Multi-copper oxidases related to laccase are extensively distributed as multi-gene families in the genome sequences of higher plants. The current study thoroughly investigated the LMCO gene family (Br-Lac) and its expression pattern under various abiotic stresses in B. rapa L. A total of 18 Br-Lac gene family members located on five different chromosomes were identified. Phylogenetic analysis classified the documented Br-Lac genes into seven groups: Group-I (four genes), Group-II (nine genes), Group-III (eight genes), Group-IV (four genes), Group-V (six genes), and Group-VI and Group-VII (one gene each). The key features of gene structure and responsive motifs shared the utmost resemblance within the same groups. Additionally, a divergence study also assessed the evolutionary features of Br-Lac genes. The anticipated period of divergence ranged from 12.365 to 39.250 MYA (million years ago). We also identified the pivotal role of the 18 documented members of the LMCO (Br-lac) gene family using quantitative real-time qRT-PCR. Br-Lac-6, Br-Lac-7, Br-Lac-8, Br-Lac-16, Br-Lac-17, and Br-Lac-22 responded positively to abiotic stresses . These findings set the stage for the functional diversity of the LMCO genes in B. rapa.Laccase-like multi-copper oxidases (LMCOs) are a group of enzymes involved in the oxidation of numerous substrates. Recently, these enzymes have become extremely popular due to their practical applications in various fields of biology. LMCOs generally oxidize various substrates by linking four-electron reduction of the final acceptor, molecular oxygen (O Multi-copper oxidases (MCOs) are a group of enzymes from the kingdom Fungi that contain laccases and peroxidases ,2, metalPrunus avium L., Trametes trogii, Arabidopsis thaliana, Liriodendron tulipifera, and Setosphaeria turcica, etc., have been extensively studied for the identification of these LMCO genes. However, there is a dearth of studies about the LMCO genes in members of the family Brassicaceae. Several members of this family are being utilized as vegetables, oilseed, and feed crops across the globe, and they play an important role in uplifting living conditions of concern. According to “whole genome triplication” (WGT), Brassica and Arabidopsis diverged from a common ancestor approximately 20 MYA. Similarly, B. rapa and B. oleracea came into existence from a common ancestor approximately 3.75 MYA [Brassica species have increased through whole genome triplication (WGT) and tandem duplication (TD), which make it an excellent model [B. rapa L. is an economically important member of Brassicaceae, formerly known as Cruciferae. This plant species is an important source of vegetables that are rich in carotenoids , β-carotene, glucosinolates, iron, and calcium contents [The genomes (transcriptomes) of different members of the kingdom Plantae (woody and herbaceous) provide valuable information for identifying oxidative enzymes from the laccase family. Genomes of different plant species, including 3.75 MYA ,14. The contents .A. thaliana. At-Lac-12, At-Lac-13, and At-Lac-22 have been reported to enhance drought tolerance in A. thaliana [Oryza sativa were enhanced by overexpressing Os-LAC-6 and Os-LAC-8 [A. thaliana [B. rapa L. [B. rapa. This study’s findings will help lay the groundwork for future research on its biological function.Five subgroups of the LMCO gene family have been reported through functional analysis in thaliana . DroughtOs-LAC-8 . LAC-12,thaliana . Previou rapa L. ,18. In tB. rapa, which were further confirmed from the SMART and NCBI websites for domain validation. The names for the identified genes were given in sequence . The nomenclature was purely based on information from A. thaliana due to sequence similarity. The phylogenetic tree divided the 18-member LMCO gene family into seven groups: Group-I (Br-Lac-2 and Br-Lac-17), Group-II , Group-III , Group-IV (Br-Lac-14 and Br-Lac-15), Group-V , Group-VI (Br-Lac-1), and Group-VII (Br-Lac-6) (We identified 18 Br-Lac (LMCO) genes in r-Lac-6) . A supplThe 18 documented putative LMCO genes were mapped on five different chromosomes: chromosome A02 consists of Br-Lac-10–Br-Lac-12 and Br-Lac-15. Chromosome A03 consists of Br-Lac-6, Br-Lac-9, and Br-Lac-17. Chromosome A05 consists of Br-Lac-2–Br-Lac-4, Br-Lac-7, and Br-Lac-22, whereas chromosome A01 contains only one of the reported genes . Chromosome A10 consists of Br-Lac-13, Br-Lac-14, and Br-Lac-16 .A. thaliana (At-Lac) and 18 from B. rapa (Br-Lac)). The ML phylogenetic tree divided all the documented 35 LMCO genes into seven groups (A maximum likelihood (ML) phylogenetic tree was constructed for the 35 reported LMCO genes . The molecular weights of the resultant proteins were between 61.22 and 65.75 kDa, while pIs varied from 6.07 to 9.73. These proteins possess a negative grand average of hydropathicity (GRAVY), indicating hydrophilic behavior. Understanding plant functions requires knowledge of subcellular localization, and our results showed that most of the proteins were found in the chloroplast and vacuoles  and synonymous substitution per synonymous site (Ks) for each pair of paralogous Br-Lac genes were calculated according to the phylogenetic tree server . This wahttps://swissmodel.expasy.org/) (accessed on 7 January 2023).To obtain a more in-depth comprehension of the framework of the Br-Lac genes, the secondary and tertiary structures of the Br-Lac proteins were investigated . Both foB. rapa seedlings to various abiotic stresses  to expose the expression patterns of its 18 documented LMCO genes. QRT-PCR was performed on the 18 Br-Lac genes at different time intervals after various abiotic treatments, and the expression levels were calculated  under salinity stress were up-regulated. The Br-Lac-12 gene showed high regulation at 12 h, while Br-Lac-14 showed up-regulation at 24 h . Three gLiriodendron tulipifera, Pinus taeda, Zinnia elegans, and Acer pseudoplatanus was used to isolate these enzymes [Pseudoplatanus cells, when maintained in suspension culture [Rhus vernicifera were found to be good in healing wounds caused either by herbivores or in response to pathogens [Japanese lacquer and Rhus vernicifera were reported to exhibit an oxidative polymerization reaction between laccase and the alkyl catechols in latex sap, causing a strong protective seal to form over the injury. This happens because laccase is a component of latex sap [Determining the physiological functions of LMCOs is comparatively difficult due to their wide distribution and complex nature across various plant species. These factors, in combination with several others, make it very challenging to identify LMCO genes and their functions. Differentiating the xylem of  enzymes ,20,21,22 culture . Prototyathogens . The truatex sap . FurtherB. rapa genome and found a total of 18 genes. Based on domain organization and evolutionary analyses, these genes were further classified into seven subgroups  have been used as the primary classification method for plant LMCOs, with the implicit belief that pI may be related to substrate kinetics and enzyme activity ,20. A seA. thaliana LMCO proteins were successfully involved in the process of drought tolerance [B. rapa were analyzed using real-time RT-PCR, as shown in A. thaliana, whereas the expression levels of At-Lac-9, At-Lac-11, and At-Lac-15 were inhibited by drought and salinity stress.Biotic and abiotic stresses define the patterns of both gene expression and function . QRT-PCRolerance . To obtaThere has only been relatively little research on the LMCO gene family in plants. The LMCO gene family’s intron–exon configurations may cause functional variability. Such findings could be attributable to a homology structure separate from the domain sequences ,33. ThisA. thaliana, i.e., At-Lac-1 (At1g18140), At-Lac-2 (At2g29130), At-Lac-3 (At2g30210), At-Lac-4 (At2g38080), At-Lac-5 (At2g40370), At-Lac-6 (At2g46570), At-Lac-7 (At3g09220), At-Lac-8 (At5g01040), At-Lac-9 (At5g01050), At-Lac-10 (At5g01190), At-Lac-11 (At5g03260), At-Lac-12 (At5g05390), At-Lac-13 (At5g07130), At-Lac-14 (At5g09360), At-Lac-15 (At5g48100), At-Lac-16 (At5g58910), and At-Lac-17 (At5g60020), were searched and downloaded using TAIR10 (http://www.arabidopsis.org/) (accessed on 20 December 2022). These sequences were then used as queries to implement BLASTP searches in the B. rapa genome to find LMCO gene sequences. Phytozome was used to search and download Brassica genome sequences  (accessed on 22 December 2022). A Hidden Markov Model (HMM) profile for laccase (IPR017761) was obtained from the Pfam database (http://pfam.xfam.org/) (accessed on 29 April 2023) using HMMER3 software to search for LMCO homologous genes [http://smart.embl-heidelberg.de/) (accessed on 25 December 2022) and Pfam databases were used to examine the required sequences [http://web.expasy.org/protparam/) (accessed on 28 December 2022) [The protein sequences of the LMCO genes in 12 At5g050, At-Lac1 At1g181, At-Lac-er 2022) .A. thaliana and B. rapa was constructed using MEGA software version 7.0. [A phylogenetic tree for the full-length LMCO protein sequences of ion 7.0. . The CluB. rapa chromosome. Syntenic relationships in the Brassica genomes were constructed using a method similar to the Plant Genome Duplication Database  (accessed on 28 December 2022) [We examined genome data for the location of LMCO genes on the er 2022) . The syner 2022) .http://meme-suite.org/tools/meme) (accessed on 29 December 2022) [http://gsds.cbi.pku.edu.cn/) (accessed on 30 December 2022) was utilized to study the structure of the LMCO gene following the standard procedure of Hu et al. [Conserved motifs in the full-length LMCO protein sequences were identified using MEME tools (er 2022) ,46. The u et al. .https://npsa-prabi.ibcp.fr/cgi-in/secpredsopma.pl) (accessed on 3 January 2022) was used to determine the structural makeup of the 18 Br-Lac genes. Similarly, the protein structural makeup of the 18 LMCO genes was also determined through an online tool (https://swissmodel.expasy.org/) (accessed on 7 January 2022) [The online secondary structure prediction tool SOPMA (ry 2022) .https://www.ncbi.nlm.nih.gov/) (accessed on 7 January 2022) was used to determine amino acid (bp), CDS (bp), and location on the chromosome of the LMCO gene to clarify its physicochemical characteristics. Isoelectric points (pI), molecular weight (MW), grand average of hydropathicity (GRAVY), and the formula of the individual LMCO gene in B. rapa were assessed through the ProtParam tool on the ExPASy server (http://web.expasy.org/protparam) (accessed on 29 April 2023). We also used the WoLF PSORT service for plant protein location (https://wolfpsort.hgc.jp/) (accessed on 29 April 2023) to assess LMCO protein in Brassica [The NCBI database  for the process of germination. The soaked seeds were then cultured in 10 cm plastic pots. The germinated seedlings were then allowed to grow in a chamber room under light and dark (16/8) at 25 °C until the four-leaf stage. Different abiotic stresses  were applied to the growing seedlings [eedlings . For droeedlings . In a si® 480 II  and SYBR Green I Master Mix  were used to perform qPCR. The gene-specific primers were designed using the NCBI online software primer designing tool (https://www.ncbi.nlm.nih.gov/tools/primer-blast/) (accessed on 15 January 2023)  was used for total RNA extraction from differently treated samples . A RevertAid First Strand cDNA Synthesis Kit  was used to synthesize purified cDNA with 1 μg of total RNA and oligo primers . Light Cry 2023) . Each qPB. rapa during this investigation. They were categorized into seven groups based on phylogenetic analysis and similarities in amino acid sequences. The basic gene parameters, such as amino acid and CDS length, molecular weight (MW/kDa), isoelectric point (PI), and GRAVY, as well as the fact that the majority of Br-Lac genes were located in chloroplasts, were unearthed by the physicochemical properties of Br-Lac genes. The divergence study further illuminated the Br-Lac genes’ evolutionary history, which revealed that the time of divergence ranged from 12.365 to 39.250 MYA. These findings point to a shared biological function of Br-Lac genes in response to enzymatic activity and offer helpful hints for further research into the diversity and function of Br-Lac genes. Expression analyses of the Br-Lac gene family were performed in this study for abiotic stress. The findings suggest that Br-lac genes resist heat, drought, and salinity stress.In conclusion, 18 LMCO genes were found in


Internet-delivered psychological interventions (IPIs) have been shown to be effective for a variety of psychological concerns, including postpartum depression. Human-supported programs produce better adherence and larger effect sizes than unsupported programs; however, what it is about support that affects outcomes is not well understood. Therapeutic alliance is one possibility that has been found to contribute to outcomes; however, the specific mechanism is not well understood. Participant perspectives and qualitative methodology are nearly absent from the IPI alliance research and may help provide new directions.In this study, we aimed to provide participant perspectives on engagement with an IPI for postpartum depression to help inform alliance research, development of new IPIs, and inform resource allocation.A qualitative methodology was used to explore participant perspectives of veteran women’s engagement with the MomMoodBooster program, a human-supported internet-delivered intervention for postpartum depression. Participants were asked 4 open-ended questions with the 3-month postintervention survey, “In what ways did you find the MomMoodBooster most helpful?” “How do you think the MomMoodBooster could have been improved?” “In what ways did you find the personal coach calls to be helpful?” and “How do you think the personal coach calls could have been improved?”Data were collected from 184 participants who responded to at least 1 of the open-ended questions. These were analyzed using thematic analysis and a process of reaching a consensus among coders. The results suggest that not only the engagement with the support person is perceived as a significant contributor to participant experiences while using the MomMoodBooster content but also the relationship factors are particularly meaningful. The results provide insights into the specific qualities of the support person that were perceived as most impactful, such as warmth, empathy and genuineness, and feeling normalized and supported. In addition, the results provide insight into the specific change processes that can be targeted through support interactions, such as encouraging self-reflection and self-care and challenging negative thinking.These data emphasize the importance of relationship factors between support persons and an IPI program for postpartum depression. The findings suggest that focusing on specific aspects of the alliance and the therapeutic relationship could yield fruitful directions for the training of support personnel and for future alliance-based research of internet-delivered treatments. Terminology section) for postpartum depression are an important part of expanding the reach of specialized mental health services and thus reducing barriers to treatment. Less than half of those affected by mental health concerns seek or receive evidence-based treatments owing to costs, limited access, stigma, and preference to self-manage  and 201603779 [IRB-01]).The final sample consisted of 184 veterans who provided at least 1 qualitative response. Responses to the 4 questions from these participants were coded into a total of 748 codes due to multiple codes being assigned to some responses. Of the 748 total codes, 390 (52.1%) were program related and 358 (47.9%) were coach related. The 184 participants answered the 4 questions that are referred by the following headings: program helpful ; program improve ; coach helpful ; and coach improve .The thematic analysis resulted in a final structure consisting of five domains: (1) program accessibility and functionality, (2) content, (3) coaching, (4) change processes, and (5) barriers.program accessibility/functionality domain refers to comments addressing how participants accessed or would like to have accessed the content and how it functioned from a technical standpoint. This domain includes two themes: (1) positive , which refers to nonspecific positive comments such as the one shared by participant 1: “Convenient, self-paced”; and (2) improve . The improve theme captures four subthemes: (1) access, (2) delivery mode, (3) functionality, and (4) technical. The subtheme access, which represented 24% (13/55) of the improve codes, refers to recommendations related to the timing or duration of access to the program. For example, participant 2 suggested, “given at discharge from the hospital.” The subtheme delivery mode, which represented 29% (16/55) of the improve codes, refers to alternative modes of delivery that participants felt would have been beneficial such as those noted by participant 3: “Offered in a classroom setting.” The functionality subtheme, which represented 20% (11/55) of the improve codes, identified electronic formatting that would have facilitated greater engagement; for example, participant 4 suggested the program be, “More game like, not literature.” Finally, the technical subtheme, which represented 27% (15/55) of the improve codes, identified technological issues that affected participant experience such as the one commented by participant 5: “I had issues with inputting my daily mood.”The content domain refers to comments identifying specific content from the program or more general comments made under the program helpful and program improve questions. This domain includes three themes: (1) positive, (2) improve, and (3) specific helpful content. Positive, referring to positive comments that were specific to content, accounted for 7.9% (31/390) of the program-related codes; for example, participant 6 noted, “I enjoyed the interactive [aspects].” Improve, accounting for 15.6% (61/390) of the program-related codes, refers to specific suggestions for ways the content could have better met participant needs such as the one requested by participant 7: “Make the program more diverse.” The specific helpful content subtheme, representing 11.5% (45/390) of the program-specific codes, refers to codes in which participants named specific pieces of content that they appreciated; for example, participant 8 noted, “Identifying negative thoughts and downward mood spiral.”The coaching domain refers to general comments relating to the coach or the amount of coaching from any of the 4 questions. This domain consists of two themes: (1) general positives, accounting for 10.1% (36/358) of the coach-related codes, and (2) amount, accounting for 9.5% (34/358) of the coach-related codes. The codes under the theme general positives were nonspecific satisfaction comments such as the one commented by participant 9: “No improvements needed.” Three subthemes emerged under the amount theme: (1) the increase subtheme, which accounted for 77% (26/34) of the codes, was exemplified by participant 10, who expressed, “Continuation a week or two after the program ended,” and participant 11, who shared, “More phone calls”; (2) the didn’t want, didn’t receive, or got no benefit subtheme was less common, representing only 18% (6/34) of the amount codes; for example, participant 12 expressed, “What calls?? Received none,” and participant 13 stated, “I never spoke with anyone, that is not what I wanted from the program”; and (3) the decrease subtheme was the least common, representing only 6% (2/34) of the amount codes; for example, participant 14 stated, “More online activities, less calls.”  