Fathers significantly influence family functioning, as coparents and partners, and must be part of family-based approaches to behavioral health interventions or programs. But little is known regarding how to support Latino fathers in health promotion within their family systems, specifically for Latino families living in border communities. Program development was embedded in a larger community-based grant and part of a longstanding academic-community collaboration. An interdisciplinary research team applied theories related to health behavior, family systems, behavior change, and community engagement to develop a father-focused and family-centered behavioral program for Mexican-heritage fathers and children living near the Texas-Mexico border to support changes in nutrition and physical activity at the individual and family levels. Promotoras de salud  delivered the program through group sessions, check-in calls, and at-home activities. Group session activities were designed to engage family triads and dyads using experiential education related to nutrition and physical activity, like cooking lessons and active play, over a six-week period. Future research can use the program approach and curricula as a roadmap for designing context-specific and culturally-relevant programs for Latino families. Additional research is needed to explore how approaches like this can support families and their health goals. Prior research suggests focusing on parents as the agents of change in childhood obesity prevention and treatment may be more effective than child-focused interventions or programs . SeveralHaz Espacio para Papi!  program for Mexican-heritage families in border communities in South Texas, which aimed to positively change nutrition and physical activity behaviors among participating fathers and their children. The purpose of this manuscript is to describe the rationale and design, including the theoretical foundation, and offer a roadmap for future behavioral programs with this priority population.There is growing interest and need for family-centered and father-focused behavioral health programs to support nutrition and physical activity within family systems ,14,15,16Salud para Usted y Su Familia  initiative that integrated research, education, and outreach to improve family and community health. The team included academic-based researchers in public health with training and experience in nutrition, physical activity, social and behavioral health, a licensed family psychologist with expertise in Latino family systems, and promotoras , with tCommunity-engaged research (CEnR) principles guided the development process ,28. The n = 334), Fathers’ Dyadic Interviews , and Fathers’ Elicitation surveys (n = 330). The children’s and mothers’ pláticas integrated participant-driven photo-elicitation [In addition, program development was based on extensive formative work. The research team conducted formative research in the community to understand needs, assets, desires, and preferences for a behavioral program focused on nutrition and physical activity. In preparation for this program, the field-based research team identified, mapped, and ground-truthed 16 geographic areas or “clusters” to describe the neighborhood environments and community resources. Clusters were defined based on similarity in size, population, sociodemographics, and naturally occurring boundaries. A sequence of activities with Mexican-heritage families followed ground-truthing: Children’s Pláticas , Mothers’ Pláticas , Mothers’ Elicitation surveys  through the design, implementation, and evaluation of HEPP. The HEPP program was a father-focused, family-centered, strengths-based program designed to initiate and support behavior change at the individual and family levels. While the program targeted nutrition and physical activity behaviors, the program primarily focused on nutrition. The literature guided the team’s approach to father engagement ,32,33,34Entre Familia: Reflejos de Salud, that used a “whole family approach” also focused on targeting family functioning and parenting behaviors related to food [The HEPP program drew on several theories, such as Social Cognitive Theory (SCT) , Family  to food ,37. SpecAs described in the SCT, reciprocal determinism exists between individual, behavioral and environmental factors and underscores the need to consider how individuals influence and are influenced by their environments . As outlAccording to the conceptual framework, program activities at the individual level would change individual cognitive and behavioral factors, which would directly change nutrition-related behaviors of children and parents . The primary individual determinants are knowledge, attitudes, self-efficacy, personal motivation, and skills related to enacting nutrition behaviors, and the individual behaviors themselves: dietary intake of fruits and vegetables and low to moderate physical activity. At the same time, program activities at the family level would change overall family functioning, family support, and family norms, which would change parenting behaviors related to nutrition and physical activity, especially modeling, and indirectly affect children’s behaviors. The program used the Circumplex Model to define family functioning as cohesion, flexibility, and communication . ApplyinAt the individual level, guided by SCT, the HEPP aimed to change cognitive factors like individual self-efficacy, attitudes, and knowledge. From SCT, self-regulatory strategies like goal setting, self-monitoring, providing feedback, and problem-solving are used to achieve behavior change in children, and parents, both fathers, and mothers. At the family level, the HEPP aims to change environmental factors related to family functioning, which is attributed to FEM. This program targeted family functioning, defined by cohesion, flexibility, and communication between family members , and focThe program included three program activities: in-person group sessions, check-ins , and at-home activities between group sessions. The research team hypothesized that the experiential education and skills-building during the in-person group sessions would change individual and behavioral factors, including motivation and skills related to dietary intake and physical activity. Problem-solving and goal-setting activities were hypothesized to change motivation and skills and support behavior change. Self-monitoring of dietary and physical activity behaviors, completed as part of the at-home activities, were hypothesized to affect change of family-level norms and support. The check-ins provided additional opportunities for problem-solving and goal-setting customized to each family. Co-participation in nutrition and physical activity, where parents and children jointly engaged in an activity, was a vital part of HEPP. According to the conceptual framework, family activities related to nutrition and physical activity behaviors, completed during in-person group sessions and at-home activities, would affect change in overall family functioning, family norms and support, and parent-child interactions related to parenting, which are sometimes described as “food parenting” . Key famThe program intentionally recruited and engaged Mexican-heritage fathers in addition to mothers. Panter-Brick and colleagues have suggested that engaging another parent-in-the-home, like mothers, supports retention . In collThe program aimed to recruit 10 to 12 families from each cluster or geographically-defined neighborhoods in the study area. Eligible families were identified using the following inclusion criteria: parents 21 years old or older and self-identifying as Mexican-heritage , cohabitating with partner or spouse and a child between 9 and 11 years at enrollment (or the start of the program), able to complete in-home measurement visits pre-and post-program, able to commit to full participation in the 6-week program, parents preferred to speak, read, and write in Spanish, and parents had to have lived in the colonia (or neighborhood cluster) for at least one year. Exclusion criteria included: parents or participating child reporting a severe food allergy or reporting physical activity restrictions ,42,46. The literature also has discussed the importance of providing transportation and childcare to support program attendance ,34. The The research team developed an informed consent process in collaboration with the promotoras and based on literature . For exaThe HEPP program was primarily a 6-week nutrition program with physical activity segments. Components included in-person group sessions, phone calls, and at-home activities, which supported the program’s overall theme. Weekly themes supported the overall theme. The overall theme was to embrace existing health-promoting traditions while encouraging new healthy traditions within families—a strategy guided by a strengths-based approach and the importance of feedback loops from the FAMILI approach  and prioOverall structure—HEPP included in-person group sessions, weekly check-in phone calls, and at-home activities, which were scheduled between group sessions.The program consisted of six weekly group sessions. Group sessions primarily focused on nutrition, though each session included a physical activity break. Within each session, participants completed the following program activities in this order: food and beverage tastings  and other sessions for the family triad . Half of the sessions were designed explicitly to support the father’s nutrition and physical activity. Decisions to focus sessions on the fathers  or both parents, as coparents and partners (week 4), were made based on formative work and promotoras’ experience and their feedback. Promotoras delivered the group sessions using a leader’s guide, which contained the curriculum with scripts, activities, and worksheets. Participants were given copies of materials for activities in their preferred language and encouraged to keep materials in their Family Guide. Each family received two binders, a Family Guide for the participating child and another Family Guide for the parents and entire family. Families were asked to bring their Family Guide to all group sessions. During each group session, promotoras guided participants through experiential education, skills building, and goal-setting activities across the interactive, cooking, and eating together lessons . The amoIn addition to the weekly in-person group sessions, the promotoras completed weekly check-in phone calls with mothers. Each call included reviewing which recipes, nutrition, and physical activity-focused activities the families tried at home, how they modified the recipes or activities, or their reasons for not trying recipes or activities. (All recipes and activities were contained in the Family Guide.) Promotoras also asked participants to identify the most valuable aspect of the last group session, share any feedback or suggestions for improvement, and if they shared any of the information or activities with their social networks. Aventuras para Niños Program provided inspiration for at-home activities related to nutrition and physical activity [The at-home component included additional activities for families to complete in between sessions. For example, as part of week 3, children received an apron and special fabric markers to customize aprons, which they could use during the subsequent cooking lessons. The “Homefun” component from the activity . Handoutactivity ).The literature informed decisions regarding duration, number, frequency, and length of sessions, and an appropriate amount of total dose delivered. The rationale was based on maximizing engagement and retention while not overburdening families with an extended program or exceeding available resources. The program lasted 6 weeks and was made up of 6 weekly group sessions (2.5 h per group session). The estimated dose delivered for fathers and children is 900 min (15 h); the estimated dose for mothers is 450 min (7.5 h). Because the program was father-focused and family-centered, there were more sessions for the fathers and children. For example, three sessions focused exclusively on fathers and children . The estimated dose does not include additional program exposure via check-in phone calls or text messages, or time spent engaged in the at-home activities between group sessions. Entre Familia: Reflejos de Salud , Aventuelivered ), Padreselivered ), Abrienelivered ), Communelivered ), and otelivered ,56 and Gbout 88% , which fThe team of promotoras delivered all group sessions in person. The research team delivered the program in July 2019 through May 2020. But the COVID-19 pandemic disrupted some program activities scheduled in mid-to-late March and through May. Changes were made to comply with policy changes at Texas A & M Univeristy. The promotoras scheduled weekly sessions consecutively on Saturdays at the Endowment Center in San Carlos, except for major holidays. The Endowment Center is a local community center in Hidalgo County, equipped with a large kitchen, flexible meeting rooms, and outdoor recreational areas. This location is convenient and considered a trusted and safe place by community members. Group sessions were offered on Saturday mornings (10:00 a.m.