Elder abuse is an important public health concern that requires urgent attention. One main barrier to active responses to elder abuse in clinical settings is a low level of relevant knowledge among nurses. This study aims to develop an educational program to promote an intent to report elder abuse among nursing students and assess its effectiveness, with a focus on the rights of older adults.A mixed method design was used with the Analyze, Design, Develop, Implement, and Evaluate model. Twenty-five nursing students from Chungbuk Province participated in the study. Attitude toward older adults and knowledge of, awareness of, attitude towards, and intent to report elder abuse were assessed quantitatively and analyzed using paired t-test. The feasibility of the program and feedback were collected qualitatively through group interviews and analyzed using content analysis.After the education program, attitude toward older adults (Cohen’s d = 1.08), knowledge of (Cohen’s d = 2.15), awareness of (Cohen’s d = 1.56), attitude towards (Cohen’s d = 1.85), and intent to report elder abuse (Cohen’s d = 2.78) increased, confirming the positive effects of this program. Overall, all participants were satisfied with the contents and method of the program.The method of program delivery should be improved and tailored strategies to boost program engagement among nursing students should be explored to implement and disseminate the program. Elder abuse is an important public health concern with serious social, economic, and health consequences . In KoreIn clinical practice, nurses are likely to witness or predict elder abuse as their work involves a careful observation of patients’ daily lives, which provides them with an opportunity to detect, treat, and prevent elder abuse . HoweverIn most autonomous districts in Korea, visiting nurses provide care to older adults belonging to vulnerable groups in the community . VisitinNurses’ understanding of elder abuse is an important factor for active responses to elder abuse in a clinical setting. However, nursing students in Korea display poor knowledge on elder abuse . A previData showing that professional knowledge about elder abuse is a potent antecedent to reporting elder abuse  highlighThis pilot study aims to develop an education program for promoting intent to report elder abuse incidents among nursing students and to examine the feasibility of the program nationwide. After developing the program, we used a mixed method design to collect baseline data to pivot the program for effective adoption in practice Fig. . We usedNursing students were set as the study population and the only eligibility criterion was the ability to participate in four sessions of education provided on an offline platform over two months. There were no other criteria, including age and gender. There are no established standards for sample determination for pilot studies. Thus, we determined our sample size with reference to the previous findings that suggested the optimal sample size to be 10–30 participants with the same characteristics as the targeted study population , 14. In Figure Next, we posted an advertisement on an online bulletin board for nursing students for four weeks from September 3, 2020, to October 3, 2020, and nine nursing students showed interest in participating in the study. Four students were additionally recruited through peer and self-referral. However, 2 of 28 nursing students who showed interest in the study withdrew their decision to participate in the study during the informed consent process either for personal reasons or due to COVID-19 restrictions.This study was approved by the Institutional Review Board at S University (IRB No S**-2020–08-011). The participants were informed about the purpose of the study, voluntary participation, freedom to withdraw from the study, guarantee of anonymity, and use of collected data for only research purposes, and written consent was obtained after confirming that the participants have accurately understood the purpose, procedure, and method of the study using the talk-back method.The education program used as the intervention in this study was developed based on the Analyze, Design, Develop, Implement, and Evaluate model, a widely used generic model for instructional design . This moA 240-min offline education program developed by the researchers for nursing students was provided over four Saturday sessions. The details of the program are shown in Table Before beginning offline education, we administered a survey to examine participants’ attitudes toward older adults, knowledge of, awareness of, attitude towards, and intent to report elder abuse. The same survey was administered immediately after the program was completed. Furthermore, group interviews were conducted using semi-structured questions after education to obtain feedback about the program and improve its feasibility.Attitude toward older adults was measured using the Semantic Differential Scaling developed by Sanders et al.  and adapKnowledge about elder abuse reporting was measured using a 12-item questionnaire. The first author developed this questionnaire based on previous studies and the Welfare of the Senior Citizens Act, which includes the regulations for punishment for elder abuse , duty and procedure of elder abuse reporting (Article 39–6), and older adult protective agencies (Article 39–5). The questionnaire comprised two items for definition (concept and type), five items for law (mandated reporter and organizations), and five items for system (reporting organization and process). Participants were asked to check “I don’t know” or “I am well aware of it,” which were scored as 0 and 1, respectively. The total possible score for knowledge about elder abuse reporting ranged from 0–12, and a higher score indicated a greater level of knowledge. The Cronbach’s α was 0.77 at the baseline and 0.82 at the post-test in this study.Awareness of elder abuse offences was measured using 12 scenarios developed by Moon and Williams  and tranAttitude toward elder abuse was measured using the tool developed for older adults by Cho . This 25Intent to report was assessed by having the participants answer yes (1) or no (0) to the question asking whether they will report each of the 12 hypothetical scenarios presented earlier. The total score was calculated by summing the score for 12 scenarios . CronbacAt the end of the program, a group interview was conducted using semi-structured questions to collect feedback on the 4-week program. The three semi-structured questions used were: “What motivated you to participate in the program?”; “What were some of the positive experiences and difficulties you faced while participating in the program?”; “What should the researchers consider when revising the education program for nursing students?”.The data were collected between September 3, 2020, and April 31, 2021. Of the 28 nursing students who showed interest to participate in the study, 26 were enrolled in the study, and 25 out of the 26 completed the program. Quantitative data collected from one student who withdrew in the middle of the program was excluded from the analysis, so data from 25 participants were included in the final quantitative analysis. Quantitative analysis was performed using SPSS 25.0 software, and the reliability of the instruments, frequency, and descriptive statistics were analyzed. The differences in the scores before and after education were compared using paired t-test. The effect size was calculated using Cohen’s d due to the small sample size. The normality of the data was tested using the Shapiro–Wilk test, and normal distributions of attitude toward older adults, knowledge of, awareness of, attitude towards, and intent to report elder abuse were checked.The interview was conducted by the first author, who had experience in qualitative research. The researcher used a list of semi-structured questions and audio-recorded the interviews. Further, an assistant researcher observed participants’ reactions and took field notes as necessary. The interviews were transcribed, and the first author and another author independently performed content analysis to extract themes by category, theme clusters, and categorization.Table After the program, nursing students’ attitude toward older adults (Cohen’s d = 1.08), knowledge (Cohen’s d = 2.15), awareness (Cohen’s d = 1.56), attitude (Cohen’s d = 1.85), and intent to report elder abuse (Cohen’s d = 2.78) increased, confirming the positive effects of the program.Table p < 0.001, Cohen’s d = 2.15). Awareness of elder abuse significantly increased from 45.16 ± 5.38 at the baseline to 52.32 ± 3.57 after education . By domain, the scores for physical abuse , emotional abuse , financial abuse , and neglect  statistically significantly increased.Attitude toward older adults significantly increased from 80.88 ± 11.39 at the baseline to 92.4 ± 9.84 after education . Knowledge about elder abuse significantly increased from 4.76 ± 1.79 at the baseline to 8.84 ± 1.99 after education . By domain, the scores for attitude , subjective norms , and perceived behavioral control  statistically significantly increased.Attitude toward elder abuse significantly increased from 56.16 ± 3.90 at the baseline to 63.12 ± 3.61 after education .Intent to