Agrobacterium tumefaciens the T6SS effector Tde1 is targeted to its cognate VgrG1 protein. Here, we attempted to use a VgrG shuttle to deliver a heterologous T6SS effector by directing Tde1 onto a T6SS spike in Pseudomonas aeruginosa. For this, we designed chimeras between VgrG1 from A. tumefaciens and VgrG1a from P. aeruginosa and showed that modification of the spike protein hampered T6SS functionality in the presence of the Tde1 effector complex. We provide evidence suggesting that Tde1 specifically binds to the VgrG spike in the heterologous environment and propose that there are additional requirements to allow proper effector delivery and translocation. Our work sheds light on complex aspects of the molecular mechanisms of T6SS delivery and highlights some limitations on how effectors can be translocated using this nanomachine.The type VI secretion system (T6SS) is a contractile injection apparatus that translocates a spike loaded with various effectors directly into eukaryotic and prokaryotic target cells. Such T6SS spike consists of a needle-shaped trimer of VgrG proteins topped by a conical and sharp PAAR protein that facilitates puncturing of the target membrane. T6SS-delivered effector proteins can be either fused to one of the two spike proteins or interact with either in a highly specific manner. In  Escherichia coli strains were grown in LB broth supplemented with antibiotics where appropriate . A. tumefaciens was grown at 28°C in minimal medium as described before  while plasmid DNA isolation using the QIAprep spin miniprep kit (Qiagen). Restriction endonucleases were used according to the manufacturer's specifications (New England Biolabs or Roche) and all used oligonucleotides are listed in P. aeruginosa deletion mutants were constructed as described previously  and 3′ (down) ends of the tse6-tsi6 gene pair were obtained by PCR using PAO1 chromosomal DNA as a template with the oligonucleotides Δtse6tsi6_upF and Δtse6tsi6_upR as well as with Δtse6tsi6_dnF and Δtse6tsi6_dnR , their sequences confirmed and sub-cloned into the pKNG101 suicide vector  or fusion to GOI, were isolated using counterselection on sucrose plates as previously described  acetone and centrifuged one more time. After removing the supernatant, the washed pellet was air-dried for 30 min and resuspended in 1x Laemmli buffer to an OD600 equivalent of 10.Secretion assays were performed as previously described . Polyclonal antibodies against VgrG1abc were used at a dilution of 1:1,000  cells was set as a standard for VgrG1a content in the cell. All measured intensities for other bands were divided by the intensity for VgrG1a under WT conditions. RpoB was used as protein loading control.P. aeruginosa strains contained the Mini-CTX-lacZ integrated at the att site, consequently resulting in blue colonies on X-gal-containing plates. Overnight cultures in TSB were collected by centrifugation at 8,000 g for 3 min before washing twice in 1 mL sterile PBS and normalized to OD600 of 1.0. The OD600 was measured again for confirmation and 100 μL of attacker and 20 μL prey strains were mixed. This mixture was centrifuged at 8,000 g for 3 min and 20 μL supernatant was removed to give a competition mixture ratio of 5:1 of attacker and prey strains. Twenty microliters of each competition mix was spotted in duplicates onto LB-agar, the spots dried and the Petri dish lids were secured using parafilm M (Bemis). Competition plates were inverted and incubated at 37°C for 5 h for H1-T6SS-inducive killing.Interbacterial competition assays were conducted on solid media due to the contact-dependent killing of the T6SS. Prey −7, plated on selective media for both attacker and prey  and grown overnight at 37°C to confirm the input ratios. Competition spots were collected using 10 μL inoculation loops (VWR) and resuspended in 1 mL PBS. The competition output mixture was serially diluted to 10−7, plated on selective media and grown overnight at 37°C similarly to the input. Both attacker and prey colony forming units were enumerated on both input and output dilution plates. All competition assays were repeated three times unless otherwise stated and the mean colony forming units (cfu) of survived prey strains obtained from all experiments with the standard deviation was plotted.The input competitions were serially diluted to 10tde1 or tap1-tde1 were cloned into pUT18C and pKT25 and sequence confirmed. Variations of both vectors were introduced into E. coli DHM1 via heat shock and selected on LB plates containing both Kanamycin and Ampicillin. Resulting colonies were picked and grown in LB containing both antibiotics and overnight cultures were spotted onto LB containing Kanamycin (100 μg μL−1), Ampicillin (100 μg μL−1), IPTG (1 μM), and X-gal (100 μg μL−1) and grown for 48 h at 30°C.Genes expressing A. tumefaciens as the heterologous effector, firstly because the Tde1 orthologs are only found in a-proteobacteria and secondly because, its basic delivery system has previously been studied in great details  is assembled to a functional trimer and capped by the cognate PAAR protein, with one PAAR protein binding the three last VgrG1A β-strands. Concomitantly, Tap1 interacts with and stabilizes Tde1 within the cell and the Tap1-Tde1 complex is recruited to the C-terminal amino acids of VgrG1A. Since Tap1 was not detected in the supernatant fraction, it is believed to be released prior to secretion, while Tde1 remains bound to the VgrG1A spike, which is propelled out of the cell . To assess whether P. aeruginosa is naturally able to deliver Tde1 using its H1-T6SS, we introduced the plasmid pTrc200 containing the A. tumefaciens tap1-tde1-tdi1-paar (t-t-t-p)  suggesting no efficient Tde1 secretion even in the presence of its cognate VgrG. Again, some traces of Tde1 are found in the supernatant of the T6SS-inactive background (lane 14) but it correlates with elevated RpoB levels. Interestingly, a decreased amount of Hcp1 in the supernatant fraction (lane 13) could clearly be seen which suggests that the H1-T6SS function is altered in the presence of VgrG1A, possibly because the heterologous VgrG is able to partially connect to the P. aeruginosa T6SS but is then not further engaged in the secretion process.We aimed at directing the heterologous effector Tde1 toward VgrG1a from the H1-T6SS in t-t-t-p)  into P. n assays . For allA. tumefaciens VgrG1A, we decided to design chimeras to directly connect Tde1 to the P. aeruginosa VgrG1a. It was established that the 31 C-terminal amino acids of VgrG1A is required for binding the Tap1-Tde1-complex and a prerequisite for Tde1 delivery in A. tumefaciens  contains the full length VgrG1aP extended by 31 C-terminal amino acids from VgrG1A, thus including amino acids likely responsible for binding the cognate A. tumefaciens PAAR and Tde1  covers the first 605 amino acids from VgrG1aP and 31 C-terminal amino acids from VgrG1A, while construct C (VgrG1aP614-G1A21) comprises of the first 614 amino acids from VgrG1aP and 21 C-terminal amino acids from VgrG1A.As an alternative to using the entire ruginosa , green aefaciens , blue toretS background and performed secretion assays  assay, in which the three chimeras as well as a catalytic Tde1 mutant carry the T18- or T25-domains (T18/25) at their C-termini. When testing interactions between Tde1 and any of the VgrG-constructs, no blue colonies appeared indicating that the two proteins do not interact . When Tap1 is present, dark blue spots could be readily observed suggesting strong interactions between Tap1-Tde1 and any of the VgrG1aP-G1A-chimeras. The fact that construct C efficiently associates with Tap1-Tde1 suggests that as little as the 21 C-terminal amino acids of VgrG1A are sufficient to mediate this interaction. Intriguingly, Tap1-Tde1 binds only very weakly to VgrG1A, which might be due to the lack of the cognate PAAR  were grown for 5 h at 37°C in the presence (+) or absence (–) of a plasmid carrying the tap1-tde1-tdi1-paar (t-t-t-p) genes. Western blot analysis was performed on whole cell lysates probed for Tde1 and VgrG1abc (P band in absence of Tde1 was quantified (bottom plot) and served as a standard for VgrG1aP level. The intensity of any bands corresponding to VgrG1aP/constructABC was quantified and divided by the standard intensity for VgrG1aP in Tde1 absence  and construct A (lane 9). We also monitored Hcp1 as a readout for T6SS functionality (bottom panel) but detected this protein only in the supernatant fractions of strains expressing and secreting VgrG1aP or construct A. Neither chimera B or C, nor Hcp1, were detected in the supernatant fractions when using strains expressed chimera B or C (lanes 10 and 11). This confirms that only construct A is able to form a functional T6SS tip.Having established that chimera A is proficiently secreted and that the heterologous effector Tde1 seems to bind to it for stability, we then aimed at testing whether chimera A could be a secretion vehicle to deliver Tde1 from ionality , and we ar genes . Westernf VgrG1A  revealedA. tumefaciens was grown under T6SS-inducing conditions  is secreted, we did not find conditions which resulted in effective Tde1 secretion. There are a few observations that may explain this controversy. First, we noticed an impact on the secretion efficiency of construct A in presence of Tap1-Tde1-Tdi1-PAAR (P and construct A are secreted into the supernatant in absence of Tap1-Tde1-Tdi1-PAAR (lanes 1 and 3). However, whereas in the presence of Tap1-Tde1-Tdi1-PAAR, VgrG1aP secretion level is unaffected (lane 2), the secretion of construct A drops to 20% (lane 4). This is a remarkable finding which suggests that Tap1-Tde1-Tdi1-PAAR does interfere with construct A secretion but not with VgrG1aP and this correlates with the evidence that Tap1-Tde1-Tdi1-PAAR interacts with construct A but not with VgrG1aP.Despite our data suggesting that Tde1 may interact with and stabilize chimeric VgrG1a spikes in di1-PAAR . ApproxiP-dependent PAAR effector Tse6 into prey cells would be affected as well. In WT cells, VgrG1aP is able to drive killing of Tse6-sensitive cells as shown previously , confirming that Tse6 delivery depends on VgrG1aP  leads to an intermediate phenotype suggesting that Tse6 delivery is affected but not completely abrogated. This correlates with the fact that construct A is still secreted but in smaller amounts (The number of recovered prey cells (cfu) was lower when incubated with strains expressing VgrG1aP , lane 1  amounts , lane 6,A. tumefaciens to the T6SS of P. aeruginosa. We reasoned that a T6SS spike/VgrG could accommodate to the endogenous T6SS machine through its conserved domain, while the additional variable domain could be manipulated to adapt recognition of a heterologous effector. With this in mind we hypothesized that specific interactions between the effector Tde1 and the appropriate C terminal region of its cognate VgrG1A might be sufficient to attach the effector to a chimeric but heterologous VgrG spike. We constructed three chimeras made of the P. aeruginosa VgrG1aP and the Tde1 binding amino acids from VgrG1A, but none of them was able to complete Tde1 delivery in P. aeruginosa.Bacterial protein secretion systems are highly specific and proteins secreted by a given secretion type (T1SS-T7SS) usually fail to be recognized by another type due to the lack of appropriate secretion motifs  could also bind to each monomer of the chimera A spike complex, with such interaction having been confirmed by the bacterial-two-hybrid assay  was not able to perform the same function. This might suggest that the C-terminal residues of VgrG1a are required for specific interactions with its cognate PAAR effector Tse6, and ultimately the presence of the PAAR in the spike would be needed for effective secretion of the whole spike. This explanation is consistent with recent findings that effector loading onto its cognate VgrG spike activates T6SS assembly  (Salomon et al., Our study confirmed that heterologous secretion cannot easily result from simple and straightforward genetic manipulations and the recognition of a secreted effector by its own machinery has likely resulted from a longstanding co-evolution which guarantees specificity. This way it would be hard to hijack the process and only intended effectors are released upon specific conditions, avoiding also any leakage of intracellular proteins. In the T6SS where C terminal motifs in the VgrG spike are proven to confer effector recognition specificity, search for motifs within the effector All datasets generated for this study are included in the article/SW contributed to conceptualization, investigation, methodology, and writing the original draft. E-ML and AF were responsible for the conceptualization, funding acquisition, supervision, and reviewing and editing the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


