To describe an undergraduate pipeline training program (PTP) designed to guide underrepresented minorities (URM) trainees into MCH-related health professions, ultimately contributing to a diverse maternal and child health (MCH) workforce that can improve health outcomes for all women/mothers, children, and their families, including fathers and children with special healthcare needs.Three cohorts with 35 total undergraduate trainees were recruited to participated in the 2 years USF MCH PTP program where they were mentored, trained, guided, and supported by program faculty/staff. Students were recruited early in their education track, and the program was individually tailored based on trainees’ educational discovery stages. Key program components included seminars, summer institutes, public health courses, mentorship, internship, experiential learning opportunities, and professional networking opportunities.The majority of the undergraduate participants were diverse URMs including Hispanic/Latino (37.1%), Black/African American (31.4%), Asian (20%), and American Indian/Alaskan Native (5.7%) trainees. Out of all the cohorts, 51.4% were first-generation college students and 74.3% had economic hardships . Resulting from the program, all cohorts increased in educational discovery stages, one-third enrolled in health-related graduate studies and half joined the MCH workforce.Recruitment in pipeline programs should be intentional and meet students where they are in their education discovery stage. The use of educational discovery stages within a pipeline program are useful in both tailoring curriculum to individuals’ needs and assessment of progression in career decision-making. Mentoring from program staff remains an important component for pipeline programs. The dissemination of the outcomes from MCH diversity pipeline training programs contribute to the knowledge and evidence base of best practices for future programs to consider. Educational pipelines in MCH are acknowledged as an essential part of building a diverse future MCH workforce, but little is known about the various programs that have been implemented.This article highlights the use of the educational stages of discovery within an MCH diversity pipeline program as both a method of assessment and tailoring of program components.With the challenges of the evolving healthcare system and the urgent need to address health disparities and inequalities through a social determinants of health lens in Florida and the nation, we must ensure availability of a competent, passionate, and reflective MCH workforce to improve health outcomes for MCH populations. High-quality MCH training programs that recruit, mentor, and engage the future MCH workforce are critical to achieving this goal. This future workforce must reflect members of historically underrepresented minorities, in the quest of reducing health disparities in MCH. An AHRQ report  reinforcWith health workforce shortages, increased attention on recruiting and training a diverse workforce is imperative  MCH PTP aimed to recruit, train, mentor, and provide enriching experiences with the goal of guiding URM undergraduate trainees into MCH-related health professions to improve levels of representation, reduce health disparities, and increase access to health care for vulnerable, underserved populations.This PTP had four overarching goals: (1) recruit and support cohorts of undergraduate students from economically and educationally disadvantaged and racially or ethnically diverse backgrounds into a high-quality training program that prepares them for a successful trajectory into MCH graduate training and professions; (2) implement an innovative training program through didactic, experiential, mentoring and peer exchange modalities that expose students to MCH leadership, broad public health perspectives, interdisciplinary training and practice, and cultural and linguistic competencies; (3) collaborate broadly with MCH Long-Term Training Programs, HRSA and Title V stakeholders and other MCH community members; and (4) develop and disseminate innovative curricula and research to advance MCH training and practice.decider: expresses interest in health science; exploring degree options; (2) explorer: declared health science; exploring double majors/minors and discussing links with coursework and other opportunities; (3) maximizer: in middle of program; seeking practice opportunities; and (4) mover: approaching graduation; preparing for post-graduate training or workforce  and tuition waivers for required coursework.A dynamic, student-centered  plan was developed using a combination of informal and formal recruitment avenues. The two-tiered approach included: (1) recruitment from within identified feeder programs ; and (2) recruitment from additional informal and formal methods and strategies .Recruitment strategies were implemented during Spring semester and focused on undergraduate students in any major in the second half of their freshmen (first) year and/or beginning of their sophomore (second) year. Trainees participated in the program for two years starting in the Spring semester and completed the program in the first half of their fourth year. Completing the program in their fourth year was optimal in the context of the educational discovery stages as it allowed mentorship and guidance in the graduate school application process. Eligibility criteria included: current undergraduate enrollment (full-time) at USF; U.S. citizenship or permanent resident visa; demonstrate economically or educationally disadvantaged status ; first generation student; family hardship ; descendants of immigrant or migrant family or multi-language proficiency; self-identify as URM; and a demonstrated interest in MCH and/or pursuing graduate training.The USF MCH PTP curriculum had six components: (1) seminars; 2) summer institutes; (3) public health courses; (4) mentorship; (5) internship; and (6) professional networking opportunities . Some seminars were also co-hosted with USF’s Center of Excellence in MCH encouraging a continuous trajectory of learning and mentoring. Example seminar topics included: program orientation; MCH 101 part 1 and part 2; community-based research in infant and child health; quality improvement in MCH; graduate/doctoral program student panel; professionalism; social networking; systems approach; MCH advocacy and policy; emotional intelligence; and communication/health literacy.Trainees participated in two virtual, self-guided institutes delivered as modules (five per summer) via the Canvas Learning Management System. The first institute introduced trainees to the field of MCH, research skills, and internship opportunities. The topics by module included: Research 101 Part 1; research 101 Part 2; research ethics; interdisciplinary practice; and conflict resolution and negotiation. The first summer institute included activities such as discussion boards, CITI training, and research activities. A more detailed description is provided later. The second institute expanded trainees’ professional development skills with an emphasis on graduate school programs and applications. Module topics included: family-centered care; cultural and linguistic competency; resumes, CVs, and finding your dream job; and personal statements, cover letters, and finding the right graduate school. The second summer institute included case studies with open discussion boards, resume, personal statement and cover letter peer review sessions, and guided activities on conducting research to find dream jobs and graduate programs. All modules contained pre and post-tests to assess changes in knowledge.Trainees were required to take two undergraduate public health courses during the program, Foundations of Maternal and Child Health and Introduction to Health Disparities and Social Determinants of Health. The first course, Foundations of MCH, served as an introductory course, providing an overview of MCH issues and trends. The objectives of this course are organized around the knowledge of health assessment and interventions for families and children. The second course, Introduction to Health Disparities, uses a social ecological framework to provide a broad overview of health disparities in the U.S. and multi-level factors influencing those disparities. It also examines social and cultural determinants of health including race/ethnicity, geography, socioeconomic position, gender, sexual orientation, disability status, migration status, age, religion and spirituality. If a trainee had already taken one of these courses, tuition was offered for another public health elective from a comprehensive list including, but not limited to: Women’s Health; Nutrition and Disease; or Public Health Education Theory and Behavior. For flexibility, courses could be taken at any time in the program.The MCH PTP provided trainees with mentorship from multiple stakeholders: (1) program faculty and staff; (2) graduate students in health professions; and (3) USF and MCH faculty. Program staff mentored trainees in navigating life challenges often faced by URM students, while faculty offered additional support and guidance on succeeding academically, refining research interests, and planning MCH careers. Program faculty and staff assisted trainees in aligning their academic, professional and career expectations; promoting professional development and developing research skills; building leadership and self-advocacy skills; and guiding graduate program or workforce preparation activities. Program faculty and staff matched a diverse pool of graduate health student mentors with trainees to provide student perspectives on navigating graduate school preparation, and guidance on MCH research poster proposals that were presented in the second year of the program at the Annual Chiles Center Symposium. An expected outcome from this mentorship structure included trainees accompanying their mentors to faculty research team meetings to increase additional research exposure and opportunities.After completion of summer institute 1, trainees were supported in identifying and completing a clinical or practice track internship. Both options were considered, as trainees represented a variety of health disciplines with different career paths. Internships made available to trainees included the following: Champions for Children ; Shriners Hospital for Children, Advent Health and community physician shadowing . Trainees were supported in applying to Title V Internships, providing