report elder abuse significantly increased from 32.08 ± 1.73 at the baseline to 39.76 ± 3.50 after education , increased perceived need for education after the informed consent process (n = 1), exploring topics for course assignment (n = 1), perceived need for education during practicum (n = 5), perceived need for education while providing care for families of older adults (n = 1), and had an interest in the topic (n = 1). The participants were satisfied with the education program overall.The reasons for participating in the program included self-improvement .Most students stated that they liked the fact that the education program was free and that they participated to learn instead of just passing an exam. Unlike other education programs, they were allowed to relieve their skepticism about nursing by interacting with their fellow students proudly about nursing and engaging in introspection, based on which they were able to better recognize the value of nursing.Many nursing students who saw the advertisement poster misunderstood the program as a geriatric nursing program when they were recruited. Thus, the students advised that we emphasize the program as an educational program for nursing students whose prospective mandates reporting elder abuse.With in-person activities restricted during the COVID-19 pandemic, students suggested developing strategies that allow more nursing students to access the program. For example, they recommended converting the offline program to an e-learning program for promoting intent to report elder abuse.This pilot study aimed to develop an educational program to promote intent to report elder abuse among nursing students and assess its effectiveness. Additionally, we aimed to collect feedback from participants to improve the feasibility of the program. After administering the developed education program about elder abuse, students showed improved attitudes toward older adults, knowledge of, awareness of, attitude towards, and intent to report elder abuse, confirming the positive effects of the program.These results support the findings of a previous study that investigated awareness, subjective norms, perceived behavioral control, and attitude toward elder abuse among nursing students in Korea, where students who took a relevant course demonstrated a higher level of awareness, subjective norms, and perceived behavioral control . TherefoFirst, the title of the program should be chosen such that the contents of the program are clearly conveyed when advertising the program. The objective of the education program developed in this study was to educate nursing students about their duty to report elder abuse. However, some participants misunderstood the program as an educational program for geriatric nursing during the recruitment process. Further, none of the participants in the program demonstrated an interest in elder abuse reporting or an increased desire to improve their ability to report the same. Therefore, the title of the program should reflect nursing students’ opinions. Students’ opinions can be collected by asking them to choose from a list of a few titles. Further, considering that a contest enhances the credibility of a company and boosts individuals’ willingness to be involved in the said company , launchiSecond, the instructors need to use questions that trigger thinking to give students adequate opportunities to think about the topic (reporting elder abuse) on their own and discuss it among them. The students reported that they experienced a positive emotional process where they felt more value in nursing as they contemplated about a topic with fellow students and engaged in introspection and reflection. Nurses in geriatric hospitals in Korea experience ethical conflicts as “being distressed,” namely moral distress, which refers to being unable to do the right thing despite being aware of it . One maiTherefore, mandated reporters in Korea choose not to execute mandatory reporting because they feel that by modifying the conditions that cause abuse, family members can participate in providing care for older adults at home. They believe that providing care at home, improving the relationship between older adults and their families, and intermediation provides a better cultural option for older adults . AdditioThird, a non-face-to-face education program should be developed. We could not expect students’ active participation amid restrictions on in-person activities due to the COVID-19 pandemic. The students also suggested that a non-face-to-face education program should be developed. In a recent study, nurses and social workers who participated in virtual-reality-based elder abuse and neglect educational intervention acquired knowledge about identifying elder abuse and neglect and demonstrated 99% accuracy in their decisions for mandatory reporting. Further, the knowledge and skills they acquired in the intervention brought positive changes in their actual work performance . These rThis pilot study aims to develop an educational program to promote the intent to report elder abuse among nursing students and assess its effectiveness. Despite the strength—developing and examining the effectiveness of an education program about elder abuse reporting based on nursing students’ educational needs—this study has a few limitations. First, some participants misunderstood this program as an education program for geriatric nursing instead of elder abuse. This misunderstanding could have contributed to the lower scores found on the pre-test. Thus, the educational goal should be clarified and promoted in the process of participant recruitment to confirm this program’s effectiveness in the follow-up study. Second, all participants were students at a single school. Additionally, students volunteered to participate in this offline program while all other courses were administered online, which indicates that only students with high educational needs may have been recruited. Thus, our findings cannot be generalized. Studies including nursing students from various regions and diverse demographic backgrounds are needed. In summary, future research should focus on planning preventive measures for elder abuse, developing suitable training programs, and supporting the older adult population. The method of program delivery should be improved and tailored strategies to boost program engagement among nursing students should be explored to implement and disseminate the program.


It has been a quarter of a century since Charles' seminal paper on shared-decision making (SDM) in medicine . Based oStolz-Klingenberg et al.). S2C is a comprehensive program consisting of four intervention modules addressing healthcare professionals (physicians and nurses) and patients, and newly-developed digital evidence-based decision aids. The SDM level before and 6–18 months after S2C implementation within the Kiel Neuromedical Center was assessed in consecutively selected patients, who reported a significant increase in perceived involvement in decision-making. Five key indications were selected: first immunotherapy for multiple sclerosis (MS) vs. “watch and wait”; deep brain stimulation vs. L-Dopa pump for Parkinson's disease; ultrasound vs. deep brain stimulation for severe tremor; selection of antiepileptic treatment; and selection of treatment for neuropathic pain. Importantly, an additional health insurance-based reimbursement currently secures the S2C program maintenance.Within this Research Topic of Frontiers in Neurology on SDM, it is worth mentioning the Share to Care (S2C) program of the University Hospital Schleswig-Holstein  involving 17 clinics , as well as two pilot trials.MS is a paradigmatic neurological disease where SDM has been studied for now nearly 20 years. Most of the resulting publications are qualitative studies, surveys, and position papers, while very few assess the impact of evidence-based interventions. The current Research Topic reports on a narrative review of SDM in MS  education program for people with MS. The program was well received by people with MS, who showed higher MRI risk knowledge and perceived competence compared to non-contemporaneous controls. Finally, the paper by Wenzel et al. describes the development of “Abouts”, a web-based relapse management intervention based on a previous face-to-face program and investigated in the “Power@MS2” trial (Communication about imaging results is a largely neglected research field in medical education in general. 2” trial . Cortico2” trial . Intrave2” trial , 8. “AboBeing aware that complex evidence-based medical decisions need personalized approaches and sufficient time, nurse-delivered coaching programs for patients in preparation for a medical encounter represent a way to deal with the decreased availability of doctors and the increased patient load and treatment options . A pilotBesides MS, recently published SDM papers focus on stroke , early dTaken together, Neurology is a paradigmatic field for SDM. Results of disease overarching education on SDM as the S2C project is encouraging and the scientific landscape is open for young researchers to move the field forward. We are on the way.CH drafted the manuscript, which AS than substantially streamlined. All authors contributed to the article and approved the submitted version.


