Background and objectivesMedical residents may work from home for various reasons, including study electives, isolation due to exposure to illness, or during parental leave when they choose to work at home instead of taking extended time off. The University of Arkansas for Medical Sciences (UAMS) Little Rock Family Medicine residency program recognized the need for a tool that provided residents with a list of resources and approved activities for at-home work and a means of tracking their performance in those activities.MethodsThe administration team at the UAMS Little Rock Family Medicine residency program custom-designed a Daily Activities Log that served multiple purposes. Family medicine residents used it to choose what activities to participate in from a comprehensive list of activities and resources including virtual conferences, recorded didactics, modules, and other online materials. The program provided the framework on the log, while residents used it to document time spent on those activities. The log also gave the program a daily update on the resident’s health, as one question specifically asked about well-being. Since it was built in an electronic survey format already owned by the residency program, it was completely customizable and available at no additional cost.ResultsIn the two years covered by this project, residents logged a total of 593 hours of at-home work. In response to a survey, 76% of participating residents (N=14) rated the log as extremely or very easy to use; 64% indicated that it was a helpful resource; and 50% said that it simplified the reporting of their daily status. The residency program faculty found that having one source to track all off-site residents was an efficient means of monitoring their well-being and their work.ConclusionsThe Daily Activities Log is a versatile tool that provides comprehensive information, resources, and approved activities for residents, documents their work, and provides updates to residency management. It can be readily modified for use in other programs that have residents working at home. Working from home at least part of the time has become an increasingly popular option for employees in many fields. In the United States between 2019 and 2021, the number of people working mainly from their homes tripled .Those in medical residency training may have several reasons for needing options to study or work from home for a portion of their program. They obviously were at particular risk during the pandemic, leading to increased virtual training to ensure their safety and health -6. COVIDOther reasons for at-home assignments can include study electives for residents who are preparing for exams and who need dedicated, intensive study time. These exams include the Step 3 exam from the United States Medical Licensing Examination (USMLE) and the Level 3 COMLEX exam  ,9. AnothIn addition, some residents on parental leave after the birth or adoption of a child want the flexibility to work from home after their formal leave period has ended -13. ThisWith the increasing numbers of residents asking for at-home assignments, residency programs are tasked with identifying suitable activities and work that can be performed at home; instructing the residents about the activities; and finding a means of documenting the work that residents are involved with when not in the office. In response to increased requests for at-home assignments, the UAMS Little Rock Family Medicine residency program faculty began searching for available resources and also devising tools of their own to keep their off-site residents engaged and productive.Study populationThe University of Arkansas for Medical Sciences (UAMS) Institutional Review Board approved this study as exempt (study #274311). The UAMS Little Rock Family Medicine residency program is a 6-6-6  program located at the UAMS Medical Center in the state’s capital.Initial tracking of at-home learning processes and engagementSince the onset of the COVID-19 pandemic in 2020, several residents in the Family Medicine program were placed on quarantine after testing positive for the virus. Others were isolated pending test results. Regardless of the reason, some residents felt well enough to work remotely and needed direction on the tasks they could perform that would keep them productive as they waited for clearance to return to the office.The residency administrative team soon recognized the need for an innovative tracking system. To keep residents engaged, the team needed to specify structured learning opportunities for residents to experience during their absence. The numbers of affected residents and their varying situations were too complex for the existing policies and forms. Additionally, no system was in place for residents working remotely to document their time, and no framework of suitable activities was readily available for them to use in planning each day they were out of the office.Expansion of project to non-COVID activities The residency administrative team designed a Daily Activities Log in response to the COVID-19 situation, but it quickly became obvious that the log could be used for study electives or other at-home assignments. It provided a comprehensive description of expectations and approved activities for residents working on at-home assignments in general, including residents on study electives, or in isolation due to exposure or illness. Additionally, it provided a means for residents to document the time they spent on each activity. Since one question asked specifically about resident wellness, it also served as a wellness check.The log could also be used for residents on parental leave. Though the accrediting body allots six paid weeks off for medical, parental, and caregiver leave, some residents requested to work from home during part of their leave or in addition to their leave. They needed the framework to know what resources were available and to document their time and activities.The activities log was set up with a web link to an electronic survey that is accessible from any device. Since the program had already purchased an electronic survey platform for other purposes, they could work within the same platform to custom-design and launch the Daily Activities Log at no additional cost to the program.The process of the Daily Activities logResidents who plan to be working at home on a given day document their status on the Daily Activities Log, beginning with a question about their wellness on that day. Then they log the activities they participated in, drawing from the log's comprehensive list of approved activities and resources, and the number of hours devoted to each. The log is available from a web-based link that can be used for an unlimited number of days.Use of the Daily Activities LogOver the two years covered by this project, 17 family medicine residents logged a total of 95 days and 593 hours of activities that were generally out of office and not part of the usual routine. Table Table Evaluating the Daily Activities LogTo elicit resident opinions on the use of the Daily Activities Log, an electronic survey was designed and distributed by the residency program's director of education. The survey introduction indicated that it was confidential, with no tracking information available, and that resident input would be used to improve the overall process of coordinating and monitoring activity outside of the office. There were 17 residents who completed the log over the two years. Two of them had graduated and were excluded from the survey. Of the remaining 15 residents, 14 responded to the survey.Table Despite the abatement of the COVID-19 pandemic, residency programs still face a variety of reasons as to why residents need options for at-home work and study. Parental leave is a particularly important consideration, as residents often become parents while in training ,18,19. EOther options may include at-home work to complete research and quality improvement projects  and to sRegardless of the reason, at-home work options provide residents with the opportunity to decrease interruptions and extensions in training. Family medicine residency programs, for example, are typically 36 months. One possible consequence of protracted leave time is the extension of the residency program to enable the residents to make up for the training they missed. Working at home (as opposed to extended leave) can support the resident in graduating on time and being available for opportunities such as fellowships that often begin immediately after the regular end-of-residency date .Though at-home training options have become more common, we found few specifics on how a program can provide at-home residents with comprehensive information on approved activities and the framework for documenting those activities all in one format. Ben-Zion et al. (2022) reported that residency programs often provide a list of activities from which to choose during a parenting elective but added that specific information on how such electives are organized is difficult to find . Cree-GrWe discovered that one easy-to-use tool can serve both purposes, in addition to giving the program a simple means of monitoring resident well-being when they are away from the training site. Faculty members and administrative staff found that the log gave them a quick overview of resident performance even at a time when they were at a distance from the office and the clinic. Residents indicated their satisfaction with having a tool that provided clear expectations about their offsite assignments.By designing our own log as opposed to attempting to use commercial products or apps, we were able to customize the content completely and make changes as often as necessary. Since the log was built as part of a survey platform that we had already purchased, there was no additional cost to the program.Based on our success, we believe the Daily Activities Log can be adapted for use in a variety of residency programs with a need to monitor residents who are assigned to at-home work. Its ability to be customized continually to the evolving needs of a specific program make it an essential element of residency training in an off-site setting.Though this study is limited by the small sample size (17 residents at one family medicine residency program), it provides an innovative means of custom-designing an activities log that offers both a list of approved activities and the means to document participation all in one easy-to-use, inexpensive survey format.Other limitations include the possibility of social-desirability bias or other response biases that might lead respondents to answer questions in an effort, conscious or not, to make themselves look good. Another limitation is that while some of the daily activities  could be verified, others relied upon the honesty of the respondents to report what they were doing outside of the office. Additional research is necessary to address these issues.Future areas for study include identifying additional approved activities and expanding the use of the Daily Activities Log to include tracking of rotational assignments, required readings, and didactics attendance. Various tracking resources exist for such activities but not necessarily all in one framework that is adaptable to multiple uses. Other resources and apps also may involve fees, whereas our log did not. Another promising possibility is requiring residents to produce scholarly work based on their offsite training and to log that work in this same format, one that includes data from the beginning of training through eventual scholarly output.As more medical residents request the option of at-home work, residency programs must be ready to provide a functional framework to support them. A flexible, no-cost, customizable Daily Activities Log proved its merit in this study. Other programs and groups can use this format as a basis to custom-design surveys to meet their own needs.


