Immunoglobulin M (IgM) is the most ancient of the five isotypes of immunoglobulin (Ig) molecules and serves as the first line of defence against pathogens. Here, we use cryo-EM to image the structure of the human full-length IgM pentamer, revealing antigen binding domains flexibly attached to the asymmetric and rigid core formed by the Cμ4 and Cμ3 constant regions and the J-chain. A hinge is located at the Cμ3/Cμ2 domain interface, allowing Fabs and Cμ2 to pivot as a unit both in-plane and out-of-plane. This motion is different from that observed in IgG and IgA, where the two Fab arms are able to swing independently. A biased orientation of one pair of Fab arms results from asymmetry in the constant domain (Cμ3) at the IgM subunit interacting most extensively with the J-chain. This may influence the multi-valent binding to surface-associated antigens and complement pathway activation. By comparison, the structure of the Fc fragment in the IgM monomer is similar to that of the pentamer, but is more dynamic in the Cμ4 domain. Immunoglobulin M (IgM) is the Ig isotype that serves as the first line of host defence during infection. Here, the authors image the full-length IgM pentamer by cryo-EM, revealing the structure and hinge motion of the antigen binding domains. Pentameric IgM is secreted into serum, or transported across epithelial cells by the polymeric immunoglobulin receptor (pIgR)3. IgM hexamers have also been found in the serum, but account for less than 5% of total IgM4. An IgM pentamer is over 900 kDa, consisting of ten heavy (μ) chains, each of which has a C-terminal tailpiece which holds them together, ten light (λ or κ) chains and a joining (J) chain, a 15 kDa polypeptide with no homology to other proteins, which sterically interrupts the addition of a sixth heavy crystal fragment (Fcμ) unit7. As the very first antibody produced after pathogen invasion, the multivalent nature of polymeric IgM molecules gives them remarkable ability to agglutinate particulate antigens in serum10.Natural immunoglobulin M (IgM) assembles into monomers (composed of two heavy and two light chains), pentamers and hexamers. Monomeric IgM serves as a membrane-associated antigen-recognition receptor on the surface of B lymphocytes17, complexes of IgM with complement components C1 and C4b have been studied at low resolution by electron cryotomography18, and two recent publications revealed the atomic structure of the asymmetric pentameric Cμ4-Cμ3 core by single-particle cryo-EM20. Nevertheless, important questions such as how the peripheral domains are positioned and move with respect to the Fcμ core remain to be answered, which can only be achieved by imaging the structure of FL-IgM as a whole. Traditionally, structures of the hinge regions of immunoglobulin molecules have been identified by enzymatic fragmentations and sequence homology, according to which IgG and IgA are classified into several subclasses23. However, little sequence similarity has been found at the hinge-equivalent region of IgM owing to the substitution of an additional Fc domain Cμ2, which has led to the conclusion that IgM lacks a hinge region25. This does not necessarily imply that IgM lacks flexibility at this region, and the two potential origins of flexibility are the interdomain regions between Cμ1 and Cμ2, and between Cμ2 and Cμ3. Evidence of flexibility between the Fc and Fab fragments of IgM have been shown in several studies, where projections of IgM alone or ligand-bound forms were captured in negative stain EM images27. However, where exactly the flexibility comes from, whether at the N- or C-terminus of the Cμ2 domain or both is still ambiguous.Efforts have been made for decades to study the structure of IgM but have been hindered by its size and flexibility. Individual Cμ4, Cμ3, Cμ2 and Fab domains have been resolved by X-ray crystallography and NMR2 at one position of the pentamer, which is stabilised with respect to the core, and interpret disordered density distributions at other Fab positions in terms of a hinge-equivalent motion of IgM. In comparison, we study the structure of the IgM Fc monomer by both cryo-EM and time-resolved single-molecule fluorescence resonance energy transfer (smFRET). We show that while the structure of the monomer is similar to that of the pentameric core, its Cμ4 domains undergo dynamic separation, which may be relevant to IgM function as the membrane-bound B cell receptor.In this study, we have addressed these questions by analysing the 3D structure of human FL-IgM using a single particle cryo-EM approach, placing the emphasis on understanding the hinge structure and flexibility of IgM. The pentameric core serves as a high molecular weight scaffold to study the structure of the flexibly-attached Fab regions. We resolve an F(ab’)19, despite the absence of the secretory component (SC) chain in our sample, indicating that the core is largely stabilised by the tailpiece and J-chain. Similarly, dimeric IgA with and without SC have been found to have relatively small structural differences28.Maps of full-length IgM (FL-IgM) obtained by cryo-EM 29.In contrast to the highly flexible Cμ2 domains which are symmetrically associated with the two adjacent Cμ3 domains in subunits 2-5 Fig. , Cμ2-1 i2-1 Fig. , though 2-1 Fig. , both of30 which reveals the F(ab’)2, which includes both Fabs and Cμ2 domains, moves as a rigid body and is able to pivot at the Cμ2/Cμ3 interface. Five conformations have been classified from the full dataset  for all the Fab domains , in fitting the oligosaccharide at N165 2 is present. The orientations of F(ab’)2 are summarised in Fig. 2 structures shows that they share an identical conformation 2 Fig. , revealiion Fig.  and indi2 is supported by a previous study, where a pair-wise surface binding behaviour was observed in an IgM-surface antigen complex with complement components studied by cryotomography, i.e., both Fab and Fab’ are facing towards the binding surface in contrast to only one in IgG (where the other Fab arm is dangling)32. This behaviour has been observed in all five subunits in the surface-bound IgM and the relative angles between the two Fab arms in the surface-bound IgM are also about 18. This supports the idea that the rigidity of F(ab’)2 is intrinsic and universal in all subunits of the IgM molecule. The potential elbow motion between the constant and variable domains in the Fab is small compared to the observed F(ab’)2 flexibility but nevertheless important for antigen binding mechanisms for immunoglobulins33. Another phenomenon worth noting is that pentameric IgM is asymmetric with a biased Fab-1/Fab’−1 orientation towards the 2 observed in the surface-bound IgM18, much larger than the 2 of subunit 1 can be highly strained when binding to surface antigens. It cannot be achieved by simply extending the pivot motion to 120° because the Cμ2-1 and Cμ3-1 A domain would clash, instead requiring an extension of the linker between Cμ2 and Cμ3 domain to accommodate the extreme bending angle of F(ab’)2. The intrinsic asymmetry of the free IgM suggests that it is more energetically favourable for IgM to engage surface antigens using the 34. The C1q binding site on Cμ3-1 may be identified by superimposing the IgM conformations and IgG-Fc/C1q complex model (pdb id 6FCZ32), which reveals steric clashes between Cμ2-1 and C1q. Therefore, the C1q binding site on Cμ3-1 may be inaccessible for C1q binding until Cμ2-1 is displaced, such as when IgM binds to surface antigens.The rigidity of IgM F(ab’)55∘ Fig.  in the f34. A typical hinge in an immunoglobulin molecule such as IgG or IgA usually consists of three parts – an upper hinge at the CH1 C-terminus, a core hinge composed of multiple prolines and cysteines, and a lower hinge at the N-terminus of CH2 domain. The lower hinge allows the movement of the two Fab arms relative to the Fc domains, while the upper hinge provides independent freedom for each Fab, as demonstrated in previously published studies of IgG and IgA36. The hinge-equivalent region in IgM is Cμ2 as well as its two junctions at the N- and C-termini. Cμ2 itself is a rigid dimer linked by a disulfide bond, which spatially separates Fabs from the Cμ4-Cμ3 core as a core hinge does in IgGs and IgAs21. The N-termini of Cμ2 with the proline-rich linker region seem not to be able to provide motions (very little if any) for each Fab arm, as suggested by the observation of the rigid V-shaped F(ab’)2 configuration in subunit 1 of IgM. The C-termini of Cμ2 are flexible which resembles a