The relative paucity of donor livers suitable for transplantation has sparked innovations to preserve and recondition organs to expand the pool of transplantable organs. Currently, machine perfusion techniques have led to the improvement of the quality of marginal livers and to prolonged cold ischemia time and have allowed for the prediction of graft function through the analysis of the organ during perfusion, improving the rate of organ use. In the future, the implementation of organ modulation might expand the scope of machine perfusion beyond its current usage. The aim of this review was to provide an overview of the current clinical use of machine perfusion devices in liver transplantation and to provide a perspective for future clinical use, including therapeutic interventions in perfused donor liver grafts. Machine perfusion (MP) was first introduced in liver transplantation in the 1930s, when the first experiments were conducted to maintain the viability of human organs perfused ex vivo . HoweverIschemia leads to the accumulation of metabolic products, causing ischemia/reperfusion injury. Upon reperfusion, an efflux of these metabolites, first, has a direct toxic effect and, second, triggers an inflammatory response, damaging hepatocytes in the graft organs . The benRecently, the demand for donor organs has steadily increased, and the need for suitable organs for transplantation is expected to further increase in the future . In the In the context of organ shortage, the anticipated increase in the number of liver transplantations, and the use of DCD grafts, further expansion of the donor pool is necessary. MP allows for the use of higher-risk donor organs, increasing the number of transplantable organs. It might reduce CIT, especially in marginal organs, which are more susceptible to ischemia and reperfusion injury . The twoHypothermic MP (HMP) is an umbrella term for various forms of MP that use hypothermic perfusion as their smallest common denominator. Systems that provide hypothermic oxygenated perfusion are termed hypothermic oxygenated perfusion (HOPE) if the perfusate is delivered via the portal vein and dual hypothermic oxygenated perfusion (D-HOPE) if the perfusate is additionally delivered through the hepatic artery.p = 0.08), significantly lower values of serum injury markers, and a shorter hospital stay in the HMP group [n = 8) compared with DBD grafts (n = 8). All organs were treated with SCS, and DCD organs were treated with HOPE for 1–2 h before implantation. The postoperative outcomes were similar, showing the protective capacity of HOPE for DCD livers [The first prospective trial to evaluate ex situ hypothermic MP, which included 20 adult HMP livers with matched SCS livers, was published in 2010. The authors reported decreased early allograft dysfunction (EAD) rates . The incidence rates of postreperfusion syndrome and EAD were, respectively, 12% and 27% in the HMP group  and 26% and 40% in the control group . The reported findings of this trial showed a relatively short CIT of 6 h 11 min and low-risk donors. Thus, whether the effects would be replicable with higher-risk transplant organs remains to be elucidated.However, high-level evidence of the clinical value of HMP is relatively scarce, with only one published randomised controlled trial (RCT) comparing D-HOPE with SCS . In thisp = 0.001; I2 = 0%) and non-anastomotic biliary strictures  compared to SCS. Two trials used non-oxygenated HMP.A meta-analysis of nine studies, including the above-mentioned randomised trial and eight non-randomised trials, reported that HMP showed reduced incidence rates of EAD . The primary outcome (peak ALT levels within 7 days after LT) was significantly decreased in the HOPE group. Secondary outcomes, including major complications and duration of ITU stay, were both significantly decreased in the livers randomised to HOPE. This trial also raised the question of ideal end points in MP trials, which is controversial [n = 66) or SCS (n = 69), showing a significantly lower EAD rate . However, 25 grafts were excluded after randomisation, making the results difficult to interpret [A recent study that could stimulate further research and the use of extended criteria donor (ECD) DBD livers was recently published. In this trial, ECD DBD organs were randomly assigned to either the HOPE or SCS group before implantation . The true value of machine perfusion in marginal DBD grafts is likely to lie in a viability assessment, where the role of HOPE/D-HOPE is not yet well established. We consider this in more detail later in the manuscript .p = 0.008), despite the significantly longer preservation time  [n = 153) or SCS group (n = 147) group. The primary outcome of the trial was EAD, which showed a significant reduction in the portable NMP group . Furthermore, the incidence of ischemia-reperfusion injury after reperfusion (defined as less moderate-to-severe lobular inflammation) was significantly reduced . The higher-use frequency of DCD livers, as previously reported by Nasralla et al., was confirmed in this study  [NMP entails the perfusion of a liver graft under normal body temperature with oxygenated packed red blood cells suspended in a colloid solution, nutrients, and medication, allowing the organ to maintain function under simulated physiological conditions. NMP devices are mainly composed of one or two pumps , a blood reservoir, a heat exchanger, and an oxygenator. Different setups have been described in the literature . NMP was< 0.001) . In addi= 0.007) .A main argument in favour of NMP is that it allows for the measurement of objective parameters related to graft function and the identification of transplantable marginal organs that otherwise would have been discarded . The ideConversely, a relevant shortcoming of NMP is its high cost compared to HMP/HOPE or SCS, although its cost-effectiveness has recently been demonstrated . HoweverNRP has shown great promise in DCD liver transplantation and donor pool expansion . To thisTo date, no RCT involving NRP has been published, but retrospective series have shown superior outcomes after NRP transplantation compared to SCS transplantation . These sWith the increasing adoption of MP strategies in clinical practice, defining a precise and important role for their use, compared to SCS, is becoming increasingly important. Given that any MP technology is more costly and logistically complex, justification for its use in clinical practice is required. Although clinical trials have demonstrated improved early outcomes, such as a reduction in EAD , the cliNMP has been generally accepted as the optimal technology for assessing ex situ liver function . This isGiven the importance of protecting the biliary tree during preservation to prevent the catastrophic complication of IC in DCD livers, which can occur in up to 30% of cases, assessing cholangiocyte viability during NMP is critically important. Data from another trial showed that differences between the bile and perfusate levels of pH, bicarbonate, and glucose can be used to identify bile alkalisation and glucose reabsorption by the biliary epithelium, thereby providing biomarkers of bile duct integrity and viability . When apCold preservation relies on the suppression of the metabolic rate, as most enzymatic reactions slow down with temperature reduction. Therefore, hypothermic perfusion technologies are traditionally considered less useful in assessing graft viability. Furthermore, in the cold, active bile secretion is low and is used as a viability parameter during NMP. Nevertheless, small-scale studies have suggested that perfusate transaminases, glucose, lactate dehydrogenase, and lactate levels correlate with early graft function ,50,51. FThe Zurich group recently found that FMN, determined using fluorescence spectroscopy in HOPE perfusate, correlated with early graft loss, cumulative complications, and hospital stay after liver transplant . If the p < 0.0001). Furthermore, death-censored 5-year graft survival significantly improved in the NRP livers (p = 0.04) [p = 0.008) [One of the most important clinical outcomes of liver transplantation is non-anastomotic biliary strictures or IC. This is characterised by strictures, dilatation, or irregularity of intra- or extra-hepatic bile ducts proximal to the biliary anastomosis and results in significant morbidity and mortality with high graft loss rates. IC mostly affects DCD grafts, with an incidence of 15–30% . Before  = 0.04) . Between= 0.008) . France = 0.008) . This co= 0.008) . As with= 0.008) . In the = 0.008) . Eleven = 0.008) .p = 0.09) and a high 5-year graft survival rate of 94% in the HOPE cohort compared to 78% in the SCS group (p = 0.024) when censored for tumour-related deaths [p < 0.0001). When reporting survival outcomes, the study excluded those with tumour-related deaths; thus, considering the large discrepancy in transplants for malignancy, this makes the tumour-censored survival data problematic. The Groningen group reported the results of a multicentre RCT that compared D-HOPE with SCS in DCD liver grafts, with the important primary end point of symptomatic non-anastomotic biliary strictures at 6 months [p = 0.03) [Before the data from the NRP studies emerged, hypothermic MP (HOPE and D-HOPE) was purported as the optimal preservation method to reduce the risk of IC. Schlegel et al.  comparedd deaths . However6 months . A total = 0.03) . These fp < 0.001), no significant difference in IC was found between the groups, with 4.5% and 8.6% of patients developing IC in the NRP and HOPE group, respectively (p = 0.22) [Muller et al. compared the outcomes in 132 NRP livers (French cohort) and 93 HOPE livers (Swiss cohort) . Althoug = 0.22) .NMP has been considered to be less effective than NRP or (D)HOPE in protecting the biliary tree and, therefore, in reducing IC rates, as demonstrated in the studies by Mergental et al.  and Watsp = 0.001) and 11% of the NMP-treated livers (p = 0.009) [However, these studies used NMP in the end-ischaemic setting, with a median CIT of 7.5 h before NMP. Furthermore, the livers transplanted in these studies were amongst the most marginal, having been declined by all UK liver transplant centres prior to recruitment. It could be that this period of cold ischaemia has been detrimental to the integrity of the bile ducts of these very high-risk grafts. In the study by Ceresa et al. , where e= 0.009) . The 3-y= 0.009) .p = 0.02). Mohkam et al. [p = 0.99), and similar 2-year graft survival rates .In the two published RCTs that compared NMP with SCS ,29, a com et al.  conducteThese data suggest that NRP appears to be the current gold standard approach in DCD liver transplantation. HOPE/D-HOPE offers a more straightforward low-cost approach, which appears beneficial, but its applicability is limited, and more clinical DCD data are needed. In a device-to-donor setting , NMP appears beneficial for protecting the biliary epithelium, almost comparably with NRP. However, end-ischaemic NMP is unlikely to protect the biliary epithelium but allows for viability assessment.MP has demonstrated potential usefulness in improving liver preservation, organ utilisation, functional assessment, and outcomes. However, one future perspective is the potential of liver-directed therapeutic interventions to further enhance marginal organs . This hap = 0.02). This was accompanied by increased lipid oxidation and exportation to the perfusate, enhanced mitochondrial function, decreased vascular resistance, and reduced values of the markers of hepatocellular injury and inflammation with improved biliary function [n = 6), with the addition of a lipid apheresis filter (n = 6) or an apheresis filter with defatting interventions using l-carnitine, forskolin, and glucose and insulin reductions (n = 6) [Liver steatosis (excess hepatocellular fat deposition) could be treated during ex situ normothermic perfusion. Consistent with the global obesity epidemic, steatosis is an increasingly common finding in organ donors . Macrovefunction . Of the  (n = 6) . The aph (n = 6) . AlthougIC remains a major concern after the transplantation of DCD liver grafts. Biliary strictures are thought to be related to micro-thrombi in the peri-biliary plexus, assumed to form during hypoperfusion and circulatory arrest . KidneysThe presented examples provide insight into the potential of NMP to further enhance liver grafts for transplantation through liver-directed therapeutic interventions. Another key area for current and future research application is the ability to prolong perfusion. While this may not be required in the context of routine clinical transplantation, prolonged preservation might be needed to allow time for a therapeutic intervention for liver reconditioning or repair. Eshmuminov et al.  first re