An increase in physical activity (PA) level is associated with reduction in chronic diseases. However, the number of older adults who meet the PA guideline is low and decreases with age. Bodywise is a free program that aims to promote healthy behavior and to encourage older adults who live in Washington, DC to adopt a healthy habit by increasing their PA. The Bodywise program offers water aerobics, yoga, low-impact aerobics, and chair exercise classes, conducted by trained instructors at the University of the District of Columbia. This study reports an evaluation of the implementation of this program based on the surveys completed by participants after finishing the classes. Participants were DC residents aged 60 or older. According to the surveys, 68% of participants have adopted one or more healthy habits since joining the Bodywise program. In addition, more than 62% of participants have an increase in awareness of healthy behavior through this program. Overall satisfaction with the Bodywise program is 93%, satisfaction with the variety of classes offered is 72% and satisfaction with offered skill levels is 75%. Furthermore, 81% of participants reported overall satisfaction with their instructor, specifically 100% satisfaction related to their knowledge and skill level, and appropriateness of selected music, moves, and exercises. In conclusion, the Bodywise program leads to an overall change in both awareness of healthy behavior and development of healthy habits in participants. Further research can investigate the correlation of health awareness and healthy habits with overall satisfaction with the program and the instructor.


Focus groups were also held with respective school teachers and principals. An inductive content analysis generated three themes that represent the perceived impacts of this urban IYMP offering: (1) Fostering Wellness, (2) Strengthening Meaningful Connections, and (3) Exploring Leadership. Findings are positioned within a communal mentorship framework that is circular and multi-directional. By bringing together Indigenous and non-Indigenous peoples, this program offering supports Indigenous cultural relevance in an urban-based wellness program.Peer mentorship is an effective approach for delivering health promotion programs that may be particularly useful among underrepresented populations. Advancing the peer-led approach, the Indigenous Youth Mentorship Program (IYMP) is a communal-led program rooted in Indigenous values aimed at the promotion of healthy lifestyles in children and youth. The program includes layers of multi-age mentoring  and incorporates three core components: physical activity, healthy eating, and cultural teachings. The purpose of this study was to qualitatively explore elementary student, mentor, and YAHL experiences in an urban IYMP offering. Eleven sharing circles were conducted; six with elementary students ( Peer mentoring in health promotion programs is an effective method of delivering content and enhancing wellness, and it may be particularly useful among underrepresented populations . Peer meRecognizing, honoring, and celebrating the strengths of Indigenous youth can have meaningful impacts on health and wellness. There is a small but growing body of scientific evidence that Indigenous peer-led programs benefit Indigenous children . As chilTM, created in British Columbia, was a school-based, peer-led program that included more traditional education or curricula  student you just sometimes, you get so busy in life you kind of forget to... you don’t have much time to work out and stuff so I was glad to run around and participate in some of those games. I mean, it was to get movement for me, so it really helped me physically in that aspect.”“fun activities that challenged their perspectives of why they engage in physical activity themselves. One of the YAHLs explained:The YAHLs and mentors benefitted from engaging in …it was nice because it was different from the activity I would typically be doing and kind of made you realize that physical activity isn’t just all working out per se; it can also be playing and just, you don’t even really realize you’re being–you’re exercising really because you’re just having fun. Um, so definitely made me kind of look at being active, I guess, in a new way or developing new ideas of how to be active.”“(Harry Potter)new games/activities and learning about healthy eating helped them change some of their habits. Overall, the focus on physical activity–and subsequently physical wellness–in the IYMP translated into opportunities for mental wellness , exemplifying the ties between different aspects of wellness.The elementary students’ perspectives of physical wellness were also expanding, as many of them expressed that learning A focus of the physical activities included in the program  was cooperation and teamwork, which created a relational element to the physical component of the IYMP, as noted by Wonder Woman (elementary student) in I feel like for sure my physical, mental, and emotional aspects were like extremely attached with being able to have this [program]…I actually wanted to participate in because I’m not a big physical activity fan but when I’m leading with other kids, I’m kind of, like, not forced to be, like, you know, excited about it, but we have to be and so, um, that encouraged me to actually start doing it. So I was definitely, um, being more physically active.”“personal physical wellness by developing a community of active people who encouraged and supported each other to make physical activity fun and engaging. Wonder Woman’s and Madeline’s sentiments exemplify the interconnected nature of wellness, and that the physical activities impacted perspectives of physical wellness in a positive and relational way. These experiences suggest that the program went beyond a sole focus on The perceived impact of the IYMP on emotional wellness was largely a result of the relationships that were developed with one another. Relationships generated in the IYMP provided safety, support, and comfort for many participants:Going to the [university], I’m kind of out of my comfort zone, like in terms of being away from home and being away from my like support system…it was a tough semester for me this past year and I’m glad I made it through and just being a part of this program here really, uh, helped me emotionally…”“Common amongst all mentors and YAHLs was the feeling of contributing to something important and having a positive impact on others. This sense of pride is a notable strength of the program. Yuzuru (mentor) described how this connected to their emotional wellness:When it’s positive growth that we’re trying to introduce into their lives and for us to be able to participate in this, that meant a lot to me because maybe in the future it might affect these children a lot more or maybe it’ll affect them less but in some way, shape, or form I’ve come to realize that it has affected me too in a positive way because whenever I saw the kids it was—it made my day better and I was much happier because I’ve realized that, you know, it’s possible that I might have been able to make, like, a small positive change in the world.”“Batman (YAHL) also shared how IYMP held emotional meaning for them as a leader in the IYMP:…like being involved with stuff like that, like volunteer-type extra-curricular stuff, it really, you know, makes me emotionally—it really helps me a lot knowing that you’re, you know, working towards a good goal and something positive and that you’re impacting people’s lives. I mean, that really, really made me feel really good.”“Yeah, um, I tried to really build my confidence because we were doing more activities. I feel like braver now because I can control more of my emotions.”While the leaders were experiencing emotional wellness because they had an important purpose in supporting the elementary students, the elementary students were also experiencing emotional wellness because of the support they were receiving, displaying reciprocity within the program. Some elementary students explained that they were able to regulate their emotions better as a result of their IYMP experiences. It’s Me (elementary student) shared: “When I was at the program I was really, really happy because I met a lot of new people.” Harry Potter (YAHL) added, “That’s what the program is all about, is having fun and building relationships.” The most common emotion mentioned when discussing the program was happiness. Jack (elementary student) shared how the opportunity to be present in a positive and happy environment impacted them see . JocelynThe prominence of happiness was strong evidence that the program impacted participants’ emotional wellness.It helped me not be lonely and just not be quiet all the time and collect my words right instead of being shy all the time.” . Connecting with one’s identity while engaging with others was an important aspect of some of the participants’ experiences, and reinforced the strengths-focused nature of the program. Participants expressed the IYMP was a safe environment to be themselves while also exploring new challenges:The perceived impacts of the IYMP on emotional and mental wellness were closely connected, making it difficult at times to clearly distinguish whether emotional or mental wellness best represented participants’ experiences. As a guide, the focus on mental wellness leans toward the mind, learning (including self-learning), and developing. Involvement in the IYMP helped some participants to build positive self-image and provided opportunities for growth: “I made a bunch of friends like you guys…helped me to not be afraid and just let me be myself there so I obviously made more friends and I learned how to be more, more gentle and more creative with myself than rather just copy other people.”“Sometimes it would calm me down and help me not be nervous. It would just calm me down.” Related to this is the stress-reducing effect that the program had on the YAHLs: There were many examples shared of IYMP helping to reduce stress, which speaks to a positive attitude generated through the program. Both Alex I think some of the things that we learned were really cool and I would like to share them and it did make me more interested in it.” This motivation to learn and grow suggests that participating in the program impacted mental wellness.The IYMP also provided a variety of new learning opportunities for participants and this fostered an openness to further exploring unfamiliar activities, teachings, and ideas. Sarah (YAHL) explained, “The IYMP’s power of connectivity was discussed by all participants. The program facilitated connections to people, to culture, and to community and, at times, the connections operated in multiple ways. For instance, it was at least partially through building relationships that program participants engaged with culture, and building a connection with community included connecting with people. In an attempt to honor each connection, this theme looks at building relationships, growing culture, and lifting community.Relationships were at the heart of the program and integral to its success:I think one of the biggest positives and one of the biggest things that everyone got out of the program, um, is probably building those relationships with everyone and I think that was such a key part of the program.”