Self-care reproductive health innovations are increasingly valued as practices that enable women to manage their fertility with greater autonomy. While self-care, by definition, takes place beyond the clinic walls, many self-care practices nonetheless require initial or follow up visits to a health worker. Access to self-care hinges on the extent to which health care workers who serve as gatekeepers find the innovation appropriate and practical. Self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is being introduced and scaled in many countries. In late 2018, health workers in Uganda began offering self-injection of DMPA-SC in the public sector, and this study examines health workers' views on the acceptability and feasibility of training women to self-inject. We conducted in-person interviews with 120 health workers active in the self-injection program to better understand provider practices, program satisfaction, and their views on feasibility. A subset of 77 health workers participated in in-depth interviews. Quantitative data was analyzed using Stata (v14) software, and chi square and student t tests used to measure between group differences. Qualitative data was analyzed using Atlas.ti, employing an iterative coding process, to identify key themes that resonated. The majority of health workers were very satisfied with the self-injection program and reported it was moderately easy to integrate self-injection training into routine service delivery. They identified lack of time to train clients in the clinic setting, lack of materials among community health workers, and client fear of self-injection as key challenges. Community health workers were less likely to report time challenges and indicated higher levels of satisfaction and greater ease in offering self-injection services. The relatively high acceptability of the self-injection program among health workers is promising; however, strategies to overcome feasibility challenges, such as workload constraints that limit the ability to offer self-injection training, are needed to expand service delivery to more women interested in this new self-care innovation. As self-injection programs are introduced and scaled across settings, there is a need for evidence regarding how self-care innovations can be designed and implemented in ways that are practical for health workers, while optimizing women's successful adoption and use. Self-care reproductive health innovations are becoming increasingly recognized and valued as strategies to enable people to manage their fertility with greater autonomy. There is renewed interest in ensuring that appropriately supported self-care interventions are available at scale as part of a fully functional health system. While self-care, by definition, takes place beyond the clinic walls, many self-care practices nonetheless require an initial visit to a health worker (or subsequent follow up with a provider), and are therefore subject to challenges related to how often and to whom the service is made available. One of the key challenges for scale up and access of self-care interventions is therefore understanding the extent to which a new product or practice is acceptable and feasible from the perspective of health care workers, who often serve as gatekeepers . While tSelf-administration of injectable contraception, made possible by the development of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in an easy-to-use, all-in-one injection device, is one of two family planning self-care practices  recognized in the WHO guidelines on self-care , and whiRecent research has shown that self-injection is feasible and acceptable in sub Saharan Africa, and moreover, that self-injection can enable women in diverse contexts to continue uninterrupted injectable use for longer –12. WhilWhen introducing a new health service innovation, it is important to assess feasibility and acceptability from the providers' perspective to identify challenges and areas for improvement or adaptation before transitioning to scale up. With respect to self-injection and self-care, quality of care is critically important if women are to become autonomous, successful practitioners. We need to learn how to effectively deliver this innovative service, which is unlike anything seen before in the family planning field. Through the Self-injection Best Practices Project evaluation, we explored health worker perspectives and (self-reported) practices in counseling and training women to self-inject. We conducted interviews to understand how providers were implementing the program, their views on the feasibility of training women and adolescents to self-inject, and their overall satisfaction with the program.In Uganda, the National Drug Authority approved DMPA-SC for self-injection in 2017 and the country began piloting self-injection through routine service delivery that same year through the Self-injection Best Practices Project. A first round of in-service self-injection training for providers, whose experiences are reported here, began in October 2017 and was completed in December 2017. A total of 230 family planning providers were trained to counsel women for self-injection, including 97 clinic-based providers, 83 community health workers  who deliver services in communities, and 50 clinic-based providers who also offer adolescent-responsive services through outreach to safe spaces. Public sector health workers in Gulu, Oyam and Mayuge districts began offering self-injection training for women who express interest at health facilities and in the community through VHTs in early 2018. In a fourth district (Mubende), public sector providers who had previously received training in adolescent-responsive service delivery began offering self-injection training to adolescents through community outreach, in addition to SI services provided at clinics in November 2017.Under the program's service delivery guidelines, health workers introduce SI in the context of informed choice (one method among many) and include five key topics during training: when and how to reinject, how to securely store devices, how to safely dispose of used units, follow up procedures including resupply and what to do in the event of problems. Women were given two units to take home following the first self-injection, which was supervised by the health worker. Clients were advised to return used units to the health worker at their convenience for safe disposal.A mixed methods approach was used to collect quantitative and qualitative data across the public sector and adolescent channels where self-injection was underway. Health workers active in the self-injection program were recruited to participate in structured surveys about their practices and perceptions of the feasibility and acceptability of the self-injection program. Specifically, structured survey questions were designed to gather information on any outreach or post-training follow up conducted; how training is implemented, including the number of people trained, the type, content, frequency and length of training, and the degree to which training is conducted consistent with service delivery guidelines ; the extent of challenges with service delivery and overall satisfaction with the program. In-depth interviews were used to collect qualitative information from a subset of survey respondents, focusing on provider and (perceived) client receptivity to SI, any restrictions imposed on who is offered SI services, the nature of challenges encountered and suggestions for program improvement.Sites were selected in a purposive fashion to capture variation in public health system levels  and geography. Thirty-four facilities were selected in Mayuge, Gulu, and Oyam districts (10 to 14 in each district), with roughly equal representation by facility level. Sites that had more clients using injectable contraception  were prioritized.For the adolescent-responsive program, public sector providers affiliated with Mildmay Uganda, a DREAMSThe target population for the evaluation of the public sector programFor the structured provider surveys in the public sector, up to five health workers at each of the 34 evaluation sites (20 facilities offering self-injection services on site and 14 facilities affiliated with VHTs offering services in the community) were interviewed, to produce a sample size of 80 providers. For the adolescent-responsive program, we interviewed 40 of the 50 providers who were affiliated with 12 facilities and who received training and provided services to Safe Space adolescent groups in Mubende district. Across all districts, providers were selected in a purposive fashion, based on their level of involvement in the program such that recruitment favored providers who had had greater involvement in self-injection training.To add more nuanced information about provider practices and opinions, 77 participants among those who participated in the structured surveys participated in in-depth interviews, with 37 of those providers from the public sector channel (20 clinic-based and 17 VHTs) and 40 from the adolescent-responsive program. Whereas, all adolescent-responsive program providers were invited to participate in in-depth interviews, the public sector providers were a convenience sample, selecting those who demonstrated a willingness to provide more detailed input on the program; favorability toward the program did not influence participant selection.With the permission of the District Health Officer and clinic managers, trained research assistants approached family planning providers at their health facility, or affiliated facility for VHTs, to assess their interest in participating in the evaluation, screen for eligibility and conduct the informed consent process.Providers were required to be 18 years of age or older, to work in the Mubende, Mayuge, Gulu, or Oyam districts, and to be employed as health workers . Eligibility required that the health worker deliver family planning counseling and services as part of their main responsibilities; that they had been trained in SI counseling; and that they had trained at least 20 women to self-inject since the program launch (approximately 6 months prior). Participants had to be comfortable speaking the language of the interviewer .Research assistants conducted structured survey interviewst–tests were used to evaluate differences between provider groups, using conventional significance levels of 95% with two-sided tests. We analyzed qualitative data from in-depth interviews using Atlas.ti. The coding process was iterative, with themes developed based on responses rather than a pre-defined coding scheme. Multiple analysts were engaged in the coding process, with disagreements over coding resolved through consensus. We developed memos to summarize key themes, and where appropriate, compared findings by the type of provider .We analyzed data from the provider surveys using STATA version 14.2. Chi square and student All staff involved in data collection, management, or analysis were trained on research ethics, including confidentiality, informed consent and the voluntary nature of study participation. All health workers who participated in the study provided signed informed consent. The Mulago Hospital Research and Ethics Committee, and the Uganda National