In the field of hospital medicine, there is both a limited pool of senior faculty to mentor the rapidly growing number of junior faculty and a lack of career development curricula focused on scholarly activities specific to the needs of the hospitalist. These deficits have resulted in a disproportionately low number of academic hospitalists being promoted to associate and full professor. We implemented a facilitated peer mentoring program with a dedicated curriculum to foster career advancement of academic hospitalists.We recruited 29 academic hospitalists and divided them into five small groups, each guided by one senior faculty. Peer members participated in a 9-month curriculum consisting of alternating large- and small-group sessions that reviewed topics important for academic advancement. Quantitative analysis assessed feasibility of the program, as measured by participation and knowledge improvement on curriculum topics, with pre- and postprogram surveys.p < .05) in nearly all of the curriculum topics.Results demonstrated feasibility of the large-group sessions as measured through participation. Small-group participation was more variable. Pre- and postsurvey results showed significant knowledge improvement (Currently, there is a gap in both mentorship and scholarly skills of academic hospitalists. Our facilitated peer mentoring program with a dedicated curriculum can be used as a framework for other hospitalist programs to support career development. For academic hospitalists, however, this model poses a significant challenge as there are more early-career clinicians than available senior mentors, so one-on-one mentoring is often not achievable. In order to overcome this barrier, peer mentoring has been recognized as an alternative to the dyadic model. Peer mentoring engages those who have similar rank and interest to collaborate and work together toward career advancement. Several peer models have demonstrated positive results, including improvement in personal and professional growth, social networks, and academic productivity.9 Furthermore, peer mentoring can be advantageous to clinician educators, a career in which most academic hospitalists will find themselves.Historically, mentorship has been a cornerstone in career advancement of academic faculty. Successful mentorship has been linked to improved faculty retention,11 Since scholarship remains a key to career success in academic institutions, lack of time and experience to produce publications is a detriment to promotion and career advancement. As a result, there is currently a critical gap in promotion, as demonstrated by a recent study that evaluated 1,500 academic hospitalists at the top 25 US internal medicine residencies and found that only 9% achieved associate professor and 3% advanced to full professor rank.12In addition to lack of mentorship, many academic hospitalists begin their careers with few scholarly skills as they start working immediately after residency without receiving training to develop and write original research-type articles. Academic hospitalists often work as clinician educators, a role in which most funded effort typically focuses on patient care and clinical productivity despite increasing demands for participation in less supported activities such as learner education and scholarly effort.MedEdPORTAL; however, these concentrate on improving mentoring relationships14 and peer mentorship of academic faculty in general.16 Additionally, we found only one article in PubMed describing the implementation of a facilitated peer mentoring model specific to hospitalists.17 That program was a small, single-center, qualitative study focusing on career goals and opportunities within hospital medicine. We expanded upon this work to include exploration of other domains. Our aims were to (1) determine feasibility of the program as measured through participation, (2) enhance knowledge of curriculum-specific topics, and (3) evaluate participants’ perception regarding efficacy for their personal career advancement.Our hospitalist program consists of over 100 hospitalists and mirrors other programs across the country with a high number of junior faculty and relatively few senior faculty. To overcome both barriers—lack of mentorship and scholarly skills—we developed a facilitated peer mentoring program incorporating a dedicated curriculum educating members on the purpose of peer mentoring, resources for career advancement, and types of scholarly activities that might be more readily achievable for busy hospitalists. Currently, scant literature exists that focuses specifically on peer mentoring of academic hospitalists. Several mentoring publications have been published in Academic hospitalists practicing at three affiliate hospitals  received an email invitation to participate. The email described the program aims, curriculum, time commitment, target audience (junior faculty at the level of instructor or assistant professor and preferably in their position for fewer than 6 years), and voluntary nature of participation. The primary author and the section chief met prior to the launch of the program to identify faculty who possessed the skills and experience necessary to serve as senior mentor-facilitators. Five agreed to lead their own small group and received a brief overview of the aims, structure, and curriculum. From the email solicitation, we recruited 29 faculty and subsequently divided them into five small groups, each consisting of four to seven peer members and one senior facilitator. We grouped mentees to optimally match clinical and scholarly interests. Each peer participant completed electronic pre- and postprogram surveys  with 20 participants at a 5% significance level. Our feasibility analysis was based on 27 participants , so our project was sufficiently powered to test the primary aim. The second aim assessed knowledge improvement on curriculum topics using a 5-point Likert scale, and we compared pre- and postprogram survey scores using the Wilcoxon signed rank test. We summarized survey responses by median with 25th and 75th percentiles, or frequency with percentage, to look at the entire distribution of the Likert scale.Power and sample size were determined prior to the start of the program. To consider this program feasible, we aimed to achieve an average participation rate of at least 50% in the large- and small-group sessions, assuming that the actual participation rate would be closer to 70%. Although we would have liked 100% attendance at all sessions, we decided a more realistic participation rate of at least 50% would signify that the program was feasible because we wanted the peer members to attend at least two of the four large-group sessions and two of the three small-group sessions. A one-sided noninferiority Two of the authors developed a dedicated curriculum consisting of four PowerPoint presentations: (1) Introduction to Facilitated Peer Mentorship and Identifying Career Goals, (2) Building a Curriculum Vitae (CV), (3) Pathways to Promotion and Introduction to Educational and Patient Care/Clinical Portfolios, and (4) Strategies for Hospitalist Educators to Achieve Scholarly Success . SessionAfter each large-group session, the presenter instructed peer members to begin work on what had been discussed in the prior large group. The presenter then instructed the small groups to meet approximately 4–6 weeks after each large-group session in order to review, continue work on previously presented topics, and have the senior facilitator available to answer questions. Senior mentors utilized facilitator guides –I that pp = .04), demonstrating feasibility, which was the initial aim of the project. Participation in the small groups was more variable. One small group met three times, with participation in each of the sessions >70%. Another group met once, with all members in attendance. The facilitator of this group then met individually with two of the more engaged members throughout the study period. The other three senior facilitators met individually with peer members. Senior facilitators and participants cited schedule conflicts and limited time as barriers to meeting with the full small group.Although 29 faculty initially joined the program as peer mentees, two members withdrew shortly after the program began, one due to lack of time and another for personal leave. Another four joined but ultimately did not participate in any of the large- or small-group sessions. These four were included in the analysis for feasibility since they did not officially withdraw. The average participation rate for the large-group sessions was 57%, which was noninferior to 50% with a margin of −10% (p = .02), promotion pathways (p = .004), and educator (p = .001) and patient care (p = .03) portfolios (p = .009); activities to include in the CV (p = .02); promotion pathways (p = .008); criteria to apply for promotion (p = .01); portfolio categories (p = .01), specifically a patient care portfolio (p = .002); activities that would count towards each portfolio (p = .002); article types they had the skills to write (p = .02); how to submit a manuscript (p = .02); and conferences accepting abstract submissions (p = .02). Those who felt they had a career goal also improved (p = .02). Moreover, 84% of participants (n = 16) were satisfied with the program, 79% (n = 15) felt participation would help in achieving career goals, and 95% (n = 18) would recommend the program to their colleagues.The second aim assessed knowledge improvement on curriculum topics utilizing pre- and postprogram surveys. A total of 19 participants completed both pre- and postprogram surveys. Overall, there was a statistically significant increase in participants’ self-rated knowledge of where to obtain resources on CV development  in nearly all of the curriculum topics addressed in the sessions. Small-group participation, however, was not as robust.We developed and implemented an innovative facilitated peer mentoring program with its own dedicated curriculum to overcome current gaps including a dearth of senior mentors, lack of skills to produce scholarly work, and the need to better prepare faculty for academic promotion. Overcoming these challenges is necessary to cultivate successful academic hospitalist programs.21 both junior and senior faculty participated voluntarily.We recognize a few limitations to the project. One limitation was the use of a Likert scale, which, although commonly used in educational research, can be influenced by acquiescence bias where participants are likely to agree regardless of how they feel. A follow-up evaluation to determine if participants used the information for their own career advancement and long-term assessment of scholarly productivity and success in academic promotion among peer members would give a more realistic evaluation of the program. Second, our results demonstrated self-reported knowledge improvement instead of objective assessment. Adding a pre- and postprogram summative assessment would provide a better reflection of actual knowledge improvement. Lastly, we experienced significant variability in small-group participation, which we acknowledge as a negative impact to a peer mentoring program. Both senior facilitators and peer mentees cited