Men residing in rural areas are less likely to participate in weight management interventions than women, and few men-specific programs target rural areas. Aussie-Fans in Training (Aussie-FIT) is an evidence-based weight management intervention that uses professional Australian Football club affiliations and settings as a ‘hook’ to engage urban-residing men. The aim of this study is to report on how findings from rural stakeholder focus groups were used to inform the adaptation of Aussie-FIT for implementation in rural areas.n = 24) in three rural towns explored existing weight management and physical activity provisions, barriers and facilitators to engaging men, and considerations for adapting Aussie-FIT for implementation in rural contexts. Qualitative data were analysed using the framework approach. Adaptations made to the Aussie-FIT program and strategies to implement the program in rural contexts were reported using a structured framework.Seven focus groups with stakeholders , considerations for program inclusivity, and the importance of local partner organisations for sustainability. We adapted the recruitment and marketing strategies, delivery settings, football program theme and partnerships for rural implementation. Stakeholders advised that an Australian Football program theme without specific local club affiliations would be important to avoid alienating men with differing club allegiances or non-sporting backgrounds. A multi-component recruitment strategy utilising local trusted sources, and program marketing that aligns with masculine ideals were considered important by stakeholders in small communities where ‘people talk’.‘a different ball game’ due to limited local services and resources in comparison to metropolitan areas. Study findings have synergies with previous studies undertaken in rural contexts including in relation to the power of word of mouth, the importance of trust, and local partner organisations. Findings have implications for engaging rural men in health interventions in rural contexts where professional sporting contexts are not available. Assessing the extent to which the adapted Aussie-FIT program can reach and engage men in rural Australia, and exploring the barriers and facilitators to delivering the program in rural contexts is required.Rural areas were described as The online version contains supplementary material available at 10.1186/s12889-023-16247-w. Yeah, it's interesting when I get some of my male colleagues together it's you know, how dogs normally greet each other? Well, they talk football. You know, just to work out where they fit in it. I always sit back and go ‘yeah okay, that's fascinating.” Stakeholders depicted Australian Football as being a connection point for social interaction amongst peers for (many) men in Western Australia, particularly in adulation” for their club. One stakeholder referred to the AFL club links and guest appearances from current or former players, as being a valuable form of “currency” that would be attractive to footy-oriented prospective participants. However, the need for a different approach in rural towns without access to professional football settings was recognised.“I can see why you had such a popular uptake in Perth. Based, you know, you've got the two AFL sides, bang. You know, and access to the change rooms. Okay, it's all there, packaged nicely. Here it's going to be a little bit harder and you're going to have to look at other alternatives.” After the Aussie-FIT pilot study presentation, stakeholders reflected on the program’s popularity when delivered in association with professional AFL clubs in metropolitan Perth, the pride the men showed in participating, and the obvious “a few snags”. For example, eligible men with links to other local clubs could be hesitant to take part: “you would only alienate them”. Indeed, this stakeholder emphasised how little love is lost between some rival clubs:“…. there's that much animosity between the clubs, is a bit like over in Europe with the soccer teams, it's alive and kicking with our footy as well.” One approach mooted was for Aussie-FIT to be affiliated with local amateur clubs, including using their team colours and football venue for program delivery. However, some stressed that close affiliations with any specific local clubs could lead to the program hitting ““with each club”. Whereas others highlighted that close affiliation with any local club could also create barriers to participation for men with limited football experience. Men perceiving others as more skilled, experienced, or active within local football communities, could be “uncomfortable” or “embarrassed” about joining the program as an inexperienced outsider. Thus, stakeholders universally agreed that program marketing materials should highlight that all eligible men are welcome regardless of footballing experience or skill, and as one stakeholder put it; “… you don’t have to be skilled in X, Y and Z [to participate].”Thus, if programs were delivered in association with specific local clubs some stakeholders considered that, in the interest of equity and maximising intervention reach, the program should be delivered “give you 30 people” through their community connections alone. Prospective Aussie-FIT coaches, given their direct involvement in program delivery, were seen as ideally placed to play a critical role in championing the program, given their local knowledge and connections.“They'd all have guys who they could tap on the shoulder and say ‘hey, come and join in’. Yeah, I think that would definitely be a good way to say lock in your core staff or people who are going to run the program locally. And then again it's their good reputation in the community that would then potentially attract people. To know that it's not going to be just some gimmick program or something that's not going to have value.” Stakeholders agreed that, in rural contexts, getting the right community champions involved would go a long way to ensuring program success. One stakeholder proposed that one well-known local contact would “…there's probably certainly people, [site 2] being a small community, that are very prominent in their community. You know, both for football and the professional lives that they have. So, but yeah, I mean maybe you could leverage their celebrity status. It's completely the wrong word to use, but the recognition they have in the community and the trust that people... and credibility that they hold as well.” Having trusted and potentially well-known community champions to support program implementation in rural towns was considered important in garnering local trust and attracting men.bring a friend or two is probably going to have to be a realistic approach.”Another suggestion was that prospective participants registering their interest may themselves be an ideal and trusted source of participants in rural communities; ““…people who would then feel uncomfortable about like coming to the program if it's closely aligned with the local team. If they've never really experienced football, but they've always wanted to. And then they think oh but I, I'm not at that level, I'll be embarrassed, I'll you know, the other guys they're all so experienced and I don't feel comfortable. I just wonder is that a risk too, that people may not want to because they think ‘oh I work with him and he's [Club Name] you know, I don't want to look silly…” Stakeholders indicated that any discomfort around attending a local-club affiliated program could be amplified within close-knit rural communities, where men may know other participants that are more active in the local football community.“smaller [rural] fishpond”, stakeholders recommended adopting a multi-faceted recruitment strategy including Facebook promotion, local media sources, and word-of-mouth recruitment through local clubs, organisations, and community champions. Indeed, the power of word of mouth was frequently alluded to as being a particularly important consideration in rural communities. Whilst having the potential to be a key avenue for raising interest in new health initiatives, this was presented as a double-edged sword, with word likely to quickly spread should anyone get “shitty”.“…with smaller towns and maybe you don't get this in your metro setting. Is... and it can work wonders and it can be really positive. And you know, word of mouth can be positive. But also if something goes awry or if someone gets shitty about something, that goes through [site 1]'s Chinese whispers channels, like nobody's business. So I think it would be a matter of getting like that champion, community champion to stay.” To maximise the prospect of engaging men from diverse backgrounds within the “people talk”. Stakeholders believed that local men will be aware of how their participation is viewed more widely in the community, including any potential threat to their identity as a local man. Given the football program theme, with careful consideration of how the program is marketed, Aussie-FIT was considered well placed to minimise this threat.“…All country towns, like people talk. And it's like ‘oh you know, such and such is doing the ol weight loss class’. You know what I mean? So I think guys won't potentially engage because of a fear of that. Whereas like ‘oh you know that like, that footy program. Like you know, the old fellas footy program’. Just you know, something like that is, will make it more likely that they, they buy in. Hence why I think Aussie-FIT will make it. But how you market that will obviously, that'll be the hardest thing...” Stakeholders speculated that in urban areas, men would likely be able to limit knowledge of their participation to themselves or to close family or friends should they wish to. This degree of privacy was seen as unlikely to be an option in rural communities, where “a means to an end”. That is, stakeholders believed that the positive physical health outcomes of participating should be emphasised; “you need to market the end”. Particularly in the context of the Covid-19 pandemic, potential mental health benefits linked to participating in the program and meeting like-minded men were also regarded as important to include within promotional materials.“…they formed those social groups at the end and people that maybe had been feeling a bit lonely. Particularly after this lovely year we've just had, I think that could be a real drawcard as well, around coming in, meeting new people. As opposed to perhaps going just purely for the fitness or the health angle.” Whilst the football program hook was deemed fundamental to Aussie-FIT’s potential success in rural towns, the football theme was described as “…you've already ticked a big box by saying it's free. That's the biggest drawcard or a barrier that gets put up is cost.” The cost of participating in physical activity programs was regarded as a major barrier to engagement, so ensuring that marketing materials clearly highlight that there is no participation cost was considered important.“premier football facility” where “people want to play”, which was a favoured site should there be availability at this in-demand facility. The second option, with greater availability, was considered well placed for accessibility and promotion to men from diverse socioeconomic backgrounds.“…location-wise that's where (venue option 2) would be a good one, because that's the area where there is, a lower socioeconomic area, state housing, some Aboriginal involvement there. So that'd be a good thing” The number of football venues that could host Aussie-FIT varied by site. In site 1 there was only one venue option shared by two local football clubs, with this likely to be the case in similar smaller rural towns. Stakeholders described a lack of public transport across all sites, with those in site 2 specifically recommending the central football precinct to optimise accessibility. In site 3, two main venue possibilities were discussed. The first was the “entrenched” barriers, “little hoops you have to jump through” and a sense of not being welcome.“…even making things free seems as though that the lowest socioeconomic still don't actually get involved all the time. It's that like there's a barrier. And we've seen that with Aboriginal participation….