–12:30 p.m.) or afternoons (2:00 p.m.–5:30 p.m.). Previous research documented the importance of scheduling program sessions at times that facilitate engagement and active involvement of fathers and their families, such as times when fathers are not working . FamilieConsistent with participants’ preferences for communication, promotoras presented all activities verbally in Spanish with props and visual aids, including large posters and written materials for participating families. However, in one-on-one conversations, promotoras often spoke English, particularly with the children. Promotoras also provided parents and children with large binders for written program materials. This binder was referred to as the Family Guide. Parents and children chose which language they preferred for the written materials for their Family Guides. Generally, children requested English written materials, and parents asked for Spanish written materials. The parents and children added new written materials to their binders each week. Materials supported the in-person group sessions and at-home activities. Charlas , which are a culturally relevant way to engage Latino/a adults in educational activities. Charlas have been used as community-based health promotion and disease prevention programs with Latino/a adults and sometimes have been combined with a promotora model [Because HEPP was a family-centered program, accommodations were made to engage the mothers. The literature on father engagement and family-centered approaches also supports engaging the children’s mothers . Mothersra model ,59. EachThe nutrition curriculum consisted of all materials and activities from the in-person group sessions and at-home materials and activities in the Family Guide. Two components of the group sessions focused explicitly on nutrition: cooking lessons and tasting recipe “mini” nutrition education lessons. However, there was an implicit focus on nutrition in the eating together and goal setting component of the program. In the eating together lessons, families had an opportunity to discuss food and nutrition while eating the recipe they prepared in the cooking lessons. Vamos a Jugar Pirinola! (Let’s Play Pirinola!), which is a version of a traditional game Toma Todo, included game cards with nutrition facts for parents and children. In addition, the at-home activities, such as Papi’s Little Chef, support increases in nutrition knowledge, attitudes, and self-efficacy related to eating fruits and vegetables  and the focus of one interactive lesson for week 5 . For exagetables . HEPP focused on nutrition principles based on MyPlate : consumeThe team intentionally developed recipes to reflect the sociocultural preferences of the program participants, accommodate resource limitations within households and the community, and minimize requirements for specialty appliances in the group sessions or at home . Prior rThe main recipes, which were used in the cooking lessons , appealeAll cooking lessons featured a “spotlight” fruit or vegetable prominently in the main recipe . The sixAdditional recipes, called tasting recipes, were presented to families as they entered the community center or the program space . The proAlthough HEPP primarily focused on nutrition, a physical activity curriculum was developed as an integral part of the program. Detailed information on the development of the physical activity curriculum is available in a separate article . Each grWhile the focus of this manuscript is not program evaluation, this section describes the primary and secondary outcomes and measurement of outcomes and a brief overview of the data collected for process evaluation. The pre- and post-test measures were collected before and after the program. Data were collected at two separate time points (A and B) to collect dietary intake and physical activity data over a seven-day period. Data collection techniques included interviewer-administered surveys, more objective techniques like reflection spectroscopy with the Veggie Meter for fruits and vegetable intake, accelerometry for physical and sedentary activity, anthropometry for height and weight), and subjective techniques like semi-structured interviews  for the process evaluation. The nutrition survey included questions to assess psychosocial indicators related to nutrition, eating behaviors, and food practices, and there was a similar survey for physical activity. Semi-structured interviews were used to learn more about participants’ experiences in the program as part of the process evaluation. All measures were collected for all individuals: fathers, children, and mothers .® . Prior research has shown preliminary evidence for feasibility and initial validity of using the Veggie Meter with a racially/ethnically diverse group of participants [HEPP targeted behavioral changes related to nutrition and physical activity among Mexican-heritage fathers and their children. The primary outcome was a change in dietary intake of fruits and vegetables for the fathers and children between the pre- and post-test (about six weeks), measured using reflection spectroscopy and the skin carotenoid score obtained from the Veggie Metericipants . Secondaicipants ,71, and icipants ), and psFor process evaluation, promotoras collected data on fidelity (the extent to which the group sessions were implemented as designed), dose delivered (delivery of group session components), and dose received (participant attendance at group sessions and participation throughout group session). More detail is provided next. Dose delivered was evaluated using an observational checklist for each session. Each checklist included a full list of session components. For each of the components, promotoras were responsible for reporting if the component was delivered or not delivered, and when delivered, the extent of modifications, if any, that were made to each of the components. When any modifications were made, promotoras were instructed to provide a detailed description of the modification and their rationale for modification. Data to evaluate dose received was collected in two ways. First, participants self-reported attendance at group sessions using printed sign-in sheets, which were completed at the start of group sessions. Second, participants completed a self-assessment of program delivery at the end of group sessions. The checklist included items to document who  participated in each of the group session activities. In addition, the checklist included two questions: (1) “What questions, concerns, or suggestions, if any, do you have about today’s session”? (2) “What else would you like to share, if anything”? For the three father-child sessions, when the mothers participated in Charlas, mothers completed a different self-assessment for them to report on dose delivered.Additional evaluation data were collected. For example, for every session, children completed a brief questionnaire to report on the food’s appearance, taste, willingness to eat that food at home or school if that food was available and provide their overall opinion of the food items. This self-assessment provided information on the general acceptability of the foods from the children’s perspectives.Approximately three to four months after the program was completed, the promotoras contacted participants to complete maintenance measures, as a short-term follow up after the program . At thatThe maintenance data collection occurred during two different home visits. During the first visit, promotoras completed a nutrition and physical activity surveys, Veggie Meter scans (to measure dietary intake of fruits and vegetables) and began physical activity accelerometer tracking with each of the participating family members , respectively. During the second and final home visit, promotoras ended the physical activity accelerometer tracking with each of the participating family members. Additionally, promotoras conducted separate in-depth interviews with each of the participating family members to capture qualitative data related to their: (1) reasons for enrollment or participation, (2) sustained behavioral changes related to nutrition and physical activity, and (3) changes in their role within the family, (4) shifts in family functioning post-program, and (5) what they shared with their social networks. Promotoras conducted the interviews using an interview guide and audio-recorded the interviews.Padres Preparados, Jóvenes Saludables, led by Hurtado and colleagues [In summary, this manuscript presented the rationale and design for Haz Espacio para Papi , a family-centered, father-focused behavioral program for Mexican-heritage families living in border colonias. Prior research has discussed important ways that Latino fathers can influence their families’ health and well-being, including related to nutrition and physical activity ,73,74,75lleagues . Given tFirst, there are many unknowns for how best to engage and support Latino fathers in behavioral programs in nutrition ,34. HoweHEPP integrated a family-centered approach from start to finish. For example, the group sessions were held in a festive and family environment with refreshments, music, colorful decorations, and end-of-session raffles with prizes selected with fathers, mothers, and children in mind. Interactive activities used in lessons included a combination of active play and movement, games, both traditional  and games popular in the U.S. culture , arts and crafts (or creative activities), which engaged all family members, including additional children who wanted to opt out of the on-site child care and stay with their parents and sibling during the group sessions. A separate manuscript discusses other strategies for supporting behavior change with Latino fathers and their families . The famSecond, within Latino families, mothers serve as gatekeepers in different ways. Prior research has discussed the moderating influence of Latino fathers on nutrition-related behaviors, which is related to authority and control. However, more attention has been paid to the negative rather than the positive aspects of their involvement . ResearcHEPP explicitly focused on the fathers, but in a way that valued them as coparents and partners . This prLimitations included designing and implementing a program for one specific community in South Texas colonias and a subgroup of Latino families in that community. In addition, the program was designed for families with co-habitating parents . Future research is needed to design more universal programs that may be effective for varied family structures. While the HEPP approach, structure, and parts of the curriculum may be relevant for other border communities and Latino families, the HEPP program may not be translated to all border communities or all Latino families. Future research will need to consider unique strengths and limitations at the community, household, and family level in the adaptation process. Another limitation may be resource demands, including the costs of training , program delivery itself, and the data collection associated with evaluation. Padres Preparados, Jóvenes Saludables shared a similar approach, and their team completed a pilot study in the Spring of 2017 [Strengths of the HEPP approach to program design included the community-engaged research process, and collaboration with promotoras, and application of behavioral health theories and models, including FAMILI (Family-centered Action Model of Program Layout and Implementation) . In the  of 2017 . The HEPFuture research can use the HEPP approach and curricula as a starting point for designing context-specific and culturally-relevant programs for Latino families. Our extensive formative work, community-engaged, and theory-driven approach provide a roadmap for designing, implementing, and evaluating a family-centered program to support behavior change. This study fills a critical gap in understanding strategies for supporting a whole family approach for health promotion. In addition, the HEPP provides curricula for nutrition and physical activity, which can be valuable in supporting prevention of chronic diseases like obesity, diabetes, and other cardiometabolic conditions.In closing, HEPP applied theories of community and father engagement and behavior change to develop a father-focused, family-centered program for Mexican-heritage families to support nutrition and physical activity. This kind of innovative program may be what’s required to “accommodate the ecologies of families and empower families in the process”  (p. 460)


