A 28-day Prostate Cancer-Patient Empowerment Program (PC-PEP) developed through patient engagement was successful at promoting mental and physical health. Thirty prostate cancer patients from Halifax, Canada participated in the 28-day PC-PEP intervention in early 2019. PC-PEP encompassed daily patient education and empowerment videos, prescribed physical activities (including pelvic floor exercises), a mostly plant-based diet, stress reduction techniques, intimacy education, social connection, and support. Quantitative exit surveys and semi-structured interviews (conducted in focus groups of ten) were used to assess perceived factors that facilitated or impeded adherence to the program. The program received high praise from the patients and was deemed extremely useful by the participating men, who rated it 9 out of 10. Patients expressed that the multifaceted, online, home-based nature of the program helped them adhere to it better than they would have had to a single or less comprehensive intervention. Feedback from the participants indicated that the program, when viewed as a whole, was perceived as greater than the sum of its individual parts. Furthermore, the program addressed various issues, including emotional vulnerability and distress, physical fitness, urinary incontinence, challenges in expressing emotions, perceived lack of control over healthcare decisions, emotional fragility, and hesitancy to discuss prostate cancer-related matters in social settings. Patients highly (9.6/10) endorsed integrating the program into the standard care regimen from the very beginning of diagnosis. However, challenges such as work commitments were noted. Patients’ high endorsement of PC-PEP suggests that its implementation into the standard of care from day one of diagnosis may be warranted. Prostate cancer, the most frequently diagnosed cancer among North American men, has witnessed substantial advancements in both detection and treatment over the past few decades ,2. ConseExpert panels focused on cancer survivorship have underscored the urgent need for evidence-based interventions that empower and educate prostate cancer survivors to address their psychosocial and mental health needs . PatientResearch aimed at uncovering the unmet needs of both prostate cancer patients and survivors has identified several substantial areas in need of support. These encompass critical aspects such as mental well-being, psychosocial factors, physical health, patient empowerment, and comprehensive health system information ,19,20,21Psychological distress among prostate cancer patients affects one in six patients and is often underdiagnosed and untreated ,20,23,24Although education and empowerment interventions to support men diagnosed with prostate cancer in addressing these needs are emerging, they remain relatively scarce ,29,30,31In alignment with these endeavors, a 2018 study systematically reviewed interventions for prostate cancer survivors, aligning with American Cancer Society (ACS) and American Society of Clinical Oncology (ASCO) guidelines. This review found that both exercise and psychosocial interventions were effective in enhancing survivorship outcomes, addressing health promotion, physical well-being, and psychosocial challenges. However, it also highlighted gaps in existing studies and the lack of diversity in participant representation, emphasizing the necessity for targeted efforts to improve prostate cancer survivorship care .Dunn et al. (2020) aimed to develop contemporary and inclusive prostate cancer survivorship guidelines for Australia, engaging a 47-member expert panel, including leaders from various clinical and community groups and diverse consumers . This stExpanding on this research, a 2021 study conducted a systematic review of 22 randomized clinical trials, evaluating the effectiveness of psychological interventions in addressing depression, anxiety, and distress in prostate cancer patients . The finMundle et al. (2021) emphasized the potential of psychological interventions to enhance the well-being of prostate cancer patients and called for further research to explore their impact on long-term clinical outcomes . AdditioWhile cognitive-behavioral, educational, and peer support interventions have demonstrated associations with improved emotional well-being and health-related quality of life outcomes in men with localized prostate cancer, their integration into medical and survivorship care standards has remained limited. This limitation can be attributed to various factors, including inadequate evidence-based data, suboptimal methodology, small sample sizes, low-quality reporting, high rates of loss to follow-up, cost considerations, and limited diversity in the studied populations ,33,34,35This study aims to explore the perceptions of patients regarding a 28-day online Prostate Cancer-Patient Empowerment Program (PC-PEP). The program, developed through active patient engagement, focuses on patient education, activation, and well-being enhancement. Prior research has demonstrated its efficacy in reducing mental distress and improving physical fitness ,30. ThroA qualitative study using a conventional content analysis approach was conducted as part of a Phase 2 feasibility study described elsewhere . This tyhttps://food-guide.canada.ca/en/healthy-eating-recommendations/ (accessed on 20 September 2023)) and are delivered through daily emails. The program also provides education on intimacy and connection through video modules that encourage authentic communication, vulnerability, and compassion. To foster social support, participants can opt to be paired with two “buddies” undergoing similar treatment for their diagnosis. The participants attended training sessions on all aspects of the program prior to starting the program, then they received 28 daily messages (3–5 min long) outlining the education and daily activities for the day, and video resources guiding the daily activities. Every day participants were asked to engage in a total of 70 min of specific activities: 30 min of aerobic or strength exercises, 24 min  of pelvic floor exercises, and 10 min of self-induced positive emotions through meditation and slow breathing.The 28-day PC-PEP Phase 2 study content, structure, administration, methodology and quantitative primary outcomes results are described elsewhere . In brieThe quantitative questions of the structured part of the focus group interviews assessing the value, strengths and limitations of the program were devised by three of the co-authors with input from patients engaged in the research from the local prostate cancer support group during a conference pre-dating the feasibility study, who were not participants in the study. They were administered via paper and pencil questionnaires pre- and post-PC-PEP program delivery. Specifically, after the end of the training session day on 11 January 2019 (which explained and demonstrated the various components of the program to patients before the program began) patients were asked to rate their interest in the program overall , their interest in each of the components of the program , their perceived quality of the PC-PEP training provided to patients, overall , and their perceived competence of the research team who conducted the physical assessments and delivered the training for the program . Three days after the end of the intervention, patients were asked to rate their interest in the program overall; rate how important/beneficial PC-PEP would be, in their opinion, if it were provided to patients from day one of diagnosis; the usefulness of the program to them personally; the usefulness of each of the program’s components; the competency of the research team; and their likelihood to recommend the PC-PEP program to men who have been diagnosed with prostate cancer on a Likert scale ranging from 0 to 10 (similar to pre- intervention assessments).The in-depth, semi-structured focus group interviews were conducted with all patients, by two of the co-investigators (GI and RDHR) three days after the 28-day intervention was completed. The qualitative questions expanded on the post-intervention paper and pencil assessment. The participants were asked: “Please describe your experience with the PC-PEP program and what changes if any you noticed in your daily living habits? What aspects of the programs did you find facilitated your engagement and compliance with the program? How useful did you find the program, and its individual components of the program: daily videos from Drs. GI and RDHR reviewed the program requirements for the day, exercise videos of various strength levels using elastic bands, Kegel’s weekly videos, meditation and breathing videos and instructions, relationships and cancer education, intimacy and connection techniques to help with problems associated with erectile dysfunction teaching videos, relationships dietary recommendations, buddy system, Kegel text reminder, weekly compliance surveys, testing sessions prior to and at the end of the program? What aspects of the program or outside the program were challenging and might have prevented you from keeping up with the program and its requirements? In your view, what aspects of the program may require further development or improvement for the program to be more easily adopted by patients? From your point of view would PC-PEP be a valuable resource for a patient’s survivorship care from day one of diagnosis? Which of your prostate cancer survivorship needs did the program address or not address, from your perspective? What barriers do you think prevented you from benefiting from the program or what aspects did you perceive to not be helpful in your engagement with the program and its successful completion? What facilitated your engagement with the program and its successful completion? Other comments or feedback that you may wish to provide with regard to your experience with the program”. The average focus group interview length was 45 min for each of the three groups. The voluntary nature of participation and assurance regarding privacy and confidentiality were emphasized before each interview.All focus group interviews were audiotaped, and their content was transcribed verbatim, and reviewed by members of the research team  to identify major themes. The primary analysis team consisted of three co-authors  who were experienced in qualitative research. The interviews were transcribed verbatim and analyzed within 12 months of data collection. During data analysis, three co-authors  read the data word by word several times and identified emerging themes. Grounded theory methodology and content analysis were used in combination. With the analysis of the data, patterns, themes, and concepts were identified that emerge from the text. At this point, we decided to apply content analysis techniques to systematically categorize and summarize the explicit content within those emerging themes. This provided a structured way to present the data and enhance the rigor of the analysis.The focus group text was divided into meaningful concepts known as meaning units (MU) coded based on similar features to create broad conceptual categories, and further classified into specific themes and sub-themes . The autMeans and standard deviations were used to describe the pre- and post-ratings of the program. All 30 patients completed the 28-day program and all its quantitative and qualitative assessments, in their