[…]… Aboriginal guys in particular, the barrier is always is that the sport is what actually keeps them involved because they actually feel welcome. And part of it, when they can actually go there and play, they don't necessarily always feel that they're welcome once they're finished.” Sports sector specialists in site 3 discussed how even when programs are free to participate in, men from the Aboriginal community would often still not participate. In the context of Australian Football, stakeholders indicated that there is often little involvement of Aboriginal men at local clubs beyond their playing years due to “culturally comfortable”, including by seeking “early buy in [from the Aboriginal community]”, employing an “Aboriginal staff member” or providing bespoke deliveries . Some optimism was expressed that a male-specific Australian football-themed program could potentially have greater appeal than existing weight management services for some Aboriginal men:“…not quite comfortable with [mixed-gender program] that would potentially prefer to be in a predominantly non-Aboriginal setting with other men, than an Aboriginal setting with a bunch of women.” Aboriginal health specialists also reflected on challenges to engaging Aboriginal men in health initiatives due to issues with trust and deep-rooted barriers to participation. Suggestions for mitigating these barriers were focused on helping to support men to feel more “every eligible bloke disappears”) was considered essential. In site 2 avoiding the cold, wet and dark winter months was considered the most important factor. Stakeholders in site 3 also advised against scheduling the program in the winter months and highlighted that the high proportion of fly-in-fly-out/rotation workers in the area was an unavoidable barrier to participation. These workers would struggle to participate in structured initiatives requiring consistent (weekly) attendance.The optimal time of year to engage local men varied across rural sites. In site 1, where a large proportion of the workforce are farmers, scheduling the program to run outside of seeding and harvest months The concept of using Australian Football to help engage men was well received by stakeholders, who could see real potential for the program in rural towns.potential” in the context of a discussion around program sustainability, hints at prior challenges to health program implementation. Indeed, many stakeholders reflected on programs which had come and gone from their communities due to funding limitations. Moreover, stakeholders cautioned that, particularly where physical activity options were lacking , participants would inevitably be enquiring as to “what [is] next?”.“Especially with funded programs like that, that run for a very short period of time. It gets very tricky. Because you know, we sort of... we manage, in the network we manage a few funded programs which runs for a year. And there's... people love it and then funding stops. And so yeah, you're going to have definitely that's going to be a challenge and people... participants will definitely ask that question. What's going to happen after 12 weeks? I mean, you do... you're going to do a follow up in three months, but then what next?” Whilst this stakeholder’s optimism is palpable, the emphasis on the word ““That's the big word, relationship. For it to be sustainable, you've got to build on it.” Various organisations that could play a role in supporting program implementation were proposed, including those in health, sporting, and community sectors. With a view to sustainability, developing relationships with key local partner organisations was considered vital.“… getting the footy commission side of it, so you'd often get the development officers down here conducting it. And that's not saying that they would be the ones taking the sessions, because you can put it out to the local coaches around here who are AFL coaches at any level, to be the ones that administering it. Like WA Footy Commission is the face of it, but I think you'll get better buy in down here type thing.” Stakeholders across the sites suggested that the Football Commission was an important potential partner to engage, ideally to help coordinate some local program logistics.“the face of it [the program]” was proposed as a potentially valuable strategy for garnering local community support. This points to the prestige, respect, and potential leverage of this organisation and their employees within their respective regions. Some stakeholders agreed informally to help “where they can”, whereas others pledged their support or appeared to take some ownership of the program through their choice of words .“…we'll just give a pledge. [Organisation] are happy to see this you know, delivered within [site 2]. And we'll do what we can to support you in that.” Rather than being promoted as a metropolitan-based university or professional football club affiliated program (as was the case in Aussie-FIT pilot deliveries), having a well-known and respected football organisation involved in grassroots work as “see the appeal” and “be quite receptive” to Aussie-FIT. Where local government representatives were present, they indicated that it may be possible to waive or reduce venue hire fees, and that they would support program promotion efforts. Two important strategies suggested for garnering support from local governments and other organisations were presented. These were: first, to make it “easy and simple for them to jump on [to support the program]”; and second, to highlight how supporting the program could help their organisation meet key performance indicators or how it aligns with their broader public health plans.“…selling it to them as something that they can tick off the public health plan, and is probably going to be your best bet to get their support” Stakeholders emphasised that rural football clubs are volunteer run, and that capacity for active involvement from club personnel beyond their already stretched capacity was unlikely. Where local government representatives were not present in focus groups, stakeholders highlighted that getting their support would be important, suggesting they would likely Informed by the stakeholder focus group results, adaptations were made to Aussie-FIT and the implementation strategies to be used for implementation in rural contexts  for rural implementation include for the program to be delivered in local football settings and adopting an Australian Football theme, without specific affiliation to any local or non-local clubs. Rather than AFL club social media posts, the rural recruitment strategy will include promotion via local media, trusted community sources, local social media pages and word of mouth. The wording of marketing materials will aim to be inclusive of all eligible men. The aim for inclusive language includes emphasising that the program is free and that no prior football experience or skill-level is required. The research team will aim to partner with local trusted football, sporting, Aboriginal-specific and other health organisations, as well as local government authorities to help support inclusivity in program implementation.Specific adaptations were made to sessions that originally included a stadium tour and Australian Football guest speaker, introducing more flexibility for the delivery of these program components to improve the intervention fit for rural contexts. Core program elements of the original Aussie-FIT program are retained. Namely, the number and length of sessions , mix of education and physical activity components in each weekly session, session topics , integration of behaviour change techniques, theoretical underpinning , fostering of group camaraderie and positive banter, and an overarching Australian Football program theme . The undIn this study we have explored rural stakeholder perspectives on existing local physical activity and weight management options, and potential barriers and facilitators to implementing an Australian Football-themed men’s health program in rural Western Australia. We describe how focus group findings have informed adaptations to Aussie-FIT program content and implementation strategies for rural deliveries, to understand how to begin to redress rural inequalities. Stakeholder focus groups pointed to a need to and strategies to consider for adapting Aussie-FIT, whilst retaining core intervention elements which are judged essential in the pathway to successful behaviour change.Findings from the current study suggest that: existing access to weight management services or physical activity initiatives across the rural sites is limited; men are less likely to participate in mixed-gender programs that are available; but gender-tailored place-based approaches could help engage many men in rural areas. Our findings resonate with recent qualitative studies aimed at identifying places that foster well-being among rural men  and whicSeveral parallels can also be drawn between our results and a recent qualitative study with local football club representatives exploring barriers and enablers of implementing mental well-being programs within rural Australian football clubs . Hutches‘drawcard’, replicating some of the inherent recognition and credibility these clubs provide was considered important by stakeholders to help garner local trust. Thus, they recommended delivering the program in association with trusted local organisations and individuals. This aligns with wider literature on engaging men in health interventions, emphasising the importance of using strategies that are congruent with masculine identities and based on trust and rapport [‘Fans in training’ programs around the world have typically used the appeal of professional sports clubs, settings, and coaches to engage participants , 17, 40. rapport –44. Stak rapport . Maintain = 7 aged 30–65years) within the target age range for the Aussie-FIT program. The range of perspectives, expertise, and local knowledge expressed within the focus groups strengthens this study.Focus groups were undertaken across three rural towns with varied population sizes and demographics. This meant that similarities and differences across sites could be acknowledged within the analysis and reporting, allowing for context specific factors to be considered in the adaptation of Aussie-FIT. The use of established frameworks for reporting content and implementation strategy adaptations allows the reader to easily establish what and why adaptations were made for rural contexts. A diverse range of stakeholders participated in the focus groups within and across rural sites. Women and men participated, including men (n = 11) and younger men (n = 5 aged 20–29years) who participated in the focus groups may not represent the Aussie-FIT target group. Moreover, although efforts were made to specifically engage target group men (aged 35-65years with a Body Mass Index > 28), this proved challenging unless these individuals believed that participating in focus groups fell within the remit of their employment . However, all participants lived and worked in rural communities, had at least some exposure to local health and football settings, and had an understanding of community health behaviours and how masculinity is expressed locally. Due to scheduling issues, one relatively short focus group  had only two participants, both from the same organisation. Although this may have limited the range of expert input provided within this individual focus group, these participants did have highly relevant expertise and experience, and two further focus groups with stakeholders from varied backgrounds were undertaken in this site. Whilst adaptations made to the Aussie-FIT program were based on stakeholder feedback, the authors took a pragmatic approach to what adaptations were feasible within the project’s budget and timelines. For example, one stakeholder’s suggestion, to deliver an Aboriginal specific program, was beyond the scope of this work. Well-funded projects that utilise co-design approaches with meaningful involvement of Aboriginal individuals, organisations and researchers would be required for such work.Sites in this study are classified as ‘inner’ or ‘outer’ regional, and travel time to the nearest city from these sites ranges from 1.5 to 5h by car. Thus, some findings from this study may not be generalisable to more rural or remote settings with very low populations. The views of the women (‘a different ball game’ when compared to urban areas due to limitations with local services and resource. The power of word of mouth in smaller rural communities was highlighted as a double-edged sword, having the potential to influence the implementation of health programs positively or negatively. In the absence of professional club settings, leveraging recognised and credible local community sources to affiliate with, deliver, or otherwise champion the program was viewed as fundamental to the success of the program, both in the short term and for potential future sustainability. Assessing the potential program reach, and implementation barriers and facilitators of the adapted Aussie-FIT program when delivered in rural contexts is now required. These findings have implications for adapting health promotion programs for men in rural areas within non-professional sporting contexts as one means to help redress rural inequalities in men’s health provisions.This study supports understandings of the health promotion landscape in rural areas for men, with a focus on barriers and facilitators to engaging men via local Australian Football settings, and the adaptation of a successful metropolitan-based men’s health program for delivery in rural contexts. Rural areas were described as Additional file 1.