The COVID-19 pandemic highlighted health inequities for vulnerable populations and the need for more equitable care and access to vaccination. This article described the implementation of a COVID-19 vaccination program for undocumented migrants in a regional academic center of general medicine and public health (Unisanté). The vaccination program’s specific components included: triple coordination between the health authorities, the regional center and community partners, a walk-in and free service, no health insurance required, qualified nursing and administrative staff with previous experience with vulnerable populations, translated information materials and interpreters, a guarantee of confidentiality and a widespread communication campaign within the communities. In total, 2’351 undocumented migrants from 97 nationalities received at least one dose of mRNA COVID-19 vaccine (Spikevax) and 2242 were considered fully vaccinated. Although it was hard to assess its global effectiveness, the program vaccinated a significant number of undocumented adult migrants in the Canton of Vaud. The difficulties linked to the pandemic context, the heavy workload for healthcare staff and the limited resources were overcome by strong collaborations between the different actors involved throughout the program. Targeted public health policies, such as vaccination programs for undocumented migrants, are essential to guarantee equitable care, especially in pandemic times. In high-income countries, studies have consistently highlighted the highest burden of the pandemic on the most socio-economically deprived residents . In Octoulations . The repulations .Among them, undocumented migrants – people living in a country without legal documents and permitsAlthough complex, the challenge of ensuring equitable access to vaccination for undocumented migrants is achievable. Through this article, we aimed to describe a vaccination program for undocumented and uninsured migrants conducted at Unisanté, a regional center of general medicine and public health located in the Canton of Vaud, Switzerland’s third most populous canton with estimated 800’000 residents in 2021, or 10% of the total population of the country.The three main steps allowing the vaccination of undocumented migrants were: the communication campaign, the implementation of the vaccination program and the vaccination uptake.Communication about the vaccination program was essential due to the lack of access to public health information and the poorer health literacy of undocumented migrants. The communication campaign was explicitly conducted in communities and adapted to be readable, understandable, and generate action. Many documents have been translated due to the low French proficiency of a significant part of this population. Moreover, the communication campaign was explicitly delivered in the communities. We contacted at least 50 community partners . They were informed about the vaccination program and played a crucial role in promoting it.First, the community partners shared the communication campaign messages informing of the COVID-19 vaccination message through existing communities’’ online social network groups, such as WhatsApp or Telegram. For example, a physician formerly working at Unisanté and his wife, members of the Asian community in Switzerland, sent a message translated into both Cantonese and Mandarin to a community’s WeChat group with thousands of Asian members, including many undocumented migrants. Second, the communication campaign promoted the vaccination program through influencers such as community-associated media . Third, the communication campaign distributed documents inside the communities informing about the COVID-19 vaccination  and translated them into ten languages.Cantonal health authorities mandated Unisanté in May 2021 to initiate a vaccination program for uninsured undocumented migrants. At that time, COVID-19 vaccination was already available for the general population in vaccination centers, general practitioners’ offices and hospitals. However, the requirement to show a health insurance card made these places inaccessible for uninsured undocumented migrants.A multidisciplinary working group composed of administrative, medical, nursing and pharmacy managers, with expertise in vaccination and migrant population, was formed to implement the program. The system already in place - intended for the general population - was adapted to address the barriers to healthcare that undocumented migrants typically face. Emphasis was placed on reducing administrative barriers, ensuring confidentiality, and providing linguistically and culturally appropriate care. Specific actions taken to ensure the implementation of the program included:  no healtThe vaccination program began on 26 May 2021. Initially, vaccination service was provided everyday from Monday to Saturday. Three months later, vaccination was eventually suspended on Saturday owing to limited resources and low turn-out of patients.The vaccination uptake involves the following sequence:Arrival at the regional center and orientation by the administrative staff.Registration for vaccination by administrative staff.Waiting room before vaccination.Vaccination. Before vaccination, healthcare staff checked medical history to rule out any contraindications. If participants did not speak the same language as the healthcare staff, they received a written questionnaire translated into ten languages. In many cases, participants came spontaneously with an interpreter.Observation of participants. As specified by the national COVID-19 vaccination guidelines, the participants were monitored 15 min after the first vaccine dose and 5 min after the second dose to assess the occurrence of side effects.Appointment for the second dose and Covid-19 vaccination certificate. Administrative staff scheduled the appointment for a second dose if needed and delivered the vaccination certificate on the way out.The vaccination campaign strictly followed policies on vaccination in Switzerland. After clarification of responsibility, this project (Reg-2021-01493) was approved by the Ethical Commission of Canton of Vaud (CER-VD).We used administrative data of participants to monitor the COVID-19 vaccination program. Vaccination data on undocumented migrants were recorded throughout a five-month period ranging from late May through late October. The recorded data included the following variables: age (in year), nationality, health insurance status (yes or no) and appointment for the second dose (yes or no).During the 5-month vaccination program organized by Unisanté (from 26 May to 25 October 2021), 2351 undocumented migrants without health insurance received at least one dose of mRNA COVID-19 vaccine (Spikevax). Among them, 2164 (92%) received an appointment for a second dose, as some of the participants had a history of COVID-19 and were therefore considered fully vaccinated after one dose. About 95% came back to receive it. Thus, 2055 undocumented migrants received two doses during the program, and 2242 were considered fully vaccinated. The mean participants’ age was 38 years, and 48% were female. Migrants from 97 different nationalities took part in this vaccination campaign.More than 2,000 undocumented migrants without health insurance and originating from 97 different countries were fully vaccinated during the vaccination program. The main reasons for this success were the coordination between the health authorities, the regional medical center and the communities and the long-term upstream work to build and maintain trust with these populations. On one side, the top-down approach through the public health authority’s impulse gave resources to implement the vaccination program and coordinate the communication campaign. On the other side, the bottom-up approach through interventions by community partners enabled targeting those populations and maintaining trust. The example of the physician member of the Asian community in Switzerland highlighted the importance to use community social networks to promote the vaccination program. Since many members only use Asian social networks and search engines, public health messages on western social media would not reach them. Word-of-mouth within communities may also have played a role: some communities were overrepresented at times and then much less present. After being vaccinated, participants may have encouraged some of their acquaintances to come and get vaccinated. In addition, the reputation of Unisanté as social medicine center and its experience in care for vulnerable populations facilitated the implementation and maintained trust through the program. The vast majority of participants showed up for the second dose, and only a few wanted the anonymous vaccination, suggesting that an atmosphere of trust was made possible. The positive feedback of participants from countries where vaccine hesitancy is widespread also demonstrated the strength of this vaccination program. Thus, such a vaccination program is feasible and effective under the right conditions. It requires a limited increase in resources, mainly the reorganization of qualified administrative and nursing staff.However, it was difficult to establish the global effectiveness of the vaccination program due to the lack of data regarding undocumented migrants in the Canton of Vaud. The only available study estimated in 2015 that about 12,000 undocumented migrants lived in the Canton of Vaud [The vaccination program was mainly challenging due to logistical barriers, the short delay in achieving it and the heavy workload due to the COVID-19 crisis.Multidisciplinary collaboration with stakeholders from different institutions was challenging but necessary. It helped overcome barriers like the short deadline to implement the vaccination program and coordinate the communication campaign.An important issue was to provide quality care while being flexible about the number of people who can be vaccinated daily. Sometimes, the vaccination area was surprisingly overcrowded, as it was impossible to anticipate the number of patients a day. Especially at the beginning, there were so many people that the queue stretched out until the street and administrative staff was deployed outside to direct patients. Accordingly, administrative managers defined different scenarios and appropriate action plans. For instance, lack of space was a problem. The different rooms for the vaccination were too small during high attendance days. Therefore, some waiting rooms had to be improvised in less suitable places, and participants were invited to come back later.Lastly, the healthcare staff was already exhausted by the Covid-19 pandemic workload . ManagerImplementing specific COVID-19 vaccination programs targeting undocumented migrants is a practical health policy that improves equitable care and protects the entire population by reducing the risk of COVID-19 outbreaks. We hope this article will serve as evidence for supporting COVID-19 vaccination programs for undocumented migrants elsewhere.


