Parent-mediated intervention (PMI) has been studied in promoting skill acquisition or behavior change in the children with autism spectrum disorder. Most studies emphasize on the improvement of child’s core symptoms or maladaptive behaviors, making parental perceived competence and self-efficacy secondary. Yet, the evaluations of intervention implementation are under-reported, especially when translating such interventions into a new population or context. This research investigated the intervention implementation of a 12-week parent coaching intervention which was delivered through telehealth and tailored to Chinese population. The intervention was based on the Parent-mediated Early Start Denver Model with culturally adapted lectures, manuals, and demonstration and commentary videos. This study aimed to evaluate the intervention implementation by assessing parents’ satisfaction, acceptability, appropriateness, and feasibility.via videoconferencing. This mixed-methods study used a concurrent convergent design to evaluate the intervention implementation at post-intervention. The quantitative data was collected from the Program Evaluation Survey and the qualitative data was collected from five focus groups.A randomized controlled trial was conducted with two telehealth conditions: self-directed and web+group therapy. Parents in the self-directed condition received intervention individually through the online learning platform. The web+group therapy condition navigated the same program with weekly 1.5-h group coaching sessions Tailored feedback, demonstration and commentary videos, peer commenting, live coaching, and guided reflection were the top-five acceptable telehealth strategies that were strongly endorsed by parents. Family centered care, home-based intervention, strategies relative to daily activities, the remote learning platform, and the program-based community were elements that parents considered when evaluating the program’s appropriateness. Parent modeling, step-by-step instructions, and tailored feedback were key components in making intervention strategies feasible for parents to implement at home.Parents in self-directed group reported significantly lower scores in total perceived competence than parents in web+group therapy condition, while there was no group difference on the total self-efficacy. via videoconferencing could be a promising home-based service model to increase parental perceived competence. A large-scale RCT is needed to investigate the effectiveness of group-based PMI via telehealth.Findings indicate the application of telehealth was acceptable, appropriate, and feasible for Chinese parents. Group-based parent coaching intervention  Early intensive behavioral intervention (EIBI) is a common treatment based on applied behavior analysis principles for young children with autism spectrum disorder ASD; . DespiteParent-mediated intervention (PMI) is an effective evidence-based practice (EBP) which was identified by the National Professional Development Center on Autism Spectrum Disorder NPDC; . PMI focFamilies of a child with ASD in China face two key challenges: limited access to appropriate health services and a shortage of trained professionals. In China, 0.70–1.00% of the population is diagnosed with autism . Accordivia telehealth. The remote coaching allowed parents to use strategies more often in their daily interactions with children. Two studies examined the effectiveness of P-ESDM on preschoolers with ASD in mainland China. The Early Start Denver Model (ESDM) is an EBP designed for young children with ASD aged 1 to 5. It adopted behavioral and developmental principles to promote overall development and autism-related outcomes . The P-ETelehealth could be a potential service delivery solution to address limited access for families in China. Telehealth is defined as a provision of health care remotely through the usage of a variety of telecommunication tools, such as telephones, smartphones, and mobile wireless devices, with or without a video connection . The appvia videoconferencing enhanced accessibility, and the effects of the videoconferencing groups were comparable to those of in-person groups . The intervention study was conducted from September 7th, 2020, to January 17th, 2021. The post-intervention program evaluation data was collected from November 30th to December 12th, 2020.Thirty-two primary caregivers who completed the post-intervention Program Evaluation Survey from the intervention study were selected in this study. The inclusion criteria for participating the intervention study were: (1) parents over age of 18, (2) with a child aged 2–5 years old with a diagnosis of ASD made by a psychiatrist within 6 months at entry, (3) have access to the Internet and a digital device to receive the web-based intervention, and (4) the participating child met or exceeded cutoff scores of 10 , 8 (communication and language), and 3 (restricted and repetitive patterns of behavior or interest) on the Autism Diagnostic Interview-Revised . Particiintervention completion ratio was calculated by dividing the number of participants who completed the 12-week intervention by the total number of participants in the group. There were 18 participants in the group-based treatment group (web+group therapy) and 14 participants in the active comparison group (self-directed). Parents were randomly assigned to the treatment or comparison group. All participants received informed consent prior to participation in the intervention study and focus group, 24 of 32 agreed to participate in the focus group. Not all participants completed all the modules at post-intervention assessment; the via the Canvas online learning management system, and each module covered one of the following topics: (1) Autism and what to expect, (2) Increasing the child’s attention, (3) Sensory social routines, (4) Dyadic engagement, (5) Non-verbal communication, (6) Imitation, (7) ABC’s of learning, (8) Joint attention, (9) Play, (10) Pretend play, (11) Speech development, and (12) Program summary. To fit the knowledge level and demands of Chinese parents, the program was modified using a family capacity-building approach with four types of intervention materials. They were: (1) asynchronous lectures with a practice manual, (2) demonstration and commentary videos, (3) web-based Q&A session, and (4) homework . The Lectures were asynchronous videos that emphasized the understanding and application of intervention strategies for young children with ASD. Each module included a practice manual with instructions and reflection questions to help parents practice on their own at home. The Demonstration videos were authentic video vignettes of parents interacting with their children while implementing intervention strategies, while the Commentary videos highlighted the timing and key characteristics of the practices. Activities in the Demonstration videos were culturally appropriate and had a Chinese subtitle. Parents were encouraged to discuss and share their experiences in a Q&A session on the Canvas website. Parents voluntarily submitted homework each week, and those who did received individual written feedback from the therapist.The Group-based Parent Coaching Intervention is a culturally adapted program that uses the P-ESDM as the structure , 2013. Tgroup therapy session every week. The weekly group therapy was a synchronous group-based parent coaching session via telehealth. Each session lasted 1.5 hours and followed a standardized protocol to guide reflection via a videoconferencing software, DingTalk. The program was designed under the supervision of a senior licensed ESDM trainer who is also a clinical psychiatrist and delivered by a licensed physical therapist who is a native Chinese and has completed ESDM Introduction and Advanced trainings.During the intervention, the active comparison group (self-directed) navigated the program on their own pace, whereas the treatment group (web+group therapy) followed the same program but also participated an additional 1.5-hour virtual Basic demographic information was reported by parents including age, sex, education level, employment status, family income and structure, as well as the age and gender of their children with ASD.Total perceived competence and total self-efficacy were calculated by adding the scores from each week, with a maximal of 50  parents’ perceptions of the program implementation, and (2) perceived competence and self-efficacy. The first 12 items (item1–12) focused on the program implementation, while the remaining 20 items (item 13–32) focused on parents’ perceived competence and self-efficacy in each week’s skills. The survey used a 5-point Likert scale, with responses ranging from 5 (very agree) to 1 (very disagree). Item 1–12 evaluated the program in the following aspects: satisfaction, recommendation, acceptability, appropriateness, feasibility, program difficulty, background knowledge, and frequency of use. Acceptability, appropriateness, and feasibility items were extracted and modified from the published measures with strong psychometric properties, the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure . The iteThe purpose of the focus groups was to learn about parents’ perceptions toward this parent coaching intervention based on their 12-week telehealth experience. The focus group allowed researchers to explore the “what” and “why” questions corresponding to the survey questions and foster insights about personal perceptions, technical and social issues and practical experience that parents encountered during the intervention. The focus group followed a semi-structured agenda with 15 prompts based on the same conceptual constructs in the Program Evaluation Survey. Twenty-four of the 32 participants in the intervention study took part in the focus groups. The 24 participants were divided into five groups based on their conditions and availability. In the end, two focus groups were held for seven participants in the self-directed group (comparison), and three focus groups were held for 17 participants in the group therapy group (treatment). Five focus groups were conducted in Chinese online, immediately after the intervention using videoconferencing software, DingTalk. Each focus group lasted about 1 to 1.5 hours, was audio-recorded, and included 2 to 6 parents. The second author (HC) facilitated all five focus groups as a moderator, following the same agenda to ensure that all questions were addressed. The specific prompts are listed in P-values below 0.05 were considered statistically significant. Independent t-tests and Pearson’s χ2 tests were conducted to test the group difference in baseline participants’ demographic characteristics. Program Evaluation Survey data was exported from Qualtrics to run descriptive statistics. All data were reviewed for independence, normality, and homogeneity of variance. Descriptive statistics including frequency, mean, percentages, and standard deviation were computed. Independent samples t-tests were conducted to compare parents’ evaluation on the program implementation, perceived competence, and self-efficacy between treatment and comparison groups.Quantitative statistical analyses were conducted using SPSS 28.0. The qualitative data from focus groups were de-identified and transcribed verbatim in Chinese. Thematic analysis was conducted with the overarching research goal of understanding parents’ perspectives based on their 12-week experiences in this telehealth intervention. Those experiences included, but were not limited to, their personal perception of the program, perceived fit of the program in terms of whether it addressed a specific issue or problem, and the extent to which the skills learned can be successfully implemented. We followed the procedures for the thematic analysis approach described by M = 0.82, SD = 0.27) demonstrated a significant lower intervention completion percentage than 18 participants in the web+group therapy condition  at the post-intervention assessment, t(14) = -2.25, p = 0.04. The participating families came from 20 provinces, which covers most provincial level administrative region in China (20 out of 32).Participant demographic characteristics were reported in Recommendation in the self-directed group was non-normally distributed, with skewness of -1.89 and kurtosis of 4.67. The other items in the survey were fairly symmetrical because the absolute values of Skewness and Kurtosis were less than 0.5 or less than 3 times the standard error. The homogeneity of variance was tested through Levene’s test, and no significant results were obtained, assuming no violence in homogeneity of variance.Thirty-two parents in the intervention completed the Program Evaluation Survey. t-tests were conducted to examine the group differences. There were no group differences on item 1 to 12 regarding parents’ ratings on the program content or telehealth delivery on satisfaction, recommendation, acceptability, appropriateness, and feasibility. According to the findings, both groups held similar perceptions on program implementation. Specifically, M = 30.14, SD = 14.78) had significantly lower scores in Total Perceived Competence than parents in the web+group therapy group , t(30) = -2.09, p < 0.05, and the effect size was median, Cohen’s d = -0.75. The negative effect size indicates that the mean in the second group was larger, and the negative effect size indicates that the effect increased the mean when adding treatment. The results showed that there existed a significant difference in parents’ perceived competence between the treatment and the active comparison groups. A median effect size indicated that there may be a moderate treatment effect on perceived competence between groups. However, there was no group difference on the total scores of self-efficacy, t(30) = -1.44, p = 0.16.Parents in the self-directed group  were summarized in 1.During the focus groups, parents talked about their personal experience with various dimensions of this web-based program, five subthemes emerged within this major theme: (1) content, (2) design, (3) delivery, (4) participation, and (5) group therapy“The knowledge covered in the program is systematic and the topics are very comprehensive.” In addition, parents mentioned that the materials covered in the program focused on the key points and was digestible. 