lack of time due to administrative and clinical duties as a major barrier to meeting together in their small groups. With no dedicated funding or time to support participation, a well-documented barrier to mentoring programs,We plan to use the lessons learned from implementation of the program for future iterations. First, we plan to develop more structured guidelines outlining the time commitment required for both senior facilitators and junior peer members. Since institutional and/or departmental funding for this type of activity is typically minimal to nonexistent, it would be worthwhile to acknowledge these voluntary efforts in other ways, such as awarding plaques of appreciation to senior facilitators and providing mentees with certificates of completion that can be listed in their CVs. Second, scheduling small groups well in advance with all members agreeing to preset dates and times may improve attendance and participation. Third, early concurrence of each small group's objective(s) could facilitate more effective use of small-group efforts. For example, one peer group might focus on CV preparation while another collaborates on a publication. Emphasizing the importance of peer participation, information sharing, and prior preparation of questions and materials to be discussed in the small groups is imperative to developing a successful program. Lastly, intermittent assessment and reorganization of the groups may be helpful since individual mentee interests can change over time.Facilitated peer group mentoring is a low-cost, replicable solution for academic mentoring when gaps exist in the availability of traditional mentor-mentee dyads. Our program was unique as we also incorporated a dedicated curriculum to meet the demands of the busy hospitalist. The large-group sessions provided essential information on topics necessary for career advancement in an academic setting. The small groups allowed for peer collaboration with senior guidance. The sessions can be easily incorporated into any hospitalist program in their entirety or as separate sessions for faculty development. They can also be easily tailored to other specialties where peer mentoring may be advantageous. We view this program as a starting point to narrowing the gap of academic rank among hospitalists.Preprogram Survey.docxPostprogram Survey.docxLarge-Group Session 1.pptxLarge-Group Session 2.pptxLarge-Group Session 3.pptxLarge-Group Session 4.pptxSmall-Group Session 1 Facilitator Guide.docxSmall-Group Session 2 Facilitator Guide.docxSmall-Group Session 3 Facilitator Guide.docxAll appendices are peer reviewed as integral parts of the Original Publication.


Gikuriro program, an integrated nutrition-specific and nutrition-sensitive intervention, was implemented in 5 districts of Rwanda for 5 y to address this problem. Postprogram quasi-experiments showed significant effect of the intervention on maternal and child undernutrition. Notwithstanding, there was a need for a qualitative study to explore the views of the beneficiaries and implementers regarding its benefits, challenges, and limitations to inform future interventions.Malnutrition among pregnant women and lactating mothers remains an issue of public health concern in developing countries. The This study aimed to explore the effect and challenges of an integrated nutrition-intervention program among pregnant women and lactating mothers.This was a qualitative study involving 25 community health officers and 27 nutritionists as key informants and 80 beneficiaries in 10 focus group discussions. All interviews and group discussions were audio-recorded, transcribed verbatim, translated into English, and double coded. A deductive and inductive content analysis approach was used with the help of ATLAS.ti, version 9.15.The study identified several positive effects, such as improved knowledge and skills on nutrition, a positive mindset toward a balanced diet, perceived improved nutrition, and economic independence among pregnant women and lactating mothers. However, some of the main obstacles of the integrated nutrition intervention were lack of awareness of the program, negative beliefs, poverty, lack of spousal support, and time constraints. Moreover, the study identified a main limitation: the lack of inclusiveness for all social categories.This study demonstrates that integrated nutrition interventions have perceived positive effect on nutrition; however, such interventions may face some challenges and limitations. These findings suggest that, apart from contributing to the body of evidence for scale up of such interventions in resource-limited settings, economic challenges and misconceptions have to be addressed to maximize the effect of such interventions. Maternal undernutrition during pregnancy and after delivery remains a dire public health problem. It affects the well-being of mothers and their offspring and has a long-lasting effect on the survival, growth, and development of children during the first 1000 d and beyond . It is wThe Lancet series for Maternal and Child Nutrition in 2013 proposed nutrition-specific and nutrition-sensitive interventions to improve nutrition and for optimum fetal and child growth and development [Community-based intervention strategies using locally accessible personnel and resources to deliver key maternal and neonatal health and nutrition interventions are now widely recognized , 8. To aelopment , 10. Nutelopment , 10, 11.elopment , 10.The Lancet Maternal and Child Nutrition series [Gikuriro (good growth as opposed to stunting). The project was funded by the US Agency for International Development (USAID), Rwanda. It was implemented by Catholic Relief Services (CRS) along with the Netherlands Development Organization and 6 local nongovernmental organization partners between November 2015 and November 2020 in 5 districts. The overall goal of the program was to improve the nutritional status of women of reproductive age and children aged <5 y, with an emphasis on the 1000-d window of opportunity from pregnancy until a child’s second birthday.Considering that there is still high maternal and child undernutrition, the Government of Rwanda and its development partners implemented evidence-based nutrition-specific and nutrition-sensitive intervention packages identified by n series , 10 throGikuriro program on maternal nutritional status and birth weight. Both postprogram quasi-experiments revealed that the intervention led to significant reduction of low birth weight and maternal undernutrition [Recent quantitative studies have been performed to evaluate the effect of the utrition , 13. Theutrition , 15.Therefore, this study explored the perceived benefits, challenges, and limitations among beneficiaries (pregnant women and lactating mothers) and implementers of the program to inform future integrated nutrition interventions to improve their delivery. The findings of this study would further provide lessons on how the success of this program can be replicated.Gikuriro program) among pregnant women and lactating mothers. The study was performed in 5 districts where the Gikuriro program was implemented by CRS in close collaboration with the Government of Rwanda and other partners. The targeted districts were Kayonza and Ngoma from Eastern Province, Nyabihu from Western Province, and Kicukiro and Nyarugenge from Kigali City. These districts were selected in 2015 owing to high proportion of malnutrition among children and a limited number of local development partners working on health and nutrition of children and reproductive age women. The study was conducted between March and June 2021.An exploratory qualitative approach was conducted to explore the effect, challenges, and limitations to the utilization of integrated nutrition-specific and nutrition-sensitive intervention package  and nutritionists. First, the nutritionists and CHWs in charge received training on the counseling guide module. Then, the CHWs in charge in turn trained the CHWs at the village level. The trained nutritionists counseled the pregnant women about nutrition during regular antenatal care visits, and sessions lasted about 30 to 45 min each. Moreover, the nutritionists trained the women through cooking demonstrations and about balanced diet through Village Nutrition School. Participants were required to come along with food items for the demonstration. In addition, the CHWs supervised by community health officers (CHOs) gave further nutrition education and counseling at the household level. Furthermore, the CHWs received in-service training monthly.In this intervention, 3 components were implemented: promotion of increased agricultural productivity, promotion of financial literacy/economic strengthening, and improved access to WASH services.Increased agricultural productivity. Beneficiaries were taught to practice nutrition-sensitive agriculture and to increase agriculture production using of bio-intensive agriculture techniques. They were grouped into farmer field learning school and advised on how to improve their production to attain food security at household level.Promotion of financial literacy/economic strengthening. The economic status of the women was improved by grouping them into Saving and Internal Lending Communities (SILC) as a way of responding to financial problems that prevent them from attaining better nutrition. The main methods of SILC were training those in charge of economic strengthening and project coordinators and district cooperative staff; then, the trained staff train the sector cooperative officers where they in turn train field agents from community. Furthermore, the field agents sensitize the people about SILC and form the groups. The goal was to help these women better manage their existing resources by teaching them basic financial management skills. This enabled the poor to build up useful lump sums without incurring excessive debt or interest charges.WASH interventions. Improved WASH services were implemented using Community-Based Environmental Health Promotion Program approach through community health clubs (CHCs) at the village level. Community-Based Environmental Health Promotion Program is a hygiene behavior change approach to reach communities and empower them to identify their personal and domestic hygiene needs. CHC and a demonstration site at every village was formed and initiated. The CHCs were responsible for ensuring that levels of hygiene were monitored, together with the CHW facilitator, who visited each household to observe the household sanitation and environmental conditions.Gikuriro program from the 5 districts. Ten focus group discussions (FGDs), 2 from each district, were conducted among the pregnant women and lactating mothers. A total of 80 women (40 pregnant women and 40 lactating mothers) participated in the group discussions. Each FGD comprised 4 pregnant women and 4 lactating mothers. They were selected with the help of CHOs (supervisors of CHWs) who had the records of the participants, which assisted researchers to select participants who fulfilled the inclusion criteria. The women were selected based on their participation in the Gikuriro program and educational background. Only women who had been in the program for its full duration were included. Moreover, in each district, one FGD constituted women with postprimary education and the other FGD women with lower than secondary level education. The discussions were conducted at the health centers and round transport for the participants was covered.The target population comprised pregnant women and lactating mothers who were beneficiaries of the n = 25) and nutritionists (n = 27) actively involved in the implementation of the project. One CHO and 1 nutritionist were selected from each health facility in the 5 districts. There was only 1 CHO and 1 nutritionist assigned to each health facility . However, those newly assigned to the post and those with <1 y of experience with the Gikuriro program were excluded.In addition, key informant interviews (KIIs) were