Council for Science and Technology (UNCST) approved the study.The description of participating providers is found in via in-depth interviews to whom they offer self-injection training, most of the 77 providers reported offering self-injection to all types of clients, with some spontaneously opining that informed choice dictates that any client who is interested can receive self-injection training.When asked That said, with probing, some providers admitted to restricting access for younger women. Eleven providers, eight of whom were VHTs, reported they impose age restrictions on unmarried adolescents, particularly those who are still in school and have not yet given birth, and will, in lieu of training them, counsel them to abstain or use condoms. In all cases, their concerns focused on adolescent sexuality and misperceptions about whether young women can safely use injectable contraception, rather than apprehension over whether adolescents could manage self-injection.We have adolescents who come and consult you and tell you they'd like an injection. I ask them how old they are. If she says seventeen years I say eeeeeeh. I educate and counsel her that she should be patient because you should not engage in sexual acts; at least use condoms instead of this injection. Then she shares that the partner refused condoms. I counsel her that she should tell her partner not to use an injection at an early age. A person to start off the injection at the earliest it should be eighteen to nineteen years, though at times I get clients as young as sixteen years. To such young ages I counsel first and educate. I cannot stop you because you have started sleeping around, so I advise them to use this other method of condoms.” VHT, HC II, Adolescent-responsive program“A smaller number (seven) indicated that they do not offer self-injection training to women who are using discreetly, largely out of concerns that injections at home may be discovered.There are sometimes when a woman escapes to my home to get the injection at night because they fear their husbands, so I just inject but not train them.” VHT, public sector (community based)“Approximately 70 percent of providers conducted training in both group and one-on-one sessions, with no difference by service delivery approach. While the program guidelines left the determination of training format up to providers, they were advised to limit the group size to 10 or fewer. Providers reported conducting approximately 3–4 individual trainings per week, with a median duration of 20 min, and 1–2 group trainings, with a median duration of 40 min. The duration of group training sessions varied somewhat (though not significantly) by service delivery approach, from 30 min at public clinics to 35 min at adolescent safe spaces to 45 min in community settings led by VHTs. The range of duration for these group sessions was large, from 5 to 150 min. The median size of a training group at an adolescent safe space was 20 clients, significantly higher than in the public sector channel, where the average was five or six clients.In the public sector, providers were either offering self-injection services in the clinic, or if VHTs, in the community. In the adolescent-responsive program, providers were supported to offer services both in the clinic and at adolescent safe spaces in the community. When providers in the adolescent-responsive program were asked where and how they usually train adolescent clients, 46% reported they train adolescents at safe spaces only, 13% train adolescents at clinics only, and 41% reported that they train at both locations. In addition, a slight majority (55%) reported that they only train adolescents with peers, as opposed to training adolescents in groups with women of all ages .While the format of training  was left to providers to decide, service delivery guidelines identified key additional subjects, beyond injection technique, that should be included for a quality self-injection training, including storage, disposal, reinjection timing, side effects and follow up. The evaluation assessed the extent to which providers reported implementing training consistent with the guidelines by asking them to describe what information they cover during training. We have reported additional topics of interest in Client fear of self-injection was a challenge raised by all provider groups in the structured surveys as well as in more detail in the in-depth interviews. When providers were asked what women struggle with the most when learning to self-inject, the most common response across providers was that women fear injecting themselves, followed by challenges activating the DMPA-SC device . ProvideIn the in-depth interviews, when asked to elaborate about fear as a challenge, some health workers indicated that fear is only an initial challenge that clients overcome with counseling or after hearing about self-injection from their peers. Other health workers noted that fear of self-injection is a persistent barrier for some clients, with indication from a few providers that those who are older and who have not attended school tend to be more fearful.At first, I was questioning myself how someone can give herself an injection because I know women are so fearful compared to men, so I thought they won't make it at the start of the program, but afterwards the fear has subsided. The women who are already self-injecting are really helping me a lot to encourage their fellow women in the community.”-VHT, public sector (community based)“The demand for self-injection is good, only that there are those who can't [self-inject]. Especially if you find someone who didn't go to school, she becomes so fearful to self-inject.” -VHT, public sector (community based)“n = 26), and excessive fear (n = 16), though these responses were mentioned by less than half of providers.The most common reasons offered in the in-depth interviews for denying the opportunity to self-inject independently were failure to demonstrate injection competence  women are so fearful. Adolescents do it confidently and speed up.” -VHT, HC II, Adolescent-responsive program“Providers were readily able to identify benefits to offering self-injection services, and chief among them, cited by about three fourths of providers who participated in in-depth interviews, was the potential to reduce the workload at the clinic.I feel it (self-injection) is a good thing because it reduces my work load. Because sometimes I really have a lot of clients to work on, and if this mother is able to help herself, it reduces what I have to do. I need to supervise her that first time and then the next time I know she is not really going to be there except if she is having a problem.” -Enrolled midwife, HC III, Public sector“In terms of the benefits to the client, just under half of providers noted that clients save time and money by not returning as frequently to the clinic, and about one in five noted that self-injection can enhance privacy, which is critical for women who are using family planning discreetly. In particular, adolescent-responsive program providers mentioned enhanced confidentiality as a benefit to young, unmarried women.It (self-injection) has been helpful for privacy as at times they (adolescents) come to the facility. You see so-and-so's daughter, but once you train her and she goes home, she can be able to inject herself.” -Enrolled midwife, HC III, Adolescent-responsive program“… others fear their husbands, but when she comes and we give her Sayana, when she has learnt to self- inject then she goes and self-injects at her home. So, when three months have passed, she waits for her husband, the one she fears, to go away then she injects herself, which helps her not get unwanted pregnancy.”-Nursing assistant, HC II, Public sector“Providers were asked to describe their experience with the self-injection program, evaluate the ease with which they could integrate self-injection training into their work and rank their satisfaction with the program. Providers reported moderate ease integrating self-injection into the services they offered . VHTs reThrough in-depth interviews, providers elaborated on specific challenges, explaining that there are often periods of high client load in the clinic, and it is during these busy periods that it is challenging to offer self-injection. Other comments suggest that lack of time for training may compromise quality.It has been somewhat difficult in such a way that self-injection clients need more time. First, they need time for counseling and secondly, they need time for the training, to observe them offering the method. Sometimes there is also other work in the facility—there may be the deliveries and the emergencies. You tell the family planning clients to wait a bit, while you are taking an emergency, but you come and find they have disappeared.” –Nurse, HC IV, public sector“At times it could be really a lot [to offer self-injection training], especially when training one-on-one with a client and yet you really have a queue of clients. It has been hard to balance my usual workload at the clinic. Not every day is a busy day but those other busy days, it can be a little bit of a challenge.” -Nurse-midwife, HC IV, public sector“It takes a lot of time to train women, so we just inject sometimes without training.” - Midwife, HC III, adolescent-responsive program“Despite the challenges, the majority of health workers reported that they were ‘very satisfied' with the self-injection programs: 63% in the clinic-based provider group, 78% in the VHT worker group, and 58% among the providers in the adolescent-responsive program .n = 77) provided recommendations for the program, but those who did generally centered on ways to improve training and community sensitization. Regarding training, some providers suggested the need to train more staff (n = 13), a few emphasizing the need to train more VHTs; some recommended increasing the duration of training for providers (n = 11); and some suggested offering refresher training and/or supportive supervision (n = 15).Not all providers interviewed , including greater focus on men. They noted that most clients had not heard of self-injection prior to arriving at the clinic, VHT or safe space. Specific suggestions were to provide branded materials so the community knew they were offering self-injection, and having more VHTs or safe space mentors provide self-injection training.Regarding community awareness or engagement around self-injection, a few providers recommend conducting more sensitization activities in the community either in the form of community dialogues and/or radio  in a positive light .This study also reveals a number of program implementation adaptations, highlighting the importance of program monitoring and supervision to maintain intervention fidelity and service quality when introducing a new practice. Specifically, we found training group sizes that exceeded the service delivery guidelines of < 10 (in a few cases with groups larger than 100), particularly in the adolescent-responsive program when self-injection training was offered at Safe Spaces. Based on observations by the research team, these larger group trainings (which were predominately in the adolescent-responsive channel) were likely to have been health