classic lower hinge37, allowing the F(ab’)2 to move relative to the core. However, the range of freedom is limited by its short length which explains why the flexibility of F(ab’)2 in subunit 1 is analogous to pivoting instead of more complicated behaviours.IgM is widely described as lacking a hinge region, which is replaced by a whole Fc domain Cμ22 and the pivot motion in subunit 1 explains the density distributions in subunit 2-5. Pivoting the Cμ2 model by 2, one can see a good agreement between simulated data and experimental data 2 can indeed bend to much larger angles when not stabilised by the J-chain. Because of the 18, possibly accompanied by some degree of linker extension similarly to subunit 1.The reconstructed map is the convolution of the map density of the molecule with the functions that describe the motions, so knowing the structure of F(ab’)ata Fig. , which iion Fig. , the map11, while the other is ‘anti-parallel’, which resembles the subunits in the IgM pentamer and the C-terminal domains of other Ig molecules such as IgG38, IgA39 and IgE40  disrupting dimerization produced a single low FRET state  by both smFRET and cryo-EM for comparison to Fc in the pentamer. Two potential Cμ4 arrangements of the IgM-Fc monomer have been reported: one is the ‘parallel’ conformation proposed by Müller et al (pdb id 4JVW)43, neighbouring IgM subunits and the J-chain. For the monomeric IgM expressed on membrane, given that the stalk that connects the IgM monomer to the cell membrane lacks a stabilising disulfide bond that is present in IgG, IgA and IgE, stability can be potentially provided by the transmembrane helices or by interactions with the Igα and Igβ subunits. Therefore, the unique dynamics at the IgM Cμ4 domains may play a role in isotype-specific assembly of the membrane IgM into the B cell receptor complex or its function after antigen binding.This observation indicates that the Cμ4 dimer in the IgM monomer is inherently dynamic and is stabilised by external interactions. In the IgM pentamer, it is achieved by the tailpiecesThe cryo-EM structure of IgM-Fc stabilised by the coiled-coil domain further confirms the resemblance between the ‘closed’ conformation of the IgM-Fc monomer to the subunits among subunit 2-5 in the IgM pentamer 2 of subunit 1, which is indirectly stabilised by the J-chain and blocks the C1q binding site, could contribute to this difference in fully symmetric complement deposition from the IgM hexamer without the J-chain18. This suggests an important effect for the asymmetric behaviour of the Fabs in complement activation.The observed asymmetry of the IgM pentamer originates from the J-chain, which extends to and interacts with the Cμ3-1 A domain, leading to the stabilisation of Cμ2 and Fab domains. The complement cascade starts from concerted antigen engagement by IgM which exposes C1q binding sites on Cμ3 domains. IgM F(ab’)49. Though the Fab regions display some flexibility, these structures show the Cμ2 and Fab domains in similar positions to those of the stabilised Cμ2 and Fab in the IgM pentamer subunit 1  was purified using a Superose 6 10/300 GL column to remove trace amounts of dimers and hexamers. The protein was concentrated at 1.0 mg/ml in PBS.IgM-Fc monomer and IgG1-Fc. Recombinant human IgM-Fc and IgG1-Fc were based on the extracellular parts of the membrane forms of the immunoglobulins. The IgM Fc monomer contained Cμ2-Cμ4 domains followed by the stalk normally linking the extracellular domains to the transmembrane region (residues 228-569) and included a mutation of C444S to prevent oligomerization and incorporation of fluorescent dyes at this position. IgG1 Fc contained Cγ2-Cγ3 followed by the stalk (residues 227-464) and included mutation of the hinge cysteine (C229S), which also interfered with labelling. None of the mutations affected the expression, dimerization, or stability of the IgM and IgG1 proteins.53. These two latter changes were introduced into IgM E526C. All constructs were cloned into pHLSec vector, in a frame with an N-terminal signal peptide sequence for secretion and with a C-terminal twin Strep Tag for purification of the secreted proteins.To introduce fluorescent labels at sites whose distances could distinguish the mode of Cμ4 orientation and dynamics, residues E526 (in the EF helix) and T556 (at the end of the G strand) at the side and bottom of Cμ4 of IgM, respectively, were mutated to cysteines. Correspondingly, amino acids S415 and S444 in Cγ3 of IgG1 were mutated to cysteines. To disrupt Cμ4 dimerization, histidine at position 518 in the Cμ4 domain was mutated to glutamic acid. The Cμ4 dimerization was stabilised by adding a C-terminal self-dimerising coiled-coil (EIAQLEYEISQLEQEIQALES)The proteins were expressed by transient transfection of the plasmids into adherent 293 T cells using PEI  DNA to PEI). Transfected cells were cultured for 5 days and the media containing the proteins were collected, filtered and applied to a Strep-Tactin sepharose column (IBA Life Sciences). Bound proteins were eluted with desthiobiotin and purified using FPLC.2 fractionated over 30 frames (dose rate 0.51 e−/Å2/s) with a 1.09 Å pixel size and a defocus range between −1 to −5 μm.Full-length IgM pentamer. Purified IgM pentamer samples were diluted to 0.25 mg/ml and 4 μls were applied to amylamine glow-discharged holey carbon copper grids  in the environmental chamber of a Vitrobot Mark IV (FEI/Thermo) at 4 °C and 100% humidity, and the grid was blotted with filter paper and then plunge frozen in liquid ethane at liquid nitrogen temperature. The IgM cryo grids were screened on Talos Arctica microscope (FEI/Thermo) at 200 kV and data collection performed on a Titan Krios microscope (FEI/Thermo) at 300 kV using EPU software. Movies were recorded on a Falcon 3 camera in counting mode with a total dose of 34.2 electrons per Å2 fractionated over 40 frames (dose rate 8.25 e−/Å2/s) with a 0.839 Å pixel size and a defocus range between −1 to −4 μm.IgM Fc monomer. Purified IgM Fc monomer (with coiled-coil extension at C-terminus) were diluted to 0.2 mg/ml and cryo-EM grids were made and screened using the same approach as the IgM pentamer above. Data were collected on a Titan Krios microscope (FEI/Thermo) at 300 kV equipped with a Gatan Imaging Filter (GIF) using EPU software. The slit width of the energy filter was set to 20 eV. Movies were recorded on a K2 camera in counting mode with a total dose of 66 electrons per Å54, followed by CTF estimation by CTFfind v 4.1.13 on the dose-weighted micrographs55. 1500 particles were manually picked in 50 micrographs acquired at various defocus values for model training by crYOLO56, which was then used for picking particles from all the micrographs. A total of 1,819,931 picked particles were extracted and exported by Relion particle extraction and export, with a box size of 600 pixels. The following image processing steps were conducted in CryoSPARC (v 3.2.0)57. All raw particles were imported into CryoSPARC and after two rounds of 2D classification, 546,583 particles were selected for further analysis. Five ab initio classes were calculated and used as initial models for heterogeneous refinement. 301,286 particles in the two best classes were then combined and subjected to non-uniform refinement58. This resulted in a map with a 4.32 Å global resolution calculated by Phenix59. Sharpening with B factor of −197 Å2 was applied to boost the high-resolution features of the map.Full-length IgM pentamer. The workflow of data processing is shown in Supplementary Fig. 1. A total of 43,530 movies were collected and imported into Scipion (v 2.0) in streaming mode. Raw movies were then aligned and dose-weighted by Motioncor230. The 301,286 particles contributing to the final refined map were downsampled by a factor of 2 (box size = 300 pixels), and three components were calculated. The volume series shown in the Supplementary Movie 2 region.3D variability analysis (3DVA) was conducted to explore the flexibility within the IgM molecule  were rigidly docked and combined into the maps and geometry minimisation was performed to regularise the models, followed by rigid body refinement using res-space refinement in Phenix61, followed by CTF estimation by CTFfind v 4.1.13. 