Background: Insufficient support for balancing career and family responsibilities hinders retention of physician-scientists. Programs to improve retention of this important group of faculty are crucial. Understanding the experiences of program implementers is key to refining and improving program offerings.Methods: We conducted an interpretive, descriptive, and qualitative study as part of an ongoing evaluation of the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists (FRCS) awards. We conducted telephone interviews with 12 program directors representing all 10 US medical schools who received the Doris Duke funding in 2016.Results: Of the 12 participants, 10 were women (83.3%). Participating program directors perceived the FRCS award as capable of producing paradigmatic changes regarding how responsibilities at home and work in academic medicine are viewed and integrated by early-career faculty members. The main qualitative themes that captured directors' experiences implementing the program were as follows: (1) championing a new paradigm of support, (2) lessons learned while implementing the new paradigm, (3) results of the new paradigm, and (4) sustaining the paradigm.Conclusions: These findings may help to inform development of similar programs to retain and support the career progress of physician-scientists with extraprofessional caregiving responsibilities. The interviews illuminate ways in which the Doris Duke FRCS award has driven institutional culture change by normalizing discussion and prompted reassessment of extraprofessional challenges and how best to aid early-career faculty members in overcoming these challenges. A robust and diverse workforce of physician-scientists is necessary to optimally advance knowledge and bridge the gap between research and practice. However, retention of this valuable workforce has proved challenging.11 Results from evaluation of this program have shown that recipients of the caregiver support awards perceived that the award meaningfully improved their productivity by ameliorating time challenges brought on by extraprofessional caregiving12 and lessened the stigma of caregiving challenges, particularly those associated with childcare and motherhood.13To support faculty development and retention, in 2016 the Doris Duke Charitable Foundation (DDCF) launched the Fund to Retain Clinical Scientists (FRCS), an innovative, multisite program to support early-career physician-scientists facing extraprofessional caregiving challenges.12–14 but little is known about the leaders' motivations and challenges experienced when implementing such awards. Therefore, we sought to explore leaders' perspectives in this study.Prior research about physician-scientist caregiver support awards has described faculty perceptions of the award on their well-being and on improving institutional culture,i.e., funds could not be used to pay for childcare or eldercare), some sites introduced additional features using institutional or other philanthropic support that generated variation in implementation and experiences across sites. Full program details have been reported previously.11–13The DDCF selected 10 US medical schools in 2016 to participate in its FRCS program, which aimed to enable these institutions to support early-career physician-scientists facing significant caregiving challenges. The selected sites then solicited applications from investigators at their institutions. Eligibility for individual awards required that faculty be MDs early in their careers (instructor or assistant professor), engaged in currently funded research with the potential to impact human health, and facing significant caregiving challenges. Individual faculty members who received the award from their participating institutions received funding of ∼$30,000–$40,000 to directly support their research. Although each site agreed to specific program elements, including the individual awards supported by DDCF funds only be used for research support , both trained in qualitative research methods, conducted the interviews. All participants were informed of the study procedures and granted verbal consent to proceed with the audio-recorded interviews. The University of Michigan Institutional Review Board determined this study to be exempt from review.19 Two analysts (L.A.S. and R.D.J.) analyzed the interview transcripts with all codes and themes reviewed and approved by the senior author (R.J.). We developed the initial codebook based on our previous knowledge of the literature, in combination with initial impressions from early interviews. We inductively generated additional codes through an iterative coding process. Each analyst independently coded all interview transcripts using Dedoose  and then met regularly to compare and consolidate codes and resolve any discrepancies. We identified initial themes and subthemes by consolidating the codes according to patterns we observed in the data. Finally, we reviewed the initial themes in comparison with the entire dataset to ensure that they accurately reflected sentiments present in the dataset as a whole.19We used thematic analysis to code the interview transcripts, identify patterns, and then organize the codes into themes and subthemes.20 we solicited feedback on the interview guide from site directors (including those who did not participate in interviews), and presented preliminary findings from the first 11 interviews during an annual meeting of the site leaders to engage in discussion of identified themes and support trustworthiness of the findings.In lieu of performing individual member checking (which has been discouraged as a method to improve rigor),Of 17 site leaders invited, 12 representing all 10 US medical schools who received Doris Duke funding participated in interviews (70.5%). Ten of the participants were women (83.3%). Interviews lasted an average of 46 minutes (range 24–68 minutes).We identified four major themes that described directors' experiences with implementing Doris Duke FRCS award program at their institutions: (1) championing a new paradigm of support, (2) lessons learned while implementing the new paradigm, (3) results of the new paradigm, and 4) sustaining the paradigm. We describe a selection of themes and subthemes in the results hereunder. Supporting quotations throughout the article are denoted by Q# and correspond to the full quotations provided in –4. sustainiThe thematic map  illustraDirectors acknowledged a preexisting paradigm within academic medicine that prioritized physician-scientists sacrificing their personal lives in favor of productivity and stigmatized seeking support for extraprofessional challenges .One director described this paradigm as outdated and built on the premise of the labor of a two-person household; the male physician-scientist who was expected to prioritize research productivity and patient care and the physician's partner  who supports the physician-scientist's ability to work by managing caregiving and domestic tasks (Q3). This outdated paradigm was perceived as unsustainable, given the current high numbers of physicians who do not have a supporting spouse upon whom they can rely.Some directors perceived that lack of resources to address or acknowledgement of extraprofessional challenges from their institutions stigmatized discussing work-life conflicts and that the Doris Duke award ameliorated some of this stigma. One director stated that the perceived stigma forced faculty members to seek support “off the institutional radar” (Q2) but that the Doris Duke award offered an “officially sanctioned” way to encourage early-career faculty members to open up about their extraprofessional challenges and seek support (Q2). The Doris Duke award explicitly promoted a paradigm of support by encouraging institutional leaders to discuss caregiving and the way it affects faculty members (Q4).Although praise for the Doris Duke program was unanimous, some directors still articulated a need for more progress in furthering a supportive paradigm within academic medicine and for institutionally embedded support for physician-scientist caregivers, such as greater availability of parental leave and emergency childcare leave .Bolstered by the successes achieved in the early stages of the program, many directors recognized the need to build institutional support to broaden the reach and impact of the program through the assistance of institutional leaders (Q7). Soliciting matching funds from awardees' departments or through other funding mechanisms at the institutions was a common way of obtaining additional support . Directors who successfully solicited additional support credited the demonstrable successes of scholars and “a recognition that the program was of value” (Q9). This approach also sent the message that the institution was willing to participate in solutions and share responsibility for caregiving demands.Program directors described the importance of demonstrating positive outcomes and impacts of the award and sharing lessons learned at their site with other FRCS directors. Capitalizing on program successes at each individual institution, directors shared their strategies with each other at the FRCS directors' annual meetings. These meetings enabled directors to collaborate with each other and expand knowledge of the needs and priorities of early-career physician-scientists (Q10).Directors' descriptions of the importance of support from institutional leaders and other site directors demonstrated a recognition that while the Doris Duke program enabled them to implement an intervention to support physician-scientist caregivers, broader institutional support and demonstration of positive outcomes such as increased extramural funding, increased research productivity, and improved well-being were necessary in promoting a new sustainable paradigm for physician-scientist caregivers.Implementing the Doris Duke program allowed directors to deepen their familiarity with the needs of their assistant professor faculty. Directors perceived a strong need for support for work-life integration among early-career faculty members at their institutions that was “more prevalent than anybody anticipated” (Q11). Many FRCS applicants experienced multiple caregiving challenges at the same time.For example, in addition to childcare, many faculty members were also responsible for their aging parents, managing domestic responsibilities, and taking care of personal health care needs (Q12). One director described that even when applying for the award, many early-career faculty members either understated or underestimated the number and impact of stressors in their lives (Q13).Another reason why faculty needs may have gone unnoticed before the Doris Duke program was the perceived stigma in disclosing extraprofessional challenges. One director described faculty members who “flew under the radar” because of the stigma associated with revealing caregiving challenges and instead of seeking support, lowered their career ambitions or left the research track entirely (Q14). Women and underrepresented minorities were perceived as particularly vulnerable to the compounding challenges of balancing work and extraprofessional challenges and therefore more susceptible to burnout and attrition (Q15).Given that the Doris Duke funds awarded to each institution were intended to support two to three award recipients each year at each site, directors and award committees faced difficult assessments of which applicants' needs were more significant when making award determinations. One director described how her views of what constituted significant need began to “[skew] toward the really devastating” (Q16). This skew led to faculty members with more typical caregiving challenges, such as those associated with child-rearing, to being judged as less critical than those with challenges such as terminal illnesses in the family or other similarly disruptive challenges (Q16).Lack of institutional support and policies to support personal flexibility for faculty members with typical parenting challenges and the difficulty of supporting this population through the Doris Duke program was perceived as a key limiter of the scope of the intervention (Q17).Once it was determined which faculty would receive the FRCS award, the primary method of intervention was direct funding for research needs (funds could not be used to pay for caregiving expenses). These funds were intended to free up valuable time for scholars by providing them the means to hire support staff, or have salary support or clinical buyout that enabled them to spend more time engaged in their research endeavors (Q18).In addition to direct funding, many sites developed novel complementary programs and services for FRCS scholars. These auxiliary services, provided using institutional funds, varied between sites and included small travel grants, support for grant writing and manuscript editing, and small grants for childcare services . Some sites even made these supplementary resources available for faculty who had applied for but not received the FRCS award or who were not eligible for the award, thus extending the reach of the support paradigm to a broader range of faculty (Q21).Directors discussed the importance of timing when making award determinations. The idea of timing referred to identifying potential award recipients who were at the ideal time in their careers and in their research projects to make the most efficient use of the FRCS funds.One director described the ideal timing as an applicant being at a point in their research where they could quickly put the award funds to use: (1) they had most of their research operations already established and (2) mostly needed additional personnel to aid with more tedious tasks such as data collection or data entry and they had a well-defined research plan (Q22). This director contrasted a “sweet spot” applicant