a unique opportunity to work in a state MCH agency. There were five trainees accepted into Title V internships with placements in the following locations: the Tennessee Department of Health, the Health Policy Institute of Ohio, the Public Health Department of Georgia State, and the North Carolina Department of Health and Human Services. These trainees participated in a variety of research activities including: participating in strategic planning, conducting literature reviews, conducting interviews and focus groups, developing survey questions and presenting findings.Trainees attended the USF Health Research Day event during their first year, guided by a graduate student. USF Health Research Day aims to encourage interdisciplinary research among undergraduate and graduate students guided by faculty, staff and keynote speakers. This event features more than 300 poster presentations with about 80 judges who nominate poster authors for research awards. For most trainees, this event was their first exposure to MCH-related research and provided a platform to network with other students, faculty, and health professionals. Additionally, trainees were encouraged to attend other local or regional conferences. There was a strong emphasis on attending Making Lifelong Connections which focused on leading, networking, and career development of current and former MCHB-funded trainees. The Florida Public Health Association conference supports Florida’s public health professionals and students in professional development, dissemination and networking. Trainees were invited to attend the Florida Family Leaders’ Summit, which brings various stakeholders together to learn about how to support family engagement for children and youth with special healthcare needs. Other shared opportunities to encourage professional development included Activist Lab events, scholarship opportunities, student organization engagement opportunities, National Women’s Health Week seminars, USF Diversity Committee events, and local research and job opportunities.This MCH PTP assumed that training and mentoring in an interdisciplinary setting, collaboration with diverse MCH partners, and linkages to MCH programs will result in effective MCH graduate school preparation. The stakeholders  and other inputs  led to the development of a series of program components and an evaluation plan to meet initial and intermediate outcomes Table . TraineeTrainees completed pre- and post- self-efficacy surveys at the start and end of the program. This survey consisted of 15 questions  totaling a possible score of 75. The questions focused on long-term career goals, MCH employment/research/funding opportunities, and the graduate school application process. Program staff formed interpersonal relationships with trainees throughout their time in the program, facilitating the collection of long-term data . Ongoing follow-up is conducted via email every 6 months to update trainee information and relevant long-term outcomes such as graduate school application, admission or work in MCH.Although trainee educational discovery stage progression was not listed as an outcome in the logic model, it was used in designing program components. We collected this data at three points in the program: start, mid-point, and end. Trainees learned about educational discovery stages at program orientation and completed their first self-assessment. During one–one–one meetings with program staff, trainees re-assessed their stage. The data presented in this manuscript were collected as part of program evaluation and was considered exempt from IRB review and does not include clinical or patient data.By Fall 2020, 35 trainees have completed the MCH PTP. Program staff communicated with trainees during and after the program to collect data . One trainee was asked to leave the program for not fulfilling agreed upon responsibilities. Trainees identified as mostly female . A few trainees (11.4%) graduated earlier than planned and thus exited the program early. Five trainees were accepted into Title V internships. Positive results across the program presented elsewhere included increases in MCH knowledge, MCH research knowledge and self-efficacy.Recruitment of participants was consistent with the diversity goals of this program. Trainees were asked to self-identify race/ethnicity and first-generation status or economic hardship or both  Table .Table 3TPaired samples t-tests were used to assess changes in pre- and post-mean scores for changes in MCH knowledge and research knowledge within each cohort, while ANOVAs were used to compare across cohorts. MCH knowledge increased within each cohort across all topics: MCH 101 part 1 ; MCH 101 part 2 ; health literacy ; and quality improvement  Table . While tMCH research knowledge increased within each cohort across all topics: Research 101 part 1 ; Research 101 part 2 ; research ethics ; interdisciplinary practice ; and conflict resolution  Table . Again, Findings from the pre- and post-self-efficacy surveys suggest the MCH PTP may have had an impact on trainee self-efficacy in applying to health-related graduate studies and positions in the MCH workforce. Significant differences in self-efficacy (p < 0.05) were observed across all cohorts. Survey questions showing the highest average increase pre-and post- focused specifically on self-efficacy as it applies to identifying funding or scholarship opportunities for graduate school and research activities supporting graduate school application.An expected outcome of the MCH PTP was for trainees to enroll in a health or MCH-related graduate program or enter the MCH workforce directly. The curriculum supported the graduate school application process and program staff encouraged trainees to request recommendations for their applications. Program faculty provided a total of 31 recommendations for trainees for graduate school, employment, internships, fellowships, and awards. Currently, 40% of all trainees have been admitted to graduate or professional schools, with most in a health-related area  were encouraged to apply for the Title V internship program.We encountered multiple challenges throughout program implementation. As a new initiative, raising awareness of a program was labor intensive; however, recruitment self-perpetuated after year one. Trainees reported a perceived overlap in content between the didactic program components. To prevent this redundancy, minor adaptations were made .Retention issues arose primarily due to unanticipated early graduation (n = 5) based on a university-system policy related to excess credit hours, with only minimal program dropout (n = 1). Several strategies were added to address program retention, including a memorandum of understanding, ongoing mentorship, and frequent touch points. Additionally, trainee schedules were assessed each semester to address needs and identify barriers to participation. Maintaining contact with trainees’ post-program is also challenging. Establishing meaningful relationships with trainees during the program and maintaining engagement post-program are key strategies for follow-up.Delivering the program under the evolving circumstances of the COVID-19 pandemic required program staff to quickly make necessary modifications to ensure trainees received the same quality program. Given part of the program was online via Canvas, trainees were already accustomed to some online program engagement.Due to the nature of grant-funding, a sustainability plan helps ensure continuity. A five-year grant cycle provides time for initial successes that may earn university recognition and garner support. Program modifications will likely need to be made, but sustaining key program elements is critical to build a diverse MCH workforce.Program staff used multiple methods to collect trainee feedback to identify strengths and areas of improvement including pre- and post-surveys, focus groups, and exit interviews. An emergent theme across cohorts was the presence of a consistent program coordinator who trainees identified as a mentor. Trainees reported benefiting from a program coordinator offering support for URM and first-generation students, providing a safe space for open discussion. These benefits, noted by program staff, led to an open-door policy for trainees. Future pipelines should consider this policy in their staffing plan, as it created a sense of connectedness among trainees.Relatedly, convening a culturally congruent mentoring match with graduate students provides meaningful relationships, facilitates student success and increases the likelihood of trainee engagement and commitment to MCH careers  as it has been shown to increase confidence in future career decisions (Healthy People 2030, Despite trainee success in a program, limitations still persist. The mentorship component was originally intended to be a triad relationship between trainee, MCH faculty, and graduate student mentor. Challenges with scheduling arose leading to adaptations to this component. Graduate students were matched as mentors to support trainees in developing their research proposal poster and program staff provided ongoing mentorship. Although a faculty member was not assigned to all trainees, they were encouraged to connect with those faculty with aligning research interests. Given the recent completion of this program, long-term outcomes are not available. Outcomes are expected to change over time based on the continued trajectory of trainees’ education and career paths.Existing health disparities and a lack of diversity in the MCH workforce continues to drive the need for a pipeline of well-trained and reflective future MCH professionals. A diverse MCH workforce supports patient access and satisfaction in addition to quality of care. Continued funding for pipeline programs is important and should look to support the dissemination of program results to improve overall outcomes and strengthen future efforts while building the evidence base. For example, dissemination should include the ascertainment of critical pipeline components that lead to success, such as mentoring and tailoring to student educational discovery stages.Our approach to a layered, dynamic curriculum that maintained a focus on trainee educational discovery stage helped guide student success in graduate school admission. Trainees moved through the educational discovery stages within our program, demonstrating our curriculum was successful in supporting their journey while also providing a metric for change.


