staff. Additionally, video scripts were written by a professional media production studio using the existing DREAM administration materials and feedback from the above stakeholders as the teaching template. Further materials  were developed to fit the adapted program suggestions from the stakeholders. Three retired elementary school teachers and two mental health experts were then consulted on an ongoing basis to review the video scripts, materials, as well as the resulting video episodes that were producedTo answer the research question of how to translate DREAM to an online-live hybrid best while optimizing the principles of the KTI framework, the authors integrated concerns noted by the school board members and parents with their own recommendations, as well as recommendations made within the literature. Within each section of feasibility, credibility, sustainability, and acceptability, stakeholders’ validation was summarized, indicating what stakeholders liked and, therefore, what should be continued throughout further program development. The author noticed a few characteristic differences between the different stakeholders’ types of comments while analyzing the results. The families in the focus group and who attended the live-administration mainly commented on the nature of participating in the program. For example, they commented on the duration of the program and the content of the program. Whereas the mental health experts, retired teachers, and school board members discussed program duration and content, how the program implementation, and more functional aspects of program translation. These differences are important because they speak to the value of having different types of stakeholders evaluate program translation. Overall, support for the online-live hybrid was observed, and buy-in from four large school boards was generated. All the school boards requested the program within their classrooms after participating in the focus groups. Through collaboration with key stakeholders, suggestions were provided in the areas of feasibility, credibility, sustainability, and acceptability.To increase the perceived ease in implementing an online-live program, one school board indicated that the program could be run by resource teachers or special education staff if conducted with select groups of students , in addition to carrying out the program in regular classrooms or behavioral classrooms. School board staff who could see clear curriculum links perceived the ease of implementation within classrooms by teachers. By contrast, school board staff who were unaware of curriculum links as they were less familiar with the program had concerns regarding implementation by teachers who already have many responsibilities. It leads that familiarity with the program increases perceived ease of implementation.school board 2 mentioned wanting the program for their French-immersion classes, the researchers included the French school boards as stakeholders in focus groups. This led to the translation of all the units, the songs, and the music videos. This increased the program’s feasibility by decreasing language as a barrier.Generally, it was recommended that the whole class participate in the program, as school boards perceived that the skills taught were relevant for all students. Collectively, even though DREAM was originally designed for intellectually gifted students, whose unique characteristics put them at increased risk for mental health concerns , all theAccess to technology was flagged as a concern of the usability of the program, and this concern varied between school boards. Most of the school boards reported that their schools have a great deal of access to technology, but one school board requested that the program be offered on a USB stick for schools with less technological access. The research did indicate that access could be a barrier. Access to resources is a function of funding that varies between school boards and could explain the differing concerns between school boards . DREAM iFor the school boards where Internet technology is readily available, facilitation of the program is reportedly simple: Staff clicks on the weblinks for the videos for each program unit. For the schools where the internet is limited, the program’s online portion would be provided on a USB stick. For the schools where televisions are limited, it is suggested that schools should be aware of the number of sessions needed to complete the program in advance in order to facilitate renting a television, as school board stakeholders suggested. This would look different for each school as they each have different needs.Along with some concerns regarding access to technology, some school board members discussed how the technology requirements would be easy to implement and indicated that they saw ways that the program related to the existing curriculum. These factors demonstrate how the online-live hybrid is viable with the existing resources in some cases.Just as Research indicated that, for technology and the goals it wishes to achieve, in this case, SEL with a meaning-mindset component, the whole system needs to be involved . This loThe program demonstrates high credibility with the stakeholders, suggesting that the program meets their needs. One parent commented that the program “Made me more patient […].” These validations are echoed throughout the acceptability section, where school board 4 commented on how the program “[…] go[es] further than modules that I’ve seen before.” This overlap in credibility and acceptability illustrates how the goals of the program inherently fit with the needs of the stakeholders. The schoolboard’s perceived program acceptability is reinforced by the parents noting that the goals of the program were achieved during the live administration. This validation cycle affirms previous studies that have established the program’s efficacy, as well as supports the mission of the present study to translate the program to an online-live hybrid. Parents also reported wanting to see the program widely implemented, which aligns with stakeholders’ suggestions in previous research .There is ambiguity surrounding stakeholder’s ability to comment on the sustainability of the program because they have not seen exactly how the online-live hybrid works in their schools. Stakeholders did formulate suggestions to ensure sustainability, which includes: incorporating memory aids such as booklets with key takeaways between unit activities and mnemonics, exercises that help identify the start of feelings, adapting the avoidance game to a read-aloud story, as well as ensure there are many games and a great deal of movement. It is the author’s and stakeholder’s view that if the program is implemented with the recommendations made by key stakeholders, the program will inherently be sustainable. If once the program has been run, it is found to not be sustainable, there are implementation changes that the school can make so that it addresses any potential issues without affecting implementation fidelity . Parents who completed the live version of the program directly stated that they have regularly referred to the skills they learned during the program suggesting that the program likely has the ability to sustain the intended goals.Some parent stakeholders indicated that face-to-face programming is important to them with respect to their willingness to use the program. There was no research exploring the parent’s beliefs about using technology in education. The School board stakeholders made technology-specific recommendations that would increase the program’s usability. These recommendations include display lyrics in the music videos with an