Promotoras de salud (promotoras) have been a valuable part of community research for Latino families, such as in the recruitment or delivery of health promotion programs. However, there has been limited discussion of how to integrate a promotora model into a father-focused program to support nutrition and physical activity within Latino families. This manuscript’s purpose is to describe how to engage and collaborate with promotoras in a father-focused, family-centered program for Latino families living in colonias near the U.S.–Mexico border. As part of a longstanding community–academic partnership, the authors outline approaches and lessons learned from collaboration with promotoras during the design (including formative work and training), implementation, and evaluation of a behavioral program—¡Haz Espacio para Papi! . Promotoras’ contributions supported the entire program, from design through evaluation. The team of all-female promotoras created a balance between the needs and preferences of the community and the goals and requirements of the research. While there is considerable time and human capital required for collaboration, the mutual benefits can make this work meaningful to all involved. In the Lower Rio Grande Valley of Texas, colonias are clusters of neighborhoods located on land previously used for agriculture along the U.S.–Mexico border; they are inhabited mostly by Latino/a individuals and families. Colonias are functionally rural communities in mostly unincorporated areas , with limited access to affordable and nutritious foods ,2. HistoAs defined by previous research articles, promotoras are female community health workers (CHWs) who work in Latino and Hispanic communities ,17. TheyIn the state of Texas, the Department of State Health Services (DSHS) provides training and certification for promotoras via a promotor(a) or community health worker training and certification program , which eGiven the opportunities and potential benefits of promotora engagement, promotora models have been incorporated into health promotion research on border communities ,20. WhilThis section describes an integrated approach to collaboration with the promotoras and the lessons learned during program design, implementation, and evaluation.A separate article in this Special Issue describes the rationale and design of the ¡Haz Espacio para Papi!  program . The HEPImportantly, the HEPP program is part of a longstanding and existing collaboration. Since 2006, academic-based researchers have engaged and collaborated with several community advisory boards (CABs), leaders of community organizations, a team of promotoras, and families living in colonias near the Texas–Mexico border, specifically in Hidalgo County, Texas . AdditioA team of academic and community researchers collaborated to design, implement, and evaluate the HEPP program for Mexican-heritage families in south Texas. The group of promotoras consisted of female community health workers who lived in the study area and self-identified as Latina or Hispanic. At the start of the SPUSF grant, there were three core (full-time) promotoras who had worked with the research team for several years. Their educational and occupational training and experiences varied but included teaching and health education experience, public health experience, and social work. The women ranged in age, from mid 20s through upper-40s. All three core promotoras were born in Mexico and were native Spanish speakers. Out of the three, one was fully bilingual (English and Spanish), another had professional working proficiency in English, and the third one had limited proficiency in English. Two of the three core promotoras were certified community health workers (CHWs). This team of three promotoras co-led the formative work. Two core promotoras co-led program training, implementation, and evaluation. These two promotoras were both bilingual.Two core promotoras co-led the program activities related to design, implementation, and evaluation. These two promotoras were both bilingual. To increase staffing to meet the future demands of program implementation and evaluation, during the latter part of the design phase and throughout the implementation and evaluation phases, new team members who were either CHWs or had served as a CHW in the program joined the team by referral (word of mouth) or by applying to the program’s job postings. In total, this accounted for eight part-time team members.The potential promotora candidates participated in interviews, where the program coordinator and current promotoras could assess their experience and skills, especially their interpersonal skills. The selection process consisted of an interview (to understand their lived and work experiences) and an evaluation  and lasted about 2.5 h. The interview focused on understanding their current and past experiences working with the community and with peers or colleagues. The evaluation focused on using objective methods to assess language skills , communication , and problem-solving skills.Academic-based team members utilized published research findings, previous experience working with Latino families, formative work, and promotoras’ insights to create the HEPP program. The program was developed simultaneously in English and Spanish, with the support of a dedicated linguistics team for translation and transcription. At the beginning of the program design, the team followed an iterative process of development, review, and revision, where the promotoras and academic researchers worked together to create the program. They provided feedback on the program structure and curricula for nutrition and physical activity, including program activities and materials. As the program structure and curricula emerged, a cyclical process of review, training, and revision was used to modify the program components before pre-testing with a group of volunteer families. Formative activities that informed the HEPP program included activities with community advisory boards (CABs), community assessment, pláticas, household elicitation surveys, and dyadic interviews. The next section describes the approach and lessons learned from the formative work.Formative work to inform program design focused on understanding the priorities related to nutrition and physical activity (including needs and assets) of different family members  and identifying valuable strategies for recruitment. Formative work began four years before program implementation in July of 2019 and included community engagement with three different community advisory boards . Figure At the same time, the team initiated a comprehensive community assessment between 2015 and 2016, which included extensive ground-truthed mapping of the community food environment and physical activity environment in study areas. Ground-truthing included area institutions, community food programs, community resources, programs, schools, street segments, and transportation. The promotoras led the formative work. They collected quantitative and qualitative data with Mexican-heritage fathers, mothers, and children living in the study area using the following data collection techniques: pláticas (defined as group discussions), household elicitation surveys (interviewer-administered surveys), and dyadic interviews (interviews between two participants). The initial formative work started in September of 2015 with children’s pláticas, and the final formative work activity finished in October 2017. The team of promotoras conducted all formative work activities in person and in Spanish and English between 2015 and 2017, and a linguistics team applied a two-stage process for transcription and translation.Children’s Pláticas. As part of the formative work, the promotoras completed children’s pláticas, a panel series of three sequential group discussions with children who were 8 to 11 years old. The purpose of children’s pláticas was to understand the children’s perspectives related to preferences and family support for nutrition and physical activity. The same group of children completed all three discussions. Each discussion was organized around a different topic and incorporated visual activities. Session 1 focused on food-related activities and included “draw, write and tell” and “circles of closeness” activities. Session 2 covered physical activity, active play, and screen time with “map and tell” and “circles of closeness” activities. Session 3 included participant-driven photo elicitation (PDPE) [n (PDPE) , which iMothers’ Pláticas. The formative work included a similar panel series with mothers to understand their perspectives on nutrition and physical activities within their families Promotoras led mothers’ pláticas that met three times over four weeks and included the same three-session foci described in the children’s pláticas above. In total, there were 51 sessions , with 91 mothers completing all three sessions of the panel series. Forty-eight sessions were conducted in Spanish and three in English. Approximately 89 h of audio recordings were transcribed verbatim and translated using the same process.Household Elicitation Surveys with Mothers. Promotoras conducted household surveys with mothers living in the study area. Another article reports on the interviewer-administered surveys with mothers [ mothers . Promoto mothers . Data weFathers’ Dyadic Interviews. The promotoras recruited fathers using multiple methods. Most, if not all, of the fathers were the partners or spouses of the mothers who participated in the mothers’ pláticas or mothers’ household elicitation surveys or were fathers to some of the children who participated in the children’s pláticas. Additional recruitment approaches included door-to-door canvassing  or re-connecting with households that had previously participated in a research study and consented to be re-contacted for a future study. The fathers did not know each other prior to the interview.The purpose of the dyadic interviews was to create a comfortable opportunity for fathers to discuss their perspectives, challenges, and desires related to food, activity, and health in their families with other fathers. Promotoras helped facilitate conversations between two fathers, which offered opportunities for the in-depth discussion of nutrition, physical activity, and family topics.In total, 31 