There is a need for intervention research to understand how music-based group activities foster engagement in social interactions and relationship-building among care home residents living with moderate to severe dementia. The purpose of this conceptual paper is to describe the design of ‘Music Connects Us’, a music-based group activity intervention. Music Connects Us primarily aims to promote social connectedness and quality of life among care home residents living with moderate to severe dementia through engagement in music-making, supporting positive social interactions to develop intimate connections with others. To develop Music Connects Us, we adapted the ‘Music for Life’ program offered by Wigmore Hall in the United Kingdom, applying an intervention mapping framework and principles of engaged scholarship. This paper describes in detail the Music Connects Us program, our adaptation approach, and key adaptations made, which included: framing the project to focus on the engagement of the person living with dementia to ameliorate loneliness; inclusion of student and other community-based musicians; reduced requirements for care staff participation; and the development of a detailed musician training approach to prepare musicians to deliver the program in Canada. Description of the development, features, and rationale for Music Connects Us will support its replication in future research aimed to tests its effects and its use in clinical practice. Loneliness, lacking companionship or a sense of belonging , is a coArticulating the meaning of loneliness and its antecedents is a first step in the development of an intervention to address this problem . Theory Group activity interventions are multi-component, involving engagement with both an activity and with others , and havPeople living with dementia respond positively to and enjoy music, even when verbal communication is severely impaired . CriticaMusic for Life, led by Wigmore Hall, United Kingdom (UK) since 2006, is an interactive music-based program developed for use with professional musicians, care staff, and people living with dementia in care homes. In 1993, Linda Rose created the program to offer people living in a dementia-friendly society with access to exceptional musical experiences. Principles of creativity, collaboration, and equality underpin Music for Life . Case stOur team has adapted this promising music-based group activity in preparation for future evaluation studies when it is used as a complex intervention in Alberta, Canada. Our adapted program is called Music Connects Us. Assessing Music Connects Us in future research will advance our understanding of engagement behaviors, and ultimately aim to address the pervasive loneliness of care home residents living with dementia. The purpose of this foundational conceptual paper is to describe the approach we used to adapt the Music for Life program for use in Alberta, Canada, outline the features of our adapted program to support its replication in future research and practice, justify the most important program adaptations, and highlight key directions for further research. In our previous research, we applied scoping review and mixed methods methodologies to identify the elements of interventions that target loneliness experienced by people living with dementia . The present manuscript reports upon the collaborative, conceptual work that we undertook to complete intervention mapping step 3: the organization of the strategies identified in our previous research into a program for use in the target population. To complete step 3 of intervention mapping, our team worked collaboratively to describe the elements and activities involved in Music Connects Us and to explicate its theoretical underpinnings, reflecting principles of engaged scholarship. Intervention mapping  and engaOur process to develop Music Connects Us can be understood within an intervention mapping framework. Intervention mapping involves a review of the literature to identify empirical findings, the identification and application of relevant theory, and collecting new data . InterveWe applied principles of engaged scholarship ,50 to deOur team held three days of face-to-face planning meetings at the University of Alberta, Canada, in June 2018. The overall goal of the meetings was to discuss our team’s planned approach to adapt the Music for Life program, considering feasibility for use in Alberta, Canada. These meetings involved research and program presentations, brainstorming and discussion sessions, and site visits. Attendees for all three full days included two members of the Winspear executive, four researchers with expertise in the arts, music, elder care and intervention design, the Music for Life program manager from Wigmore Hall, and the executive director for the Institute for Continuing Care Education and Research (ICCER). On day two, Edmonton Symphony Orchestra musicians, an Alberta continuing care policymaker, and five dementia care service providers who expressed interest to serve as pilot sites also joined the meetings to meet the team, review research and program presentations, and to raise issues and discuss their questions. Notes from the presentations and discussions during the meetings identified the key features of an adapted intervention, rationale for adaptations, and the research questions for a future pilot study.On days 1 and 2, research and program presentations aimed to orient the group to the science underpinning the future pilot study and show the synergistic value of the team members’ roles and expertise. Presentations related to group activity interventions (O’Rourke), music interventions (Bartel), and the Music for Life program . ICCER’s executive director described the organization’s role in supporting continuing care organizations’ involvement in this research and identifying opportunities to disseminate research findings within the continuing care sector in support of practice change. Presentations were delivered on day 1 to the group of researchers, and the delegates from Wigmore Hall, the Winspear and ICCER. On day 2, versions of these presentations appropriate for the audience of Edmonton Symphony Orchestra musicians and continuing care policymaker and service providers were delivered to promote further discussion. Brainstorming and discussion sessions, facilitated by O’Rourke, then followed the didactic presentations. Days 1, 2, and 3 included brainstorming and discussion sessions to: (i) identify the key research questions of interest to the group; (ii) discuss the opportunities and challenges that this group may experience, and strategies to mitigate challenges in order to build a cohesive, interdisciplinary, international team; (iii) consider issues related to intellectual property and fees for service, and begin to develop a framework for meeting the group members’ needs in this regard; and (iv) consider the similarities and differences between the UK and Alberta, Canada contexts to discuss specific program adaptations. On day 3, the researchers, ICCER director, and Winspear and Wigmore Hall partners visited several congregate care sites that expressed interest in participating in the Music Connects Us program. In Alberta, congregate care includes facility living (long-term care) and several levels of supportive living (SL) . For thiIn the months following the planning meetings, we developed a detailed description of the Music Connects Us program and a manual to describe musician training to deliver Music Connects Us. We developed these materials based on review and synthesis of our planning meeting notes and available Music for Life program documents, including a book describing features of the program from the perspective of musician participants  and unpuIn this section, we will describe the main product of the adaptation process, the description of the Music Connects Us program, followed by the key adaptations that were considered in developing this program to fit the context in Alberta, Canada.Music Connects Us is a music-based group activity intervention to promote engagement and address loneliness and related outcomes for use with older adults living with moderate and severe dementia residing in care home settings in Canada. The primary components of this intervention target modifiable factors which influence loneliness, including social contact and social participation. The two mechanisms through which these factors are targeted are engagement in an activity  and in interactions with others. Moderators are factors that may influence the impact of the program on outcomes and include gender and the level and nature of engagement during sessions . Responsibility for the project management is shared between the research project leads who organize sites, oversee training, and supervise research assistants and program delivery, and a Winspear Centre partner. The Winspear Centre partner supports musician scheduling and selection , and locates appropriate space for musician training. Professional and semi-professional musicians are recruited and are asked to identify their students that may be a good fit for the program. A facilitator supports the musicians to deliver sessions. All are asked to commit to a growth mindset, a philosophy of person-centred dementia care, self-reflection and mindfulness, and clear and open communication throughout the project. For each Music Connects Us project, a consistent group of eight men and women living with moderate to severe dementia participate in Music Connects Us sessions once per week for eight weeks. Residents living with dementia are selected prior to the