icon above the lyric indicating the tempo, online platforms should be easy to access like applications, using Pear Deck if it already exists within the school board , and uniResearch on how to support facilitators in implementing an online-live program is varied. School board stakeholders indicated specific areas they believed a manual could best support their teachers, which were consistent with the research ; those iAfter either participating in the live administration or after hearing a detailed description of the program, stakeholders reported that the program was appealing to them for reasons including interesting and age-appropriate content, depth of learning, use of technology is consistent with current school trends, as well as fun and engaging crafts, games, and activities. The acceptability of the program is important because when a program appears to be helpful, engaging, and easy to use, the knowledge users are more likely to use and benefit from the content of the program .The conclusions of this study have many important applications, but, as with any study, it has limitations. The demographics of the stakeholders are representative of the city where the study took place. However, they are not representative of the whole province or country. With the city population being majority White and the socioeconomic status being higher than the national average, the results of this study would not capture the lived experiences of minorities in Canada and those with a lower socioeconomic status. Therefore, future research should include a more diverse set of stakeholders. There is also a lack of representation for rural stakeholders, both parents and school board members. It is possible that, although some recommendations might be similar, there would be different considerations for rural versus urban environments. This concern is relevant as rural children may benefit the most from resilience programming, given higher mental health concerns in these areas, as well as less access to mental health services .While transcribing and analyzing the data, it became clear that there was some confusion around the structure of the program. This led to some recommendations that were not relevant. This lack of clarity could be due to the fact that one focus group involved a change in participants shortly before the group happened . This meant that the program had to be described to the participants in detail, but the participants were making comments before they fully knew about the program. For future stakeholder engagement, it is recommended that designated time be assigned to explaining and detailing the structure of the program. This will hopefully lead to more relevant recommendations and more clarity for the stakeholders.A similar confusion happened with the parent stakeholders regarding the perception of program formatting. Due to time restrictions and stakeholder availability, the live administration was conducted in 2-h sessions over three weekends, with several units grouped together at a time. While making recommendations, the stakeholders reported that the allotted time was too long. This comment was applied to the results. However, it would have been beneficial if it was made clear to the stakeholders that the format they experienced would not necessarily be the same as it would be administered. In fact, as an online-live hybrid program, schools could choose to deliver a single unit each week, with the reinforcement activities in between, giving time also to apply the related Ministry of Education curriculum.A further limitation includes the over-representation of females throughout the research process. In the translation of French to English focus group transcripts, transcription of the focus groups, and analysis of the data, all but one of the researchers included were female. Due to the subjective nature of language translation and grounded theory analysis, this research could hold a female bias.The next step for this project is the ongoing implementation of the recommendations made in this paper while allowing some flexibility for school board specificities without compromising implementation fidelity. As seen with the comments made by the seventh data set, the retired teachers and mental health professionals, stakeholder consultation is a standard. This is important since the demographic used in this study lacked representation for diverse and rural communities and, therefore, consultation with the incoming setting is necessary. To date, one of the current research assistants and translators is an expert in children’s media, having written scripts and music lyrics for both French and English children’s television programming.It would be interesting to research how this program fits with minority gifted children to see if the program’s design allows for enough facilitator support and flexibility to cater to the children’s individual needs.Another interesting research follow-up would be to see the longitudinal benefits of participating in this program. A future planned randomized control trial (RCT) to assess the DREAM Edition program online-live hybrid, in comparison to school programming, as usual, could provide evidence in support of the program or indicate more consultation needs to take place. Within this future RCT, controlling for gender and socioeconomic status could give important insights that may inform further development of the program.The online-live recommendations can be used to further develop other versions of the program as well, such as a version for families on mental health waitlists, as well as other SEL programs. The recommendations above summarize important considerations stakeholders have while approaching an online-live transition. Therefore, this research can be used to aid other programs looking to transition to or create an online-live hybrid program.This study highlights the importance of tuning in to children’s needs and listening to those who support them. Stakeholders offered many valuable concerns, recommendations, and validations that will help shape this iteration of the DREAM program and future additional program versions. This research adds to the existing body of SEL programming literature by showing the value of consulting with a diverse group of stakeholders, the benefits of an online-live hybrid program in this pandemic context, and meaning making as a foundation social-emotional education. Overall, to extend program reach, the present study supports developing an online-live hybrid model for the existing DREAM program, which was previously found to promote internalizing and externalizing mental health . Furtherjparr088@gmail.com.The data analyzed in this study is subject to the following licenses/restrictions: Although no names or institutions were recorded, to protect the identity of the participants, only excerpts of the qualitative data was included in the manuscript. Requests to access these datasets should be directed to JP, The studies involving human participants were reviewed and approved by the Research Ethics Board, Saint Paul University. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.JP conducted the literature review, developed and executed the methods, co-facilitated focus groups and the live administration, and produced the results and discussion. LA created the research study, identified the need, built the research team, and supervised the research. EW contributed to the data from her research study that is associated with the LA research. RF assisted with the translation of the French transcripts. BT assisted with the translation of the French transcripts and helped facilitate the live administration. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.