7,411,324 particles were picked from 13,012 selected micrographs by a trained model in crYOLO and extracted with a box size of 50 pixels (pixel size=3.356 Å). The particle stack was cleaned by 2D classification in CryoSPARC for two rounds, with 961,072 particles selected and re-extracted with a box size of 256 pixels , which were then processed with Relion for 3D initial model, 3D auto-refine, Bayesian polishing and CTF refinement62. The polished and CTF-refined particles were transferred back to CryoSPARC for non-uniform refinement with C2 symmetry. The final map has a global resolution of 3.6 Å and a B factor of 185 Å2.IgM Fc monomer. 14,815 movies were collected, which were aligned and dose-weighted by Motioncor2 in Relion3.160. Details on data recording and processing of IgM Fc monomer are summarised in Supplementary Table Initial model of mIgM-Fc is obtained from chain E and F from the IgM pentamer cryoEM structure (pdb id 6KXS). Tailpieces were removed and single mutation C414S was made on both chains. Real-space refinement of the model against the mIgM-Fc cryo-EM map was then conducted in Phenix (v1.19.2) and manual refinement in Coot (v0.9.6). map-model FSC at 0.5 cut-off is 3.79 Å. The maps and models were displayed in Chimera v 1.13.1The whole IgM map is composed of a series of cross-sections along any orientation, as shown in Supplementary Fig. 2 clouds along both in-plane and out-of-plane directions, and thus represent the maximum angle that the Fab can reach in each subunit. The curvatures of the inner and outer arc indicate that they share the same centre, which is the hinge region of F(ab’)2 motion at the C-terminus of the Cμ2 domain. This is confirmed by fitting the centre of each arc into a circle  and Fab variable domain (outer arc). The values of all three peaks decrease monotonically with The Fab motion range can be quantified based on the grey values on the inner (Fab constant region) and outer (Fab variable region) arcs on the cross-sections. One can see from the cross-sections that for either the inner or outer arc the grey value at the centre is the highest (brighter), and it becomes darker with the length of the arc extending both ways and finally falls to the level of the background. Supplementary Fig. The criteria used in this study for the peak grey value to be considered as above noise is described in Eq. 1\documenThe proteins were labelled at the introduced cysteines with FRET pair dyes using Alexa Fluor 555 C2 maleimide and Alexa Fluor 647 C2 maleimide (both from ThermoFisher). Before labelling, proteins were buffer-exchanged into 50 mM Tris (pH 6.8), 140 mM NaCl and 20 μM TCEP. A five times molar excess of each dye, prepared in labelling grade DMF (Lumiprobe), was simultaneously added to the protein and the mixture was incubated with shaking at room temperature for 2 h. Labelled proteins were purified by size exclusion chromatography using a Superdex 200 10/300 GL column. Dye incorporation was examined by SDS-PAGE gels using ImageQuant imaging system (Amersham) and by absorbance measurements. Calculation of dye incorporation generally showed a near 1:1 incorporation of each dye with more than 90% protein labelled. No significant labelling was observed of control proteins lacking the introduced cysteines.Borosilicate glass coverslips (VWR) were treated with acid piranha solution (a 3:1 mixture of concentrated sulphuric acid with hydrogen peroxide) in glass jars for 15 min. The coverslips were extensively washed with distilled water followed by 2 washes with ethanol and one final wash again with distilled water. Coverslips were then washed three times with acetone to remove all traces of water. The coverslips were then incubated with 2% (v/v) silane  in acetone. After 2 min, coverslips were rinsed thoroughly with distilled water. The coverslips were dried under argon and mounted on microscope slides using two 0.12 mm-thick strips of double-sided adhesive tape (Sigma). The two strips were separated by a gap of about 4 mm creating a channel for the application of the samples.64, Feinstein Institutes for Medical Research). IgG1 Fc proteins were captured using anti-IgG1 antibodies directed against the Cγ2 domain .In order to specifically attach the labelled proteins, the slide-mounted coverslips were first coated with biotin-PEG as follows: 2 mg biotin-PEG SVA and 150 mg of mPEG-SPA (both from Laysan Bio) were dissolved in 1 ml of 0.1 M NaHCO3 (pH 8.2) and applied to the channels between each coverslip and the slide. The coverslips were left with the coverslip side down in a humidified chamber for 3 h. Afterwards, the channels were washed extensively with distilled water and dried under argon. The coverslips were either immediately used or stored under vacuum in a desiccator for up to 3 weeks. Prior to the experiments, the channels were coated with streptavidin (1.0 mg/ml in PBS) for 30 min. After washing out unbound streptavidin, the channels were loaded with biotinylated anti-IgM or anti-IgG antibodies serving as anchors for the fluorescent proteins. IgM Fc was captured using monoclonal antibodies directed against the Cμ2 domain of IgM  in Tris-buffer saline pH 8) was introduced for single molecule imaging.The samples were imaged on an Olympus IX-81 TIRF microscope with iLAS laser illumination system, 100x objective, image splitter and Andor iXon camera (CAIRN imaging). The sample was initially imaged by acquiring a donor image  and a directly excited acceptor image (illumination at 637 nm and emission at >650 nm), followed by time-lapse imaging at 30 ms per frame using 552 nm excitation and simultaneous imaging of the donor and acceptor (FRET) emission.66 using automated image processing in Matlab (Mathworks) and semi-automatic identification of single-molecule fluorescent traces. All imaging channels were spatially aligned using multispectral beads. Background in each channel was subtracted using background images generated by medium filtering at each pixel position across many experimental images containing sparse single-molecule fluorescence spots. Spots containing both donor and acceptor molecules were identified using initial snapshots of the acceptor fluorescence and recovered donor fluorescence, which was calculated as Eq. , crystal structure of the IgG1 (pdb id: 3DO3) and Cryo-EM structure of the IgM pentamer (pdb id 6KXS) were used to virtually attach the donor and acceptor dyes to the Cβ atoms of the appropriate residues after the original sidechains had been removed. The accessible dye volume clouds were generated using the FPS software using the settings stated in Supplementary Table 467.To compare the measured FRET values to FRET estimated from the distances of the dyes attached to the proteins at the indicated positions, we calculated the mean dye accessible volume for each labelled position as described0 for the Alexa Fluor 555 – Alexa Fluor 647 pair set to 5.1 nm.The accessible volume was then used to derive the mean inter-dye distance (FRET-weighted) and the predicted FRET value for each labelling situation, with RFurther information on research design is available in the Supplementary InformationDescription of Additional Supplementary FilesSupplementary Movie 1Supplementary Movie 2Reporting Summary


The University of Rhode Island (URI) team implemented a pilot program designed to bridge the digital divide between older adults and younger generations. Through this project, the goal was for older Rhode Islanders to become digitally literate by engaging them in a formal program that provides digital devices , connectivity , and training by supervised and trained university student mentors. This project specifically worked to promote social and economic equity by recruiting participants from lower-income communities and areas hit hardest by the COVID-19 pandemic, including those who speak English and Spanish. The final sample (N=124) for the study was primarily female (79%) and low income (82%). They were 41% Non-White and 23% Spanish speaking with 23% having a college degree or more. We conducted preliminary analysis on the first 38 participants who completed both a pre- and post-survey. Based on these analyses, the program participants have shown statistically significant improvements in frequency of tablet use (p<.05), digital competency across all questions (p<.05), quality of life (p<.05), and social isolation (p<.05). In addition, the loneliness and depression questions/variables are trending in the expected direction, so it is possible that with a more robust sample size we may see significant improvement in these areas as well. This presentation will describe the key elements of the pilot intervention and explain the findings from the full sample. The presentation will also discuss the plan for state-wide implementation of the program.