implementation of the project. The project manager describes the purpose of the program and inclusion criteria and asks the facility manager and care staff to identify approximately 15 residents over 65 years of age who are diagnosed with dementia and live with moderate to severe cognitive impairment. Residents who express poor communication, display responsive behaviors, or are frequently withdrawn should be specifically considered.A selection meeting is then held between the facility manager, the lead musician, the facilitator, and the project manager to create a ranked list of the 15 residents who will be invited to partake in Music Connects Us. The facility manager (or other care staff) approaches these individuals or their designated decision makers in sequence to ascertain their interest, and the research assistant then obtains consent to participate from interested residents, until eight residents have consented. If someone drops out, another resident can be approached to take their place. The facility manager identifies a quiet activity space of the care home for the sessions. The space should minimize distractions, promote a feeling of intimacy, and comfortably seat all participants and musicians in a circle.Prior to each session, the musicians and facilitator arrange seating in a circle, welcome residents to the session, and support them to become familiar with their physical space. Consistent assigned seating promotes familiarity. Each session lasts one hour, to allow time for individualized engagement of all group members, without causing fatigue. The session begins by offering each resident an instrument to use. This is an opportunity for residents to express their individuality and autonomy. Sessions open (and end) with a framing composition, which the musicians create over about 2 h together in advance of the project. The framing composition is a four-bar instrumental fragment and used as a motif to begin (and end) each session. Improvisation upon this motif does occur . For example, at the end of a very active session, if may be delivered at a slower, more calming tempo. A welcome song follows the framing composition. The name of each resident is sung, led by one musician , while a base instrument plays to ground the song. Musicians discuss the welcome song before the project, or they may choose an existing welcome song that has been used for other projects. The main Music Connects Us activities begin after the welcome song, when focus shifts to creating musical pieces focused on each participant, validating the personhood and experience of each resident. Residents are assessed throughout the session and approached at least once in a session to ascertain their interest  in being the focus of an improvised piece. Residents can be approached more than once during the session. Focused pieces last no more than a few minutes and are led by one musician and accompanied by the other musicians. All eight residents engage in any way they desire: actively observing, playing their instrument, moving their bodies to the music, or interacting verbally or non-verbally with others in the group. Once the piece is finished, the musicians choose another participant and begin another focused piece. When a focused piece is being created, one or more of the musicians move closer to that resident and respond to the musical  and non-musical emotional cues  to create music with the resident, and which reflects how the resident is feeling and responding. Musical frameworks and a range of musical and improvisational techniques are used to motivate interactions with individuals and between the group, such as repetition, imitation, and matching . Even noFollowing each session, the facilitator leads the musicians in a 30-min reflective debrief discussion. During the reflective debrief, the facilitator guides the musicians to consider their musical and relational experiences during that session, and identify challenges and strategies related to engaging residents during the sessions. The facilitator comments on the observations they made of musicians and residents during the session and may offer recommendations for future sessions. Musicians can also take the lead by sharing their experiences. This discussion is held in a separate room and prompting questions such as “did you see anything that surprised you?” and “did you learn anything new about a resident or colleague?”, are used to facilitate the debrief. The debrief is an opportunity for the group to develop a sense of cohesion and for the facilitator to support musicians. The opportunity to reflect and debrief as a group helps to build musicians’ self-awareness, resilience, and empathy. The facilitator is a research assistant who has expertise in person-centered dementia care and a background in music, to allow them to communicate effectively with the musicians. For example, a recreation therapist or registered nurse with formal musical training, who has worked closely with people living with dementia in care homes, would be ideal for this role. The facilitator helps to set up each session, attends each session to observe and take field notes related to the tone of the session and their observations of engagement and the challenges or strategies used to engage participants. If engagement is to be formally assessed, then the facilitator also sets up a 360-degree video camera to record the sessions. Engagement can be rated by the facilitator or another research assistant following sessions using the Observed Emotion Rating Scale to quantify the extent and nature of resident engagement during the session  . The facThree highly trained musicians lead the sessions . The aim is to have a consistent musician trio deliver all 8 sessions to a group of residents, and the musicians’ styles and personalities should be complementary. Each musician trio plays a different instrument or sings to offer a range in musical tone responsive to different moods and preferences. Musicians’ backgrounds  and specialties  may vary. Musicians begin with a high level of technical skill , and develop improvisational proficiency during training and program delivery. One musician leader in each group is designated to develop and maintain a supportive environment among the three musicians. They require leadership skills to guide the flow of the sessions, create trust and confidence within the musician group, encourage reflection, and reliably develop musical elements, and themes. The musicians’ instruments are selected to work well within the circle of participants and should not overpower the session. This is one reason why pianos are not typically used by musicians. Musicians are patient, flexible, self-reflective, and open to showing vulnerability. The musicians use language that is genuine and affirming, ensuring to be gentle and clear, and use open facial expressions and touch such as hand-holding to help build a rapport with the residents and make them feel more comfortable in the session. Musicians consider both space and pace throughout sessions. Pace is giving an individual enough time to process an interaction that has taken place. Space is listening openly to participants and creating an environment where authentic interactions can occur. Space can refer to physical space, musical silence, or stillness in body language.Instruments are selected which can stimulate the senses, have interesting tactile characteristics, and should be easy to use (but not childish). Budget constraints must also be considered, as well as how easy they are to transport and clean. Instruments are displayed before the start of the session in a way that will be appealing to participants. Examples of instruments used by residents may include the ghungroos, djembe, tingsha bells, shaker, caxixi, maracas, metallophone bass bar, soprano bass bar, hand chime, kalimba, spirit chime, agogo bell, bodhran, cabasa, castanets, claves, gato drum, guiro, frame drum, ocean drum, rainstick, tambourine, and wood block. Residents may also choose not to use an instrument, but may use the voice, clap, or tap their feet, for example.Care staff who attend and reflect upon Music Connects Us sessions may see the person with dementia in a different way and may continue to incorporate music into residents’ lives after the project ends. We will invite three care staff to each session to explore how including them may help sustain the positive effects of Music Connects Us after the eight-week program ends. We will aim to include the same care staff within each group, whenever possible. Care staff who attend each session can play an instrument or simply observe. They may speak and interact with participants during the sessions but will be asked not to push any person living with dementia to engage in any way that they do not want in that moment. Care staff could be from any professional background, so long as their work involves the care and wellbeing of persons living with dementia. Examples of care staff may include care aides, registered nurses, unit managers, or recreation therapists. The first main consideration for adaptation was related to conceptualization of the primary program aim, an essential piece in explicating the theory of the intervention  . In MusiThe second main consideration for adaptation was related to who would participate in the reflective debrief session. In Music for Life, the debrief is aimed to support both the musicians and the care staff to develop a reflective practice . In contThe third main consideration for adaptation related to the number of times that the program is offered within a care home per year. Music for Life sets the