conducted among CHOs . Both were highly experienced as they had previously conducted several qualitative data collections. However, they were trained by the principal investigator regarding the objectives of the study, the guide questions, approach, recording, and confidentiality. Kinyarwanda was used to collect the data using a face-to-face approach. The FGDs and KIIs were audio-recorded where there was optimal privacy and low noise in the respective selected health centers. Discussions were held in a circle to facilitate face-to-face dialog and numbers from 1 to 8 were assigned to participants to allow anonymous transcription. A moderator and a notetaker were assigned to each FGD, whereas, for KIIs, only 1 person was assigned for notetaking and interviewing. At the end of the FGDs and KIIs, the keynotes were shared/reviewed to validate what they had said. The audio-recorded data were saved on a personal computer for security and confidentiality. On average, the FGD lasted ∼1 h and the interview ∼45 min.The discussions and interviews were first transcribed verbatim in Kinyarwanda and translated into English. These transcriptions and translations were supervised and double checked to enhance validity. The translated data were saved using unique names and imported to ATLAS.ti version 9.15 (Atkas.ti) for coding and analysis. Four main stages—decontextualization, recontextualization, categorization, and compilation —were folThe study was reviewed and received ethical approval from the institutional review board of the University of Rwanda, College of Medicine, and Health Sciences (No. 362/CMHS IRB/2020), in compliance with the tenets of the Helsinki Declaration. Subsequently, the study received approval to collect data from the Ministry of Health’s National Health Research Committee (No. NHRC/2020/PROT/046). Before data collection, each participant was informed about the purpose, procedure, voluntary participation, and confidentiality of the study. A verbal audiotaped consent was obtained from each participant. Participants did not receive any compensation apart from the round trip transportation cost. From the start of recording, participants used an assigned number, and no identifiers were recorded. The principal investigator was responsible for the security of the data (transcripts). There were no direct benefits for participation.Gikuriro program (integrated nutrition-specific and nutrition-sensitive intervention package). The key subthemes identified for effect were as follows: 1) enhanced knowledge and skills on nutrition, 2) perceived improved nutritional status, and 3) women empowerment/independence. The following 4 subthemes were identified as key challenges in the utilization of this integrated nutrition-specific and nutrition-sensitive intervention: 1) lack of awareness, 2) negative attitude/beliefs, 3) poverty/economic constraints, and 4) lack of husband support and time constraints. Finally, 1 key limitation of the intervention emerged during the analysis, which is the lack of inclusiveness to all social groups.The main themes are presented further followed by their subthemes. The findings are described with quotes generated from the FGDs and KIIs.Gikuriro program. One of the main advantages mentioned frequently was enhanced knowledge and skills gained in cooking a balanced diet. They claimed that they did not know how to cook a balanced diet before the program was implemented. They expressed how lucky they were to have got the opportunity to gain knowledge and skills, especially on having a balanced diet from readily available food. Some of the views expressed were as follows:Now we know how to cook a balanced diet with locally available items, which don’t require us to be rich. Before Gikuriro, we were ignorant, and we didn’t know how to cook a balanced diet. Now we have learned a lot from Gikuriro Program.” “There were so many who were getting sick with malnutrition, not because they did not have sufficient food but because they didn’t know how to prepare a balanced diet.” “Most of the pregnant women and lactating mothers expressed their views on the perceived positive effect of the intervention and the benefits gained from the Pregnant women and lactating mothers learned how to prepare a balanced diet. Before they used to think that a balanced diet meant eating meat but now, they know that it includes a variety of food” .“The same benefit was expressed by nutritionists who observed an improvement in skills on cooking a balanced diet quoted as follows:Gikuriro had a great effect on the economic wellbeing of the women by enhancing their economic growth through saving groups.Gikuriro project taught us how to save money, make money, borrow money, get into business, buy food, a farm and a lot of other things, I am satisfied, and I don't always have to ask for money from my husband.” “Another benefit was that Gikuriro project has changed a lot for people by teaching them how to improve their income by creating saving groups and now they can buy vegetables and fruits from their savings without waiting from their husbands.” “This improved the livelihoods of the households, especially for women because they stated that they no longer asked money from their husbands to buy food and other items, which was reinforced by a KII.Gikuriro program had increased their knowledge and skills on how to promote increased agricultural productivity through kitchen gardens, which led to food security.We have learned how to make different kitchen gardens which we did not know before Gikuriro came. Now we are planting different vegetables and fruits so that we have enough vegetables and fruits instead of buying them.” .“Another subtheme category that emerged strongly was the improved knowledge and skills in kitchen garden and cultivation. Most participants claimed that the Gikuriro encouraged people to start rearing small domestic animals to improve their livelihood. They have also been raising awareness about low-cost livestock breeding so that the family can earn a living from small livestock.” .“In addition, rearing small domestic livestock improved significantly. For example, one key informant stated his views as follows:We used to struggle with hygiene and you could find households and parents with poor hygiene, but Gikuriro taught and alerted us about hygiene and sanitation practices such as how to keep water, food, household utensils clean; and how to wash our hands and encourage us to construct handwashing station around the latrine.” .“Gikuriro has a special training program on the use of clean water, training of people called village social workers, and cleaning and sanitation to prevent disease from contamination.” .“The study further revealed an increased awareness of hygiene practices, including maintaining safe and clean water, food and household utensils hygiene, and hand washing.Gikuriro program led to perceived improved nutritional status among lactating mothers and pregnant women and their children aged <5 y. In addition, they testified that before the Gikuriro program was implemented, there were some children who were previously malnourished, but at the time of the study, they nourishment improved. This is how the discussants and key informants expressed their views:Gikuriro program brought a change in terms of nutrition because we have learned how to cook a balanced diet, and now the children are well off and have no problems with malnutrition.” .“Gikuriro really helped to reduce malnutrition significantly, for example, we used to have around 175 children with malnutrition in this sector but now after Gikuriro we have only about 10.” .“Most participants voiced that the Gikuriro project mainly taught them how to properly use what they have by changing their mindset positively. It was reported that people had changed their practices regarding the way they were feeding their children and themselves.Gikuriro was a very good project, before people were used to being given money and they were wondering at the beginning what is the benefit, whether to get milk, rice, porridge, but the Gikuriro project was aimed at changing people's attitudes and training them to improve their lives based on what they already have.” .“Before the Gikuriro program come, people were less likely to care about eating vegetables and fruits, but when the program came, people woke up and began to give importance to the inclusion of vegetables and fruits in their diet.” .“Participants indicated that they had been expecting to get some money or other goods, but the Gikuriro program empowered them economically through savings because they claimed that they are no longer dependent on their husbands and were able to help their families.Some of the saving groups they worked with made women less likely to expect anything from their husbands and be able to support their families.” .“The women spoke out highly that the Some women were isolated in their homes, but with the Gikuriro program, they are now in cooperatives. Some are producing soaps; others are doing other activities that allow them to be independent. They are no longer depending on their husbands.” .“Moreover, they were taught how to start small businesses and projects, such as soap making, food processing, sewing, making skirts, and weaving clothes, which in turn supported the women to become economically empowered.Gikuriro program activities. They mentioned that the main challenges they faced were that some parents were not interested in Gikuriro project, which could be owing to poor knowledge of its importance.The goal was to change people's attitudes, but some people were not available to join groups. They didn't think that these nutrition services were relevant to them.” .“There is something I find that prevents pregnant and lactating mothers from attending the Gikuriro program which is ignorance, sometimes women do not understand the value of nutrition intervention projects.” .“Some women initially were not interested but later they realized the importance of Gikuriro program and began to use the project.” “Under this subtheme, participants revealed that some women were ignorant and lacked awareness on the importance of When Gikuriro proposed to give pig or rabbit, Adventists and Muslims refused though they were provided with options such as chickens.” .“The findings revealed that some of the interventions may not have been culturally appropriate for all religions. For instance, some participants from certain beliefs/religions were not comfortable rearing animals, such as pigs or rabbits.Some had misconceptions that Gikuriro was for poor people or for those who have children with malnutrition, and they did not want to join the program at the beginning because they felt very poor and ashamed. This was the obstacle to justifying poor participation at the beginning.” .“There were some rich parents who felt like going to sit with someone who is poor is so disrespectful which prevented them from attending and most of the time they were the ones who were found with children who are malnourished, and that obstacle prevented them from attending Gikuriro programs which were good for their babies and themselves.” “Another barrier described was the misconception that some women thought the nutrition intervention was only for poor people or those having undernourished children, which led to low attendance at the beginning as some were ashamed to participate in the nutrition program.Gikuriro program rather than knowledge and skills.Participation was not for everyone because there were those who gave up because they are not getting money and goods as many people were expecting to be given money or other things.” .