“The program facilitated the development of new relationships, as well as the growth of existing relationships. For the elementary students, engaging with people who were older than them was often mentioned as a favorite part of the program: “What I really liked is getting to meet everybody and making new friends” . These new relationships held meaning for many of the mentors as well, as exemplified by Yuzuru (mentor) who enjoyed the chance to strengthen relationships with the elementary students see . Multiplwould just get mad at us and yell at us.” Though few in frequency, the effects of these instances included diminished feelings of belonging amongst the elementary students, while the mentors felt disrespected as leaders. Integral to quality relationships within the IYMP was reciprocated respect; when individuals in one role offered respect to others, they received respect in return; and vice versa. There were instances when a lack of respect was evident; John Cena (elementary student) shared that sometimes the mentors “I felt like I was meant to be there” (Elsa), and another elementary student explained, “The more and more I went there the more I felt like I belonged there ‘cause it was really fun meeting all these people, playing games with them, and sharing stuff with them” (Sir Blargon). Batman (YAHL) expressed their own sense of belonging:When respect was evident, relationship-building created a sense of belonging. One elementary student stated, “I felt like I belonged with a lot of the First Nations kids that were there. Felt really good being there. The program was great, I mean the people you work with was really good…I think that’s key, you know, like having just team players in the program is really, really, really important.”“There were times when relationship-building within the IYMP extended to impacting relationships outside of the program. Yuzuru (mentor) shared how the program motivated them to put more energy and time into important relationships:I was able to kind of find more joy in hanging out with my siblings and being with them because usually I get along with them fine but you don’t necessarily go out of your way to just interact with them, so that was fun because I realized that some kids don’t really have older siblings to look up to or they—if they do, it’s kind of a tumultuous relationship, so I tried to reach out to them more.”“This increased effort and appreciation of existing relationships external to the program speaks to the power of relationship-building within the IYMP.I’m definitely more curious and if I get a chance, I want to learn more,” .As a core component of the IYMP, the YAHLs and mentors planned a range of cultural teachings  that were memorable for many program participants. The increased awareness and knowledge of Indigenous cultures sparked a desire in some participants to continue learning: “The structure and philosophy of the IYMP is centered in an Indigenous worldview, which includes an inherent shared responsibility of learning and belief that learning is relational. It was apparent that participants in all roles of the program were learning and growing together:I think every session and every year I learn more and more. There’s always people that know stories that you’ve never heard before or know of cultural activities that you’ve never seen or engaged in before so, um, I definitely learned more I think.”“Many program participants reported enhanced engagement with the cultural component of the IYMP because of the shared responsibility for learning. Yuzuru (mentor) explains:I felt as if I was able to connect more with what we were learning. Not necessarily that I learned more but that we were exploring it on a different level—kind of having to understand it and then explain to the kids for them to be able to understand it and for us to explore these concepts together was very important.”“I was really happy and excited to be able to share some things about Métis culture and that made feel really proud and excited to share.” . Similarly, Alex (YAHL) expressed:The YAHLs experienced a sense of pride in being able to share pieces of their own culture: “Practicing making the Métis sashes at home, my family was helping with me [laughter], like they were really excited to hear about this program and I think—my dad is where the Métis ancestry comes in my family, so I think he was really excited that I was making these connections, so I’ve shared a lot with them and then friends and other people at school. I think it’s important to know that these programs are here and they’ve been really beneficial so I’ve been trying to share a lot about what we’ve been doing.”“Especially having grown up without knowing much of my heritage—my First Nations heritage—it was nice to have, uh, be involved in a program that was about educating on it and learning some of the cultures”. The IYMP was therefore meaningful for some participants because they had the serendipitous opportunity to engage with cultural teachings that related to aspects of their personal identity. Engagement with one’s own culture was also evident for some participants, including Shrek  quote in We got to, um, combine kind of our two schools, um, which I think really helps bring together the community.” Sometimes guest instructors or visitors from the larger community were invited to lead program sessions, again, fostering community connection:Some program participants also felt stronger connections to the wider community outside of those involved in the IYMP. Madeline (mentor) expressed “I also liked the days where we brought in people from the community. Like the days that we did Pow Fit and then the Cross Fit days. I think that was really cool to bring in other people that had knowledge that we didn’t necessarily have and then we all got to do it together.”“It made me feel safer because I love some of these places and I can walk to them.” As a result of building and nurturing connections to the wider community, some mentors and YAHLs placed more value on community and were inspired to give back: “It made me, I think, want to become more involved in volunteering activities in the community so I’m getting involved with those things too.” . This suggests a potential rippling effect of lifting community that was fostered in the IYMP.Elsa (elementary student) shared how nurturing community connections through the IYMP impacted their own feeling of safety while they were out in the surrounding neighbourhood: “I think that was my favourite thing, is like seeing the way they look up at us and like how much they actually value like, what we’re teaching them.” . Batman (YAHL) shared:Many of the mentors and YAHLs viewed a large part of their responsibilities as being a leader and role model for the elementary students, and they valued this important role: “Any time that I can be present in a school setting like that is really important so I know to be a good role model and to, you know, let kids know that, uh, especially First Nations, let them know that us too, we can flourish in those environments and, you know, in those settings, you know, be active and be able to participate in extra-curricular activities and sports, especially too.”“Mentors and YAHLs displayed leadership not only by leading group activities, but also by leading by example and finding ways to engage with students who required more support and encouragement. As touched on by Daisey (mentor), they had the opportunity to practice and build a variety of skills and qualities related to leadership, including patience, communication, responsibility, initiative, and time management, amongst others see .These leadership qualities were required from the mentors to create a positive experience for the elementary students. If ever leadership was lacking from the mentors, who themselves were still growing and learning, it negatively impacted the elementary students’ enjoyment of the program. …uncomfortable and they retracted” . For others, they immediately embraced working with the elementary students and rose to the position of leader: Embracing a leadership role required many individuals to step outside their comfort zone. Given the high school students were serving as mentors as part of a high school class, as opposed to volunteering to be a mentor, this presented challenges for some who were “By having it like as a course requirement to take part in this program, um, I think we got girls engaged with children and working with children and seeing strengths in themselves that we—they wouldn’t have been able to find had this program not existed.”““…I’m quite shy, so I actually think this program really helped me, um, get out of my shell a little bit, so I think I gained a lot of, um, confidence in being in more of a leadership role.”Many of the YAHLs and mentors embraced their leadership role and looked for ways to grow in their roles. Alex (YAHL) explained, The willingness to bravely engage in new experiences resulted in enormous growth:Our role was to grow ourselves, to grow as our own people and become more accustomed to interacting with others, especially younger children, in being able to communicate well and participate in these activities and learning these leadership skills and community values.”“Madeline (mentor) offered another perspective about growing as a leader:…for us it was like a learning experience, you know? Like learning how to lead in our communities and stuff and realizing how easy it is to, like, make an impact. And then our role was also to be, you know, show these positive characteristics and stuff and so that the [elementary students], who look up to us, can like see those, um, and learn and be like, ‘That’s what like, you know, a good high school student is like.’ It’s like, ‘That’s who I want to be,’ kind of thing and so that they can take that and incorporate that into their own lives I think and just, like, be that role model for them.”“When I’m older I want to be a teacher and so this gave me a really good perspective on, like, what that’s going to be like I think,” (Madeline). The IYMP may have a lasting impact on the opportunities that Madeline and other mentors decide to pursue in the future.The IYMP provided the opportunity to practice leadership skills in a safe context. One mentor shared that this experience has affected and reaffirmed their future career goals: “Both the mentors and YAHLs recognized the importance and impact of mentorship and building relationships as part of their leadership roles. Though mentorship may not always be considered an inherent part of leadership, being a mentor was identified as a salient component of leadership experiences in the IYMP.[In the first few sessions] we were unable to communicate clearly because we didn’t really have an understanding in how to interact with younger children, even us with younger siblings because it’s different when you’re interacting with kind of complete strangers and you try to become closer with them, like an older sibling figure, so later on in during later dates, when we were doing IYMP, it was easier for us to speak with them and to get them to do the activity that we were planning, to get them to participate.”