number of residents to eight per session and delivers sessions to just one group of eight in a care home at any one time. Following our tours of the care homes, our Wigmore Hall partners remarked upon the similarities of the care home context and populations to the settings where they deliver the program in the UK. However, a key difference was noted in the size of the care homes: they had not delivered the Music for Life program in a care home with such a large resident population, yet homes with 100 or more residents are common within Canada. Given this, our partners discussed how we may have a difficult time choosing just eight participants from a single, large care home. As a result, we will propose to offer Music Connects Us to two groups over one year within each care home.The fourth main adaption of the program was related to the composition of the group of three musicians who would be selected to deliver each session. Again, this discussion was prompted by a concern for the feasibility and sustainability of the program within Canada. The planning meetings identified several approaches to reduce the costs of each session including involving music students and other semi-professional community musicians. While our Edmonton Symphony Orchestra partners are enthusiastic about spearheading the development and implementation of Music Connects Us, professional symphony musicians have very busy rehearsal and performance schedules, which limits their availability to participate in programs like Music Connects Us. Involving student and other community musicians will allow us to train more musicians and increase the number of offerings of Music Connects Us per year. This addresses our continuing care partners’ and Government of Alberta requests to offer the program more often within continuing care sites once its effectiveness is established following a future pragmatic clinical trial. The fifth main adaption to the program was the development of an explicit training program for musicians. We discussed at length the importance of training musicians to engage with people living with dementia and to improvise musically. However, the complex task of training Music for Life musicians had not previously been described in written materials. Our discussions and consultations with Wigmore Hall highlighted that their current training approach relies primarily upon an apprenticeship model where new musicians observe and participate within projects lead by experienced Music for Life musicians. Based on our planning meetings, and our consultation with Winspear and Wigmore hall musicians and program leaders, we have developed a three-phase musician training approach that involves a 28-h program to: (1) learn about person-centered dementia care, (2) practice musical improvisation, and (3) observe and practice in sessions lead by an experienced Music Connects Us musician (or a Music for Life musician in the first iterations of the Canadian program). Phase 1 is completed by Canadian musicians in advance. In the first iteration of the program in Canada, Phases 2 and 3 will occur with the support of in-person Music for Life musicians during a 1-week intensive. Phase 1, learning about person-centered dementia care , involves review of the detailed training manual (3 h), completion of online modules and review of several additional resources (3 h), and a visit to a long-term care home (2 to 3 h). Knowledge of person-centered care, effective communication skills, and strategies to help interpret the person with dementia’s actions and expressions are essential to support the musician to engage the person living with dementia through music. Phase 2, musical improvisation , involves an introduction to Music Connects Us (1 h), an improvisation half-day workshop led by a Music for Life musician (3 h), and an improvisation half-day to allow practice between Canadian musicians (2–3 h). This phase helps to refine a musician’s skills in improvisation. Phase 3, Music Connects Us sessions , involves observation and participation in eight mentored Music Connects Us sessions over three weeks. Each session lasts 1 h, and is followed by a 30-min de-brief period to discuss in detail the musicians’ experiences of the session. Sessions one to six occur over four days during the 1-week training intensive. Music Connects Us trainee musicians start in a mostly observational role, but by sessions five and six, each of the trainee Music Connects Us musicians will have participated in two sessions (and have observed other sessions) while the Music for Life musicians observe and provide a supportive role. Sessions seven and eight occur in the two weeks following the training intensive. These sessions are led by the trainee Music Connects Us musicians. Video footage is shared with experienced Music for Life musicians, who will offer expert consultation by distance related to the quality of the program delivery. We propose that theory-driven, music-based group activity interventions like Music Connects Us can be used specifically to engage people living with dementia in order to promote feelings of social connectedness and increase quality of life. In this conceptual paper to describe the features of the Music Connects Us program, we have detailed the development of Music Connects Us and outlined the collaborative process that we applied to adapt a previous program, while mapping the intervention components and activities to empirical literature and theory. People living with dementia in care homes require a richly textured living environment to support their quality of life , and musIntervention mapping ,58 and tPreviously, descriptions of interventions developed for older adults to address loneliness have been sparse, identifying the name of the activity and including the mode and frequency of delivery, but the specific activities and theoretical underpinnings were not described in the detail required for replication studies to test the interventions’ mechanisms . Recent By applying principles of engaged scholarship, we are confident that key stakeholders including policy makers and continuing care providers, view the problem of loneliness as essential to address in order to improve the quality of life of people living with dementia. The core principles of engaged scholarship include high quality scholarship, reciprocity, identified community needs, knowledge democratization, and boundary crossing . The proA key strength of our work, the need for an adaptation of Music for Life for use in Canada was identified by local community musicians and received enthusiastic support from policy makers and continuing care providers within the province. By working in an interdisciplinary team and with community-based collaborators, we are crossing boundaries. However, this work is also framed in a way typical to the health sciences, with a primary focus on health and quality of life outcomes of people living with dementia. While this was the most appropriate framing for this project at this time, future research to explore this program from different angles could apply a more social science or arts-based lens to design studies about Music Connects Us which prioritize the experiences of musicians or continuing care staff. This work is a first step in a larger program of research and remains closely tied to traditional academic structures. Our meetings and discussion sessions were focused on the design of a pilot study, lead by a University of Alberta faculty member, and for implementation in Alberta, and included stakeholders essential to this specific project; however, future research aimed to spread Music Connects Us must also include stakeholders from other jurisdictions and continue to explore the most meaningful ways to engage with those stakeholders . To this end, future sessions with larger groups of stakeholders would use small group activities and be facilitated by someone other than a research lead, in order to ensure all voices are heard and to further break down any hierarchical structures which exist in the team. What is the extent and nature of engagement behaviors and mood displayed during Music Connects Us sessions by men and women living with moderate to severe dementia in care homes?How do engagement behaviors change over the course of a 1-h session?What are the effects of musical engagement on people living with dementia? For example, can participating in a weekly session improve feelings of loneliness, and related outcomes like responsive behaviors, depression, and quality of life?Our collaborative work to develop Music Connects Us highlights several gaps in knowledge that we can address during future pilot and effectiveness testing of the program during steps 4 and 5 of intervention mapping including: The next steps in this program of research are to conduct an in-depth exploration of the processes of this music-based group-activity intervention, and advance understanding of engagement behaviors during sessions for people living with dementia. We will continue to work closely with our Wigmore Hall partners to ensure quality delivery of our program and to share materials and learnings from each stage of the evaluation. Moving in this stepwise approach, we are developing the foundation for further research and practice to activate engagement among people living with dementia in care homes. This novel program of research will, ultimately, test how music-based group activity engagement can address loneliness and quality of life in an understudied population and aims to contribute to the diverse and growing body of research aimed to promote the use of music in healthcare.