with applicants who were not perceived as ideal award recipients owing to not being able to make use of funds because of considerable extraprofessional caregiving challenges (Q23).Challenges that directors faced in implementing the intervention included finding the right balance of additional resources and enrichment experiences without requiring too much time from awardees . Some directors also voiced concerns that young faculty members may not be seeking support because of the perceived stigma of disclosing their extraprofessional challenges and asking for assistance .The FRCS program was perceived as having far-reaching effects for awardees, their families, and their institutions.Directors noted an extraordinary level of program impact for awardees, including improving awardees' ability to perform research data collection, article publication, grant attainment, and scholar-reported improvements in work-life integration and psychosocial wellbeing (Q28–Q30).Some directors noted the possibility that the FRCS award had a positive impact on their institutions more broadly. One director suggested that the award had a significant return on investment, implying that the $30,000–$40,000 in grants to individual FRCS awardees could result in significantly more external grant funding for the scholars and the institution in the long run (Q31).Of note, some directors commented on how the FRCS award improved the institutional culture by creating an “institutionally sanctioned” model for supporting faculty experiencing extraprofessional demands and other life stressors, with the potential to inspire other departmental support for faculty by acting as a model program . A few directors also noted a reduction in the stigma of discussing work-life integration issues as a benefit that signified a paradigm shift occurring in academic medicine .In addition to the direct benefits to scholars and their institutions, directors noted benefits the Doris Duke award had for scholars' family members and the broader community. One director noted that scholars' family members and others who were dependent on them benefitted from the increased amount of time that the scholar had to spend on caregiving and domestic tasks. This included scholars' family members  who benefitted from the increased amount of time that scholar had to spend in their home lives . One director also noted that the broader scientific community of society benefitted from the awardees being retained as physician-scientists (Q37).Directors' comments indicated that shifting the paradigm toward support of work-life integration for physician-scientists was an ongoing process. The thematic map  illustraDirectors explained that frequent evaluation of program effects was key in identifying new ways and new groups of faculty to promote the program, offer new resources, or reassess award criteria. These lessons learned during program implementation (as discussed in Theme 2) strengthened directors' ability to champion a new paradigm by recognizing new opportunities and interventions to support physician-scientists with caregiving needs. Some directors described soliciting feedback from FRCS applicants and awardees as essential to improving program efficacy (Q5). For example, directors sought ways to make more efficient use of the FRCS funds by identifying resources already provided by their institutions such as faculty development, coaching or administrative support, and connecting applicants to those .In addition, the FRCS award was only available for early faculty members involved in human research; however, some sites received interest from later career faculty members or faculty involved in nonhuman research who were also experiencing caregiving challenges but were not able to be served by the FRCS funding mechanism (Q40). Site directors discussed plans to extend the benefits of the new paradigm by identifying more efficient ways to intervene through incorporating the award into existing institutional supports and identifying those who were not having their needs met through the Doris Duke funding.Directors worked to sustain the new paradigm of support by reaffirming the necessity of a new approach to supporting physician-scientist caregivers. Directors described plans to present outcome data to institutional leaders to advocate for the success of the program and seek other philanthropic or institutional funds or services to sustain and expand the program . Reaffirming the importance of the Doris Duke FRCS intervention to institutional leaders was described as an essential means of continuing to champion the new paradigm (as discussed in Theme 1) and creating additional ways to increase program reach and impact.In this qualitative interview study, we examined directors' perceptions of a novel national program intended to support early career physician-scientists experiencing extraprofessional caregiving responsibilities and their experiences with implementing the program at their institutions. Our results show that site leaders perceive the program can produce changes regarding how home and work life in academic medicine are viewed and integrated by early-career faculty.Some directors recognized that new cohorts of physician-scientists desire a culture in academic medicine that is more tolerant of the need for flexibility in managing life and work demands. They noted that an outdated paradigm within academic medicine supported a work culture that relied on the domestic work of one spouse, typically a woman who was not employed outside the home, to support the research productivity of the physician-scientist, typically a man.21 this paradigm of relying on a supportive spouse is increasingly less feasible for younger generations of physician-scientists. First, women are less likely to have stay-at-home spouses compared with men. Moreover, even in partnerships where both spouses work full-time out of the house, earlier research has shown that women still spend more time on domestic tasks and childcare as compared with their male counterparts.5With increasing representation of women in the physician-scientist work force,22 experience higher levels of burnout and depression, particularly women.24 Several of our respondents indicated that the paradigm of relying on a spouse for support is unsustainable in academia and more institutional support for time flexibility and family leave owing to caregiving is needed to retain physician-scientists. Research on “sandwiched” caregivers within academic medicine is needed to understand the lived experiences of these faculty members, how they manage dual caregiving roles, and what steps can be taken to support them.Second, the caregiving demand placed on physician-scientists who belong to “Generation X” or older Millennials has increased because of the necessity of caring for aging parents in conjunction with childcare and other domestic tasks. Studies have shown that caregivers within this dual role, also called the “sandwich generation,”25 where individuals attempt to avoid career penalties by minimizing or hiding caregiving responsibilities because of the perceived stigma of being seen as not completely devoted to work.26 Prior research has shown that recipients of caregiver awards perceive these awards as indicative of a culture shift toward validating caregiver needs.27Several directors believed that situating the Doris Duke award within existing institutionally supported funding mechanisms, such as Clinical and Translational Science Award units, or gaining contributing support from institutional leaders, was an important factor associated with reducing stigma associated with discussing caregiving challenges. Prior research has documented “bias avoidance,”The current results further support the idea that the benefit of the Doris Duke award lies partly in the fact that it is awarded for research merit as well as caregiving need. This dual purpose works to reduce stigma and augment the normalizing of the paradigm shift toward supporting work-life integration and away from expecting all support to derive from within the faculty member's family unit.28 This would indicate that integrating the FRCS intervention with established institutional processes would serve to strengthen the likelihood of a paradigm shift toward support being maintained.In addition, research in the program evaluation field has identified “institutionalization,” the routine integration of programs into existing organizational structure, as an essential component of sustainability.This institutionalization was also an important method of sustaining the paradigm by creating additional avenues for funding the program. Directors explained that soliciting additional funds from their institutions was an important method of ensuring program sustainability, considering that they were entering their last year of funding from the Doris Duke Foundation. Several directors had already put this plan into action by integrating institutional funds with Doris Duke Foundation funds through matching funds to support additional scholars and supplementary programs. Directors also discussed plans for soliciting further funds from other philanthropic organizations.29 A recent National Academies report has synthesized evidence raising concerns that the COVID-19 pandemic will lead to a quantifiable decrease in the productivity of women faculty,30 including both commentary31 and bibliometric analyses.32 Institutions need to take deliberate action to support women to ensure that the existing gender gap in academic medicine does not continue to widen.33These findings may help to inform development of similar programs to support retention and productivity of physician-scientist caregivers by illuminating ways in which the Doris Duke FRCS may have driven institutional culture shift. Furthermore, programs aimed toward support and retention of women faculty members are particularly important in light of the COVID-19 epidemic. School closings, shelter-in-place orders, and social distancing have made caregiving and childcare more difficult to manage, exacerbating challenges already faced by early-career faculty members, particularly women. By limiting in-person connections, these measures have also decreased collaboration, networking, and mentorship opportunities that are critically important for early-career faculty.34Programs such as the Doris Duke FRCS that affirmatively address caregivers' challenges will be essential to supporting the work of women in academia. Indeed, the Doris Duke Foundation recently announced plans to offer additional grants through a special “COVID-19 Fund to Retain Clinical Scientists” program.11 This research also benefits from careful use of qualitative data collection and analytical methods.36Strengths of this study include a diversity of settings represented by site directors in terms of institutional size and geographic location.37 Data saturation, the point at which we had captured the participant's full understanding of the phenomena being studied, was achieved and aided by the directors' role as participant researchers. Directors' intimate knowledge of the program helped to narrow the focus of the interview guide and enabled the interviewers to fully capture program details and participant experiences. In addition, directors' feedback during the annual meeting aided in achieving saturation by confirming that themes that were identified resonated with their experiences.37We obtained a rich, descriptive dataset, and we reached thematic saturation, the point at which no new codes were identified with subsequent interviews, with the sample providing enough data to support the emergent themes.17Limitations include that the work is qualitative and situated in a small number of institutions. Nevertheless, although some of our findings are specific to the population studied, we believe our study has broader policy implications for institutions interested in implementing programs similar in nature to the Doris Duke FRCS award. Finally, although some may argue that insider researchers may introduce bias because they are too close to the subject at hand, in the context of this study, engaging site directors as researchers and participants led to robust findings owing to directors' embedded knowledge and understanding of the Doris Duke program at their institutions.Directors responsible for implementing the Doris Duke FRCS award at their respective institutions described perceptions that the award is effective in alleviating burdens associated with extraprofessional caregiving challenges for early-career faculty members. In addition, they believed that the award was capable of creating a paradigm shift in the culture of academic medicine that validated the needs of physicians with caregiving challenges and supported a healthier approach to work life.The COVID-19 pandemic and its associated disruptions have recently heightened awareness of work-life conflict and its disproportionate impact on women in medicine. Although this study and the program it evaluates pre-date the pandemic, the lessons it illuminates are particularly timely as many institutions seek models for how best to support faculty to integrate their professional and extraprofessional caregiving demands.