Harvest for Health mentored vegetable gardening intervention among cancer survivors.Health behavior interventions, especially those that promote improved diet and physical activity, are increasingly directed toward cancer survivors given their burgeoning numbers and high risk for comorbidity and functional decline. However, for health behavior interventions to achieve maximal public health impact, sustainability at both the individual and organizational levels is crucial. The current study aimed to assess the individual and organizational sustainability of the Harvest for Health feasibility trials. Surveys ascertained whether participants continued gardening, and if so, whether they had expanded their gardens. Additionally, surveys were emailed to 23 stakeholders  who were asked to rate the intervention’s ability to generate sustained service and produce benefits over time using the eight-domain Program Sustainability Assessment Tool (PSAT).Telephone surveys were conducted among 100 cancer survivors  completing one-of-two The survey among cancer survivors (91.9% response rate) indicated that 85.7% continued gardening throughout the 12 months following intervention completion; 47.3% expanded their gardens beyond the space of the original intervention. Moreover, 5.5% of cancer survivors enrolled in the certification program to become Extension Master Gardeners. The survey among stakeholders generated a similar response rate  and favorable scores. Of the possible maximum of 7 points on the PSAT, the gardening intervention’s “Overall Capacity for Sustainability” scored 5.7 (81.4% of the maximum score), with subscales for “Funding Stability” scoring the lowest though still favorably (5.0) and “Program Evaluation” scoring the highest (6.3).Harvest for Health vegetable gardening intervention for cancer survivors. Indeed, few interventions have proven as durable in terms of individual sustainability. Furthermore, Harvest for Health’s overall organizational score of 5.7 on the PSAT is considered strong when compared to a previous review of over 250 programs, where the mean overall organizational PSAT score was 4.84. Thus, solutions for long-term funding are currently being explored to support this strong, holistic program that is directed toward this vulnerable and growing population.Data support the sustainability capacity of the NCT02150148ClinicalTrials.gov Identifier:  The steadily increasing number of cancer survivors, who now comprise 5.0% of the U.S. population , are facA program centered around a home-based, vegetable gardening intervention may prove durable, as it takes place at home, where people may be especially motivated to “nest,” i.e. nurture and cultivate their immediate surroundings. Additionally, people need only step outside their front or back door, thus limiting travel . Also, since the vast majority of cancer survivors are seeking complementary and alternative medical therapy to improve their health , a holisMaintaining programs over time is increasingly difficult even for the most beneficial and successful of interventions. Program benefits can only be delivered if these programs can be sustained. In many settings resources for public health programs are limited and decreasing . SustainThe growing field of implementation science has increased the amount and diversity of research in the area of “maintaining programs and their benefits over time,” or sustainability , 14. ProHarvest for Health vegetable gardening interventions tested for feasibility among cancer survivors. Both interventions were delivered in partnership with the Cooperative Extension Master Gardener Program to facilitate one-on-one mentorship of cancer survivors in planning and maintaining three seasonal vegetable gardens over 12 months as well as providing gardening supplies, plants, and seeds. The intervention aimed to improve diet, physical activity, and physical functioning [We evaluated the capacity for sustainability of two ctioning , 18–20. Harvest for Health is a 12-month home-based, mentored vegetable gardening intervention for cancer survivors. Designed with dissemination and sustainability in mind, the intervention capitalizes on an extant infrastructure — the Cooperative Extension System (Extension) — operated by land-grant universities across the U.S. The Master Gardener Program is one of the more popular education and outreach programs offered through the Extension and exists in all U.S. states and territories. In Alabama specifically, there are 44 county and regional Master Gardener Associations with about 1,800 new and veteran volunteers in total.Harvest for Health was offered as a community service project that Master Gardeners in Alabama could select as part of their volunteer hours.Through a certification process, the Master Gardeners receive research-based training in horticulture with the expectation that they will use this training to serve their communities. In testing feasibility, Harvest for Health, survivors are individually matched with a Master Gardener (based on geographic proximity) who works with them to plan, plant, tend, and harvest three vegetable gardens over the course of a year. Via grant support, survivors were given an estimated $500 of gardening supplies, which included a raised bed garden or four garden boxes, gardening tools and supplies, and plants and seeds. The participants were able to keep all the gardening materials to encourage continued gardening upon completion of the intervention.In Harvest for Health was evaluated in two randomized controlled trials employing a waitlist-controlled design. Detailed methods and results have been published [The feasibility of ublished –20. A suTelephone surveys were pursued among the 100 participants who received the full 1-year intervention and completed either of the randomized controlled trials , 20. ParHarvest for Health, went on to pursue Master Gardener training were documented.In addition, ACES maintains records of all Master Gardeners in the state. Thus, any participants who, after participation in Harvest for Health interventions were contacted via email in April of 2017 to complete an anonymous survey regarding the potential for organizational sustainability of the program. Stakeholders played instrumental roles in program planning, participant recruitment, intervention delivery, and their ongoing assistance in program evaluation. A representative sample of these stakeholders, comprised of ACES county agents and Master Gardener Program Coordinators (n=14), leaders of patient support groups (n=5), and UAB Cancer Care Network leaders (n=4), were among those contacted for the survey.Twenty-three stakeholders who were familiar with the Organizational sustainability was assessed using the Program Sustainability Assessment Tool (PSAT). The PSAT is an instrument that was designed to be used by researchers, evaluators, program managers, and public health program staff to assess program capacity for sustainability , 22. ProThe PSAT has been developed and tested on a large number of programs at differing levels and has established reliability  . PrelimiDescriptive statistics that relied on the generation of frequencies, percentages, and means were used to analyze the data for both individual sustainability and organizational sustainability. Univariate logistic regression was used to identify individual predictors of continued gardening and garden expansion, which included sociodemographic and health-related characteristics collected prior to intervention delivery (data collected previously described ). For eaOf the 100 cancer survivors who were identified for the individual sustainability survey, one was deceased, and 8 were unable to be contacted (91.9% response rate). Respondents of the survey were primarily female and breast cancer survivors , non-Hispanic White (76.9%), and resided in urban counties (78.0%). The mean age was 63.0 years (SD 9.6). On average, the sample reported 4.5 (SD=2.6) functional limitations and 3.6 (SD=2.6) comorbidities at the start of the feasibility trials.n = 5), plans to return to gardening in the future (n = 2), preference for flower gardening (n = 1), moving homes (n = 1), lack of time (n = 1), lack of interest (n = 1), discouragement after bad gardening seasons (n = 1), and unknown (n = 1).Of the respondents, 78 (85.7%) continued gardening throughout the 12 months following the completion of the intervention. Further time since diagnosis and receipt of chemotherapy were the only sociodemographic or health-related characteristics associated with reduced likelihood of continued gardening . Of those who continued gardening, 43 (47.3%) had expanded their gardens beyond the initial 4x8 foot raised bed or 4 Earthboxes®  provided by the project. Participants who had received chemotherapy were less likely to report having expanded their garden . For those who did not elect to expand their gardens, roughly half stated that they planned to do so in the future, and the other half were satisfied with maintaining the current space they had . Among the 13 participants who reported discontinued vegetable gardening, reasons for discontinuation included illness of self or partner  (n = 2); Susan G. Komen Breast Cancer Foundation (n = 1); UAB Cancer Center Education & Support Services (n = 1); and the St. Vincent’s Bruno Cancer Center Support Group (n = 1). Three stakeholders were members of the UAB Cancer Care Network, satellite hospitals throughout the southeast U.S. that were key in referring cancer survivors to Harvest for Health.Twenty-one of the 23 program stakeholders completed the PSAT (91.3% response rate). Eleven stakeholders were ACES county agents who, as a part of this program, assisted in recruitment, screening, training, and supporting Master Gardener volunteers who agreed to become mentors for the project. Two stakeholders were Master Gardener Program Coordinators who aided in communications between all parties of ACES and made local visits to support mentor recruitment and training. Five stakeholders were leaders of patient support groups that Harvest for Health received a 5.7 out of 7 (81.4% of the maximum score) in overall capacity for sustainability. All PSAT scores and the domain descriptions are reported in Table Harvest for Health’s strongest scores were in the domains of Program Evaluation, Program Adaptation, Environmental Support, Organizational Capacity, and Communication . Its weakest scores, while still relatively high, were in the domains of Partnerships, Strategic Planning, and Funding Stability .To our knowledge, this is one of the first studies to demonstrate the capacity for sustainability of a behavioral intervention among cancer survivors and key stakeholders. Moreover, it is likely to be the very first to collect such data on a vegetable gardening intervention that focuses on this patient population.Harvest for Health is successful in engaging participants in the intervention behavior  that lasts long beyond the initial 12-month intervention. Based on recent reviews, few diet and physical activity interventions report post-intervention follow-up, and even fewer report long-term follow-up (≥12 months). For example, only 4 of 14 studies reported on maintenance of functional change after home or community-based physical activity interventions, with follow-up ranging from 12 to 26 weeks post-intervention [The resulting data suggest that rvention . The lacrvention , 24.Harvest for Health continued to garden one-year beyond intervention completion. Furthermore, we found that nearly half of participants drew from their own resources  to expand their gardens. This investment on the part of the prior participants speaks not only to their commitment to the vegetable gardening intervention but also to the skills they learned and retained from their Master