program and (2) coach, with 3 and 5 subthemes, respectively. The program theme refers to codes that identified change processes either specifically related to program content or nonspecifically under the program helpful question. The coach theme refers to codes that specifically indicated a link to coaching or were responses under the coach helpful or coach improve questions. Replicated subthemes  across program and coach themes emerged through the inductive coding process. Coding these subthemes separately, rather than collapsing, was prioritized to compare the relative contributions across themes  codes were included under this subtheme. These included codes were managing negative thoughts, increased self-awareness, learning coping strategies, increased agency, and others. Participant 15 commented, “I learned how to be calm and take care of my baby.” Some participants indicated that the coach was the most helpful aspect of the program; for example, in response to the program helpful question, participant 16 commented, “Helpful to talk to someone who is supporting.” Of the 390 program-related codes, 34 (8.7%) codes referenced the coach and were therefore included as a subtheme of the program-related change processes. These were coded separately from the coach theme for 2 reasons. First, these comments were more general than those captured under the coach theme and second, because it felt important to differentiate and identify how often the coach was named as the salient helpful aspect of the program as a whole. The third subtheme under program theme was accountability. This subtheme refers to comments indicating that being held accountable was the most helpful aspect of the program. Only 3 respondents identified accountability in response to the program helpful question, and it represented 0.8% (3/390) of the program-related codes. Interestingly, 2 of these participants also named relationship factors in other responses; for example, participant 17 who commented under program helpful, “Having a system to be accountable to,” which was coded as accountability, also commented under coach helpful “having a live person to check in with is very comforting,” which was coded as relationship/interpersonal (which are subthemes under coach theme).Under the change processes domain is coach, which included 5 subthemes. Intrapersonal  refers to growth and change identified by the participant specifically credited to the coaching interaction. Some of the intrapersonal processes include self-reflection, challenging negative thinking, perspective-taking, increased self-compassion, normalizing, and processing problems. For example, participant 18 commented, “Helped me reflect on myself and identify negative talk to myself.” , refers to codes that referenced the importance of the relationship between the participant and the coach. Some of the codes in this domain were requests from participants for what they would like to be different in the coaching interactions such as the one shared by participant 19: “more input, deeper conversation,” which was coded as increase depth. Others were experienced by the participant; for example, participant 20 shared “[specific coach name] listens even if I haven’t completed the week and gives praise and good thoughts,” which was coded as relationship because of the use of the coach’s name and coach qualities, active listener and supportive. Participant 21 shared, “I really liked my coach” which was coded as interpersonal relationship.The second coach subtheme, qualities, represented 19.3% (69/358) of the coach-related codes and refers to specific attributes named by participants. For example, the comment by participant 22, “Felt very genuine,” was coded as genuine, and the comment by participant 23, “No matter what was going on in my life she always empathized and worked with me,” was coded as empathetic. Note that this response, which is similar to the one shared by participant 20 above, was not coded as relationship, as the participant did not name her specific coach  of the coach-related codes.The fourth coach subtheme, accountability, refers to codes that specifically identified the coach as the agent of holding participants accountable. These codes represented 9.2% (33/358) of the coach-related codes. Interestingly, 24% (8/33) of the participants who provided responses that were coded under coachaccountability subtheme also provided responses that were coded under relationship/interpersonal subtheme.The fifth barriers including (1) time, (2) motivation and mood, (3) coaching delivery method, (4) contextual factors, and (5) scheduling and rescheduling problems . barrier domain, and The final domain refers to the challenges that respondents named that prevented them from engaging with the content and coaching. Five themes were captured under This study aimed to illuminate participant perspectives regarding engagement with a telephone-supported IPI for postpartum depression, the iCBT MMB program. Results of this study will inform future IPI alliance research, training of support personnel, program development, and allocation of resources for supported IPIs.program content, accessibility/functionality, and barriers, provide ideas for program developers regarding particularly helpful aspects of program content and design. In addition, some of the information found in the intrapersonal theme under change processes domain may identify specific processes that can be targeted via content in future human-supported programs.Our thematic analysis of 184 veterans’ responses to 4 open-ended questions regarding MMB program content and impressions of the support person provided a unique look at participant perspectives of this supported iCBT. Furthermore, we were able to compare participant perspectives across program content and the support person specifically. Overall, 3 of the 5 identified domains, program helpful question, it is clear that some were considering the entirety of the program, rather than strictly the content, when referencing intrapersonal processes. Future IPI alliance research may want to be mindful of construct validity issues and whether questionnaires probe intrapersonal or interpersonal processes. Similarly, qualitative researchers may want to be mindful of how they query these processes.More significantly, these data illuminate some of the important change processes facilitated by the support relationship and specific qualities of the support person that elicit participant responses. For example, the intrapersonal subthemes and relationship or interpersonal subthemes represent the largest proportion of codes. This indicates that interpersonal processes and relationship factors may warrant further investigation in the context of alliance-based research for iCBT specifically and IPIs more generally. Although some program-related intrapersonal processes are clearly attributable to the program content , others may be attributed to either the content or the coach. Without a clear reference to one or the other, such processes were assigned to the content. However, given the number of participants who referred to the coach under the program helpful referenced the coach. Furthermore, of the participants who identified the amount of time with the coach under coach improve, approximately 3 times as many indicated wanting more contacts compared with the combined total across no change, didn’t need, or decrease codes, suggesting that participants valued the support time and, in many cases, wished for more. Significantly, approximately 60% of the coach codes (from the coach helpful and coach improve questions) identified relationship or interpersonal factors, and >40% identified coach qualities that cannot exist outside of an interpersonal relationship. In summary, the participants acknowledged the importance of the coaching relationship. This is in line with previous research emphasizing the importance of the therapeutic alliance in supported IPIs [Our findings also suggest that the coach is perceived as one of the most important aspects of the program, as approximately 20% of the responses under ted IPIs ,16,17.change process domain. Accountability was identified in <1% of the program helpful codes, and in response to the coach helpful question, accountability was identified in <20% of the codes. However, because accountability has been found to be related to better adherence to IPIs [In contrast, fewer participants identified accountability as an important aspect of the program or coaching compared with other themes under  to IPIs , it is i to IPIs  and that to IPIs , suggestprogram helpful question. In addition, some of the emphases in the results on coaching and the relationship could be reflecting the specificity of one set of questions compared with the other. Second, participant responses were very brief in many cases, meaning that coders had to interpret meaning using familiarity with this sample and the program overall. Despite constantly challenging assumptions and biases, elements of bias may have certainly influenced the final coding and thematic structure. Finally, the final thematic structure does not represent the women who were noncompleters in the study or who did not provide follow-up data. It is possible that the nonresponders had very different experiences with the program and coaches that were not captured in this study.This study has several limitations that should be acknowledged. First, the 4 questions that were used to collect these data were not crafted with the intention of completing a qualitative analysis and were not designed for exploring the importance of the coach relationship in comparison with the program content. As a result, there is some ambiguity in the responses provided under the One model of support, Supportive Accountability , a manuaIt should be noted that accountability and alliance are not mutually exclusive, and one should not be used at the expense of the other. Our findings suggest that being responsive to client needs in IPIs is likely as important as it is in FTF therapy , and supInherent in the adherence literature is the idea that specific ingredients of the IPI or iCBT content are responsible for outcomes, and higher “doses” of these ingredients are associated with more positive outcomes. In contrast to this medical model of therapeutic change is the contextual model , which eFurther refinement of the model given by Gelso  has resuFurther refinement may also be necessary in terms of differentiating alliances based on the mode of contact. The meta-analysis by Kaiser et al  determinThese findings provide a unique perspective regarding participant experiences in a supported iCBT program for postpartum depression. These data suggest that the most helpful coaches are those who are empathetic and validating, supportive and nonjudgmental, flexible, patient, and genuine. These qualities are highly relevant for trainees in health service delivery and research. Similarly, coaches might avoid emphasizing accountability alone unless the participant specifically identifies this as their primary need from support. Several participants commented that they wanted their coaching sessions to feel