ABL1 was detected in a cohort of hematologic malignancies carrying AML1-ETO and NUP98 fusion proteins. Abl1−/− murine hematopoietic cells transduced with AML1-ETO and NUP98-PMX1 gained proliferation advantage when compared to Abl1 + /+ counterparts. Conversely, overexpression and pharmacological stimulation of ABL1 kinase resulted in reduced proliferation. To pinpoint mechanisms facilitating the transformation of ABL1-deficient cells, Abl1 was knocked down in 32Dcl3-Abl1ko cells by CRISPR/Cas9 followed by the challenge of growth factor withdrawal. 32Dcl3-Abl1ko cells but not 32Dcl3-Abl1wt cells generated growth factor-independent clones. RNA-seq implicated PI3K signaling as one of the dominant mechanisms contributing to growth factor independence in 32Dcl3-Abl1ko cells. PI3K inhibitor buparlisib exerted selective activity against Lin-cKit+ NUP98-PMX1;Abl1−/− cells when compared to the Abl1 + /+ counterparts. Since the role of ABL1 in DNA damage response (DDR) is well established, we also tested the inhibitors of ATM (ATMi), ATR (ATRi) and DNA-PKcs (DNA-PKi). AML1-ETO;Abl1−/− and NUP98-PMX1;Abl1−/− cells were hypersensitive to DNA-PKi and ATRi, respectively, when compared to Abl1 + /+ counterparts. Moreover, ABL1 kinase inhibitor enhanced the sensitivity to PI3K, DNA-PKcs and ATR inhibitors. In conclusion, we showed that ABL1 kinase plays a tumor suppressor role in hematological malignancies induced by AML1-ETO and NUP98-PMX1 and modulates the response to PI3K and/or DDR inhibitors.Deletion of  ABL1proto-oncogene encodes a cytoplasmic and nuclear protein tyrosine kinase, which has been implicated in regulation of differentiation, proliferation, adhesion, and stress response  into retroviral plasmid pCMMP-MCS-IRES-mRFP  by XhoI and BamHI restriction sites. MigR1-AE9a plasmid containing AML1-ETO-9a gene was a gift from Dong-Er Zhang (Addgene plasmid # 12433). AE9a was also recloned into pMSCV-mCherryFP plasmid [https://pubmed.ncbi.nlm.nih.gov/26758680/]. Nonmyristoilated WT-ABL1 was cut out from pLenti6.3-TO-V5-WT-ABL1-6xHis-Flag by SpeI blunted and XbaI restrictions and replaced with mouse myristoylated Abl1 gene. plasmid  by EcoRI5 mouse bone marrow cells or 32Dcl3 cells were resuspended in 1 ml of virus-containing medium with 6 μg/ml polybrene (Sigma). GFP, RFP or mCherryFP -positive cells were sorted 48 h after the initial infection.Ecotropic retroviruses were prepared by co-transfecting HEK 293 T/17 cells (ATCC® CRL-11268) in a 10-cm plate with 10 μg of packaging pCL-ECO (Addgene plasmid # 12371) and 10 μg retroviral based vectors by using Lipofectamine 2000 Transfection Reagent (Invirtogen) according to manufacturer’s protocol. For lentiviral infection, transfer vectors were co-transfected into HEK 293 T/17 cells with packaging pCMV delta R8.2 (Addgene plasmid # 12263) and envelope pVSV-G  vectors. Viruses were harvested 40 h and 64 h after the transfection and filtered through a 0.45-µm PES filter (Millipore). For viral infections, 5 × 10ABL1 lentiviral stocks on two consecutive days in the presence of 6 µg/ml polybrene (Sigma). Cells expressing both constructs were selected for over 10 days using 10 μg/ml blasticidin (Invitrogen) and 500 µg/ml geneticin (Gibco). NUP98-PMX1 or AML1-ETO-9a cDNAs were introduced into Tet-inducible Abl1-32Dcl3 cells by retroviral infections. A total of 1 µg/ml of tetracycline (Invitrogen) was used to induce expression of myristoylated wild-type mouse Abl1 in 32Dcl3 cells.Lentiviral infections were performed with the pLenti6.3-TO-V5-myrAbl-6xHis-Flag viral construct or pLenti3.3/TR vector (for tetracycline repressor expression) using the ViraPower HiPerform T-Rex Gateway Expression System (Invitrogen) following the manufacturer’s instructions. 32Dcl3 cells were infected first with TR lentiviral stock and then with the myristoylated Viable cells were counted using Trypan blue exclusion test. Cells were also plated in MethoCult H4230 (StemCell Technologies) and colonies were counted after 7–10 days.Buparlisib , olaparib , doxorubicin , NU7026 (#S2893), KU-60019 (#S1570), imatinib  were from Selleck Chemicals. Rapamycin  was from GlpBio Technology. 6-hydroxy-DL-dopa (#H2380), ATR inhibitor IV (#504972), 5-hydantoin (DPH) (#SML0202) and tetracycline hydrochloride (#T3383) were from Millipore Sigma.Data are expressed as mean ± standard deviation (SD) from at least 3 independent experiments unless stated otherwise. When conducting subgroup comparisons between two groups, two-tailed unpaired t-test was used for normally distributed variables. p values less than 0.05 were considered statistically significant.ABL1 may alter malignant transformation preferentially in the hematopoietic cells. Most of the cases carried complex karyotypes, but we identified the following chromosomal translocations in del(9q34) cases  and AML displaying low levels of ABL1 mRNA expression had shorter overall survival, while opposite effect was detected in ALL ias Fig. . OverallALL Fig. . In addiAbl1−/− and Abl1 + /+ murine hematopoietic cells were employed. Since homozygous disruption of Abl1 in mice caused neonatal lethality/poor viability [Abl1−/−;Vav-Cre (n = 19), Abl1 + /-;Vav-Cre (n = 52) and Abl1 + /+;Vav-Cre (n = 13) mice. Vav-Cre starts to express specifically in hematopoiesis system after the birth and can knock out Abl1 efficiently, which has been confirmed by PCR using peripheral blood leukocytes from the peripheral blood samples and tail tissues  generating fusion protein AML1-ETO and NUP98 translocations, e.g., t encoding NUP98-PMX1. To test the role of ABL1 in leukemogenesis mediated by these genetic aberrations iability , 20, firAbl1, Lin-c-Kit+ AML1-ETO and NUP98-PMX1 cells displayed higher clonogenic activity  and 32Dcl3-Abl1ko cells were challenged to achieve early transformation potential by starving them from growth factors (IL3). Only 32Dcl3-Abl1ko cell populations  generated growth factor-independent cells  cells showed altered expression of major genes involved in different biological pathways , a selective inhibitor of PI3K p110α/β/δ/γ subunits [3F, Gleft panels, insets). NUP98-PMX1;Abl1−/− murine leukemia cells were highly sensitive to buparlisib when compared to NUP98-PMX1;Abl1 + /+ counterparts , at the same time ABL1 did not affect the sensitivity of AML1-ETO cells to the inhibitor .Since PI3K-AKT pathway was identified in two independent analyses, we tested the sensitivity of AML1-ETO and NUP98-PMX1 –positive subunits  which reTo test if ABL1-positive NUP98-PMX1 leukemia cells may be sensitized to PI3K inhibitor, cells were treated with ABL1 kinase inhibitor imatinib and PI3K inhibitor buparlisib followed by clonogenic assay. The results clearly show that imatinib increased the sensitivity of NUP98-PMX1 leukemia cells to PI3Ki Fig. .Abl1−/− cells when compared to NUP98-PMX1;Abl1 + /+ counterparts  KU-60019, ATR inhibitor (ATRi) 504972 and DNA-PKcs inhibitor (DNA-PKi) 260961. Inhibition of these kinases was confirmed by Western blots detecting reduced phosphorylation of their substrates  . AML1-ETO;Abl1−/− cells were modestly more sensitive to all three inhibitors when compared to AML1-ETO;Abl1 + /+ cells . Remarkably, NUP98-PMX1;Abl1−/− cells were exceptionally sensitive to ATRi, but displayed similar sensitivity to ATMi and DNA-PKi when compared to NUP98-PMX1;Abl+/+ cells.ABL1 kinase functionally interacts with DNA-PKcs, ATM and ATR, three major serine/threonine kinases regulating DDR , 34. The, PARPi and RAD52i). Both inhibitors were validated by detection of elevated levels of DNA double-strand breaks (DSBs marked by γ-H2AX) in the treated cells .In addition, ABL1 kinase phosphorylates and regulates the activity of two DNA repair enzymes, PARP1 and RAD52, inhibition of which triggered synthetic lethality in BRCA1/2-deficient leukemia cells , 35–37. 4A, B, Genotoxic). Genotoxic effect of doxorubicin was confirmed by elevated levels of DSBs marked by γ-H2AX .Although ABL1 kinase affected survival/apoptosis after genotoxic treatment by regulation of p53 and p73 –42, it d4A, BTo test if ABL1-positive NUP98-PMX1 and AML1-ETO leukemia cells may be sensitized to ATRi and DNA-PKi, respectively, cells were treated with ABL1 kinase inhibitor imatinib and 504972 and 260961 compounds followed by clonogenic assay. The results clearly show that imatinib increased the sensitivity of NUP98-PMX1 and AML1-ETO leukemia cells to ATRi and DNA-PKi, respectively Fig. .FLT3(ITD), WT1, KRAS, NRAS, KIT, MYC, NOTCH1, ASXL1, IDH1/IDH2 mutations, which contribute to leukemic transformation and/or accelerating more malignant disease progression [ABL1 could be also detected in a cohort of leukemias carrying AML1-ETO and NUP98-fusions and that murine hematopoietic cells expressing AML1-ETO and NUP98-PMX1 displayed accelerated proliferation and/or reduced differentiation in the absence of Abl1. This observation is supported by our previous report that normal ABL1 kinase exerted tumor suppressor activity in leukemias expressing oncogenic forms of the kinase such as BCR-ABL1, TEL-ABL1 and NUP214-ABL1 [AML1-ETO and NUP98-fusions are usually accompanied by recurrent cooperating genetic events, for example gression , 13. Her214-ABL1 . The absABL1 has been previously reported as a rare but recurrent genetic abnormality in B- and T- ALL, but its impact on treatment response and prognosis is not known [ABL1 might be a favorable prognostic factor in ALL.Loss of ot known , 44. We ABL1 kinase can be also a therapeutic target. We reported that stimulation of the normal ABL1 kinase by a chemical compound DPH  enhancedABL1 loss may serve as important diagnostic factor predicting more malignant phenotype of AML1-ETO and NUP98-fusions -positive leukemias as well as their unique pharmaceutical vulnerabilities to PI3K, ATR and DNA-PK inhibition. On the other hand, ABL1 kinase could become a therapeutic target since imatinib increased the sensitivity of AML1-ETO and NUP98-fusions -positive leukemias to PI3K, ATR and DNA-PK inhibitors.In summary, Supplemental Material