fathers completed 15 dyadic interviews, and 1 father completed a one-on-one interview. The dyadic interviews lasted from 1.25–3 h each; the length was determined by the participating fathers. Interviews were held in spaces considered to be neutral or comfortable to fathers, such as local community centers and churches. Interviews were held near their homes to address transportation needs and accommodate work commitments. All interviewers were in Spanish. The interviews were audio-recorded. Transcripts were created using the same transcription and translation process. A separate manuscript has reported initial findings from the fathers’ dyadic interviews [Household Elicitation Surveys with Fathers. Importantly, insights from the fathers’ dyadic interviews motivated additional data collection—the household elicitation surveys of fathers. Before that point, formative work only included the perspectives of children and mothers. However, promotoras realized that they had learned a great deal from the fathers’ dyadic interviews and wanted to better understand fathers’ perspectives. Promotoras completed interviewer-administered face-to-face surveys with 300 fathers who were recruited from the study area [udy area . They coudy area . All datThere were three lessons learned from the formative work. First, the promotoras leveraged their knowledge and skills to develop customized recruitment strategies to center family values and prioritize relationships with children. Second, they identified ways to connect with mothers and fathers in different ways during recruitment. Third, the promotoras created additional opportunities to give back to the community by forming and sustaining new community advisory boards (CABs), which promoted trust and facilitated the academic–community collaboration. Promotoras identified potential barriers to connecting with community members or completing data collection activities and generated creative solutions. For example, during the formative data collection, the promotoras incorporated a “playroom in a bag” into the formative activities to make settings and activities more child-friendly. The promotoras also developed a “playroom in a bag” to re-create a welcoming environment in different settings. Components included lounge pillows, an interlocking foam puzzle floor mat, and pre-session games. Overall, the formative data collection activities allowed the promotoras to collect data, review materials, iteratively provide feedback to the research team, and then develop a customized recruitment strategy for connecting with individual families and specific family members . Collaboration with promotoras during formative work helped ensure that the formative work activities would be well received by the community; this benefited both the research project  and the community.Lesson #1: Customized recruitment approach to fathers to center family values and prioritize relationships with children. During recruitment for the formative activities, the promotoras intuitively built support for the program by working with fathers, their children, and their partners or spouses. They knew that fathers would be interested in the program if their children wanted them (the fathers) to participate. In early conversations with children, promotoras focused on chances to have fun and spend time with their fathers. One promotora said: “In Latino families, especially with fathers, children are the best agents of change”. The children seemed to encourage fathers to “step out of their comfort zones” and consider enrolling in the program. The recruitment efforts (for the formative activities) improved as promotoras obtained the “buy-in” of the rest of the family, especially the children.Feedback from the promotoras about the importance of family values and developing relationships with their children also motivated decisions regarding program design. For example, the program included more children-focused and father–child activities to strengthen the bonds between fathers and children. At the same time, the program considered the reciprocal interactions between fathers and children, where fathers may have been more willing to try something new because their children felt excited and wanted them to participate. Promotoras also knew how important fathers were to their children and wanted to see the program explicitly show how the fathers could lead activities related to nutrition, activity, or health in their families. Their feedback informed the program design and decisions related to implementation.Lesson #2. Identified different ways to connect with mothers and fathers during recruitment. Another observation by promotoras from the formative work related to misunderstandings about the fathers’ interest and motivation to engage in health promotion. During recruitment, promotoras reached out to fathers after first connecting with the mothers and children. Specifically, promotoras went door-to-door to talk to the mothers about the program’s value and presented the program to children as a fun way to spend time with their fathers. After this initial connection, promotoras followed-up with fathers by phone/text/in person to present the program and gauge their interest in participating.While there have been prior efforts to engage fathers ,27,28, tPromotoras guided the recruitment approach of fathers and ensured that the process was culturally appropriate and did not discourage or exclude potential families. The promotoras felt strongly about getting buy-in from the mother of a family before connecting with anyone else in the family. From the promotoras’ perspectives, the women/mothers are the gatekeepers to the family. The promotoras shared information about the program and their intentions, which allowed these women/mothers to learn of the value of their partners/spouses participating in the program. These conversations allowed the women/mothers to ask questions and share their intentions of communicating with their partners/spouses about the program. Without these conversations, promotoras were concerned with the potential for misunderstandings regarding why promotoras were reaching out to someone else’s partner/spouse. The promotoras communicated the importance of creating a welcoming space for fathers, so they could feel supported as they learned more about nutrition, physical activity, and health. During the formative activities, promotoras created two “pitches” (or “elevator speeches”), one for fathers and one for their spouses/wives. The fathers’ pitch highlighted why the fathers would want to participate in the program, considering the context of their culture and traditionally gendered norms. Their pitch (to the fathers) acknowledged the spouses/wives as gatekeepers within families, presented the program as an opportunity for fathers to spend time together with their families, and emphasized the fun activities related to food and physical activity.In addition, communication between promotoras and participants emerged as a critical part of engagement for recruitment during the formative work and later during program implementation. During the formative work, participants commented on the promotoras’ communication with them  and the ways in which the promotoras’ interpersonal interactions aligned with the community’s values . Because the promotoras were from the community and lived there, they were already navigating local culture and spoke in ways the community understood and trusted. This inherent knowledge and language allowed them to customize how they presented the formative work to the families and later generated insights for presenting the program to potential program participants.Lesson #3: Created additional opportunities to give back to the community through community advisory boards (CABs). Finally, the promotoras further provided guidance and insight on community engagement through the CABs [the CABs . Previouthe CABs . The proThrough their work with the CABs, the promotoras secured locations for research and outreach activities, including the program site at the Endowment Community Center. The promotoras also influenced the research activities by centering the community’s interests. For example, CAB members would share concerns, ideas, or feedback, and the promotoras would incorporate the community’s interest in their activities. Giving back to the community with resources and valuable activities was key for the promotoras. Another example was the promotoras’ approach to establishing new relationships with community members. With their focus on helping the community and understanding community values and culture, they went into new communities with donations and distributed donations to meet residents. Activities like this supported the grant’s activities but also went much further in bolstering community relationships.While not part of the formative work to inform HEPP’s program design, the promotoras organized and hosted charlas, or friendly conversations, as part of community engagement and outreach (January 2017–July 2018) during the pre-design phase . The chaIn the HEPP, the promotoras delivered the program and prepared for their roles as group leaders/interventionists through intensive training. The training offered a valuable opportunity for the promotoras to collaborate. Prior research has emphasized the importance of equipping group leaders who deliver the program with the knowledge and skills to value fathers’ contributions as parents and co-parents and reduce biases related to mother-based child-rearing practices . Given tMost training activities occurred between January 2018 and June 2019, which was before the launch of the program in July 2019 see . HoweverAlmost all training activities were completed in-person and over multiple days see . Some boTraining topics covered foundational terms and concepts in nutrition and physical activity, the theoretical framework for the program, and a strengths-based approach to program delivery, which was informed by principles from MI, in addition to hands-on training to prepare promotoras to lead cooking lessons and physical activity segments and collect evaluation data for pre-, post-, and maintenance measures. Overall, the training attempted to increase their knowledge of nutrition, physical activity, and social-cultural influences on nutrition and physical activity behaviors; it increased their skills related to supporting behavior change, preparing food, and engaging in movement and exercise safely and efficiently. There were also training activities to prepare promotoras to deliver the mothers’ charlas, which were educational lessons with art and crafts activities. The mothers’ charlas occurred concurrently with the father-focused program sessions; however, the charlas happened in different rooms. A separate article provides detail on training activities for the physical activity parts of the program .