Gardener mentors. Moreover, while the telephone surveys did not systematically ascertain reasons for continued gardening (as it did for discontinuation of gardening), it is likely that intervention participants experienced the benefits reported in these two studies. Benefits included increased reassurance of worth , improved physical performance and the production of fresh vegetables which improved their diets [In contrast, the majority of those enrolled in ir diets , 20.Harvest for Health regarding sustainability is that Master Gardeners are volunteer workers who depend on annual hours of education and volunteer work to maintain their accreditation status. While there are many volunteer opportunities to select from, an ACES survey indicated that Master Gardeners are motivated by volunteer activities that allow them to help other people, and to learn and advance their knowledge and skills, especially through hands-on experiences. Importantly, with some participants becoming Master Gardeners, there will be more of a connection between the program and the community (Partnerships), more resources (Master Gardener mentors) to effectively manage the program and its activities , and more people to strategically disseminate the program outcomes and activities to stakeholders, decision-makers, and the public (Communications).One of the core strengths of Harvest for Health demonstrated several notable strengths. First, its overall capacity for sustainability was robust (5.7 out of 7.0 points), suggesting this program has strong capacity for sustainability, especially when compared against an average score of 4.84 rendered in a review of 252 various public health programs by Luke et al. [Harvest for Health to more similar programs, namely health promotion interventions for cancer survivors, would likely be more appropriate; however, as mentioned, few other studies have been performed.In terms of organizational sustainability, e et al. . It is nThe specific strength of the program in the domain of Program Evaluation is substantiated given the regular meetings with funders and stakeholders in which program staff report outcomes, use evaluation results to inform planning and implementation, and demonstrate successes of the program. Also, outcomes of the program are regularly presented at national meetings and provided to the public in the form of media  and social network . While qualitative outcomes related to satisfaction are important, quantitative outcomes are of primary interest to the Master Gardener Programs for evaluation. Given the Programs’ priority of teaching home gardeners to become successful growers, the key outcomes from Harvest for Health were sustainment of gardening and expansion of garden size by cancer survivors one year after the study ended. Thus, these activities and outcomes likely contributed to the strong score.Harvest for Health was designed from the start to be delivered by Extension Master Gardeners – a decision that was informed by early involvement of ACES . Thus, Harvest for Health likely required fewer and simpler adaptations compared to interventions designed to assess efficacy that consider sustainability late in the program’s life cycle. Second, the minor adaptations that have been made to the program were made through an iterative process to further improve the fit to the intended recipients, both cancer survivors as well as the Master Gardener Program. Any components of the program that have been found ineffective or too expensive (price increases) are regularly assessed and de-implemented or replaced  in order to reduce costs. Conversely, deer fences and frost cloths were found to be necessities for some survivor gardens and were added.Program Adaptation, another strength, was likely the result of several factors. First, , Harvest for Health, wanted to help publicize the study or recruit additional participants. They also provided extra support through donating extra seeds on hand, extra transplants they grew, or in some cases, retail purchases for an extra item they deemed important for their participant’s success in gardening. In addition, support was also provided by the O’Neal Comprehensive Cancer Center at UAB, other cancer support groups, as well as strong public support (interest generated via word of mouth). Donations or discounts on gardening supplies for the study were provided by local retailers such as independent nurseries and hardware stores, and individual Walmart® stores ($50 donations to support the purchase of gardening gloves and seeds), charities, and other interest groups. Master Gardeners who enjoy working with the program regularly approach Harvest for Health for future volunteer opportunities. Moreover, previous participants, i.e., cancer survivors, have called in to see if they can participate again.Environmental Support emanated from the champions who strongly supported the program, who were likely to be individual Master Gardeners, but also the leadership support within the larger organization of ACES. Master Gardeners, many with family and friends interested in Harvest for Health. Organizational systems are in place to support the various program needs, leadership effectively articulates the vision of the program to external partners , leadership efficiently manages staff and other resources , and Harvest for Health has adequate staff to complete the goals of the program .Organizational Capacity is evident in the strong support and resources within the ACES Master Gardener Program to effectively deliver https://www.facebook.com/harvesting4health/ is being monitored by ACES and Harvest for Health staff to allow anyone to share his or her gardening experience to the benefit of others. Improvements can be made in communicating the need for the program to the public (establishing more of a media presence) and marketing in a way that generates interest (targeting our population with messages of interest). Additionally, strategies are needed to increase community awareness of the issue , and demonstrating the program’s value to the public (more coverage of previous participants’ benefits gained).Regarding Communications, there were many presentations at local and state Master Gardener meetings and conferences, as well as cancer-related venues that were convened at chapters of community-based support groups, public health offices, and hospitals. While initially there had been less communication with the general public, strides have already been made to secure and maintain public support. Notably, a publicly available Facebook page, Although PSAT scores were strong overall, they also speak to areas where the program can be improved. The weaker scoring domains of the PSAT were Strategic Planning, Partnerships, and Funding Stability. These will be areas for improvement and growth. For Harvest for Health, the greatest investment in time for the Master Gardener Program has been recruitment of volunteers and monitoring fidelity via monthly check-ins. Strategic Planning after the feasibility studies has led to processes to address these and other activities. For example, one central person was hired to manage the logistics and communication. Also, there has been increased and repeated promotion of the study at Master Gardener Program trainings and meetings. Areas for improvement include better planning and communication of future needs for resources and a long-term financial and sustainability plan. Furthermore, making sure that the program’s goals are well understood by all stakeholders and clearly outlining the roles and responsibilities of all stakeholders will improve the program and increase capacity for sustainability.Harvest for Health is involved with many community organizations currently, and has established strong Partnerships with FORGE  and the Jefferson County Master Gardener Program in which the intervention is disseminated more broadly. However, the intervention’s Partnerships could be further strengthened through forging connections with more diverse community organizations. For example, more community organizations are needed that can provide garden supplies, plants, and seeds. While the garden boxes worked well for many participants with limited space, not all apartment facilities are able to accommodate these small containers. Therefore, organizations that could offer space for garden plots to these individuals would help to bring this intervention to scale. Community leaders play an important role in Harvest for Health. By better communicating with these leaders and getting them more involved in the program in a more visible way, community members will be more committed to and engaged in the program and its goals.Harvest for Health. Locally, a community organization, the Women's Breast Health Fund of the Community Foundation of Greater Birmingham, has provided scholarships to encourage breast cancer survivors who cannot afford gardening supplies and wish to reap the benefits evidenced by this intervention. In addition, ACES reduced the cost of Master Gardener credentialling by 25% and fundraising efforts through UAB have resulted in further scholarships to cancer survivors who have completed the program. As Harvest for Health initially began as a small pilot study, it is understandable that stakeholders may have considered the program transient; however, it has grown over time to a statewide initiative, and is currently being evaluated in the Southwest [Funding stability is a concern for many programs like outhwest . To faciHarvest for Health, in response to the feasibility studies in which the research team helped to support the delivery of the intervention by the Master Gardener Programs. Future evaluations will be needed as the Master Gardener Programs transition towards supporting all aspects of intervention delivery.While this study is one of the first to document individual and organizational sustainability and does so in a systematic manner with strong response rates, there are limitations. First, both surveys relied on self-reported data, and the survey conducted among stakeholders had a fairly small sample. Also, there is potential for demand effects as stakeholders may have provided a more positive evaluation of the program. Although stakeholder responses were aggregated and anonymous, with such a small sample, there is nevertheless the concern that they may not have felt completely free to evaluate the program openly. While thoughtful planning for sustainment early in the translation process is crucial for achieving public health impact, this requires an iterative process , 28. ThiHarvest for Health’s weaker elements of capacity for sustainability, this will mean closely examining longer-term funding options and ensuring a strategic plan is not only in place, but made known to all involved. Lastly, closer partnerships will need to be formed and maintained with regular communication.Next steps will include developing an action plan and then taking action. The action plan will involve assembling a planning team, reviewing the program mission and purpose, reviewing PSAT results, determining program elements that need to be maintained, eliminated, or adapted, and prioritizing areas of sustainability capacity to address first. Taking action will involve implementing the action plan and reassessing sustainability capacity annually . FocusinHarvest for Health’s capacity for sustainability from the perspective of cancer survivors receiving the intervention  and the perspectives of various stakeholders. The majority of previous participants continued to engage in gardening and nearly half expanded their gardens so that they could engage on a larger scale, which means they are more likely to benefit long-term from the intervention’s health benefits. Additionally, some cancer survivors who completed the intervention went on to become Master Gardeners in an effort to continue the program. The general desire of previous participants to pursue skills and gain experience shows promise for multiple aspects of sustainability . From stakeholders’ perspectives, program evaluation was considered Harvest for Health’s strongest component, while funding stability was considered its weakest, though still favorable. In sum, Harvest for Health has many strengths in regard to capacity for individual-level and organizational sustainability. Future research will capitalize on the present research to maximize this novel intervention’s reach and impact on the steadily increasing population of cancer survivors in the United States.This paper examined