2029 added, “The whole program was presented in a very clear way to me. There are many techniques to use and steps to follow. These were clearly explained and emphasized.” Furthermore, parents identified their favorite and most challenging techniques for interacting with their children. The most frequently endorsed techniques were presented in “I found his communication becomes much better after using gestures and his emotional problems get better as well, and I believe that the use of gestures opens a door for him in communication.” Another parent (2021) mentioned joint attention was her favorite topic, “It allows me to build a connection between me, my kid, and an object, and this connection is like magic that makes the interaction between me and my child more natural in a harmonious way.” However, 3135 found joint attention techniques quite challenging, “If I initiate the joint activities, now he can respond and follow. However, it is challenging for him to initiate and share first. We are still working on that.”Parents across both intervention groups had overall positive perception on the program content, and they particularly commented on the program being professional and systematic with substantial learning materials. 2029 stated, “I really liked the way the instructor breaks down each module into steps, which are very easy to follow. In addition, the duration for learning is about 30 min, which can be finished quickly.” In addition, parents endorsed the topic sequencing in a learning progression and the structure encouraging participation and self-learning. 1002 stated, “There are setups in the program which really motivate me to learn, such as the new module unlocks when you finished the prerequisite in previous week.” The tailored feedback, demonstration and commentary videos, and group discussion were the top three learning components that parents stated as their favorite. For example, 1019 stated, “The teacher explains why we should do it and how to do it in the commentary videos. She uses lay language and presents the theoretical part in a digestible, easy-to-understand way.”When asked about the program’s design or structure, parents stated that it was well structured and easy to follow, and that the design was innovative, with an acceptable weekly dosage. 1005 stated, “Remote learning is more convenient and timesaving, especially after COVID. It is flexible for parents to arrange time for learning and for practice with the kids.” The limitations of remote learning were the high demands on the Internet and the reliance on technology. 1018 stated, “There’s only one computer in the household which is my husband’s. Therefore, I have to study when he is not working.” Most parents experienced slow downloading speeds when viewing learning materials, and other incidents for smartphone and tablet users included Canvas app crash and video stuck in processing. For example, 2043 mentioned, “I was really frustrated with the Internet speed; it took forever to download the videos. Then I went to upgrade my broadband and problem solved.”Parents shared their personal perceptions and experience on the program delivery when discussing about the telehealth format of this web-based program. They stated that telehealth delivery increased access to services and professionals, was time-efficient, and provided an alternative method without location or space constraints, particularly during the pandemic. 1002 stated, the kid does not always respond like a textbook or respond as you expected. I need to repeat the skills in the previous week so that I can use newly introduced strategies to interact with him.” Parents encountered numerous situations when submitting homework, the most commonly described ones were children unwilling to participate, target behaviors hard to capture, and failure practice not being reviewed. For instance, 2036 stated, “There are times that I cannot record the video as I planned. Sometimes it’s because I cannot proficiently use the skills, sometimes it’s the child not being cooperative.” However, majority of parents stated that homework assignments helped them reflect on the skills and techniques learned in the program, and that tailored feedback was useful and help guide learning. For example, 1002 stated, “The feedback is very informative, and I benefit a lot from that.” 1019 stated, “I can go back and watched it (homework) with the comments from the teacher …And this is the biggest takeaway from the program.” The main reason for not submitting homework videos was a lack of family support. For example, 1018 stated, “It’s very difficult for me to submit the video homework because I am the only parent in the household.”Parents felt empowered and strengthened when they realized they could integrate techniques learned each week into their children’s daily activities. It did, however, take some time for parents to implement the techniques with their children, and some reported that the rate of progression differed between themselves and their children. For example, 3233 mentioned, “… “We have a scheduled time spot every week …I believe this is a core strength that online group session holds compared to the one-to-one therapy because it helps every family in the group to relieve their parenting stress at different levels.” 2036 stated, “The feedback that I got from group discussion session was splendid.” Many parents stated that they felt committed to participating in the group session, with guided reflection, peer commenting, and role-playing receiving the most votes as their favorite group activities. For example, 3230 stated, “I know things that I need to accomplish within the week, which gave me lots of motivation. The group session is great for me and keeps me in tune and updated.” 2021 mentioned, “The teacher made a live demonstration, and then each parent played a role and practiced the skills online. I was really overwhelmed because I did not know the virtual group can be interactive and highly engaged.”This subtheme was generated based on prompts solely for parents in the treatment group (17 out of 24). They indicated the group therapy sessions relieved stress and created an interactive learning environment where they received direct coaching from the therapist and interacted with peers. For example, 3131 stated, A second theme that emerged was the perceived fit of the web-based program to address a specific problem or to achieve a specific purpose. Five subthemes emerged: (1) family centered care, (2) home-based intervention, (3) strategies relative to daily activities, (4) remote learning platform, and (5) program-based community (see text footnote 1).“My biggest takeaway is the environment that we built as a family and its impact on the child, because we REALLY are seeing his progress every week.” Many parents commented that the intervention skills and techniques emphasized parent-child interaction and the program emphasized parent mental health. For example, 1014 stated, “My arms had a lot bruises that his bites as he attacked a lot, I was very anxious back then. But now, we are very close and intimate, our relationship is influenced the most.” Meanwhile, parents reported that their interaction with their children after work was limited. As 2026 mentioned, “We have two kids… Sometimes the kid could already be asleep by the time I get home. It is challenging.”According to the parents, this web-based program provided an opportunity for all family members in the household to participate. For example, 3131 stated, “The remote learning is time-saving. We don’t have to take the kid to the institution …it is really convenient.” Furthermore, parents stated that they had never considered home as a possible intervention site, and their attitude toward early intervention shifted from a heavy reliance on local resources to a more balanced partnership between family and professionals. For example, 3233 stated, “I used to believe placing the kid in an institution that works 24 hours a day was the best solution, but I don’t have the financial ability to do so. I now realize I can interact with my kid with skills, and he trusts me more.” However, several parents experienced interruptions during intervention, such as business trips, being sick or other life responsibilities. For example, 1018 stated, “I take care of my child all by myself. I had a fever once and had trouble concentrating on any task.”Parents stated that this web-based program was a good fit since materials or skills provided could be used at home, and the self-directed program was flexible without time or location limits. Many parents indicated the remote learning was advantageous since it saved time and money that would have been spent on travel. For example, 3227 stated, “All the skills enable me to have a better understanding of my child. I often use steps and skills to plan out our daily activities now.” Many parents mentioned the child-led mindset was fitting to promote the parent-child relationship. It also aided in better understanding the motivation behind the child’s behaviors. For example, 1019 stated, “The ESDM is more like a mindset to me. It has a good concept, to follow the child’s lead. You should start with his interests and incorporate that into his daily routines and games.”Parents viewed this web-based program suitable because they learned intervention skills through the life events, and these intervention strategies could be integrated into their child’s daily routine to intervene. For example, 2029 stated, “I can arrange time to study the learning materials because we can watch these videos repetitively.” 3233 stated: “I think remote learning is extremely awesome because we can get in touch with American experts.” However, most parents had negative experiences with the Canvas app or video streaming to varying degrees, and many complained that remote learning lacked in-person interaction and could not provide instant feedback. As 3227 mentioned, “The only thing that I am not satisfied with is the difficulty of using the APP. The DingTalk meetings sometimes get very laggy …but it is common for remote learning.” 1020 also mentioned that the communication was not timely, she stated, “I gave some feedback on the software problem at the beginning of the program and I had to wait for the next day to get a response. The problem could not be solved in time due to the time difference.”The web-based program used Canvas to distribute learning materials. Parents valued this program because it supplemented the limited local resources and allowed them to access the materials repeatedly as needed. For example, 3135 stated, “After discussing with other parents, I find comfort in the fact that everyone is in the same situation, and that means I am not bad at taking care of my child.” 3233 mentioned, “I feel less anxious when I get to know other moms with older kids. I feel it is ok that my kid doesn’t have some skills now, I believe he will gradually get it, just like other kids.”Parents, in the treatment group, viewed the online group therapy as efficacious for creating a program-based community where they provided social-emotional support, shared personal experiences, and reduced stress and anxiety. For example, 2029 stated, Parents discussed the components that enabled them successfully to implement the intervention skills with their child. Five subthemes emerged: (1) parent modeling, (2) step by step instruction, (3) learning by doing, (4) formative and tailored feedback, and (5) peer learning (see text footnote 1).“I will not know how to practice the strategies out if I only watched the lecture videos. The combination of lectures and demonstration videos makes the intervention a relatively easy and doable task.” 3227 also mentioned, “You can observe directly what techniques other parents use in demonstration videos.”Many parents stated the demonstration and commentary videos facilitated them to carry out the intervention skills at home. Especially through parent modeling, they found it doable and intuitive to observe and learn. For example, 1019 stated, “There was a practice manual for each module, it tells us what to do at each step.”One of the practical reasons for the success of the intervention strategies was the step by step instructions. It guided parents to interact with their child and perform the intervention strategies. For example, 3135 stated, “This program focuses more on social interaction strategies which can be used in parent-child interaction at home.” They expressed that skills learned in the program was easy to apply and implement as most situations occurred in a naturalistic setting. 