®  and ActiGraph GT9X accelerometers  for nutrition and physical activity, respectively. Briefly, the Veggie Meter® is a rapid, non-invasive device that measures skin carotenoids, which is a biomarker for dietary intake of fruits and vegetables. Accelerometers are a wearable technology that measures physical activity.There were specific training sessions on food preparation for the cooking lessons and movement and exercise for the physical activity segments. Parts of the training emphasized techniques for ease of movement and safety to minimize injuries. Training included demonstrations led by the nutrition and physical activity leads and research staff and opportunities for the trainers to “walk through” the different lessons with the promotoras. All training provided ample time for discussion. The training made time for the promotoras to provide feedback and ask questions. The promotoras also participated in role-playing, where they functioned as the lesson leader and delivered different program components. Lastly, the training sessions focused on how to set up and use the devices for program evaluation. The program assessed primary outcomes with the Veggie MeterAfter several rounds of review, training, and (re)design, the promotoras completed several practice sessions of the HEPP Program with the research team . PracticRegarding the MI training, a consultant hosted an initial two-day training that focused on practical skills related to open questions, reflective listening, and summarization. The promotoras received initial two-day training, completed homework assignments, and participated in booster training (in August 2018 and February 2019). Pre- and post-tests, along with recorded practice conversations, were used to assess fidelity to motivational interviewing skills and identify areas for improvement.There were three lessons learned. The training identified: (1) a need for an iterative process for program refinement; (2) the importance of customizing training to the promotoras; and (3) that the process of training provided an opportunity to extend intervention effects.Lesson #1. A need for an iterative process for program refinement. During the training, it became clear that training offered opportunities to refine the program, and an additional step of training was added to the iterative process: draft, review, train, and revise. This emergent approach reflected the team’s commitment to CBPR and the principles of cultural humility [humility . While thumility ,41, the As the academic team members prepared for the initial training sessions, the promotoras identified important priorities. A key concept was to provide training that would enhance promotoras in their helping role rather than have them “mimic” research professionals and to do so in a way that was credible and efficient . Many chFor example, the promotoras were concerned about affordability during the review of the recipes and cooking lessons. As a result, the nutrition lead (C.J.) obtained food prices from a popular local supermarket (H-E-B) and calculated the total cost for preparing the entire recipe and the per-serving cost. The promotoras approved the affordability, and the recipes were integrated into the program.Another example was the final session (Session 6), where the promotoras believed it was important to celebrate the family’s journey in the program. From their perspectives, the families had committed considerable time and energy to the in-person and at-home activities and deserved to celebrate their accomplishments. While training, promotoras shared their idea to improve the final session. Their feedback led to creating a memorable final session, complete with a circle of sharing, presentation of special family stones, completion certificates with family photographs, and celebratory cake.One more example was from the practice run-throughs. The promotoras realized that Session 5 required participants to have more nutrition knowledge and skills with food labels. Through discussion, they identified an opportunity to integrate additional nutrition education into the program so that participants would be ready for the nutrition-focused Session 5. Specifically, the promotoras believed that more experience with MyPlate and reading food labels (including nutrition facts) would boost engagement in a traditional game called “toma todo” with nutrition education game cards. As a result, the nutrition lead worked with the promotoras to develop “tasting recipe lessons” for all sessions. Each tasting lesson included an important topic from the promotoras’ perspectives and supplementary educational handouts. The tasting lessons happened before the start of the 2.5-h session and progressively targeted the nutrition knowledge and skills required for Session 5.In addition, training the entire team, including the promotoras, in MI affected the program design in a substantial way. The promotoras wanted cues to apply MI skills in group sessions, and after the MI training, the leader’s guide and activities were revised. For example, the academic team members notated and provided examples of where open questions could be asked, phrases that could demonstrate reflective listening during discussion exercises, reminders about remaining non-judgmental, and how to assess a participant’s motivation about the behaviors of focus. Because the MI training included more than just the promotoras, the team identified opportunities to apply this person-centered approach to the program design and strengthened the program. For example, post-training, the leaders’ guide scripts were rewritten to provide more open questions and check-ins, and lesson activities were revised to highlight families’ unique goals. Activities were reviewed and modified to incorporate MI skills more explicitly, such as the use of confidence and motivation rulers as part of the goal-setting activities. The promotoras also wanted cues to apply MI skills in the delivery of group sessions. Thus, academic researchers revised the leader’s guide and activities to enhance supportive opportunities for exploring health behavior changes within families.Lesson #2. The importance of customizing training to the promotoras. Training is a critical element of promotora-delivered programs because it prepares them to provide important health information and interventions to underserved communities with limited access to health programs. During training, the academic-based researchers realized that accommodating promotoras’ preferences and goals was critical to supporting them as group leaders/interventionists and data collectors. The academic researchers tailored the training to individual promotoras based on language skills, preferences for training intensity , and their existing knowledge and skills related to the program. For example, at the beginning of the design phase, one promotora had basic knowledge and skills related to food and nutrition, but she had minimal experience with food preparation and cooking. She did not feel comfortable leading the cooking lessons and wanted more opportunities to increase her knowledge and develop skills. The lead nutrition trainer provided additional booster training sessions and videos related to cooking lessons. Further, videos of the lead physical activity trainers conducting lessons were made for promotoras to view at their leisure to reinforce techniques and cues [and cues .Aside from individual preferences for training, the team of promotoras also had preferences as a group of learners. For instance, the promotoras preferred to review materials in advance of the training and have opportunities to discuss the rationale for the decisions, ask questions, and provide feedback prior to engaging in more formal training activities such as demos, role-playing, and discussions. These strategies, including the review of the materials ahead of time, enabled them to feel more confident and prepared for implementation. The promotoras explicitly described the importance of being well-prepared for the training and wanted a say in the focus of the training. While the promotoras were interested in building the knowledge and skills required for program implementation and evaluation, they had additional goals for training.For example, the promotoras communicated that their goal for the training was to benefit their professional development. While the academic team members focused on increasing the knowledge and skills required for the program, the promotoras’ wanted training to increase their confidence in program delivery and prepare them to help their communities. For example, the program coordinator acted as a liaison to request additional time for studying, providing feedback, and scheduling enough time for reviewing program materials and practice sessions with each other before completing role-playing with the program team. Further, the promotoras viewed the training as valuable professional development that would benefit them after the program and the communities they serve. This was especially true for the MI training.Lesson #3: The process of training provided an opportunity to extend the intervention effects. Through observations, check-ins during the training, and training debriefs, it was observed that the promotoras’ involvement in training affected their self-efficacy, beliefs, skills, and health. The promotoras commented on changes they noticed in their own behaviors and the behaviors of their family members. Previously, Sanchez-Hucles and Sanchez have described reciprocal empowerment as a “leadership style of reciprocal respect, equality, and personal authority that is characterized by concepts such as mutuality, compassion, collectivity, engagement, and a consensus to enhance oneself and others (p. 216)” [p. 216)” . Having The HEPP