OBJECTIVES/GOALS: Introduction: Between 2014 and 2019 the National Institute of Health (NIH) through the National Center for the Advancement of Translational Science (NCATS) has awarded about $2.7 billion to U.S. Academic Medical Centers to build a national network of clinical and translational science program hubs that serve to meet their key goals and initiatives. Today there are about 60 Clinical and Translational Science Award (CTSA) program hubs. Each CTSA program hub has a corresponding website highlighting its clinical and translational science centered programs and activities. These websites are a critical communication gateway to promote NCATS goals and initiatives. Objective: The objective of this research is to evaluate the NIH funded Clinical and Translational Science Award (CTSA) program hub websites for NCATS goals and initiative content alignment, navigability, and interactivity. METHODS/STUDY POPULATION: Methods: Each CTSA program hub website was systematically evaluated for information or tools that align with the five NCATS / CTSA Goals and eight CTSA nationally identified program initiatives. Each NCATS goal and CTSA initiative was subsequently ranked by information diversity level  and navigation level (click distance from the home page). RESULTS/ANTICIPATED RESULTS: Results: Four of the five NCATS goals are thoroughly and consistently represented among the CTSA Consortium with workforce development, patient and community engagement, and quality and efficiency of research being the top three. Informatics is thoroughly and consistently represented, but not always clearly identified on the home page. The most underrepresented goal is integration of special and underserved populations which was identified on only 60% of CTSA program hub websites. The most common focus of the eight CTSA program initiatives is the Trial Innovation Network in CTSA program hub websites. The Smart IRB comes in a distant second. The remaining six initiatives are severely underrepresented. DISCUSSION/SIGNIFICANCE OF IMPACT: Discussion: The identification of these gaps among the CTSA program hubs presents an understanding of content management and website functionality among the consortium from 3 principal approaches. First it creates an understanding of CTSA program hub content alignment with its funding source goals and initiatives. Such an understanding presents an opportunity to promote ways to create a better aligned consortium with improved collaboration pathways by the funding source through program hub website content standards. Second, it creates an opportunity for program hubs to understand and respond to the messaging their websites are presenting as it relates to the funding source. Third, it provides an opportunity to identify specific program initiatives and goals the CTSA institutions independently chose to highlight which can open a dialog to the better understanding the value of the program initiatives as they relate to the needs of CTSA program hubs. Ultimately, CTSA websites through content alignment should lead to an improved user experience.


The KT Challenge program supports health care professionals to effectively implement evidence-based practices. Unlike other knowledge translation (KT) programs, this program is grounded in capacity building, focuses on health care professionals (HCPs), and uses a multi-component intervention. This study presents the evaluation of the KT Challenge program to assess the impact on uptake, KT capacity, and practice change.The evaluation used a mixed-methods retrospective pre-post design involving surveys and review of documents such as teams’ final reports. Online surveys collecting both quantitative and qualitative data were deployed at four time points  to measure KT capacity  and impact on practice change. Qualitative data was analyzed using a general inductive approach and quantitative data was analyzed using non-parametric statistics.Participants reported statistically significant increases in knowledge and confidence across both workshops, at the 6-month mark of their projects, and at the end of their projects. In addition, at the 6-month check-in, practitioners reported statistically significant improvements in their ability to implement practice changes. In the first cohort of the program, of the teams who were able to complete their projects, half were able to show demonstrable practice changes.The KT Challenge was successful in improving the capacity of HCPs to implement evidence-based practice changes and has begun to show demonstrable improvements in a number of practice areas. The program is relevant to a variety of HCPs working in diverse practice settings and is relatively inexpensive to implement. Like all practice improvement programs in health care settings, a number of challenges emerged stemming from the high turnover of staff and the limited capacity of some practitioners to take on anything beyond direct patient care. Efforts to address these challenges have been added to subsequent cohorts of the program and ongoing evaluation will examine if they are successful. The KT Challenge program has continued to garner great interest among practitioners, even in the midst of dealing with the COVID-19 pandemic, and shows promise for organizations looking for better ways to mobilize knowledge to improve patient care and empower staff. This study contributes to the implementation science literature by providing a description and evaluation of a new model for embedding KT practice skills in health care settings. Contributions to the literatureDisseminates information about a promising and innovative KT capacity-building program/modelCharacterizes unique elements of the program including its focus on health care professionals who have responsibility for implementing practice changes, a multi-component support model, low cost, and applicability to a variety of professionals in diverse practice settingsProvides evidence from early evaluation of improvements in knowledge, confidence, and ability to implement practice changeThere is an urgent need to reduce the gap between the creation of evidence and its implementation into practice. However, alarmingly, up to 70% of all organizational improvement efforts fail, including those in health care settings . To addrProviding KT training takes a dedicated effort from health care organizations. Much of the research conducted on how to close the evidence-to-practice gap has been led by and/or focused on academic researchers with minimal involvement from those who provide or use health services . First-gMany programs exist to increase KT capacity, including some that offer training in implementation skills, but there is lack of information on their effectiveness. Programs that use active forms of learning to promote the acquisition of KT skills have been shown to be effective in transferring knowledge, but there is scant evidence of sustained practice change resulting from these sessions –9, 13. KArmed with these findings, we developed an implementation support program for HCPs, aimed at building capacity to move research evidence into practice. The program, called the “KT Challenge,” was modeled on a similar research capacity-building initiative for clinicians. That program, in place at our organizations for more than 10 years, has been shown to be effective in supporting practice changes, enhancing evidence-based practice, and increasing interest in research engagement, including increased interest in graduate school , 15. TheThe KT Challenge is a multi-component implementation support program that involves training, funding, peer review, and mentorship. The key components of the KT Challenge program are briefly described below.In the LOI, teams identify the practice change they want to implement, document the need for this change in their practice context, and summarize evidence of its effectiveness. LOIs also require the signature of a manager to ensure management support and endorsement, and the identification of team members. The LOIs are formatively reviewed and, in keeping with the capacity-building approach of this program, revisions are suggested when required. Some teams are screened out of the program at this point if their proposed LOI does not identify an evidence-based practice change, but most teams are given feedback and invited into the next stage.Teams attend two half-day workshops, focusing on developing an implementation plan, and evaluating the effectiveness of the implementation of the practice change. Topics include implementation theories and frameworks, stakeholder engagement, identifying barriers and facilitators, implementation strategies, and evaluation planning.Teams are supported to find a mentor within their clinical area to support the implementation of the practice change and assist with navigating facilitators and barriers. Mentors are also invited to participate in the evaluation of the KT Challenge program throughout the project.Teams have access to an online learning site where a curated set of readings and resources is posted.Teams are required to obtain their manager’s support for conducting the implementation project and dedicating time to it.Successful teams are awarded $5000 to cover costs related to personnel, materials and supplies, stakeholder engagement, and services.The KT Challenge is run by a program lead from each organization. The leads promote the program, coordinate the review processes, monitor team progress, support teams to successfully navigate barriers, and lead the evaluation of the program.Figure To evaluate the KT Challenge, we used a mixed-methods retrospective pre-post design , 16 to ap < 0.05.The qualitative data were analyzed using a general inductive approach, which involved the identification of themes and sub-themes related to the quality of the program, usefulness of various program components, impact on participants, impact on practice changes, and challenges. The themes were initially identified by one of the authors and then reviewed by two other authors. The quantitative data were analyzed in Excel (Microsoft Corporation), using the Wilcoxon signed-ranks test to compare pre- and post-scores on self-ratings of knowledge, skills, confidence, and ability. Statistical significance was set at Four cohorts of participants have taken part in the program, with a fifth cohort recently launched. The first cohort 2016) has completed their projects. To date, 24 teams have been funded, comprising 185 HCPs. Participants have included a wide range of HCPs involving 23 types of practitioners working within a range of practice settings . While 9 teams initially joined cohort 4, the number of teams dropped significantly when the COVID-19 pandemic struck, and only 2 teams submitted funding proposals. However, cohort 5 was launched in October 2020, and 13 teams applied to participate, including teams