“It was observed that some of the participants were expecting to receive monetary benefits from the My advice is for other projects not to give money to the people, instead, they should give them lasting things, because often the community gives them money to do something and use it sometimes without producing the same profit as it was intended.” “However, contrary to this, other participants recommended that other projects should also not give money to participants for the projects to be sustainable.Some of the challenges pregnant women and lactating mothers face are lack of food because as it was time to go to the village kitchen, everyone had to bring food to come together to learn how to prepare a balanced diet and be ashamed of as they did not see what they had to do with others.” .“Women were asked to bring what they have at home to the nutrition education sessions but those poor women could not attend without bringing something, they thought that other women were going to laugh at them.” .“They are poor because of the lack of means/money and they wanted to be given food and prepare it, and someone would say, ‘I don't have it.’” .“Regarding the demonstrations on cooking a balanced diet, participants were required to bring the food items from home. This was because the main aim of the project was to help the community become self-sustainable and teach them to prepare a balanced diet with what they have. However, most informed that they did not have food and money to buy those food items, which led some to missing out, resulting in a low turnout of participation.Sometimes we tell them to bring food and some don’t have, but also the feeling that they had a responsibility to find food was useful, not like a project that comes and goes and brings food and then stops, which I see as a good thing that happened by Gikuriro program even though it was a challenge on the other hand that there were those who weren’t able to get what they were asked to bring for the cooking demonstration sessions. .Although this mostly came off as a challenge, it was, however, seen as a positive effort to change the mindset of the community by other participants who expressed otherwise.Gikuriro program. Some reported that their husbands indicated that the program was for poor people. Another obstacle that women often faced was the lack of a caregiver at home to take care of other children who are not attending kindergarten and often missed out the programs. Lack of time, being busy looking for jobs, or working was another barrier to women attending the program.Some people resist change. Here for instance, some men did not want their wives to attend Gikuriro activities thinking that those activities were for poor people.” .“Women have a lot of responsibilities in their homes, and sometimes they find themselves being busy at home including caring for children which may result in missing out Gikuriro programs, because she does not have someone to leave with the children.” .“The challenge was that some women were very poor and are busy looking for jobs or are always at work and failed to attend educational sessions on nutrition.” .“Furthermore, participants described that some pregnant women and lactating mothers lacked support, especially from their husbands to attend the Gikuriro program was excluding pregnant women and lactating mothers from the higher social categories because it was targeting those only from social categories 1 and 2. The socioeconomic status in Rwanda is assessed using poverty social category established by Minister for Local Government and Social Affair in 2015. These are 4 categories based on ascending income levels: category 1, extremely poor; category 2, poor; category 3, self-sustaining; and category 4, rich [Most participants felt that the  4, rich .The obstacles that existed are the Ubudehe social categories, because Gikuriro was for the first and second categories. A pregnant or breastfeeding mother in the third category who needed that help was not allowed into the program although they should be taught about nutrition.” .“The only problem was that it was not accessible to all, it was only focused on women of the first and second wealth categories. Those in Ubudehe 3 and 4 were not allowed to participate though they wanted it.” .“It is also important to look at how targets in wealth categories 3 and 4 can be helped, as some of them have poor nutrition and find that this kind of help is not available to them as they do not know how to prepare a balanced diet.” .“My advice is that if there is another project, I wish it can give everyone the right to participate regardless of Ubudehe categories.” “The program included mothers from higher social class only if their children were malnourished. The beneficiaries described that even women in high social classes may also lack the skills and knowledge on balanced diet, WASH, kitchen garden, and savings. Hence, the main recommendation for the success of such projects emanating from the beneficiaries is inclusion of all social categories.Gikuriro program, in this case), such as enhanced knowledge and skills gained on cooking a balanced diet, kitchen gardening, saving and hygiene practices; perceived improved nutritional status; and a positive mindset regarding nutrition and women economic empowerment through social safety nets. However, some of the factors that were identified as challenges hampering the use of the integrated nutrition-intervention package were lack of awareness, negative attitudes/beliefs, economic constraints, and lack of husband support and time. In addition, the study found that one key limitation of the program, which was the lack of inclusiveness for all social groups.This qualitative study has demonstrated the various potential effects of the integrated nutrition-intervention package (Gikuriro, they neither knew how to cook a balanced diet with what they had nor how to make a kitchen garden for planting vegetables and fruits. This finding adds to the literature that communities exposed to integrated nutrition interventions are significantly more likely to gain knowledge about nutrition and are more likely to practice the behavior [Gikuriro program to understand whether this knowledge has translated into practice and to explore the barriers of practice in Rwandan context.Most of the study participants indicated that before behavior . It is ebehavior . Furtherbehavior , 21. Howbehavior . TherefoSeveral studies in different countries have demonstrated that kitchen gardens improve food security of households . MoreoveGikuriro program had 2 domains: economic and agricultural production empowerment. Economic empowerment helps women to buy specific foods, and agricultural production empowerment is associated with feeding practices [Another effect of the nutrition-sensitive component mentioned highly in our study was the skills of group savings that led to women empowerment and economic independence to buy food items. This adds to the empirical evidence that women empowerment and autonomy improves nutritional status of mothers, their children, and other members of the household . Literatractices , 39.Gikuriro intervention was associated with a significant reduction of low birth weight and maternal undernutrition [All these improved knowledge and skills; in addition, a changed positive mindset regarding nutrition and women empowerment could have affected on the perceived improved nutritional status by addressing both immediate and underlying causes of malnutrition as highly expressed by many of the key informants and FGDs participants in the study. This is supported by quasi-experimental studies conducted by the same authors, which found that the utrition , 13.Despite the positive effect/benefits of the integrated nutrition-intervention program, this study identified some challenges and limitations to the implementation or use of services from the program. One of the subthemes of the challenges was a lack of awareness and negative beliefs/misconceptions. Under this subtheme, being ignorant and lacking knowledge on the importance of a balanced diet emerged as a key barrier. Respondents mentioned that some women were not interested and did not care about nutritious food even if they had a diversity of food. According to some participants, if they are satisfied, there is no problem. This is acknowledged by findings from another study that some individuals are resistant to change in dietary practices . SimilarNegative attitudes, such as the belief that nutrition interventions are only for the poor or malnourished, feeling ashamed to participate in the nutrition-intervention program because such programs are associated with having a malnourished child, and expecting only money from projects instead of knowledge and skills were reported to negatively affect participation in the integrated nutrition intervention. Although not very common, religious beliefs, which led to the refusal to rear animals, such as pigs, were also mentioned as barriers. Moreover, various studies have shown that community beliefs, cultural effects, and religious influences contribute to utilization of nutrition intervention . These bGikuriro program. In the program, pregnant women and lactating mothers were required to bring food items to the village Kitchen School. The inability to obtain those foods was frequently mentioned by the study participants. Such a barrier may prevent pregnant women and lactating mothers from using nutrition interventions. Similarly, other studies reported that poverty and economic constraints were the key barriers to obtaining those foods and nutrition-intervention utilization among low social class families [In this study, economic constraints were identified as a major barrier hampering attendance in the families . Moreovefamilies .Furthermore, most of the participants identified lack of support and time as the main hurdles to using the nutrition-intervention program. Under this subtheme, lack of spousal support and lack of time owing to hefty workload at home or at work were key barriers preventing the women from attending the nutrition program. Similarly, studies have evidenced that heavy workload and poor husband support are barriers that limit pregnant women and lactating mothers in using integrated nutrition intervention and services , 50, 51.The strengths of the study include using a big sample size of various community members, such as pregnant women, lactating women, nutritionists, and CHOs, involved in the integrated nutrition intervention. Another strength is the use of triangulation and confirmation from KIIs and FGDs by including different study groups to deeply explore the effect/benefits and challenges of using nutrition programs. However, attention should be given to the limitation of bias because of social desirability in which the study participants having been the beneficiaries and implementers of the program may over report the positive aspects of the program. To overcome this, to understand what the participants really felt about the barriers to the intervention, the investigators and facilitators clearly explained and emphasized that the purpose of the study was to inform future nutrition program implementation.The study has demonstrated several positive effects of an integrated nutrition-specific and nutrition-sensitive intervention package, such as promoting women empowerment, perceived improved nutritional status and enhanced knowledge/skills on cooking a balanced diet, kitchen garden, hygiene practices, and savings. Despite these benefits, there were some challenges identified that hindered pregnant women and lactating mothers from using the integrated nutrition intervention, including poverty/economic restrictions, lack of husband support and time, and lack of awareness and negative beliefs about the nutrition intervention. Finally, excluding social categories 3 and 4 was identified as a key limitation as emphasized by the study participants. Therefore, these challenges and limitations should be considered in future nutrition programs or interventions for more robust outcomes. Awareness campaigns on the misconceptions about nutrition interventions, involving husbands/men in the interventions, support for pregnant women and lactating mothers, and their economic development/empowerment should be enhanced.MH, AGA, MU, MM, and CM, no conflicts of interest.