“Yuzuru speaks to the positive impact of the ongoing mentorship relationships with the elementary students and how this affected program implementation. Rhino spoke to how they felt in the mentorship role as a YAHL, and hopes for both a good and lasting impression as a role model see .liked the [mentors] ‘cause they helped us out,” and Amelia (elementary student) took comfort in knowing that “there is always someone there for you if you need it.” Support also flowed from the YAHLs to the mentors. Harry Potter (YAHL) explained that their role was “… guiding them [mentors] along and um, encouraging them to come up with their own ideas and encouraging them to participate.” Alex (YAHL) expanded:An inherent feature of the IYMP was that each role in the program was supported by other roles, and this was recognized by many participants. The elementary students recalled that they had people to turn to when they needed help. Brenda Bob (elementary student) shared that they “The students that weren’t participating or kind of hesitating, like, I tried to really talk with them and get them to be more engaged because I think this was about bringing everyone together, so some of the quieter students that didn’t want to help out—the high school students at first—tried to support them and make them feel welcome and that they can step up and be that mentor as well. I think, um, was a role that we had as university students that I think was beneficial.”“This helping hand to those that needed it was very important to fostering relationships between YAHLs and mentors with elementary students.Something that hindered the impact of mentorship within the program was the lack of young men as mentors. As a girls’ high school class served as the group of mentors, the elementary boys lacked men role models/mentors, which impacted experiences in the program:That was one thing that the [elementary students] said that—they didn’t like that they didn’t have kind of a group of guys. The guys felt like, ‘I’m not gonna go up to a girl and ask if she wants to be my partner.’ So…they felt really out of place.”“every student through mentorship.There were a few men YAHLs involved in the program that, when present, facilitated an increased sense of belonging, comfort, fun, and support for the elementary boys. However, the attendance of these men YAHLs was sporadic due to other commitments, creating a challenge in trying to reach We qualitatively explored YAHL, mentor, and elementary student experiences in the IYMP, and in doing so we identified a number of perceived impacts of the program; namely, wellness, connectivity, and development of leadership skills. Rather than the success of the program and potential impacts falling on the responsibility of a select few, every role in the IYMP contributed to fostering wellness, connections, and leadership. While the findings of our qualitative description stood near to the data, we offer nuanced interpretation  by elaboMentorship is an inherent feature of the IYMP , and ourUnanticipated mentorship may have also contributed to perceived program impacts. The IYMP offering described in this paper included unintended mentorship beyond that from the YAHLs, mentors, and national IYMP team. For instance, having the program delivered during school hours as part of students’ classes meant the involvement of teachers and principals. Though their novel inclusion led to some uncertainty regarding their roles , the involvement of these individuals provided unexpected mentorship opportunities. For instance, teachers offered gentle suggestions to YAHLs and mentors on how to get students engaged. As another example, as a member of the research team our community advisor provided invaluable guidance within the school system and facilitation with school staff and school leadership. These examples of unanticipated mentorship are a form of partnership development between researchers, practitioners, and various knowledge users. Our research, therefore, contributes to a larger body of literature that underscores the importance of developing meaningful partnerships to enhance program development and implementation . For insFostering Wellness in the current study was spiritual wellness. A few of the YAHLs spoke of the personal engagement they experienced between learning Indigenous cultural teachings and their own spirituality. However, spiritual wellness was discussed to a much lesser degree and from fewer participants than other wellness dimensions. Given that all of the YAHLs self-declared their Indigenous identity, some components of the program may have more closely aligned with their own spiritual wellness than non-Indigenous mentors and elementary students. Spiritual wellness has been affirmed as an important aspect of maintaining human wellness, not just Indigenous peoples’ wellness [As a healthy lifestyle program, it was perhaps not surprising that participants identified positive impacts on their wellness, namely physical, emotional, and mental dimensions of wellness. Wholistic wellness, consisting of physical, emotional, mental, and spiritual wellness, is essential for human potential ,37. Absewellness . It is pwellness . Personawellness  may haveAlthough not dimensions of wholistic wellness, autonomy and self-determination are meaningful for health and wellness. Autonomy is an innate psychological need referring to the desire to self-organize experience and behavior in a way that aligns with one’s sense of self . Self-deIt is important to note the unequal gender representation among leaders in the program. The school division associated with this program has separate grade 10 wellness classes for boys and girls, and school division partners had selected the girls’ class to be mentors for the program. Moreover, there were nearly double the number of women YAHLs compared to men YAHLs across the two years the program was offered. This gender disproportion in the program is echoed in the literature where, for example, Indigenous women surpass Indigenous men in educational attainment . Having Growing Culture sub-theme is particularly meaningful because establishing cultural relevance can be challenging in an urban community research setting [The IYMP offering associated with this study was unique in that it was one of only a few urban-based IYMP programs . As the program took place during class time, teachers linked the program to various physical education, wellness, and health education curricular outcomes. It is important to recognize the unique context of this IYMP offering and the adaptations made by the community, as the contextual features may have contributed to perceived impacts of the program.As an urban offering, the program included both Indigenous and non-Indigenous mentors and elementary students. The inclusion of non-Indigenous peoples in an Indigenous-based program provided an opportunity for non-Indigenous peoples to respectfully learn about Indigenous ways of knowing, being, and doing. The potential benefits of learning Indigenous ways of knowing, being, and doing include enriching, expanding, and challenging non-Indigenous approaches to wellness . It has We embrace a relativistic approach and invite the reader to adjudicate our qualitative study based on its context, conditions, and purpose . In doinBuilding on the findings reported in this study, three directions for future research are proposed: (1) exploring the potentially unique benefits emanating from programs with prescribed versus elected mentorship; (2) directly examining the benefits of learning about and experiencing Indigenous ways of knowing, being, and doing for non-Indigenous program participants; and (3) program evaluation that embraces a culturally responsive approach. As discussed elsewhere , it will


Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings.To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships.a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted.An electronic search was conducted using four databases for manuscripts on EM training programs – defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care – developed through partnerships. The search produced 7702 results. Using Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding.Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally. The World Health Assembly Resolutions 60.22, 68.15, and 72.16 all highlight the significant gap between the need for and the provision of emergency care that currently exists globally 12. Low-incEmergency care systems – which broadly include the provision of both acute and emergency care and services – are comprised of at least five major components: individual and community capacity, preparedness, and resilience; delivery of appropriate out-of-hospital care by laypersons; a means of access to formal services by the public; transport and/or delivery of appropriate pre-hospital care by trained professionals; and clinical care and referral networks 6. The sp56789Although still a relatively young specialty, EM has been expanding rapidly across the globe, and more than 50 national EM organizations are now members of the International Federation for Emergency Medicine (IFEM) . Althoug121314Though programs developed from such educational partnerships are increasingly common, there is little to describe their features. One review describes some of the features of training programs in LMICs, but it does not specifically focus on programs resulting from partnerships . Additioa priori were EM training programs developed in the hospital or clinical setting in an LMIC – as defined by the World Bank at the time of the search – and supported by at least one higher-resource international partnership [An electronic search using PubMed, Web of Science, CINAHL, and EMBASE was conducted for all available publications to the date of the search (30 August 2018) without restriction on the scope of the EM content, the training level of the learners , or the length of the program . The search strings may be found in Supplement 1. We have defined an EM training program as “structured education and/or training in the methods, procedures, and techniques of acute or emergency care”. Inclusion criteria determined The included manuscripts were then scored by the reviewers in order to select and more closely examine a high-quality subset. Each manuscript was scored by two reviewers and manuscripts with scores differing by more than three points (n = 13) or that differed between reviewers across the threshold for inclusion n = 19) were reviewed and scored a third time. Scoring (0–2 points for each category) focused on seven areas: manuscript design, overall quality, overall clarity, ethical considerations, significance, description and/or study of program attributes and/or learner or clinical outcomes, and type of providers (Supplement 2). The methods used for this scoring were adapted from methods established in other reviews in the field of global EM [ were revAbstracts were screened using Covidence . Statistical analyses  were done using Microsoft Excel and Stata/IC v15.1 . The study was registered and approved by PROSPERO (Registration: CRD42018100194).The search produced 7702 results. A total of 2433 duplicates were removed prior to screening, leaving 5269 studies to be screened by two reviewers. From this, 105 manuscripts met inclusion criteria for scoring. Of these, four were found to be in high income countries, six could not be obtained, and one was found to be a duplicate, leaving 94 manuscripts in the final analysis . Additionally, eight programs