Objective: The genetic markers for the detection or treatment of cervical squamous cell carcinoma (CESC) are not yet complete. This study aimed to identify the role of MSMO1 (Alternative name: SC4MOL) in the occurrence and development of CESC.Methods: We evaluated the significance of MSMO1 expression in CESC by using analysis of a public dataset from the Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) database. Oncomine and GEPIA2 were used to validate MSMO1 as an independent prognostic factor in CESC. Multiple tools were used to analyze the factors and functions associated with MSMO1, such as methylation, miRNA, and co-expressed genes. Furthermore, TIMER and TISIDB were used to study the relationship between MSMO1 expression and immunization in CESC.Results: MSMO1 was highly expressed in tumor specimens and could be used as an independent prognostic factor of CESC (p < 0.05). But Casiopeinas chemotherapeutics and p63 loss could reduce the expression of MSMO1. The level of methylation MSMO1 was significantly increased in tumor tissues but there was an insignificant effect on the prognosis. MSMO1 was also closely related to hsa-miR-23a-3p, hsa-miR-23b-3p, hsa-miR-130b-3p, and gene IDI1. Specifically, the expression level of MSMO1 had a significant negative correlation with the infiltration level of CD4+T cells, Macrophages, Neutrophils, and DCs in CESC. In addition, GSEA identified differential enrichment in systemic lupus erythematosus, vascular smooth muscle contraction, cytokine receptor interaction, focal adhesion, chemokine signaling pathway, and Leishmania infection pathway in KEGG.Conclusion: Our findings provide evidence of the implications of MSMO1 in tumors, suggesting that MSMO1 is a promising prognostic biomarker in CESC. Cervical cancer is currently the fourth most common cancer among women in the world . Cervicain vitro function of immune cells (Methyl sterol monooxygenase 1 (MSMO1) is also known as Sterol-C4-methyl oxidase-like (SC4MOL) and catalyzes the demethylation of C4 methyl sterol in the cholesterol synthesis pathway . SC4MOL ne cells . A previne cells . Anotherne cells . Moreovene cells , which cThus far, the mechanisms underpinning the oncogenic role of MSMO1 in CESC remain mostly unknown. The significance of MSMO1 in CESC has not been reported. The present study systematically evaluated candidate signature gene MSMO1 and clarified the association between MSMO1 and CESC prognosis, as well as the correlation between MSMO1 and tumor immunity. These may assist in evaluating therapeutic decisions and the prognosis for CESC patients. Therefore, this study uses tumor data from TCGA, GEO, and other websites to research the expression and clinical significance of MSMO1 in cervical squamous cell carcinoma.https://portal.gdc.cancer.gov/). We obtained 304 cervical cancer tissue samples and 3 paracervical cancer tissue samples in TCGA. Data were sorted and the differential genes were screened using Wilcox.test. We also obtained the correlation between MSMO1 and clinical information by calculating the AUC value through multivariate Cox analysis to obtain the genes with independent prognoses. The correlation between the MSMO1 gene and clinical prognosis parameters was obtained. These were achieved with Perl5.30.0.1 and R4.0.3.The Tumor Genome Atlas (TCGA) project was jointly launched in 2006 by the National Cancer Institute (NCI) and the National Human Genome Research Institute (NHGRI) in the United States. Cervical cancer transcriptome data (FPKM gene expression profile) and related clinical information were downloaded from TCGA (http://www.ncbi.nlm.nih.gov/geo/). These included 21 cervical cancer tissue samples and 10 paracervical cancer tissue samples in GSE7803. R4.0.3 was used to process data. In addition, we used the GEO Profiles webpage to explore the sensitivity of MSMO1 expression to chemical drugs.We then obtained the microarray profiles of CESC from the GEO database  was used to analyze the expression difference of the MSMO1(SC4MOL) between cervical squamous cell carcinoma and normal cervical tissue. We selected the Biewenga Cervix data set, which included five normal samples and 40 tumor samples. The analysis then compared them with several data sets. To help clarify the expression of MSMO1 and its influence on patient survival and prognosis, we used the GEPIA2 database (http://gepia.cancer-pku.cn/) for further analysis. The conditions were as follows: | log2FC | > 1, p < 0.01. In addition, the UALCAN database  was consulted for further proof. We then used the tissue information provided by HPA (http://www.proteinatlas.org/) to obtain the effect of MSMO1 on cervical squamous cell carcinoma.The Oncomine database  to screen 275 cases of TCGA cervical squamous cell carcinoma and gained 10 genes with the highest correlation with MSMO1. We used Spearman’s correlation test to screen genes with p < 0.05 and passed UCSC Xena (https://xenabrowser.net/) to visually verify the correlation between the two. In addition, we used the STRING (https://www.string-db.org/) gene interaction analysis tool to construct a PPI network diagram. Finally, the expression of the co-expression gene in CESC was analyzed by GEPIA2.We used cBioPortal  . The CpG located near or near MSMO1 was analyzed on survival by using MethSurv (https://biit.cs.ut.ee/methsurv/), which is a network tool for survival analysis based on CpG methylation pattern that can also associate methylation patterns with clinical characteristics. We used this database to analyze the methylation of the MSMO1 gene in each CpG in CESC.The methylation status of genes was analyzed through the UALCAN database , miRWalk, miRDB[(http://mirdb.org/), TarBaseV.8 (http://www.targetscan.org/vert_72/). Meanwhile, excel was also used to screen for commonly targeted miRNAs in the prediction database.The targeted miRNA binding to MSMO1 was predicted according to five prediction tools, namely ENCORI  , miRDB[, (Liu an), miRDB  can use gene expression profiles to infer the number of tumor infiltrating immune cells (TIICs). We used it to analyze the expression of MSMO1 in cervical squamous cell carcinoma and its correlation with the abundance of immune infiltration. These immune infiltrations including B cells, CD4+ T cells, CD8+ T cells, neutrophils, macrophages, and dendritic cells were obtained through gene modules. The immunomodulators and immune cells associated with MSMO1 were retrieved from an online integrated database TISIDB (http://cis.hku.hk/TISIDB/), aiming to elucidate tumor immune system interactions. We chose immune inhibitors and immune stimulators that were significantly correlated with MSMO1 regarding gene expression  for further study.TIMER    . We also < 0.01) .p <0.001) (p <0.001) (p <0.01) . The results showed a high correlation between clinical data and the expression of MSMO1. Meanwhile, we analyzed and evaluated the impact of MSMO1 expression and other clinic pathological factors such as age and gender on survival. It was shown that multiple clinical characteristics were closely related to the expression of MSMO1 in CESC especially T stage (AUC = 0.720) , which h <0.001) . This wa <0.001) . Moreovep <0.01) , which wp <0.01) . In addip <0.01) .p = 1.92e-26)  . In addi.92e-26) . Meanwhi.92e-26) . The fol.92e-26) . It coulp-val) <0.05, FDR q-val<0.25). The enrichment pathways of the KEGG pathway in MSMO1 high expression phenotypes included glycolytic gluconeogenesis, P53 signaling pathway, glutathione metabolism pathway, and the enrichment pathways in low expression phenotypes included systemic Lupus erythematosus, vascular smooth muscle contraction, cytokine receptor interaction, focal adhesion, chemokine signaling pathway, Leishmania infection pathway   . This inFor understanding the other up-regulation mechanism of MSMO1 in CESC, we identified and obtained the targeting miRNAs using various prediction tools. There were six targeting miRNAs including hsa-miR-19b-3p, hsa-miR-23a-3p, hsa-miR-26a-5p, hsa-miR-106a-5p, hsa-miR-23b-3p, hsa-miR-130b-3p , of whicp <0.05). We also explored the possibility that MSMO1-related immunomodulators might modulate the immune response in CESC. We identified 22 immune stimulators  (p<0.05), and 14 immune inhibitors  (p<0.05), which were significantly associated with MSMO1 in CESC. We, therefore, concluded that the MSMO1 might be a relevant factor in the immune response of CESC.We next examined the impact of MSMO1 on the immune system. In CESC, some immune subsets were either negatively or positively associated with MSMO1 mRNA levels . Among tNFRSF17)  (p<0.05)d VTCN1)  (p<0.05)p = 9.68e-02), macrophages , Neutrophils , and DCs   . We then.15e-01) . In consThe GDS4665/209146 in the GEO database showed that the Casiopeinas chemotherapeutics could reduce the expression of the MSMO1 gene in the HeLa cell line . The GDSStudies have shown that MSMO1 plays an important role in the regulation of energy metabolism, obesity, and dyslipidemia. In human hepatoma cells, the major transcription regulator of lipid metabolism PPARα incorporates with SREBP in regulating MSMO1 expression. Evidence suggests that the PPARα governs the expression of numerous genes involved in lipid metabolism, fatty acid oxidation, gluconeogenesis, and cholesterol catabolism . HoweverHere, we used R code, Perl language, and various databases to find the role of MSMO1 in the cervical squamous cell. We found that the high expression of MSMO1 was closely related to the positive prognosis of CESC, meaning it could be used as an independent prognostic factor for positive CESC. Moreover, the possible key pathways in CESC were regulated by MSMO1 including calcium glycolysis and gluconeogenesis, P53 signaling pathway, glutathione metabolism pathway, etc. Meanwhile, our study revealed that diverse immune marker sets and immune infiltration levels were correlated with MSMO1 expression in CESC. There was a negative correlation between the expression level of MSMO1 and the degree of immune cell infiltration. Among them, CD4 + T cells were a factor related to the cumulative survival rate of CESC over time. Co-expressed IDI1 genes are also highly similar to the gene expression and miRNAs combined with it might affect the expression of the MSMO1 gene. However, the level of methylation of MSMO1 had little to do with its expression. Thus, co-expressed genes and miRNA might affect the expression of MSMO1, and MSMO1 might have a potential impact on the tumor immunity, indicating that MSMO1 can be used as a promising cancer candidate biomarker.via 30UTR mRNA binding (In addition, miRNA could regulate the expression and replication of HPV genes . The miR binding . This pr binding . The 3p  binding . Meanwhi binding . Besides binding . The mic binding . Moreove binding , suggestA past study revealed that axon growth gene SC4MOL was up-regulated in TD-GC B cells and expressed preferentially in tumor post-GC B cells . ImmunolPoor survival in CESC may be identified by a molecular marker MSMO1. However, there are currently few studies on MSMO1 in cervical squamous cell carcinoma or other solid cancers. Therefore, to improve the clinical outcomes of patients with CESC, we strongly recommend further research on this topic to gradually improve evidence of the biological effects of MSMO1.The results showed that high expression of MSMO1 was closely related to immunity and that it could reduce the survival rate of CESC. MSMO1, therefore, has prognostic value and can be used as an independent prognostic element. It could be used as a prognostic marker and provide a new candidate therapeutic target for CESC. Such research may have significant and long-term implications for CESC. However, the study only uses bioinformatics databases for research, which has certain limitations and still needs to be verified by experiments. In summary, this study provides a possible new gene therapy target for the treatment of cervical squamous cell carcinoma. Nevertheless, the regulatory mechanism of MSMO1 on CESC is not yet clear, and further research is needed to more accurately use this gene to detect and treat diseases.The work described has not been published previously, that it is not under consideration for publication elsewhere. Its publication is approved by all authors and tacitly or explicitly by the responsible authorities.