2029 stated, “Without the demonstration videos, I would never know there are strategies which can be used when putting on shoes, putting on clothes, even when eating meals together.”Many parents indicated this web-based program emphasized the application of intervention skills and strategies through daily routine activities or play. For example, 1002 mentioned, “After reading the feedback, I know where I did well and why it worked, also what I lacked, I will try to improve that for next time.” They also indicated that the tailored feedback provided them with relevant information or cues to guide them toward a possible solution given their existing personal resources and circumstances, rather than just a simple judgment of whether their performance was correct or not. A few mentioned the feedback was delayed due to the nature of the program structure. 3228 stated: “My practice feels different given the feedback I got. It made me understand my child’s behavior and reflect on my own behaviors.”Tailored feedback was one of the program components that most parents praised. Parents stated that the feedback facilitated them to complete the program and implement the strategies in a relatively easy way. For example, 3226 stated, “At the reflection section, the parents comment on each other’s homework, which is a great learning activity. We are able to learn from others’ strengths.”Peer learning experience was another subtheme emerged from responses within parents in the treatment group. They valued the group session because it allowed them to share ideas and learn through group discussion and group activities. For example, 3135 stated, During the focus groups, we asked about how the program could be improved to encourage participation, and parents responded with suggestions based on their own experiences and needs. Three subthemes emerged: (1) personalized pace, (2) advanced program in need, and (3) group-shared platform for maintenance.“…could we extend the module? For example, we could have divided 1 week into two and studied more thoroughly.” 3131 suggested, “The instructor could gradually step back from a central role. In this case, we, parents, not only learn theoretical concepts, but master these techniques in a real-world setting.” Some parents suggested having case study opportunities to address a specific problem they encountered in their lives, such as bedtime routines, mealtimes, and challenging behaviors. 3233 stated, “How about the group session solely focused on one family, we could discuss everything about the child, such as his functioning level, what he can and cannot do, and then propose intervention strategies for the mother?” Parents in the treatment group proposed a grouping strategy based on children’s levels of functioning, so that the session’s topic could be packed together. Some parents also suggested a live stream coaching session in which parents and children interact in front of the camera and receive feedback. 2036 stated, “Perhaps the courses could be assigned to parents based on their child’s level of functioning.”Although parents navigated the program at their own pace, many expressed their preferred progression. Some wished that the first few weeks be extended so that they could practice more, while others wished that the content in the latter weeks be given more time. For example, 1002 stated, “My child’s receptive and expressive language skills have greatly improved, but there’s still room for improvement in daily living skills. I wish there was more content focusing on that.” Parents expressed their needs for an in-person program and group therapy for their children. For example, 3131 stated, “We would also like to see an improved in-person version of this remote-learning program. If possible, I believe our family would benefit greatly from this.”The advanced program was in high demand among the parents, particularly those in the treatment group. Several parents inquired about a motor or language-specific program, while others suggested that more information on adaptive skills in the future. As 2023 stated, “I wish there was a way for us to share with individual accounts so that we could watch each other’s videos.” Parents suggested that the program groups be kept for follow-up and additional group therapy sessions be held. 3227 stated, “I wish we could keep talking for another 2 or 3 months after the program is over. stay in touch with the instructor and each other.”In addition to extending access, parents in the treatment group suggested establishing a shared platform for practice videos or their own toy collection. 3124 stated, Parents highlighted their success and accomplishments in the focus groups, and the discussion expanded beyond project implementation, from an individual to a service level. Three subthemes that most connected to service outcomes emerged: (1) cost, (2) timeliness, and (3) perceived effectiveness.“I am willing to pay. Nowadays we all know that you must pay for knowledge. It’s worthwhile if the expertise and service are decent.” Some parents reported that they could detect the difference between high- and low-quality services after the intervention, and the cost for equivalent services relied on the therapist-to-patient ratio and the therapist’s qualification. 3233 stated, “When it came to the cost, I always evaluate if the treatment session is one-on-one or one on many. Our group has a one to six ratio, which is acceptable.”Even though the current study was funded, parents expressed a willingness to pay for telehealth services, particularly high-quality services. 1019 stated, “If I had the chance, I would’ve enrolled my child in the program when he was younger, and I would strongly recommend it to younger kids. I feel like time is more valuable when we integrate strategies in the play to promote his development.” Parents noted the remote learning could assist underprivileged families receive timely treatment, and they recognized the potential of adopting ESDM in the neural typical family as well. 2023 stated, “Many clinicians, including therapists, in the second-tier city here at southwest China are unfamiliar with ESDM. I also met speech therapists who do not heard of ESDM. This online program gave me access.” 2043 added, “I believe that most families, including NT families, require such a program because parents are too busy working to educate and raise their children.”Another subtheme emerged on the service level is the timeliness. Most parents would recommend such a program to newly diagnosed families, and to families with young children aged 2–5. 1002 stated, “I did not know anything about ASD. I started to learn about Autism while watching other kids’ behaviors in the demonstration videos.” 1002 stated, “I feel that once I began to use the program’s strategies or skills, parenting became easier for me.” Parents also highlighted individual changes, such as changes in child behavior, parenting skills and parent-child interaction. For example, 1018 stated, “I learned how to interact or play with my child in a natural living environment, how to follow him and set up the joint activity… I feel he progressed tremendously.” 2021 stated, “I love my kid more because I discovered something subtle in her behaviors which I missed before. I understand her better now.” 2023 stated, “My child improved greatly over the past 3 months. He could only say ‘hua’ and ‘shi’ on September 7th, but now he can speak sentence, count numbers, even recite poetry. Great improvement.” Parents also mentioned parental self-efficacy and mental health improvement. 3131 stated, “Now I can see his progress from the beginning, and I can identify how he improves and appreciate his progress. It is the parenting mindset that changed most.”Parents shared their perceived changes during the focus groups, and they indicated how much they learned about ASD and how their attitude toward ASD intervention changed. 3228 stated, The mixed methods findings occurred by merging the quantitative and qualitative results. A more complete understanding of the research question was achieved by relating the conceptualized themes and subthemes to interpret and develop inferences between the quantitative and qualitative findings. The joint display provided descriptive statistics of the program evaluation with the qualitative themes and subthemes from the focus group, and the meta-inferences are reported accordingly in Project-level suggestions complemented the survey by offering detailed suggestions for future program. In addition, Service-level considerations partially related to the survey on the recommendation and parents’ perceived competence and self-efficacy, but complemented the survey on Cost and Perceived Effectiveness of Intervention.Overall, the two types of findings related to each other with regards to the majority of implementation outcomes, such as acceptability, appropriateness, and feasibility. The mixed methods findings showed expansion with central overlapping commonality as well as broader non-overlapping interpretations. Specifically, via telehealth. We employed a mixed-methods approach using the post-intervention survey and focus groups to evaluate the program implementation from parents’ perspectives. The mixed methods findings provided detailed understandings of the elements or ingredients that determined the implementation success in this culturally adapted program. It revealed (1) the elements of this program that were acceptable to parents, such as program content, design, delivery, participation, and group therapy; (2) how this telehealth program met parents’ needs or addressed their problems ; and (3) what practical elements made this program feasible for parents to implement, such as parent modeling, step-by-step instruction, learning by doing, formative and tailored feedback, and peer learning. Findings of this study have implications for better understanding of the telehealth delivery of evidence-based autism-related services among Chinese parents, such as P-ESDM. Results are discussed below.The current study aimed to investigate Chinese parents’ experience of participation in a 12-week group-based parent coaching intervention based on the P-ESDM and delivered Overall, parents across groups rated the elements of program implementation  positively. Most parents rated the program’s difficulty levels as moderate, believing that there was some background knowledge required for participation. The majority of parents used the program less than four times per week. Despite the fact that parents in the treatment group had significantly higher scores in total perceived competence on the skills gained during the intervention, there was no group difference in self-efficacy. The observed increase in total perceived competence in the treatment group could result from the group therapy itself. Another possible explanation for this might be that fewer people in the self-directed group completed the intervention compared to the treatment group, with the intervention completion ratio 57 to 94%, respectively. However, the findings suggest that parents in both groups had a comparable level of confidence in their ability to carry out the intervention skills after the program, even though the self-directed group had lower total perceived competence scores and fewer people completed the intervention. Self-efficacy was considered as a predictor of health behavior change and maintenance . Accordiprogram content, design, delivery, participation, and group therapy were five aspects that parents considered when evaluating the program’s acceptability. The evaluation was mainly based on whether their needs, preferences, or expectations differed (tailored feedback, demonstration and commentary videos, peer commenting, live coaching, and guided reflection were top five telehealth strategies strongly endorsed by the majority of Chinese parents. With opportunities in pediatric telehealth created by the COVID-19 pandemic for families of children with disability (Telehealth created opportunities to deliver acceptable and appropriate services for children with disabilities, particularly during the COVID-19 pandemic . Our findiffered . Specifisability , therapiAppropriateness of Telehealth Delivery, compared to other items in the program evaluation survey. Thirdly, future research or service providers need to explore strategies to promote parent engagement and completion for telehealth interventions. Despite the numerous advantages of telehealth services, there are still challenges to overcome. Firstly, the availability of equipment and a stable Internet connection are key factors for the implementation of telehealth interventions. Although telehealth interventions have been successfully implemented in rural areas , barriervia digital service because it required extensive parental involvement. As home-based strategies into daily activities, and the remote learning platform increased the accessibility to both services and professionals. Long work hours, unexpected interruptions from life events, a lack of in-person observation, and a lack of face-to-face communication were barriers in this program. Feasibility was evaluated by practical experience of parents if a task can be performed relatively easily (modeling and instructions. The formative and tailored feedback corrected and guided parents’ practice. In addition, the synchronized videoconferencing group sessions provided parents with peer learning experience. All the components mentioned above helped parents successfully implement intervention techniques with their child at home.The program’s appropriateness and feasibility were critical when delivering early intervention y easily , 2011. Tvia telehealth, with all three reporting a high level of satisfaction (via videoconference to parents of children with ASD. Our findings demonstrated that the telehealth delivery format was