proposing COVID-related projects.The average survey response rate from the three cohorts was 76% for post-workshop #1 survey, 59% for post-workshop #2 survey, and 100% for both the 6-month check-in survey and the end-of-project survey.p < 0.05). In addition, at the 6-month check-in, practitioners reported statistically significant increases in their ability to implement practice changes  and cohort 3 (n = 6 teams) are currently completing their projects, with promising results, including one team that has significantly increased the percentage of patients with spinal cord injury receiving functional electrical stimulation treatment. Another team has garnered strong interest in their topic—treating problematic methamphetamine use—and was approached by local health care policymakers as well as staff from the United States Office of National Drug Control Policy, wanting information on their implementation plan.Three teams completed their projects but were not able to demonstrate measurable practice change. Cohort 2 . The content of the KT Challenge workshops is designed to address the identified barriers to successful implementation of evidence into practice, including lack of knowledge, skills, time, and leaders’ endorsement –10. The Program leads provide feedback and suggestions to teams in response to their quarterly reportsWorkshops and program documents were revised to specifically highlight the need for the project evaluation to collect data on the uptake of the practice changesProgram leads undertook more promotion of the program within their organizations to strengthen management’s commitment to the funded teamsAmong challenges faced by teams, lack of time, changes in personnel, and shifting work priorities were the most commonly cited. The following steps were taken to improve the program for future cohorts:However, even the teams who were unable to complete, or whose projects did not lead to measurable practice change, agreed that participation in the program was beneficial. We had hoped to see all projects result in demonstrable practice change arising from their interventions, but given the many barriers to practice improvements, it is unreasonable to expect 100% success. As Durlak and Dupre have noted, “Expecting perfect or near-perfect implementation is unrealistic. Positive results have often been obtained with levels around 60%...no study has documented 100% implementation for all providers.” . In comparison, 50% of our completed teams reported evidence-based practice changes, demonstrating the effectiveness of the KT Challenge program. Furthermore, the 185 HCPs who participated in the program gained knowledge and confidence in KT practice skills, as well as improved ability to implement practice change.We revised the KT Challenge program to enhance the relevance of the projects to patients and families and to improve the dissemination of the findings to audiences that include patients and families. Beginning with the 2019–2020 cohort, all KT Challenge teams were required to include a Patient-Family Partner on their implementation team, and all funding proposals are now reviewed by a panel that includes Patient-Family Partners.Our evaluation shows that the KT Challenge has been very effective at increasing capacity in KT skills and has provided information on areas where the program can be improved. We have carefully reviewed evaluation comments from each cohort in the KT Challenge and have made adjustments to the program based on feedback from participants, offering progressively improved support with each cohort. We hope this support will lead to a higher percentage of teams demonstrating measurable practice changes.These findings are based on the first cohort of teams who completed the entire program, which limited our ability to do more fulsome comparisons between the teams who were able to demonstrate practice improvements and those who were not able to complete their projects.The KT Challenge program is a promising initiative that can be adopted across a variety of clinical settings to support the effective uptake of evidence-based practice. This evaluation demonstrates that clinicians will respond to opportunities for KT training, that enhanced capacity for KT skills is achievable with support, and—most importantly—that successful practice change can result from small-scale, mentored, and funded KT projects in clinical practice settings. This evaluation study contributes to the implementation science literature by providing a description of a new and effective model for embedding KT practice skills in health care settings.


This cross-sectional study estimates the seroprevalence of antibodies specific to the receptor binding domain of the spike protein of SARS-CoV-2 and vaccination coverage among adults in Los Angeles County, California, in April 2021. We tested for differences in potential protective immunity by demographics and whether presence of RBD antibodies waned with time since infection.Understanding the presence of adaptive immune responses that are associated with protection from disease  caused by SARS-CoV-2 at the population level is critical for public policy. Potential protective immunity can be acquired either through vaccination or past infection.STROBE) reporting guideline.This cross-sectional study was approved by the LAC Department of Public Health (DPH) institutional review board and electronic informed consent was obtained. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology . We established 8 testing sites in LAC and residents who lived within a 15-mile radius (99% of LAC population) were eligible for participation. Testing was offered from April 9 to April 25, 2021. We used a proprietary database representing about a quarter of the LAC population maintained by a market research firm , to select participants. A random sample of these residents were invited, with quotas for enrollment for subgroups based on demographics of LAC residents. All participants were invited to participate in antibody testing and participants self-selected to consent for testing. Participants who had participated in a similar study conducted in April 2020 were oversampled.We used these weighted data to estimate the fraction of LAC adults that had received at least 1 dose of vaccine or had RBD antibodies, as a whole, and by vaccination status, demographics, and area poverty level. Statistical analysis was performed using Stata version 15 (StataCorp) from April to November 2021.Of 5500 adults who completed a screener to determine eligibility for the study, 2314 (42%) provided consent and 1335 (57.7%) were tested. Of the 1335 tested adults, 790 (59.2%) were female, 672 (50.3%) were aged 30 to 49 years, 186 (13.9%) were Asian individuals, 125 (9.4%) were Black individuals, 463 (34.7%) were Hispanic individuals, 498 (37.3%) were non-Hispanic White individuals, and 413 (30.9%) had annual household income less than $50 000. This study found that in April 2021 approximately 72% of LAC adults had potential protective immunity against SARS-CoV-2. Despite this high level of population immunity and continuing vaccination efforts, LAC experienced a surge in COVID-19 cases in July 2021 suggesting that reaching herd immunity might be more difficult than anticipated,Rates of potential protective immunity were much lower for Black individuals and those from lower-income households, which justifies increased vaccination efforts for these communities. The findings also suggest a much higher cumulative incidence of infection in high poverty areas, which likely contributed to the steep socioeconomic disparities in COVID-19 mortality rates observed in LAC.Almost all of the unvaccinated individuals with prior infection had RBD antibodies, even though many participants had infections several months prior to antibody testing. This suggests that RBD antibodies were not waning.The study has limitations. We used self-reported vaccinations and presence of antibodies as a marker for immunity instead of, for example, measuring cell-mediated immunity. Even though we weighted our estimates to match percentage of confirmed cases and percentage vaccinated—the 2 most important factors associated with protective immunity—we cannot rule out selection bias.


In southern California, the Alaska-Aleutian subduction zone has been identified as an earthquake source region of particular concern for a worst-case scenario distant-source tsunami. Here, we explore how RSLR over the next century will influence future maximum nearshore tsunami heights (MNTH) at the Ports of Los Angeles and Long Beach. Earthquake and tsunami modeling combined with local probabilistic RSLR projections show the increased potential for more frequent, relatively low magnitude earthquakes to produce distant-source tsunamis that exceed historically observed MNTH. By 2100, under RSLR projections for a high-emissions representative concentration pathway (RCP8.5), the earthquake magnitude required to produce >1 m MNTH falls from ~M Rising sea level in the next century exposes the Ports of Los Angeles and Long Beach to higher hazards from Alaskan tsunamis. By 2100, waves generated by an M8 Alaskan earthquake cause similar impacts in California to waves from an Alaskan M9 today. Increasing tropical cyclone-driven flood heights due to changes in storm characteristics and RSLR over the past millennium and forecast increasing flood heights in the coming decades have been documented for specific locations such as New York City10. Other research shows increased extreme sea levels during coastal storms due to RSLR along coasts in California6 as well as the contiguous United States11. Still, other studies have investigated changes to extreme sea levels associated with coastal storms and RSLR in locations such as Australia12 and Europe13 and from a global perspective14. However, the impacts of RSLR on coastal inundation during other potentially damaging events, such as tsunamis, need further research16. Along coastlines affected by distant-source tsunamis, where potential tsunami amplitudes are generally on the order of or lower than projected twenty-first-century RSLR, rising baseline sea levels can significantly increase tsunami impacts17.To the more than one billion people worldwide living in the coastal zone below 10 m of elevation18. Over the past two centuries, at least 14 distant-source tsunamis have damaged the California coast, with 8 of the 14 occurring in the last ~70 years19. The economic impacts of distant-source tsunamis in California have increased as coastal populations and infrastructure have grown. At the low-lying, densely populated, and economically important Ports of Los Angeles and Long Beach, recent maximum tsunami amplitudes  recorded at tide gauge 120 , Alaska , and Japan 19. The 1960, 1964, and 2011 tsunamis coincided with differing stages of low tide at the ports; therefore, their maximum