Rural communities are noted as having poor health outcomes. Rural areas experience barriers to care primarily due to a lack of resources, including education, health insurance, transportation, and social support. Additionally, poor health outcomes are a consequence of poor health literacy skills. Community Health Workers (CHWs) are utilized as a resource to combat these issues. This study focused on a CHW led Self-Management Blood Pressure (SMBP) program offered through the University of Texas at Tyler Health Science Center. The goal of the program was to improve management of hypertension through awareness, education, navigation, advocacy, and resource assistance. The SMBP program included structured workshops and regular follow-up with participants including connections to community resources and social support. CHWs worked closely with physicians providing bi-directional feedback on referrals and engagement of communities through outreach events. Furthermore, CHWs aided to bridge cultural or linguistic gaps between service providers and community members. Data is provided indicating this CHW-led intervention played a significant role in improving hypertension through education of how to make lifestyle changes that impact overall health and quality of life. Participants gained knowledge encouraging them to create lifelong healthy habits, coping skills, stress management, self-care, and accountability. Through this innovative approach, participants thrived in the supportive and encouraging environment led by CHWs as well as improved their blood pressure management. Cardiovascular disease and stroke are respectively the number one and five leading causes of death in the United States  and in NCHWs are known to build community capacity in efforts to improve health outcomes. Additionally, CHWs play a significant role in shifting the trajectory of chronic disease by encouraging lifestyle changes that impact overall health and quality of life . CHWs alCHWs play an important role in their communities, providing services at the individual and group level , 11. AccCHW led interventions have been shown to be effective in the management of non-communicable health conditions . For exaThis study examines the outcomes of a hypertension focused CHW-led Self-Management Blood Pressure (SMBP) program operated by the University of Texas at Tyler Health Science Center. The population of interest is people living with hypertension in Northeast Texas. This study: (1) describes a CHW-led SMBP workshop series designed to improve health outcomes among patients with hypertension receiving care at a rural academic health center; (2) evaluates the program's impact on participant knowledge and behavior regarding blood pressure management before and after completion of the program; (3) assesses the effect of the intervention on hypertension control from blood pressure measures taken at baseline and at the end of the program; and (4) reports participants perceptions and experiences of the program.The University of Texas at Tyler Health Science Center's Self-Management Blood Pressure (SMBP) program is a multi-component lifestyle change intervention that combines and adapts evidence-based components from lifestyle change and hypertension management curricula disseminated by the National Heart, Lung, and Blood Institute  and the The process began with an orientation session during which participants learned more about the program and completed all required paperwork including an informed consent form before participating in the program. Participants who agreed to join the program were provided blood pressure monitors to use throughout the program and upon graduation they were allowed to keep the apparatus. Participants were taught how to use the blood pressure monitor according to TARGET:BP  guidelinThe SMBP program is a community-based health program therefore participants self-selected into the program. No statistically based sampling method was employed in the selection of participants, it was a convenient sample. Participants in the SMBP program were recruited from the East Texas community at large through several methods: (i) The primary modes of recruitment were through referrals from University of Texas Health East Texas (UTHET) physician clinics and by word-of-mouth referrals from persons who had previously participated in the program. (ii) UTHET Emergency Medical Services Mobile Integrated Health unit also provided referrals for some of their patients to the SMBP program. (iii) Community outreach fairs and presentations at assisted living centers and the Tyler Library contributed the remaining SMBP participants.The SMBP sessions included in this study were conducted from August 2019 to June 2022. Three separate data sets, capturing different dimensions of program performance, were collected from persons who enrolled in and participated in the SMBP program. These were (1) the assessment of changes in participant knowledge and behaviors, (2) change in systolic and diastolic blood pressure and, (3) the participants' self-reported experiences of completing the SMBP program.Participants completed knowledge and skills assessments related to blood pressure management at the start of the program and then upon program completion. The pre-test was comprised of a 5-question knowledge exam followed by a three-question self-assessment of the participant's skills for controlling hypertension. This pre-test was self-administered at the time the individual enrolled in the program. The post-test repeats the questions from the pre-test and is administered at the graduation ceremony from the program. Because results from the pre- and post-test were collected anonymously and tabulated in the aggregate for record retention, we were unable to present measures of significance for the variation in the data.CHWs taught participants how to accurately take their own blood pressure using the automated arm-cuff monitor so that they were able to record daily blood pressure readings in their booklet, My Blood Pressure Passport.t-tests were utilized to assess the hypotheses that there were no differences between pre- and posttest mean systolic and diastolic blood pressures for the study population. Within group changes in mean blood pressure were assessed for each participant's characteristics available in the data, including age, gender, race, ethnicity, education level, body mass index (BMI), whether the individual was currently on antihypertensive medications, whether they had ever smoked, and whether they were subject to additional comorbidities, diabetes and/or cardiovascular disease. Based on the demographic composition race was defined in this study as being White or Black. Ethnicity was defined as either Hispanic or non-Hispanic. Racial and Ethnic categories are not considered to be mutually exclusive, for example, an individual can be Black and Hispanic or Black and non-Hispanic. Race and Ethnicity data were self-reported by participants. Underlying assumptions for the use of paired t-tests were assessed, with no influential outliers noted, and the results of a Shapiro-Wilk test of normality met the requirement for approximate normality. All analyses were conducted using STATA version 16. Statistical significance was set at the 0.05 level.A one group pre-test/post-test design was utilized to assess changes in the participants' mean blood pressure, with separate analyses conducted for changes in systolic and diastolic blood pressure. The pre-test time point was defined as the time of the blood pressure reading taken during the program's first-week session. The post-test time was defined as the time of the measurement conducted during the program's last session week 12. Participants measured their blood pressures in millimeters of mercury using the Omron 7 Series Blood Pressure Monitor and following American Heart Association/American Medical Association TARGET:BP: SMBP guidelines . SeparatThe final data source utilized in this study was a participant experience survey completed at the end of the week 12 intervention. This was a self-administered survey. Responses were anonymous and tabulated at the aggregate level for record retention. The instrument was comprised of five-questions that used a Likert format gauging agreement with the base question on a scale of strongly agree to strongly disagree. All individuals who finished the SMBP program completed at least part of the survey. Because response data were retained at the aggregate level, we were not able to calculate measures of significance for variation in responses. In addition to the formatted questions, participants were invited to provide any additional comments in free form text. For the purposes of reporting here, the responses were divided into four categories, (i) including constructive comments about the CHWs who ran the workshop, (ii) the workshop content, (iii) delivery mode, and (iv) the overall experience with the program.p = 0.32), race (p = 0.43), age (p = 0.65), or education level (p = 0.28).Total enrollment for these SMBP cohorts was 242. Enrollment in the program consists of a participant's agreement confirmed by a signed consent to participate in the program. The consent was delivered to potential participants by email and then electronically signed and returned prior to attending the orientation session. The actual number of participants who started the program was 212, which includes a signed consent form, attendance at the orientation or session one, and providing a minimum of one blood pressure reading. Of these enrollees, 197 completed the program by regularly providing blood pressure readings. However, five of the 197 participants failed to complete all 12 weeks of the program and thus did not provide blood pressure readings at the final week of the program leaving us with 192 subjects included in the blood pressure analytical file. The decline from participant enrollment (242) to participants who completed the program (197) could be attributed to multiple factors including, lost to follow-up, family emergencies, COVID-19 pandemic related stress and/or anxiety, over commitment, and other causes. Comparison of the individuals who were dropped from the study sample with those included in the analysis showed no statistically significant differences in gender (As depicted in p < 0.05). The association between the intervention and a statistically significant drop in mean systolic blood pressure was found for both women and men as well as for all racial and ethnic groups in the study population. Similarly, significant reductions in mean systolic blood pressure were observed for both those currently on blood pressure medications and those not taking medications. Individuals who had not earned college degrees experienced a significant reduction in mean systolic pressure, while those with college degrees experienced a non-significant decline. Individuals who were overweight or obese experienced significantly lower mean systolic blood pressure, but reductions for participants of normal weight did not reach statistical