personal, to include conversation beyond simply what was happening with program content, to deepen and explore emotions, and to feel that the coach was genuinely interested in how they were feeling. As such, coaches might work to flexibly apply program content to the participant’s ongoing experience and context while prioritizing responding with genuineness and empathy. Creators of manualized support models should consider how these results inform the training of their support personnel.Future research may explore associations among qualities of coaches, amount of synchronous telephone contact, alliance ratings, and participant outcomes. Our findings demonstrate that the participants were capable of discerning beneficial coach qualities through an IPI program in which there was synchronous audio contact. Previous research has suggested that it is possible to form therapeutic alliance within 2 weeks of initiating an intervention and that early alliance associations with outcomes may indicate that guidance may not be necessary for the entire duration of the IPI . This stThese results call into question previous research that has indicated that the bond subscale of the model by Bordin ,13 is leKaiser et al  call forAlthough some have suggested that alliance-related factors may be less impactful in IPIs , the parImportant to consider in future research is the model from which coaches are trained and supervised, as this is likely to impact treatment outcomes, engagement, adherence, and attrition. Future research with these data is planned that will compare the association between relationship factors, engagement measures, and outcomes under accountability-focused and alliance-focused support models.The literature on therapist responsiveness also suggests that strict standardization of support may be counterproductive. Swift et al  summarizAlthough these participants engaged with their coaches for an average of 12 minutes per coaching session , much lePerhaps the most important feature in the training context was that the coaches for this program were doctoral level trainees in clinical and counseling psychology. Future implementations of iCBT for postpartum depression and other IPIs may use trainees knowing that the therapeutic alliance and responsiveness variables identified as beneficial herein are trainable and regarded highly by participants. However, given the nature of the valued coach characteristics identified herein, properly trained peers may also be a viable and scalable option for future IPIs and research.One strength of this study is the relatively large sample size (n=184), particularly in terms of typical qualitative studies. Several characteristics of the sample suggest that the results are generalizable to other supported iCBT interventions and supported IPIs. For example, participant demographics were diverse and, through nationwide recruitment, represented diverse areas of the country, including both rural and urban locations. In addition, previous work demonstrated that engagement and outcomes of this program were comparable with those of other IPIs .Given that most codes were not specific to CBT ingredients or to the functioning of this specific program, but instead were intrapersonal and process comments, these results are likely generalizable to non-CBT IPIs. Furthermore, qualitative analysis, as a methodology, is nearly absent from the IPI literature, and as such, these data provide a unique perspective into potential mechanisms of change, which has been an elusive aspect of process and outcomes research .


Med Sci 2020; 15)  2195-2203). Frequent recurrence and consecutive medical interventions in patients with NMIBC lead to psychological problems such as anxiety, fear of recurrence, depression, and stress, resulting in reduced quality of life , 3877-3885). It is expected that the increased accessibility and convenience of mobile health  will be effective in providing a mobile-based psychological intervention program to promote the mental health of patients with NMIBC.Bladder cancer, which is primarily a non-muscle invasive bladder cancer (NMIBC), is prevalent worldwide and its incidence is increasing. NMIBC shows a high recurrence rate of 50-70%, and in 25% of cases, progresses to muscle-invasive disease  (Image 1). The topics of each session were as follows: Session 1 (Understanding of bladder cancer and treatment), Session 2 (Understanding and respecting myself), Session 3 (Maintaining reasonable thoughts and positive emotions), Session 4 , Session 5 , and Session 6 (Finding happiness and meanings in daily life).The protocol for evaluating the feasibility of the developed program is outlined in Image 2.Image:Image 2:The feasibility of the mental health improvement program for patients with NMIBC based on mobile messenger  will be evaluated through the developed protocol. Moreover, by introducing a program that reflects the feasibility of test results into practice, the results of this study can contribute to improving the quality of life of patients with NMIBC.None Declared


SmartCoach is a life skills training program for addiction prevention where adolescents are proactively invited for program participation in secondary school classes. The mobile phone-based program provides individualized coaching for a period of 4 months and addresses self-management skills, social skills, and substance use resistance skills. This study examined sociodemographic and other predictors of program participation and program use. Methods: A total of 476 adolescents in 28 secondary and upper secondary school classes in the German-speaking part of Switzerland were proactively invited for participation in the SmartCoach program. Using generalized linear mixed models (GLMMs), we examined predictors of both program participation and program use at the individual and school class levels. Results: In total, 315 (66.2%) of the present 476 adolescents gave their active consent and provided the necessary information to be included in the program. None of the individual sociodemographic characteristics significantly predicted program participation, however, the participation rate was significantly higher in upper secondary school classes (84%) than secondary school classes (59%). The mean number of interactions with the program was 15.9, i.e., participants took part in almost half of the 34 possible interactions with the SmartCoach program. None of the baseline characteristics on the level of the school class significantly predicted program use. On the level of the individual, the univariate models showed that, compared to the reference category of 14-year-old students, program use was significantly lower for students who were 16 or older. Furthermore, participants with a migration background or an origin from a non-German-speaking country showed significantly lower program use. Finally, students with a medium level of perceived stress showed higher program use compared to those with a low level of stress. Within the final multivariate model for program use, only the variable “origin from a non-German-speaking country” remained significant. Conclusions: SmartCoach is an attractive offer for young people, in which two out of three young people who are invited in the classroom to participate do so. Among the program participants, the use of the program is acceptable, with an average of almost half of the content being worked on. There is potential for improvement in terms of recruitment, especially in school classes with a lower level of education. The most important starting point for improving program use lies in taking greater account of needs and wishes of students with non-German-speaking countries of origin.Background: Digital interventions are an emerging and promising avenue for addiction prevention and mental health promotion, but their reach and use are often limited, and little is known about the factors associated with youth accessibility.  Although there is increasing recognition of social inequalities in adolescent health  and sociThe Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework is a planning and evaluation framework that was developed to help make research findings more generalizable by encouraging scientists and evaluators to balance internal and external validity when developing and testing interventions ,6. BasedHaug et al.  investigA web- and text-messaging-based life skills program for vocational school students in Switzerland, with a participation rate among the present students in the classroom of 81%, showed that female gender and occasional binge drinking were positively associated with willingness to participate, while an immigrant background and tobacco smoking were negatively associated .A recent Australian study investigated the uptake of an app-based health promotion program among adolescents in 71 secondary schools. Among 2489 students who had the ability and opportunity to access the Health4Life app, 407 (16.4%) accessed it . FactorsBeyond program participation, use or engagement is a major dimension of program reach which could determine the effectiveness and public health impact of an intervention . ReviewsSmartCoach, a digital intervention program for addiction prevention, for young people.The studies cited above show that socioeconomic and lifestyle factors can influence participation and engagement in digital interventions for addiction prevention and health promotion. However, only a few variables of social inequality were usually collected and examined. The present study aims to extend the existing knowledge by considering a more comprehensive set of socioeconomic and lifestyle factors that influence the accessibility of SmartCoach targets social skills, substance resistance skills, and self-management skills [Based on social cognitive theory, the fully automated SMS- and Internet-based intervention program t skills ,19. Progt skills ,20. Of tt skills .Longer-term results based on an 18-month follow-up showed that, compared to controls, those in the intervention group experienced reduced tobacco-smoking prevalence, however, no effect was observed on at-risk drinking. No significant moderators of the primary outcomes were observed, i.e., effectiveness of the program was independent of age, sex, migration background, and school level.While the access of young people