focus solely on nurses and six on medical students. Finally, more than half of the programs are of short duration. Only three are of medium duration, and 15 are of long duration . When assessing the inter-rater reliability to distinguish “low-scoring” from “high-scoring” manuscripts, the reviewers agreed 80.0% of the time . A total 26 manuscripts received an average score of 12 and above.Fifteen of the high-scoring manuscripts focus on seven specific content areas . They span the years 2012–2018, are published in twelve journals, and highlight work in thirteen countries (Table 202122232425262728293031323335363738394041424344Participants include nurses (two programs), medical students (two programs), physician assistants (one program), physicians (five programs), and nurses and physicians together (one program). All of the manuscripts describe all or a subset of the following components: goals/objectives, program certification/recognition, curriculum outline/content, methods of assessment, funding, logistics, educational resources, outcomes, and challenges Table .Each of the eleven programs conducted formal needs assessments and/or had focus group discussions to identify learning gaps and to determine the content, style, and/or duration of each program, fulfilling the first two steps Kern et al.’s six-step model for curriculum development . These e3841More than half of the manuscripts discuss alignment with local or national governing bodies, such as the Ministry of Health (MoH) regarding formal recognition, licensing, and/or certification of their respective programs.The curricula highlighted in these manuscripts span short, foundational programs to medium-length programs with abbreviated, comprehensive EM curricula to full-length residency programs (of at least three years). All offer mixed learning methods ranging from traditional didactic lectures and small group discussions  to hands-on practical sessions and workshops, such as simulation and procedural training. Curricula are often organized into blocks or modules by topics or organ systems. Longer programs allocate one to three half-days every one or two weeks for learning sessions in addition to daily bedside clinical teaching. Volunteer patients, mannequins, laminated algorithms, white boards, and other simulation materials as well as video/online materials, handbooks, and textbooks are highlighted as curriculum tools. Many programs incorporate pediatrics as well. All residency programs list the requirement of off-service rotations, such as surgery, anesthesia, and critical care. Only one manuscript offers extensive online access to their curriculum map and resources . One of All programs have a written component of assessment. These examinations consist of multiple-choice questions, short-answer, and/or essay questions. Many manuscripts highlight programs that also have practical examinations – skills stations, oral and/or case-based examinations as well as objective structured clinical examinations (OSCEs). Longer programs also often track attendance and require case and/or procedure logs with minimum required numbers. Minimum passing requirements for examinations and attendance, when specified, range from 70–80%. There are often end-of rotation evaluations and performance audits, especially for residency programs with off-service rotations. There is usually ongoing informal feedback and mentorship. One program mentions requiring a thesis .Three of the 11 manuscripts do not discuss how their programs are supported, while the others note a combination of private donors, non-profit organizations, healthcare organizations, and funding from universities in higher-resource settings. Manuscripts that mention their funding sources note a mix of self-funding or subsidized funding for international faculty. Among the larger funding sources listed are the Abbott Fund, USAID, Grand Challenges, and Project HOPE. Salary for learners in residency programs and fees for learners for non-residency programs are less clear – at least one program notes that there are no fees for their learners, and those who had to travel for the program received room and board .All of the programs involve international visiting faculty for ongoing full or supervisory support either in person and/or via teleconferencing, messaging, or other methods of remote engagement. Visiting faculty contributions are described as ranging from one week up to multiple years onsite and/or remotely. Longer programs tend to have curricula that repeat one or more times over the course of the program. Train-the-trainer techniques are used in two of the programs 43. Two p38International Journal of Emergency Medicine), and American and Canadian graduate medical education (GME) resources.Content for the curricula is drawn from a variety of sources – usually initially from EM content belonging to the high-resource partner. Specific materials and organizations listed among the programs for reference include basic life support (BLS), advanced cardiac life support (ACLS), advanced trauma life support (ATLS), pediatric advanced life support (PALS), textbooks , World Health Organization (WHO) resources (such as Integrated Management of Adolescent and Adult Illness and Integrated Management of Childhood Illnesses), Canadian Association of Emergency Physicians (CAEP), American College of Emergency Physicians (ACEP), IFEM, Society for Academic Emergency Medicine (SAEM), African Federation for Emergency Medicine (AFEM), European Society for Emergency Medicine (EuSEM), World Association for Disaster and Emergency Medicine (WADEM), Australasian Society for Emergency Medicine (ASEM), Consortium of Universities for Global Health (CUGH), Johns Hopkins Global Health, international EM journals  as well as issues with remote connection and use of local and remote technologies are also highlighted. Additionally, lack of continuity and connection between learners and the rotating visiting faculty – who may be present in person for as little as one week – leads to reduced engagement and morale. Decay in knowledge, especially after short programs, is also a concern, with re-assessment between 2–3 months highlighted as potentially an ideal time for re-assessment or refresher training. Difficulties with both learner  and curriculum flexibility leads to attrition for many programs. There are also ongoing concerns regarding sustainable funding highlighted in several of the manuscripts – for the program, for visiting faculty, as well as for learners/graduates.These manuscripts describe many types of EM programs being implemented via partnerships worldwide to train in-hospital personnel critical for the overall development of emergency care systems – from short, focused courses on topics such as ultrasound training or trauma training to full residency programs. The most established programs are those that are of at least one year in duration and those with formal integration into the healthcare and/or medical education system of the country (e.g. supported by the MoH). These programs can then offer official certification and/or credentialing to ensure that graduates will have both potential positions and financial security as well as a career path as EM develops and the culture of practice changes.All of the programs involve on-site and/or remote international faculty for varying lengths of time; however, programs in which at least a core subset of faculty are involved in face-to-face teaching through the duration of the program foster stronger partnerships and allow for continuity of evaluation as well as continuous improvement and adaptation of the program. Given the differences in resources and culture of practice, all visiting faculty need at least prior experience in education/training and low-resource environments and/or a comprehensive orientation to the site prior to providing instruction. One manuscript describes the challenges of conflicting expectations between instructors and learners due to the limited preparation and experience by the visiting faculty .Furthermore, the use of international faculty is rarely sustainable, especially when support for these faculty is not available. Programs that involve a train-the-trainer component as well as faculty development are essential, although limitations of these models  must be kept in mind and addressed using other mechanisms such as refresher courses and mentorship or preceptor programs. Additionally, given the increasing familiarity with and use of technology, non-traditional training mechanisms such as the use of messaging applications and other mobile technology-based training tools should be considered, especially as they can be effective mechanisms to extend training beyond face-to-face interactions and/or to continue training during protracted and/or complex emergencies 4849.48These programs also highlight the inability to simply transfer EM curricula from one setting to another. Some fundamental concepts can be shared, as is evidenced by international guidelines for curricula, and there are several groups that have offered open-access materials that are already adapted to low-resource settings to varying degrees Table . In orde5051Finally, in order to continue to advance EM training and the overall provision of emergency care, programs must include training in quality improvement (QI) and research, topics not traditionally taught in many medical and nursing schools in low-resource settings. To illustrate this point, less than half of the programs mention a component of QI and/or research, and only two of the manuscripts have a local first author 44. Furth2026Despite ongoing work to develop metrics and quality indicators for emergency care and research and to provide guidance in the development of emergency care systems , there is still very little research that has focused specifically on the impact of training programs 956575860616263.606162Overall, we used only four search engines and excluded programs in the gray literature without peer review (i.e. abstracts) – an area in which many more programs are likely highlighted based on an informal review of the excluded abstracts. Also, our results are limited to manuscripts only in English. Additionally, the search terms used to define this rapidly changing and developing field were difficult to specify, leading to one additional manuscript that was identified on informal review that could have been included in this study . FurtherTraining in EM is an essential component to developing strong emergency care systems. This study identifies a broad range of EM training programs developed through partnerships that are representative of the programs that exist globally and highlight programmatic components essential to the development of effective programs. Sharing knowledge and practice across high- and low-resource settings can be an effective mechanism for the global development of programs within a specialty, however significant adaptation to the educational setting as well as true investment and partnership must occur, even for short-term programs. Even when all of the complexities and components are addressed, there are still limitations to this practice. Short-term programs need to expand beyond the few topics that are represented now, and we must invest in comprehensive, long-term emergency care training and professional development programs. Finally, as tools and guidance regarding the development of emergency care systems increase, a strong focus on strengthening educational practices as well as evaluating their impact through research is imperative.The additional files for this article can be found as follows:10.5334/aogh.2681.s1Supplement 1.Search Strings.10.5334/aogh.2681.s2Supplement 2.Scoring Rubric.