Less than half of women with urinary incontinence (UI) receive treatment, despite the high prevalence and negative impact of UI and the evidence supporting the efficacy of pelvic floor muscle training (PFMT). A non-inferiority randomized controlled trial aiming to support healthcare systems in delivering continence care showed that group-based PFMT was non-inferior and more cost-effective than individual PFMT to treat UI in older women. Recently, the COVID-19 pandemic highlighted the importance of providing online treatment options. Therefore, this pilot study aimed to assess the feasibility of an online group-based PFMT program for UI in older women. Thirty-four older women took part in the program. Feasibility was assessed from both participant and clinician perspectives. One woman dropped out. Participants attended 95.2% of all scheduled sessions, and the majority  completed their home exercises 4 to 5 times per week. Most women (71.9%) were completely satisfied with the program’s effects on their UI symptoms after completion. Only 3 women (9.1%) reported that they would like to receive additional treatment. Physiotherapists reported high acceptability. The fidelity to the original program guidelines was also good. An online group-based PFMT program appears feasible for the treatment of UI in older women, from both participant and clinician perspectives. Urinary incontinence (UI) is one of the most prevalent health concerns in women age 65 and over ,2, with However, the COVID-19 pandemic prevented group gatherings, especially for older adults, who were at higher risk of complications. For the past two years, it therefore limited the implementation of in-person group-based interventions, such as the GROUP trial’s program. At the same time, the pandemic also drove an impressive surge in many remotely delivered healthcare services , which hOne promising solution is telerehabilitation, which refers here to the remote delivery of synchronous rehabilitation services using information and communication technology. It has already shown good feasibility and favorable clinical outcomes for the treatment of various orthopedic and neurological conditions ,31,32,33This study thus aimed to assess the feasibility of an online adaptation of the GROUP program (the teleGROUP program) for UI in women age 65 and over, from both participant and clinician perspectives. Feasibility studies are a critical component of the evaluation of study processes. They establish the necessary groundwork to shape the subsequent phases of clinical development and provide insights for successful implementation ,36,37,38This pilot pre-post feasibility study is part of a larger research program aiming to assess the feasibility, acceptability, effects and costs of the teleGROUP program . The present study focused on feasibility. More specifically, the study aimed to determine the feasibility of teleGROUP in terms of attendance, adherence, complications, dropouts, satisfaction and the overall experience data of participating women; acceptability for the evaluating physiotherapists; and conformity with the original program guidelines from the physiotherapist leading the teleGROUP program. This study follows the Consolidated Standards of Reporting Trials (CONSORT) for reporting results. A detailed study protocol was previously published .The research team recruited participants through advertisements, a research participant database and referrals from collaborating clinics. Women were eligible if they were age 65 and older; able to walk independently; presented stress or mixed UI, as confirmed by the Questionnaire for Incontinence Diagnosis (QUID) , with atDuring an initial individual in-person evaluation session, participant eligibility was confirmed by an experienced local physiotherapist with specialized training in pelvic floor rehabilitation. During this session, the physiotherapist also took the time to teach the participant how to correctly contract her pelvic floor muscles (PFMs) through digital vaginal palpation and verbal cues .Participants who were able to voluntarily contract their pelvic floor muscles following a verbal command by the end of the evaluation session were deemed eligible and then took part in the teleGROUP program ,15. TeleA videoconference connection link, which was unique for each cohort, was sent weekly via email to all participants two to three days before the session. No login was required, and participants could click to join the session directly from the email they received. Each weekly virtual session began with a 1–3 min individual exchange between the physiotherapist and each participating woman in a private breakout room to quantify UI episodes and exercise adherence in the previous week. In the meantime, the rest of the group were invited to socialize in the Zoom meeting’s “main room”. All sessions were then divided into a 10–15 min educational component and a 30–45 min PFMT exercise component. More detail on both the educational and exercise components of the teleGROUP program are available in The research team pre-screened women for eligibility through a telephone interview. A specialized physiotherapist located in the participant’s region then confirmed their eligibility through an individual in-person evaluation. During this evaluation, the physiotherapist collected sociodemographic and health data, namely, age, height, weight, socioeconomic status, medical history and general health characteristics, including type of UI symptoms, duration of symptoms and cognitive status through the MMSE  and MontTo assess feasibility from the participant perspective, the physiotherapist leading the teleGROUP program recorded attendance at weekly sessions  and adheTo assess feasibility from the clinician perspective, both the evaluating physiotherapists and the treating physiotherapist were considered. First, the physiotherapists conducting the initial individual in-person evaluation session completed a questionnaire based on the Theoretical Framework of Acceptability (TFA) , using sSecondly, still within the assessment of feasibility, the physiotherapist leading the teleGROUP program recorded fidelity to the original program guidelines at each session for the full 12 weeks  using a Data were tabulated and interpreted using descriptive statistics, such as means, medians, standard deviations and interquartile ranges for continuous variables and frequency distributions for categorical and dichotomous variables, as appropriate.Participants were recruited from March 2021 to April 2022. Of the 150 women who were interested in participating in the study, most were contacted through community groups, associations or public events , journals or magazines , a participant database  or through word of mouth and past experiences with the research team  . Among tThirty-four women were included in the study and divided into four cohorts. Of those, 33 completed the program. Eight participants requested the Zoom introduction and technical support over the phone before the program. Participants waited a median (IQR) of 21 (26) days between their initial recruitment phone contact and in-person evaluation. There was a median of 26 (33) days between their in-person evaluation and first session of the program. These wait times were due to the availability of the participants and physiotherapists, in addition to the time required to receive and complete the 7-day bladder diary prior to their initial individual in-person evaluation session. 1 participant (3%) dropped out after the seventh week of the program due to personal reasons, and 1 participant (3%) was unreachable and lost to follow-up after program completion, leading to an attrition rate of 2/34 (6%) for the study. The complete flowchart of participants is available in Throughout the 12 sessions provided to each of the 4 cohorts of older women, no technological problem arose that could have prevented their participation in the online program. Secondly, the physiotherapist leading the teleGROUP program delivered the program to groups of 6 to 11 women, thus exceeding the initial group size established in the protocol. The time dedicated to individual exchanges with the physiotherapist at the beginning of each session was longer than anticipated, which demonstrates the appreciation and unexpected enthusiasm of participants for this component of the program. Yet, it resulted in some subsequent time constraints. Time constraints increased with additional participants in the group, and program delivery took an additional 10 to 20 min, depending on the number of women present at the session and the time spent in individual exchanges. Throughout the program, fidelity to the program content was good, as reported by the leading physiotherapist, with only a few non-central elements that were not completed . The phyThis pilot feasibility study is the first to investigate the feasibility of an online group-based PFMT program. The study showed that the teleGROUP program was feasible from the participant perspective, with high attendance at the online classes, high adherence to the home exercises, infrequent and minor side effects resolving quickly, low attrition throughout the 12-week program, high satisfaction with the program and good perceived usability of the online program. In addition, this study showed good feasibility from the clinician perspective, with high acceptability from the evaluating physiotherapists and relatively good fidelity to the original program guidelines from the physiotherapist leading the program, despite time constraints. Compared to the original in-person version of the program, teleGROUP showed a similar attendance rate  and lower attrition throughout the program  . ExercisThroughout the program, the clinical expertise of the specialized physiotherapists played a key role in ensuring adequate treatment delivery, regardless of the online or group format. First, during the initial in-person evaluation, the physiotherapists taught participants to contract their PFMs. They were able to guide the participating women so that they could achieve an adequate PFM contraction by overcoming perineal inversion , compensations  or difficulty relaxing their PFM. These challenges are similar to those observed in other studies, where between 17% and 43% of women initially strained, pushed or used a Valsalva maneuver when attempting to contract their PFMs ,70. Additionally, when facing time constraints during the 12-week program, the physiotherapist leading the teleGROUP sessions made some decisions that were informed by clinical expertise and experience. This clinical decision process was reflected in the fidelity findings: Besides the individual exchange and the educational session, the physiotherapist prioritized the four main PFM exercises constituting the core elements of the program over the other exercises from the program. Comparatively, in the GROUP trial, the per protocol fidelity percentage was higher overall , compared to 31.2% and 12.5%, respectively, in the teleGROUP program). Yet, the disparities between the in-person and online versions of the program tend to disappear when considering the core elements of the program, notably, the four main PFM exercises. Indeed, the fidelity was relatively similar for these 4 PFM exercises, with 90.7%, 96.2%, 100.0% and 98.7% for each exercise (unpublished data), compared to 96.7%, 97.0%, 98.4% and 100.0% in the GROUP and teleGROUP programs, respectively. Moreover, the physiotherapist leading the teleGROUP program limited the position changes during the sessions to avoid multiple camera angle adjustments by both the physiotherapist and the participating women and to reduce the time spent correcting posture. Additional time was still needed to complete the treatment sessions due to the time spent in individual exchanges, particularly when dealing with a high number of participants. As adherence to the PFM exercise program constitutes the cornerstone of successful UI treatment ,72, the The findings of the present study represent an important first step in guiding the upcoming research steps towards the implementation of group-based PFMT telerehabilitation programs in various healthcare settings. This format provides a safe UI treatment option during pandemic periods or in any other situation that presents a health risk . An online option could also increase the accessibility of continence care for women living in rural or remote areas, where pelvic floor rehabilitation services are unavailable or scarce. It could also be an additional asset for any woman who cannot attend in-person treatment due to her living situation , transportation difficulties or any other personal reason. This study also presents some limitations. As this was a feasibility study on an innovative treatment approach, a relatively small sample size was included, and the intervention was delivered from a single institution, limiting the generalizability of the findings. However, pilot studies constitute an important part of the research process , and theIn conclusion, this study shows that an online group-based PFMT program for older women with UI is feasible from both patient and clinician perspectives. The time constraints due to time spent in individual exchanges emphasized the importance of respecting the program’s pre-established group size of eight women. The study also highlighted the pivotal role of the physiotherapist leading the program in prioritizing the activities according to the clinical objective pursued. Further investigation is needed to determine the clinical effectiveness of the teleGROUP program.