Physical Literacy (PL) is a synthesis construct that ties together movement competencies with affective, motivational, and knowledge-based elements. It is considered foundational to the development of physical activity-related outcomes. Many diverse organizations and programs have embraced the concept and are implementing programs targeting each of those core elements. However, research has lagged behind its interest and adoption. Among the more prominent gaps is the design and evaluation of programs that aim to increase PL within special populations such as new immigrants or refugee youth.IPLAY) program is a co-developed evidence-informed 8-week PL program designed for new immigrant and refugee youths who have recently settled in Calgary, Alberta, Canada. This study aims to use a convergent parallel mixed-methods approach to collect, analyse, and interpret quantitative and qualitative data in the evaluation and iteration of the IPLAY program.The Immigrant-focused Physical Literacy for Youth (PL programs can be used as a tool to build confidence and physical competencies among newcomer youth. Furthermore, academic-community collaborations in the design and delivery of PL programs can help improve the access and interest for PL programs among newcomer youth. These partnerships are critical and timely considering the recent and upcoming waves of immigration to “arrival cities” across Canada. Physical inactivity is a major public health concern –4. RegulCanada has one of the highest rates of immigration and acceptance of refugees in the world , with thAddressing physical inactivity is a complex issue , and somDeveloping PL through a wide range of skills, activities, and environments may be particularly beneficial for recent newcomers to Canada . Coming Immigrant-focusedPhysicalLiteracy forYouth (IPLAY) program and evaluate its impact. Specifically, the research objective of this study will be to examine the feasibility, acceptability, and efficacy of the IPLAY program for newcomer youths. We hypothesize that the PL, PA, and overall mental health of newcomer youths will improve from baseline to post-intervention across each 8-week session.Overall, the purpose of the current study is to evaluate a newly developed PL-based program targeting new immigrant and refugee youth. In collaboration with a community organization, the current study will co-develop the IPLAY will be an 8-week program designed for newcomer youths. Inclusion criteria includes self-identification as a new immigrant and aged 12–16 years. This program will take place at the large community centre of WinSport, in Calgary, Alberta. Youth participants will attend a session once per week for 90 minutes, engaging in novel movement and sport activities aimed at challenging movements on land, air, and ice. This program includes unique games like Gagaball , Kin-ball , wheelchair basketball, and sledge hockey or ice luge in the arena. The basic idea is that newcomer youths will be able to experience a variety of different movement activities and games within a supportive group-based setting. Trained facilitators with a PL background will lead these sessions specifically targeting participants’ competence , confidence , motivation , and knowledge and understanding . The aim of this study is to co-develop a PL-based program tailored for newcomer youth, implement the program across two separate iterations, and evaluate both sessions using a mixed methods approach.IPLAY will take place in the Fall of 2022 for 8 weeks and then again in the Winter of 2023 for 8 weeks. Each session will include two groups engaging in the same program concurrently, accommodating up to 20 participants in each group. We will use a multipronged recruitment strategy that includes a partnership with local newcomer-focused service organizations to engage the community and enroll eligible participants into the study. First, we will work with these local organizations to plan appropriate strategies and develop promotional materials . Participation in the IPLAY program will come at no costs to the youth, and those agreeing to take part in the research component will be remunerated $25 in gift cards for each part of the study that they engage in .The initial implementation of The current study will use a mixed-methods approach, with three distinct phases of the evaluation. Firstly, using a pre-post test design, this study will conduct quantitative evaluations of all participants (up to 80 newcomer youths) to examine the impact of the IPLAY program on youth participants’ PL, PA, and its influence on participants’ overall mental health and wellbeing. Secondly, following each 8-week program, qualitative interviews will be conducted with approximately 10 participants in the Fall and Winter sessions, respectively. Together, using the triangulation of the quantitative and qualitative data in addition to process metrics such as program attendance and participation, will help to establish the feasibility, acceptability, and overall impact or efficacy of the program. Written consent from legal guardian and youth participants will be obtained, with all research protocols receiving institutional ethics approval from the Brock University Office of Research Ethics (Project ID # 21–295).All participants will be assessed quantitatively, pre and post program. Each PL domain will be assessed through a combination of direct observation and questionnaires. Specifically, movement competence will be assessed with the PLAYfun tool . The PLATo reflect Bowen et al (2009)’s 8-domain framework for assessing feasibility studies, we will also include the following domains and questions to the quantitative survey package: 1) Acceptability ; 2) Implementation ; and 3) Practicality (appropriate time commitment) .IPLAY program. According to information power theory, we expect this sample size to provide the context and data necessary to develop robust themes [IPLAY sessions, respectively, aim at eliciting self-assessment of how the program may or may not have impacted each domain of PL, how this program impacted their future plans for maintaining regular physical activities, and to also acquire constructive feedback regarding the program itself. The resultant interviews will be immediately transcribed and analyzed using initial coding, focused coding, axial coding, the comparative method, and memo-writing [To gain a much richer and contextually relevant caption of their experiences and potential impact on our outcomes, we will also be conducting a qualitative study of approximately 15–20 participants that enrolled in the t themes . Specifit themes , 60. Eac-writing . We willIPLAY program and the efficacy of the program as it relates to changes in PL, PA and/or mental health and wellbeing outcomes. Joint displays are visual displays that are used to explicitly integrate qualitative and quantitative data and for this study will be used at the point of data interpretation to report key points of data convergence and divergence [Following both independent quantitative and qualitative data collection and analyses , we will integrate findings using a joint display technique to determine youths’ acceptability of the vergence , 63. We Participant data will be anonymized for the data analyses. All reported study outcomes will be grouped and disseminated without any identifying information included. For instance, participants will be assigned a specific unique code  which will then be used in all data files, and not linked in any way to their personal information, except for in a master file which will be password-protected and stored securely . The master file with identifiers will be kept in a separate, private electronic folder with limited access to the principal investigator and designated research team members. This data will be kept for a period of 10 years.Participants’ safety will be prioritized throughout each IPLAY session throughout the 8 weeks of the program and during the physical pre- and post-assessments. The IPLAY instructors will be trained prior to the beginning of each 8 week session by WinSport staff. This will include familiarization with the facility, proper technique and use of the equipment that will be used during the program, and the safety procedures if an injury should happen which includes ensuring that one of the instructors/staff members remains with the participant while another immediate contacts the onsite WinSport safety patrol and first aid team. Trained research staff will administer the physical pre- and post-assessments. While the tasks included in the assessment are commonly performed by youth in physical education and/or other sport and recreation settings , some physical risks may be present. For instance, participants may become fatigued when performing the tasks and, as such, rests and water will be provided. Participants will also be reminded that they do not have to perform a task if they do not want to and a demonstration of the task will be performed