talks, rather than specific and detailed trainings. The challenge of offering self-injection training to large groups in the adolescent responsive program (at Safe Spaces) may also explain differences in training quality, and specifically, the omission of information on side effects (as described below). Although these Safe Space outreach events may function well to raise awareness of self-injection among an underserved population, confidential service delivery, which is a central tenet of a rights-based quality of care framework in family planning , requireWhile individualized training in self-injection may be appealing from a quality-of-care standpoint, the duration of comprehensive training, and the finding that a majority of clinic-based providers are sometimes or often unable to offer training due to workload constraints, requires a more efficient approach. If self-injection is to be made available to all women who would like to adopt it, group training, with provision for a shorter one-on-one consultation, is a reasonable program adaptation to reduce time burdens on providers. Since VHTs were less likely to report time challenges and indicated higher levels of satisfaction and greater ease in offering self-injection services, involving more community and clinic-based VHTs is likely to increase program reach. Increasing self-injection outreach and training through community health workers and Safe Space mentors was specifically recommended by providers in the program. Note that, for one of the early  studies of self-injection in Malawi, the majority of providers were community health workers . When exIn addition to limiting the availability of self-injection training, workload constraints may also impact training quality. Some in-depth interview comments imply that an abbreviated training approach was a response to time constraints and a heavy workload. Specifically, we saw differences in the comprehensiveness of training, and particularly notable was the omission of discussion of side effects in the adolescent-responsive program. Method side effects are a common cause of discontinuation , and sidEnsuring training comprehensiveness and enhancing overall training quality will likely increase client self-confidence and reduce fear, identified across provider groups as the greatest difficulty that clients face. Its notable that our companion study of client experiences in the SI program reinforces providers' impression that quite a few clients are fearful of self-injecting . In our We found that a small number of providers expressed reluctance to train adolescent women, highlighting persistent challenges with provider bias against adolescent contraceptive use, and hormonal contraceptive use specifically. These findings are consistent with a previous study in Uganda, which showed reluctance to offer adolescent women contraception , injectables (related to infertility impacts) as well as self-injection (perceptions of lack of maturity) . MonitorFinally, we note that for many of the issues described above, we see differences, often statistically significant, between types of providers with respect to experiences with, and perceptions of, the SI program. To sum up, VHTs expressed higher satisfaction and ease of incorporating SI services into their family planning offerings than did the clinic-based providers. VHTs were however, more likely to express challenges with a lack of materials and were less likely to discuss side effects. We also saw more VHTs express reluctance to serve adolescent clients, suggesting the possibility of provider bias. While the data is qualitative and therefore merely suggestive, it is consistent with a finding from our companion paper focusing on the adolescent experience which showed significantly fewer adolescents receiving services from VHTs . We noteTo understand how the program was being implemented, the sampling strategy for the evaluation prioritized providers who had trained at least 20 clients over the first 6 months of the program. While this criterion maximized information about program implementation, the strategy over-sampled providers who were committed and actively involved. The reported satisfaction and ease of integration of self-injection into routine services is likely inflated due to our sampling approach. Second, we employed purposive sampling for the in-depth interviews, selecting those willing to discuss experiences in detail to collect more vibrant and expansive data, and avoiding respondents who would provide terse responses because they are rushed, bored, or indifferent. There are trade-offs with this strategy however, and it is possible that our sample includes a preponderance of providers with more extreme views. Third, as this evaluation was based on a small-scale introduction of self-injection, the sample size is small, increasing the risk of type 2 error . Finally, the findings are self-reported, and therefore subject to courtesy and social desirability bias.As self-injection programs are introduced and scaled across settings, there is a need to collect and share evidence and guidance regarding how self-injection programs and supported self-care innovations can be designed and implemented in ways that optimize women's successful adoption and use. Our findings suggest that, from the provider perspective, it is both feasible and acceptable to offer self-injection services through multiple channels and by different cadres of providers within the public sector. This paper complements two companion pieces that focus on the experiences of self-injecting women  and adolThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Mulago Hospital Research and Ethics Committee; Uganda National Council for Science and Technology (UNCST). The participants provided their written informed consent to participate in this study.JC, AN, CM, DN, and JKT were involved in the study design, including development of the protocol and design of data collection instruments. AN, DN, and JKT supervised data collection. CM and JC led the quantitative data analysis and AS engaged in the qualitative data analysis. JC, AN, CM, DN, JKT, AS, and JKD were involved in the interpretation of results, writing and revision of the article. All authors have approved this manuscript.This work was supported by the Bill and Melinda Gates Foundation, Seattle, WA under Grant Number: 1154309. The funding source did not play a role in study design, the collection, analysis, and interpretation of data, the writing of the report, and the decision to submit the article for publication. The Bill and Melinda Gates Foundation provide funds for open access publication.All authors were employed by PATH. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Endobronchial ultrasound-guided transbronchial needle aspiration is a minimally invasive and effective sampling approach for patients with mediastinal or hilar lymphadenopathy. Increased recognition of the ultrasonographic features revealed the value of its images in predicting mediastinal lymph node malignancy. However, its diagnostic validity and the predictive value of its ultrasonographic features have not been demonstrated well in patients after systemic anti-tumor therapy. This study aimed to evaluate the efficiency of endobronchial ultrasound-guided transbronchial needle aspiration in patients with suspicious lymph nodes after anti-tumor therapy.We retrospectively reviewed cases of endobronchial ultrasound-guided transbronchial needle aspiration performed between January 2019 and August 2021 at a single tertiary hospital center. Patients with suspected mediastinal or hilar lymph nodes within 5 years of systemic anti-tumor therapy were enrolled. Final diagnoses were determined by pathologic diagnoses of samples from transbronchial needle aspiration, surgery, or follow-up for at least 6 months. Ultrasonographic features were analyzed to assess the predictive value of malignant lymph nodes after treatment.Overall, 168 lymph nodes of 138 patients were analyzed. Among 110 (65.5%) malignant lymph nodes, 75 originated from lung cancers; the other 35 were from other malignancies. No complications related to endobronchial ultrasound-guided transbronchial needle aspiration were observed. Of 58 negative results of transbronchial needle aspiration, 51 were proven to be true negatives; 7 were false. The overall sensitivity and the negative predictive value were 94.02% and 87.93%, respectively. Univariate and multivariate analysis revealed the absence of central hilar structure and short axis > 10 mm as independent predictive factors for malignancy.Endobronchial ultrasound-guided transbronchial needle aspiration performs satisfactorily in diagnosing mediastinal and hilar lymphadenopathy even after anti-tumor treatment. Currently, increasingly more patients with various malignancies benefit from anti-tumor therapy and have longer survival. After treatment of the primary tumor, some patients may display a suspiciously enlarged intrathoracic lymph node (LN) due to metastasis or recurrence of the primary tumor or a secondary tumor, as well as benign diseases. To decide on a treatment regimen, the cause of the lymphadenopathy needs to be identified. Especially in lung cancer, neoadjuvant therapy is introduced for better prognosis. In certain cases, immunotherapy can cause enlargement of the intrathoracic LNs, like immunological reactions . If the The effectiveness and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been well demonstrated in various clinical settings –7. IncreThis study aimed to evaluate the use of EBUS-TBNA in patients with suspicious LNs after anti-tumor therapy for lung cancer or other malignancies.In the present study, data of patients with enlarged mediastinal or hilar LNs who underwent EBUS-TBNA between January 2019 and August 2021, at a single tertiary hospital center within 5 years after systemic anti-tumor therapy, were retrospectively reviewed. During EBUS, ultrasonographic features, including short axis, margin, central hilar structure (CHS), round shape, and necrosis, were identified and recorded in real-time. The diagnostic value of EBUS for these LNs after treatment was investigated. In addition, the predictive value of the EBUS features was assessed for malignancy.Patients with suspected intrathoracic LNs who had undergone any systemic anti-tumor therapy because of any malignancy within 5 years were enrolled from January 2019 to August 2021. EBUS was performed by three experienced endoscopists, mainly under surface anesthesia. Rapid on-site cytological evaluation was unavailable. EBUS features were described in medical documents during the procedure before the pathology results were revealed.The inclusion criteria were as follows: (i) previously underwent systemic anti-tumor therapy within 5 years; (ii) suspected intrathoracic LN malignancy by clinical observation (Computed tomography (CT) scanning with contrast and/or positron emission tomography (PET)). The detailed criteria was: (i) the short diameter of the lymph node ≥ 1 cm or necrosis of lymph nodes (CT scanning); (ii) the SUVmax ≥ 2.5 (PET/CT); (iii) successful EBUS-TBNA with a pathological result; (iv) if EBUS-TBNA specimen was negative, additional specimen was acquired by surgery , or no progress was observed in a 6-month clinical and radiological