IWJ has a lot to celebrate. Firstly, it is our 20th birthday and secondly our performance metrics have continued to improve year on year.In 2023 the IWJ's impact factor has jumped slightly to 3.1. It has also risen 7 places in the Dermatology category ranking, now 22nd of 70 journals, and 24 places in Surgery, now 49th of 212 journals.Our impact factor has marginally increased again in 2022. As editors, we are very pleased to confirm that Other important journal metrics also increased in 2022 over 2021 (Table IWJ as a valuable resource to the scientists and clinicians researching wounds around the world.While many of the metrics presented in Table A fantastic result, and we thank all involved in this achievement.IWJ, but here are some updated facts that prove its continued evolution towards the number one international resource for those involved in both the science and practice of wound healing.As a reader of or a contributor to our journal, you are probably aware of the continued success of the IWJ, we have taken some bold steps, in the time periods covered in Table IWJ available to all readers for free. This was both necessary as the publishing world moves in this direction and our desire to be accessible by all.The biggest step we took was to move to open access, making the IWJ, it was important to provide mechanisms to those without the resources to pay publishing fees. This is particularly true for some developing countries. Our publisher Wiley has a waiver policy that is applied to the IWJ and provides a mechanism for authors in these geographies to publish their work.Tied to the open access of the We increased our editions from 8 to 10 in 2022/2023, and in 2024, we will move to 12 editions. This is necessary as our submission volumes have increased exponentially over the 4 years covered.As this submission backlog increases, it was impacting our submission to publication times. This increase in editions will help reduce this backlog, helping publish important global research in a timely fashion.In 2024, we will be publishing several ‘special’ editions to supplement our annual editions. Watch this space for more information, and you never know you may be approached to be an author in these important initiatives.To facilitate the continued evolution of the IWJ continues to achieve the international profile and status we desired and is now recognised as the premier international, high‐quality, peer‐reviewed resource in wound care.All in all, the As the editorial team, we would like to thank all contributors to this success to date and to also encourage bigger and better things by asking for your continued and increased participation in growing this valuable resource.


Community pharmacies provide a promising platform for monitoring and improving therapy adherence and providing pharmaceutical care. Structured methods and appropriate software are important tools to increase pharmacist effectiveness and improve health outcomes. In 2006, the Medication Monitoring and Optimization (MeMO) program was introduced in several community pharmacies in the Netherlands. MeMO facilitates targeted and continuous patient-centered pharmaceutical care around chronic medication, such as for osteoporosis, cardiovascular disease, and asthma/chronic obstructive pulmonary disease (COPD).To describe the MeMO program and summarize findings from publications on its effectiveness, patient satisfaction, and cost-effectiveness.In the first part of this article, the MeMO program is extensively described. In the second part, a review of the evidence of effectiveness, cost-effectiveness, and patient satisfaction of the MeMO program is provided. Evidence is based on 5 previously published articles.The MeMO program starts with structured counseling sessions with patients at the initiation and follow-up of chronic therapies. This process is followed by a continuous phase in which patients’ therapy adherence is monitored on a monthly basis, using standardized search algorithms in the pharmacy database. When the algorithm detects a patient’s discontinuation of therapy, tailored interventions are used to improve adherence and optimize pharmacotherapy. For osteoporosis patients, treatment discontinuation with bisphosphonates after 1 year dropped from 31.7% to 16.1% (P  less than  0.001). This program was shown to be cost-effective in patients initiating osteoporotic therapy. Future scenarios with lower drug prices  result in cost savings for the MeMO program. For lipid-lowering drugs, the MeMO program has been shown to lower therapy discontinuation after 1 year from 25.9% to 13.6% (P  less than  0.001). By extrapolating these results to patients’ lifetimes, the intervention was estimated to be cost-effective, with gains for primary prevention of cardiovascular events, and even cost saving in secondary prevention. Results from the ongoing MeMO asthma/COPD program are promising, showing marked improvements in therapy control and quality of life for asthma and COPD patients. Almost all patients participating in MeMO programs are satisfied with the pharmacy team and have gained knowledge of the effectiveness and administration of their medications and the importance of therapy adherence.The MeMO program is an effective and structured method to improve patients’ adherence to chronic medication in the field of osteoporosis, lipid-lowering drugs, and asthma/COPD and is well received by patients. By targeting the program toward nonadherent and high-risk patients, the program showed favorable cost-effectiveness.


In the Netherlands, a very ambitious falls prevention program is being implemented in 2023 and 2024. Falls among older adults lead to a high burden on healthcare and high societal costs. This program is therefore part of the current government coalition agreement. Each year one in seven persons over 65 should be screened on fall risk and should be stimulated to reduce fall risk. The whole program includes specific falls prevention programs (FPPs) as well as Physical activity (PA) programs outside these FPPs to keep fall risk restricted. Large responsibility is given to municipalities for implementation at the local level, and to regional public health services at a higher level.At present there is no good organisation of falls prevention. A whole infrastructure has to be set up to be able to carry out the prevention program. This is coordinated by VeiligheidNL.It involves a considerable number of stakeholders and different working packages on FFPs, implementation, and communication. Starting in 2022, a number of sessions have been held to inform municipalities, regional health services, and professionals. Funding frameworks are set up including refunding of FPP participation and support of coordination by municipalities.As part of the process, we evaluated among scientists, PA professionals and municipalities what is needed to organise PA for maintenance after FPPs and for people without increased risk. This includes more available organised PA, increase in frequency and intensity of current group PA, and involving regular sports clubs to increase overall capacity.Most municipalities need to take a much stronger coordinating role, including also a professional with ‘broker’ role, generally the so-called neighbourhood sports coach (NSC). This professional guides older people to suitable PA and is a connector between health, social care and PA professionals.The ambitious falls prevention program, supported by considerable financial resources, has the potential to give a large boost to PA in older adults. There are still a lot of challenges at the national as well as local level before implementation is successful, but several locations have already managed to develop a good infrastructure.