in these previous efficacy studies ,20 may hPrevention specialists from cooperating regional centers for addiction prevention asked secondary and upper secondary schools in the Swiss cantons of Aargau and Zurich to participate in the current study. The objectives of the program, its implementation, and procedure in the school class were explained to interested teachers. Participating teachers reserved a period of 30–90 min during the usual school lessons for the program implementation.During these 30–90 min, the present students were (1) introduced to the topic through a short workshop, (2) informed about the program and the accompanying study, and (3) invited to participate in the program. The workshop and information session were led by prevention experts or master students of psychology, who had training on the study and the program to be provided, as well as expertise working with young people and providing preventive interventions. The 20–60 min workshop aimed to arouse the young people’s interest in the topic of stress and provide basic information on its origins. First, the young people had to explain to an alien in a group discussion what they understand by stress. Then, the development of stress as an imbalance of demands and resources was explained. By means of interactive exercises, such as subtracting 7 from 996 several times in a group, stress was deliberately induced and the young people were asked to observe how stress affects their bodies and thoughts. Finally, the young people were asked to describe their stress level in the areas of family, friends, school, and future by means of emojis.SmartCoach program with the help of an introductory video available at www.smartcoach.info (accessed on 12 July 2023). Students were asked to use their smartphones to complete an online baseline assessment and study registration. Students without a smartphone and students not willing to fill in the online baseline assessment were asked to fill in an anonymous paper–pencil questionnaire for non-participants. This questionnaire included assessment of demographic data, sociodemographic status of the family, health literacy, and reasons for not participating in the online assessment or the SmartCoach program. Students with a running smartphone were asked to participate in an anonymous online survey that included assessment of similar data. Subsequently, within this online assessment, students received detailed information on the SmartCoach program, the related study, and friendly competition and were invited to participate.Subsequently, the students were informed about the After giving their informed consent, participants were asked to choose a username, to provide their mobile phone number, and to complete additional assessments on stress and social skills which were necessary for the tailoring of the intervention content. Subsequently, the program participants received individually tailored web feedback directly on their mobile phone . During the subsequent 4 months, program participants received individually tailored mobile phone-based life skills training. Students without consent were thanked for their information and asked in a free text field why they did not participate in the program.SmartCoach  program provided tailored web-based feedback and text messages to promote self-management skills, social skills, and substance use resistance skills over a period of four months. The intervention elements of the program were based on social cognitive theory [The e theory ,23 and le theory . IndividFollowing baseline assessment and feedback, participants received between two and four individually tailored text messages per week on their mobile phones for a period of 17 weeks. The fully automated system created and transmitted these messages. For the first seven weeks, the messages emphasized self-management techniques, such as stress management, emotional self-regulation, and anger and frustration management. In weeks 8–12, the messages focused on social skills, such as making requests, declining unreasonable demands, and interacting with new people. The messages during weeks 13–17 emphasized the development of substance use resistance skills, such as the ability to recognize and resist media influences, social norms of alcohol and tobacco use, and the relationships between social and self-management skills and substance use. The messages were individually tailored, based upon data from the baseline assessment and upon text messaging assessments that occurred over the course of the program.During the four-month coaching phase, participants received a total of 37 text message prompts that invited interaction like replying to quizzes, retrieving media objects, and participating in challenges or contests. To stimulate program engagement, a friendly competition amongst participants was integrated into the program. Within the friendly competition, program participants could collect credits for each interaction, such as participating in quizzes, creating messages or pictures within contests, or accessing video links integrated in text messages. The more credits participants accumulated, the better their chances were of winning one of several prizes that were part of a prize draw  after the program’s completion. Participants could access their credit total at any time from their own profile page and compare it to the total of other program participants. Sample screenshots of the program from the coaching phase are shown in Adolescents’ access was considered both at the school class level and at the individual level. At the school class level, data from the class recruitment protocols were used. These were completed separately for each school class by the recruiting professionals and included the following information: number of students present, time of recruitment, duration of the introductory workshop, as well as the educational level of the school class: secondary or upper secondary school.n = 470). Adolescents’ subjective perceptions of familial socioeconomic status were assessed by a brief instrument [All students, whether participating in the program or not, were invited to fill in an anonymous survey on socially stratifying factors. The assessments were be based on the PROGRESS framework  but werestrument ,30 that strument .Among students participating in the program, the following health-related variables were additionally assessed within the online baseline survey: perceived stress, social skills, problem drinking, tobacco smoking, and cannabis use. Perceived stress was measured using a single item from the Swiss Juvenir study : “How ofFor this study, we defined program participants as students present in the classroom who (1) completed the survey on their smartphone, (2) gave informed consent to participate in the program, and (3) provided the necessary baseline data on stress, social skills, and their mobile phone number to receive the coaching. Non-participants were students who (1) did not participate in either the smartphone survey or the paper–pencil survey, (2) participated in the non-participant paper–pencil survey, (3) participated in the smartphone survey but did not give informed consent to participate in the program, or (4) participated in the smartphone survey and initially provided informed consent to participate but then did not provide the baseline data necessary for program participation.SmartCoach system.Program use was operationalized in terms of the total number of interactions with the program that were logged by the system. During the four-month coaching phase, participants received a total of 37 text message prompts that invited interaction like replying to quizzes, retrieving media objects , and participating in self-challenges or contests within which they could post short messages or photos and vote on other posts. This information was available for each program participant through the log files of the p < 0.05, two-tailed) at the univariate level. In a further step, the predictors with the highest p-values were removed one by one from the multivariate model until the final solution contained only predictors that significantly contributed to the prediction of program participation and program use, respectively. Regarding the prediction models for program use, we observed signs of overdispersion in the model residuals. Overdispersion occurs when the observed variance of the count outcome is greater than that expected from the Poisson distribution, which assumes that the mean and variance are equal. To account for overdispersion, we chose a negative binomial distribution, which allows greater flexibility in modeling count data with variance greater than the mean. Model diagnostics, including residual plots and goodness-of-fit statistics, were examined to ensure that the assumptions of the negative binomial GLMM were met. All analyses were performed using R version 4.1.2 and GLMMs using the lme4 [p < 0.05 on two-sided tests was considered statistically significant.We used generalized linear mixed models (GLMMs) to examine predictors of program participation and program use at the individual and school class levels. Within each GLMM, a random intercept for class was modeled. The general procedure for calculating the multilevel models at the class and individual levels was to first test all individual characteristics univariately and to include in the multivariate model only those predictors that were significant (the lme4  package.SmartCoach program was possible in 28 school classes from 11 schools from September 2022 to December 2022. Recruitment for the p < 0.01). A duration of the introductory workshop on stress of more than 50 min resulted in a participation rate of 79.1%, while only 54.3% participated in school classes with a workshop duration of up to 20 min .p < 0.01, intraclass correlation coefficient (ICC) 0.19, conditional R2 0.28).The variable “workshop duration” was excluded in the selection process for the final multivariate model and only “educational level” was retained for the final prediction model for program participation  or interest (n = 4) in participating in the program. Another 22 students said they had no stress at the moment or saw no need to participate. A further five indicated that they had other ways of dealing with stress and four said they were already