acceptable to Chinese parents. Despite certain suggestions and concerns for better serving parents’ needs, this group-based parent coaching intervention might be a successful program and a promising method of delivery for a low-resource population, such as Chinese parents.Group-based therapy provided psychosocial support for parents of a child with ASD , and vidsfaction . Howeversfaction . Peer bosfaction . Overallcost emerged as a subtheme that complemented the survey outcomes. For example, parents stated the remote program was cost-efficient for them. Limited availability of services in the healthcare and educational systems and a pervasive shortage of resources are key factors in the financial burden faced by parents (via telehealth may offer a promising solution. More research is needed to determine the feasibility and effectiveness of such programs or instructional materials across a variety of contexts.Group-based programs delivered by telehealth would potentially become a more affordable option for Chinese families with a child diagnosed with ASD. According to  parents . Parents parents . Under sProject-level suggestions and service-level considerations complemented the quantitative results by emphasizing the need to personalize treatment to optimize outcomes and proposing a potential solution to establish a group-shared platform for longer sustainability. Those results indirectly reflect there is a great need for high-quality early intervention services in mainland China. Future studies should include components or strategies to improve parent engagement and participation, such as practice manuals, homework, and tailored feedback. Such programs should be adjustable in the difficulty level with an acceptable and a manageable dosage to avoid putting additional strains on parents. Furthermore, strategies and methods that can be used to advance personalized interventions need to be further investigated to better serve children at different stages of development and families with diverse characteristics.The mixed methods findings provided suggestions for improving future iterations of the program. There were several limitations in the current study. Firstly, despite efforts to recruit families from a variety of demographic profiles, most participating families included parents with a college degree or higher. The telehealth program excluded those families who did not have access to the internet or digital devices. Second, the sample size is relatively small. However, given this culturally adapted telehealth intervention was newly developed and still on feasibility testing, the current mixed-methods findings provided enriched and comprehensible information about the program implementation compared to solely quantitative ratings. Although it is typical for a convergent design to have the qualitative sample nested within the quantitative sample, most responses from the focus groups came from parents who completed the intervention. We were able to invite one parent from each group who did not complete the program to contribute their views. There was a lack of information from those who did not complete the program or dropped out. More research is needed to discover why some parents dropped out or did not finish on time. Future telehealth research should consider including web-activity data to gain a better understanding of digital service usage and intervention dosage, such as the number of unique views and minutes viewed on intervention videos. Furthermore, for future research, a user-friendly learning platform and Internet access may be critical factors in telehealth program participation.via telehealth. According to our findings, parents in both self-directed and web+group therapy groups had positive perceptions in program satisfaction, acceptability, appropriateness, feasibility, and recommendation. Both groups reported high parent perceived competence and self-efficacy, and group-based parent coaching session increased parent perceived competence. Findings indicate the application of telehealth was acceptable, appropriate, and feasible for Chinese parents. It may suggest the possibility of using telehealth as a service delivery option. In addition, group-based parent coaching intervention could be a promising home-based service model to increase parental perceived competence. Future research should continue to identify culturally appropriate PMI for parents in low-resource contexts, and a large scale RCT is needed to investigate the effectiveness of group-based PMI via telehealth. More studies are urgently needed to develop and evaluate the feasibility and effectiveness of this type of intervention during and after the COVID-19 pandemic in resource-limited communities.The current study used a mixed methods approach to better understand parents’ perceptions of the implementation outcomes of this modified Chinese version of P-ESDM delivered The original contributions presented in this study are included in the article/The studies involving human participants were reviewed and approved by University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.LQ conceptualized and designed the study, analyzed and interpreted the data, and drafted the manuscript. HC collected the qualitative data, analyzed, and interpreted the results. AM and CC conceptualized and designed the study. CC, WC, HM, and DU oversaw the fieldwork and data collection and interpretation. All authors revised the manuscript and approved the final version of the publication.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.


Further, we found that adolescents gradually decreased their basal OT level during a long separation from parents . A combination of these findings suggest the OT level may be a marker for psychological independence.While wilderness programs are recognized as a feasible intervention to promote psychological independence in adolescence, little is known about physiological changes. The present study focused on oxytocin, a key hormone for social cognition and behavior, and investigated changes in OT concentrations during a wilderness program among adolescents. Twenty-one 4th–7th graders were separated from parents and immersed with adventures and challenges in the woodlands of Motegi, Tochigi Prefecture, Japan for 31 days, and dataset of 20 boys aged 9–13 years-old were used for analysis. OT concentrations in early morning saliva samples on days 2, 5, 8, 13, 18, 20, 21, 22 and 30 were determined using ELIZA. We performed multi-level regression analyses to compare the OT concentrations before and after solo and team-based survival challenges, and across the nine observational points, adjusting for potential covariates. We found that adolescents increased OT level in a situation where they needed others’ cooperation and support for survival (coefficient: 2.86, SE: 1.34,  Adolescence is marked by profound biological and social transformation  and manyOne way to nurture independence in adolescents is to provide proper encouragement and reinforcement to explore the world on their own and take responsibility for their decisions in a safe setting . WildernWhy the wilderness programs promote independence in adolescents is less understood. Qualitative studies have identified self-reflection and introspection with facilitators playing a vital role in the participants’ psychosocial benefits . On the The objective of the study was to investigate changes in oxytocin (OT) concentrations during a wilderness program in adolescents.r = 0.4) correlation, and estimated effect size and SD to be 3.0 and 4.0 based on the previous study [We conducted a single armed observational study as part of “Hello Woods”, a 31-day residential wilderness camp organized by Honda Mobilityland Corporation. The required sample size for a mixed model which takes into account of within-individual correlations was calculated to be 19 by the standard formula for paired t-test with a 95% confidence level, a 5% margin of error, a moderate .Hello Woods was taken place in a 42-hectare peri-urban woodlands in Motegi, Tochigi Prefecture, Japan. The program  consiste® cotton roll  [n = 1) was replaced with the average of three participants with the same age, and missing information on OT level on day 2 (n = 2) and day 18 (n = 2) was replaced with subsequently measured OT level of the same participants.Saliva samples were collected using the SalivetteGermany) ,29 at arGermany) . MissingBecause there are individual differences in OT concentrations and reactivity to laboratory-induced or naturalistic stress due to age, body mass index (BMI), medical use and preexisting medical and psychiatric conditions ,30,31, aWe performed multi-level linear regression model analysis nested within individuals to investigate if salivary OT level changed from just before to during or after the solo and small-group bushcraft camping  and over the course of the program , using the STATA SE ver. 17 for Windows . We chose the within-subject design  over the between-subject design  because OT levels across the nine time points were likely to be dependent on individuals at a considerable extent, and to increase statistical power . We builThe participants’ characteristics are summarized in p = 0.43). The OT level was also similar on the second day of the team-based bushcraft survival challenge compared just before it stared . However, it was significantly elevated on the third day of the challenge . The coefficient, SE and p-value remained the same even after adjusting for the participants’ age, presence of self-motivation at the time of application, history of the wilderness program, height, and BMI.The results of the mixed-effect regression analyses to compare OT levels before and after the bushcraft survival challenges are presented in Trajectories of OT levels during the wilderness program for the 21 participants is presented in p = 0.029; coefficient = −2.74, SE = 1.10, p = 0.013, respectively).Mixed-effect regression analyses showed the statistically significant decline during the whole camping program before and after adjusting for the participants’ age, presence of self-motivation at the time of application, history of the wilderness program, height, and BMI . Among tTo the best of our knowledge, the present study is the first to examine changes in OT levels in adolescents during a wilderness program. A total of 20 male adolescents were separated from parents and immersed in high adventures and challenges in the wilderness for 31 days. While we found no significant change in the OT level following the solo bushcraft survival challenge, we found a significant increase in the OT level during the team-based bushcraft survival challenge. We furthermore found a significant gradual decrease in OT level over the course of 31 days.We observed temporal increase in OT release during team-based bushcraft survival challenges while we did not find a significant increase in OT release following solo bushcraft survival challenge. These finding are consistent with existing reports on OT reactivity in adolescents under various experimental conditions ,23,25,33We also found that OT level in adolescents decreased over time by prospectively measuring OT levels for nine times in total from the same participants. This finding is consistent with the earlier studies that reported lower levels of OT in adults and decreased level of OT receptors in rats experiencing parental separation in childhood ,27. A hiThere are several limitations in the present study. First, our participants included early and pre-teens, and our main analyses were limited to boys only due to small sample size of girls. Age and gender may affect how adolescents respond to the wilderness program. For example, boys and girls may have different motivations  and different understanding of the program  . SimilarSecond, our study was a single-arm observational study. A control group  is necessary to affirm that the wilderness program induced the changes in OT excretion level as seasonal change in temperature  and the Third, we did not measure psychological independence directly utilizing existing scales such as Psychological Jiritsu Scale . AlthougFourth, we measured OT in saliva, which encompasses a simple and painless collection method suitable for multiple-time collection from young people . SalivarFifth, we measured early morning OT concentrations nine times during the 31 days, but we were not able to measure before or after the program as the participants were gathered from all places in the country. Future studies should follow the participants beyond the program to measure basal and after-the-program OT levels. As a single measurement of salivary OT may not be enough to reflect an individual’s OT system, multiple measurements for an extended period would be recommended . This woIn summary, this study is the first to examine the changes in OT concentrations during the wilderness program in adolescent boys. Our findings indicate that adolescents increase OT level in a situation where they need others’ cooperation and support to survive, which is consistent with previous studies that suggested a role of OT in within-group cooperation. Our findings further indicate that adolescents gradually decrease their basal OT level when separated from parents and confronted with adventures and challenges for 31 days. Our exploratory study suggests that OT level may be a marker for psychological independence in healthy adolescents. Further research is warranted to confirm the changes in OT excretion and their association with growth of psychological independence during a wilderness program in a diverse group of adolescents.