nearshore tsunami heights ) were dampened. Nevertheless, strong currents and inundation caused by MNTH of 0.27 m in 1960 and 0.41 m in 1964 caused ~$17 M and ~$149 M (amounts referenced in this paper are in 2019 inflation-adjusted U.S. dollars) of damage in Los Angeles, respectively21. In 2011, MNTH of 0.13 m created strong currents at the ports and disrupted operations, and higher MNTH (>1 m) along the northern California coast caused ~$115 M in damage21.The economic impacts of future distant-source tsunamis are estimated to be in the billions of dollars for parts of the Pacific Rim, including the southern California coast23. The Semidi section of the Alaska-Aleutian subduction zone, defined as the portion of the subduction zone between western Kodiak Island and the Shumagin Islands, has been identified as a source area of particular concern because the continental slope azimuth there directs tsunamis towards southern California , and probably older prehistoric ruptures, propagated east into the Kodiak section  tsunami amplitudesnia Fig. 24. Howevion Fig. . Such evIn this work, we explore the effect of RSLR on low-probability, high-impact distant-source tsunami events at the Ports of Los Angeles and Long Beach. We combine single and multi-section earthquake and tsunami modeling along the Alaska-Aleutian subduction zone with probabilistic local RSLR projections for the ports to estimate potential MNTH for the ports during the twenty-first century.w8.0 to Mw9.4 (15 magnitude steps) along the Semidi and Kodiak sections of the Alaska-Aleutian subduction zone31. To account for source variability, we use 50 randomized earthquake areas (composed of adjacent NOAA unit sources) and hypocenter locations (assumed to be in the center of the earthquake area) for each step in earthquake magnitude  over which the slip is distributed for each earthquake magnitude varies (see “Methods” section). Our approach differs from probabilistic tsunami hazard assessments in that we use the same source region, suite of earthquake magnitudes, and slip variations for every year from 2000 to 2100, without considering the probability of each earthquake magnitude. This approach allows us to consider the changing impact of the same suite of significant earthquakes and tsunamis during twenty-first-century RSLR.We use a time-independent, deterministic earthquake modeling approach to generate a dataset of possible tsunamigenic earthquake sources ranging from M33 for the simulation of tsunami wave propagation  generates 750 deformation fields that are input into GeoClawion Fig. 20.35. Our method produces a broader range of MNTH similar to a non-uniform slip approach, although there may be an underestimation of the higher extremes of possible MNTH35 . Instead, we use TG2 as a reference point to compare how MNTH distributions are influenced by RSLR over time. We acknowledge that strong and erratic currents may be induced by distant-source tsunamis at the ports  and that the interaction of tidal currents with distant-source tsunamis may amplify MNTH38. Not including these processes in our modeling may underestimate the possible effects of distant-source tsunamis at the ports.Note that we do not analyze inundationb-value = 0.75) to calculate the relative rate of earthquake magnitudes along the Alaska-Aleutian subduction zone  in order to put the relative frequency of our chosen earthquake magnitudes into context. We used a declustered earthquake catalog , the 95% CR of MNTH is 0.19–1.78 m  of MNTH at the Ports of Los Angeles and Long Beach generated by tsunamis from M45. To account for the influence that tidal stage has on MNTH at the Ports of Los Angeles and Long Beach, we linearly combine our MNTH with tidal stages derived from a distribution composed of ~30 years of tidal data from TG120 , of −0.45–2.03 m 48, considered to be the most vulnerable ice sheet in a warming climate49, causing the coast to be exceptionally sensitive to RSLR.Changes in relative sea level during the twenty-first century vary by location as a result of processes such as atmosphere-ocean dynamics, the gravitational, rotational, and dynamic effects of ocean/cryosphere/hydrosphere mass redistribution, glacio-isostatic adjustment, sediment compaction, and tectonic uplift or subsidence50 (see “Methods” section). We examine low and high greenhouse-gas emissions pathways . RCP2.6 represents a low-emissions future with mitigation measures most consistent with the Paris Climate Agreement, while RCP8.5 represents a high-emissions future with no firm mitigation targets52. We consider each pathway under two different treatments of Antarctic Ice Sheet uncertainty (denoted K14 and DP16)  Fifth Assessment Report53. The DP16 projections use outputs from a continental-scale model incorporating marine ice-sheet and ice-cliff instability mechanisms and are highly sensitive to atmospheric warming55. Using the year 2000 as a baseline, we generate projections of local RSLR at the Ports of Los Angeles and Long Beach for the two emissions pathways during each decade of the twenty-first century.To estimate the contribution of RSLR to future MNTH at the Ports of Los Angeles and Long Beach, we use probabilistic projections of local RSLR15 and storm surge10 studies also highlight the potential nonlinear effect of RSLR on flood heights over time, but the effect is small for RSLR of < 2m56.To study the influence of future RSLR on MNTH at the Ports of Los Angeles and Long Beach over the twenty-first century, we linearly combined a subsample of local probabilistic RSLR projections  spanning the low and high-end values of RSLR for each decade with our MNTH distribution including tidal variability. Our approach of linearly combining MNTH with RSLR projections resulted in a difference of −7% to +15% in MNTH compared to an approach that accounts for changing bathymetry due to RSLR for each tsunami simulation (see “Methods” section). Previous tsunamiw8.0 to Mw9.4) with no RSLR included. By 2050, median MNTH distributions range from 0.74 m (RCP2.6 DP16) to 0.84 m (RCP8.5 K14). By 2070, the median of MNTH distributions ranges from 0.83 m for RCP2.6 DP16 to 1.08 m for RCP8.5 DP16. The medians of the MNTH distributions in 2100 reflect the wide range in emissions pathways and sea-level projections, ranging from 0.95 m for RCP2.6 DP16 to 1.86 m for RCP8.5 DP16.At the ports, RSLR causes tsunamis from our full suite of earthquakes to have higher median MNTH in 2050, 2070, and 2100 than today Fig. . The med16 and the highest storm-driven extreme sea level recorded at the ports57).To explore the temporal relationship between earthquake magnitude and MNTH, we calculated the earthquake magnitude that generates tsunamis that have a 50% chance of exceeding a defined MNTH as a function of time Fig. . We examw8.7 earthquake generates tsunamis that have a 50% chance of exceeding MNTH of 0.5 m. By 2040 (RCP2.6 K14 and RCP8.5 K14), 2050 (RCP8.5 DP16), and 2060 (RCP2.6 DP16), a Mw8.0 or lower earthquake generates tsunamis that have the same probability of exceeding MNTH of 0.5 m .For all RSLR projections considered , the earthquake magnitude required to exceed MNTH of 0.5 m drops to the lowest considered magnitude between 2040 and 2060. Today, a ~M5 m Fig. . Along tw9.1 earthquake generates tsunamis that have a 50% chance of exceeding MNTH of 1.0 m. By 2100, an earthquake of Mw8.9 (RCP2.6 DP16) or Mw8.8 (RCP2.6 K14) generates tsunamis that have the same probability of exceeding MNTH of 1.0 m  and 2100 (K14). A Mw8.0 earthquake is ~6.7 times more likely to occur than a ~Mw9.1 along the Alaska-Aleutian subduction zone.The influence of different RSLR projections becomes more apparent for higher MNTH. For RCP2.6 K14 and DP16, there is a small decrease in the earthquake magnitude required to exceed MNTH of 1.0 m by 2100; today, a ~M0 m Fig. . A ~Mw8.w9.4 or larger earthquake generates tsunamis that have a 50% chance of exceeding MNTH of 1.5 m. By 2100, under RCP2.6 RSLR, an earthquake of approximately Mw9.2 generates tsunamis that have the same probability of exceeding MNTH of 1.5 m. For RCP8.5 K14, a ~Mw9.0 earthquake generates tsunamis that have a 50% chance of exceeding MNTH of 1.5 m by 2100. A ~Mw9.0 earthquake is 2.0 times more likely to occur than a ~Mw9.4 along the Alaska-Aleutian subduction zone. For RCP8.5 DP16, we see a more rapid and substantial drop in the earthquake magnitude required to produce MNTH of 1.5 m: by 2100, a ~Mw8.4 earthquake generates tsunamis that have a 50% chance of exceeding MNTH of 1.5 m. A Mw8.4 earthquake is ~5.6 times more likely to occur than a ~Mw9.4 along the Alaska-Aleutian subduction zone (see “Methods” section).The wide range of RSLR projections strongly influences future MNTH of 1.5 m or higher Fig. . For RCPw9.1 earthquake and its tsunami sourced along the Semidi section of the Alaska-Aleutian subdiction zone  Science Application for Risk Reduction (SAFRR) project modeled a Mone Fig. . The SAFone Fig. 18. Howev18 will increase as the earthquake magnitude required to exceed MNTH of >1.0 m drops dramatically (from Mw9.1 to a Mw8.0). A similar increase in flood frequencies under future RSLR in southern California has been predicted in storm surge and tidal flooding studies11.By including future RSLR, multi-section ruptures, and tidal variability in our tsunami modeling, we provide a more complete picture of potential future MNTH at the Ports of Los Angeles and Long Beach. We show that under rising sea levels, the possibility of economically and socially disruptive distant-source tsunami events like the one simulated in the SAFRR scenario17.Our results highlight the need to consider RSLR when assessing possible future MNTH and planning for RSLR at the Ports of Los Angeles and Long Beach. Finally, given that changing sea levels threaten coastal communities around the globe, these results suggest that RSLR should also be considered as part of the planning and decision-making process at other distant- and near-source tsunami-prone coasts worldwide58. For a low-emissions future with mitigation measures most consistent with the Paris Climate Agreement [Representative Concentration Pathway (RCP) 2.652], the Fifth Assessment Report (AR5) from the Intergovernmental Panel on Climate Change (IPCC) projected a “likely” (> 66% probability) GMSL rise of 0.28–0.61 m by 2100 relative to 1986–201553. For a high-emissions “business as usual” future with no particular mitigation targets (RCP 8.5), IPCC AR5 projected a “likely” GMSL rise of 0.52–0.98 m by 2100 relative to 1986–201553. However, recent studies suggest the IPCC AR5 GMSL rise estimates may be too low. For example, a physical ice-sheet model that includes important mechanisms such as ice-shelf hydrofracturing and the structural collapse of marine-terminating ice-cliffs shows the Antarctic Ice Sheet (AIS) could contribute far greater amounts to GMSL rise than previously expected: >1.5 m by 2100 