significance. Program participants who smoked or had diabetes experienced significant decreases in systolic pressure, but those with cardiovascular disease did not.Results of our paired t-test analyses of change in blood pressure, presented in The results for diastolic blood pressure, presented in Findings from the participant experience surveys, presented in In addition to completing the participant experience survey, forty-eight percent (48%) of participants completing the SMBP program provided written feedback at the end of the 12-week program. These free form comments provide a qualitative perspective on the program. Three percent (3%) of participants who provided feedback felt the program should include additional visual aids, experienced issues with virtual connectivity, or commented on the time of day a specific workshop occurred. Twenty-two percent (22%) of participants felt the content presented by CHWs was helpful in creating healthier lifestyle habits.This study evaluates a CHW-led hypertension self-management program implemented among 197 participants in rural northeast Texas. We used three different data sources to evaluate the program. These were: a pre-test knowledge and skills assessment survey, an assessment of change in systolic and diastolic blood pressure before and after the 12-week program, and an assessment of participants' experience with the program after the completion of the intervention. The study found that knowledge about hypertension and hypertension management has improved. Participants showed behavioral change in hypertension management as measured by monitoring their blood pressure at home regularly and taking their medication as prescribed. Changes in both systolic and diastolic blood pressure were observed between mean baseline and last (at the end of the 12-week program) BP measures across subpopulation groups. Finally, participants expressed positive experiences of the program in terms of the information that they were able to obtain as well as the ease of understanding the content.Knowledge about hypertension and hypertension management improved from baseline measurements. From a conceptual perspective, the increase in participant awareness of the risks of hypertension and understanding of the management of their condition are the first steps toward improving health outcomes. In our study, participants demonstrated increased awareness from 88% to 91%) that high blood pressure was a risk factor for heart disease and stroke. Similarly, knowledge of proper technique for taking blood pressure (83% to 99%) and interpreting its measurement (85% to 100%) improved from baseline to the week 12 assessment. These findings are conceptually consistent with those found by Boulware et al. (8% to 91%Our findings showed that participants reported an improved behavior to monitor their hypertension and take their medications. The majority (92%) of the participants reported that they were able to adequately use their BP cuffs at home to monitor their blood pressure regularly. Adherence to hypertension medication also improved as 86% of the participants self-reported taking their medications properly after the program compared to (76%) of those who did so before the intervention. These findings are similar to other CHW-led interventions designed to improve disease control and medication adherence. These includes interventions for diabetes and/or hypertension program in Mexico , DiabeteOur study participants experienced changes in blood pressure measures (both systolic and diastolic) after the 12-week intervention. Analyses of changes in blood pressure indicated an association between the Self-Management Blood Pressure (SMBP) hypertension program and reductions in both mean systolic and diastolic blood pressure among a sample of 192 individuals from a region of Texas that faces complex, well-documented health challenges –34. Whilvia CHWs who delivered instruction using language, practical examples and vocabulary that were regionally and culturally sensitive to this specific audience. This observation aligns with similar studies that used CHWs to address health outcomes (diabetes and hypertension management) for specific minority populations (These results show that the program had a positive effect on improving certain dimensions of access for rural East Texas community members to information and support to improve their health outcomes. Through the dissemination of information and instruction on a schedule that was flexible and accessible through a distance learning management system, participants were able to self-pace how the information was consumed within the limitations of week-long modules of content. The dissemination of information ulations . RegionaThis study's findings regarding the effectiveness of CHW-led SMBP interventions in combating hypertension in largely rural East Texas are encouraging. They also indicate the need for further research in this field. Introducing a matched control group would enhance the design, as would the incorporation of multiple pre- and post-test measurements of participant blood pressure. Having additional post-test measures would also make it possible to examine the sustainability of the program's influences on blood pressure levels. A final area of promise for future research is in implementation science. A robust examination of the delivery process from the participants and program staff perspectives could reveal areas of strength in the program and areas that need modification.via convenience sampling methods. Therefore, participants who agreed to join the programs were particularly motivated to self-enroll into the program in order to address their BP conditions. Hence, if we were to align participants' motivations to change their BP-related health behaviors using the Health Behavior Theoretical Model (This study evaluated the efficacy of a SMBP program among rural community participants. Rural communities exhibit disproportionately poorer health outcomes as compared to their urban counterparts . Unfortual Model —the partThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the University of Texas Health Science Center at Tyler. The patients/participants provided their written informed consent to participate in this study.KB developed, supervised, and directed the project. CP was involved with planning, coordinating, and delivery of the project. KB and CP validated the data. PM served as principal investigator of the project. MM completed the statistical analysis of the data. KE and YT provided an analysis of the results and discussion sections. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


This study proposed a conceptual framework and explored the influence of personal-level variables such as cognition, affection, conation, and attitude, as well as the theory of planned behavior, on tenant loyalty using situational influence as a moderator variable. Structural equation modeling was employed for parameter estimation. A total of 315 questionnaires were administered to housing tenants residing in Kaohsiung City, of which 300 were recovered, a recovery rate of 95.2%. The results are as follows: Tenants’ cognition, affection, and conation positively influenced their attitude toward their tenancy; tenants’ attitude significantly and positively influenced their satisfaction and loyalty; tenant satisfaction significantly and positively influenced tenant loyalty; perceived behavioral control significantly and positively influenced tenant loyalty; and subjective norms significantly and positively influenced tenant loyalty. Regarding the influence of attitude on tenant loyalty, the inclusion of a situational influence-based moderator variable—i.e., whether a tenant has friends or relatives living nearby—revealed that the presence of this variable significantly diminishes the influence of attitude on loyalty. The findings indicate that landlords could improve the quality of their services by implementing sustainable management measures to strengthen tenant satisfaction and, consequently, tenant loyalty. Renting a house is a process most people experience. According to data from the 2018 Population and Housing Census conducted by the The theory of planned behavior (TPB) can be used to analyze the factors affecting tenant loyalty. Furthermore, discussions on the behavioral intentions of tenants should consider the relationships between tenants’ attitude, satisfaction, and loyalty. Interestingly, situational influences may interfere with or moderate the relationship between tenant attitude and tenant loyalty. Situational influences are factors that arise from the factors considered by a customer, as well as the time and place, which subsequently affects the customer’s decision-making process. They can affect customer behaviors at any stage during the purchasing process, and may also shorten, prolong, or halt the purchasing process . Ajzen . Customer support is a key factor that determines a company’s sustainability. Customers who feel satisfied with a product or service are more likely to become loyal customers and may actively share relevant information about the product or service with others through word-of-mouth. This effect is essential for ensuring the sustainability and success of an actor in the real estate industry against temporal changes and rising competition.In conclusion, it’s found, by referring to the previous discussion on relevant issues, that the Theory of Planned Behavior (TPB) is mainly applied to the behavioral intention of word-of-mouth on tourists’ purchase of souvenirs  and the The main contribution of this study is that, based on the traditional TPB model, personal perception variables including cognitive, affective and conative elements were taken into account, and the moderating effect of situational influence was also considered for an empirical study on tenant loyalty. This study not only further expanded the TPB model in theory by including personal perception variables and situational influence into the model, making the TPB model more complete and breaking through in theory, but also made the expanded TPB model more consistent with the actual situation of tenancy, thus making the empirical results of this study more representative.H1: Cognition has a positive and significant influence on attitude.H2: Affection has a positive and significant influence on attitude.H3: Conation has a positive and significant influence on attitude.Tenant satisfaction is a multidimensional cognitive attitude whereby its expression cannot be measured by proposing a simple question. The cognitive image shaped by tenants through the process of perception shapes the basis of their personal attitude and feelings toward each component, and the totality of these attitudes and feelings forms the basis of tenants’ satisfaction with their house . By meanH4: Attitude has a positive and significant influence on tenant satisfaction.H5: Attitude has a positive and significant influence on tenant loyalty.H6: Tenant satisfaction has a positive and significant influence on tenant loyalty.H7: Perceived behavioral control has a positive and significant influence on tenant loyalty.H8: Subjective norms have a positive and significant influence on tenant loyalty.H9: The influence of attitudes on tenant loyalty is moderated by the availability of friends and family living nearby.We first developed a conceptual framework as shown in The nine hypotheses proposed in this study were compiled into the conceptual framework, shown in The variables in this study consist of four personal variables  and five other variables . The operational definitions of the variables are as follows:Merriam-Webster (1993) highlighted that conation is the innate motivation or striving toward a goal and the willingness to complete a