This study aimed to evaluate the real-world implementation of the Friendship Bench (FB) – an evidence-based brief psychological intervention delivered by community health workers (CHWs) – three years after its implementation in three city health departments in Zimbabwe. Implementation sites were evaluated according to their current performance using the RE-AIM framework making this one of the first evaluations of a scaled-up evidence-based psychological intervention in sub-Saharan Africa (SSA).www.re-aim.org), the authors designed quantitative indicators based on existing FB implementation data. Thirty-six primary health care clinics (PHC) in Harare (n=28), Chitungwiza (n=4) and Gweru (n=4) were included. Among these clinics 20 were large comprehensive health care centers, 7 medium  and 9 small clinics . Existing data from these clinics, added to additionally collected data through interviews and field observations were used to investigate and compare the performance of the FB across clinics. The focus was on the RE-AIM domains of Reach, Adoption, and Implementation.Using the RE-AIM guide  and medium clinics (9%). Adoption was high in all clinic types, ranging from 59% to 71%. Small clinics led the implementation domain with 53%, followed by medium sized clinics 43% and large clinics 40%. Small clinics performed better in all indicators and differences in performance between small and large clinics were significant. Program activity and data quality depends on ongoing support for delivering agents and buy-in from health authorities.The Friendship Bench program was implemented over three years transitioning from a research-based implementation program to one led locally. The Reach domain showed the largest gap across clinics where larger clinics performed poorly relative to smaller clinics and should be a target for future implementation improvements. Program data needs to be integrated into existing health information systems. Future studies should seek to optimize scale-up and sustainment strategies to maintain effective task-shared psychological interventions in SSA.The online version contains supplementary material available at 10.1186/s12913-022-08767-9. Common mental disorders (CMD) such as depression and anxiety are a leading cause of disability worldwide, and the burden is especially high in low- and middle-income countries (LMIC) where up to 90% of those needing care have no access to it , 2. GrowThe Friendship Bench (FB) is a brief psychological intervention delivered by CHWs which has shown effectiveness for predominantly female primary health care (PHC) clinic users through a cluster randomized controlled trial . The proThe program was developed in Zimbabwe in 2006  and has The Zimbabwean CHWs are mostly elderly women who have been employed as health promoters by the respective city health authorities over 35y ago. They receive a basic salary and have continued to work past their retirement age due to economic necessity. They have been involved in the delivery of diverse public health initiatives which include treatment strategies for TB, HIV awareness, and community immunization campaigns commissioned by local health authorities.The FB program was formally handed over to the Harare city health department in 2016 by the University of Zimbabwe (UZ) which had administered it as a research initiative. The formal hand over included the development of data collection tools aimed to integrate the FB into routine PHC services. Since 2016, the FB team has continued to play a technical supporting role albeit with reduced activities due to lack of funding. CHWs were expected to independently integrate the FB intervention into their ongoing health promotion work.Transitioning from research to practice has unique challenges, and despite many guidelines for PHC staff, scale-up of evidence-based practices (EBPs) is slow and often encounters unique challenges that did not exist during research-based implementation –15. ImplStudying the FB program offered a unique opportunity to gain insight on an EBP which focuses on mental health on PHC level and has been implemented at a larger scale. We sought to understand in more detail which factors contributed to differences in implementation performance among 36 FB implementation sites .The aim of this study was to evaluate the implementation of the FB program three years post scale up using the RE-AIM framework.To gain an overview of the FB activities at the 36 PHCs, we carried out a review of the FB data that should have been routinely collected in a data collection book at each clinic since 2016. However, we found that FB related data since the scale-up exercise started was not reliably available. Upon investigating reasons for the lack of reliable data, several factors became obvious: a) CHWs had not been trained in data collection and responsibilities were unclear; b) data was collected only from those clinics whose CHW supervisors received continual guidance from FB research team members which was only happening in Harare; c) FB data was not integrated in the routine clinic data collection efforts and therefore not prioritized.Since reliable routine FB data was unavailable, we restructured our research approach which required a deviation from our protocol . Insteadwww.re-aim.org), we designed quantitative draft indicators based on availability of Friendship Bench implementation data such as PHC clinic user numbers, number of clinic staff, catchment area size, number of CHWs, FB program user number, data pertaining to program usage such as frequency of consultations, FB-related tools such as benches, questionnaires, notebooks, frequency of supervision meetings for CHWs and support group meetings for clients.Using the RE-AIM guide .In total, we created 16 indicators , Chitungwiza (n=4) and Gweru (n=4).This study was carried out in 36 PHC clinics in three cities Harare  characterized by informal income generating activities. Depending on their size, PHC clinics serve between 20,000-80,000 people from the most socio-economically disadvantaged sectors of the population and are defined as large (poly clinics), medium  and small (satellite) clinics .CHWs are present at all clinics and do health promotion at clinic level as well as outreach activities. CHWs are overseen by health managers . Clinic size defines how many CHWs (currently between 1-14 CHWs) are attached.The group of CHWs who had prior experience with the FB program through their participation in the FB RCT  were assDepending on the size of the clinic, different numbers of wooden benches (Friendship Benches) are placed on the clinic premises. CHWs see clients between Monday and Thursday mornings at the clinic and at other times during the week in the informal setting of the community. Patients waiting for services at the PHC clinic are being sensitized about mental health and the FB program by FB CHWs who are trained as “mobilizers”. These can refer to the CHW on the bench who will administer a locally validated screening tool, the Shona Symptom Questionnaire SSQ-14) . Clients4 . ClienWe investigated FB activities in 20 large, 7 medium, and 9 small clinics, as shown in Table The study was authorized by the city health authorities who run the PHCs and had received ethics approval from the Medical Research Council Zimbabwe (MRCZ). All 36 clinic leads were informed about purpose and duration of the study and key informant groups .Four trained research assistants collected data between October and November 2019. Two research teams visited first clinics in Harare, then Gweru and Chitungwiza. Two consecutive days were spent at each clinic to conduct all questionnaire-based interviews and each team covered two clinics per week.http://support.kobotoolbox.org/) to allow for complete data collection. CHW notes and notes from the supervisor of the CHWs were read to verify the responses given in the interviews. Data was verified on site after collection and then uploaded daily onto a password protected cloud. Only the local research team had access to the data base.As each clinic had varying numbers of CHWs and we had time constraints, half of all FB counsellors were selected randomly in their presence and subsequently interviewed. All FB program activities for a period of one month prior to the data collection were investigated and data was entered into KOBOtool , except for the two indicators for Reach that were assigned % values. Indicator scores represented the level of performance, mean results per clinic group are presented.Additionally, individual indicator scores were summed, and each clinic received a total summary score for each domain which was ranked according to a procedure suggested by Farris et al. . The higWithin each indicator and domain, there were cases where several clinics had the same combined domain rank and, therefore, ended up with the same rank.The mean of all three domain ranks per clinic formed a composite ranking which represented the overall level of FB site performance  was used to determine any significant differences among the clinics’ scores and differences according to type of clinic. Additionally, a Tukey post hoc test was used to confirm the differences between clinics individually and when aggregated as type groups.To establish whether clinic types had an influence on the performance of a FB site, we aggregated the clinics according to their types  and compared their performance using their overall composite ranking .n=74), Community Health Worker supervisors (n=35), nurses in charge (n=36) and the district health promoting officers (DHPOs) (n=7). Only one approached key informant, a District Health Promotion Officer (DHPO) from Harare, was not available for the interview.Our questionnaires were administered to 152 key stakeholders: Community Health workers  = 1.08 p = .352]. Therefore, the distribution and/or spread of scores around the mean of the three clinic types were considered equal. Analysis of variance showed a significant difference between the types of clinics based on their final ranking .Final rank scores ranged from 1-36. From this distribution of mean ranks across the three types of clinics, Levene's test indicated homogeneity of variance [p = .002), rankings did not differ significantly between large and medium clinics (p = .38) as well as between those of small and medium size (p = .20).Post hoc analyses using Tukey’s HSD (Tukey honestly significant difference) indicated that rankings were significantly lower for larger than smaller clinics (p<0.05) confirming the independence of domains in terms of classifying levels of performance. As expected, the ranks for all domains correlated strongly with the total ranks. Nonetheless, small differences can be observed. The Adoption