follow-up  without changing current treatment regimen.All patients empty stomach (nil by mouth) for at least 4 h before undergoing EBUS-TBNA. Routinely surface anesthesia  was used. If the patient could not tolerate EBUS, general anesthesia was administered. First, the bronchoscope  was inserted into the trachea and bronchial tree through the nostrils or mouth. After scope insertion, lidocaine saline solution was sprayed onto the mucosa of the airway for anesthesia as needed.After identifying the targeted LNs, ultrasound images were saved and features described. Punctures by a 22- or 25-gauge needle, approximately 1–3 times( in rare cases a maximum of 5 punctures if the specimen was not sufficient), were needed to aspirate enough samples, which were smeared on 2–4 slides and collected in a bottle that containedcytopreservation solution. The core tissue was then expelled into a bottle containing 40% neutral buffered formalin for histological examination, while the remaining aspirate and other needle passages were used for cytological examination.All patients or their families provided written informed consent prior to any medical examination or treatment. This study was approved by the Beijing Cancer Hospital Research Ethics Committee and conducted according to the guidelines of the Declaration of Helsinki.Sensitivity, negative predictive value (NPV), specificity, and positive predictive value (PPV) were calculated using standard formulae. Prior to EBUS-TBNA, radiological evaluation, such as contrast CT and/or PET was conducted for the mediastinal and/or hilar LNs. Final diagnoses were carefully affirmed; positive results were determined by pathology reports of EBUS-TBNA specimens. Malignant TBNA pathology would not need confirmation by a follow-up surgery. Negative reports were confirmed using specimens from mediastinoscopy, surgery, or a at least 6-month clinical and radiological follow-up.No EBUS-TBNA procedure-related complications such as pneumothorax, mediastinal abscess, or excessive bleeding, were observed during this study.The LN was used as the unit of analysis. Quantifiable variables are presented as mean ± standard deviation, or number (percentage). Categorical variables are analyzed using Pearson’s Chi-square analysis. Several ultrasonographic features which were suggested as predictive factors  are included.p < 0.05).Univariate binary logistic regression and multivariate logistic regression was completed  LNs; 75 LNs were diagnosed with lung cancer. Other malignancies revealed in 35 patients included colon and rectal adenocarcinoma .5% LNs; , prostatOverall, the sensitivity, specificity, NPV, and PPV were 94.02%, 100%, 87.93%, and 100%, respectively . Multivariate analysis revealed CHS and short axis to be independent factors of malignancy  was observed during the 6-month follow-up without changing treatment regimen, it was confirmed to be truly negative. For non-tumor patients, a longer follow-up may be a better choice; however, for patients with definite tumors, a longer follow-up interval might be influenced or misled by many other factors, resulting in a confusing analysis. Overall, for the follow-up duration, we chose 6 months in accordance with other clinicians . EBUS-TBOur series had a larger volume and included patients with lung cancer and other diseases, thus confirming a wider applicability of EBUS-TBNA. The procedures in our study were mainly performed in outpatient units; patients left the endoscopy center two hours after the procedure. No major or minor complications were observed in our series. This also proved the safety and practical value of EBUS-TBNA.EBUS is not only concerned with the acquisition of specimens. Diagnostic value of endobronchial ultrasonographic features as a supplement to pathology diagnosis has attracted increasing attention in recent years , 15, 24.p < 0.05). In multivariate analysis, CHS and short axis showed statistically significant difference.After anti-tumor treatment, the LN may change, thus affecting ultrasonographic features. The predictive value of ultrasonographic features is not well explored. During our study, because of another study, we recorded the ultrasonographic features during EBUS process; hence, we collected and documented these data. In this retrospective study, the records of these image features were almost immediately obtained. In clinical settings, the simpler the features are, the better. Hence, we chose the simple ones with high interobserver-agreement, which could be obtained from gray mode. For these characteristics, we carried out univariate and multivariate analyses. The round shape is defined as long axis/short axis ratio of less than 1.5 . In the On this basis, EBUS images still have certain predictive value for LNs after treatment. Independent factors related to malignancy are CHS and short axis. Compared with previous reports about image characteristics of LNs, it seems that image divergence between benign and malignant LNs is smaller after treatment. So for suspicious LNs after treatment we should rely more on sampling. Without doubt, the pathological results of specimens for untreated LNs are irreplaceable in determining the nature of LNs.For negative EBUS-sampling pathologies, if EBUS features could be taken into account, interruption or delay in treatment caused by repeated investigations might be avoided. Specimens with a negative pathologic result obtained by EBUS-TBNA were likely to be true-negative findings as reported by many scholars –29, and As a minimally invasive procedure, EBUS-TBNA could be conducted in outpatient settings. As per our study, considering its efficacy, EBUS-TBNA could be applied more aggressively after or during anti-tumor therapy. Thus, by helping rule out malignant lymphadenopathy and minimize interruptions in treatment, or quickly discover resistance to initial treatment, EBUS-TBNA could be more widely applied to improve patient outcomes.The present study had some limitations. It was a single institution analysis and the results were based on a small number of samples. In clinical practice, some questions are not clearly confirmed. For example, the false negative-cases (7 lymph nodes of 6 patients) were not confirmed by surgery or other procedures thus no positive specimen was obtained. Multi-center prospective trials will be needed to support the efficacy of EBUS-TBNA for the repeated evaluation of recurrence as well as treatment effectiveness during the course of cancer treatment.EBUS-TBNA for patients with previously treated cancer showed a high diagnostic yield and was found to be safe. With the increasing need of tissue for managing optimal treatment, EBUS-TBNA after or during the course of treatment could play a more active role. Ultrasonographic features like CHS and short axis are potential independent factors related to malignant lymphadenopathy. Recognizing specific imaging features could help clinicians in decision-making especially under negative TBNA situations. Larger prospective investigations are needed to confirm the NPV of EBUS-TBNA after treatment for malignancies.


Compassion is a key component of quality care. Encouraging Health Care Professionals (HCPs) to develop a patient-centered care relationship through mindfulness and compassion training may be beneficial for both patients and HCPs.We assessed the impact of a compassion-centered mindfulness program  on healthcare practice conducting 10 phone interviews with HCPs who experienced the program.The training had an overall positive impact on the HCPs ability to feel compassion toward their patients and themselves, helped them develop kindness toward themselves and their patients, and enhanced their attention to their patient’s needs and theirs. Participants were better able to accept the difficult work experiences or those their patients experienced, with more perceived equanimity and less reactivity.Professional mindfulness and compassion training programs could be operational levers for institutions aiming at fostering more compassionate HCPs–patients relationships. Many elir care” . Compassir care” . Howeverir care” . Compass person” . It has  person” .Self-compassion is defined as involving “feelings of caring and kindness toward oneself in the face of personal suffering and involves the recognition that one’s suffering, failures and inadequacies are part of the human condition”  shondition” . Consequfeelings . Thus, tfeelings . Notablyfeelings . As suchfeelings . It has feelings . In factfeelings . Althougfeelings . TherefoMindfulness is “a state of mind that permits insight, presence, and reflection, and also a habit of relating to the world”  corresponds to the attitude of withdrawal and indifference adopted by an individual toward work and people in general. Finally, the Reduction of personal fulfillment at work corresponds to the individual’s feeling of professional failure and inability to meet the demands of the job. Burnout consequences include emotional , physical , cognitive , behavioral/interpersonal , and motivational/attitudinal manifestations . The HCPs were invited to register on a voluntary basis through a large communication conducted via institutional newsletter  or through a continuous medical education program in the community. Because HCPs had to be fully engaged into the program and be perfectly available, we chose to offer the program in full day sessions and not weekly 2 to 3 h sessions. The HCP’s were totally off duty on those days. Once participants agreed to take part in the program, they received an email informing them that a study-which would take the form of a one-on-one interview—would be conducted to evaluate the impact of the program on their professional practice. They were invited to accept or refuse to participate in this study by return email. Participants followed the program according to the following modalities:The MB CARE program was introduced n = 4) vs. once a week for 4 weeks (n = 7);Program implementation of 4 days in a row (n = 7) vs. at the Espace City’zen ;At the hospital (n = 4) vs. free training (n = 7);Paid (n = 5) vs. inexperienced (n = 6) in mindfulness ; andExperienced (n = 4) vs. Training given by T. .Training given by C.  at least 1 year before the interview period to assess the long-term effects of the program. They were all experienced HCPs (over 10 years of practice) as defined in the Public Health CodeWe conducted our study after the delivery of the MB CARE sessions. For participant recruitment, we used a relevant convenience sample of former participants who were contacted through their email addresses that they had provided to the MB CARE organizers during their participation. Participants were 11 HCPs who had fully completed the program ;How HCPs take care of themselves ; andHow the program has impacted the practice of HCPs . This third category had three sub-categories:Impact on practice ,Impact on metacognitive skills , andImpact on the participants’ empathy skills and the therapeutic relationship .The grid had two purposes. First, it provided answers to the questions raised in the introduction. Second, it allowed for the assessment of the four levels of The interview always ended in the same way. We asked the participants how they felt. We also reminded them of the purpose of the interview and asked for