entirety. Sample characteristics have been published elsewhere  then I might just slip back”  can play in providing emotional support  and overcoming feelings of isolation and disconnect. Patients noted that the program facilitated their understanding of identifying their preferred mode of communication and fostering awareness of the preferred communication styles (love languages) of those in their social circles. This awareness aided in initiating more profound connections and interactions. The encouragement to explore secure, suitable, mutually advantageous avenues for connecting with loved ones, which augmented emotional stability and bolstered relationship contentment, was viewed positively. Certain patients also highlighted the program’s positive influence on their proximate and long-distance relationships. They reported a heightened willingness to engage in vulnerability and genuine sharing during telephone conversations or face-to-face interactions with partners and distant relatives. One patient stated: “It’s been so tremendously valuable to me, and I really hope that there are ways found to enable more men and their loved ones to benefit from this type of support program that will enable them to lead better lives. Because, you know, the good thing about prostate cancer is that [it has a] 95% 10-year survival rate. But there’s being alive and then there’s living… and I think there’s 95% of people that are alive—but I’m not sure what percentage of them are still really living. And if we can improve that percentage, I think that would be incredibly valuable”. Another patient stated: “When I started this program, I was struggling, and this program was a way for me to turn it around. […] This program is invaluable, and it should be for everybody” , and they were struggling with overcoming these side effects on their own. Two-thirds of the patients stated that their treatment  rendered them unable to have or maintain an erection, and experienced decreased or loss of libido. Patients stated that their loss of sexual function was accompanied by a decrease in the ability to meet their emotional needs such as feeling respected, loved, appreciated, feeling admired, feeling that their partner is proud of them, feeling attractive, and feeling that they are a priority and accepted for who they are. Among younger patients, the switch from being sexually active to losing sexual function following treatment was reported to have been psychologically traumatic and compared to “ernight” . Patienterybody” .what we did was share in talking more, as a result of the program, but that’s it”).The ability to have a social support network (“buddy system”) and the encouragement to cultivate connections (delivered by the program’s leads through daily email videos) was perceived as a facilitating factor. This facet of the program engendered a feeling of inclusion and concurrently enhanced mental well-being. Most patients not only acknowledged the advantages derived from the support provided by fellow participants who were also survivors, but they also appreciated the heightened depth of their relationships with partners and family members during the program’s duration. Three patients stated the program, however, had a small to no influence on their relationships , to be encouraged to eat healthy foods and be told why this is important, to connect with others for social support, and connect more closely with loved ones, were essential elements to their perceived program’s success. Most patients highlighted that they lost weight and that they were very pleased with the impact the program had on their overall physical fitness. Patients also stated that the program gave them achievable goals and reignited their motivation to exercise which they had previously lost. All patients indicated the intent to continue to exercise after the program ended .Patients stated that urinary incontinence was a common side effect of either their radical prostatectomy and/or radiation therapy and perceived this to have been a significant factor in their perceived decreased quality of life. Most patients found the Kegels component of the program highly valuable for improving their urinary function. Patients discussed how the specific Kegels education in PC-PEP differed from other previous Kegels education they received. Twelve patients stated that they were handed a pamphlet in the hospital that described Kegel exercises with no additional instructions, while eight patients stated that they were seen by a pelvic floor nurse on a weekly basis for several weeks or paid for a psychotherapy nurse to provide them with instructions on how to do the exercises correctly). During the PC-PEP program patients stated that they were not only instructed on how to do the exercises through explanatory and demonstrative videos, but they had a meeting with a nurse Kegels specialist right at the start of the program and received daily text alerts via their phone three times a day instructing them to do the 8 min of Kegels prescribed for that week. Patients attested that in their view this difference contributed to an improvement in their urinary control which they noted. Some participants stated that they went from using three urinary pads a day to being 95% dry at the end of the 28-day program. Patients stated that the change in the Kegels routines from one week to the other, made this a progressive training program, and they perceived this aspect of PC-PEP to be a helpful, and effective feature of the program. However, not every patient had urinary issues; when asked if they complied with this aspect of the program even if they did not have urinary problems, most participants said they did, adding that they perceived this to be a helpful skill to have for future age-related urinary problems .While acknowledging the significance of exercise, Kegels, and other program components for enhancing post-prostate cancer treatment quality of life, most patients admitted lesser awareness concerning aspects such as meditation, meeting emotional and intimacy needs, and their impact on perceived well-being. Numerous patients expressed a gap in their understanding of practical strategies to effectively manage both intimate and non-intimate relationships during their cancer journey, along with the potential influence of these aspects on their holistic well-being. These individuals acknowledged that the program’s emphasis on social support and pursuit of diverse forms of intimacy  facilitated their progression toward acceptance, healing, and alternative avenues for fulfilling psychological and emotional closeness .The majority of patients were initially unfamiliar with the beneficial impact of meditation and slow deep breathing on stress reduction. Despite finding the concept of meditation somewhat bothersome initially, most participants noted that the daily prompts for meditation and breathing exercises contributed to enhanced relaxation throughout their day and heightened awareness of their emotional state over the course of the week. Notably, the integration of technology and diverse communication channels  for program delivery proved highly effective in both motivating patients and maintaining their adherence to the program .In general, patients expressed that the program reinstated their confidence in adopting healthier lifestyle habits and empowered them to actively address the changes and challenges they encountered both physically and psychologically after cancer treatment. They conveyed an enhanced sense of self-efficacy, feeling capable of positively impacting their own health and well-being. The program activated their autonomy, allowing them to assert control over their role in supporting their health and lifestyle. Describing the PC-PEP program as a “gestalt”, patients emphasized that its collective impact exceeded the sum of its individual components. In essence, the program was more than its parts, combining knowledge, motivation, accountability, and support to benefit and empower participants .Although all patients acknowledged the significant benefits of the PC-PEP program, they also expressed that they would have likely gained even more from it had it been offered earlier in their survivorship journey, even as early as their initial diagnosis. This sentiment was particularly pronounced among patients currently undergoing treatment. In hindsight, patients recognized that the program could have provided invaluable consolation during the challenges of treatment by directing their attention to controllable aspects such as lifestyle choices. They believed it could have assisted in preparing for treatment-related side effects and even influenced treatment decisions, potentially reducing apprehension around options such as active surveillance.The majority of patients found the 28-day duration of the PC-PEP program suitable; however, they proposed two potential enhancements: the introduction of follow-up sessions  or an extension of the program’s duration  . Even thIn general, the majority of patients encountered few obstacles during their engagement with the PC-PEP program within the stipulated 28-day timeframe. Among the 30 participants, five individuals reported specific challenges. These included concerns about the time commitment for daily program activities , work-related scheduling conflicts, personal aversion to meditation and slow breathing exercises, and environmental limitations such as winter weather impacting outdoor aerobic activities. While the program catered to both partnered and unpartnered men, those who were single or lacked a willing partner for the intimacy-focused activities expressed regret at not being able to partake in partner-oriented exercises. One patient cited his partner’s advanced age as a factor preventing deep connection and intimacy engagement. Additionally, a subset of patients experiencing relationship difficulties noted that the intimacy education aspect of the program illuminated existing challenges in their partnerships, leading to a constructive examination of relational dynamics. While this was deemed positive, it was acknowledged that this aspect might present challenges to future participants. Some patients found the social connection facet of the program somewhat demanding, particularly as age-related isolation could impact their ability to engage fully. For instance, reaching out to distant acquaintances as prescribed on Sundays became more complex when confronted with the reality of friends’ passing or drifting apart. Despite these hurdles, all patients affirmed that their quality of life underwent positive transformations upon completing the program, underscoring the overall benefits they derived, even in the face of challenges.The daily dietary prompts were deemed beneficial, though patients suggested enhancing the dietary element by including a pamphlet, cookbook, or cooking videos alongside the daily video reminders. Additionally, a couple of participants shared that engaging in the buddy and mentor features of the program occasionally led to social awkwardness when discussing program-related interactions with other men. Nonetheless, these instances were generally seen as positive experiences. One patient elaborated that discomfort in connecting with a buddy occasionally stemmed from difficulty determining the optimal timing for contact, resulting in avoidance. For instance, they noted that reaching out sometimes coincided with the buddy’s