Within many public health settings, there remain large challenges to sustaining evidence-based practices. The Program Sustainability Assessment Tool has been developed and validated to measure sustainability capacity of public health, social service, and educational programs. This paper describes how this tool was utilized between January 2014 and January 2019. We describe characteristics of programs that are associated with increased capacity for sustainability and ultimately describe the utility of the PSAT in sustainability research and practice.https://sustaintool.org/), from 2014 to 2019. In addition to the PSAT scale, participants were asked about four program-level characteristics. The resulting dataset includes 5,706 individual assessments reporting on 2,892 programs.The PSAT is comprised of 8 subscales, measuring sustainability capacity in eight distinct conceptual domains. Each subscale is made up of five items, all assessed on a 7-point Likert scale. Data were obtained from persons who used the PSAT on the online website . Specifically, smaller programs (with staff sizes of ten or below) consistently reported lower program sustainability capacity. Capacity was not associated with program age and did not vary significantly by program level.The mean overall PSAT score was 4.73, with the lowest and highest scoring subscales being funding stability and program adaptation, respectively. Internal consistency for each subscale was excellent . Confirmatory factor analysis highlighted good to excellent fit of the PSAT measurement model  to the observed data, with a comparative fit index of 0.902, root mean square error of approximation equal to 0.054, and standardized root mean square residual of 0.054. Overall sustainability capacity was significantly related to program size (The PSAT maintained its excellent reliability when tested with a large and diverse sample over time. Initial criterion validity was explored through the assessment of program characteristics, including program type and program size. The data collected reinforces the ability of the PSAT to assess sustainability capacity for a wide variety of public health and social programs. What enables programs to continue delivering effective services over time? This is an important question funders and public health leaders pose as they look beyond the initial investment and implementation of a program. As Shelton et al.  note, fuSustainability has been defined as the ongoing use of an intervention with enough fidelity to continue to have desired program impact with subsequent improved outcomes . In addiDespite these research successes, it remains challenging for practitioners to maintain evidence-based activities and programs across a wide range of settings. Public health and community programs often depend on time-limited financial resources, after which programs are expected to secure alternative funding . ProgramPublic health program sustainability can take many forms . For exaTo better understand the factors that affect a program's ability to deliver benefits over time, Schell et al.  developeThis eight-domain conceptual framework is useful to help programs and organizations looking to understand the factors beyond simple funding that affect a program's capacity for sustainability. For example, programs that collect evaluation data about their processes and outcomes can better demonstrate the necessity of their program to leadership and stakeholders . CommuniTo address the relative lack of tools available to evaluate program sustainability, Luke et al.  translatThe PSAT was originally created to reflect the concepts represented in each of the eight domains in the program sustainability framework . The assThe PSAT was designed to allow comparisons between programs as well as within-program comparisons over time. Since 2014, the tool has been used by more than 5,000 people to rate sustainability capacity of more than 2,500 public health, social services, clinical care, and education programs of varying sizes in the US and internationally. Among many others, the PSAT has been used to examine the sustainability capacity of inter-professional collaborative practice model for population health, evidence-based practices in adolescent substance abuse, local health department programs and policies, and chronic disease prevention interventions –21.The variety of settings and amount of use provides the opportunity for further exploration of program sustainability capacity across program type, size, implementation level, and age. An example application of the PSAT in public health programming is how the Centers for Disease Control & Prevention (CDC)'s Office on Smoking and Health requires state tobacco control programs create a sustainability plan and encourages programs to use the Program Sustainability Assessment Tool to drive sustainability planning . Additiohttps://sustaintool.org between January 2014 and January 2019. We also examine how a small set of programmatic factors are related to program sustainability capacity. This paper adds to the sustainability knowledge base in two important ways, first, by identifying characteristics of programs that are associated with organizational capacity for sustainability, and second by providing further evidence supporting the utility of the PSAT as a continuing part of the implementation science sustainability toolkit.In this paper we describe program sustainability capacity for public health, clinical care, social services, and education programs using data passively collected on In this paper we report updated reliability, measurement model characteristics, and validity data for the Program Sustainability Assessment Tool (PSAT), which can be used to assess capacity for sustainability of a wide variety of public health, social service, and educational programs.no extent) to 7 (program has or does this to the full extent). Subscale and total scores are the averages of the individual item scores, so scores can range from 1 to 7. Higher scores are interpreted as the program having greater sustainability capacity in that area .The PSAT  consistsProgram type classified programs into five groups: public health, social service, clinical care, education, and other. As an example of a clinical setting, the PSAT has been used to examine the sustainability capacity of pediatric asthma care coordination , users passively consented to analysis of their de-identified PSAT profile data upon submission.The PSAT analyses presented here are based on PSAT profile and data passively collected on After downloading the PSAT data from the web server, the raw data were cleaned up by deleting test entries, and entries that had missing data for every item in the PSAT.  After cleaning, the dataset included a total of 5,706 respondents reporting on 2,892 programs. Examining missing data patterns, 65% of the respondents filled out every one of the 40 items in the scale, and 96% filled out at least half of the items (≥20).Users of the online PSAT can fill out an individual assessment , or a group assessment (multiple people rating the sustainability capacity of the same program). Of the 2,892 program assessments included in the dataset, 2,283 were individual assessments (79%). For group assessments, the respondent numbers ranged from 2 to 31, with a median group size of 5. The main purpose of this paper is to understand characteristics of program sustainability capacity, so the raw data were aggregated by program. Specifically, the group PSAT total and subscale scores were calculated by averaging the scores for all individuals taking part in a particular group assessment. So, the scores are meant to represent program and organizational characteristics, not individual characteristics.Frequencies and means were calculated to obtain descriptive statistics of the sample, as appropriate. One-way analyses of variance were conducted to understand PSAT score differences related to program focus, size, age and level. Two-way analyses of variance were conducted to assess the interaction between program focus and program size, age and level. Psychometric analyses were conducted to assess the reliability  of the eight PSAT subscales. Finally, confirmatory factor analysis was used to test the measurement model of the PSAT, and how well that measurement model fit with the observed PSAT data.The goal of these analyses is to describe the characteristics of the Program Sustainability Assessment Tool (PSAT) as it has been applied to rate sustainability capacity in a variety of settings and programs. These analyses can help determine if the psychometric properties have remained stable as the PSAT has been rolled out for wider application, and to assess how a small number of program characteristics are related to PSAT overall and subscale scores.M = 3.97), followed by strategic planning (M = 4.42), partnerships (M = 4.47), communications (M = 4.64), organizational capacity (M = 4.98), program evaluation (M = 5.08), environmental support (M = 5.08) and program adaptation had the highest average score (M = 5.23). Although the subscale and total mean scores are somewhat high relative to the seven-point scale, score variabilities are relatively high (standard deviations ranging from 1.13 to 1.43), indicating only minor issues with restriction of range. All of the scores for the PSAT were out of a possible total of 7, with 7 being the greatest extent of each domain. Across all programs, the mean PSAT score was 4.73 . PSAT suIn our original PSAT development study, average internal consistency  of the 8 subscales was 0.88 and domain subscales ranged from 0.79 to 0.92 . In the p < 0.001)  to see how well the observed data matched our overall conceptual framework of eight distinct conceptual domains see . CFA res< 0.001) . More deM = 4.92), followed by public health (M = 4.78), social services (M = 4.64), and finally education (M = 4.61). PSAT scores were analyzed by program type for four types of programs: public health, social services, clinical care and education. Overall, PSAT total and subscale scores varied significantly by program type, except for organizational capacity see . ClinicaF = 25.6; p < 0.001). In general, larger programs  were perceived as more sustainable than smaller programs . This pattern was apparent across all of the subscale domains as well-programs with three or fewer staff and volunteers reported significantly less capacity for sustainability compared to programs with 21 or more staff and volunteers for all eight of the subscales. Additional analyses were conducted to understand how program size, age and level impact sustainability capacity . OverallF = 1.49; p = 0.226). However, older programs  reported higher capacity for funding stability , while younger programs (< 1 year) showed greater capacity in program evaluation  and program adaptation .In comparison, program level and program age were not as strongly or consistently related to sustainability capacity scores. Overall sustainability capacity was not associated with program age . However, state-level programs reported the lowest level of communications capacity  while higher level (beyond state) programs reported higher financial stability .Overall program sustainability capacity did not vary significantly by program level (This study evaluated the PSAT continued performance in two major areas: first, through assessment of reliability and measurement structure, and second, in understanding some program characteristics that affect programs' sustainability capacity. The PSAT maintained its excellent reliability when tested with a larger and more diverse sample over time, further solidifying it as a reliable tool for assessing sustainability capacity. Initial criterion validity was explored through