any additional information that they felt would help meet that purpose and had not been addressed during the interview.This study received a favorable ethical decision from the INSEAD-Sorbonne University Behavioral Lab, ensuring, in particular, compliance with (1) of the Declaration of Helsinki criteria and (2) the French law regarding personal data protection in research studies in health sciences. Before the interviews, the participants’ willingness to be involved in the interviews was provided through email written consent. During the interviews, consent was ensured by asking if participants agreed to take part in the interview and have their data processed afterwards, and they were reminded that they were free to accept or refuse to answer each question.When transcribing the recorded interviews into Word documents, each interview was anonymized by being assigned a number . We chose to remove one person’s interview from the analyses because of irrelevance. We made sure that the transcriptions accurately reflected what the participants had said. We analyzed these interviews using King’s template analysis method . Each quOverall, the training was considered to be a very enjoyable experience: “The experience of the program [was] very pleasant” (Interviews 5 and 9). Only one person found the experience in itself difficult, pointing out the resulting effects as positive. When participants described what they liked about the training, they brought up the small group size: “What I liked a lot was that we were a very small group” . This encouraged sharing and allowed participants to realize that other HCPs shared their difficulties, without feeling ashamed or embarrassed, because everyone understood the situations they were facing. The majority of the participants perceived the program not as professional training, but as personal development training that could have indirect positive effects on their practice afterwards: “It is personal development at the service of professional development” (Interviews 10 and 6). Only one person, who had been meditating for many years, considered this training to be fundamentally professional: “Obviously it involves the whole being, both in its private and professional dimensions, but the internship is very structured on the care relationship, it is very structured on work, it is really centered on that. So it is 100% professional training” (Interview 5).When asked what they would like to change in the program, the participants often mentioned a need for post-training follow-up and reminders: “So what I would like is to have something after […] a reminder” . One person also reported that the program should offer more intersessional follow-up to encourage the sharing of feelings and changes that they were experiencing. Finally, some people mentioned the duration of the training, which was considered too short to have a long-term impact: “Afterwards, I sincerely think that 4 days of MB CARE training will not be enough to develop caring listening skills. If the people who follow this training do not continue on this path, well, I am not sure of the impact on their daily professional life” .The participants mentioned a variety of stressors that hindered their well-being in their daily work, such as their work environment and hierarchy , and psychological factors related to self-confidence and overwork . A large part of the participants reported that their self-confidence had evolved following the MB CARE program, and that they allowed themselves more room for error: “It allowed me to evolve, to have more confidence in myself” ; “I’m now less a perfectionist” (Interview 4). Nevertheless, some noted that this confidence was still fragile: “My confidence in myself is fragile and needs to be supported and encouraged” (Interviews 1 and 6). Participants also reported practicing multiple stress-reducing activities, for example, “By taking breaks […] By trying to give myself time […] I take care of myself with meditations at home, which are more formal practices and then sports” (Interview 5). They also mentioned the exercises they learned in the program, such as the use of breathing techniques.We evaluated the impacts of the MB CARE program along three axes: the impacts on HCPs’ professional practice, on their metacognition skills and on their empathy/compassion/self-compassion skills.Interestingly, one participant noted the importance of the HCP’s emotions in providing optimal care: “I realized how much my positioning or emotional state could influence the quality of the relationship” (Interview 5). The program appeared to have taught the participants to remain calm in stressful work situations, including those who did not continue practicing meditation. The participants also mentioned a greater capacity to take a step back . According to them, the training helped them to manage strong emotional feelings and to reflect on their emotions, thereby enabling them to react in a more appropriate way: “So the MB CARE training has taught me a lot, like to take a step back, to try to understand what state I’m in, what’s going on inside me, that’s how I can better face things” (Interview 10). The program seems to have enhanced participants’ ability to balance their emotions and reason as well: “Trying to respond to the situation rather than reacting according to one’s emotions” (Interview 3). They were also better able to realize when they were immersed in their emotions and thoughts: “So it happens to me sometimes in extreme situations, but it does not last long. I notice it pretty quickly” (Interview 4). However, a number of participants were still overwhelmed by their emotions, sometimes at the expense of their being grounded in reality. They mostly used breathing methods to manage their emotions and defer their effects to give themselves time to reflect. However, this kind of practice seemed to only be effective under certain conditions, such as anticipating the situation: “If I can anticipate the situation, the problem, yes. But if I really get caught up in a situation where I know I’m going to escalate, no.” (Interview 2). The participants also reported being more able to manage their workloads in order to make time for themselves: “It did not necessarily change my relationship with work, [but] it changed the way I perceive the effect work has on me” (Interview 5). This tendency to take better account of one’s limits and needs was noted when participants talked about burnout. The program seemed to have helped them to become aware of “risky” situations as well as to accept their human condition and an ability to let go: “I accept that when I’m tired I’m less efficient and that, therefore, it is necessary to stop and hand over work” . Moreover, many of the interviewees spoke of increased caring listening skill: “I am more attentive to what the other person says to me, I leave room for the other person, I really listen to them” (Interview 2). The participants paid attention to their patients, especially through the identification of perceptual clues. The former also mentioned paying more attention to the latter by managing their priorities: “Well, I’m getting better […] I can see what is a priority and what is not” (Interview 4). However, there were those who said that they did not really pay more attention to themselves or the patient in their interaction. The MB CARE program also reduced the participants’ tendency to be judgmental: “My view of others, of life, of myself, of judgment, all of this has changed” (Interview 4). The interviewees explored their feelings and emotions to a greater extent, and the majority were more accepting of them. This included acknowledging the emotion and accepting its existence: “That was quite new during the training. To tell myself I can recognise emotion without judging it and without asking myself why it is there […] I do not inhibit it, I regulate it” (Interview 10). The participants were more likely to regulate them than inhibit them. A few of them, however, felt that they were still judgmental toward their emotions, which they considered to be inadequate and not required. These people were the ones who preferred to inhibit those emotions: “I cannot welcome them without judgment. I will consider myself as weak, as fragile if I still feel fear or anxiety” (Interviews 1 and 3). The program also helped the participants to live more in the present moment: “There you are, you are really in the moment, you are listening to your body, you are in what’s happening right now for you, and it helped me to put things into perspective and get back to work” (Interview 4). They reported refocusing through short meditative practices : “I realize that I am doing some sort of micro meditation. It means micro refocusing on the present moment” (Interview 6). Furthermore, the program appeared to have had a great influence on participants’ ability to concentrate: “It allowed me to better identify my needs and, therefore, better focus on what I’m doing” (Interview 2). More specifically, the program impacted participants’ ability to focus on one task at a time: “I stopped doing two things at the same time […] That’s one of the big points of the program. To understand that actually I’m like everyone else—I’m not able to do two things at the same time” (Interview 8). Many participants talked about exploring their sensations as a way to refocus on the present moment, including vision, hearing and taste: “I’m reconnecting to the heat […], a breeze, some air, a ray of sunlight […] I’m going to be more attentive to the texture, the taste, of what I’m eating” (Interview 1). These sensations were also used during the professional practice to monitor one’s state: “When there is something that I am experiencing that is too intense […] I feel it quite quickly and I sit down. And I take a deep breath” (Interview 4). Nevertheless, two participants reported not being able to explore their sensations, especially during difficult experiences at work. When participants talked about their current practice of mindfulness, this mostly included informal practices, such as micro-meditations in the workplace: “I practice in informal micro meditation all day long, but not ritualized” (Interview 6); “On stressful consultations, I try to take 3 min afterwards to try to refocus on myself” (Interview 9). This informal practice was often coupled with formal practices, especially between consultations. The participants mostly practiced meditation for short periods of time, ranging from 10 to 30 min, often daily: “I try to do 10 to 15 min of breathing techniques. It’s going to be at home [where I] do a scan, do a compassionate meditation” (Interview 9). The body scan was often cited, but some found it rather unpleasant. Regarding the equipment used, two people mentioned a guided meditation application: “I practice it with the Petit Bambou application” (Interviews 1 and 3). However, two participants had abandoned this practice. Others said they often thought about practicing, especially when they experienced difficulties, but did not do so: “When I feel that I am beginning to be overwhelmed, when I feel that I am starting to feel emotions that are too intense, that tend to parasitise me, then I think about it” .The majority of the trainees reported that the program improved