unavailability or preoccupation, causing hesitation. Despite these observations, most patients actively participated in the buddy component, built meaningful relationships and found the experience very rewarding .The lowest-rated aspect of the PC-PEP after the training session and before the program began was the meditation component  while the highest-rated was the pelvic floor training component . After the PC-PEP was completed, the lowest-rated aspect of the program was the meditation component  while the highest was the daily video and email messages prescribing, describing, and demonstrating the various components of the program . The competency of the leads of the PC-PEP was rated 9.73 (SD = 0.52) and 9.89 (Sd = 0.32), pre and post-intervention, respectively.The program received a strong likelihood of recommendation from patients to their peers  and was rated as highly valuable, averaging 9 out of 10 (SD = 1.19), particularly if it were to be administered upon diagnosis. Patient interest in the program remained consistently high, with comparable levels observed from the pre-test  to the post-test .There is a paucity of research evaluating multifaceted health promotion lifestyle interventions for prostate cancer patients and survivors. This study aimed to evaluate patients’ feedback and perspectives on the overall PC-PEP and its components, through a content analysis of their semi-structured focus group interviews. Overall, patients had a positive experience participating in the 28-day PC-PEP program. These results provide context to the physical and mental health quality of life improvements previously reported and offer opportunities for program improvement as well as support in its integration into standard care for prostate cancer patients ,30.The first theme that emerged from the group semi-structured interviews, as well as the quantitative ratings, was an overall high perceived value of the PC-PEP program in meeting patients’ education and survivorship needs. Patients stated that the program filled a gap between the medical care they received in the hospital and their psychosocial survivorship needs that could be traced back to the time of diagnosis, which became more complex post-treatment due to treatment side effects. Indeed, research shows that prostate cancer patients report receiving inadequate information on strategies to address psychosocial needs cooccurring with oncological treatment, such as the need for social support, the adoption of healthier lifestyle habits related to sleep, physical fitness, eating, and stress around treatment and the possibility of cancer reoccurrence ,36,41,42Meaningful conclusions about the effect of the PC-PEP intervention, however, also require an understanding of its components and how they might have driven its effectiveness. Patients reported that they valued the multifaceted nature of the program and the “gestalt” it represented. This qualitative descriptive result was corroborated by patients’ quantitative mean ratings of their perceived value of the program, overall , post-intervention. Interestingly, the mean rating for the program in its entirety was higher than the mean ratings for each of the individual components of the program . This maPatients reported that the PC-PEP program gave them agency and motivation to take better care of themselves and return to a happier way of living. However, although the group lost weight, “weight loss” was not discussed or emphasized during the program, instead the leads emphasized through daily emails, the importance of staying fit to feel good, support good health, and a good quality of life. Research has demonstrated several benefits of exercise for weight loss in prostate cancer patients. Engaging in regular physical activity as part of a comprehensive program can lead to weight loss, improved body composition, and overall better health outcomes ,52. PatiPatients further reported that the “buddy” aspect of the program helped them “keep each other accountable” and “helping each other” stay on schedule, which facilitated forming new healthy habits. These results are corroborated by research showing positive habit formation and sustained maintenance of healthy habits can be facilitated through social support ,55,56. FWhile focus group interviews revealed that patients perceived the PC-PEP intervention to be of an appropriate length of time (28 day), they suggested it be expanded to 3 or 6 months to allow their newly developed healthy habits to solidify. Patients perceived the program to be demanding  yet they still supported the idea of extending the duration of the program to 3 or 6 months, to maintain newly formed healthy habits. Indeed, one highly cited study on the duration needed for new healthy habit formation shows that it takes between 18 to 254 days (median 66 days) to form and maintain new healthy habits long-term and ongoing engagement to help facilitate subsequent automatic adherence is necessary . Habit fFocus group interview results showed that the PC-PEP program was well received by all participants, with only a few patients perceiving some aspects of the program as challenging. The “boot camp” aspect of the program was perceived as challenging by some participants, but it was also perceived as highly successful and resulted in average weight loss for the group from pre- to post-intervention . PreviouParticipants found the prescribed strength, aerobic, and Kegel exercises beneficial for their overall perceived quality of life, in line with literature demonstrating exercise’s positive impact on prostate cancer survivors’ quality of life ,52,67,68Another factor that may have played a significant role in program adherence  and meriThis qualitative study is not without limitations. The utility of qualitative data is strongly linked to the effectiveness of the researcher’s interviewing techniques. Although every attempt was made to keep interviews standardized and semi-structured not all patients in the focus group answered every question posed during the focus groups, particularly if another patient articulated what they intended to say. This may have introduced systematic variations in the type and detail of information shared. Second, the study’s reliance on focus group data from a convenience sample of 30 men who voluntarily participated in the intervention introduces a potential bias, as these participants may be more inclined to view the intervention favorably. This limitation underscores the challenge of generalizing findings from this specific sample, particularly when considering the influence of contextual factors, such as masculine values, which must be considered when interpreting the results. Another study limitation is that the focus group interviews were conducted by the program’s leads. This might have led participants to a positive bias in their responses. We note, however, that the quantitative assessments (completed independently prior to the focus group interviews were completed remotely and independently by each participant) highly mirror the qualitative responses provided during the focus group interviews. Nonetheless, future studies should attempt to replicate the qualitative assessments for the PC-PEP with independent interviewers. Two follow-up studies by our team are underway attempting to qualitatively evaluate the effectiveness of Phase 3 RCT and Phase 4 multisite implementation trials, testing the effectiveness of a 6-month PC-PEP program with interviews performed by independent interviewers ,76.Given the voluntary nature of the study, not all patients’ viewpoints may have been represented. While our sample was sufficient to attain saturation, future work should attempt to gain a greater representation of diverse subpopulations of patients and survivors during their cancer journey.Despite these limitations, this study has many strengths. The concurrent use of quantitative ratings and focus group interviews allowed for a comprehensive assessment of participants’ perceptions regarding the program’s value and integration into standard care for prostate cancer patients. The congruence between the qualitative and quantitative findings enriched the evaluation from the patients’ viewpoint. While exercise, pelvic floor training, intimacy, connection, stress reduction, and social support all contribute to enhanced quality of life for prostate cancer patients and survivors, no other intervention has integrated these facets into a singular program, systematically educating and empowering patients, maintaining accountability through weekly compliance surveys, and being guided by qualified professionals. The PC-PEP program effectively aimed to address common unmet needs reported by patients during their prostate cancer journey, thereby enhancing their quality of life. Findings from both qualitative and quantitative assessments, both in this study and others, have demonstrated the feasibility, safety, and positive impact on mental and physical health ,30. A loWhile cutting-edge medical procedures and innovative therapies are essential in addressing prostate cancer, they often fall short of achieving optimal outcomes when used in isolation. Patient agency, education, and empowerment play pivotal roles in the survivorship journey, fostering enhanced self-efficacy, autonomy, and preparedness to manage treatment side effects, thus significantly contributing to the overall quality of life ,50,66,75Contemporary research increasingly focuses on developing comprehensive approaches to support men diagnosed with prostate cancer ,31,33,34This information is crucial for understanding how such interventions are received by patients and how they can effectively address unmet needs in survivorship care. Notably, patients’ recommendations regarding the integration of the program into standard care represent practical and actionable guidance. These insights can inform healthcare providers and policymakers when considering the incorporation of similar patient empowerment and education programs as routine components of care for prostate cancer survivors.The qualitative findings also shed light on the intricacies of survivorship needs, extending beyond medical treatment to encompass psychosocial, lifestyle, and emotional aspects. These facets are often inadequately addressed within standard clinical care, emphasizing the importance of holistic survivorship programs. Additionally, the study underscores the pivotal role of patient engagement and empowerment in improving outcomes, aligning with the broader healthcare trend toward patient-centered care. Finally, the study’s emphasis on involving patients from the outset of program development carries significant implications. It suggests that such patient-centered approaches can lead to more effective, tailored, and patient-focused interventions. This insight has the potential to guide future research and program development endeavors.In summary, the findings presented here underscore the value of collaborative efforts between physicians and scientists in implementing patient education and empowerment initiatives, particularly during the challenging phases of the cancer journey. Establishing patients as active partners in their care remains of paramount importance. Clinicians should be encouraged to cultivate robust skills in patient activation, education, and empowerment, alongside strategies for shared decision-making, thereby fostering meaningful patient engagement.