Physician Assistants (PA) are important members of the medical team, and increasing diversity in healthcare professionals has been consistently associated with improved health outcomes for underrepresented minority patients. In this study of a national cohort of PA program applicants, we investigated whether the number of programs a student applied to  was significantly associated with increased likelihood of matriculation into a PA program.n = 27,282) to the 2017–2018 admissions cycle of the Central Application Service for Physician Assistants, which is utilized by over 90% of accredited PA programs in the US. As we a priori hypothesized that associations would be non-linear, we used natural cubic splines to estimate the associations between matriculation and AN, controlling for multiple metrics of academic achievement, experience, and applicant demographics. We subsequently used segmented regression analyses (modified poisson regression with robust error variance) to investigate log-linear associations above and below inflection points identified in the spline analyses. Additionally, we explored for effect modification by race/ethnicity.We examined all applications  vs non-Latinx White , with no additional, incremental benefit beyond 7 program applications. For all other races, significant increased likelihoods of matriculation were observed until 16 program applications.These findings can help guide pre-PA advisors and PA programs, providing recommended thresholds to applicants on the most cost effective ways to increase their likelihood of admissions, and the PA profession as a whole by providing actionable information that can potentially increase Race/Ethnic diversity in the PA profession and, by extension, medical teams. Over 50 years ago the Physician Assistant (PA) profession was formed to address the primary care shortage in the United States (US) . During Admission to a PA program is highly competitive: 2014–2015 data indicates that for every seat there are 2.95 applications in PA compared to 2.43 for medical school . This fiThe compounding disadvantage of multiple, expensive admissions requirements may help partially explain why applicants accepted to PA programs do not reflect the racial and ethnic diversity of the US population. US Census data indicate that the population is 18.1% Latinx, 13.4% Black or African American, 1.3% American Indian/Alaska Native, and 0.2% Native Hawaiian/Other Pacific Islander , 9. PA aWe hypothesize that the matriculation of students from all backgrounds will be related to the number of programs to which they apply, and that this association will likely have a threshold effect. Further, we hypothesize that the association between application number and matriculation will be impacted by URM status.This is a secondary analysis of a data set including all applicants to the 2017–2018 admissions cycle of the Central Application Service for Physician Assistants, which is utilized by over 90% of accredited national PA programs. Access to the CASPA dataset was provided by the Physician Assistant Education Association (PAEA), and all participant identifying information was removed prior to PAEA providing the data to us for analysis. This research was determined to be exempt (non-human-subjects research) by the University of Utah Institutional Review Board and all methods were carried out in accordance with relevant guidelines and regulations.The primary predictor of interest was number of applications submitted to various programs by a given applicant , which was collected as a count variable. In addition, models were adjusted for important potential confounders, including age (continuous), sex , URM status , patient care experience hours , whether the GRE was taken , and overall science grade point average .Given the extreme range of AN (1 to 118), and its significantly right-skewed distribution, we hypothesized a priori that AN would be non-linearly associated with odds of matriculation, likely with an upward threshold effect beyond which no incremental benefit would be observed. Therefore, we first used natural cubic splines to investigate the association between AN and participants’ likelihood of matriculating into a PA program. We subsequently utilized segmented regression analysis with ψ = 5, yielding cut points for four categories of AN. Subsequently, we used modified Poisson regression with robust error variance  to invesTo visualize predicted probabilities of matriculation in our figures, we created a hypothetical data set for AN of 1 through 50 with every permutation of categorical covariate while holding GPA and age at mean levels of the participant data set; this resulted in 432,000 observations for visualizing predictions.Our data were highly complete, with only 6.9% of subjects having missingness on any covariate. To ensure that our results were not biased by missing data, we performed multiple imputation with chained equations  to generdiff < .0001).Table Table Table Our study is the first to demonstrate the association between application number and likelihood of matriculation in a national cohort of PA program applicants. The associations we identified were non-linear, with the strongest associations observed between application number 2–7, and a threshold effect at > 16 applications, beyond which there is no significant incremental benefit in matriculation likelihood. We additionally found that associations differed by race, particularly for application number 2–7, wherein the incremental benefit from each additional application was highest for Black applicants vs non-Latinx White (LR: 1.243 vs 1.098). The increased likelihood of matriculation with the increased number of applications is intuitive but the difference by race is astonishing. In addition, there appears to be no added benefit for Black applicants after application to 7 programs, while all other races continue to increase likelihood of matriculation until 16 applications.While our finding of an upward threshold effect at > 16 applicants was consistent with our a priori hypothesis, our findings of three distinct associations in the 1–16 AN range was surprising. A number of potential explanations for this exist. First, for applicants with AN = 1, it is likely that many, if not the majority, of these students were applying to programs with special admissions pathways connected to the bachelor’s degree (e.g. 3 + 2 programs or guaranteed matriculation agreements) or due to geographic constraints unique to the applicant . The subsequent precipitous increase in matriculation likelihood for the AN 2–7 increment demonstrates that applicants who apply to more schools, even one more school, dramatically improve their odds of matriculation, while this effect is moderated for AN 8–16. Beyond 16 applications, we found no incremental benefit in likelihood of matriculation.Importantly, while the likelihood of matriculation is non-linear, the cost for applying to additional schools increases in a linear fashion for applicants, where the costs for CASPA students can be described as follows :\documeAs a result, the cost to students for each additional application between 2 and 7 is $55, with an associated increased likelihood of matriculation of 11.7% for this investment. However, incremental increases in matriculation likelihood beyond AN 16 is not significantly different from zero, and for Black students, matriculation likelihood does not increase after AN = 7. While the median AN number overall is 6, this finding potentially provides important information for pre-PA student mentors regarding how to guide students in their selection of the number of programs to which it makes sense to apply. Namely, an additional investment of $55 is associated with an increase in matriculation likelihood of over 11%.We observed that Black applicants had the strongest incremental benefit for additional applications between 2 and 7, with associations nearly 2.5 times higher than for non-Latinx White applicants. However, the median number of programs applied for by Black versus non-Latinx White and Latinx applicants is 33% lower 4 vs 6). Importantly, Black students applying to 7 programs have matriculation likelihoods nearly 73% higher than those who applied for the median (4) for this group. Only one previous study has examined associations between pre-admissions student characteristics and matriculation, and found that URMs and older applicants without current GRE scores were less likely to matriculate than non-URMs and younger applicants . This fi. ImportaOur study has a number of important limitations. First, it is likely that unmeasured confounding is affecting our results, particularly as we were unable to control for objective measures of socioeconomic status. Second, while we observe significant associations between AN and matriculation, we lack information on admission offers. Admission offers are made by programs and reflect a combination of factors such as total number of applicants, logistic, and program factors; therefore, the degree to which AN impacts admissions decisions was unable to be assessed. Further, the matriculation rationale used by any given accepted applicant to a given program is unknown. Third, while our dataset was national, CASPA is not used by every PA program and thus our results may not be applicable to all PA programs. Fourth, our findings for URM applicants may have additional confounding due to the limitations that Deferred Action for Childhood Arrival (DACA) students encounter when trying to finance their education using federal aid programs. This may lead to a substantial number of applications that, despite being provided offers of admission, result in non-matriculation. Last, while our dataset was largely complete, it is possible that the self-reported nature of the data and/or missing race/ethnicity data may bias our results.These limitations are counterbalanced by a number of important strengths. First, we are using the CASPA dataset, which is the largest dataset on PA applicants and matriculants available, and has important and high quality information on important potential confounders, such as demographics, academic achievement, and prior clinical experience. Second, while we did have some missing data, we used robust missing data imputation techniques which, under assumptions of missing completely at random and missing at random, will yield unbiased results.In a national cohort of PA program applicants, the number of programs a student applied to was significantly associated with increased likelihood of matriculation into a PA program. Associations were non-linear, and varied by student race. These findings may help guide pre-PA student mentoring as well as program initiatives to increase diversity by facilitating increased program applications with fee waivers.