by the researcher at the participants’ request. Similarly, if an injury should happen during these tasks, the researcher will ensure that one of the instructors or staff members remains with the participant while another immediately contacts the onsite WinSport safety patrol and first aid team. Instructors and research staff will also be certified in emergency first aid and CPR.IPLAY program can be an effective intervention program to reach the newcomer youth population and illicit positive changes in both PL and their overall mental health and wellbeing. The nexus of the quantitative and qualitative approaches proposed will be integrated to provide a rigorous and rich contextualized account of IPLAY, including opportunities for future iterations of such community-based programs. Following these mixed methods analyses, we will have key learnings that can be applied to implement evidence-informed programming targeting newcomer youths.Overall, the primary purpose of this feasibility study will be to evaluate a co-developed PL-based program targeting new immigrant and refugee youth. Using a multi-staged mixed-methods approach, we aim to assess whether the The proposed activities, including the development of a new academic-community partnership, represents a critical first step towards developing a PL-based intervention targeting newcomer youth to Canada. This group is at a greater risk of inactivity and disease burdens as their time in Canada increases , 29–31 a 29 Mar 2023Development and evaluation of the IPLAY program: A protocol for a mixed-methods feasibility study targeting newcomer youthPONE-D-23-06294Dear Dr. Kwan,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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For more information, please contact Kind regards,James MockridgeStaff EditorPLOS ONE 4 Apr 2023PONE-D-23-06294 IPLAY program: A protocol for a mixed-methods feasibility study targeting newcomer youth Development and evaluation of the Dear Dr. Kwan:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. 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Midcareer women physicians face numerous obstacles to career advancement and leadership roles resulting in their contributions and achievements becoming “invisible.” This paper addresses the paradox of increasing professional experience coupled with decreased visibility for women in medicine at this stage in their careers. To address this disparity, the Women in Medicine Leadership Accelerator has developed a leadership skill development program specifically tailored for midcareer women physicians. The program incorporates key principles derived from effective leadership training models and aims to combat systemic barriers while equipping women with the necessary tools to navigate and transform the medical leadership landscape. Midcareer women physicians often find themselves confronting an array of obstacles to career advancement. These obstacles, which fall on a spectrum including gender biases and inequities, financial implications associated with pregnancy and motherhood, and overt sexual harassment, collectively contribute to their contributions and achievements becoming “invisible.” This contradiction—the rise in professional stature coincident with a decrease in visibility—poses a significant paradox for women at this stage in their careers, a problem well articulated in leadership literature . Both imDrawing on the work of Carnes and Bigby , it is eWithin the Women in Medicine Leadership Accelerator, we have created a unique leadership skill development program designed explicitly for midcareer women physicians. This program is rooted in key principles derived from effective leadership training models, which aim to combat systemic barriers and equip women with the necessary tools to navigate and ultimately transform the medical leadership landscape. A recent meta-analysis identified four key elements that positively impacted results from training reactions to organizational outcomes . These wActive learning strategies: The most effective programs encouraged participants’ active involvement, providing them with opportunities to apply what they have learned in real or simulated situations.Feedback and coaching: Participants showed significant improvement when they received regular feedback on their progress and coaching to help them refine their leadership skills and behaviors.Program duration: Longer programs that provided opportunities for practice and reinforcement were more effective than shorter ones. This is reflected in our program’s design, which spans a considerable 6-month period, allowing participants to learn, practice, and reinforce their leadership skills.Consideration of participant characteristics: The effectiveness of leadership programs varied based on participant characteristics such as age and prior leadership experience. This underscores the importance of tailoring programs to meet the specific needs and context of the participants.Informed by these insights, our leadership accelerator program is designed to provide a robust and tailored learning experience. Participants are given opportunities to actively learn, practice leadership skills, and receive feedback within the group; they also benefit from personalized one-on-one coaching. Our program aims to amplify the visibility and leadership potential of midcareer women in medicine through this comprehensive approach.A critical tool that has not been widely implemented in midcareer development is 360° feedback. This assessment facilitates feedback collection from different perspectives about a leader’s effectiveness across specific competencies. This tool aims to promote program participants’ self-awareness and guide their understanding of key strengths and growth areas , and is There are major benefits to the use of 360° feedback. The synthesis of responses can guide targeted development activities, including training, coaching, and mentoring programs . One of With two cohorts having completed the leadership accelerator training, we are able to measure its effectiveness through participant satisfaction and self-report. Additionally, 360° pre- and postprogram surveys provide an effective measure of behavioral change, and we are also assessing early organizational impacts through objective evaluations of promotions, publications, grants received, and other productivity metrics where gender parity is crucial.Anecdotes from participants underline the potential of our initiative in bridging the leadership gap for midcareer women in medicine. Participants credit the program for significant professional accomplishments, including delivering keynote speeches at conferences, journal publications, securing grants, and earning promotions. Many of these accomplishments are highlighted below, in the participants’ own words.One participant remarked:After joining the program, I have gained the confidence to take on more responsibilities. I was invited to give a keynote speech at a prestigious conference, and recently, my article was published in a renowned journal.Another shared her experience, saying:The program has been transformational for me. I have been able to secure grants for my public policy work, earn a promotion, and even find the courage to take on roles that I would have hesitated to pursue earlier. I now feel more equipped to handle the challenges of my profession.Another cohort member stated:I feel more comfortable as an expert. I am giving three talks at national conferences and had a piece published about the work at my organization in a well-read publication. My boss is advocating for me to take on a larger role within my organization.Similarly, a participant who transitioned to a new role at a new institution submitted multiple awards and successfully relocated her family across the country credited the program for her success reports:I couldn't have navigated through all these changes smoothly without the skills and insights I gained from the program.Another woman, after completing our program, took up a directorship with a clearly defined mission and vision. She said:I felt prepared and ready for the challenges ahead. I also published multiple papers, including one focused on gender equity and leadership. I have set better boundaries at work and home and feel in control of my professional life.Initiatives such as our leadership accelerator program signify not only a beacon of hope but a model for success, offering vital support, feedback, camaraderie, and enhanced visibility to midcareer women physicians. Through this, we envisage enabling these accomplished professionals to not only persist on their chosen trajectories but also rise to leadership roles that they aspire toward and are more competently prepared for by equipping them with the support that is lacking at this stage in their careers. Such efforts could represent a transformative shift in medicine, ushering in a more inclusive and equitable landscape for all.