Although cyberbullying and cybervictimization prevention programs have proved effective in the short term, their effectiveness remains unclear in the long run. Thus, the present study evaluated the long-term effects of the Tabby Improved Prevention and Intervention Program (TIPIP). Participants were 475 middle and high school students , of whom, 167 were in the Experimental Group , and 308 were in the Control Group . Students completed measures assessing cyberbullying and cybervictimization at three time points: baseline (T1), immediately after the intervention , and at 1 year (T3). The results showed no significant effects of the TIPIP in reducing both cyberbullying and cybervictimization over time. Overall, our results confirm the lack of effectiveness of long-term preventive programs and emphasize that different curricula should be implemented in future programs to prevent and manage cyberbullying and cybervictimization, also taking into account psychological mechanisms and processes involved in such behaviors. The increasing spread of digital devices and the Internet, especially among youth, has developed new social relationships and behaviors . HoweverOver the past decades, research has examined the prevalence and consequences of cyberbullying to unravel the complexity of the phenomenon.Given the heterogeneity and the relative lack of consistency in the definition and methodological differences in existing epidemiological studies , prevalence rates are highly inconsistent ,6,7,8.For example, examining 159 prevalence studies, Brochado et al. [Despite the high heterogeneity in prevalence estimates, cyberbullying could still be on the rise, especially following the COVID-19 pandemic, perhaps due to students’ increased technology use , which aA recent systematic review found a strong negative association between cyberbullying and mental health outcomes in youth, suggesting the pervasive impact of digital harassment on individual well-being . Meta-anConsidering the social alarm due to the increasing spread of cyberbullying over time, numerous cyberbullying prevention and intervention programs have been implemented, evaluating their efficacy. While some pre-existing school bullying or school violence programs have been extended to include modules on cyberbullying, other programs have been developed to target cyberbullying and cybervictimization .Comparisons across cyberbullying intervention and prevention programs’ features, activities, duration, and targets are often complex.In this regard, in recent meta-analytic research, Lan et al.  categoriPolanin et al. , alongsiHowever, the extant research agrees on the absence of a long-term evaluation of anti-cyberbullying programs, underlining that evidence concerning their efficacy in reducing cyberbullying behaviors over time remains scarce ,26,30,31To the best of our knowledge, only five studies have evaluated the long-term effectiveness of anti-bullying programs see : the CybThe Learning Together Program  is desigIn Spain, the PREDEMA  socio-emThe Visc Social Competence Program  is a oneIn Australia, the Cyber Friendly School (CFS) program  involvedLastly, the third edition of the Italian prevention program NoTrap!  providedAlthough changes between pre-test and post-test assessments  have been extensively studied, only a few empirical studies have evaluated the ongoing impact of such programs with long-term follow-up assessments ,30,33,37Although extant literature provides evidence of the effectiveness of cyberbullying prevention programs in the short term, their long-term sustainability remains unclear. There is a dearth of empirical research, including follow-up over the long run for these programs. Therefore, to address such a gap in the existing literature, the present study examines the long-term effects of the Tabby Improved Prevention and Intervention Program (TIPIP)  on cyberTIPIP is a theoretically based multi-component program. Combining Bronfenbrenner’s Ecological System Theory  and the www.tabby.eu (accessed on 10 February 2023)); and (4) in-class activities with students.Four main components constitute the TIPIP program: (1) training activities with teachers; (2) school conferences with parents; (3) online materials for students, teachers, and parents  delivered once a week plus an additional day on the possible civil, criminal, and administrative, legal implications of cyberbullying and the age of responsibility.School conferences with parents aim to: (i) inform parents about the prevention and intervention program activities and aims; (ii) sensitize and inform them about the cyberbullying problem and how to protect their children by setting clear rules about internet use and how to monitor their online activities best.The third component of the program is the Tabby “toolkit” . The tooIn-class activities with students consist of four sessions (2 h each) for each of the experimental classes. (i) First, group work is used to negotiate a shared definition of jokes, cyberbullying, and aggression. (ii) Next, students watch the Tabby toolkit videos. The videos were used as a stimulus to start a guided discussion regarding students’ experiences in cyberspace. (iii) Afterwards, group work was used to prepare at least ten rules or tips on avoiding risky online behaviors and involvement in cyberbullying and/or cybervictimization. (iv) Lastly, the fourth session focused on facing the legal consequences of cyberbullying. During this last session, a young boy who had been a cyberbully in the past met all experimental classes to share his story and explain his point of view, answer questions and discuss what made him realize the damage caused by his actions and what he is doing to address it to change. Further details on the program are available at .TIPIP effectively reduced cyberbullying and cybervictimization immediately after the intervention implementation . HoweverParticipants were middle and high school students recruited from a convenient sample of 5 schools in the Campania region, South of Italy. Of the 49 classes involved, 20 (40.8%) were randomly allocated to the Experimental Group , while 29 (59.2%) were in the Control Group . None of the schools agreed to participate as a pure control school. Hence, classes were randomly assigned either to EC or to CG by the first author, in order to avoid possible teacher selection bias or class bias. Possible contaminations effects were controlled using intraclass correlation coefficients ; moreover, the first author coordinated and delivered all the activities that involved participants in the EG.ageM = 12.20, SD = 1.46). At T2, the sample consisted of 622 . At T3, the sample consisted of 475 students .Data were collected from December 2015 to December 2016 at 3-time points: at baseline (T1), immediately after the delivery of the intervention , and after 1 year from the baseline measure (T3). At Tl, the sample consisted of 759 students (M = 47.9%) aged between 10 and 17 years  [A unique code was created by each student and matched throughout the study’s stages .).All study procedures were conducted by the guidelines of the Declaration of Helsinki and its later amendments . In addiThe TABBY Improved checklist ,43 is a The checklist consists of 12 scales for a total of 130 items. Although participants completed the entire measure, for the present study, we used only two scales: involvement in cyberbullying and cybervictimization . According to the taxonomy proposed by Willard , particiIn the present study, Cronbach’s alpha ranged between 0.64 and 0.84 for cyberbullying and 0.72 and 0.77 for cybervictimization throughout the three-time points.All statistical analyses were conducted using the IBM Statistical Package for the Social Sciences (version 26) .F = 2.300, p = ns; cybervictimization: F = 0.11, p = ns) between retained participants and those who dropped out. Students’ dropout was mainly due to absence on data collection days and mistakes in personal ID creation. Therefore, the dataset was not likely to be biased due to attrition, suggesting that the main effects should be considered stables.Firstly, we conducted attrition analyses to examine potential bias between participants who had completed measures across all time points and participants who dropped out at times 2 and/or 3. Results indicated no statistically significant differences in the study’s variables , we examined the intraclass correlation coefficients (ICCs) to measure the strength of the association among EG and CG groups repeatedly measured at baseline and follow-up stages. The ICCs were generally small—under the 0.05 value proposed for clustering design —and the To evaluate the within-group changes in cyberbullying and cybervictimization over time (long-term program effectiveness) we used two 2 × 3 mixed ANCOVAs for longitudinal analysis, with group as the between-subjects factor (EG vs CG) and time as the within-subjects factor (pre- and 2 post-tests). Participants’ gender was introduced as covariate.p-value < 0.05 was considered statistically significant for all analyses.A ageM = 13.15; SD = 1.52; M = 51.5%) and 308 were in the CG .The sample consisted of 475 students, of whom 167 were in the EG  spend between 2 and 4 h online, and 16.4% indicated that their parents had never given them clear rules about Internet use. Similarly, 24.4% have parents who do not monitor their online activities  = 0.56, p > 0.05) and cybervictimization (F(15) = 1.67, p > 0.05) at the baseline.However, no differences emerged between the EG and CG groups regarding cyberbullying  = 0.063, p = 0.803, η2 = 0.000), a non-significant time*gender interaction  = 0.381, p = 0.683, η2 = 0.002) and a non-significant group*time interaction  = 0.337, p = 0.683, η2 = 0.002). A similar pattern of results was found for cybervictimization, mixed ANCOVA’s results indicated a non-significant group effect  = 0.558, p = 0.455, η2 = 0.001), a non-significant group*time interaction  = 0.821, p = 0.441, η2 = 0.004) and a non-significant time*gender interaction  = 0.082, p = 0.921, η2 = 0.000). However, looking at average scores  and assessing and managing risk factors associated with the involvement in cyberbullying and cybervictimization.There were also several limitations that must be acknowledged. Firstly, the study relies exclusively on self-report measures, which may be biased by common method variance . Future Lastly, the reliability value for cyberbullying was relatively low (around 0.60) and required caution. However, the value is deemed acceptable given the short-scale dimension . DespiteConsidering that according to a meta-analytic review, few anti-cyberbullying programs have been assessed for their efficacy over time, the present study aimed to evaluate the long-term effectiveness of the TIPIP, assessing its sustainability in reducing cyberbullying and cybervictimization after one year from the baseline. Evaluating such programs’ long-term effects and sustainability in preventing and reducing cyberbullying and cybervictimization could be a turning point for developing effective primary and secondary prevention programs.In fact, despite our results underlying the TIPIP inefficacy in the long-term assessment, such studies contributed to increasing our knowledge about what works in preventing and reducing cyberbullying and cybervictimization.From this perspective, future anti-cyberbullying programs should be developed or integrated to include modules and activities proven effective in the long run in contrasting adolescents’ involvement in cyberbullying and cybervictimization, thus making possible cross-cultural comparisons possible and the development and the implementation of transnational effective strategies and policies.