task. Conation differs from cognition, which is defined as the mental processes involved with thinking, learning, and memory throughout the process of knowledge acquisition. We adopted Merriam-Webster’s (1993) concept as our operational definition of conation.Tenant satisfaction encompasses four different types of satisfaction: (1) Satisfaction with a house; (2) Satisfaction with the services provided, including maintenance; (2) Satisfaction with the rent paid, including the house and services; (4) Satisfaction with the residential area . Other sSituational influences must consider various factors that affect a customer’s decision-making process, such as the factors that contribute to an event, as well as time and location constraints. The questionnaire comprised two sections: the first covered the participants’ basic information, including their gender, age, occupation, and length of tenancy; the second covered items regarding cognition, affection, conation, attitude, tenant satisfaction, tenant loyalty, perceived behavioral control, situational influences, and subjective norms. Based on studies by Based on studies by via convenience sampling. The researchers administered a questionnaire to each participant face-to-face. The questionnaire survey period lasted from 1 June to 30 June 2019. A total of 315 questionnaires were administered, all of which were recovered. After omitting 15 invalid responses, there were 300 valid responses, indicating an effective recovery rate of 95.2%, which exceeds the required 271 responses for observation purposes.The sample size must be considered before sampling because it affects the accuracy of the estimation results. Assuming a tolerable error of 0.05, a level of significance of 10% , the required sample size is 271. Tenants, with the exception of student tenants, who were residing (at the time of study) in eight administrative districts in Kaohsiung City  were recruited The questionnaire survey results are shown in via the method recommended by We divided the 300 valid responses into two equal groups based on the code number. Each group was analyzed for non-response bias A reliability analysis, represented by the reliability of measurement variable, is an important indicator of a questionnaires’ stability and consistency. The value of the suitable reliability coefficient should range between 0 and 1 . ReliabiIn addition to its reliability, the validity of a questionnaire must also be considered. There are three types of validity commonly discussed in research. The first is content validity. The questionnaire in this study centered on the loyalty of tenants. We designed our questionnaire items by referring to previous tenancy-related questionnaires, discussed the contents with expert scholars, and subsequently revised the items and grammar. Therefore, the content validity of our questionnaire should be acceptable and reliable.Convergent validity is based on the factor loading of each item in each construct. According to Regarding discriminant validity, The empirical results of this study are presented in terms of the fit of the conceptual framework and the estimation results of the linear structural model.R2 of the three structural equations in this study were 0.590, 0.448, and 0.578. In short, the preliminary fit criteria of this study were within an acceptable range.The fit of a model’s internal structure mainly assesses the level of significance of the estimation parameters as well as the reliability of each indicator and latent variable. The overall fit of the model is mainly used to assess how fit the overall model is for the data. (1) Absolute fit measuresp = 0.001) and statistically significant. This means that the model easily rejects the null hypothesis and the conceptual model fits poorly with the sample data structure. In other words, the conceptual framework differs from the observed data structure. Because the chi-square statistic is easy affected by the sample size, whereby a large sample size will increase the chi-square statistic and therefore reject the null hypothesis , it is necessary to consider other fit indices for evaluating the fit of the overall model (2/df) was 4.817, the GFI was 0.801, the RMR was 0.197, and the RMSEA was 0.113, which were all close to an acceptable fit.As shown in ll model . Hair et(2) Incremental fit measuresIncremental fit measures assess the improvement in the fit by comparing a preset model and an independent model. As shown in (3) Parsimonious fit measuresParsimonious fit measures the fit that each parameter is able to obtain. As shown in As shown in The estimated coefficient of the influence of conation on attitude was 0.605 and attained a 1% level of significance. Therefore, conation has a positive and significant influence on attitude, and the higher the level of tenants’ conation, the better their attitude toward their tenancy. Hypothesis 3 is supported. The empirical results supported The estimated coefficient of the influence of attitude on tenant satisfaction was 0.648 and attained a 1% level of significance. Therefore, attitude has a positive and significant influence on tenant satisfaction, and the better the tenants’ attitude toward their rented house, the more satisfied they are with their tenancy. Hypothesis 4 is thus supported. This is consistent with The estimated coefficient of the influence of perceived behavioral control on tenant loyalty was 0.141 and attained a 5% level of significance. Therefore, perceived behavioral control has a positive and significant influence on tenant loyalty; that is, tenants’ needs, desires, and exchanged values have significant influences on their loyalty. According to 2 of 843.120 . The competing model is derived by adding the baseline model into a constraint, whereby the two groups with the situational influences-based moderator variable of the availability of friends and family living nearby have the same path coefficient. The competing model has a χ2of 855.853 . The difference in the chi-square statistic (Δχ2) between the original and competing models was 12.733 and was statistically significant. Because the difference between these two models is that the competing model includes a constraint, and the difference in the chi-square statistic is significant, the constraint is invalid, and the path estimates of the situational influences-based moderator variable in both groups are different in terms of attitude (0.447) and loyalty (0.741), as shown in This study focused on tenants who are currently renting a house, seeking to examine the influence of personal variables such as cognition, affection, conation, and attitude, as well as subjective norms, perceived behavioral control, and tenant satisfaction, on tenant loyalty, with situational influences as a moderating variable. SEM was used for analysis. GFI test results show that the conceptual model designed in this study had an acceptable fit, which indicates that the model can be supported. The cognition and affection has a significant effect on the attitude, the same is conation on attitude, attitude on tenant royalty, tenant satisfaction on tenant loyalty, perceived behavior control on tenant royalty, subjective norms on tenant loyalty.Tenants’ cognition and conation have a positive influence on their attitude toward their tenancy. Tenants’ personal cognition and conation toward the public facilities and security of their neighborhood, as well as the services provided by their landlord, enabled the tenants to perceive the benefits of their rented house, improve their self-value, and thereby increase their perception toward their own attitude as a tenant.As tenants improve their attitude toward their tenancy, they also enhance their self-value and the benefits incurred. Landlords can increase tenants’ satisfaction and loyalty by increasing the quality of their services and incorporating the principles of sustainability into these services. Tenants who are satisfied with their tenancy are more likely to renew their tenancy and recommend their landlord to other potential tenants.Perceived behavioral control has a positive influence on tenant loyalty. Tenants who are capable of renting a house as well as acquiring tenancy-related information increase their tenant loyalty. This is because they must first comprehend whether they have the need to rent a house; if they have and decide to do so, they are less likely to move away once they understand the information about their tenancy. Subjective norms have a positive influence on tenant loyalty. Subjective norms mostly include the opinions of others toward a rented house as well as whether tenants themselves perceive whether they have the need to buy a house during their lifetime. Society opinions toward a rented house will affect tenants’ loyalty. Regarding the degree of influence of perceived behavioral control and subjective norms on tenant loyalty, the results showed that the influence of subjective norms on tenant loyalty was higher than that of perceived behavioral control. Concerning the relationship between attitude on tenant loyalty, the availability of friends and family living nearby significantly diminishes the influence of attitude on tenant loyalty.In the housing rental market, there are two actors: the supplier and the demander. As the present study focused on the demander (tenant), future studies can focus on the supplier (landlord) to elucidate and broaden the depth of information regarding housing rentals. Given that this study did not consider the effects of government subsidies on tenant loyalty, future studies can examine this in more detail, in addition to examining whether policies such as rent rebates and subsidies affect tenant loyalty.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.CL: concept, method, and writing. WY: method and revised. HC and ZY: revised and response. ZT: data collection. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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As an NIA-funded mentorship program, MADURA addresses the lack of diversity among Aging and Alzheimer’s Disease & Related Dementia (ADRD) researchers and clinicians. Aims include improving retention and academic success of URM MSTEM undergraduates, and increasing rates of graduate/medical school applications and entry into Aging/ADRD clinical careers. MADURA offers paid research lab experience, weekly whole-cohort research skills training, guest seminars and presentations, and weekly faculty-facilitated small group supervision, advising and support. It served 23–29 undergraduates/quarter, in its initial five quarters. The Program accepts students at varying undergraduate educational levels, particularly because students from target populations often enter as Junior-level transfers from community colleges. Thus, although the Program just completed its second year, 17 MADURA trainees have already graduated. While ongoing data collection on Program, Mentor and Student Mentee performance is beneficial, outcomes data are of utmost importance to ensuring achievement of aims. This poster will present descriptive data on MADURA graduates’ immediate employment and educational activities. Notable findings include a significant proportion of trainees who take a gap year before applying to graduate or medical school , and others taking internships, post-baccalaureate training or research jobs, to strengthen future medical and graduate school applications. Understanding the multiple pathways of recent graduates will enable mentorship programs to help current trainees critique and optimize preparations for their selected educational and career trajectories. These findings also suggest additional mentorship program outcomes of interest (beyond a sole focus on graduate program acceptance), and the need for longer-term alumni follow-up.