The emergence of implementation science has driven an increase in research examining the implementation of evidence-based programs and policies. However, there has been less attention through program sustainability. To achieve the full benefit of investment in program development and implementation, there must be an understanding of the factors that relate to sustainability; additionally, there is a need for a robust set of tools and trainings to support strategic long-term program sustainability. This paper presents results of our sustainability training intervention and a new conceptual model of sustainability. The proposed conceptual model builds upon the intervention design, further specifying the implementation strategy, strategy-mechanism linkages, and effect modifiers.This research is part of the larger randomized control trial evaluating the effectiveness of the Program Sustainability Action Planning Model and Training Curricula. Specifically, this multimethod study establishes a conceptual model for program sustainability and related capacity-building interventions. The training intervention was delivered through workshops and technical assistance to 11 state tobacco control programs, principally entailing the development and implementation of a sustainability action plan. We utilize descriptive statistics and participant perspectives to evaluate the training intervention and propose an empirically-grounded conceptual model for sustainability capacity-building interventions in public health settings.Participants found intervention components  to be effective. Overall, participants found the intervention improved their ability to develop sustainability action plans and assess their program and partners. Throughout the study, program managers emphasized the importance of the workshop in providing direction for their sustainability work and the value of robust, ongoing technical assistance. Program managers identified several factors that interfered with intervention reception including staff turnover, competing priorities, partnership challenges, and the COVID-19 pandemic.The present study documents the development and implementation of a novel Program Sustainability Action Planning Model and Training Curricula, one of the first interventions designed to improve program sustainability. In addition, we present an empirically-grounded conceptual model for program sustainability. Considering the paucity of research in this understudied and undefined topic area, this is an important contribution that can serve as a framework for similar intervention designs and implementation efforts.Clinical Trail Registration: ClinicalTrails.gov identification number is NCT03598114. The emergence of dissemination and implementation (D&I) science has driven an increase in theoretical and empirical understanding of evidence-based program and policy implementation. However, D&I science has paid less attention through the post-implementation period of sustainability. To achieve the full and continued benefits of significant investment in public health research and program development, there must be an understanding of the factors that relate to program sustainability in the post-implementation period; additionally, there is a need for a robust set of tools and trainings to support strategic long-term program sustainability .the maintenance of health benefits over time”  is maintained; the program and individual behavior change may evolve or adapt while continuing to produce benefits for individuals/systems”  that influence program sustainability . In addiProgram Sustainability Action Planning Model and Training Curricula, an intervention which aimed to build capacity for sustainability in state tobacco control programs (TCPs)   of this intervention. Using results from this study, including participant perspectives regarding the implementation strategy including intervention component utility and suitability as well as programmatic outcomes, we propose an empirically-grounded conceptual model for implementing sustainability capacity-building interventions in public health settings. The proposed model builds upon and refines the original intervention model used in the development of the intervention, further specifying the implementation strategy, strategy-mechanism linkages, and effect modifiers .This paper outlines the development and assessment of the s (TCPs) . Specifi theory)  that add theory)  proven tProgram Sustainability Action Planning Model and Training Curricula, to increase the capacity for sustainability among state level tobacco control programs. In the first phase of the PACT study, the intervention was developed through a rigorous multidisciplinary literature review process and a series of expert consultations. We used SCOPUS, ERIC (ProQuest), PubMed, Education Full Text, and PsychINF databases to conduct a formative literature review to inform the development and evaluation of the training intervention. Specifically, we performed formative literature reviews regarding experiential models of learning  and technical assistance (type and duration) to design the intervention. To design the evaluation of the intervention, we conducted formative review to assess previous metrics of experiential learning and technical assistance effectiveness. We also consulted with our PACT advisory team which was comprised of two academic experts in sustainability, two state tobacco control program directors, and three officials from the Centers for Disease Control and Prevention Office of Smoking or Health to determine the final Program Sustainability Action Planning Model and Training Curricula.The Plans, Actions, and Capacity to Sustain Tobacco Control (PACT) study utilized a multiphase approach to develop and assess the effectiveness of a novel intervention, the Program Sustainability Action Planning Model and Training Curricula was delivered to 11 TCPs through tailored workshops at baseline and ongoing, robust technical assistance through their participation in the multiyear randomized control trial (2018–2022). This paper presents only the results of the evaluation of the training and technical assistance delivered to the 11 intervention states as these data were used in defining the proposed conceptual model.In the second phase of this study, a multiyear randomized control trial was conducted to assess the effectiveness in improving the capacity for sustainability [as defined by organization outcomes and Program Sustainability Assessment Test (PSAT) scores] among 24 State Level Tobacco Control Programs (TCP). Ultimately, 11 intervention and 12 control TCPs participated. The The intervention consisted of a two- day workshop to design a program sustainability action plan, two years of tailored technical assistance for implementing the action plan and sustainability outcome assessment. Participants of the workshops actively engaged in developing state TCP-specific sustainability action plans. Each state action plan outlined one or two domain-focused objectives, matched with time-specific activities to be shared across stakeholders present. One person at each workshop claimed responsibility for overseeing the implementation process. Sustainability plans were designed to be implemented over the course of two years. All Program Sustainability Action Planning Training workshops followed the same structure, but were tailored to each state depending on the Program Sustainability Framework domain chosen for the action plan. The two-day workshop involved the TCP staff and as well as a number of stakeholders  actively participating to design a sustainability action plan and develop an implementation strategy. Inclusion of and participation by all stakeholders engaged was an important component of the sustainability action plan development process and ensuring all components of the state TCPs were considered. n = 106) completed a 29-item survey evaluating intervention components for their utility and suitability. Survey items assessing the workshop, workbook, and the instructors utilized a Likert-type scale with anchors “strongly disagree” (1) and “strongly agree” (5). Survey items were grouped by component, forming evaluation areas: Workshop Evaluation, Workbook and Workshop Usefulness, Workbook Satisfaction, and Instructor Evaluation. Survey items were based on the theory of change that allows for study on how a change (intervention) has influenced the design, implementation, and institutionalization of a program and were designed specifically to assess outcomes related to Kolb experiential learning components  What suggestions do you have for improving this workshop? A total of 220 answers were recorded in response to most important things learned at the training. Responses such as, None, and Not applicable, were excluded from analysis (n = 13). The remaining 207 responses were reviewed and grouped into themes. A total of 100 answers were recorded in response to suggestions for improvement. Responses such as, None, and Not applicable, were excluded from analysis (n = 37). The remaining 63 responses were reviewed and grouped into themes.Included in the evaluation survey of the intervention were two open-ended questions, (1) n = 46). These calls lasted about 30–45 min and were audio recorded.From December 2018 to January 2022, staff from the 11 intervention TCPs participated in TA calls to assess their progress on implementing their sustainability plans and to determine challenges and resource needs. Each state received an average of 2 calls/year during their two years of study participation . Transcripts were reviewed for accuracy and uploaded to NVivo 20 (released in March 2020) for coding. We used an inductive approach for thematic analysis. We developed a codebook based on the items addressed in the TA calls. The codes and sub-codes of the initial codebook were revised throughout the coding of transcripts. The final codebook consisted of four codes and sixteen sub-codes.For the coding process, three research team members coded transcripts until they reached substantial inter-rater reliability (kappa = .72) . DiffereQuantitative and qualitative intervention component data were fit to the original intervention model through an Agile Science-informed causal pathway diagram modeling process to propose a generalizable, empirically-grounded conceptual model for implementing sustainability capacity-building interventions in public health settings. An Agile Science informed process was utilized due to the focus on intervention modularity and condition specification. As outlined by Lewis et al. , in implM = 4.24, SD = 0.81). At the item level, participants indicated that the workshop augmented their understanding of the action planning process and their capacity to move these plans forward , and was overall beneficial for their program . Participants indicated that they planned to translate workshop learning objectives into their tobacco control work . See The workshop evaluation area comprised nine survey items assessing logistics, utility, suitability, and outcomes. At the component level, the workshop was favorably assessed by intervention participants , Understanding Sustainability , Reflecting on Results , Building an Action Plan , Continuing Progress , and Appendix Resources . At the component level, participant responses indicate that the workbook and workshop were useful  (see .72) see .The workbook satisfaction area comprised 4 survey items assessing design , content organization , ease of use , and instructional clarity . At the component level, participants were highly satisfied with the workbook  (see .63) see .M = 4.68, SD = 0.56), used effective teaching and facilitating techniques , and discussed how workshop learning objectives could be applied to their tobacco control work . At the component level, instructors were favorably assessed   see .Overall, participants found that the sustainability training intervention provided them with a better understanding of program sustainability and improved their ability to develop sustainability action plans. Participants noted it was useful to have a common language around sustainability and a shared action plan to be completed collaboratively by the TCP and its partners.It was very important and helpful to have common language and definitions for the domains –State Health Department staffParticipants also shared that the workshop enhanced their ability to assess the strengths and weaknesses of their program. The workshop also helped participants gain a better understanding of their partners, noting how valuable it was to have dedicated time with their partners and include them in their sustainability action plan.