A diverse workforce trained in dissemination & implementation (D&I) science is critical for improving cancer outcomes and reducing cancer-related health disparities. This study aims to describe and evaluate impact of the Cancer Prevention and Control Research Network (CPCRN) Scholars Program in preparing scholars for collaborative careers in cancer control and implementation research and practice, and offers evaluation-driven recommendations for program improvements.The CPCRN Scholars Workgroup conducted a sequential, mixed methods evaluation. We collected baseline and follow-up surveys and invited all 20 scholars and ten mentors to participate in an exit interview. We assessed the experience with the Scholar’s program, ratings of D&I competences, progress on their project, feedback about the curriculum, and understanding of implementation science.Over 86% partially or fully completed their project within 9 months; 78% of scholars engaged with a CPCRN workgroup. Scholars rated the following program components as valuable: the Putting Public Health Evidence in Action (PPHEIA) training (88.9%), D&I training modules (83.3%), and webinars (kickoff webinar-88.9% and selecting theories/models-88.9%). There was an increase in D&I competencies from baseline to posttest, with the greatest in community engagement topics. About 78% reported that they were satisfied with format of the activities and increased confidence in ability to discuss D&I concepts. From the qualitative interviews, the benefit of the program was becoming more knowledgeable about D&I research and networking.The inaugural year of the program yielded positive results, particularly related to increasing knowledge about D&I science and cancer control. This program builds the capacity of students, researchers and practitioners in D&I science.The online version contains supplementary material available at 10.1007/s10552-023-01702-1. Training of students, public health professionals, and researchers is an important strategy to expand this workforce. Over the past two decades, there have been numerous efforts to increase training opportunities in D&I science through workshops, institutes, and degree-seeking programs. The National Institutes of Health’s Training in Dissemination and Implementation Research in Health (TIDIRH) began as a 5-day institute including a balance of structured content topic areas, interactive small-group discussions, and personalized sessions on individual trainee projects . We then invited all Scholars and ten of their mentors to participate in 30-min interviews from September to November 2021. Four interviewers completed the interview after verbal consent was given.The survey included demographic questions and information about their affiliation either their current educational program or organization, in addition to assessing the baseline metrics of D&I competencies. The exit survey asked about overall program evaluation, and attitudes about the program. Scholars were asked to assess their D&I science competencies on a scale of 1-beginner to 3-advanced, as they did at baseline . The 48 n = 10) to facilitate rapid data collection once the program was complete. The Scholars Program leadership team compiled a list of 15 actively engaged Scholar program mentors whom represented diverse D&I science and geographic regions to participate in the interview. Mentors with availability were interviewed. The exact number of mentors engaged with scholars across the program is unknown due to scholars changing mentors throughout the program and the practice of garnering informal mentorship through workgroup projects. The interview guide included 14 items that covered their overall program experience, reasons for joining the program, description of their project and working with their mentor(s), opinions of the training and webinars, and how the program enhanced their cancer control research, and/or understanding of D&I science. Finally, the guide asked about benefits of the program, suggestions for improvements, and how the program helped them with their career goals. The interview guide for the mentors was composed of 19 questions that covered three domains: mentor experience, Scholar’s project, and the program in general.An evaluation subgroup of the Scholar’s Workgroup designed the semi-structured guide. A program director administered the survey and sent reminders. The sample included all of the scholars and pre-selected mentors  completed the baseline survey and 17 completed the exit survey. For the interviews, 18 scholars (90% response rate) and 10 mentors  completed the interviews. For the inaugural year, 50% of trainees were students, 45% researchers, and 5% practitioner scholars , describing relationships between organizational dimensions and D&I research (d = 0.54), identifying a process for adapting an evidence-based intervention (d = 0.53), and using evidence to evaluate and adapt D&I strategies for specific populations, context, etc. (d = 0.48) Although there was not a significant increase in the total D&I competency score (M = 4.39 vs M = 4.56), the scholars reported significant increases from baseline to post-program on all of the subdomains (data not shown). The subdomains that reported the largest increases from the baseline survey were practice-based considerations and D&I design and analyses.st Table . Some ofEngagement Related to the curriculum, 94.4% reported attending the PPHEIA webinars and 77.8% reported completing the NCI Dissemination and Implementation modules . One scholar stated, “So it's introduction to implementation science, theory, methods, and frameworks, implementation strategies. So these are also very useful. But it's always more interesting at the—at least for me it's very interesting to hear from people actually doing projects on the ground because it helps you.” Some scholars (n = 4) noted that the program’s variety of teaching methods and mediums such as using websites, PowerPoints, modules, and a variety of other tools, were very beneficial aspects of the program. Some participants (n = 3) found that the curriculum helped with their work outside of the program as a teaching assistant, or through a class assignment, dissertation, or another project.Scholars reported a variety of benefits of the program. Scholars reported that learning implementation strategies, frameworks, and methods was useful (n = 4) shared that due to the CPCRN program they have more knowledge about D&I research: “I think one of the things that I got the most out of it was just the educational experience, getting a better grasp and understanding of D&I research and supporting building a foundation to it. That’s probably what I got the most out of it, was just through the webinars and, in the readings, became much more, I guess, knowledgeable about D&I research. That’s probably what I benefitted or enjoyed the most out of it.” Participants shared how the program was beneficial for their careers (n = 4), for their own research (n = 2), and for building their network (n = 2). Regarding how the program benefited one’s career, one scholar shared: “I think it was a nice addition to what my work has been as a project director. I feel like there was a fair amount of overlap, and it allowed me to really be integrated into the network, and it also allowed me to have a better understanding with D&I science and its scope and its range since that's not my area of study currently…”.Scholars were asked to share their experiences in the CPCRN Scholars program. Several scholars (n = 3). For example, one scholar described how she was able to collaborate with another scholar from a different institution on a K award  to provide support to junior faculty on their research) due to shared research interests and both their expertise complemented each other. A few scholars described workgroups as inviting and reported workgroups had an inclusive, positive culture (n = 2). Some workgroups met more frequently than others. Scholars involved with workgroups who met frequently found that helpful. For example, one scholar stated: “There is a biweekly meeting that we had with a smaller health equity group just to keep the project going. So that was very helpful.” In workgroups, scholars were able to get feedback from collaborators outside of their institution (n = 2) and they gained an understanding of the structure and inner workings of the workgroup and its projects (n = 2). One scholar stated: “And people would seek broader opinion from the group, and that is how I had an experience getting feedback from the other collaborators who are not associated with the institution. So this is again a great learning experience, especially at a student level. So it is my first time working with so many collaborators from different universities.” One major disadvantage that participants (n = 5) noted was not joining a workgroup during their time in the program, and other challenges to workgroup engagement included having trouble joining a workgroup (n = 1), workgroups conflicting with their class schedule (n = 1), and workgroups having infrequent meetings (n = 1). For example, one scholar stated: “I tried the organizational readiness one. But I think only one of the meetings actually happened. The rest of them were canceled. And the one that happened I was in an all-day board meeting. So I couldn’t attend.”We assessed the scholars’ perspectives on the workgroup opportunities in the program and their involvement in workgroups. Scholars reported a positive aspect of the workgroups was the opportunity the workgroup provided to meet others, network with people, and collaborate with other scholars on projects (n = 3). One participant stated: “I have made connections with a couple of faculties to get into my PhD research work. So yes, I have made connections, and it was very helpful networking with people through my participation as a scholar in this program.” Select scholars (n = 3) mentioned that the program helped them expand connections through access to the established CPCRN network or professionals. Other ways the CPCRN program impacted the scholars’ networks included facilitating connections with different academic centers (n = 2), the ability to make connections through the workgroups (n = 2), and getting to know people outside of the scholar’s home institution (n = 2). Table Other valuable program components were mentioned. One positive effect of the program on the scholars' networks was that it provided access to future collaborators on papers and post-doctoral positions  shared that there was little to no interaction with other scholars. One participant specifically shared, “I had a chance to interact with them {fellow CPCRN Scholars}, but not much. Just it would have been an introductory interaction kind of thing. But I was not able to continue interacting with them.” Similarly, mentors wanted more information about the program and expectations to help them with their roles.This mixed methods evaluation also asked about recommendations for program improvements. Open-ended questions on the survey and an interview item were included to allow respondents to suggest programmatic changes. Recommended areas for improvements from scholars included greater opportunities for networking and mentoring, more communications around program expectations, and extending the length of the program or project completion timeline. For example, many students . This participation resulted in submission of abstracts and manuscript writing with a cohort of researchers and practitioners. Scholars who engaged in workgroups that met frequently reported a higher positive experience compared to scholars who were involved with workgroups who met on rare occasions or could not attend the meeting due to other commitments. Additional, scholars improved in their competency around contemporary D&I issues of health equity and community engagement ; researchers and practitioners have promoted these critical concepts and skills in practice –20. FutuThe Scholars program fulfills the CPCRN goals to build the D&I workforce. Research has demonstrated the need for more D&I training and building capacity of various professionals across career stages , 22. ThiThe evaluation results from the inaugural year of implementation identified several areas for continuous process improvements. Scholars reported a desire for the program to be longer, with more interactions with each other. The flexibility of the program’s structure was greatly appreciated by all, however, explicitly communication about program roles and expectations was requested. For example, some of the tracks had extra meetings for check-in with the scholars while others did not. Expectations for mentor–mentee interactions could be clarified, as those frequently engaging found this valuable. Similarly, engagement in WG was reported to be important to program satisfaction. Importantly, the inaugural training program was launched during the international pandemic of COVID-19, thus limiting opportunities for face to face interactions which may have furthered engagement and possibly improved communications, but did allow for digital and later accessible webinars.The inaugural year, during the height of the pandemic, served as a soft launch of the program. It was encouraging to see the number of represented institutions grew by seven, including one that is international, Swiss Tropical and Public Health Institute) in its second year (2021–2022 Scholars Cohort). The 2022–2023 Scholars applicant pool indicates continued strong growth with a 135% increase of applications from the second year and the 2022–2023 cohort consists of 21 schools and organizations globally. Programmatically, we had fewer practitioners who applied during the inaugural year of the program than in the second year of the program. Recruitment channels were expanded with partnering agencies and funders to increase awareness of the program among this group. The Scholars Workgroup made program modifications based on the evaluation results in extending the program by a few months (9 to 11), providing more information about the program and its components in advance of enrollment, establishing more frequent communications overall, providing additional information for mentors about the program and mentor expectations, and adding virtual Scholars mixers to the programming. The mixers were added for scholars to voluntarily share a few PowerPoint slides about their project aims and methods, gain input from other scholars and mentors and refine outputs and next steps. These additions were to enhance peer exchange and collaboration which have been identified as capacity-building mechanisms .Strengths of this program evaluation study included use of mixed methods to assess opinions of the program and in-depth feedback about its components qualitatively. The data collection covered a breadth of topical domains for the evaluation from ratings of program components, D&I competencies, mentoring, and career developments. We included the mentors as part of the evaluation. However, the evaluation results may not be generalizable to other D&I trainees of students, researchers, or professionals as our training program has unique features. All data were based on self-report and information on progress on projects were not validated with the mentors. We interviewed a lead mentor for only half of the Scholars due to time and funding constraints. Future evaluations could include perspectives of all mentors.The inaugural CPCRN Scholar program year yielded positive results, particularly related engaging with about the CPCRN and increasing knowledge about D&I science and cancer control among its student, researcher, and practitioner scholars. There were many reported benefits, largely centered on new professional relationships, connections and networking, and some suggestions for improvements. This training program can build the capacity of current and future researchers and practitioners in D&I science. Future research could explore the long-term impact of the CPCRN D&I scholar training and networking on career trajectories in cancer prevention and control as well as cancer health disparities research.Supplementary file1 (DOCX 43 KB)Below is the link to the electronic supplementary material.