program consisted of six weekly in-person sessions focused on family functioning, nutrition, and physical activity, along with at-home activities and check-ins. A separate article presents the details of the program . Before The promotoras played a critical role in implementation because they were trained as group leaders/interventionists and were wholly responsible for delivering the program. Program implementation reflected the promotoras’ desire to provide families with a truly family-centered program. In-person and at-home activities focused on supporting a family systems-level change rather than on behavior changes for only individual family members, such as the child or one parent. Promotoras’ feedback influenced the decision to allocate half of the sessions to the fathers and children and create distinct opportunities for the co-parents (or couple) to strengthen their relationship. For example, the decision to ensure that the first two sessions (Weeks 1 and 2) focused on the family triad as a unit  and to begin the first father–child session in Week 3 was based on formative work and promotoras’ insights. Additionally, the decision recognized that mothers, especially those of Mexican heritage, tended to serve as gatekeepers for their families. Thus, allowing the family to start the program and complete the first two weeks together was essential for building trust and rapport with each of them, especially the mother, to later have her support and encouragement to ensure that the father- and child-specific sessions, starting in Week 3, would be successful. As for the reasoning behind the co-parenting session in Week 4, promotoras worked with academic-based researchers to discuss how to make space for the parents to learn strategies for supporting each other as partners and co-parents. The promotoras believed that explicitly focusing on co-parenting would facilitate positive long-term effects on nutrition and physical activity for families.There were four lessons learned specifically from implementation: (1) The importance of making fathers feel included and supported in their families; (2) a need to consider the language skills of fathers and children; (3) the importance of designing sessions with time for promotoras to engage in their own ways; and (4) the value of coordinating resources to meet families’ needs. Given that the role of the promotoras as partners was entrenched and committed to the success of the program within their communities, they were able to point out potential issues, provide specific solutions, and ensure that the approach was compatible with the families’ needs without compromising the program’s integrity.Lesson #1: The importance of making fathers feel included and supported as leaders in their families. The promotoras felt concerned that the program might undermine the fathers as leaders in their families. They wondered if a father-focused program might make some fathers feel “less than” mothers based on their potentially low prior knowledge of nutrition and physical activity, existing food and nutrition-related skills, or past actions to model health-promoting behaviors in their families. They identified potential unintended consequences of fathers feeling embarrassed, uncomfortable, or isolated and communicated their perspectives to the team. In response, the program engaged fathers separately from mothers in some sessions  and worked to showcase fathers’ unique abilities and contributions to their families throughout the program.Lesson #2: A need to consider the language skills of fathers and children. The promotoras noticed that some fathers had challenges with literacy. Some fathers had no reading ability, and, generally, limited literacy was more common among fathers than mothers. The promotoras stressed the importance of reliance on graphical illustrations and pictures, with visual aids and verbal presentations, as part of effective communication. The delivery of the program was modified so that the promotoras had time to check-in with fathers during session activities. This attention to the fathers’ literacy extended from implementation to evaluation, and the surveys integrated graphics and pictures to present response options for survey items. Applying strengths-based principles facilitated the promotoras’ inclusion of fathers and the validation of fathers as leaders (co-parents) in their families rather than focusing on deficits or weaknesses. Additionally, during the pre-testing of a trivia-style game in Session 6, the promotoras noticed that children with less-developed reading skills in Spanish were not participating in the game, which was presented visually in Spanish. This observation mattered because the team had assumed that bilingual children had similar skills in reading in Spanish and English. Based on the promotoras’ observations and suggestions for accommodation, visual materials for all activities were presented in Spanish and English and supported with verbal instructions in both languages.Lesson #3: The importance of designing sessions with time for promotoras to engage in their own ways. Making time for promotoras to engage with the fathers was intentional. A key aspect of the implementation was ensuring that the weekly sessions had enough time for promotoras to tailor engagement to specific families and individual family members . In addition, the promotoras wanted to motivate the families to make changes related to nutrition and physical activity, which could also strengthen their families. However, it is important to say that these decisions would not have been made without explicitly recognizing the strengths of the promotora model and the individual strengths of the promotoras on the team. In the authors’ opinions, collaborating with the promotoras in the delivery of the program in advance offered unique advantages that would not have been available with group leaders from outside the community. However, making time for the promotoras to connect more one-on-one with families meant that they not only built rapport but learned of other needs the families may have had that could affect program retention. As such, promotoras created efficient procedures so they could spend more time communicating, engaging, and supporting families through a six-week program. For example, the promotoras reviewed processes for setting up, delivering, and breaking down/cleaning up post-program and made changes to streamline the process. In addition, the promotoras suggested that rather than shopping for the ingredients and other supplies themselves, the program place orders for curbside pickup. As another example, promotoras were able to reduce set-up time by developing an agreement with the community site (the Endowment Center) to store program materials on-site and requesting an additional storage room near the Endowment Center.Lesson #4: The value of coordinating resources to meet families’ needs. Throughout implementation, promotoras were keen on pointing out potential barriers that would hinder family engagement and sought logistical support from the program coordinator and research team to resolve the issue. Their contributions emphasized the importance of coordinating resources to make it easier for families to participate. For example, the promotoras learned that some families were having issues attending the in-person sessions. Due to family or work demands or transportation challenges, some families, who attended the afternoon session, needed to make last-minute changes in their schedules to attend a morning session instead. The community center space was large enough to allow promotoras to accommodate more than the five or six families expected in each session. As another example, some families had challenges with transportation and could not drive their vehicles to the community center for a session. Given the lack of public transportation and limited access to rides (private transportation), families would have missed the session. The promotoras wanted the families to engage fully with the program, and, as needed, they coordinated and provided transportation to sessions. Another example is childcare. The program provided on-site childcare and activities for children of all ages, and children had access to an outdoor playground and recreation area behind the community center building. However, some children, who were the siblings of the participating child in the program, did not want to be separated from their parents or participate in the children’s activities. To keep families together and to remove barriers to engagement during sessions, additional staff would care for other children or guide them in arts and crafts activities or games while their parents and sibling engaged in program activities (in the same space). These adjustments promoted retention over the six-week program.The promotoras, as group leaders and interventionists, were invested in their communities, wanted to help the families in their community thrive, and actively solved problems to encourage and enhance program engagement. Therefore, additional duties such as making phone calls to confirm attendance and arranging rides to or from the community center, rearranging the physical space for the different program activities , preparing additional tasting recipes and ingredients for the main recipe for the additional families, and driving to people’s homes to pick up families and bring them to the community center were relegated to additional paid staff and volunteers. In this way, the promotoras focused on maintaining relationships with families and delivering a valuable program. Again, there are benefits to applying strengths-based and community-engaged approaches to program implementation in collaboration with the promotoras. The promotoras, as group leaders and interventionists, were invested in their communities, wanted to help the families in their community thrive, and actively solved problems to encourage and enhance program engagement.As program partners, the promotoras helped guide the program evaluation. The program included pre-test, post-test, and short-term maintenance evaluations, completed three to four months post-program. The promotoras were involved in discussions related to both outcome and process evaluations. A separate article describes the outcome and process evaluations in more detail .