their ability to understand patients’ perspectives in order to better accept situations: “Well, if I had someone talking to me like that in front of me, what would I understand? […] Do I get the impression that he is interested in me or that he is not interested in me.” I find this change of perspective interesting […] It allows me to see my position in relation to the patient’ (Interview 5). Some participants mentioned conditions that affected their ability to change their perspective, such as the emotional intensity felt at the time. Some participants showed signs of developing their metacognitive capacity, but were not able to express it clearly: “[There is] a lot of confusion at first […] I try to think about situations at the same time and then I try to reassure the person […] There are a lot of things going on in our heads, I cannot necessarily identify them, I recognise them” (Interview 10). One person mentioned the possibility of analyzing one’s thoughts afterwards in order to react in a more appropriate way in the future. Regarding decision-making, the majority of the HCPs considered that they were aware of the decisions they made: “Well, when I make a decision, I usually know” (Interview 4). For some, they considered that they now took more time to think about it: “It has evolved a bit, because at the beginning I tended to make decisions from scratch […] I’m going to give myself time to think about what I’ve been asked to do, or what could be done” (Interview 1). However, their decision-making remained very factual and did not yet demonstrate high-level metacognitive abilities. One participant even said he did not think anything through during the decision-making process. Much of the thinking seemed to come after the decision was made: “Well, there is always a questioning, ‘Did I make the right decision?’ and a questioning of ‘I did not make that decision’” (Interview 7).The HCPs felt that they were kind to their patients: “I think I am kind to them” (Interviews 1 and 7). They also felt that the program had helped them to be kinder to themselves, which they thought had positive repercussions for their patients: “With MB CARE’s meditation approaches, I try to be kinder to myself and it helps me to be kinder to others as well” (Interview 3). Some, however, stated that they were already kind to their patients even before the training. A few expressed the fact that the term “kindness” was not appropriate, pointing out instead the characteristics of a warm relationship: “I do not think “kindness” is really the right term […] maybe a lot of things that might pass for kindness from the outside, but I think it’s not really the same” (Interviews 6 and 10). Overall, the participants were still self-critical but considered this criticism to be constructive and benevolent: “I am still self-critical but in something constructive” (Interview 10). This self-criticism also seemed to encourage acceptance of boundaries: “What MB CARE has done for me is that before, when there was a conflict, I always told myself that I was the only one responsible […] And now I tell myself, “Well, maybe.” Anyway, there is always responsibility on your part when something goes wrong, but maybe there was no solution anyway” (Interview 6). Only one participant stated that they never criticized themselves anymore and were strongly opposed to it. The interviewees were generally more benevolent toward themselves. The majority of the respondents considered that they were able to feel the pain of their patients: “I share their suffering a little and without feeling it […] Sometimes, it can shock me […] there is a form of acceptance” (Interviews 4 and 7). Some indicated that the program did not enable them to feel the patients’ suffering, but that it had helped them identify and perceive it: “I imagine how I would feel if I felt the same suffering, but it is not the reality of his suffering, because I am convinced that the reality of his suffering is something only he can feel” (Interview 5). The participants also seemed to be more accepting of their patients’ negative experiences. Some people pointed out a greater ability to distance themselves from patients when necessary: “So it may seem a little negative, but I am not always available for them” (Interview 1). However, two participants considered that there had been no changes in their relationships with patients. Finally, reflecting an empathetic image was important to the participants. It seemed to be the cornerstone of the HCPs-patient relationship for them: “I hope they have a warm and empathetic image of me. It’s part of the job” (Interviews 3 and 4). Interestingly, one participant mentioned the use of empathy and compassion as a practical resource to be consciously integrated into the HCPs-patient relationship: “If we manage to put empathy and compassion in even a 2/3 min regulation, it changes things completely, but really fundamentally” (Interview 5).The growing concern regarding stress and burnout in the workplace raise the question of the quality of life of HCPs and the quality of the care they provide. In view of this situation of HCPs’ work-related stress and the resulting negative consequences on patients’ health, many authors have called for the development and generalization of emotional resource management programs to cultivate, among other things, the compassion of HCPs and prevent compassion fatigue and burnout . Indeed,Our content analysis results showed that the training seemed to have an overall positive impact on the HCPs’ ability to take care of themselves, particularly through the ability to “take a step back.” It appears to have helped the participants to remain calm in stressful situations. In terms of their relationship with the patient, caring listening seemed to be one of the main skills that the program helped the HCPs to develop. Participants seemed to use mainly informal practices in their workplace. In comparison, formal practices were preferred at home, in time slots not exceeding 30 min. The program also appears to have enhanced the participants’ ability to recognize the presence of their emotions, which were better accepted—especially negative ones—with benevolence. The participants also seemed to be able to change their perspective in order to better understand their patients. They were more attentive to their patients and their needs, without being able to articulate how well they were paying attention to them. The participants felt they shared their human nature with their patients, although they still acknowledged their individuality. The majority considered themselves empathetic and thought they could perceive their patients’ suffering without feeling it. The program also facilitated the development of kindness toward themselves and their patients. Overall, the participants were better able to accept the difficult experiences they encountered in the workplace or those reported to them by their patients. A graphical summary of the results can be found in One of the most crucial elements in this series of interviews was to determine whether HCPs considered the MB CARE to be a vocational training or a personal development program. The respondents offered a variety of responses, ranging from viewing it as a full personal development program or as a very grounded, practice-oriented training. However, the modal response is that it is a personal development program that can have positive consequences for the HCPs–patients relationship. The MB CARE program, therefore, seems to be perceived as a kind of support that enables HCPs to better cope with their practice and protect themselves from problems related to personal exhaustion and lack of consideration for their limits. Exerting efforts to better understand their needs and listening to their feelings would enable them to be more empathetic toward themselves and, indirectly, toward others, thus resulting in compassionate care. These results are very encouraging insofar as HCPs are able to see the value of the program for their professional practice and for the majority of them to use those teachings for the benefit of their HCPs–patients relationships. It now remains to be established whether there is a need for more emphasis on the vocational aspect or whether this perception of the program as personal development with indirect vocational effects is sufficient to have truly positive effects on their relationships with their patients. Future studies of other practice-based and compassion focused programs should be undertaken to determine what adaptations are needed.One potential area for improvement would be a focus on the development of metacognitive skills, as many participants expressed difficulties in this area. The development of HCPs’ metacognitive abilities was notably intended to enable them to better identify the internal processes involved in their practice and to foster their capacity for empathy. However, many HCPs were not able to demonstrate significant metacognitive abilities. The majority of the respondents were not able to spontaneously express any internal processes, or when they did, it was very superficial. This could bring us back to the vision of meditation as an ongoing training that needs to be nourished by regular practice, a classical condition for self-development through mindfulness. These results could also suggest that the MB CARE program, based on MBSR may inherently lack impact on metacognition. The development of more compassionate health professionals–patient relationships through mindfulness is still in its infancy. This study is an encouraging first step toward more comprehensive programs that are, hopefully, attended by more HCPs. Our goal is to adjust the program so that it better aligns with the areas for improvement that we have identified. Thus, we plan to conduct further series of evaluations in order to validate the positive effects of the MB CARE program for developing a caring relationship based on compassion and empathy while preventing burnout. Moreover, mindfulness impacts care through other constructs. As we have seen here, metacognition is particularly of concern, but this could be the case for other concepts as well, such as for example critical thinking. Since the work of However, some limitations should be noted in this study. The main limitation is due to the time lag between the program and the investigative phase of the interviews we conducted. The program was conducted in 2018 and 2019, and we carried out the interviews in 2020. Therefore, for the participants, 1 to 2 years had elapsed since they had completed the program. This implies that their memories were very fragmented, and only the most vivid memories remained in their minds. In fact, many participants brought this up spontaneously, as noted: “This program was [implemented] a long time ago.” However, one can argue that this period of time allowed professionals to implement real changes in their practice following the program. Furthermore, it is important to note that participation in the MB CARE program was voluntary. Therefore, the interviewees had a certain degree of interest in a humanistic perspective in their work. They were also those who suffered the most in their daily practice. Individuals who do not feel this kind of distress generally do