The prevalence of non-communicable diseases, such as diabetes and cardiovascular disease, is rising in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the widely used Diabetes Prevention Program (DPP) are effective at reducing chronic disease risk, but have not been adapted for LMICs. Leveraging mobile health  technology such as text messaging (SMS) to enhance reach and participant engagement with these interventions has great promise, yet we lack evidence-informed approaches to guide the integration of SMS specifically to support HBC interventions in LMIC contexts. To address this gap, we integrated guidance from the mHealth literature with expertise and first-hand experience to establish specific development steps for building and implementing SMS systems to support HBC programming in LMICs. Specifically, we provide real-world examples of each development step by describing our experience in designing and delivering an SMS system to support a culturally-adapted DPP designed for delivery in South Africa. We outline eight key SMS development steps, including: 1) determining if SMS is appropriate; 2) developing system architecture and programming; 3) developing theory-based messages; 4) developing SMS technology; 5) addressing international SMS delivery; 6) testing; 7) system training and technical support; and 8) cost considerations. We discuss lessons learned and extractable principles that may be of use to other mHealth and HBC researchers working in similar LMIC contexts.Trial registration Clinicaltrials.gov, NCT03342274. Registered 10 November 2017. The global burden of disease has shifted in recent decades from infectious diseases toward non-communicable, “lifestyle” diseases, particularly in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the Diabetes Prevention Program (DPP) have shown evidence in high income countries for reducing diabetes and cardiovascular disease risk –3. TheseFor these same programs to be similarly effective in LMICs they need to be adapted for resource-poor communities where many residents are low-income, have lower levels of education, have low health literacy, have limited access to transportation, and there exists limited capacity of health professionals to effectively deliver programs. LMICs also possess potential facilitators of HBC programs. For example, mobile phone use is widespread in LMICs , 5 and cmHealth broadly entails the integration of portable and wireless technology  to enhance delivery of health interventions . The mulThere are limited evidence-informed guidelines in the literature for implementing mHealth in LMICs. A few “universal” toolkits and frameworks do exist, yet by design they are general in their direction and applicability across various mobile technologies and intervention applications. For example, the “mHealth Assessment and Planning for Scale Toolkit”  focusesLifestyle Africa”, Catley et al. 2020) [Our group recently completed a study in which we adapted the DPP for a low-resource community in South Africa (SA) utilizing community health workers (CHWs) together with a supplementary SMS system to support, extend, and enhance intervention delivery . The stul. 2020)  as well l. 2020) .Lifestyle Africa intervention, and to inform similar efforts. To do so, we draw upon our specific experiences in developing Lifestyle Africa, our broader expertise in mHealth design and implementation, and integrate these perspectives with broad guidelines in the field . Accordingly, we identify eight development steps specific to SMS that we posit were crucial to successful development and implementation of the custom system in our South African study and that we believe forms a framework to develop other SMS-based mHealth intervention supports in other LMIC contexts. The development steps include: 1) determining if SMS is the appropriate mHealth approach; 2) developing the SMS system’s architecture and programming framework; 3) developing theory-based SMS message content; 4) developing SMS technology; 5) addressing specific requirements of international SMS delivery; 6) establishing testing procedures of the technology; 7) developing system training and technical support guidelines for staff managing the SMS system; and 8) ongoing monitoring and assessment of the cost of sustaining the SMS system for the duration of the study.The primary aim of this report is to discuss the process that we used to design and implement an SMS system to support the seventeen in-person sessions of the Lifestyle Africa SMS system. We also address some of the challenges of working internationally to deliver the program, as mHealth interventions lend themselves to delivery across the world and do not necessarily require systems to be housed in the country or region in which they are delivered.Below we describe the steps and illustrate our real-world experience implementing them to design the Researchers first must decide which type of mHealth approach  is most feasible for their intervention. One major factor affecting this decision is cellular connectivity in LMICs. “Second-generation”  cellular connectivity has existed since the early 1990s and supports basic functions such as voice calls and SMS. “Third generation”  cellular connectivity emerged in the 2000s and added internet connectivity to mobile devices, allowing for streaming of multimedia content and mobile applications . 3G celAlthough SMS systems have fewer capabilities  than other mHealth approaches, SMS can nevertheless provide intervention support in key areas. For example, messaging can be designed to help participants retain curricular content and knowledge between intervention sessions. It can also provide motivation and enhance self-efficacy for HBC , 17. TheAn initial survey of potential study participants revealed that smartphone ownership was rare in our target population in South Africa, so 2G connectivity was judged to be the appropriate platform for reaching most of the participants. SMS, therefore, represented the best implementational option to achieve project goals. This was also consistent with evidence from the local context where studies have documented the potential of SMS for expanding health care access, facilitating health-promoting behaviors, and increasing participant adherence in community-based programs in SA , 19.System architecture and programming frameworks are helpful for SMS implementation planning as they can guide researchers in determining different parameters for the way messages should be sent to participants. A message architecture specifies aspects such as the message types , timing and scheduling of message delivery, the volume of messages, personalization and any other advanced programming or logic considerations. These frameworks should be broadly robust  and not produce additional barriers to access ,The first SMS system decision researchers should make is whether it should function as a two-way or one-way messaging program. In two-way systems, participants not only receive program messaging to their mobile devices, but they are supported to text back questions and receive individual attention and responses from program staff assigned to monitor the system  or advanced chatbots . One-way SMS systems only support communications to be sent to participants; participants may text into the program, but in a one-way system, inbound communications are not monitored in real time  and participants would generally receive no replies to their text messages. Deciding upon implementing a two-way vs. one-way system involves discussion around both pragmatism  and need .Attrition and retention are key indicators of the system’s implementational success, and conceptualization and measurement of these outcomes may differ depending on system architecture – specifically, whether a one-way or two-way system is built. For both types of systems, if a “STOP” command is built in , tracking the number of participants who opt out is one metric for attrition. Regarding retention, most SMS systems will allow researchers to identify if participants are successfully receiving SMS messages to their phones. For one-way systems, retention can be measured over time by tracking how many messages are successfully delivered between and within individual participants. For two-way systems that generally elicit dialogue between a coach and participant or require the participant to reply to particular messages, participant responses can be tracked as a measure of retention. Overall, to mitigate attrition and support retention with the SMS system, a research team member  should be tasked with reaching out to participants who are either not receiving their SMS messages or not responding as requested. In some cases technical assistance may be necessary  to be culturally appropriate to their needs and preferences. One way to ensure system architecture matches the target population’s preferences is to seek the help of a community advisory board (CAB) made up of multiple stakeholders from the target community  who can assist researchers by making system programming recommendations regarding timing and frequency that would be acceptable to target participants . FeedbacResearchers should also consider specific requirements of the intervention program that the SMS system is designed to support in terms of “types” of messages and timing. For example, is it sufficient to send messages from a single bank of messages  on a consistent schedule over time ? Alternatively, some intervention programs may require different types of messages to be sent at different times and at different frequencies . Based on these kinds of considerations, the types of messages and the schedule may be quite simple or very complex to design. Researchers should also consider the possibility of potential schedule disruptions and how any time-based message system will adapt to those scenarios.In many LMIC contexts, program participants may be close friends, neighbors, or family members living within the same household or community—and participants may share their individual text messages with others. This prompts another level of consideration of the system’s architecture – the degree of personalization integrated into SMS logic and content . With close cross-participant interaction in mind, messages may be more impactful if some elements of personalization are adopted, which may enhance participants’ internalized feelings of program “fit”, commitment, and engagement . For SMSResearchers may choose to adopt an SMS framework that incorporates an individualized “tailoring” process. This strategy from behavioral science is intended to enhance motivation and engagement with intervention content by making participants feel individually supported in achieving program goals and having a program that is “personalized” for them . Text meLifestyle Africa program staff were already significantly burdened with program responsibilities and there were no resources to hire additional staff to monitor and respond to participant text messages so a two-way SMS system was deemed not feasible and likely an impediment to program scalability. Had it been possible to engage additional staff on SMS system implementation and management, we would have considered designing the system to be two-way. In this scenario, staff members would have served as “SMS coaches”, answering program questions in real-time via SMS and providing tailored behavioral supports to participants as they went about their daily routines practicing the skills they learned in the last in-person Lifestyle Africa session.After careful consideration of resources