…just working through the actual action plan because we're all so busy and so being able to do that and get that started in that meeting. I don't how long it would have taken us to get that done otherwise. –State Health Department, DirectorProgram managers emphasized the importance of the workshop in providing direction for their sustainability work throughout the study.The TCP managers often commented on the importance of robust, ongoing technical assistance to continue implementing their sustainability plan. Ongoing access to program sustainability resources and intervention-facilitated peer learning were frequently requested during TA calls to further implementation of their action plans.I think it's always been nice to have timely reminders to focus on the strategic planning process and make sure that we're continually looking at how we're tracking against those milestones, the way outlined in the sustainability plan. That's been really useful for me … –State Health Department, Program ManagerManagers also felt that the alignment of their action plan with other grant requirements facilitated implementation. Strong partner engagement was also identified by program managers as a factor which augmented sustainability training and technical assistance effectiveness.I appreciate the technical assistance and all of the tools that you put together for us to use. It was really, really helpful and it helped catalyze some really robust conversations at some of the stakeholder meetings we've had …  –State Health Department, Program ManagerProgram managers identified several factors that interfered with their progress in implementing their plans throughout the study. Most notable were high levels of staff turnover, competing priorities, partnership challenges, and the COVID-19 pandemic. In discussing staff turnover, program managers shared they were responsible for covering the duties of the vacant positions in their TCP making it difficult to prioritize their action plan. They also noted the vacancies they experienced in their program were at times the individuals directly responsible for aspects of the action plan, which slowed down and at times halted their progress.While that position is vacant, I'm kind of doing double duty, which just makes it hard to be focused on longterm just because of dealing with the day to day. We still try to do that as much as we possibly can, but I'm definitely looking forward to getting that position filled so we can share that workload a little bit. –State Health Department, Policy Section ManagerRegarding competing priorities, managers discussed the prioritization of funding and contractual agreements, as well as emergency bans on tobacco products which required immediate attention.Plus we had that emergency ban on vapor products, flavored vapor products that kind of inundated our time. So, we had to push a lot of our dates back, and so that's what we did. So, we spent a lot of time revising the action plan in terms of dates and really moving towards completing some of the activities that we had said that we would do by January. –State Health Department, Unit ManagerSome program managers noted they struggled to maintain engagement with their partners throughout their participation in the study, leading to slower responses to communication and lack of follow through on action plan responsibilities.Trying to make sure that partners were continually engaged and that when they left the meeting, that they felt empowered enough to actually follow through on activities that have been discussed. Because sometimes we would have meetings and everybody would leave with what they were supposed to do but when we met again there hadn't been any movement on anything. –State Health Department, Program DirectorFinally, the COVID-19 pandemic impacted the overall capacity of TCPs, as public health staff were reassigned to work on pandemic response activities.And we also were impacted with COVID and capacity, so we definitely had a plan and we had a product to share with legislators, but one of our staff has been and remains full-time on COVID … –State Health Department, Program Manager…I'm sure you've heard this from other people, but partners are dealing with COVID too… they don't have the time or ability to sit in on some of the meetings that they normally would with us. So that's been somewhat of an issue as well. –State Health Department, Program DirectorWhen asked about recommendations for sustainability training and technical assistance intervention improvement, participants wanted it to be more adaptable to the changing needs and priorities of their TCP. They also requested additional opportunities to interact with other states enrolled in the study to further peer learning.I think, as we go through the strategic planning process, if you have seen strategic plans from other States that you think look amazing, feel free to send them… if you've been working with other States and you're really impressed with the caliber of work that they're doing, they have innovative ideas, I definitely think it's a good idea to learn from the best so that we might be able to emulate. –State Health Department, Program ManagerProgram Sustainability Action Planning Model and Training Curricula. The mechanism through which the Program Sustainability Action Planning Model and Training Curricula intervention was implemented was through action oriented, participatory training, as defined by Kolb's experiential learning theory .The present study makes several important contributions to implementation science. Notably, the present study documents the development and implementation of the novel Program Sustainability Action Planning Model and Training Curricula was an effective capacity building intervention in developing and implementing a sustainability action plan. Those in receipt of the Program Sustainability Action Planning Model and Training Curricula assess it favorably in regards to its utility and suitability, across all evaluation areas. Thematic analysis further qualified quantitative results: participants indicated that the Program Sustainability Action Planning Model and Training Curricula enhanced their understanding of program sustainability and related program-specific characteristics as well as the role of TCP partners. In addition, throughout the study, program managers emphasized the importance of the workshop in providing direction for their sustainability work and the value of robust, ongoing technical assistance. Ongoing access to program sustainability resources and intervention-facilitated peer learning and partner engagement were also noted as factors augmenting Program Sustainability Action Planning Model and Training Curricula intervention component effectiveness.Our results indicate that We used both qualitative and quantitative results in refining a conceptual model for implementing sustainability capacity-building interventions in public health settings. Other studies focused on understanding sustainability have recognized similar components (mediators and moderators) identified in our proposed model but none have considered the complete process including the implementation strategy and mechanism for which to plan for and improve program sustainability. For instance, when utilizing the Normalization Process Theory in evaluating the implementation of an evidence-based violence screening model, Hooker et al., found several organizational components that mediated program “normalization” or programmatic sustainability including lack of staff capacity . SimilarThere are several limitations to this study. First, although evidence-informed and developed through a systematic process, the proposed model has not been empirically tested. The present study also utilized programmatic data and the perspectives of individuals at 11 state TCPs. Although this is of sufficient size to statistically evaluate the intervention for its effectiveness, findings may not be completely generalizable across all state TCPs. Further work is therefore needed to establish generalizability. Finally, our data were generated throughout the COVID-19 pandemic, and therefore are not unaffected by the unprecedented conditions the event produced. Throughout this time state TCPs operated in nonroutine ways, and the extent to which emergent phenomena in our study were products of this is unknown. While we feel that any public health event might disrupt the state health department system, one may not have the same magnitude effect.By establishing a method for action planning and technical assistance for program sustainability, the present study supports public health programs broadly in their understanding of and achievement in sustainability, an outcome that has become increasingly critical given the environmental complexity. In addition, this work advances the field of study regarding action planning and technical assistance, which contributes to implementation science beyond the topic area of sustainability. Finally, the present study advances implementation science by establishing an empirically-grounded conceptual model for program sustainability and related capacity-building interventions. Considering the paucity of research in this understudied and undefined topic area, this is a significant contribution that can serve as a framework for similar intervention designs and implementation efforts. Future research in the application of this framework will be beneficial in defining its utility and refining its components.