good at dealing with stress. No time was given as a reason by nine students, while two found the effort to participate in the program too high. Seven people found the questions within the program too personal. Five students each stated that they did not have a smartphone or that its battery was empty. Three persons did not participate for data protection reasons, because they already receive enough messages via smartphone, or are not allowed to register for such programs themselves, respectively. One student found the program too anonymous.Of the 116 students who completed the non-participant survey, 90 provided usable free text information on the reasons for not participating in the SmartCoach program by baseline characteristics on the level of the individual and the school class. None of the baseline characteristics on the level of the school class significantly predicted program use. On the level of the individual, the univariate models identified the variables “age”, “migration background”, “origin from a non-German-speaking country”, and “perceived stress” as significant predictors of program use. Compared to the reference category of 14-year-old students, program use was significantly lower for students who were 16 or older (incidence rate ratio (IRR) 0.71, 95%-CI 0.63–0.81, p < 0.01). Furthermore, participants with a migration background  or an origin from a non-German-speaking country  showed significantly lower odds of program use. Finally, students with a medium level of perceived stress showed higher program use, compared to those with a low level of stress .The mean number of interactions with the SmartCoach program was 15.9 (SD = 14.7), i.e., participants engaged in almost half of the 37 possible interactions with the program. p = 0.02, ICC 0.01, conditional R2 0.04).The variables “age”, “migration background”, and “perceived stress” were excluded in the selection process for the final multivariate model and only the variable “origin from a non-German-speaking country” was retained in the final prediction model for program use  participated in the program, with upper secondary school students showing significantly higher participation rates (84%) than secondary school students (59%). On average, program participants took part in almost half of the interactions prompted by the SMS text messaging program, with significantly higher program use by students from German-speaking countries of origin.Through proactive recruitment of students within the school curriculum, the majority of those present were recruited to participate in SmartCoach. The participation rate is thus similar to other interventions where a personal invitation for a mobile phone-based prevention program took place in the classroom ,9,10,38.SmartCoach program, young people were invited to participate following a workshop on stress in the context of their school class. Participants then received individually tailored life skills messages on their personal smartphones for a period of four months. Interestingly, but not unexpectedly, predictors on the level of the school class  were associated with program participation whereas predictors on the individual level  were associated with program use. This underlines the importance of class characteristics in recruiting participants and the greater relevance of individual characteristics for program use.In the SmartCoach program.In contrast to several previous studies, we could not identify sex or migration status as significant predictors of program participation ,9,10,11.On the other hand, the type of school played an important role, and the participation rate in classes from upper secondary schools was significantly higher than in secondary schools. Based on the free text answers, which attribute non-participation mainly to a lack of interest in the topic of stress, a lower level of stress among young people in secondary than upper secondary school classes might be a reason for the lower participation rate in this subgroup. An exploratory comparison of the perceived stress scores between secondary and upper secondary school students of this study revealed that the stress level is significantly higher among the upper secondary school students, which supports this assumption. An increased consideration of stressors relevant for students with lower educational level in the workshops, beyond pressure to perform, might be appropriate to increase interest and participation in the program.With regard to program use, the results of this study are in line with previous studies that found higher use among younger youth and those without a migration background ,17,21. WAs the reach across the target population determines the public health impact of an intervention  and poorSmartCoach program were rewarded with credits, and credits were linked to a prize draw. Fourth, the statistical power was limited, particularly for the examined predictor variables on the level of the school class.The results of this study must be interpreted in light of its limitations. First, they rely on a convenience sample, and the findings might not be generalizable to the adolescent population. Second, this study used self-report data, which carries the potential that social desirability may have affected the findings. Third, the interactions with the SmartCoach is an attractive offer for young people, in which two out of three young people who are invited in the classroom to participate do so. Among the program participants, the use of the program is acceptable, with an average of almost half of the content being worked on. Regarding socioeconomic inequalities, the results do not indicate a negative equity impact of the intervention, as socioeconomic status was neither associated with program participation nor program use. There is potential for improvement in terms of recruitment, especially in school classes with a lower level of education. For these, a less strong focus on performance pressure and a stronger consideration of other stressors could increase the willingness to participate in the program. The most important starting point for improving program use lies in taking greater account of needs and wishes of students with non-German-speaking countries of origin.


Academic departments universally communicate information about their programs using static websites. In addition to websites, some programs have even ventured out into social media (SM). These bidirectional forms of SM interaction show great promise; even hosting a live Question and Answer (Q&A) session has the potential for program branding. Artificial Intelligence (AI) usage in the form of a chatbot has expanded on websites and in SM. The potential use of chatbots, for the purposes of trainee recruitment, is novel and underutilized. With this pilot study, we aimed to answer the question; can the use of an Artificially Intelligent Chatbot and a Virtual Question-and-Answer Session aid in recruitment in a Post-COVID-19 era?We held three structured Question-and-Answer Sessions over a period of 2 weeks. This preliminary study was performed after completion of the three Q&A sessions, in March–May, 2021. All 258 applicants to the pain fellowship program were invited via email to participate in the survey after attending one of the Q&A sessions. A 16-item survey assessing participants’ perception of the chatbot was administered.Forty-eight pain fellowship applicants completed the survey, for an average response rate of 18.6%. In all, 35 (73%) of survey respondents had used the website chatbot, and 84% indicated that it had found them the information they were seeking.We employed an artificially intelligent chatbot on the department website to engage in a bidirectional exchange with users to adapt to changes brought on by the pandemic. SM engagement via chatbot and Q&A sessions can leave a favorable impression and improve the perception of a program.The online version contains supplementary material available at 10.1186/s12909-022-03872-z. Although web based interviews (WBIs) have substantial cost and time benefits, they do pose their own new challenges; mainly due to the lack of in-person, face-to-face interactions and the difficulty in picking up non-verbal cues on a screen [The COVID-19 pandemic has brought sweeping changes to how we recruit residents and fellows. Due to travel restrictions, social distancing and limits on gatherings, the norm of in-person interviews has been replaced by virtual interview platforms. Multiple regulatory bodies, including the Accreditation Council for Graduate Medical Education (ACGME), have called accredited programs to “commit to online interviews and virtual visits” . With the growth of AI, its effects have permeated into various aspects of our lives, including the medical field. AI is changing traditional methods of medical imaging analysis, health data acquisition, and even medical education. AI has practical uses for distance learning and various inquiry systems, however AI for the application of trainee recruitment has not been reported [SM appears to have an increasing influence on residency decisions . With threported . AI usagreported . Chatbotreported . While treported . While mreported . AI and In order to adapt to changes brought on by the pandemic, we recently employed an artificially intelligent chatbot on the department website to engage users in a bidirectional exchange. The chatbot is a conversational AI agent which uses natural language to understand phrases. It was tested by a third party to create the appropriate flow of information and allow users to ask questions and search for information. For example, applicants could ask the chatbot “Show me faculty that trained at <applicants home residency> or where do fellows live?” The chatbot would then return profiles of faculty that met criteria and an interactive google map of where fellows live, respectively. In addition, we used the chatbot to schedule and coordinate live, synchronous Question and Answer sessions about our program. Instead of using separately purchased scheduling software which would still rely on human monitoring, we employed the use of a chatbot to aid in some of the work usually performed by a human coordinator. We used these new technologies to complement the traditional strategies that are used to engage potential applicants. With