available to support the SMS system, the research team decided that it was more pragmatic to design the system architecture and programming framework as being a one-way SMS delivery system. Lifestyle Africa curriculum was engaged in the SMS planning and development process. This advisory board was made up of multiple stakeholders including local residents living with diabetes, local residents with expertise in diabetes, and other community leaders . The CAB indicated that most participants had employment, family, or healthcare obligations between late morning and late afternoon. The CAB also noted that three or more messages a day would likely feel like an “overreach” and become an annoyance to community members. The team used this feedback to create a two-message per day programming scheme, with the first text being sent early morning  before participants generally left their homes for the day and again in the early evening  after participants had likely finished supper and were home for the night.The same CAB that was providing guidance on the seventeen-session fixed messages”. Fixed messages were sent five days, three days, and one day before session 1 to excite participants and encourage them to come to the first Lifestyle Africa in-person session. Fixed messages were also sent the evening before each of the following seventeen weekly intervention sessions reminding participants about coming to the in-person program and which specific materials to bring. The intent was that fixed messages would not only facilitate attendance and preparation, but also support staff by reducing the need to personally communicate with each participant individually each week. Although personal calls from a staff member may be more effective than a text message for encouraging program attendance, the incremental gain of a phone call over a simple pre-programmed SMS was not sufficient to warrant the labor required.Type 1 consisted of “session-specific messages” sent twice a day at a random time to each participant between 9 am and 11am, and then again at a random time between 5 pm and 7 pm. Session-specific messages were sent on the six days between weekly scheduled intervention sessions. These messages were intended to enhance and extend programming by continuing to reinforce the concepts learned the last time participants met in-person, and supporting participants in enacting skills in their daily lives that were assigned as “homework” or skill practice. For example, after a participant attended Session 2 on a Tuesday, they received session-specific messages for Session 2’s curriculum from Wednesday through the next Tuesday’s session (Session 3); thereafter, the SMS programming logic delivered session-specific messages between sessions for the entire program. All participants received the same session-specific messages throughout the week, except each participant received their SMS in a random order to emulate an individualized tailoring process (in the event they shared their messages with close others in the program).Type 2 consisted of “delayed holding pattern” messages that could be sent in the event a class was cancelled until programming resumed. For example, in our SA community, businesses shut down for multiple weeks in December and January in observation of holidays. In addition, during the trial there were also multiple bouts of inclement weather that required rescheduling of weekly sessions. We addressed this by including a “pause” function in our SMS system that postponed sending of session-specific messages until the missed in-person session was able to be held. Continuing contact with program participants during “paused” or “off” time from the program was important in order to maintain interest and engagement over long periods without in-person meetings. To this end, a set of generic “delayed holding pattern” messages  were sent as general support  during weeks where programming was postponed or paused and no new session-specific content was being introduced. Upon resuming normal programming, these delayed holding pattern messages ceased, and the system returned to its normal schedule and scheme for sending session-specific message flows.Type 3 consisted of generic “See Fig. A crucial step in developing the SMS system is developing a library of SMS messages with a sufficient number of messages to match program needs. A helpful starting point may be reviewing the program’s core components and contents  to identify targeted content areas across the various functional message types. Principles of thematic analysis  can be uMessages should also be developed based on empirically supported principles of health behavior change. There are over fifty theoretical frameworks in health communication and behavioral science to choose from  . The entire message library should be reviewed by the research team to ensure the messages accurately match core program content and reinforce strategies from behavioral science for supporting HBC. In addition, steps  may be taken to ensure that messages are reviewed to ensure they adhere to social and cultural norms of participants.Depending on the situation it may also be necessary to develop messages in one language  that then need to be translated to another language . We strongly recommend that any such message translation should be conducted by bilingual, bicultural research team members or hired professionals, and translation should be cross-checked using an inter-rater method, such that all messages are iteratively reviewed twice by two different native-speaking translators.Lifestyle Africa CAB, as well as with bi-lingual SA research staff. A complete Lifestyle Africa message library of 336 messages across the three different predetermined types was developed in English, and these messages were carefully stratified by Lifestyle Africa curricular content recommendation . The Lifestyle Africa research team members had extensive training and previous intervention development successes working with the Theory of Planned Behavior . Table The research team completed multiple iterations of message drafting, development, and translation with the SA ior (TPB ) and theior (TPB ) to deveior . Discussions and negotiations with multiple companies can lead to identification of the right technology developer. Conducting a series of early meetings with the selected developer, during which the research team shares their SMS system architecture and programming framework and drafts of messages  will help to determine the scope of the project and pricing. This is particularly important for determining the project timeline and ensuring the SMS system is programmed, tested, and fully functioning by the time the intervention study is scheduled to begin. Researchers can negotiate pricing for SMS development and implementation services and should finally agree upon a price that fits their budget.The technology developer then builds the web-based SMS management system. Ongoing  meetings with the research team help to ensure open communication with the developers as they prototype multiple versions of the SMS management system, which are typically accessed via a website portal. A web-based system is likely preferred (as opposed to a system using native computer applications) so that members of the research team in different geographic locations can manage and monitor SMS activity from any device with a web browser and internet.The developer will also assist the research team in deciding if their SMS communications should be sent from a “short” 5-digit code, or a “long” 10-digit code that appears more like a traditional phone number. For participants to be able to identify SMS communications from the program, a dedicated code or number must be secured. This allows program participants to always receive messages from the program from the same number, and allows them to easily find previous messages on their mobile phones.The research team met with and vetted multiple US and SA technology companies to describe the project’s SMS development and programming needs and obtain quotes. The research team eventually decided to contract with a US-based company that had prior experience and vested interest in academic research and HBC via SMS. Specifically, the company had advertised on their website a previous partnership with US academic researchers to implement an HBC text messaging program in a foreign country. During initial meetings with the company, the CEO provided an in-depth overview of how their team approached international SMS campaigns with academic partners in the past and provided some initial “ballpark” thoughts on pricing for the project. Given this company’s well-aligned experience and their proposal of a price within the project’s budget, the research team quickly decided to hire and execute a contract.Lifestyle Africa research staff provided the company with all the relevant information needed to design the SMS system. A draft of the SMS library was sent to the company, as well as an outline of the system architecture and programming framework. Between these meetings and these materials, the technology company was able to successfully develop the system to meet the project’s needs in approximately five months.Early in the timeline of the overall project, multiple months of weekly planning meetings between the company’s project managers, engineers, and The developer designed a web-based system that allowed for enrollment of program participants and their personal mobile phone numbers into the SMS program. Because there were multiple program locations with associated cohorts moving through the program at somewhat different points in time, the systems allowed for tracking of each location’s progress throughout the program; this ensured the appropriate session-specific and reminder messages were delivered to the relevant participants in sync with their location’s progress through the curriculum.Lifestyle Africa participants received SMS. The technology company helped the research team develop language for participants around recognizing the program’s short code and unblocking any receipt issues.The technology company also walked the research team through the pros and cons of using a 5-digit “short code” versus a 10-digit phone number. For example, some participants’ mobile devices may block 5-digit short code messages, misidentifying them for spam messages. On the other hand, participants may mistake messages from 10-digit numbers as coming from a person with the wrong phone number instead of the program. The CAB was consulted and indicated that most local participants would be more familiar with short codes, so researchers decided to select a 5-digit short code as the sender number from which If the technology developer is based outside of the country in which the program is being delivered, it is likely the servers and technology that host the web-based SMS system are also located in the country in which the platform is developed. Establishing a “gateway” avoids considerable costs to the program and possibly to the recipient of sending international text messages. A gateway company with international access to the LMIC’s cellular networks is therefore most times necessary to facilitate sending messages from the originating country to mobile phones overseas to help control costs and ensure direct contact with international participants. The SMS system’s domestic platform and the gateway company must have compatible “application programming interfaces”  to establish a successful connection. It is worth noting that some particular countries require the SMS