domain ranking results had marginally lower correlation with total ranks (r = .60) compared to the reach (r = .75) and implementation (r = .71) ranking results . The reason for this could be that CHWs in small clinics have more time to focus on the FB program and mobilize those coming to the clinic. Community members receive care in small clinics before being referred on. Thus, their first contact with FB is in small clinics and they will not reengage with the program once referred to a large clinic (unpublished data). Patients reported not having time to speak to FB CHWs at large clinics when seeking care for specific health issues (unpublished data). Small clinics also had better rates of Adoption and Implementation domains. For example, were the wooden benches that are used by CHWs and their clients more in order due to less patient traffic. CHWs at small clinics deliver fewer competing programs which enables them to focus more fully on the FB program.Admittedly, the FB program had been discontinued in both other cities (Gweru and Chitungwiza) as health authorities had reduced their focus on mental health care and redirected CHWs to other duties (unpublished data). Despite the program being inactive, we collected data on various domain indicators which placed clinics in the ranks showing weak performing. From a systems perspective, successful program implementation depends on all combined program factors explored in this study and hypothetically barriers on one area affect other domains but this study shows that domains performed rather independently among high performance clinics but there was much stronger correlation across domains at the bottom of the overall performance ranking.Additionally, parallel research carried out by the FB research team led to more contact and support for CHWs based in clinics located in Harare as well as collaboration with the city authority staff which led to the FB program being continuously offered between 2016 and 2019.Harare based small clinic settings with less competing health care program and ongoing support from the program designers as well as from the health authorities had better FB program performance compared to bigger clinics.Furthermore, we had learned in the formative phase that the FB related data collection was not integrated into the clinic data reporting system as it was not a priority in the clinics’ activities. Health information systems in LMIC are often affected by lack of reliable data . Our finAn additional important outcome of this study was discovering barriers that hindered the FB program which we decided to address right after we finished data collection. We reengaged and supported the City Health departments and clinic leads in all three cities by distributing material, repairing or replacing benches, and offering refresher trainings to the CHWs to ensure a new start and/or continuation of the FB program, respectively.Scaling up efforts need to be well planned and strongly supported to prevent losing fidelity of the program and data should be used to monitor the process to detect and overcome difficulties as soon as it may be possible .Scaling a program like the FB requires an approach that takes into account contextual determinants such as clinic setting, availability of program specific aspects, structural support from all stakeholders and emphasizes the integration of the program data into the existing health information system. The data collection process has to be designed in a “user-friendly” way when delivering agents are being relied on to document and report program activities.This study has contributed to our understanding of the implementation, these results and the ones of the follow up study (unpublished data), we create strategies to address barriers and enablers (unpublished data) as laid out in the study protocol .Only clinics in Harare, the capital of Zimbabwe, still had program activity at the point of data collection which makes the results less generalizable. As scale up data since 2016 was insufficient and unreliable, we had to focus on the implementation activities one month before our research visits which does not reflect well the three years prior of FB program activities.Some RE-AIM domains were not assessed and the need to weight indicators and outcomes for the domains included is debatable. As routine data collected prior to the study was unreliable, we had to choose indicators according to what our expert team agreed on and what was possible to obtain. Since the study, we implemented ways to ensure better data collection such as hiring data clerks in each city, distribution of tablet computers and use of a data collection app that was created inhouse. Additionally, we have put in place a financial reward system for all FB CHWs for correct data reporting.Unfortunately, we only had a limited time at each implementation site to carry out data collection and some results of observations might therefore be less reliable. For instance, there was relatively little patient traffic during the observation period which also affected our plan to measure fidelity through analysis of audio recordings which we were only able to collect in insufficient numbers and had to leave out of this analysis.Despite having a large key informant sample, we were not able to interview all of them due to logistic constraints. However, we think the sample interviewed is representative of the staff working in the FB.Overall, our RE-AIM evaluation found strong ongoing implementation and adoption of the Friendship Bench program over 3 years after implementation was passed to local City Health officials. However, Reach across all clinics was relatively low and especially low for large clinics. Across all RE-AIM domains, small clinics performed better than large clinics. Future studies should examine heterogeneity in RE-AIM indicators across key contextual factors in low-resource settings, as well as seek to optimize scale-up and sustainment strategies to maintain effective program implementation over the long term.Additional file 1: Table 1. Overall ranking for all clinics (n=26).Additional file 2: Table 2. OPT FB RE-AIM Main Study Questionnaire 2019.


Eucalyptus globulus essential oil (EGEO) possesses many biological effects such as antibacterial, antifungal, and insecticide properties. In the current study, the chemical composition of EGEO was first investigated using GC-MS analysis. Then, a nanoemulsion and nanogel containing EGEO (EGEO-nanoemulsion and EGEO-nanogel) were prepared. After that, the successful loading of EGEO was confirmed using ATR-FTIR analysis. EGEO-nanoemulsion and EGEO-nanogel with LC50 values of 27 and 32 μg/mL showed promising efficacies against Anopheles stephensi larvae. Besides, the efficacy of EGEO-nanogel (IC50 187 μg/mL) was significantly more potent than EGEO-nanoemulsion (IC50 3732 μg/mL) against Staphylococcus aureus. However, no significant difference was observed in the efficacy of EGEO-nanoemulsion and EGEO-nanogel against Pseudomonas aeruginosa. Natural components, straightforward preparation, and proper efficacy are some of the advantages of EGEO-nanogel; it could be considered for further consideration against other pathogens and mosquito larvae. Eucalyptus globulus (Family Myrtaceae) is a fast-growing evergreen and magnificent tree cultivated worldwide [E. globulus and other Eucalyptus species, including E. citriodora, E. camaldulensis, E. microtheca, and E. sargentii, has been reported [Pseudomonas aeruginosa, Escherichia coli, and Staphylococcus aureus [S. aureus and P. aeruginosa are opportunistic pathogens that cause acute and chronic hospital-acquired and respiratory tract infections [orldwide . Its extorldwide , 3. Morereported , 5. Besireported –8. For is aureus , 9. Morefections , 11.Anopheles stephensi mosquitoes, as a domestic species, are one of the most important malaria vectors [A. stephensi is now a great threat to human health [E. camaldulensis EO with an LC50 value of 397.75 ppm against A. stephensi has been reported [E. tereticornis EO inhibited the pupal and adult activity of A. stephensi and showed nearly 100% mortality rate at the highest dose (160 ppm) [About 241 million malaria cases were identified worldwide in 2020, of which 627,000 people lost their lives . Anophel vectors . Insecti vectors . Howevern health . Therefon health . For exareported . Further160 ppm) .Nanoemulsions with small droplets, optical transparency, and long-term physical stability  are easily absorbed by microorganisms. Therefore, their bioavailability is high and their efficiency increased compared to the nonnano state –20. DespP. aeruginosa, S. aureus, and A. stephensi were investigated.In this study, the chemical composition of EGEO was first investigated. After that, nanoemulsion and nanogel containing EGEO (EGEO-nanoemulsion and EGEO-nanogel) were prepared. Finally, their antibacterial and larvicidal activities against P. aeruginosa and S. aureus (ATCC 27853 and 25923) were obtained from the Pasteur Institute of Iran. A. stephensi late 3rd or early 4th instar larvae were provided by Urmia University of Medical Sciences (Iran). Mosquitos were reared and kept at 29 ± 2°C with 70 ± 5% humidity. E. globulus EO bark' EO was purchased from Tabib Daru pharmaceutical company (Iran) (TaDa 1729). Carboxymethylcellulose (CMC: C4888) was bought from Sigma–Aldrich (USA). Mueller Hinton agar (103872), Mueller Hinton broth (110293), and Tween 20 (817072) were bought from Merck Chemicals (Germany).Standard species of −1 and held for 60 minutes. The temperatures of the injection port and detector were set at 250 and 230°C, respectively. Helium (99.999%) was used as a carrier gas. The septum purge and column flow rate were fixed at 6 mL/min and 1 mL/min, respectively. Mass spectra were taken at full scan mode at 50–550 m/z with 70 eV ionization energy. Van den Dool and Kratz formula was applied to calculate the retention indices of n-alkanes [EO constituents were analyzed by a GC-MS system  using a 6890 gas chromatography and a 5975 mass selective detector . The column was an HP-5MS silica-fused . The column temperature profile was as follows: 40°C (fixed for 1 min), then raised to 250°C at the rate of 3°C min-alkanes , 25.