this preliminary study, we aimed to answer the questions; can the use of an Artificially Intelligent Chatbot and a Virtual Question-and-Answer Session aid in recruitment in a Post-COVID-19 era and how will AI change what tasks machines can perform?We held three structured Question-and-Answer Sessions over a period of 2 weeks. These sessions were coordinated to be live and synchronous. Invites to these sessions were sent out to all applicants to our program through the Electronic Residency Application Service (ERAS) email contact information provided. Applicants were instructed to sign up through the chatbot for one of three Q&A sessions. The chatbot registered each invitee and sent out a calendar invite with a direct web link to the Q&A session. This way each applicant that signed up would have a reminder for our Q&A session with a link on their calendars. These sessions were held 2 months prior to sending out interview invitations and participation had no bearing on the decision to offer an interview. Each 30 minute session briefly covered the mission and vision of the division (led by Division Chief), highlighted the local area and attractions , then described clinical sites and the details of the fellowship throughout the year (led by Program Director). The moderators discussed research opportunities and emphasized the multidisciplinary aspect of training. Finally, participants were given a chance to ask any program specific questions.https://www.userlike.com/en/blog/consumer-chatbot-perceptions). If participants indicated that they participated in a Q&A session, they were presented with 7 additional items  to participate in the survey. A 16-item survey assessing participants’ perception of the chatbot was administered online via Qualtrics. The items were adapted from the System Usability Scale  and fromForty-eight pain fellowship applicants completed the survey, for an average response rate of 18.6%. In all, 35 (73%) of survey respondents had used the Department of Anesthesiology website chatbot, and 84% indicated that it had found them the information they were seeking. Respondents often asked the chatbot multiple questions, with 31% asking at least 5 questions.Not surprisingly, most survey respondents used the chatbot to find information about the fellowship program (69%), and many also sought to learn about the University (41%), the Anesthesiology Department (37.5%), and its residency program (28%). 37.5% of respondents used the chatbot to sign up for a Q&A session. Less often, they used the chatbot to find people in the department, to learn about the city, and where the program is located. Of the chatbot’s features, 31% of respondents found scheduling a Q&A session most appealing and an additional 31% found asking it questions to be the most appealing feature. Another 22% found all features appealing and 6% found none to be appealing.Survey questions also targeted the chatbot’s advantages and disadvantages. Most respondents perceived the chatbot to provide a quick 84%) or helpful (56%) response, to be a cool new technology (66%), and to be friendly (50%). In terms of disadvantages, 22% indicated the chatbot was unable to help them, 11% said that finding the information they needed required a prolonged effort, and the chatbot couldn’t understand an additional 11% of survey respondents. However, 59% of respondents found no disadvantages to the chatbot. Overall, respondents seemed to find conversations with the chatbot a positive experience and the chatbot to be useful and usable Figs.  and 4.Fi% or helpSeventeen (39%) survey respondents participated in a Q&A session out of a total of 58 participants who logged on for a Q&A session. Of these, 93% participated to learn more about the pain fellowship program and 87% to show interest in the program. Q&A session participants indicated they learned more about the program from the Q&A session than from the Department Anesthesiology website (73%) or that both sources of information were equally useful (27%); none found the website more useful for learning about the program than the Q&A session. The perception of the pain fellowship program improved for 87% of participants after the Q&A session and made them more likely to interview for the program. Many found the research, education, and clinical experience provided to be appealing; a minority found the education and location of the program to be unappealing Fig. .Using AI technology, in the form of a chatbot, to provide auxiliary information appears to have advantages. Once participants landed on the website, they did use the chatbot frequently to ask specific questions. They found the chatbot to be more useful than the information found on the website and interacted with the chatbot for multiple questions. Using the chatbot to coordinate Q&A sessions was well accepted by applicants. Finally, hosting a live, synchronous Q&A session scheduled through the chatbot, had an overwhelmingly positive effect on the perception of the program. Participants found many aspects of the program appealing after the Q&A session and were more likely to interview if given the opportunity.We know that interview days heavily influence match list rankings giving applicants an overall impression of the atmosphere of the program . The losWhile Machine Learning and AI have been incorporated into certain aspects of medical education such as procedural assessment tools for cases involving image analysis , to our With an increase in SM use, especially due to the pandemic, a program’s website and SM platforms can have a significant impact on recruitment and application decisions . IncorpoAdditional file 1: Survey Questions.


This study explored the views of 30 gastrointestinal cancer patients on the adoption of a prehabilitation multimodal program, including exercise, nutrition and psychological counselling, which was delivered via e-Health. Most of the patients undergoing gastrointestinal cancer surgery were confident using technology, perceived the preoperative online program safe to be delivered at home, and of potential benefit to their wellbeing. However, “poor preoperative health”, “lack of motivation” and “lack of personal encouragement” were identified as the main barriers to the uptake of a preoperative online program. The safety and efficacy of the online program would need to be tested in a larger randomised controlled trial.This study aimed to explore patients’ perspectives on the adoption of a prehabilitation multimodal online program. Patients recovering from gastrointestinal cancer surgery at a tertiary hospital between October 2021 and November 2022 were invited to participate. An e-Health program including intensity exercises, nutrition and psychological counselling was used. Patients were instructed to navigate the e-Health program over 24 h using an iPad and then complete the study survey. Patients’ characteristics, use of technology, views and minimal expected outcomes from a preoperative online program were collected. Of the 30 patients included, most were female, most reported confidence in the use of technology, most considered the online program safe and most agreed it would be beneficial for their health. “Poor preoperative health” and “lack of motivation and encouragement” were identified as the main barriers to the uptake of a preoperative online program, while program ‘simplicity’ and perceived ‘benefits’ were the main facilitators. Significant improvement in postoperative outcomes is perceived to influence patients’ willingness to participate in a preoperative multimodal e-Health program. Gastrointestinal cancer patients perceived the adoption of a preoperative multimodal e-Health application as safe to be performed at home and of potential benefit to their health. A range of patient’s characteristics, barriers and facilitators to the uptake of an online program were identified. These should be considered in future preoperative multimodal online programs to enhance patient experience, adherence and efficacy. The safety and efficacy of the online prehabilitation program will need to be determined in a larger randomized controlled trial. In 2020, approximately 20 million new cases of cancer were diagnosed worldwide, and almost 10 million cancer-related deaths were reported . DespiteTo overcome this, several randomised controlled trials have been published in the last few years, investigating the effectiveness of a wide range of preoperative interventions on postoperative surgical outcomes for patients with gastrointestinal cancer ,18,19,20A potential solution to these limitations is the implementation of a preoperative multimodal intervention via an e-Health app, allowing access to an individualised intervention at home. Recently, a published systematic review explored the evidence of technology-driven preoperative interventions on postoperative complication rates, length of hospital stay and quality of life outcomes in patients undergoing cancer surgery . SurprisThis cross-sectional study explored the adoption of a prehabilitation multimodal online program in patients undergoing gastrointestinal cancer surgery at the Royal Prince Alfred Hospital (RPAH) between October 2021 and November 2022. This design was selected as it is a quick and unexpensive design used to study the exposure  and outcome  at the same time . A studyPatients aged 18–85 years recovering  from elective lower gastrointestinal cancer surgery for primary or recurrent malignancies were eligible to participate. Patients were excluded if they have cognitive impairment such that they are unable to give informed consent and/or inadequate English to complete the study survey or verbal instructions. Participants were identified by their treating team and provided with the patient information sheet and consent form. An experienced research officer confirmed eligibility and answered any questions. Consenting patients were provided with the prehabilitation multimodal e-Health program.https://www.standingtall.org.au/ accessed on 1 September 2023). For the purposes of this study, StandingTall incorporated gentle warm-up exercises, sit-to-stand exercises and stepping exercises that can be undertaken with weights, to improve exercise capacity and overall muscular fitness. These exercises were appropriate for our population and were used, together with