The COVID-19 pandemic has exacerbated mental health issues among adolescents. Exercise is well-regarded for boosting mental health. Riding for Focus (R4F) is a 6–8 week cycling education program designed to equip middle school adolescents with basic cycling skills and introduce students to lifetime physical activity. A secondary goal of the R4F program is to improve adolescent mental health and psychosocial well-being. This study aimed to quantify the change in adolescent psychosocial well-being associated with the R4F program during the COVID-19 pandemic. Program evaluation also examined associations between participating in the R4F and mental health outcomes in the context of established risk factors, including gender, race, socioeconomic status, involvement in IEP programs, participation in after-school clubs, screen time, hours of sleep, and physical activity levels.Anonymous surveys were collected before and after the program in 20 schools in North America, with psychosocial well-being quantified using WHO-5 and PSC-17-Y. 1,148 middle school students, aged 11–14, completed pre intervention surveys. 815 students also completed post intervention surveys.There was a general increase in psychosocial well-being after the R4F program and positive psychosocial well-being changes in students that identified as female, non-white, physically active, part of an IEP program, meeting screentime recommendations, and engaged in school programs, though effect sizes were small. Despite mental health improvements among underrepresented groups, relative risk assessments still indicated that males, white students, those from high socioeconomic status families still had reduced relative risk of developing psychosocial disorders post intervention.These analyses illustrate the feasibility of cycling as a viable PE elective and the need for further, more robust studies to better assess the positive impacts of the R4F scholastic cycling program on the psychological health and well-being of middle school age children. One in six school-aged children are diagnosed with mental health disorders ; 13% of Data from the National Center for Education Statistics shows that adolescents in the United States spend an average of 6.64 h in class, and that they are in school for roughly 180 days each year . BecauseOne fun and engaging physical activity that gained popularity during the COVID-19 pandemic is cycling. Introducing cycling is a promising approach to engage students in physical activity during the school day . CyclingPrograms centered around the bicycle therefore afford opportunities and benefits that many other physical activity programs cannot. One such cycling program is the Outride Riding for Focus (R4F) program. The R4F program is a 6–8 week middle school physical education program with a curriculum designed to equip students with basic cycling handling skills and introduce them to the lifetime physical activity of cycling. Current literature indicates that physical activity interventions have the ability to positively increase adolescent mental health and psychosocial well-being , 21. The2.2.1.Data for this program evaluation study were collected via a voluntary anonymous survey from participants in the Outride R4F scholastic middle school cycling physical education program. Student participants filled out online surveys via the Qualtrics platform on classroom or at-home electronic devices before and after the R4F program. Institutional review board approval was obtained by IntegReview (now Advarra) and for secondary data analysis by the institutional review board of Loma Linda University. The data were collected from 1,268 pre-program respondents and 910 post-program respondents from 20 middle schools in North America participating in the R4F program from January–May 2021. Students were between the ages of 11 and 14, as commensurate with their grade level (6–8). Schools included in this study were from a mix of urban, suburban, and rural regions throughout the United States. There was roughly an equal proportion of 57% male and 43% female respondents before and after the program. 64% of respondents self-identified as white, while 36% of respondents self-identified with other racial or ethnic groups , consistent with the demographics of the participating schools. There was not enough statistical power to measure differences between all racial groups and as a result, for analyses reported here, we report differences between participants who self-identified as white and those who self-identified as a different racial or ethnic background (non-white). Despite COVID-19, 45 schools implemented the R4F program in the 2020–2021 school year; thus, our sample represents 44% of the total number of schools who were able to implement the program during that school year.Students were asked to take a survey before the R4F program through a Qualtrics online portal, which included questions about student experiences and perceptions of physical activity, cycling, school, and overall well-being. Students also answered questions about hours of sleep, hours of screen time, level of physical activity, and involvement in clubs and sports teams. Students self-reported their gender, race and ethnicity, whether they previously participated in a R4F program, and whether they received free or reduced-cost school lunches, which was used as a proxy for socioeconomic status (SES). They were also asked whether they were enrolled in an Individualized Education Plan (IEP), which is a legal plan or program developed to ensure that a child with an identified disability receives educational accommodations that ensure educational performance in elementary and secondary school . StudentDue to COVID-19 school closures, not every student was able to complete both a pre-and post-program survey. The number of respondents for the pre-survey was 1,268 and 910 for the post-survey. The mean time to completion of the survey was 11.6 min, with a median of 9.3 min. Surveys were removed if they were completed in fewer than 3 min or were not completed within 2 standard deviations longer than the mean completion time (2.77 h). A secondary filter was performed to ensure the quality of the PSC-Y-17 and the WHO-5 responses. Only those responses that included a response to each sub-item were included to ensure scores were not skewed by non-responses to individual items. This final filter resulted in the removal of 8.1% of PSC/WHO responses, with 1,148 pre-program and 815 post-program surveys being analyzed.2.2.The Riding for Focus (R4F) program is a middle school cycling education program designed by the organization Outride. The program is designed to teach cycling safety skills so that participants can cycle competently, efficiently, and effectively Students learn how to form an exercise habit, enjoy exercising, and how exercise can be used to improve other aspects of their lifestyle. The program was developed based on principles of effective instruction, program design, and evaluation and was motivated by Social Cognitive and Self-Determination theories. The curriculum was designed to be taught in chronological, developmentally progressive order, ultimately leading teachers and students through a structured, repetitive, and iterative 12 lesson process. The key lesson topics covered are listed in The R4F program was designed to be implemented during the school day, often during a Physical Education class, for a minimum of three days a week for at least six weeks where possible, with a focus on achieving at least 20 min of moderate-to-vigorous physical activity during each class session. The lessons can be taught on a wide range of terrains and settings including basketball or tennis courts, track fields, empty parking lots, or a grass field.2.3.U test was used to identify potential differences in the well-being metrics on non-parametric datasets. For analysis of more than two groups, a Kruskal-Wallis ANOVA with a Dunn's multiple comparisons test was performed on non-parametric datasets. Graphs present violin plots with median, 25% and 75% quartiles, along with minimum and maximum data ranges. A Chi square analysis was performed to examine the proportion of students in each group before and after the program. A P-value of P < 0.05 was considered significant and was further broken down to P < 0.01, P < 0.001, and P < 0.0001 where appropriate. Additionally, Cohen's d test statistic was calculated to approximate effect size in pre and post intervention comparisons. Based on benchmarks recommended by Cohen, interpretations of effect size included small (d = .2), medium (d = .5) and large (d = .8) . Data was tested for normality prior to analysis. None of the data was normally distributed. For analyses between two groups, a Mann–Whitney (d = .8) . Because(d = .8)  for the (d = .8) . The cut(d = .8) . The cri(d = .8) , 26.3.The efficacy of the R4F program in improving mental health and well-being was evaluated for a primary effect of the program in all students. Following the R4F program there was a significant increase in the WHO-5 composite score and a significant decrease in PSC-17-Y composite score post-program . There w3.1.3.1.1.We analyzed the efficacy of the R4F program in male and female adolescent students to examine the influence of gender, as gender related differences in psychosocial well-being and responses to exercise programs are well documented , 33–35. There were differences in how each gender responded to the R4F cycling program. Participation in the R4F program was associated with a significant improvement in WHO-5 psychosocial well-being scores in female students but not their male counterparts . However3.1.2.To examine the influence of race and ethnicity we analyzed the efficacy of the R4F program for both white and non-white students, because previous evidence indicates that minorities report lower levels of psychosocial well-being . There wFollowing the R4F program there was a significant increase in the WHO-5 well-being composite scores of non-white students but no differences in white students. No significant differences were observed in white and non-white students' well-being scores in the PSC-17-Y metrics following program participation . However3.1.3.We analyzed the efficacy of the R4F program within the context of socioeconomic status (SES), a demographic factor that is known to increase risk for adolescent psychosocial well-being . BaselinParticipation in the R4F program had no effect on WHO-5  but was 3.1.4.We analyzed the influence of having an Individualized Education Plan (IEP) on the efficacy of the R4F program to increase the psychosocial well-being and mental health of adolescents as the available