Rhodotorula sphaerocarpa) with biomass concentrations varying over nine orders of magnitude. While after the initial chloroform-methanol extraction ~87% of the ergosterol was recovered, a second extraction recovered an additional ~10%. Testing this extraction method on samples collected from the open Atlantic Ocean, we successfully determined ergosterol concentrations as low as 0.12 pM. Thus, this highly sensitive method is well suited for measuring fungal biomass from open ocean waters, including deep-sea environments.Ergosterol has traditionally been used as a proxy to estimate fungal biomass as it is almost exclusively found in fungal lipid membranes. Ergosterol determination has been mostly used for fungal samples from terrestrial, freshwater, salt marsh- and mangrove-dominated environments or to describe fungal degradation of plant matter. In the open ocean, however, the expected concentrations of ergosterol are orders of magnitude lower than in terrestrial or macrophyte-dominated coastal systems. Consequently, the fungal biomass in the open ocean remains largely unknown. Recent evidence based on microscopy and -omics techniques suggests, however, that fungi contribute substantially to the microbial biomass in the oceanic water column, highlighting the need to accurately determine fungal biomass in the open ocean. We performed ergosterol extractions of an oceanic fungal isolate ( In marine environments, heterotrophic microorganisms are the main drivers of biogeochemical cycles due to their orders of magnitude higher biomass-specific metabolic rates than metazoans. The main heterotrophic organisms in terms of biomass are bacteria, followed by their grazers , the hetChlorella vulgaris and some Protozoa can synthesize ergosterol +  and the unusual [M+H-2H2]+  ions as precursors. The following six transitions were monitored for 50 ms each ): 379.3 > 295.2 (20 eV), 379.3 > 159.1 (30 eV), 379.3 > 145.1 (35 eV), 379.3 > 69.0 (55 eV), 393.3 > 268.2 (30 eV), 393.3 > 173.1 (35 eV). Analyst version 1.6.3 was used for data acquisition and evaluation.For the ionization of ergosterol in positive ion mode, a heated nebulizer APCI probe was used in the Turbo V source with the following settings: curtain gas 30 psi, nebulizer gas 40 psi, temperature 500 °C, nebulizer current 3 µA. The mass spectrometer was operated in selected reaction monitoring mode using both the + and the [M+H-2H2]+ ions being the most intense. An LOD of 1.5 nM (S/N = 3/1) and an LOQ of 5.0 nM (2 ng/mL) at S/N = 10/1 could be obtained, thus being about 25 times more sensitive than with the HPLC-UV method. A chromatogram of an ergosterol standard (1 µM) with all six SRM transitions is shown in For the developed LC-APCI-MS/MS method, the observed ionization was in agreement with results obtained from Ory et al. , with thOverall, we successfully adapted a method originally developed for ergosterol extraction from fish tissue  to pelag


Rural residents are at high risk for obesity; however, little resources exist to address this disproportional burden of disease. Primary care may provide an opportunity to connect primary care patients with overweight and obesity to effective weight management programming.The purpose of this study is to examine the utility of different physician referral and engagement processes for improving the reach of an evidence-based and technology-delivered weight management program with counseling support for rural primary care patients.A total of 5 rural primary care physicians were randomly assigned a sequence of four referral strategies: point-of-care (POC) referral with active telephone follow-up (ATF); POC referral, no ATF; a population health registry–derived letter referral with ATF; and letter referral, no ATF. For registry-derived referrals, physicians screened a list of patients with BMI ≥25 and approved patients for participation to receive a personalized referral letter via mail.P<.001) and for proportion screened  but not for proportion enrolled . Patients receiving ATF were more likely to be screened  and enrolled  than those not receiving ATF. On the basis of the number of referrals made in each condition, we found variations in the proportion and number of enrollees . Across all conditions, participants were representative of the racial and ethnic characteristics of the region . Recruitment costs totaled US $6192, and the overall recruitment cost per enrolled participant was US $63. Cost per enrolled participant ranged from POC with ATF (US $47), registry-derived letter without ATF (US $52), and POC without ATF (US $56) to registry-derived letter with ATF (US $91).Out of a potential 991 referrals, 573 (57.8%) referrals were made over 16 weeks, and 98 (9.9%) patients were enrolled in the program . Differences based on letter  versus POC  referrals were identified for completion (100% vs 7%; Letter referral with ATF appears to be the best option for enrolling a large number of patients in a digitally delivered weight management program; however, POC with ATF and letters without ATF yielded similar numbers at a lower cost. The best referral option is likely dependent on the best fit with clinical resources.ClinicalTrials.gov NCT03690557; http://clinicaltrials.gov/ct2/show/NCT03690557 Obesity is a pressing health concern nationwide, particularly in small rural communities. Rural residents are more obese, on average, than their urban counterparts  and ofteA challenge for weight management interventions is ensuring that not only is an intervention effective but it also has the potential to reach populations at risk that could most benefit . FactorsHowever, when drawing more broadly from the behavioral intervention literature, a number of examples of both active and passive recruitment strategies can be found that have been used to engage various target populations ,10-13. OThe purpose of this study is to examine the utility and cost of different physician referral and engagement processes for improving reach  for a rural, evidence-based, and technology-delivered weight management program with counseling support. Our design is based on feedback gathered from prior qualitative work ,17; thatWe use the RE-AIM  framework to guide our assessment of reach  and hypoBefore this pilot trial, we conducted focus groups with primary care staff employed at rural primary care clinics regarding the feasibility of implementing a weight loss program through primary care. Overwhelmingly, primary care staff agreed that a program to which physicians and nurses could refer eligible patients and track their progress throughout was more favorable than a program that would require physician- or nurse-led delivery ,17. We tThe study design used the hybrid methodologies described by Curran et al , which a2, (2) no contraindications to participation, and (3) visiting the clinic for a chronic care or well visit. In the population health approach, a clinic administrator pulled a list of patients from the electronic health record system with BMI≥25 who had visited the clinic in the previous 2 weeks. Each physician reviewed this list and removed any patients with contraindications to participation in the evidence-based weight loss program. The remaining patients were mailed a personalized invitation letter to participate in the weight loss intervention that was signed by their physician.Referral strategies varied by POC versus a population health electronic health record–derived letter referral and ATF versus no telephone follow-up. For POC referral, physicians were instructed to refer any adult patient to an evidence-based weight loss program with diet and physical activity counseling based on (1) BMI≥25 kg/mFor ATF, the referred patient was informed that they would be contacted by a member of the research team to determine if they would like to participate in the program . In conditions without ATF, the referred patient was provided a telephone number to call if they were interested in discussing participation in the program. The study was reviewed and approved by the University of Nebraska Medical Center Institutional Review Board (#581-18-EP).We designed this pilot study to recruit over a 16-week period, with the goal of enrolling approximately 100 participants and projected a 10% enrollment rate based on the overall denominator of potential referrals based on prior work ,22. EachAll referred and interested patients were required to undergo a brief telephone screening with a member of the research team and, if eligible, were given instructions over the phone and via email on how