While eHealth programs equip survivors with tools at where and when they need, their benefit to and engagement patterns among older adults are less known. Data come from the Springboard Beyond Cancer RCT, a cancer survivor self-management program  and the corresponding qualitative evaluation/user testing (N=40). Younger survivors, but not older, preferred socially interactive and personalized long-in features which enable greater tailoring of the program. However, the older survivors who did enroll in the RCT were equally as likely as their younger counterparts to engage with one or more aspects of program. Health self-efficacy improvement from baseline to 3 months was significant among younger participants in the intervention (p<.05) but not the control arm (p=.54) (d=.20) and marginally significant among older survivors (age 60+) in intervention (p=.06) but not the control arm (p=.58) (d=.28). Results suggest that the program may benefit survivors regardless of age. Part of a symposium sponsored by the Cancer and Aging Interest Group.


The Accreditation Council for Graduate Medical Education (ACGME) mandates that residency training programs form program evaluation committees (PECs) to monitor program delivery and outcomes, generate annual program evaluations (APEs), facilitate strategic planning, and implement continuous quality improvement projects. Though PECs provide essential documentation to position programs for successful accreditation decisions, few resources exist in the literature for PEC members.Employing Kern's model for curriculum development, we conducted a needs assessment in 2016 that resulted in adding a 2-hour workshop on building and supporting effective PECs to a certificate program for residency program directors. The workshop used a flipped classroom model with prework readings and guiding questions to familiarize participants with ACGME requirements for PECs and APEs. Several activities helped participants identify best practices for PECs and discuss authentic examples of mission statements, APEs, and action plans.From 2017 to 2019, we offered this workshop on three different occasions to a total of 42 participants (34 residency program directors/associate program directors and eight program coordinators). In 2019, 14 participants completed a web-based evaluation after the session. All agreed or strongly agreed that the workshop met the learning objectives, utilized interactive teaching methods, included useful APE examples, and provided valuable resources.This workshop addresses a gap in the literature by helping program directors identify best practices for PECs. The APE template and workshop examples can be adjusted to fit the needs of individual institutions. Additionally, PECs document program improvements, review program mission statements, and engage in strategic planning. All of these activities, when done well, foster program improvement and curricular innovation and provide essential evidence to prepare graduate medical education (GME) training programs for 10-year accreditation site visits.3The Accreditation Council for Graduate Medical Education (ACGME) requires residency program directors (PDs) to appoint program evaluation committees (PECs) with the charge to conduct and document annual program evaluations (APEs) for continuous quality improvement.1 While the medical education literature provides guidance on how to conduct program evaluations,8 limited resources offer best practices for PECs in GME.9 The resources that do exist may not reflect current accreditation requirements or are difficult to access.10 We could locate no PEC materials in MedEdPORTAL and doubt whether busy clinicians would have time to review excellent textbook-length resources on program evaluation used in higher education.13 The dearth of existing PEC resources underscores the need to develop targeted resources and training, especially as PEC members typically consist of clinical faculty and residents who may not have formal experience with program evaluation methods or who may not appreciate the importance of APEs for program improvement and accreditation purposes. To address this gap, we developed a 2-hour workshop to orient PDs to PECs and discuss best practices for APEs.Given the importance of PECs, it is surprising that few resources exist to assist PEC members. For instance, the ACGME's Common Program Requirements offer limited guidance on how PECs should function beyond listing PEC composition and residency program elements to review.14 we conducted a needs assessment in 2016 with residency PDs at our institution in order to identify gaps and strengths within the existing Program Directors' Certificate Program (PDCP). This yearlong program consists of 15 workshops that occur monthly on our main campus. The needs assessment revealed that PDs desired guidance with program evaluation as well as more interactive, skills-based sessions in the overall PDCP curriculum. In response, we added a new session titled Best Practices for Building and Supporting Effective ACGME-Mandated Program Evaluation Committees to this workshop series. During workshop planning, we met with personnel in the Office of Graduate Medical Education to identify institutional policies about PECs and APEs, and we reviewed the ACGME's Core Program Requirements.1 These efforts helped us identify some of the challenges GME personnel encountered when helping residency PDs appoint PECs and develop APEs. For instance, we learned that confusion existed about who should serve on PECs. In relation to APEs, several programs submitted written reports to our GME office that lacked clear mission statements, strategic plans, or detailed action plans even though these elements existed on the institution's structured APE template. Finally, we discovered a paucity of resources on PECs in the literature, making it important for us to adopt an interactive format to solicit participants' experience with PECs and provide skill-building activities.Using Kern's model for curriculum development,We implemented this flipped classroom workshop on three different occasions (2017–2019) within the PDCP and used participants' questionnaire feedback to make improvements. Our target audience included PDs, associate PDs (APDs), and GME personnel at our institution. In 2019, we invited program coordinators (PCs) to participate in the workshop as well. We chose a flipped classroom model to engage participants and provide opportunities for large- and small-group discussion. The workshop took place in a classroom setting with rectangular tables and movable chairs.Participants received preworkshop required readings (see the recommended reading in The workshop began with introductions (10 minutes). We solicited participants' experience with PECs during this time and distributed instructional materials –H. The nWe devoted 15 minutes to Activity 1  in whichAfter briefly reviewing the features of program aims, presented in the PEC Best Practices Presentation , the facActivity 3  continueThe final portion of the workshop allotted 10 minutes for participants to discuss tools used to generate an APE and review the standard APE template . The facIn 2019, we asked participants to complete an electronic feedback questionnaire at the close of the session via the learning management system used for this longitudinal series. The questionnaire contained Likert-scale as well as open-ended questions . In prioWe aggregated participants' ratings for Likert-scale questions and computed descriptive statistics. Content analysis of responses to open-ended questions helped us identify major themes.To date, more than 170 PDs, APDs, and PCs have participated in the PDCP. Of these participants, 42 (34 PDs and eight PCs) have attended the workshop's three offerings.In the 2019 iteration, 14 participants completed a workshop questionnaire and provided positive ratings about the workshop. For instance, all participants agreed the workshop met the learning objectives, utilized interactive teaching methods, and provided valuable resources. Additionally, all participants agreed the small-group discussions and APE examples were useful components of the workshop.Participants' responses to open-ended questions included comments such as “I better comprehend the role and issues regarding the program evaluation committee” and “The example of an excellent program evaluation form was very helpful to use as a guide.” Others noted, “A structured committee with standing members and rotating members was a good idea I will try to implement” and “Having model documents to model our own behavior is of great utility.” A compilation of questionnaire feedback can be found in the Tasked with reviewing and evaluating residency training programs, PECs play a critical role in GME. PECs monitor training program delivery, effectiveness, and outcomes. Additionally, PECs generate APEs that include recommendations to improve residency training program processes and outcomes. Highly functioning PECs contribute to continuous quality improvement activities and provide essential documentation for ACGME accreditation. We developed this workshop in response to our residency PDs' desire for guidance about PECs and program evaluation.We offered this workshop on three different occasions and received positive feedback from participants. The workshop appeared to achieve the desired learning objectives, based on participants' ratings, and addressed a gap identified in the certificate program's needs assessment. We were successful with facilitating an interactive session, and workshop attendees actively participated in both large- and small-group discussions. Qualitative comments revealed that participants appreciated discussing best practices for PECs, such as having standing members serve on the committee, and reviewing authentic examples of APEs. We added SWOT  analysis to the workshop presentation and updated APE examples to illustrate superficial and detailed approaches to program evaluation. We also invited PCs to participate in the workshop as these individuals often serve on PECs or assist with APE completion. Locating up-to-date prereadings remains a challenge. To help address this gap, we plan to write a manuscript on PECs and APEs, using a 12-tip format, to add to the workshop materials. We have committed to offering the workshop virtually this coming year due to social distancing requirements. Zoom may serve as the best platform to support small-group discussions through the use of breakout rooms.Our workshop has a few limitations. We delivered this session on the main campus of a large institution hosting a yearlong certificate program for PDs and APDs. Thus, participants may reflect a self-selected group interested in career development who could negotiate for release time from clinical responsibilities to attend. Our workshop evaluation collected only participant satisfaction data and did not include intermediate or long-term outcomes. Additionally, we did not have a session-specific evaluation for the first two offerings of the workshop as the leadership team for the certificate program obtained focus group feedback from certificate recipients at the end of the program. We received IRB approval to conduct two focus groups with program participants at different stages in the accreditation process prior to the COVID pandemic. Our aim was to explore the extent to which the workshop and structured APE template helped PDs appoint PECs, generate written APEs, and prepare accreditation self-studies. We have delayed these focus groups until the COVID crisis subsides.We believe this workshop addresses a gap in the literature in that it helps PDs identify best practices for PECs and discuss authentic examples of APEs. We received positive feedback about workshop activities and believe this workshop is appropriate for any institution with ACGME training programs. Furthermore, the APE template used in workshop examples can be adjusted to fit the needs of individual institutions, which GME offices can use to help PDs generate APEs and standardize APE documentation across departments.Facilitator Guide for PEC Workshop.docxPEC Best Practices Presentation.pptActivity 1 Pair-and-Share.docxActivity 2 Small-Group Discussion of Aims.docxActivity 3 Small-Group Discussion of Data Sources.docxAPE Weak Example.pdfAPE Strong Example.pdfAPE Template With Notes.docSession Evaluation Form.docxAll appendices are peer reviewed as integral parts of the Original Publication.