μL  and stirred for 40 minutes (room temperature). Finally, prepared nanoemulsions were subjected to a DLS-type apparatus for size analysis. EGEO-nanoemulsion with optimal values (droplet size <200 nm and droplet size distribution (SPAN) <1) [The nanoemulsions were prepared using the spontaneous method as reported in our previous study . The EGEPAN) <1)  was seleE. globulus EO.The optimum EGEO-nanoemulsion was gelified as follows. Then, CMC (3.5% w/v) was first added to the EGEO-nanoemulsion and the mixture was then stirred at 2000 rpm for 4 h at room temperature to complete the gelation process. The viscosity of EGEO-nanogel at shear rates of 0.1–10 1/s was analyzed by the rheometer apparatus  under atmospheric pressure at 25°C. Moreover, nanoemulsion (-oil) and nanogel (-oil) were also prepared using the same method, only without −1 [ATR-FTIR analysis was used for the investigation of the loading of EGEO in EGEO-nanoemulsion and EGEO-nanogel. Spectra of EGEO, nanoemulsion (-oil), nanogel (-oil), EGEO-nanoemulsion, and EGEO-nanogel were recorded in the wavenumber range of 400–4000 cm−1 . The samFurthermore, EGEO-nanoemulsion stability was checked using three tests. First, EGEO-nanoemulsion was 30 min centrifuged  at −4, +4, and +25°C, 30 min. Second, EGEO-nanoemulsion was subjected to freeze-thaw cycle tests; samples were placed for 48 h at −20°C (freezer) and room temperature for six successive periods. Third, EGEO-nanoemulsion was subjected to heating-cooling cycle tests; samples were placed for 48 h at +45°C (Bain–Marie) and room temperature for six successive periods. After each test, samples were visually checked for sedimentation, creaming, or biphasic. Moreover, EGEO-nanogel samples were stored at 4 and 26°C for six months and then were visually checked for sedimentation, creaming, or biphasic .A. stephensi were first prepared. The larvicidal effects of the EGEO-nanoemulsion and EGEO-nanogel were then investigated at 12.5, 25, 50, 100, and 150 μg/mL. After 24 h exposure, larval mortality rates were recorded. The control and blank groups were treated with ethanol and nanoemulsion (-oil) and nanogel (-oil).Larvicidal bioassays of EGEO-nanoemulsion and EGEO-nanogel were carried out according to the WHO recommended process . Glass b5 CFU/mL in the Mueller Hinton broth) to adjust final concentrations of 1250, 2500, and 5000 μg/mL. Then, treated plates were incubated at 37°C for 24 h and 10 μL-microbial suspensions were cultured on the Mueller Hinton agar plates and incubated for 24 h. The number of bacterial colonies forming units (CFU) was counted, and growth (%) was calculated by the following formula: (CFU sample/CFU control) × 100.The antibacterial properties of EGEO-nanoemulsion and EGEO-nanogel were investigated using the ATCC100 method . First, 50 value is measured this way, as calculated in this study.Furthermore, MIC (Minimum Inhibitory Concentration) and MBC  values are determined in semiquantitative assays such as disc or well diffusion methods. This study used ATTCC100 as a quantitative method; it investigated antibacterial effects, % bacterial growth, or % bacterial growth inhibitory, at different concentrations. The IC50  and LC50  values were calculated using CalcuSyn software .Three replicates were carried out for all tests and final values were reported as mean ± SD. The final values for all samples were compared with SPSS software using one-way ANOVA with a confidence interval of 95%. Turkey's test evaluated statistical differences between groups. Besides, ICα-pinene (15.33%), trans-pinocarveol (4.32%), aromadendrene (3.95%), and globulol (3.69%).Eleven identified compounds in EGEO using GC-MS analysis are listed in The ingredients of five prepared EGEO-nanoemulsions and their size analysis are listed in Moreover, no creaming, sedimentation, and phase separation were observed in EGEO-nanoemulsions after all stability tests, including centrifugation , freeze-thaw cycles, and heating-cooling cycles. Besides, EGEO-nanogel did not show any biphasic or phase separation after six months of storage at 4 and 26°C. Therefore, the stability of EGEO-nanoemulsion and EGEO-nanogel was confirmed.−1 can be related to the OH group. The characteristic bands at 2880, 2921, and 2966 cm−1 are attributed to CH stretching vibration, and the bands at about 1682 and 1644 cm−1 can correspond to C=C stretching vibration in olefin. The strong peak at 1446 cm−1 is allocated to symmetrical bending in the plane of C-H bonds and the strong band at 1375 cm−1 can be related to CH3 deformation. The bands at 1079 and 1214 cm−1 corresponded to symmetric and asymmetric stretching of the C-O-C group. A sharp and strong band at 984 cm−1 can be attributed to symmetrical bending out of the CH2 plane.The ATR-FTIR spectra of EGEO, nanoemulsion (-oil), EGEO-nanoemulsion, nanogel (-oil), and EGEO-nanogel are presented in −1 is attributed to OH stretching vibration due to hydrogen bonding between tween and water. The band at 2923 cm−1 corresponds to the C-H stretching. The characteristic peak at 1732 cm−1 is related to C=O stretching due to the carbonyl group in tween 20. Besides, the characteristic absorption at around 1457 cm−1 exhibited CH2 bending. Finally, the strong and characteristic band at 1087 cm−1 is attributed to C-O stretching.In ATR-FTIR spectra of nanoemulsion (-oil), the broad peak at about 3200–3600 cm−1 can be related to OH groups in tween 20, H2O, and EO that lead to hydrophilic interaction. The peak at about 2923 cm−1 is related to C-H stretching due to EO and tween 20. The bands at 2341 and 2359 can be related to CO2 and the band at 1733 cm−1 is attributed to the carbonyl group in Tween 20. The band at 1457 cm−1 can be related to CH3 bending in EO and Tween 20. Totally between 400 and 4000 cm−1, the intensities of the EGEO-nanoemulsion were higher than those in nanoemulsion (-oil), which is a sign of successful loading of EGEO in EGEO-nanoemulsion.The ATR-FTIR spectrum of EGEO-nanoemulsion displayed the broad and characteristic band at around 3200–3700 cm−1 can be related to OH due to hydrogen bonding. The peaks at about 2923 and 2855 cm−1 are related to C-H stretching due to CMC. The characteristic band at 1734 cm−1 related to C=O stretching is due to the carbonyl group in Tween 20 and CMC. The characteristic band at about 1577 cm−1 is attributed to the carboxylate group's asymmetric stretching. Besides, the peak at about 1417 cm−1 corresponds to CMC's symmetric stretching of the carboxyl group. Finally, the strong band at about 1081 cm−1 can be attributed to C-O stretching vibration.In the ATR-FTIR nanogel (-oil) spectrum, broadband in the region 3200–3600 cm−1 corresponded to OH due to hydrogen bonding in CMC, Tween 20, and the EO. The band at around 2923 cm−1 is related to C-H stretching due to the EO, Tween 20, and CMC. The band at 1734 cm−1 showed C=O stretching that exhibited the carbonyl group in the EO, Tween 20, and CMC. The sharp and strong band at 1080 cm−1 corresponded to C-O stretching. In the presence of CMC, the carboxylate band at 1579 cm−1 demonstrated intramolecular H-bonding between Tween 20 and CMC. The physical interaction between the surface –OH of the Tween 20 and the –OH groups of the CMC molecule led to the consumption of a small amount of –OH groups. The appearance of the other bands in EGEO and nanogel (-oil) confirmed the successful loading of EGEO in the prepared EGEO-nanogelIn the ATR-FTIR spectrum of the EGEO-nanogel, a broadband in the region 3200–3500 cmS. aureus are illustrated in μg/mL (P < 0.001), 2500 μg/mL (P < 0.001), and 5000 μg/mL (P=0.012). Interestingly, about 80% of bacterial growth was reduced after treatment with 5000 μg/mL EGEO-nanogel and EGEO-nanoemulsion. Besides, nanoemulsion (-oil) and nanogel (-oil) did not affect the growth of bacteria. Furthermore, EGEO-nanogel with IC50 187 μg/mL was significantly more potent (P < 0.05) than EGEO-nanoemulsion  and nanogel (-oil) did not affect the growth of P. aeruginosa. As efficacies of EGEO-nanogel and EGEO-nanoemulsion at the highest concentration (5000 μg/mL) were less than 50%, their IC50 values were not determined  and 50 μg/mL (P=0.002), however, the efficacy of EGEO-nanogel at a concentration of 100 μg/mL was significantly more potent than EGEO-nanoemulsion (P=0.007). Interestingly, perfect larval mortality was observed at two concentrations of EGEO-nanogel (100 and 150 μg/mL). However, as summarized in 50 values of EGEO-nanogel and EGEO-nanoemulsion were not significantly different (32 and 27 μg/mL). Moreover, nanoemulsion (-oil) did not affect larvae and nanogel (-oil) with 6% mortality had a negligible effect on larvae.The larvicidal activities of EGEO-nanoemulsion and EGEO-nanogel against S. aureus is one of the most important pathogens of food-borne diseases and community-associated infections worldwide. It is resistant to harsh environmental conditions and is highly stable in different temperatures (7 to 48.5°C), pH (4.2 to 9.3), and 15% NaCl concentrations [P. aeruginosa plays a major role in increased morbidity and mortality rates in respiratory diseases like cystic fibrosis. Moreover, antibiotic resistance in P. aeruginosa due to low permeability in the outer membrane has created many therapeutic challenges [Microbial infections and mosquito-borne diseases are still major public health challenges. trations , 34. Besallenges .Furthermore, excessive use of insecticides has led to resistance in mosquito populations and environmental pollution , 37. Theα-pinene (15.33%), trans-pinocarveol (4.32%), aromadendrene (3.95%), and globulol (3.69%). These findings were consistent with the literature that 1,8-cineole and α-pinene were introduced as two major components of EGEO or other Eucalyptus spp. EOs [Eucalyptus species' essential oils from Tunisia [EGEO in the present study was used as a natural antibacterial and larvicide. Therefore, its ingredients were first identified using GC-MS analysis. 1,8-cineole was the most abundant component, followed by spp. EOs , 44. ForE. coli, S. aureus, and P. fluorescens [A. stephensi; a 98% mortality rate was obtained at 250 ppm [Furthermore, some studies have been published on the antibacterial effects of eucalyptus extract on orescens –47. Besiorescens , 49. Mororescens , 49. Somorescens . Moreove 250 ppm . Howeverα-pinene, trans-pinocarveol, aromadendrene, and globulol were identified as five major components of E. globulus EO (EGEO). The antibacterial and larvicidal effects of nanoemulsion and nanogel containing the EO (EGEO-nanoemulsion and EGEO-nanogel) were investigated. The efficacy of EGEO-nanogel against S. aureus was significantly more potent than EGEO-nanoemulsion; bacterial growth after treatment with 2500 and 5000 μg/mL of EGEO-nanogel was reduced by more than 80%. Besides, 100% larval mortality was observed after treatment with 100 and 150 μg/mL EGEO-nanogel. The EGEO-nanogel could thus be considered for further investigations against other pathogens and mosquito larvae.1,8-cineole,