®). Secondary outcomes included low and moderate physical activity (measured with accelerometers), family functioning , andThere were three primary lessons learned from the evaluations: (1) Minimize the respondent burden required for evaluation; (2) maximize one-on-one time with individual family members for mutual benefit; and (3) incorporate the promotoras’ perspectives on evaluation to value the family’s  experiences of the program.Lesson #1: Minimize the respondent burden required for evaluation. First, the promotoras advocated for paring back the data collection with surveys or other nutrition assessments to minimize the respondent burden. Longer scales, such as the Family Adaptability and Cohesion Evaluation Scale (FACES-IV) to assess family functioning [®  because the device enables the rapid, non-invasive assessment of a biomarker for dietary intake. From a research perspective, the use of objective measures to assess outcomes, such as the Veggie Meter®, is recommended for reducing sources of measurement error. However, eliminating longer scales such as the FACES-IV (with 62 items) from the evaluation was a trade-off. Overall, the promotoras appreciated selecting measures or assessments that were convenient  and fast .ctioning ,45, requLesson #2: Maximize one-on-one time with individual family members for mutual benefit. During the evaluation visits, the promotoras wanted to have dedicated time with each individual family member to make the person more comfortable and collect evaluation data, which meant more coordination in scheduling the in-person home visits. The team modified the evaluation procedures so the three-member promotora team could complete in-person home visits and collect data separately for fathers, mothers, and children. This process allowed each promotora to focus on one family member at a time. From a research perspective, the one-on-one interactions also helped provide more support for family members to freely share about the program without the influence of other family members. Potential benefits of the one-on-one evaluation visits are potentially enhanced trust between the research team and the community and more honest responses to questions .Lesson #3: Incorporate the promotoras’ perspective on evaluation to value the family’s  experiences of the program. The promotoras believed that evaluation should prioritize interviews with individual family members  to capture the family’s experiences of specifically how the program has affected family functioning or dynamics. While changes in nutrition and physical activity outcomes  were important, understanding the impact on the family experience was valuable to the promotoras. They believed that stronger family functioning could translate to better outcomes. This meant that the academic researchers included fewer quantitative assessments to assess outcomes and focused the evaluation instead on capturing families’ qualitative experiences with interviews. For example, most of the interview guide questions asked about family functioning or family dynamics  rather than on individual-level behavior changes. While completing the interviews , promotoras commented that fathers expressed their gratitude for being included and considering their perspectives, while mothers were grateful for the fathers’ opportunities to engage in the program and support mothers at home. Both fathers and mothers voiced how participation enabled them to consider things they had not before and helped them become more aware of ways to be a more supportive parent and partner. Participating children shared how they were able to spend time with their fathers and learn more about them. Research findings from the evaluation are forthcoming and will be reported in a separate article.As far as the authors are aware, HEPP is the first behavioral program that has explicitly focused on Latino fathers and families living in U.S.–Mexico border communities. To date, there have been two behavioral programs identified in the literature that have focused on Latino fathers and supported health-promoting nutrition, eating, or physical activity behaviors. The first is Padres Preparados, Jóvenes Saludables, an obesity prevention program for Latino fathers and early adolescents ,47. The The team of promotoras was engaged throughout the program design, implementation, and evaluation. Apart from the process evaluation data, the program collected minimal data related to the promotoras’ engagement. However, because the promotoras and academic-based researchers worked together to design, implement, and evaluate the program, their contributions to the program were clear. There were many opportunities to review their knowledge and skills , provide feedback, and support them as group leaders and data collectors. The process evaluation included frequent debriefings, team meetings, and opportunities to address emergent challenges. Additionally, positive experiences were evident during group sessions, check-in calls, and follow-up interviews. Participants felt especially impressed by the welcoming environment created by the promotoras. In addition, program participants regularly commented on how attentive, positive, and friendly the promotoras were during the program, which participants had not always experienced in other programs. In many cases, family participants started inviting promotoras to family gatherings and social events.Considerable resources are required to do this type of work , which iThis collaboration has generated three overarching lessons learned for future community-engaged research. First, the partnership with promotoras is especially important as the promotoras presented solutions and developed strategies based on their lived experiences. Research teams may not have had the same experiences and, without the promotoras, may have missed opportunities to develop a meaningful program. Promotoras’ contributions supported the entire program, from design through evaluation. Second, the promotoras created a balance between the needs and preferences of the community and the goals and requirements of research. Specifically, this kind of collaboration provided opportunities for promotoras to offer their insights into the best approaches to meet the needs of the community while also maintaining scientific rigor. Third, the HEPP program demonstrated a well-trained team of female promotoras who understood the community, used strategic approaches in the formative work, and were able to co-create a program that engaged men successfully.Researchers considering how to move forward with community-engaged research would benefit from building trust and relationships with community organizations, leaders, and families in the study area well in advance of the planned pre-testing and recruitment for the actual program rather than the typically allotted one to two years before a program begins. Our program benefited from and expanded the community partnerships developed over more than 10 years of research and outreach in the Lower Rio Grande Valley.Additional time  is critical to present and discuss ideas with promotoras and create opportunities for their insights to be integrated into the work. Because of the promotoras’ experience and perspectives, they identified solutions and implemented strategies that were unavailable to the researchers and, thus, made valuable contributions to the research project. Promotoras provided valuable insights into the appropriateness of research due to their knowledge and experience, which allowed researchers to develop and adapt the approaches and methods to benefit the community and the research study. The promotoras served as liaisons between the research team and community members throughout the grant and program process. This two-way communication ensured that the research project gained what was needed and was well received by the community, and the project and the community both benefited. With their knowledge and experience, promotoras ensured that the families and community benefited from the program.Future research projects would benefit from early engagement and shared decision-making with promotoras. Without engagement and collaboration with the community members, including promotoras, there are missed opportunities not only to design an effective program but also to recruit and engage with potential participants and their families. In addition, there are risks of doing harm when programs are developed and implemented in ways that are misaligned with a community’s values, needs, and resources.A community-engaged process that integrates a promotora model is essential for designing more effective behavioral programs. This team of promotoras guided design, implementation, and evaluation strategies that translated into a culturally meaningful program with high participant engagement. With their knowledge, skills, and commitment to their community, the promotoras implemented positive health behaviors at multiple levels—personal (self), family, and community. The promotoras maintained their dual focus on the goals of the community and research. Through this research collaboration, they fostered mutuality, where the promotoras could enhance their own skills and support their community in a meaningful way ,56,57. TCollaboration with promotoras was crucial to supporting behavior change at the individual and family levels, and the promotoras’ contributions to the CABs may have also promoted positive changes within the community. Thus, promotoras are essential partners in community-based research. The approaches and lessons learned that are described here demonstrated the mutual benefits of promotora engagement, from initial design through evaluation. Existing and emergent evidence from similar programs, in combination with the evidence from HEPP, can help identify opportunities for promotora collaboration as part of future health promotion efforts. Lastly, with limited evidence from father-focused programs designed specifically for Latino fathers, it is important to discuss what it means to design and implement a father-focused program with Mexican-heritage fathers living in U.S.–Mexico border communities. Community-engaged programs require sustained investment in the community and collaboration with community members, including promotoras, leaders, and the residents.