evidence demonstrates that adolescents with IEPs are at increased risk for an array of mental health challenges , 39. Ana3.1.5.Because sleep is an important factor with regards to mental health and well-being we analyzed the influence of sleep on the association between the R4F program and mental health –42. Befo3.1.6.We analyzed whether being physically active influenced the efficacy of the R4F program to improve mental health and psychosocial well-being because of the known associations between physical activity and mental health , 8, 18. The significant differences in WHO-5 and PSC-17-Y scores associated with physical activity were further reflected in post-program results. Interestingly, participation in the R4F program was associated with an increase in the WHO-5 composite scores of those who exercised at least 4 days a week, which remained higher compared to those who exercised less. Participation in the R4F program was not associated with a change in the PSC-17-Y general composite score in either group . Those w3.1.7.We then analyzed the influence of screen time on the efficacy of the R4F program as current literature suggests that spending more than 2 h a day on electronic devices has a negative influence on psychosocial well-being . Before The significant differences in WHO-5 and PSC-17-Y scores between those who did and did not exceed the 2-hour threshold remained following the R4F program . What is3.1.8.We analyzed the influence of participation in school activities on the efficacy of the R4F program as current literature indicates that participation in school activities such as sports, clubs, and musical programs provide a positive influence on psychosocial well-being . Before Following the R4F program, WHO-5 scores increased significantly in students involved in school activities  while PSd statistic was calculated. Nearly all aggregate changes in psychosocial metrics had a small effect size , female PSC-17-Y internalization scores , and PSC-17-Y externalization scores for students who were active less than 4 days a week   .4.Our study examined the impact of a scholastic cycling physical education program on a few key factors. Analysis of the R4F surveys confirms the hypothesis that a middle school cycling education program is associated with positive impacts on student psychosocial well-being. Self-reported WHO-5 and the PSC-17-Y scores in an American adolescent population during the COVID-19 pandemic improved on aggregate after the R4F program. The scores were also stratified based on several factors. The primary finding of this stratified analysis was that the relative risk of developing psychosocial disorders was reduced in males, white students, those from high socioeconomic status families, those who get adequate sleep, those who are more active, those who have reduced screentime, and those who are involved in school activities, both before and after participating in the R4F program. Students who were involved in an IEP program did not have increased risk. Participating in the R4F program was generally associated with improved psychosocial measures, and had a positive effect in females, non-white students, students who are active, those who have reduced screentime, and those who are involved in school activities.We first considered the general impact of the R4F program on WHO-5 and PSC-17-Y values, independent of any other factors. The finding that roughly a quarter of the pre-program respondents were below the critical thresholds in both the WHO-5 and PSC-17-Y metrics of psychosocial well-being and were at risk of depressive symptoms is in line with a recent meta-analysis . The dis4.1.The finding that males had improved psychological well-being relative to females is consistent with a large body of research suggesting that females are more at-risk in terms of psychosocial outcomes , 34, 48.The disparity in psychological well-being between white and non-white students corroborates current literature, which illustrates that minority racial groups have worse psychosocial well-being and have experienced a greater decline in psychosocial health during the COVID-19 pandemic as compared to white individuals . The posThe varied findings regarding the impact of socioeconomic status on adolescent mental health and wellness are illustrative of the complexities associated with deriving associations based on SES. The finding that psychosocial well-being as determined by PSC-17-Y was lower in socioeconomically disadvantaged students was expected and follows recent studies , 55. HowThe lack of appreciable improvements in psychosocial well-being after participation in the R4F program for students who were socioeconomically disadvantaged follows recent findings that indicate exercise programs in low-income youth are largely ineffective . We cannStudents with an Independent Education Plan appeared to be protected, having equivalent risk of depressive, attention, and other psychosocial issues measured in our study as compared to students who did not have Independent Educational Plans. This finding is especially interesting as a recent study shows that during COVID-19, students who have attention deficit/hyperactive disorder experienced worsened psychosocial well-being , 63 and Sleep was critically important to psychosocial well-being. The finding that students who did not meet the CDC-recommended 8.5 h of sleep per night had worse baseline psychosocial well-being values across the various domains was expected. Indeed, a lack of sleep is a positive predictor of depressive symptoms and many individuals with depressive symptoms experience a lack of sleep , 42. TheWe were surprised that the R4F program selectively improved the psychosocial well-being of those students who self-identified as having higher physical activity levels. The finding that the R4F program was not associated with improved mental health in students who had low activity levels is disheartening, especially as a recent study illustrated that there was a decrease in the physical activity of adolescents due to COVID-19 pandemic-related restrictions . While wThe analyses regarding screentime use and the impact of the R4F program were revealing. The high proportion of students in our study who did not meet CDC screentime recommendations parallels studies showing that screen time use during COVID-19 increased appreciably, up to over 7 h per day . InterfaThe finding that students engaged in school activities such as clubs, sports, and music programs had better baseline psychosocial well-being scores as compared to uninvolved students is encouraging. Our studies are backed by current literature indicating that involvement in school-structured activities improves psychosocial maturity and well-being in adolescents . Interes5.There are several limitations to the current study. The anonymous nature of the surveys that were used did not allow for within student, matched analyses. The current study also did not have control groups of students who did not receive the program, while the effect size was small. These issues will be overcome in future years with access to paired responses from individuals, by having appropriate control groups who do not receive the program, and by having subjects from a larger number of schools. Ongoing R4F programs are also more diverse, overcoming the narrowness of the racial demographics used in the current study. The current study was performed during the middle of the pandemic, which presented a confounder due to potentially declining levels of mental health and wellbeing. We look forward to collecting data from students in a post-pandemic world who have reduced stress, anxiety, and health risk. Future studies would benefit from a more nuanced and consistent method of stratifying the socioeconomic status of the students' families as compared to the enrollment in school lunch programs that have varied cutoffs that depend on family size and can vary from state to state. This is an important consideration as obtaining more precise income details may reveal hidden aspects regarding program effectiveness; trends that may help shape R4F curriculum and implementation to maximize the benefit for students from low-income families. Our study also only examined the acute effects of the program and did not examine the long-term impact of the R4F program on participant psychological well-being or their tendency to make healthy lifestyle choices. While some program effects may decline following the program, one might also see improvements for those who continue to ride bikes and exercise regularly. Lastly, the current surveys provide only limited information as they do not interrogate other lifestyle pillars. While exercise alone has proven to be effective in improving mental health, adopting changes to diet, sleep, and avoidance of risky substances positively influences mental well-being .6.Our results indicate that participation in a school-based cycling intervention program has the capacity to improve psychosocial well-being in adolescents aged 11–14. Our results also indicate that the R4F program is associated with improved psychosocial outcomes that are negatively impacted by a number of well-established modifiable and non-modifiable risk factors. Though the R4F program on its own does not fulfill CDC recommendations for daily physical activity, student results demonstrate that program participation was still associated with improvement in youth mental health and well-being and a positive physical education experience.6.1.Despite limitations, we were able to use program evaluation data to both demonstrate feasibility of implementing a program under difficult conditions (COVID-19) and show encouraging program outcomes that are in-line with previously published studies. Moving forward, we propose several recommendations for future studies to increase the validity of program outcomes. First, future studies should make use of a control group and employ parallel controlled trial design to assess causation. In the context of continued surveillance and monitoring, it is recommended that participant data is tracked individually, along with being examined in aggregate. Additionally, to provide the broadest applicability it would be beneficial for the study populations to match US demographic trends more closely. Further, longitudinal studies will allow us to explore if participants continue to ride bicycles, build an active lifestyle, and examine the long-term effects of the R4F program on adolescent health and well-being. One additional consideration, even at this early stage of our understanding, is that providing culturally grounded versions of R4F could improve program efficacy .