platform to be housed within the country (or region) to which the messages are being delivered to protect participants’ data and ensure privacy . To work around such requirements, system integrations can still be accomplished by deploying the solution in cloud computing systems that can be housed and maintained in authorized regions based on local privacy legislation.The SMS technology developer spearheads identification, vetting, and recommendations to the research team on cost-effective and reliable international gateway providers in the LMIC of interest (note that we discuss more details about the costs in the “Costs” section below). Once a gateway collaboration is established and company hired, the technology developer then works with the gateway to establish the SMS system’s code for participant communications . The gatLifestyle Africa participants’ mobile phones). See Fig. The US-based technology developer explored multiple international SMS gateway companies in SA, their individual pricing structures, and other factors such as security standards. A recommendation was made to partner with a company that was affordable, had a positive reputation for customer support, and most importantly used a technology platform that could successfully connect with the SMS system’s API to successfully transfer messages from the US platform to the SA gateway , and report them back to the technology developer, who can address the problems. The technology developer can provide specific instructions for diagnosing issues during testing, any standard troubleshooting suggestions, and their preferred method and frequency for being notified of system bugs.Lifestyle Africa SMS curriculum’s flow, while other testers were only enrolled for a select number of sessions. Multiple weeks of iterative testing revealed a few minor system errors. Research staff who identified the issues first tried to pinpoint the problem via internal troubleshooting. If the research staff was unable to alleviate the problem, the issue was triaged to the technology developer. If there was a programming issue on the SA gateway’s end of the system, the technology developer worked to alleviate the issue, then reported back to the researchers that the problem was resolved. This provided for rapid response and resolution to most issues and had a clear communication process.With the help of the domestic technology developer, system testing was conducted at different rates and with different testers, allowing some testers to go through the entire seventeen-week One example of an issue that arose during testing was that one tester was not receiving any messages. After working with the technology developers, the research team determined that the tester’s phone number was entered incorrectly during SMS enrollment. Another example of an issue was that during one particular week, multiple testers reported not receiving their text messages at the correct time. The research team worked with the technology developer and identified an issue in discrepancy between US daylight savings time and overseas time zoning. The issue was quickly and easily addressed by the technology developer.Given the possibility of errors of various sorts  throughout the intervention delivery period, we suggest that researchers identify a team of “SMS managers” – individuals tasked with day-to-day management of the web-based SMS system concurrent with core intervention programming. SMS managers’ general responsibilities might include, by way of example, enrolling new participants into the SMS system and monitoring SMS delivery schedules to match core programming. SMS managers can also periodically check that the messages participants at each location are programmed to receive match the planned SMS protocol with respect to sequence, frequency, and timing.The research team should consider developing training materials in different formats to familiarize SMS managers with the web-based interface and ensure they understand how to implement the system as intended. These might include video tutorials that show step-by-step on-screen recordings of using the SMS web-based management system, and manualized guides with screenshots and FAQs. The researchers also should consider hosting multiple live  with SMS managers to answer questions and conduct real-time demonstrations to ensure they are able to demonstrate functional competence with the SMS interface and system management responsibilities. The technology provider can assist in developing training materials and facilitating training sessions.Unexpected problems normally emerge despite extensive testing. For example, it is not always possible to account for how extreme weather, internet connectivity, or power supply issues in either the host country or LMIC location may create system sending or receipt issues. As another example, wireless network carriers may change their guidelines without notice regarding how they process short-code and 10-digit code SMS, which might interrupt message delivery to participants. As such, we believe it very helpful to develop a chain of real-time technical support for SMS managers. Given possible time zone differences between the research team and the LMIC location, having some mechanism of support for SMS managers  that they can access any time is important for prompt reporting and response to issues with SMS.The research team developed a variety of materials to assist in training SA and domestic SMS managers for enrolling participants and monitoring the system. This included extensive training manuals that the domestic technology developer helped create, printed FAQ sheets, and step-by-step troubleshooting guides. Web-based training videos were developed and hosted on a private cloud-based service as a primary training tool for SMS managers to watch. Web-based video was selected, as in-person training of SMS managers in SA was not possible from afar in the US; even live-streaming video calls needed to be minimized because they were hampered by significantly different time zone differences and internet stability issues.A chain of technical assistance was implemented so SMS managers would have real-time help if any problems emerged with the system. SMS managers would reach out to a dedicated email or phone number monitored by research team staff. If research staff could not alleviate the problem, they would triage the issue to the technology developer, who provided proactive technical assistance to address questions very quickly (most times within a few hours). In the event a particular program group had to cancel or postpone a session, SMS managers were also in charge of activating the “delayed holding pattern” generic messages for that specific group, and then re-starting session specific messages when normal programming resumed.Researchers must ensure that the budget allocated to support SMS implementation is enough to sustain the cost of maintaining the system throughout the duration of the intervention program. The SMS technology developer should help to guide budget planning at the beginning of the project and inform researchers of all costs that could be anticipated throughout the project. On top of initial development costs , other financial obligations may include: paying a nominal flat fee for each SMS message sent (which can be purchased in batches as needed throughout the study from the gateway company); possible rental fees  by the gateway company to retain possession of the dedicated phone number used for participant SMS communication; and possible bi-annual renewal fees to the gateway company to maintain constant access to the LMIC’s cellular network providers. Most SMS technology developers should support monitoring of fees, purchasing SMS messages and rental/renewal costs as needed throughout the project, and then invoicing all necessary purchases back to the research team.Continued monitoring and assessment of cost should be an ongoing discussion point for the research team. For example, if researchers want to add a new feature late in the development process, there may be cost overruns. If during the program there are high attrition rates, more SMS messages will need to be purchased from the gateway than originally budgeted for. Staffing and participant support costs may end up requiring more resources than originally anticipated. The recommendation here, generally, is to consider cost thoughtfully within the research team and with the developer, and to think and plan broadly for possible scenarios that may result in unplanned charges or extra fees.Lifestyle Africa trial are reported elsewhere .Lifestyle Africa research team worked through. The development and implementation recommendations provided in this report align with a number of the broad mHealth tenets from WHO and Labrique and colleagues  but provide information specific to text messaging and also describe a real-world example of our application of this guidance. For example, the existing broad mHealth in LMIC recommendations suggest direct user-centered research with participants to define architecture and content preferences. In some instances to save resources, researchers may instead use relevant partners  as proxies to inform culturally appropriate approaches to SMS design and implementation. As another example, WHO and Labrique discuss training of end-users; however, researchers may not always find it necessary to direct participants on how to send and receive text messages [Given the rising prevalence of non-communicable disease and lifestyle-related illnesses in LMICs, there is burgeoning need for research on how mHealth implementation can support and enhance the effectiveness of health programs through greater reach and tailored content to vulnerable communities. The primary purpose of this report was to disseminate to other researchers working in similar contexts our proposed development steps for building custom SMS systems, as well as the specific factors and decisions that the messages , 10. OveThese SMS development steps were presented in what we hoped was a logical order; in real-world practice, however, these steps are not necessarily addressed in this specific order. An iterative design and testing process can be utilized , 32, 33.Our suggested recommendations provide additional ideas with unique detail specific to SMS. We broadly recommend researchers be focused on creating mobile SMS messaging that is highly aligned with tenets of the program’s core curriculum so that messages bolster exposure to the therapeutic components of the intervention. Messaging should also be developed using theoretically sound methods from behavioral science to ensure messaging strategies are evidence-based, and therefore more likely to effectively support HBC. We believe having this set of SMS-specific guidelines , that have been developed from mostly first-hand experience and also build upon extant literature, offer an effective “checklist” of sorts for other researchers planning to integrate SMS into HBC programs in LMICs.Lifestyle Africa research team will translate to all other contexts. Nonetheless, this report contributes to a growing body of literature around the potential of mobile technology for improving HBC program implementation, expanding the reach of interventions by providing additional program supports to participants, and using SMS as a method for enhancing participant motivation and self-efficacy for HBC.The case study was conducted in a very specific international population , so we recognize that not all of the situationally-specific barriers faced and decisions made by the