Orthopedic Relief Services International (ORSI), in partnership with the Foundation for Orthopedic Trauma and the department of Orthopedic Surgery of La Paix University Hospital in Haiti, has developed a year-round Orthopedic Grand Round series. This series is moderated by Haitian faculty, features presentations by American orthopedic surgeons, and is broadcast to major state hospitals in Haiti for residents and attendings.To introduce clinical concepts and increase knowledge in an area that is medically underserved, especially in the field of orthopedics, through lectures that tailor to the educational needs of Haiti.Topics for lecture series are requested by Haitian attending orthopedic surgeons and residents in collaboration with American orthopedic surgeons to meet the educational needs of the residents in Haiti. These lectures reflect the case mix typically seen at state hospitals in Haiti and consider the infrastructural capacity of participating centers. Grand rounds are held an average of twice per month for an hour each, encompassing an educational lesson followed by an open forum for questions and case discussion. Feedback is taken from Haitian residents to ensure the sessions are beneficial to their learning.To date 95 sessions hosted by 32 lecturers have been completed over Zoom between the US and Haiti. The fourth year of the lecture series is currently ongoing with an expansion of topics. In an underserved medical area such as Haiti, programs that educate local surgeons are crucial to continuing the growth and development of the medical community. Programs like this have the potential to contribute to the educational infrastructure of countries in need, regardless of the specialty. The model of this program can be used to produce similar curricula in various specialties and areas around the world. For many years Haiti has struggled with some of the worst healthcare conditions in the Western hemisphere 23. When 2116Immediately following the earthquake, hundreds of organizations responded to aid Haiti with orthopedic, trauma, and humanitarian support 9. Althou1011In 2010, Orthopedic Relief Services International (ORSI), a 501(c)(3) not-for-profit, was founded to address these challenges, in the form of infrastructural, clinical, and educational aid to the State Hospital System in Haiti. To address gaps in education specifically, an Orthopedic Grand Rounds series has been developed that is broadcast from the US to the major state hospitals in Haiti. The lecture series, initiated in 2020, features prominent US orthopedists who are experts in their fields. These lectures cover various orthopedic topics, ranging from specific needs of Haitians to new advancements in the field of orthopedics.The planning process for grand rounds lectures each year begins with Haitian orthopedic surgeons recommending topics of interest to attending orthopedic surgeons at ORSI. With these ideas in mind, US surgeons are recruited to prepare presentations on specific topics. A schedule is prepared by ORSI with speaker names and presentation titles before being finalized in accordance with Haitian program coordinators. This schedule is then distributed by email to all participating Haitian hospitals and orthopedic residency programs.Grand round sessions are held an average of twice per month and are moderated through the educational program director at La Paix Hospital. Lectures are given in English and are all translated into French in real time. Each session is one hour, consisting of a 45-minute lecture presentation followed by a 15-minute open discussion where residents are encouraged to ask questions . Often, Each lecture, including the question and case discussion session, is recorded on the Zoom platform, and uploaded onto the Vimeo online database. The website links are readily available to all Haitian residents, allowing them to access the archived videos at any time.Feedback is requested on a quarterly basis in the form of an email survey that is distributed to Haitian residents and attendings. Using the results of this survey, the team at ORSI meets with Haitian orthopedic surgeons and program coordinators to discuss feedback and recommend topics for the following year. Tentative lecture topics are drafted for the upcoming year and the process is started again.Since the initiation of the program in 2020, 95 lectures have been virtually broadcast to Haitian State Hospital residency programs. These topics have ranged from basic orthopedic principles to metabolic and congenital diseases, with each lecture being taught by orthopedic experts from across the US. The cohort of lecturers consists mainly of orthopedists who lecture at least one to two times per year to create a consistent curriculum and is further supplemented with guest lecturers to address newly requested topics. These lectures are continually followed by both ORSI and Haitian program coordinators to ensure consistent quality regardless of who is lecturing. To date, 32 orthopedic experts in their respective fields have prepared and given lectures within this series. Many of these speakers have been a part of the series for years, giving at least one lecture per year. The current fourth year of the series consists of 20 unique grand round lectures, hosted by 10 returning orthopedic experts as well as 10 new guest preceptors .Feedback, including questions regarding usefulness and practical applications of topics taught, is vetted and has successfully been used to optimize lecture topics for upcoming sessions; presentations have been adapted over time to address the Haitian clinical needs and capabilities more appropriately. While the case mix is skewed towards trauma, coordinators have been careful to include other relevant topics to represent typical orthopedic maladies in Haiti per the request of multiple Haitian residents and attendings. For example, with recent spikes in food insecurity due to civil unrest, starvation and malnutrition have become more prevalent and therefore lectures on metabolic bone disease, seen in malnutrition states, such as rickets, osteomalacia, and scurvy have become more relevant.Survey results show that the majority of residents find these lectures to be valuable to their education and provide them with a solid foundation in orthopedics. They report that these formal didactic sessions give them access to lectures they wouldn’t see otherwise. Residents find the question segment of each lecture to be especially beneficial, as it allows them to gain further information from subject matter experts on specific cases from their own practice. Attendings and residents find the recorded archives helpful as well and report that they refer to it often for review.The main goal of these grand rounds is to provide educational training opportunities for Haitian orthopedic surgeons to further help their career development. In conjunction with the leadership at major state hospitals in Haiti, ORSI has organized a comprehensive year-round orthopedic surgical lecture series that addresses this goal to provide Haitian residents with a strong foundation in the basics of orthopedics. It has been possible to address a broad range of topics that are pertinent to orthopedics in Haiti, including trauma, pediatrics, orthopedic oncology, and even metabolic bone disease. By training these surgeons further, the series is generating knowledgeable teachers, thus contributing to the education of further generations.It has been important to follow feedback regarding the content of each presentation. Initially, lectures focused on complex technology and techniques from the US, but Haitian residents reported that these presentations weren’t pertinent to their practice. By following feedback, the program has evolved over the years to successfully address the case mix and infrastructural capacity more appropriately.While giving a lecture solely on modern orthopedic technologies that are not available in Haiti is inappropriate, dedicating a small part of the lecture series to such topics is still valuable in demonstrating to the orthopedic community what is possible with proper infrastructural support. Resource limited settings should aspire, with proper support, to evolve their technologies to meet standards for modern medicine. Within this lecture series, the future goal is that the orthopedic surgeon who lectures on a particular topic and technology can ultimately serve as a champion and philanthropist to bring this technology to Haiti.To date, no formal data has been collected to assess the impact of these lectures on the clinical skills of Haitian residents, however feedback gathered after lecture sessions and on a quarterly basis through survey feedback has been overwhelmingly positive from both residents and attendings. Residents report that the lectures provide a good foundation for their daily practice. The question and discussion section at the end of each session has continuously received praise from residents. They look forward to these sessions to ask about current cases and look to their US preceptors for advice. In the future, competency measures will be added to determine the efficacy of the lectures being presented, in addition to measuring resident and attending satisfaction with the program.A secondary goal of this program is to build relationships between Haitian and American orthopedic surgeons. By building relationships, a further understanding of the needs of Haitians can be learned so that the program can grow and continue to provide more help to colleagues there. In the past, many of the American orthopedic residents that have visited Haiti to work along their Haitian counterparts have been inspired through those experiences to continue to volunteer services in resource limited settings. Programs such as these not only provide for medical knowledge, but also offer the distinct advantage of bidirectional learning and added cultural competency . FurtherThese educational programs carry even more significance currently, as didactic teams have been unable to travel to Haiti due to political insecurity and instability. Barriers like this exist around the world as well. Expanding this program to other clinical teaching programs can allow for expanded educational services to orthopedists beyond Haiti; residents from Honduras, Benin, Burkina Faso, and Ethiopia have recently joined conferences as well as the program continues to grow. In the field of orthopedics, case mixes tend to be similar in nature in resource-limited settings, therefore this lecture series has great application globally in such locations.Furthermore, similar challenges in travel and access to education exist throughout the world in many areas of medicine. While this program has focused on orthopedic surgery, many specialties could create similar programs to benefit countries in need. As noted previously, orthopedic clinical needs and capabilities are similar in resource-limited settings, however this applies to most areas of medicine as well. Programs like this can be designed and widely broadcast to resource impoverished areas of the world.“If you give a man a fish, you feed him for a day. If you teach a man to fish, you feed him for a lifetime.” Providing quality orthopedic educational resources to Haitian residents and attendings is an essential supplemental tool that strengthens their training pipeline and is an investment in their ability to be self-sustainable 16. By utFurther measurable outcomes-based data may be required to demonstrate the benefit of educational grand rounds series. However, based on feedback obtained thus far it is clear that this model can be used as a guide to develop similar educational programs in other medically underserved populations to improve access to education throughout the world.