the nutritional and psychological advice. Participants were instructed on how to use the program by an experienced research officer. The study iPad was left with the participants for a minimal of 24 h. Participants were instructed to navigate the preoperative multimodal online program during this period, but not to complete the exercises or follow the nutritional or psychological advice, as all patients were recovering from surgery in hospital. This population was selected as they would be able to better recall the preoperative period and provide greater insight into the developed online program.Consenting participants were provided with a demonstration of a prehabilitation multimodal e-Health program, delivered on a study iPad. The e-Health exercise program, called StandingTall ,32, was Patient characteristics, experiences, barriers and facilitators related to the preoperative multimodal program were explored, aimed at guiding the future development of a standalone preoperative program. The developed survey was piloted in five patients, five clinicians and one cancer consumer. The feedback provided during the development process helped identify key areas of focus, rewording of questions and helped deciding on which questions should be retained or dropped. The following open-ended question was used to identification of barriers and facilitators related to the preoperative multimodal program, “Please describe what would be the main facilitators/barriers for the uptake of a preoperative online program involving exercise, nutrition and psychological intervention?”.The length of time each participants spent navigating the exercises was not recorded, but participants were instructed to navigate the program as much as possible. All participants reported that they have explored all features of the online preoperative multimodal program.Patient outcomes included their characteristics , self-reported nutritional (PG-SGA Short Form) , and phyDue to the design of this study, we have used a non-probability sampling method , where wDuring the study period, a total of 30 participants navigated the preoperative multimodal online program. Of these, most were female (80.0%), born in Australia (70.0%), with a university degree (56.7%). Overall, 80.0% of participants were engaged in moderate or high physical activities, 50.0% of patients were at high risk of malnutrition. Between 3.4% and 31.0% of the sample reported an adverse health condition. Detailed characteristics of the included participants are described in Most of the included participants owned an Apple or Android smartphone (96.7%), iPad or tablet (56.7%), and a computer or laptop (76.7%), with the majority using these devices at least once a day to check their emails and browse the internet. Most of the included participants were confident or extremely confident about the use of technology . The views of the included participants towards a preoperative online program are included in Of the 19 (63.3%) patients that responded to this section of the study survey, the main facilitators to the uptake of a preoperative online program included two main overarching themes related to “simplicity”, and “benefit”. “Simplicity” was related to the preoperative multimodal program being easy to use and understand, and “Benefit” was related to the perception of effectiveness of the program on improving their health and promote wellbeing.Of the 16 (53.3%) patients that responded to this section of the study survey, the main barriers to the uptake of a preoperative online program included three main overarching themes related to “poor preoperative health”, “lack of motivation” and “lack of encouragement”. “Poor preoperative health” was related to the presence of comorbidities and symptoms , “lack of motivation” was related to lack of enthusiasm, difficulty in getting started and lack of clear goals, while “lack of encouragement” was related to lack of support/involvement  to reinforce they were on the right track.The minimal effectiveness of the preoperative online program on postoperative outcomes expected by the participants are detailed in This study describes the views and expectations of gastrointestinal cancer patients on the adoption of a preoperative multimodal intervention delivered via e-Health. We found that most patients undergoing surgery are confident using technology, perceived the preoperative online program safe to be delivered at home, and of potential benefit to their wellbeing. The safety and efficacy of the prehabilitation online program would require to be explored in a larger randomised controlled trial. “Poor preoperative health”, “lack of motivation and “lack of personal encouragement” were identified as the main barriers to the uptake of a preoperative online program. Whereas the “simplicity” of the program and the perceived “benefits” were identified as the main facilitators to the uptake of a preoperative online program. Clinically significant reductions on postoperative complications, length of hospital stay and pain, and improvement in quality-of-life outcomes are some of the outcomes perceived to influence patients’ willingness to participate in a preoperative multimodal online intervention.This is one of the first studies to seek consumer feedback on the development of a preoperative multimodal intervention delivered via an e-Health app. The information gathered in this study will support the development and guidance of future preoperative online applications for patients undergoing cancer surgery. Evidence suggests that adherence to unsupervised programs that are delivered at home is poor when compared to face-to-face programs . This haOther studies are currently developing mobile apps as a tool to facilitate the delivery of prehabilitation. Wang et al., 2021 described a mobile app including a prehabilitation program for elective patients (N = 8 participants) . This inDespite most of the participants reporting no preoperative comorbidities and being confident on the use of technology, some participants reported the presence of multiple comorbidities and lack of confidence when using mobile devices. This information is important for the development of future preoperative e-Health programs. Previous studies have reported an increased number of comorbidities within cancer patients, and an association with greater risk of postoperative complications . Thus, iOne of the main barriers to the uptake of a preoperative multimodal e-Health program included “poor preoperative health”. Presence of preoperative comorbidities are common amongst cancer patients undergoing surgery. In our study, high or low blood pressure were present in 40% of the sample. It is recommended that patients presenting with these comorbidities are treated appropriately, so they can undertake the preoperative multimodal online program safely. Hearing and visual impairments were observed in over 30% of the patients. Preoperative online programs should be modifiable to patient’s needs, and the ability to easily adjust display light, font and volume is required for this population. Other barriers identified included, “lack of motivation” and “lack of encouragement”. Online motivational coaching, incorporating combined strategies of supervision, feedback, and reinforcement has been suggested to increase adherence to exercise programs . InteresFacilitators to the uptake of this preoperative multimodal e-Health program are that is easy to use and navigate and provides information on the benefits of patients’ wellbeing. Interestingly, whereas most patients would accept an approximately 50% reduction on postoperative complications and a reduction of 3 days on the length of hospital stay as the minimal outcomes perceived to influence their willingness to participate in a preoperative multimodal online intervention, a considerable number of patients indicated higher postoperative improvements, which are currently not supported by the prehabilitation literature . Clear eOne of the strengths of this study is the inclusion of participants with lived experiences of gastrointestinal cancer. The recruitment was completed during their postoperative in-hospital recovery period, following gastrointestinal cancer surgery, thus facilitating recall of the preoperative period . In addition, this study includes a range of questions that provided greater details of their characteristics and perspectives towards the adoption of a preoperative multimodal online program. The main limitations are the bias toward the highly educated, predominantly female population, who were comfortable using technology. Additionally, patients were recruited from a single tertiary hospital following gastrointestinal surgery. Thus, it is important to note that the results of this study may not be generalised to other settings and populations. Furthermore, only 50–60% of the participants responded to the questions related to facilitators and barriers to a preoperative online program. This may be because they did not actually try the exercise program. Future studies investigating different consumer aspects and perspectives are warranted to further support the development and guidance of preoperative multimodal online programs.Prehabilitation e-Health programs have the potential to improve preoperative physical, nutritional and psychological outcomes of patients undergoing cancer surgery, leading to a reduced number of postoperative complications and shorter recovery time. This technology can be used for delivering a prehabilitation program for patients undergoing surgery in the comfort of their homes, especially for patients that live in rural or remote areas. Future prehabilitation trials should consider the information reported in this study to further support the development of e-Health programs for patients undergoing cancer surgery.Gastrointestinal cancer patients perceived the preoperative multimodal e-health application safe to be performed at home and of potential benefit to their health. Several patient’s expectations, barriers and facilitators were identified. These should be considered in future preoperative multimodal online programs to enhance patient experience, adherence and efficacy. The safety and efficacy of the online prehabilitation program should be tested in an appropriately powered randomized controlled trial.