At the onset of the COVID-19 pandemic, protocols for community-based management of acute malnutrition (CMAM) were implemented to support continuity of essential feeding services while mitigating COVID-19 transmission. To assess correlations between adaptation timing and CMAM program indicators, we evaluated routine program data in Uganda, Ethiopia, and Somalia for children 6–59 months of age. We specifically analyzed facility-level changes in total admissions, average length of stay (ALOS), total children screened for admission, and recovery rates before and after adaptations. We found no statistically significant changes in program indicators after adaptations. For Somalia, we also analyzed child-level changes in ALOS and in weight and mid–upper arm circumference at admission and discharge. ALOS significantly increased immediately after adaptations and then decreased to preadaptation levels. We found no meaningful changes in either weight or mid–upper arm circumference at admission or discharge. These findings indicate that adapted CMAM programs can remain effective. In 2020, severe acute malnutrition affected 13.6 million children <5 years of age  in Somalia and Ethiopia and all targeted supplemental feeding programs (TSFPs) in Uganda supported by Action Against Hunger USA for children 6–59 months of age to provide electronic data for all dates for which historical data were available via a secure file-sharing platform. Data for all countries ended in December 2020, and for Uganda, data began in January 2019; for Ethiopia, in July 2019; for Somalia at the facility level, in November 2019; and for Somalia at the child level, in January 2017. Analyses included facility-level (outpatient community clinics) indicators of enrollment and treatment outcomes for all 3 countries and child-level indicators for Somalia . ProgramWe evaluated several measures reported monthly by facilities, including total persons screened and total admitted, as well as 2 measures of treatment outcomes: recovery rate and average length of stay (ALOS). Total screened included the number of children for whom MUAC, weight and height, or both were measured at the facility or in the community to assess whether they were malnourished and eligible for admission. Total admissions included all children newly enrolled each month. ALOS was defined as the average number of days elapsed between admission and discharge for all children discharged as recovered, and recovery rate was defined as the percentage of children discharged from the treatment program meeting the discharge criteria by MUAC or weight-for-height z-score.In Somalia, selected additional indicators were available for all children admitted into OTPs; indicators included length of stay (days) and anthropometric measurements. For each child, weight (kilograms) and MUAC (centimeters) were measured at admission and discharge. For a sensitivity analysis, we compared models testing weight with models testing weight-for-height z-score and weight-for-age z-score.During the study period, several facilities experienced closures and stock outages. We excluded from analysis all outcomes for months when facilities did not have any children enrolled, and we did not calculate recovery rates for months when children were discharged en masse because of closures or stock outages. For months when a data point from some facilities was missing, we calculated aggregate or mean values for all remaining facilities.To account for typical increases in enrollment in CMAM programs during the seasonal period of increased food insecurity (lean season), we adjusted models for the timing of the lean season in each country. Similarly, to account for anticipated declines in care-seeking associated with national COVID-19 restrictions, we included as covariates in our models indicators of domestic lockdowns or travel restrictions to assess independent associations with measured program indicators. We extracted data for the period of the lean season in each country from Famine Early Warning Systems Network reports  were calculated at discharge and were therefore theorized not to be modified immediately after implementation of program adaptations. Models presented include no time lag in recorded recovery rates and ALOS; however, given an observed median length of stay of 42 (interquartile range 42–49) days, we conducted a sensitivity analysis using time lag periods of 1 and 2 months between the change in COVID-19 policies and those 2 outcomes (data not shown). All other indicators  were captured at admission and analyzed with no lag.https://www.r-project.org). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq).We performed all data aggregation, cleaning, and analysis by using R version 4.0.3 , suspending community-based screening, and modifying admission and discharge criteria from an upper MUAC threshold of 12.5 cm to 12.9 cm . In May In Uganda, COVID-19 mitigation measures started in March 2020 and extended through the last date for which CMAM data were available (December 2020); measures included a national curfew, a temporary ban on public transit, and a 14-day national lockdown. In Ethiopia, COVID-19 mitigation measures began March 2020 and were still in place through the last date with available CMAM data (December 2020). In Somalia, COVID-19 mitigation measures started in April 2020 and extended through December 2020 and included a national curfew.Mean total admissions in Uganda, Ethiopia, and Somalia did not change significantly after program adaptations , panel ASimilarly, the models showed no significant change in recovery rates after program adaptations . Changes in trends after adaptations were not statistically significant for MUAC at admission or weight at discharge ,7. HowevFor all 3 countries evaluated, changes in total admissions and total number of children screened after CMAM protocols were adapted for COVID-19 did not differ significantly. Although several facilities temporarily closed because of stock outages, these closures were short term, and after reopening, admissions and total number screened returned to preclosure levels. Modifications to CMAM programs—including family MUAC instead of active case finding by healthcare workers, revising enrollment criteria from either low MUAC or weight-for-height to low MUAC alone, and widening MUAC thresholds—were predicted to affect admissions, but it was not clear if they would cause admissions to rise or fall. Retrospective, observational studies in refugee camps in Cox’s Bazaar, Bangladesh, and in Zambia showed increased total admissions after implementation of family MUAC and reduced frequency of follow-up visits (>1 study has shown that reduced frequency of follow-up visits does not necessarily reduce treatment efficacy (Our analyses further show no immediate or long-term change in the proportion of children discharged as recovered. Recovery rates were anticipated to deteriorate in programs that decreased the frequency of follow-up visits because the interval between nutritional and medical assessments would be longer, although >1 study has shown that MUAC-based discharge can result in greater relapse rates (Although the month-to-month trend in admission weight rose significantly after program adaptations, the magnitude of the change—an increase of 0.04 kg/month, or 0.3% of the weight of an average 36-month-old girl—is not programmatically meaningful. Sensitivity analysis accounting for height and age and admission weight also showed no meaningful changes after program adaptations. We may not have observed a meaningful increase in weight at admission because a similar proportion of children were admitted by MUAC only before facilities shifted to all admissions by MUAC only with COVID-19 adaptations. MUAC and weight at discharge, indicators of child profile and health, did not change meaningfully within the Somalia facilities that provided child-level data, consistent with expectations because no adaptations to discharge criteria were adopted. Monitoring future changes in discharge criteria may be useful because Within Somalia, ALOS at the facility level did not change after program adaptations; however, in the subset of Mogadishu-based facilities providing child-level data, ALOS increased by an average of 12.3 days/month, peaking at 60.8 days in April 2020 immediately after program adaptations and then declining. Although the change in program adaptations overlaps with a lean season, potentially confounding the analysis, we found no evidence of such annual pattern in previous years among the 3 facilities providing multiple years of data. A similar immediate increase in ALOS in the month after frequency of follow-up was reduced was also observed in an observational study of OTP data in Nguenyyiel Refugee Settlement in Ethiopia in 2020; however, the program reinstated weekly visits the next month, limiting analysis of longer-term trends (>1 year of preintervention data would have been ideal for detecting changes that may be attributed to the COVID-19 protocol adaptations. However, despite limited statistical power, analyzing the magnitude and direction of change of CMAM indicators provides key insight for nutrition programs because the effects of adaptations were previously unknown, and there were multiple, conflicting hypotheses of how programs would be affected. Second, isolating the effects of CMAM program adaptations from other COVID-19 mitigation efforts was challenging because those efforts were implemented around the same time. Third, our data represent a limited number