Similar to other organizations that encourage positive youth development, the American Kennel Club (AKC) created the Junior Showmanship program to develop skills and pave a path for the next generation of competitors in canine conformation. Although participants age out of the Junior Showmanship Program when they turn eighteen, the hope is that Juniors will continue to be active in dog sports into adulthood. Females are overly represented in all age groups in this survey and in current participation. Although both males and females most commonly stopped participating at age 17 or 18, males had a significantly higher drop out at age 15. Further study is warranted to investigate factors specifically pertaining to male participation. A strong Belief System Model which accounted for positive responses associated with camaraderie and mentoring during the showmanship program was significantly (p=0.01) associated with commitment, member interest and active participation as an adult. In addition, success in the show ring was associated with future involvement in conformation or dog sports. Thus, both perceived achievement and mentorship by adult “volunteers” were associated with continued participation. Many exIn 1932, the Westbury Kennel Association offered the first “Children's Handling Class.” The goal of this innovative new competition was to provide a distraction for the restless children accompanying adults at dog shows. It had the added benefit of increasing future involvement in the dog show community. The class was judged only on the ability to present the dog “quietly, proficiently and to its best advantage. “The first judges were local celebrities, who were later replaced by AKC judges. In 1951, the Children's Handling Class was renamed “Junior Showmanship” and it became a recognized AKC event in 1971 .There are limited studies that address short-term retention in PYDs and youth sports –8. ThereWe hypothesized that retention in the program is positively correlated with future activity as an adult exhibitor or breeder.The study was reviewed by the University of Pennsylvania Institutional Review Board and determined to be exempt from review requirements. Participants were recruited through social media, including outreach to current AKC delegates . Data coThe 50-question survey was divided into three segments  were collected directly from the AKC .p value of < 0.05 was considered statistically significant. A Belief System Model (BSM)  and Chi-Squared analyses was used to show differences between groups or categories observed in the data. A el (BSM) ; was devel (BSM) . Correlan = 710, 52.63%), followed by their family's dog , followed by other's dogs . Of all survey respondents, 78.2% of respondents began the program in the Novice Junior class and 86.8% finished in the Open Senior class. When respondents were asked at what age they participated in their last Junior Showmanship class, 18 years old was the most frequent response. However, only 36.7% of the respondents were 18 years old the last time that they participated. 63.3% of respondents dropped out of the program prior to aging out at 18 years old. The proportion of males and females dropping out each year was similar, except significantly (p < 0.05) more males dropped out at age 15  and family support (mentor), p < 0.01. Four hundred and ten Juniors had parental encouragement, while 442 did not. For the Juniors who spent 8 or 9 years in show, most of them had parental encouragement. Juniors were more likely to indicate family support and mentorship the more years they spent in show.There was a highly significant relationship between years spent in show with parental encouragement, p < 0.01. Around a third of Juniors fall into the “very high success category” (n = 366). Out of the 366 Juniors with very high success, most of them spent >4 years in show, with 91 of them spending 8 years in show.There was a highly significant relationship between years spent in show and having very high success in the ring during participation, p ≤ 0.05) or mother (p ≤ 0.05) as a mentor. There was no relationship between a father as a mentor and success in the ring and sibling mentorship was inversely related to success in the ring (p ≤ 0.01). Furthermore, success in the show ring was significantly (p = 0.01) correlated with future member interest (memberships to clubs and AKC eligibility- recent) (r = 0.5220) and commitment  (r = 0.4648).There was a statistically significant relationship between success in the ring as a Junior and having a friend  of respondents agreed or strongly agreed with the statement “The judges were friendly.” Over half, (56.9%) of the respondents agreed or strongly agreed with the statement “The judges provided guidance,” whereas 80.2% of the respondents felt that “the judges were business-like.”p = 0.01 and positively correlated 0.4001), commitment  and success as a Junior . Several weak correlations were highly significant (p = 0.01) and positively correlated with BSM, including AKC Receny (0.1438) experience of fun (0.2238), stress  (0.2411) and show years (0.1639); whereas education level (−0.1285) feelings about judges' indifference (−0.2372) and competition decade (−0.2433) were inversely correlated.The Belief System Model (BSM) was correlated with Member Interest  and negatively correlated (−0.1503) to the experience of fun, , member interest  and AKC recency .The majority of respondents were female. Gender was weakly but highly significantly , girls are also overrepresented. This may represent a stronger affinity for animals, stronger female mentorship, or fewer options for programming for young girls . In contrast to animal based youth sports and organizations, boys are over-represented in traditional organized sports, even from a very young age. In 2012, the percentage of boys in the US between 6 and 12 participating in organized sports (49.1%) far outnumbered girls (33.5%) (https://www.aspenprojectplay.org/youth-sports/facts/participation-rates). A Canadian study of involvement in high school sports identified adolescents' sex , parental involvement, best friends' participation in sports and family income as significant predictors of participation  of dogs, like that of horses, offers the rare opportunity for direct competition between men and women, but young boys frequently struggle with losses to female peers . A 1987 cipation . Parentacipation , 19.By definition, participation in the Junior Showmanship Program is limited to minors. The majority of these children are not yet able to drive, so assistance is necessary to overcome even just the first hurdle of transportation. Adults also play a crucial role in supporting the Junior and dog financially. In addition to these roles, it is important to consider the adult's role in providing guidance and emotional support. Respondents were prompted to qualify the mentorship that they received during their participation in the Junior Showmanship Program. The data from this survey show a diverse mix of adults supporting Junior participation. The most common supporting adults were reported to be mothers, siblings, friends, and professional handlers. Support of friends and mothers was associated with “success in the ring.” The majority of respondents became interested in Junior Showmanship because they were already traveling to shows with parents or friends.The data collected in this survey emphasizes the importance of mentorship and parental support. The existing literature , 20, sugThere was a strong consensus among respondents that “working with a dog,” “feelings of accomplishment,” and “winning” were some of the more important aspects of Junior Showmanship that made it fun. This indicates that self-satisfaction and sense of fun is a primary motivator for continued participation in Junior Showmanship, which is a common theme for teens that continue participation in sport , 23. UndIn an attempt to increase retention the AKC founded the Junior Recognition Program with the goal of rewarding Juniors for diverse engagement in AKC events. The point system recognizes participation in conformation, as well as companion and performance events. At the end of the year, Juniors that receive the most points are awarded scholarships . The AKCExhibitors and breeders often articulate the belief that Juniors are “the future of the conformation and dog sport.” The validity of this credence is readily illustrated by the data collected in this survey. Despite the potential limitations of recall bias and recruitment bias, this survey demonstrates that a multitude of factors influence children participating in AKC events. Perceived achievement and adequate mentorship by adult volunteers supports continued participation in the Junior Showmanship Program and this important component can be applied across several sports and animal related programs. It may also provide guidance for development of new opportunities to engage youth in educational, sport or volunteer opportunities with animals. Furthermore, retention in the program leads to future activity as an adult exhibitor or breeder. However, the survey also indicates that dropping out of the Junior Showmanship program does not always correlate with cessation of participation in AKC events. Future studies, should included qualitative data to gain additional perspective on factors that influence participation, retention, a sense of fun and success.Broad social factors clearly have a significant influence on continued participation in the Junior Showmanship program and future engagement, therefore it would be beneficial to prospectively study the factors related to the perceived attitudes about a lack of success in the ring to determine if they are linked to the dropout rate and/or gender discrepancies. Further study is warranted to investigate factors specifically pertaining to male participation across the animal based sport and education programs including 4-H and Pony Club. It would also be valuable to investigate how male program participants viewed their success, what aspects made the program attractive or “fun,” and how peers viewed their participation.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.All authors contributed to the writing of this manuscript. The survey itself was designed by CB and CO. 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.


A graduate aging fellowship experience can provide participants with unique opportunities for professional development in interdisciplinary and transdisciplinary research, community engagement, and team science. Program success is contingent on multiple factors beyond participant recruitment and customizable curriculum to meet the educational goals of individual participants. Stakeholder buy-in, strategic planning, and identification of funding streams are all necessary to support an internal program beyond its first year. In this session, we will offer guidance in planning, building, and sustaining a fellowship program for current graduate students with a professional interest in supporting older adults.