Despite many advantages of web-based health behavior interventions such as wide accessibility or low costs, these interventions are often accompanied by high attrition rates, particularly in usage under real-life conditions. It would therefore be helpful to implement strategies such as the use of financial incentives to motivate program participation and increase adherence.This naturalistic study examined real-life usage data of a 12-week web-based physical activity (PA) intervention (Fitness Coach) among insurants who participated in an additional incentive program (incentive group) and those who did not (nonincentive group). Users in the incentive group had the perspective of receiving €30 (about US $33) cash back at the end of the intervention.Registration and real-life usage data as part of routine data management and evaluation of the Fitness Coach were analyzed between September 2016 and June 2018. Depending on the duration of use and the weekly recording of tasks, 4 adherence groups  were defined. Demographic characteristics were collected by a self-reported questionnaire at registration. We analyzed baseline predictors and moderators of complete adherence such as participation in the program, age, gender, and BMI using binary logistic regressions.2, median (IQR) BMI 23.8 (21.7-26.4) kg/m2; 65.12%  female; and 3131 users decided not to use the incentive program (nonincentive group): mean age 40.7 (SD 13.4) years, mean BMI 26.2 (SD 5.0) kg/m2, median BMI 25.3 (IQR 22.6-28.7) kg/m2; 72.18% (2260/3131) female. At the end of the intervention, participants in the incentive program group showed 4.8 times higher complete adherence rates than those in the nonincentive program group (39.2% vs 8.1%), also yielding significantly higher odds to complete the intervention (odds ratio [OR] 12.638) for the incentive program group. Gender significantly moderated the effect with men in the incentive group showing higher odds to be completely adherent than women overall and men in the nonincentive group (OR 1.761). Furthermore, older age and male gender were significant predictors of complete adherence for all participants, whereas BMI did not predict intervention completion.A total of 18,613 eligible persons registered for the intervention. Of these, 15,482 users chose to participate in the incentive program (incentive group): mean age 42.4 (SD 14.4) years, mean BMI 24.5 (SD 4.0) kg/mThis is the first naturalistic study in the field of web-based PA interventions that shows the potential of even small financial incentives to increase program adherence. Male users, in particular, seem to be strongly motivated by incentives to complete the intervention. Based on these findings, health care providers can use differentiated incentive systems to increase regular participation in web-based PA interventions. Promoting a healthy lifestyle, especially reducing sedentary behavior and increasing physical activity (PA), is crucial in the prevention of chronic diseases such as cardiovascular disease, type 2 diabetes, breast and colon cancer as well as hypertension . Personsprogram adherence to web-based interventions, that is, using the program as intended by the developers over the course of the intervention, has always been a major challenge . Despitttrition -16. Thisdherence ,18, thatface-to-face settings, financial incentives have been shown to increase real-life exercise adherence (behavior adherence) in the short term and partially even in the long term among children, adolescents, and adults  on the part of the investigator” ). In order to categorize adherence, login data were summarized per week. If a user had at least one login per week with at least three logged tasks in the week, the user was adherent and participation in that week was defined as successful . Based olow adherence group included all users participating for 1-3 weeks during the 12-week intervention span. Occasional adherence was defined as participation between 4 and 6 weeks. If users had 7-9 weeks of successful participation, we categorized them as strongly adherent. All persons completing 10 or more weeks successfully were defined as the complete adherence group . We combined the first 3 adherence groups  and compared them with the complete adherence group (=1) to best display the incentive effect on adherence. Incentive participation , gender , and age and BMI (both continuous variables) were considered as baseline predictors. Furthermore, the interactions of incentive × age, incentive × gender, and incentive × BMI were considered as moderators for the association between incentives and program adherence. There were no missing data for adherence, incentive participation, age, and gender. Because it was not mandatory to enter height and weight, BMI data were missing in 530 cases, resulting in a total number of 18,083 users included in the logistic regression. After checking for multicollinearity between incentive participation, age, gender, and BMI (variable inflation factors between 1.024 and 1.066), all demographic variables and interactions were included in the regression model. Model fit was judged using Nagelkerke From September 2016 to June 2018, a total of 30,821 persons registered for the Fitness Coach intervention. Of these, 755 (2.45%) registered as guests who were not insured by the health insurance company and were therefore unable to participate in the incentive program. In addition, there were 11,453 (37.16%) insured persons who visited the internet intervention only once and had no further login. All guests and one-time users were excluded from further analyses, so the demographic analyses included the total number of 18,613 insured users .P<.001), BMI (P<.001), and gender (P<.001) differences indicated that older and more male users with a lower BMI register for the incentive  were completely adherent . Among tP<.001) at baseline for completing the intervention  and gender (P=.017) proved to be significant baseline predictors of complete adherence to the Fitness Coach intervention for all users , both age . This incentive effect on program adherence was moderated by gender, but not by BMI and age. Males in the incentive group showed the highest odds for program completion. Furthermore, gender and age also exhibited significant main effects on program adherence: being male and being of older age were associated with higher program adherence. However, BMI was not a significant predictor of program adherence.This large-scale, naturalistic study with a nationwide sample of 18,613 users examined the effect of an incentive program and its moderators on program adherence to a web-based PA intervention. Participants were members of the largest German health insurance who either decided to take part in an additional incentive program at the beginning of the intervention or rejected the use of the incentive program. Results showed that complete program adherence was 4.8 times higher in the incentive group than in the nonincentive group. In line with this finding, binary logistic regressions revealed incentive program participation to be a strong and significant predictor for complete adherence  was able to enhance program adherence by almost five times, emphasizing the important motivating role of external rewards, at least in the initial phase of a new health behavior ,39,43. Tmoderating effect of gender on the association between incentive participation and program adherence. Men in the incentive group had significantly higher odds to complete the intervention than female users overall and male users in the nonincentive group, indicating that financial incentives may appeal particularly to men. This is supported by Czap and colleagues [This study also found a lleagues  who repomain effects of age on program adherence, we found older users to be significantly more inclined to complete the intervention than their younger counterparts, yet with a small OR of 1.023 . This result is well known from the literature, which indicates that older users have higher chances to be adherent than younger users [By looking at the er users ,27,29,30er users ,8. However users ,27. For program adherence; therefore, no definite conclusions can be drawn on the actual adherence to regular PA after the end of the 12-week intervention (behavior adherence). However, it is in the logic of time-limited behavior change programs that after finishing the program the newly acquired health behavior has to be continued in everyday life on one’s initiative. We cannot be certain how successful the health behavior change has been in the present sample, yet there is evidence that a higher level of program adherence also leads to sustained health behavior change in everyday life [The scope of this study was on day life .This study is the first large-scale examination that investigated whether financial incentives increase program adherence to a web-based PA intervention under real-life usage conditions. Because of the naturalistic study design, the results of this investigation have high ecological validity.However, some limitations need to be addressed. Internal validity might be threatened as the assessment of program adherence depends on self-reported participation behavior. There is also a risk that self-reported data on age and BMI may be distorted by socially desirable response tendencies or even worse, false data, to reveal as little information about oneself as possible. The study uses a naturalistic design with self-selection of participants into the incentive or nonincentive conditions. Given this design, it was not possible to randomize users into these two groups. Overall, both groups differed substantially regarding age, gender, and BMI with older users, more men, and users with lower BMI choosing to participate in the incentive program. It might be hypothesized that participants in the incentive group were more motivated from the beginning to use the program than users who did not register for the incentive.Age 1.023, 95% CI 1.013-1.033; P<.001). However, the decision for the large comparison group was made from a content perspective focusing on representativeness and external validity. The unbalanced analyses took account of the naturalistic data and better displayed how complete adherers differ from the other users who did not successfully finish the intervention. The logistic regression was also based on large sample size. While the unbalanced distribution might have affected the width of the confidence intervals, it has not affected the ORs in the logistic regression because there is enough power in this analysis.Given the unequal sample sizes for incentive and nonincentive groups  as well as for the low, occasional, and strong adherence groups combined and the complete adherence group , the results of binary logistic regressions might be overestimated. This is reflected, for example, in very large CIs and statistical significance despite small OR . Therefore, health care providers may encourage program participation by providing differentiated incentives depending on gender, age, or BMI in web-based interventions promoting PA. Further investigations are needed to support these findings; in particular, it is necessary to further clarify the moderating role not only of gender, age, or BMI, but also of other potentially relevant factors such as socioeconomic status or education. The study results are based on naturalistic data with a high ecological validity; in the next step, it is necessary to confirm these findings in more controlled studies  with higher levels of internal validity.