of country experiences; to draw more general conclusions, we would need a larger dataset covering a wide range of countries and program adaptations. Fourth, the lack of country-level average changes in program indicators does not mean that there was no effect in individual facilities. This concept is particularly true in the context of COVID-19, which may have affected use of CMAM facilities in multiple, unpredictable ways. Last, models do not capture the qualitative experience of putting program adaptations into practice. The full context of personnel, environment, and events that shape program success and the challenges facing staff, children, and caretakers are not measured by program indicators and cannot be fully modeled.The first limitation of this study is that changes in trends observed for several outcomes were not statistically significant; lack of statistical significance may result from insufficient power based on limited time points  and highOverall, our results suggest that CMAM programs in Uganda, Ethiopia, and Somalia did not undergo consistent, significant changes in program indicators in the first months after adaptations began in response to COVID-19. This finding in turn suggests that CMAM programs may have been able to generally maintain their effectiveness with adapted protocols while continuing to provide service. Although no major or consistent changes were observed after adaptations in these countries in the limited set of indicators considered in this study, it is highly likely that the effects of these program adaptations on program indicators depend on context. Severe acute malnutrition affects 18.7 million children worldwide (


Exercise has been one of the key strategies for preventing frailty. While training programs for preventing frailty have been mainly developed in person, which have now become difficult to perform due to the coronavirus disease pandemic. It would be worthwhile to explore a feasibility of methods for a remote-based training with information and communications technology (ICT) in the pre-frail/robust older adults living at home.We assessed the feasibility of a remote-based training with ICT device in terms of 1) a measurement accuracy and 2) whether it could be used for remote-based training of different intensities. To evaluate a measurement accuracy of the ICT device, we evaluated an inter-rater reliability between a true score and scores obtaining from the ICT device in 20 participants aged 65 years and older. Intraclass correlation was calculated. To evaluate a feasibility of remote-based training interventions of different intensities, we did a parallel, randomized, active controlled trial. Participants aged 65 years or older were randomly allocated to the two 3-month intervention programs with different intensity of exercise with the ICT . The primary outcome was 3-month scores of the 30-s chair-stand test (CS-30), which was compared between two groups using mixed models for repeated measures to account for within-person correlations.p = 0.955), which was not statistically significant. No harmful incidents, such as falls, occurred in either group.The ICT device showed a high intraclass correlation of over 0.99 for all outcomes including CS-30. Between Aug and Oct 2020, 70 participants  were randomized. After 3 months of intervention, CS-30 scores and other physical function improved in both groups. Difference in the 3-month CS-30 scores between two programs was found to be 0.08   Frailty is defined as “a clinically recognizable state of increased vulnerability resulting from an aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised .” This cConceptually, frailty can be divided into three domains: physical, psychological, and social . Among tPrevention of frailty in the Elderly living at home using Exercise with Remote Supervision), which was conducted using an ICT-based training system to evaluate the comparative effectiveness and safety of two remotely delivered frailty prevention exercise programs with different exercise doses on pre-frail/robust community-dwelling older adults Japanese individuals aged 65 years or older.This current study evaluated the feasibility of a remote-based training program in terms of 1) a measurement accuracy of ICT device and 2) whether it could be used for remote-based training of different intensities. To evaluate a measurement accuracy of the ICT device, we evaluated an inter-rater reliability between a true score of outcomes which used in a remote-based training system and scores obtaining from the ICT device in individuals aged 65 years and older. To evaluate a feasibility of remote-based training interventions of different intensities, we conducted a randomized parallel-group open-label trial, the “PEERS trial” . After confirming the inter-rater reliability of the device, we conducted the PEERS trial . These studies were conducted jointly by the University of Tokyo, Moff Co., Ltd., and the Kobe City Government with the approval of the Ethics Committee of the Graduate School of Interdisciplinary Information Studies, University of Tokyo . Moff Co., Ltd., is a for-profit company that provides services using this ICT device, and in this regard, we declare in advance that a conflict of interest exists for this study. All procedures were performed according to the ethical standards of the responsible committee on human experimentation  and the Helsinki Declaration of 1975, as revised in 2013. Written informed consent was obtained when the patients voluntarily agreed to participate in this study after explaining the purpose and procedures of this study.The Moff Corporation  had developed an ICT-based training system named “Moff-Trai” (short for “Moff Training”), which consists of wearable motion sensors, (Moff-Trai bands) and an application (Moff-Trai Check) loaded onto a tablet that can be used to measure physical function Fig. . Given tThe outcome measures used to evaluate the interventions in the PEERS trial included the 30-s chair-stand test (CS-30), the Timed Up and Go test (TUG), and the standing on one leg with eyes open (SOLEO) test. Outcomes were measured using both Moff-Trai and visual review of the recorded test videos. Moff-Trai measurements were obtained by first wrapping a Moff-Trai band around one of the participants’ thighs and launching the Moff-Trai Check application on an iPad. Thereafter, a Bluetooth connection was established between the iPad and the Moff-Trai band. Once the “start measuring” button in the application was tapped and the subject started the test, the measurements were performed automatically. One author (Y.K.) recorded the video and conducted the visual scoring. The visual scores were treated as the “true values” for this analysis. Although the Moff-Trai application displays the results (in seconds) to two decimal places, comparisons were made only up to one decimal place given that the video camera used in the trial had a frame rate of 30 fps.Participants were asked to sit on a chair with arms crossed at their wrists and held against their chest. The test score reflected the number of times the participant could stand up and sit down in 30 s . IncomplParticipants started from a seated position with both feet on the floor and both hands resting on their knees or thighs. The person then stood up from the chair, walked straight forward for 3 m, and at the other side of the 3-m mark on the floor, turned 180°, walked back, and sat back down in the chair in the same way they started . TraditiThe test score was estimated by recording how many seconds the participant could continue standing on one foot with eyes open. The time is measured from the moment the other foot left the ground to the moment it returned to the ground . The limThe inter-rater reliability of the Moff-Trai scores were tested by comparing the scores from the two measurement methods using the intraclass correlation coefficient (ICC) and the Bland–Altman plot. The ICC was estimated using a mixed-effects model with measurement methods and participants as random effects (2-way random effects single rater model). We also evaluated a fixed biases whether a difference between visually determined score and Moff-Trai score was within 2 times the CS-30 score or 2 s for the TUG and the SOLEO test. Correlation coefficient between the two measurements was also calculated.https://mycondition.city.kobe.lg.jp/) or who received an information leaflet distributed at Kobe city office were candidates for this trial. Those who were interested in participating in the PEER trial sent an email to the secretariat and attended a briefing session on participation in this trial through the Zoom. Eligible criteria were 1) pre-frail/robust based on the Brief Frailty Index  related to the primary outcome using MMRM. Additionally, we also evaluated the influence of participant compliance for each program. A complier was defined as a participant who had attended 75% or more of all sessions . To estimate the complier-averaged treatment effect, defined as the average causal effect of the program on those who complies with their assignments, inverse probability of censoring weight generalized estimating equations were used after censoring data for participants if the compliance was lower than 75% .The 3-month changes in the TUG and SOLEO test scores of the participants were analyzed in the same way as the primary analysis of CS-30 scores. To determine the pre- to post-intervention change in self-rated health, changes in the score between enrollment and after end of the 3-month