the assessment of program characteristics, including program type and program size. The data collected across differing programs and users reinforces the ability of the PSAT to assess sustainability capacity in relevant areas. The PSAT aids in assessment of many areas of public health, including those that address addiction and mental health programming.The PSAT, therefore, remains a reliable and valid instrument for practitioners to use when assessing their program's sustainability capacity. While some work has adapted the PSAT for specific areas, this work suggests that the PSAT remains valid in its entirety, even when assessed in a larger and more diverse sample . While tFurther, this data provides information about real-world programs to support and enhance program sustainability. This allows for practitioners and researchers to better understand what constructs should be targeted to enhance program sustainability in public health, mental health, and clinical care.Ultimately, this theoretically driven work helps move from considerations about definition into better understanding of measurement of this construct. Next, studies of sustainability need to focus more about prediction and mechanisms on which sustainability acts. This study helps tie important information about theory and frameworks to data around these contextual factors that can drive sustainability capacity. These PSAT domains could inform future qualitative studies to explore the concepts further and elucidate how they could contribute to interventions to increase future sustainment.A strength of this study is the large number of participants, even though the sample was comprised of those who sought out the measure for use. The time span covered by the sample further allows for strengthening of outcomes related to reliability and validity. Finally, this sample represents many types of programs as well as locations of assessment, including programs both within the United States and internationally. International participants were from countries including: Australia, Canada, and the United Kingdom. However, we do not collect specific location of sites through our online survey at this time. Additionally, this assessment was conducted prior to a Spanish translation of the measure being available, so is limited to English speaking respondents. Future validation work can expand on the initial variables used in this sample to assess criterion validity as well as explore PSAT responses in multiple languages.The PSAT provides a reliable tool for assessing a program's sustainability capacity. In addition, the PSAT has been found to be easy to use, requiring no or minimal training . As a reAdditionally, clinical settings often have been identified as having unique processes and structures to those in public health programs . For exaIn addition to future work focused on broader dissemination of this tool for practice, there are opportunities to explore how different organization contexts influence program sustainability. The contexts within which different programs, such as public health and educational programs, are delivered can vary widely, even within similar geographic regions. Therefore, further work should focus on understanding this varying context, including differences in program level, populations, and settings, and their relationship to overall sustainability capacity. While other work has adapted this tool for specific clinical contexts, the PSAT should continue to be utilized and tailored for other audiences.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.CB led the design of the study and drafting the manuscript. SM assisted with planning the study, reviewing the data, and drafting the manuscript. KP provided supervision of the study and assisted with the design of the study and drafting the manuscript. RH assisted with data collection, data preparation, and editing the manuscript. MH assisted with the design of the study and drafting the manuscript. SD assisted with data collection and study design. DL led the data analysis and assisted with planning the study and drafting of the manuscript. All authors reviewed and approved the final manuscript.This work was funded by the Centers for Disease Control and Prevention, Office on Smoking and Health, contract no. 75D301-20-R-68063.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This cross-sectional study investigates the diversity demographics of academic medical leadership among various medical specialties compared with the average of all residency programs. What are the diversity demographics of academic medical leadership in various specialties compared with the average across all residency programs?In this cross-sectional study of academic medical leadership , surgical specialties consistently had lower leadership diversity than the average across all residency programs, whereas primary care specialties typically had similar or increased diversity.Select specialties in academic medicine have bridged diversity gaps in academic medical leadership whereas others continue to lag behind. For the past 50 years, significant gaps have existed in gender and racial diversity across various medical specialties, despite the many benefits of a diverse physician workforce. One proposed approach to increasing diversity is top-down diversification, in which diverse leadership results in increased minority and female workforce representation.To investigate the changes in academic medical leadership diversity from 2007 to 2019 and to assess the recent leadership diversity of various specialties compared with the averages across all specialties.This was a cross-sectional analysis of physicians in varying academic roles in 2007, 2019, and 2020. Demographic data were collected via specialized reports from the Association of American Medical Colleges. Included were 4 primary care specialties . Study participants were faculty, program directors, and chairpersons. Data were analyzed for the years 2007, 2019, and 2020.Self-reporting of demographic information to residency programs collected via the Graduate Medical Education Track Survey.Proportions of each race/ethnicity and sex among cohorts of participants and comparisons between them.P = .01 and 96% increase ; P < .001), respectively; meanwhile, several specialties saw significant increases in female representation during this period . In general, surgical specialties had lower leadership diversity than the average diversity of all residency programs, whereas primary care specialties had similar or increased diversity.The total number of individuals investigated included 186 210 faculty from 2019 , 6417 program directors from 2020 , 1016 chairpersons from 2007 , and 2424 chairpersons from 2019 . When comparing chairperson diversity from 2007 to 2019, only internal medicine and general surgery experienced significant increases in minority (aggregate category used throughout the investigation to refer to anyone who self-identified as anything other than non-Hispanic White) representation  publishing efforts and outcomes of diversity representation, (2) incorporating a representative demographic for leadership selection committees, and (3) actively promoting the importance of diversity throughout the selection process. Recently, there have been pediatric, general surgery, and orthopedic surgery programs that have been successful with top-down diversification.38A proposed approach to increasing diversity is “top-down” diversification, which refers to diverse leadership within a specialty resulting in higher levels of minority and female representation within the workforce.42 Therefore, a different approach using diversity of leadership could be helpful in transforming academic medicine into a more diverse field. However, in order to use this top-down approach in medicine, one must first start with an understanding of the diversity of existing leaders in medicine and whether that has changed over time.Despite the demonstration of a lack of diversity over the last 40 years and numerous organizations, including the Association of American Medical Colleges (AAMC), speaking to this issue, progress has been relatively slow in several medical fields. Over the last 20 years, numerous recurrent studies within the fields of academic medicine, including general surgery, family medicine, and orthopedic surgery, have found the same lack of representation as that found in the 1980s when these studies began.41 Although diversity in medicine has been previously examined in residents and faculty members,42 few studies have included the representation of program directors and chairpersons.The primary purpose of our study was to assess the recent diversity of academic medical leadership in terms of program directors and chairpersons for several surgical and nonsurgical specialties in comparison with the averages across all specialties. Our secondary objective was to examine changes in chairperson diversity from 2007 to 2019 using a snapshot analysis for each specialty. For continuity, the specialties chosen have been similarly analyzed in other studies.46 Specialized AAMC data reports use self-reported demographic data from the Graduate Medical Education Track Survey sent to all residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME). Institutional review board requirements were officially waived by an institutional review board ethics committee owing to the lack of direct human participants within the investigation. Using these reports, we analyzed the racial, ethnic, and gender compositions of faculty, program directors, and chairpersons in ACGME-accredited residency programs in the US for 4 primary care and 4 surgical fields. For purposes of continuity with other published studies comparing the diversity of medical specialties,48 we chose to analyze internal medicine, family medicine, pediatrics, and obstetrics/gynecology (OB/GYN) for the primary care specialties and orthopedic surgery, neurologic surgery, otolaryngology (ENT), and general surgery for the surgical specialties. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.Faculty and leadership demographic data were collected from a nationally recognized source for the diversity of medicine: the AAMC. Data were obtained through specialized AAMC reports titled “Diversity in Medicine: Faculty Roster for 2007, 2019, and 2020.”49 the AAMC FACTS Glossary,43 and the US Census Bureau (USCB),50 race was defined as Asian American, Black or African American, White, or other, which included American Indian or Alaska Native, multiracial, Native Hawaiian or Pacific Islander, other, or unknown. According to the AAMC’s FACTS glossary43 and the USCB,51 ethnicity was separated into non-Hispanic or Latino and Hispanic or Latino. Based on demographic data from the USCB,52 a race or ethnicity must represent at least 5.0% of the general US population for individual representation in data analysis. To account for this, we combined the underrepresented groups falling below this threshold, including American Indian or Alaskan Native, multiracial, Native Hawaiian or Pacific Islander, other, or unknown, into a category titled “other.” Using the Population Reference Bureau’s definition of an individual identifying with a racial and ethnic group other than non-Hispanic White,53 a “minority” category was aggregated and used as a generalized measure of racial and ethnic diversity. Despite Asian Americans no longer being considered underrepresented in medicine by a majority of academic medical institutions, this race category was still considered under the broader minority category in order to represent them individually in our analysis, as is consistent with other studies on diversity in medicine.58 Thus, leadership diversity was defined as program directors and chairpersons identifying as female or any racial and ethnic group other than non-Hispanic White.Using categories from the AAMC’s Faculty Roster,Because leadership roles are likely to be chosen from a recent composition of faculty members, our analysis compared faculty from 2019 with program directors in 2020 and chairpersons in 2019. Furthermore, we performed a snapshot comparison of minority and female chairpersons from 2007 to 2019. Lastly, we analyzed the diversity of program directors and chairpersons in each specialty by comparing their respective proportional racial and ethnic and gender compositions with the average leadership diversity metrics across all residency programs.2 tests. If at least 25% of the sample count was less than 5, Fischer exact test was used. Statistical significance was set at a 2-sided P value < .05. All analyses were performed using SAS, version 9.4 (SAS Institute). Data were analyzed for the years 2007, 2019, and 2020.Statistical proportions were compared using 1- or 2-sample χThe total number of individuals investigated included 186 210 faculty from 2019, 6417 program directors from 2020, 1016 chairpersons from 2007, and 2424 chairpersons from 2019. All together, 79 441 of the 186 210 faculty members in 2019 were female (42.7%) and self-identified with the following race and ethnicity groups: 6889 African American (4.2%), 38 100 Asian American (20.3%), 6197 Hispanic or Latino (3.6%), 117 914 White (63.3%), and 17 110 other (8.8%). A total of 2392 of 6417 program directors in 2020 were female (37.3%) and self-identified with the following race and ethnicity groups: 217 African American (3.5%), 1586 Asian American (25.9%), 306 Hispanic or Latino (5.0%), 3893 White (63.5%), and 129 other (2.1%). A total of 89 chairpersons in 2007 were female (8.8%) and self-identified with the following race and ethnicity groups: 53 African American (5.2%), 37 Asian American (3.6%), 35 Hispanic or Latino (3.4%), 861 White (84.7%), and 30 other (3.0%). A total of 435 chairpersons in 2019 were female (17.9%) and self-identified with the following race and ethnicity groups: 102 African American (4.2%), 261 Asian American (10.8%), 90 Hispanic or Latino (3.7%), 1885 White (77.8%), and 86 other (3.5%).P < .001; pediatrics, 287 [28.3%] vs 8470 [35.1%]; P < .001; orthopedic surgery, 80 [20.5%] vs 1090 [25.0%]; P = .047; neurologic surgery, 24 [23.3%] vs 753 [35.0%]; P = .01; general surgery, 105 [26.9%] vs 4800 [33.4%]; P = .001) , and family medicine had significantly increased minority diversity in its program director pool  (P <.001) among program directors in 2020. With the exception of ENT , chairpersons in all included specialties were significantly less racially and ethnically diverse than the respective faculty of each specialty due to their lower percentages of minority representation   demonstrated significantly lower diversity in the other category in both leadership positions . Furthermore, program directors in neurologic surgery  and chairpersons in 5 of 8 specialties had significantly lower proportions of Asian American chairpersons than their respective faculty representation in 2019 . Although 2 of 8 specialties had significantly less African American program director representation , orthopedic surgery program directors and family medicine chairpersons had significantly higher African American representation than faculty in 2019 . Regarding Hispanic or Latino representation, 3 of 8 specialties had significantly increased program director diversity , and family medicine had significantly lower program director diversity than faculty . When analyzing program director demographics in 2020 compared with that of faculty in 2019, program directors for 5 of 8 specialties demonstrated significantly lower minority representation than faculty  . Meanwhi < .001) . This waP = .01) . When coP < .001; family medicine, 343 [38.4%] vs 3318 [53.1%]; P < .001; orthopedic surgery, 40 [9.0%] vs 867 [19.9%]; P < .001; neurologic surgery, 11 [9.3%] vs 475 [22.1%]; P < .001; ENT, 47 [27.6%] vs 856 [35.2%]; P = .045)   . In term < .001) .P < .001; chairpersons, 435 [17.9%] vs 79 441 [42.7%]; P < .001); meanwhile only chairpersons had significantly lower minority representation . When analyzing each race/ethnicity individually for program directors, the aggregated specialties had similar African American representation , significantly lower representation in the other category , and significantly higher Asian American and Hispanic or Latino representation compared with faculty in 2019 . For chairpersons, the 8 aggregated specialties had significantly lower Asian American and other representations , and similar African American and Hispanic or Latino representation .When analyzing all specialties together, both program directors and chairpersons had significantly lower gender representation when compared with the combined faculty in 2019  and 96% increase , respectively, in the proportion of minority chairpersons (P = .002), pediatrics by 83.1% , OB/GYN by 53.2% , orthopedic surgery by +4.1 percentage points , and general surgery by 226.9%   .P < .001; neurologic surgery, 24 [23.3%] vs 2238 [36.5%]; P = .01; ENT, 41 [27.7%] vs 2238 [36.5%]; P = .03; general surgery, 150 [26.9%] vs 2238 [36.5%]; P < .001; pediatrics, [28.3%] 287 vs 2238 [36.5%]; P < .001) (P < .001)  (P < .001) (P = .004) (P = .047)    were a minority . On comp < .001) . In cont < .001) . When av < .001) . When co < .001) . Regardi < .001) . For His = .004) . Meanwhi = .047) . In term = .001) . In cont < .001) .P = .008) , whereas general surgery had significantly higher than average Asian American diversity  (P < .001). All 8 specialties had similar proportions of Hispanic or Latino chairpersons compared with the average. For other representation, pediatrics had greater representation compared with the average . In regard to female chairpersons, orthopedic surgery, neurologic surgery, ENT, and general surgery displayed significantly lower than average gender diversity when compared with the average of all specialties together at 17.9%    . Althoug = .008) . When avP < .05) . Meanwhi < .001) . In cont < .001) .Although diversification of academic medical leadership has been proposed as a potential solution to the lack of minority and female representation in medicine, there have been limited studies exploring this topic. Results of our cross-sectional analysis suggest that when compared with faculty in 2019, only program directors in family medicine had greater minority representation than their faculty counterpart, which was primarily caused by the greater proportion of Asian Americans. However, the majority of chairperson and program director analyses of minority and female representation for each specialty showed decreased diversity when compared with faculty in 2019, specifically in the categories of Asian American and other. Although some specialties demonstrated significant increases in minority or female chairperson representation from 2007 to 2019, all specialties displayed significantly lower racial, ethnic, and gender diversity among chairpersons in 2019 when compared with faculty in 2019, with the exception of ENT. These data suggest that, although there have been some gains across various specialties in terms of leadership diversification, there is still a decrease in minority and gender diversity when advancing from faculty to leadership positions in academic medicine.29A key finding of our study was that surgical specialties had consistently lower leadership diversity when compared with the average diversity of all residency programs, whereas primary care specialties typically had similar or increased diversity. All 4 surgical specialties had significantly lower proportions of minority program directors, female program directors, and female chairpersons than the average for all specialties. However, in terms of minority chairperson diversity, 3 of 4 surgical specialties showed similar diversity to the average across all specialties. In contrast, orthopedic surgery was the only specialty with significantly lower minority chairperson representation than the average. Our results suggest that surgical specialties lag in leadership diversity, which is similar to previous studies that have shown a gap between surgical specialties and primary care specialties in terms of resident and faculty diversity.42 In 2 studies,42 one investigating gender diversity in orthopedic applicants at 107 medical schools and the other investigating residents in 143 orthopedic residency programs, increased gender diversity among both applicants and residents was either influenced by  or connected to  with increased female orthopedic faculty and women in leadership positions. With regard to racial diversity, a 2020 study38 out of the Children’s Mercy Kansas City (CMKC) pediatrics program found that with the addition of minority faculty during the residency selection process and a diversity committee, their 2019 residency class was the most diverse class in recent history. In addition, more minority residents elected to remain at the CMKC for their fellowship programs.38 Based on these findings that show a strong influence of diverse faculty on residents and applicants, the same concept may apply to diversity in chairpersons who typically have the opportunity to build leadership teams of residency program directors and faculty. Based on our findings, supporting research, and initiatives by the AAMC,59 we recommend 3 possible solutions to help bridge the diversity gaps in academic medical leadership: (1) advocating for programs and institutions to proactively publish the efforts and outcomes of diversity representation, (2) incorporating a representative proportion of minority and female members on academic medicine leadership selection committees, and as has been effective in other industries,36 (3) encouraging leaders of academic health care systems to actively promote the importance of leadership diversity to their selection committee members.Studies examining a top-down approach to diversification have now begun to highlight the correlation between diverse faculty and increased diversity in residents.Our study has several limitations. First, the data used in this study included self-reported race, ethnicity, and sex. This method allows for self-report bias and potential errors in self-reporting. Second, respondents to the Graduate Medical Education Track surveys used to collect data for the AAMC database were not prohibited from selecting multiple races or ethnicities from which they identified. Therefore, for statistical analysis, we used the sum of responses for each separate race or ethnicity selection as the total sample size instead of the total sample size reported by the AAMC. Additionally, the sample size of chairpersons was smaller relative to the other investigated populations; this limited our statistical analysis, and therefore, this may have underestimated statistical significance.In this cross-sectional study, results suggest that the majority of specialties in academic medicine saw no improvement in racial diversity despite the greater diversity of the pool of available faculty members to choose from; meanwhile, several specialties did experience significant increases in gender diversity among their leadership. However, all of the specialties analyzed continued to have lower leadership diversity when compared with their own faculty members, with many of the surgical specialties having lower than average racial and gender diversity in their leadership. In conclusion, persistent monitoring of diversity in leadership allows us to accurately assess the trends of diversity in medicine and determine the potential to promote a diverse physician workforce.