not turn to this type of training. Our study, therefore, focused on HCPs who may not be wholly representative of the HCPs population. We cannot guarantee that comparable results would be observed in individuals who had no particular interest in the mindfulness approach. Thus, future studies could address this issue and consider those related to adherence to programs without prior motivation and issues of engagement and reactance. Because participation was voluntary and few participants had the opportunity to attend the MB CARE program, the study was conducted on a relatively small sample of HCPs. We believe that this sample is of sufficient size to discern patterns of impact of MB CARE, but future studies should include larger samples, possibly of 20 or even 30 HCPs. Indeed, we consider to have reached good data saturation on results referring to the HCP-patient relationship . However, a larger sample would make our findings more robust, or be more likely to highlight between group  differences. In addition, we did not make any selection in regard to the HCPs’ professions, which gives access to a sample of HCPs in different positions with similar problems but with significant disparities . Thus, future studies should propose methodologies that ensure better control of samples, allowing conclusions that can be better generalized to specific HCPs populations. Furthermore, we did not control for the level of pre-program mindfulness practice among the participants. This was noticeable in the interviews, as some participants emphasized the richness of this first experience, without really being able to describe how the training had changed their practice, while others were unable to tell us about the specifics of the program, because they already had so much experience in this area. Unfortunately, we do not have precise data on mindfulness training participants may have received before, during, or after MB CARE . Future studies should collect this information in order to accurately determine the effects of a program comparable to MB CARE in conjunction with other mindfulness programs that participants may have taken. Besides, we decided to look at the overall impact of MB CARE without distinguishing between the different modalities available in the program . This is because we wanted to assess the impact of MB CARE as a whole. However, the training experience section of the interview grid was intended to help identify whether there were any differences in the program that were important. Further studies could investigate, among other things, the variation in results according to the location of the training, the type of trainers, or the timing of the training. Also, the very focus of the program means that we have little insight. Indeed, as previously stated, many mindfulness programs have demonstrated positive effects. However, as programs that specifically develop compassion are, to our knowledge, currently very under-represented, it is difficult to make comparisons. Therefore, the results of this study cannot be compared to other similar studies. Furthermore, if participants were recruited with achievement of data source triangulation in mind , all of The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by INSEAD-Sorbonne University Behavioural Lab. The patients/participants provided their written informed consent to participate in this study.CB: conceptualization, methodology, investigation, formal analysis, and writing-original draft preparation. AA: supervision, conceptualization, methodology, formal analysis, and writing-reviewing and editing. LH: conceptualization, methodology, formal analysis, and writing-reviewing and editing. CM: investigation. TC: investigation. CI: supervision, conceptualization, funding acquisition, and writing-reviewing and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


There are considerable health divides between residential areas in many Swedish cities. In more disadvantaged areas children grow up with poorer health outcomes than the country average. To meet the greater needs of children growing up in these areas through proportionate universalism, an extended home visiting program has been delivered. A novel part of this program has been the social worker and nurse later conducting home visits meeting the parents at the maternity care clinic before childbirth. The aim of this study was to explore parents’ experiences of that antenatal visit.Semi-structured interviews were carried out with nine mothers and three fathers around 3 months postpartum. Nine of the participants were foreign-born and a translator was used for four of the interviews. The interviews were recorded and transcribed verbatim and the data was analyzed with thematic analysis with an inductive approach.The parents’ overall experiences are comprised in the main theme: ‘A feeling of security and care for the whole family'. This main theme is derived from the three following themes: 1) ‘Staff - a trustworthy source of information'. Parents perceived the staff as experienced and knowledgeable and appreciated obtaining information about practical things and about the Swedish system; 2) ‘Access to emotional support'. Several parents expressed the need for emotional support and valued that by meeting the staff they knew they had someone to turn to; 3) ‘Becoming familiar with the staff'. It was appreciated to know who will come to your home as this gave parents an increased sense of security.Initiating the program through introducing home visiting staff at a scheduled antenatal visit benefited parents, by giving them useful information and social support. The visit also seems to be indirectly beneficial as it contributes to building trust for the staff and the rest of the program.• Initiating an extended home visiting program at a scheduled antenatal visit benefited parents, by giving them useful information and social support.• Initiating an extended home visiting program at a scheduled antenatal visit contributed to building parents’ sense of trust for the staff and the rest of the program.


Both programs included a 6-month follow-up period without PA. HRQL was assessed with the Short Form 36 Health Survey (SF-36) and physical condition by VO2 max, strength, flexibility, and balance. Participants in the AM6 program as compared with those in the AM3 program showed significantly higher scores in the subscales of physical functioning, mental health, energy/vitality, and general health. Mental health and general health at 6 months of follow-up were also scored significantly higher by AM6 participants. VO2 max and flexibility improved more in the AM6 group, whereas strength was better in the AM3 group. Half of the participants in the AM6 program expressed a strong willingness to continue exercising vs. 38% in the AM3 program. In this study, a community-based PA program with individualized progressive training loads of 6-month duration showed a more favorable impact on HRQL than a 3-month non-individualized PA program.We compared the effect of two community-based physical activity (PA) programs on health-related quality of life (HRQL) and physical condition in people with cardiovascular risk factors. Fifty-one subjects participated in the “ACTIVA Murcia” AM Health-related quality of life (HRQL) is a key benefit of physical activity (PA). Much research including recent systematic reviews and meta-analyses provide strong evidence of a consistent positive association between PA and HRQL ,2,3,4. SIn the past decade, there has been a marked increase in the number of PA interventions at the community level aiming to address the global public health problem of insufficient PA. Although systematic reviews and meta-analyses support the effectiveness of community-based PA interventions with positive outcomes ,17,18, iIn the field of cardiovascular diseases (CVD), community-based PA programs have been shown not only to determine a positive impact on hypertension, diabetes, obesity/overweight, and altered lipid profile in people with cardiovascular risk factors, but also on improving sustained PA levels ,22,23,24Therefore, the present study was conducted to determine whether the characteristics of these two community-based exercise programs for subjects with cardiovascular risk factors were associated with differences in their effects on HRQL and improvement of the participants’ physical condition.This was a prospective observational cohort study, which was carried out in the Region of Murcia (Spain) and consisted of comparing the effects of two community-based exercise programs on exercise adherence, cardiometabolic biomarkers, and body composition in subjects with cardiovascular risk factors. Detailed description of the characteristics and findings of this study have been previously reported . The preBriefly, participants were subjects of both sexes, aged 30–65 years, attended in the primary healthcare centers of four cities in the Region of Murcia, in whom some of the following cardiovascular risk factors were present, including: sedentary behavior, active smoking, hypertension, prediabetes, overweight or obesity, and alterations of the lipid profile. Subjects diagnosed with cardiovascular disease , blood pressure 180/110 mmHg or higher, uncontrolled metabolic disease, or musculoskeletal diseases limiting or worsening with exercise were excluded.3 and AM6, run in parallel in two sports centers, one developing the AM3 program and the other, the AM6 program. Recruitment of subjects started in October 2017 and those who agreed to participate were referred to the sports center closest to their home. The study finished in December 2017 (for the AM3) program and in March 2018 (for the AM6 program). In all cases, a 6-month follow-up period after completion of the program was established  would result in a more favorable impact on HRQL and physical condition than a shorter (3 months) and non-individualized PA training program (AM3) both at the end of the programs and after a 6-month follow-up period. A greater effect of the AM6 program on these variables  would further strengthen the previously reported greater benefits of the AM6 as compared with the AM3 on adherence, cardiometabolic markers, and body composition [6 program rather than the AM3 to older subjects with cardiovascular risk factors considered eligible for PA prescribed by their primary care professionals.It was hypothesized that a physical activity (PA) training program of a longer duration (6 months) combined with an individualized training load  and signed informed consent was obtained from all participants.3 had a duration of 3 months; the AM6, a duration of 6 months (AM is the acronym of ACTIVA Murcia). Both consisted of uninterrupted exercise sessions, followed by a 6-month follow-up without PA.Eligible participants were users of the public healthcare system who agreed to perform PA as part of the management of their cardiovascular risk factors. They aimed to make a change in their lifestyle habits and to reduce the risk of overt cardiovascular disease. The PA programs were different in regard to both the duration and type of training. The AM3 included three 1 h exercise sessions per week , with a resting period between sessions of 24–48 h. Sessions included a 5 min warm up, 25 min of aerobic circuit and strength exercises, and 