under RCP8.560. The possibility of higher-end projections being realized or even exceeded has many stakeholders preparing for sea-level rise in excess of 1 m by 210061, and under extreme scenarios 2+ m of sea-level rise by 210062.In the coming centuries, global mean sea level (GMSL) will continue to rise due to the warming climate, generating hazards for coastal populations, economies, infrastructure, and ecosystems around the world65. Higher sea levels will also leave southern California coastlines even more vulnerable to distant-source tsunamis, which have repeatedly impacted the coast in the last few centuries66.The early impacts of higher sea levels are already being felt in southern California, where coastal flooding during storms, periodic tidal flooding, and increased coastal erosion are becoming more frequent and extensive67; TG1 in Fig. 60 under two methodological approaches for the Antarctic ice sheet (K14 and DP16) and two different emissions pathways (RCP2.6 and RCP 8.5)68. RSL projections are determined from 10,000 Monte Carlo samples of SLR projected at the Los Angeles Tide Gauge using the approach outlined in Kopp et al. 68. Both K14 and DP16 projections combine estimates of thermal expansion and ocean dynamics from CMIP5 global climate model simulations, glacier melt from CMIP5-forced surface-mass balance modeling, global land water storage changes from semi-empirical modeling, long-term non-climatic relative sea-level change based on spatio-temporal statistical modeling of tide-gauge data, and gravitational, rotational, and deformational effects of glacier and ice sheet changes from geophysical modeling. Both sets also use Greenland ice sheet projections based on a combination of AR5 expert assessment regarding likely changes and tail-risk information from the structured expert judgment exercise of Bamber and Aspinall69. The K14 projections use the same approach for Antarctica as for Greenland 68, while the DP16 projections60 replaced the K14 Antarctic projection with projections from the continental-scale ice-sheet/ice-shelf model of Deconto and Pollard59. The DP16 projections were the first continental-scale RCP-driven projections to account for marine ice-cliff instability associated with the combined effects of ice-shelf hydrofracturing and gravitational instability70. The two sets of projections taken together provide a reasonable approach to bracketing the range of plausible probability distributions of future rise47.We consider probabilistic sea-level rise projections from the Los Angeles tide gauge  in each year. We do not take the occurrence probability of each earthquake magnitude into account in order to focus on the tsunami impact that each magnitude step would have under different sea-level rise projections. For our analysis, we generate robust distributions of maximum nearshore tsunami heights (MNTH) that are based on 50 spatially varying earthquakes in each magnitude step to address uncertainties in epicenter locations (see more details on this approach in the paragraph below). We also considered another possible source of uncertainty in the MNTH generated by our earthquake realizations: uniform vs. non-uniform slip. Traditionally, it was assumed that the tsunami-wave dynamics filters and averages the slip differences across the rupture area as the tsunami propagates away from the source area. However, Li et al. and Melgar et al. 71 demonstrated that tsunami amplitudes are underestimated in earthquakes with uniform slip across the earthquake area, even in the far-field. Indeed, slip inversion studies of historical earthquakes show that slip distribution varies greatly across the plate interface, and if this is not considered in earthquake realizations, MNTH will be underestimated35. To avoid underestimating tsunami amplitude in the Ports of Los Angeles and Long Beach, we devised the method of varying the number of unit sources over which slip is distributed for each earthquake magnitude (described below). Our approach is similar to the variable-area-uniform-slip (VAUS) applied by Davies35.To study the influence of future relative sea-level rise (RSLR) on tsunami impacts in the Ports of Los Angeles and Long Beach, we consider the same suite of earthquakes between M72 to estimate the average earthquake area that characterizes each magnitude step (15 magnitude steps between Mw8.0 and Mw9.4). Because the earthquake area varies in each magnitude step around the average, we multiply the calculated earthquake area by a random factor varying between 0.5 and 1.5 to produce 50 randomized earthquake areas (15 magnitude steps × 50 earthquake areas per magnitude = 750 simulations). We use the 50 earthquake areas per magnitude step to determine how many adjacent NOAA unit sources (100 km × 50 km)32 per earthquake have to be used to cover the earthquake area. At the same time, to vary the hypocenter locations within each magnitude step, we place the unit sources associated with each earthquake randomly within the unit source grid of the Semidi and Kodiak sections  for each of the 50 randomized earthquake areas and hypocenter locations per magnitude step, we use the following equation, derived from the moment magnitude and the seismic moment:We employ the empirical equations from Strasserons Fig. . Unit sow8.1 can be composed of one, two, or three-unit sources, translating into slips of D ≈ 8 m (one unit source), D ≈ 4 m (two unit sources), or D ≈ 2.7 m (three unit sources). Thus, for each earthquake magnitude, slip can be concentrated over a variable amount of unit sources to account for slip variability within each magnitude step. The minimum, average, and maximum slip and resultant deformation for each magnitude step are reported in Supplementary Table For example, a M31 to generate the maximum vertical ocean-surface deformation that is responsible for tsunami generation (Supplementary Table 32).To generate the initial conditions for the tsunami simulations from the aforementioned suite of earthquakes, we employ the Okada deterministic method73. GeoClaw has been validated and verified74 and applied to a variety of different past tsunamis, such as the 2015 Chile75 and 2011 Japan77 events. One of the main advantages of GeoClaw is the Adaptive Mesh Refinement (AMR) that is implemented and available for tsunami simulations. AMR automatically refines the computational grid in areas where a finer resolution of the employed grid helps to find a more accurate numerical solution. For tsunami simulations, this area coincides with the traveling tsunami wave train. It is possible to force the refinement level in certain areas , which is a powerful method to reduce the computational time, for example, when many model runs are needed such as in our case. Supplementary Fig. 78  was employed for Boxes A and B. The resolution of the elevation data employed for Box C is 0.3″.We use GeoClaw to carry out the tsunami simulations. GeoClaw is a widely used modeling tool for geophysical flows and is part of ClawPack software package67, therefore not registering that a tsunami has occurred. The tide gauge location at TG2 is far enough offshore to register the lower MNTH. We omit inundation analysis from our study because of the spurious results possible in a flat port setting and the highly resolved computational grids necessary to accurately complete the analysis. Our MNTH distribution is based on the 750 individual tsunami simulations for 15 magnitudes steps between Mw8.0 and 9.4 and 50 random hypocenters and earthquake areas per magnitude step. The blue histogram in Fig. w8.0 to Mw9.4) in the year 2000 relative to MSL with no RSLR or tidal variability included.For each of the tsunami simulations, we determine the maximum tsunami amplitude relative to mean sea level (MSL) at a synthetic tide gauge in the port . The Ports of Los Angeles and Long Beach have a mixed semidiurnal tidal cycle in which two high and two low tides of different sizes appear every day. The maximum tidal range (MLLW-MHHW) observed at the ports is 1.68 m, while the difference between mean high water (MHW) and mean low water (MLW) is 1.16 m . The greatest storm-driven sea level observed at the Ports of Los Angeles and Long Beach tide gauge is 1.55 m relative to MSL (10 January 2005), following the wettest 15-day period on record in Los Angeles79. We use a Gaussian kernel density estimate of the full tidal data to create 2000 random tidal subsamples. We linearly combine each of the tidal subsample values with each of the 50 maximum tsunami-amplitude values for the 15 magnitude steps between Mw8.0 and 9.4. Androsov38 found that in some instances, linearly combining tides and MNTH could significantly underestimate tsunami heights, and argue that tidal amplitudes and tidal currents need to be fully integrated into a tsunami model. However, the integration of tidal amplitudes and tidal currents into a tsunami model is complex and requires more research38. We acknowledge that our linear approach may underestimate MNTH at the ports but argue that the effect is likely much smaller than not considering tidal variability at all.To incorporate tidal variability into our MNTH distribution, we create a tidal distribution from the Ports of Los Angeles and Long Beach tide-gauge record 80, the Geological Survey of Canada (GSC)81, and Stover and Coffman39. For the USGS and GSC catalogs, online searches retrieved earthquakes since 1900 that meet the following characteristics: (a) magnitude ≥ 3.8, (b) 46°N ≤ latitude ≤ 73°N, and (c) +165° ≤ longitude ≤ −120°. Catalog processing generally followed the methodology described by ref. 40, with steps including reformatting, estimating a moment magnitude for each event, deleting duplicates, and declustering. The final catalog used for the analysis was spatially trimmed to the area of the Alaska-Aleutian megathrust and depth < 50 km. Magnitude-frequency distributions were modeled using the maximum-likelihood methodology of Weichert82. Incremental earthquake rates in 0.2-magnitude-unit bins were determined by counting earthquakes in the catalog, assuming completeness levels for M7.4 since 1900, M7.0 since 1950, M5.6 since 1964, and 5.0 since 1990. Fits to the binned rates yielded a b-value 0.75 for the declustered catalog , we also considered b-values of 0.7 and 0.8 in our calculations. Using b-values of 0.7 and 0.8, the relative frequency of a M8.0 vs a M9.1 changes to 5.9–7.6  times, respectively. Because our consideration of b-value variability did not result in significant changes to the relative frequency of earthquake magnitudes, we use the declustered catalog b-value of 0.75 to calculate our relative earthquake frequencies in the main text and in Supplementary Table We use the regional b-value to assess relative rates of earthquakes of various magnitudes along the Alaska-Aleutian subduction zone (Supplementary Table Supplementary informationPeer Review File