intervention were recorded in a cross table. The prevalence rates for improvement in each group were calculated as the differences between both groups and the 95% CIs. For changes in daily life after participating in the study , improvement prevalence rates were calculated for each item.Statistical analyses were performed using JMP Pro 15.2.1 and SAS STAT 15.1 .For the evaluation of the inter-rater reliability of the ICT device, all 20 participants agreed with the study  describing the progress of the trial through the phases of enrollment, intervention allocation, follow-up, and data analysis is presented in Fig. Ultimately, 70 participants were enrolled and allocated into the two groups, with the Exercise-Intensive and Light-load exercise programs comprising 36 and 34 participants, respectively. Table The monthly attendance rates for each program over 3 months are detailed in Fig. For the live training classes, no significant difference in attendance rates was observed between the two programs. For the Active Centenarian Physical Fitness Program, approximately 40% of the participants in the Exercise-Intensive program attended more than 75% of the classes. Meanwhile, around 80% of the participants in the Light-load exercise program attended more than 75% of the video sessions. The Exercise-Intensive and Light-load exercise programs contained 11 (30.6%) and 24 (70.6%) compliers who had attended 75% or more of all sessions for each program, respectively. Although participants in the Exercise-Intensive program were not supposed to attend the video sessions and participants in the Light-load exercise program were not supposed to attend the Active Centenarian Physical Fitness Program, some participants (one participant in the Exercise-Intensive exercise program and six participants in Light-load exercise program) participated in the intervention for the other group.Figure p = 0.955). Similarly, no significant differences in secondary endpoints were found  and 9.39 ± 6.25 among non-compliers (N = 18) in the Exercise-Intensive program. Similarly, the crude mean change in the CS-30 score after 3 months was 10.65 ± 4.92 among compliers (N = 23) and 6.00 ± 6.35 among non-compliers (N = 6) in the Light-load exercise program. Compliers exhibited a greater change in the CS-30 scores after 3 months than non-compliers in both the programs . However, the complier-averaged treatment effect, defined as the average causal effect of the program on those who complied with their assignments, was 1.44 (95% CI: − 2.33–5.21), without a significant difference between the programs (p = 0.454).Participation compliance differed between programs Fig. . The crup = 0.571).To compare the groups according to changes in self-rated health, we examined the percentage of improvement reported in each program. Accordingly, 59.2% and 51.7% of the participants in the Exercise-Intensive and Light-load exercise programs showed a decrease in their numerical ratings, respectively. Although more improvement was found in the Exercise-Intensive program, no statistical difference was observed between the programs  and “Moff-Trai” score. The PEERS trial showed that it could be used for remote-based training of different intensities without any safety issues. The trial revealed that the primary outcome  showed a difference of only 0.08 between both programs, which was not statistically significant. Similarly, no significant differences were found for the secondary outcomes, which included changes in the TUG or SOLEO scores. Nevertheless, the least square means for the 3-month CS-30 scores were 27.30 and 27.22 for the Exercise-Intensive and Light-load exercise program, respectively, which was higher compared to the test scores obtained before participating in the trial. Notably, a meta-analysis of healthy Japanese individuals aged 60 years and older found that the standard CS-30 score for the population considered was 17.26 (95% CI: 15.98–18.55) , suggestRecently, Glass et al. evaluated the association between light physical activity  and incident mobility disability in older women . They noAnother possibility could be that both programs in this trial made the participants more health-conscious, thereby increasing their daily physical activity level outside of program participation. Although this would be natural for the participants in the Exercise-Intensive program, participants in the Light-load exercise program were merely watching videos for health maintenance and having their physical functioning assessed every month, suggesting that both groups may have become more proactive than usual regarding health maintenance in their daily lives. Interestingly, compared to those participating in the Exercise-Intensive program, participants in the Light-load exercise program were more likely to have more conversations and phone calls with family and friends, to be more sociable, and to have less anxiety about falling. A previous study indicated an association between social frailty and physical frailty . As suchCompliers for the program showed greater improvement in physical function compared to non-compliers, although no statistically significant difference in complier-averaged treatment effects were noted between the programs. While exercise compliance has been known to affect outcomes, it is difficult to improve compliance among older people , 33. RisWhen the programs were compared in terms of safety, no particularly harmful incidents, such as falls, were confirmed using Moff-Trai. However, depending on the content of an exercise program, doing it at home can pose risks. Therefore, care needs to be taken when adding training exercises to a program while also confirming how safe they are when performed at home.i.e. measures of frailty was not evaluated.) Finally, another limitation was the non-blinded assessment of the outcome measures, which increases the chance of bias for some soft endpoints.This study has several limitations worth noting. First, although the minimum target was 44 participants per group , this could not be achieved because we had to close the enrollment in October 2020 (follow-up until December 2020) due to human resource issues. Thus, the current study may have lacked the statistical power to sufficiently detect significant differences. However, statistical significance would not be achieved even with the target sample size given that the observed difference was close to 0 in this study. Secondly, considering that we could not measure daily physical activity level through the device, it remained unclear how much training and other exercises participants had done, especially for the Light-load exercise program, in this study. Thirdly, this study does not evaluate the prevention of frailty (We showed a remote-based training program with ICT device in the older adults living at home was feasible. In the PEERS trials, no statistically significant differences were found between the two 3-month remote exercise interventions with differing exercise intensities. Further large-scale studies are warranted to determine what kind of remote exercise intervention programs is more effective for maintaining a physical performance and further preventing frailty.


It's been a while since we focused our end of year editorial on the journal itself. COVID kind of swamped the airwaves so to speak. But as the International Wound Journal enters its 20th year in 2023, we decided that it's time to reflect not only on the past year but the entire lifespan of the journal.When we were developing the idea of a truly international offering in the wound care space, where geographies are at different stages of the evolution of wound care as a specialty, we wanted it to have equitable access for all researchers and readers. Some 20 years on we are proud of what Wiley and the IWJ team have developed and recognise that the IWJ of today remains true to that initial vision. In the past few years, we moved from a subscription‐based model to full open access, being the first wound care focussed journal to do so. This step also remained true to the equitable access vision and was essentially a move based on the evolving publication mechanisms of today.As the world of research and publication evolves, the IWJ has and will evolve to meet the needs of its authors and readers. Since its inception in 2004 the IWJ has always been at the leading edge of publication trends.Our impact factor has grown year on year and the IWJ remains one of the top three journals in the wound care field. Citation is only one of the measures of success, albeit an important one. Downloads are another measure of interest and utility. Over the years our downloads have increased steadily but not surprisingly took an exponential jump upon open access. In 2022, we are on track to reach a million downloads. This shows the value of the IWJ in the field of wound care.Reaching these lofty goals and remaining one of the worlds most valued resources did not happen alone. Yes, the team at Wiley and our IWJ editorial team started and maintained some momentum of success, but it is our contributors and readers that achieved this success. Think of the IWJ team as the engine and the contributors and readers as the fuel. Both are required for successful operation of the vehicle.So, as we approach our 20th birthday in March 2023, we would like to thank everyone who has ever contributed to the IWJ and everyone who has ever read its contents. We truly appreciate your efforts and support and here is to the next 20 years of the International Wound Journal.