5 min of static exercises. The training load was progressive and not individualized. The AM6 program also included three 1 h exercise sessions per week  with a rest period of 24–48 h. However, the intensity of training load was individualized according to the participant’s level of physical fitness. The general scheme of warm up, strength circuit or aerobic exercises, and cool down phases was similar to the AM3. A full description of the exercises, training mode, rates of perceived exertion, and other details of the AM3 and AM6 programs have been published previously [All PA programs were conducted and supervised by professional sport monitors. The AMeviously . Subject3 and AM6 programs. Data were collected before starting and after finishing the 3-month or the 6-month PA programs, and after a follow-up observation period of 6 months.Outcome measures were HRQL and physical condition in participants in the two community-based AMHRQL was evaluated using a Spanish-validated version of the Short Form 36 Health Survey (SF-36) . The SF-2 max, mL/kg/min) was measured using the 1-mile Rockport Walk Test [3 and MA6 programs. Participants in the MA6 program underwent an intermediate testing coinciding with the end of the MA3 program.The maximum aerobic capacity or maximal oxygen consumption , and willingness to continue exercising regularly .3 and AM6 program and sex); and covariates . Within-group comparisons were analyzed with the analysis of variance (ANOVA) for repeated measures with one study factor: time ; post hoc analyses were performed with the Bonferroni’s correction. The SPSS version 25.0  was used for data analysis, with a p < 0.05 value as statistically significant.The analysis was based on the per-protocol (PP) data set corresponding to those participants who finished the study. Categorical variables are expressed as frequencies and percentages and continuous variables as mean and standard deviation (±SD). For the comparison between groups of the initial characteristics, the Student’s t test was used for quantitative variables  and the chi-square test or the Fisher’s exact test for categorical variables (sex and cardiovascular risk factors). The analysis of covariance (ANCOVA) was used for the comparison of quantitative variables between the study groups: dependent variable ; fixer factors (AM3 exercise program and 42 in the AM6 exercise program. The mean of the study population was 59.3 ± 8.4 years. Women accounted for 77.4% of participants. Dyslipidemia (77.3%), high blood pressure (64.7%), obesity (51.7%), overweight (48.3%), and prediabetes (37.4%) were the most common cardiovascular risk factors. Baseline data are shown in A total of 108 subjects recruited from primary care centers in four cities of the Region of Murcia (Spain) by their physicians were assessed for eligibility, but 15 were excluded (not meeting the inclusion criteria (10), decline to participate (5)). Of the remaining 93 recruited subjects, 51 were included in the AM3 and AM6 groups are shown in 6 program was associated with increases in more dimensions of HRQL than the AM3 program.Results obtained in the different subscales of the SF-36 questionnaire at baseline, at the end of the PA program, and after 6 months of follow-up in the AM3 program showed significantly better scores at baseline than participants in the AM6 program , at 6 months of follow-up after the end of training, participants in the AM6 program showed significantly higher scores than those in the AM3 program . Moreover, within-group differences in the AM6 program as compared with baseline were statistically significant at all time points . Mean changes in the two study groups are shown in In the subscale of physical functioning, although participants in the AM6 group than in the AM3 group . Additionally, within-group differences at 6 months and 6 months of follow-up as compared with baseline were significant (p < 0.05). In the dimension of bodily pain, within-group differences in the AM6 group at 6 months and at 6 months of follow-up as compared with the baseline were statistically significant (p < 0.05).In the subscale of mental health, scores at 6 months of follow-up were significantly higher in the AM6 group than in the AM3 group at 6 months of follow-up  and also at the end of each program (p = 0.048). Significant within-group differences as compared with the baseline at 6 months and at 6 months of follow-up were found in the AM6 program (p < 0.001). Mean changes in the two study groups are shown in In the subscale of energy/vitality, scores were significantly higher in the AM6 group as compared with the AM3 group . Within-group differences at 6 months of follow-up as compared with baseline were significant in the AM6 group (p < 0.05).General health improved significantly in the AM3 and AM6 groups.In the remaining subscales of social functioning, role physical, and role emotional, changes in HRQL were not significant in any of the AM6 group than in the AM3 group, particularly at 6 months of follow-up .Change in health status over the last year showed a decrease, which was more noticeable in the AM2 max) increased significantly in both AM programs at the end of 3 and 6 months, respectively, as compared with baseline . At the end of the programs, increases in VO2 max were significantly higher in the AM6 group (p = 0.001).Results obtained in the four variables of physical condition in the study groups are shown in p < 0.001) in the two groups at the end of the exercise programs when compared with the baseline, but at 3 months (end of the AM3 program and intermediate assessment of the AM6 program), results were significantly better for the AM3 group (p = 0.023).Strength improved also significantly (p < 0.001). However, final flexibility values were significantly higher in the AM6 program (9.57 ± 4.93 cm) than in the AM3 program (5.0 ± 6.96 cm) (p = 0.046).Similar findings were obtained in the improvement of flexibility, with significant differences in both study groups at the end of programs as compared with the baseline (p < 0.05) at the end of the program as compared with the baseline were found in the two study groups, but differences between the AM3 and AM6 were not observed.In the balance test, significant improvements .Subjects in the AM3 and AM6 groups reported “much better” physical fitness at the end of the program, with 55.2% and 54.5% reporting “somewhat better”. Similar results were obtained for mood improvement, with 34.5% and 18.2% of participants in the AM3 and AM6, respectively, reporting “much better” mood, and 62.1% and 68.2% reporting “somewhat better”.A total of 37.9% and 31.8% of participants in the AM6 program than in the AM3 reported “yes, for sure” (50% vs. 37.9%). “Probably yes” was selected by 55.2% of participants in the AM3 group and 40.9% in the AM6 group, and “probably no” by 6.9% and 9.1%, respectively.For willingness to continue exercising regularly, more participants in the AMPhysical inactivity and sedentary behavior are associated with increased risk of CVD incidence and mortality. A recent systematic review and meta-analysis showed dose-dependent associations between sitting time (and television viewing time) with CVD, cancer, and all-cause mortality . In a co6 program characterized by individualized progressive intensity of training load, with a duration of 6 months, reported better effects on HRQL than those in the MA3 program, in which training load was progressive but not individualized and which had a duration of 3 months. Independently of differences in the progression of training , the longer duration of the MA6 program favored adherence [6 program indicating their firm desire to continue exercising.Reducing sedentary behavior by increasing PA at the community level is an effective intervention aimed at CVD prevention, but still remains a difficult challenge. In our experience, implementation of a preventive PA exercise program recommended in primary care by general practitioners with the regional governmental support has shown health benefits and improvements in physical fitness ,26. The 6 program as compared with those in the AM3 program showed significantly higher scores in the subscales of physical functioning, mental health, energy/vitality, and general health. Differences were particularly remarkable in the subscale of energy/vitality both at the end of the programs and after 6 months of follow-up. Mental health and general health at 6 months of follow-up were also scored significantly higher by participants in the AM6 group. On the other hand, significantly better scores at the end of the AM6 program and after 6 months of follow-up as compared with baseline were observed in five subscales , whereas there were no significant within-group differences in any subscale in the AM3 group. However, despite overall improvements in HRQL associated with the community-based PA programs, the perceived health status over the last year decreased during the study period, being significantly better at 6 months of follow-up in the AM3 group. It could be possible that increasing awareness of participants of their abilities and limitations to perform PA elicited by the longer program made them perceive a worse health transition during the last year.Participants in the AMp < 0.05) of the SF-36. In this study, however, patients were recruited from hospital outpatient clinics and the intervention was not delivered in a community-based setting. In the study of Arija, et al., [The beneficial effect of PA on HRQL documented in the present study is consistent with results reported by other authors. In two Brazilian populations, 3 months of community-based programs  were associated with significant improvements in physical functioning, general health, and role physical as compared with controls . Tsai, e et al., , a commu2 max, strength, flexibility, and balance among participants in both PA programs, although VO2 max and flexibility showed higher improvements in the AM6 group with significant differences as compared with the AM3 group.Changes in physical condition of participants with cardiovascular risk factors resulting from benefits of PA are well-established . We foun6 program cannot be dissociated as primarily due to the longer duration of PA or due to the individualized characteristics of the training program. The assessment of potential differences between men and women of the impact of community-based PA programs on HRQL may be also evaluated in future studies.Limitations of the study include the relatively small number of participants in the two community-based PA programs, but the comparison of the two exercise programs with different duration and load progression training characteristics can be helpful for optimizing the design of further studies. However, it should be noted that the improvements in HRQL and physical condition found for the AM6 program also elicited better improvements in the physical condition of participants and a greater willingness to continue exercising.Subjects with cardiovascular risk factors who participated in a community-based physical exercise program characterized by individualized progressive training loads for 6 months could benefit from a greater improvement in HRQL than those involved in a program of non-individualized training loads for 3 months. The AM