to complete web-based program enrollment. In addition, all interested and eligible patients were scheduled for an in-person enrollment visit with a member of the research team where they were given intervention program materials  and a tutorial of the intervention’s mobile app, provided with tips on how to stay engaged with the program, and completed the web-based program enrollment . Patient consent to participate in the weight loss program was obtained during the web-based enrollment process. Patients were given the opportunity to raise questions before consent and during the in-person enrollment visit.All referred patients were offered a 12-month, digitally delivered, evidence-based weight management program free of charge. The program featured a social cognitive theory–based curriculum with counseling support delivered through daily emails and text messages. Program features also included daily meal plans and physical activity recommendations . EstabroP values <.05 were considered statistically significant for this study.Program reach was measured by the number and proportion of individuals who were (1) referred, (2) screened, and (3) enrolled and was compared across referral strategies relative to the number of eligible patients who visited the clinic during the recruitment period. Representativeness of the enrolled sample was assessed relative to the demographic characteristics of the region, as measured by the US Census . We usedCosts of recruitment were prospectively and retrospectively estimated based on the costs of recruitment materials , supplies, and recruitment activities, including telephone follow-up, telephone screening, and in-person sessions. Labor costs were calculated using the research assistant (RA) annual salary  and publicly available average salary estimates for primary care physicians  and clinic managers . RAs tracked the time spent on various recruitment activities, number of phone calls made, enrollment sessions completed, and number of flyers printed in a custom computer database. Cost results are presented for each referral strategy.P<.001) and enrolled  than those without ATF. Chi-square test results revealed significant differences in terms of patient screening  and enrollment status  among referral strategies . The actual number of referrals made by the 5 physicians was 573  and, out of the 573 referrals, 98 (17.1%) patients were enrolled, representing an overall enrollment rate of 10% of the potentially eligible patient population. Of the 485 potential letter referrals, 485  were completed, 229  patients were screened by telephone, and 57  were enrolled. Of the 506 potential POC referrals, 88  patients were referred, 60  were screened, and 41  were enrolled. Patients receiving ATF were more likely to be screened , participants did not significantly differ among demographic characteristics. Comparing by referral strategies, participants differed significantly in age.Our results provided some support for the hypothesis that a physician letter referral with ATF is most effective for enrolling a large number of participants into a digitally delivered weight management program compared with POC referrals with and without telephone follow-up and physician letter referrals without follow-up. However, when considering the combined outcomes of penetration into the target population, overall and proportional yield, and cost of recruitment, letter referral without ATF may be the most attractive option for rural primary care clinics that wish to recruit patients into a weight management program. Importantly, all (100%) of the 485 potential letter referrals were made, as compared with the 88 (17%) of the 506 potential POC referrals. Letter with ATF (n=30), letter without ATF (n=27), and POC with ATF (n=27) yielded a similar number of participants. Finally, the costs associated with the letter without ATF referral strategy were relatively low (US $51 per enrolled participant).save that referral for a patient in greater need. However, we do not believe this influence was significant because not all of those potential referrals were used; <60% (573) of the potential referrals were distributed to eligible patients. Although not assessed in this study, primary care physicians often cite a lack of time during patient visits as a barrier to health counseling [Owing to the financial constraints of this pilot study, we limited the number of potential referrals to 991, knowing that this would be far less than the total number of eligible patients seen by the 5 physicians during the recruitment period. Awareness of the finite number of referrals may have influenced the physicians’ decision to refer a patient to the program, perhaps causing them to pass on referring an eligible patient to unseling ,27, whicWe calculated the proportional yield per referral strategy using potential referrals and referrals made as the denominator. These two analyses revealed different stories. When considering enrollees compared with potential referrals, the letter with active follow-up (15%) and POC with active follow-up (14%) strategies appear to be the best for enrolling a large number of participants into the weight loss program. However, when considering enrollees compared with the number of referrals made, POC with active follow-up (50%) emerges as the clear leader for proportional yield. When considering costs, POC with ATF again appeals as the least expensive recruitment strategy (US $50 per participant), although letter referrals without ATF (US $51) had similar costs. The time-intensive nature of recruitment strategies with ATF not only drives up costs but also places a higher burden on recruitment personnel compared with strategies without ATF. In kind, the cumulative time associated with POC referrals may be similar to that of clinic administrator time spent preparing the letter referrals. Primary care clinics that are considering referring patients to a weight management program should reflect on these approaches with regard to clinical flow and costs. Resource costs in the large volume of letters and telephone calls for letter referral with ATF may make POC referral strategies with active follow-up appealing to small rural clinics, or if system processes are in place to make patient identification and mailing easy, the letter referral without ATF may be the most attractive.Similar to previous studies ,11, our Our sample was older and had a higher proportion of females than the target population. This is easily explained by the following: (1) our intervention was limited to adults aged ≥19 years, whereas the male age of Butler County represents children and adults; (2) women traditionally have higher health care use than men ; and (3)Identifying the best method for maximizing the reach of a weight management program is important for future scale-up efforts. However, maximizing participant retention is a critical next step in the scale-up of any behavioral intervention. An interesting future point of investigation will be the intervention attrition gap of our intervention—the proportion of patients who initially enroll in the program and subsequently do not engage with any program features. This is an especially curious investigation given the conflicting literature regarding the effectiveness of active versus passive recruitment strategies for retaining participants in behavioral interventions ,13.There are limitations to our study that should be considered when interpreting our results. As the selected intervention and referral methods were tailored to fit the needs of our target population, the findings of our feasibility study may not be fully generalizable to other primary care clinics. However, the process by which we selected an evidence-based intervention is likely translatable to other researchers and practitioners attempting to select and implement an evidence-based intervention. As previously mentioned, we were not able to track the number of times a physician attempted to make a referral during a clinic visit but was immediately rejected by the patient being seen. Anecdotally, we can attest that this was a rare occurrence, as the physicians reported that the majority of patients were willing to receive or inquire for more information about the program. We did not collect demographic or qualitative data from the 5 physicians involved in referrals and therefore cannot comment on their national representativeness to physicians caring for rural patients or their perceived lack of time for distributing referrals. In addition, census data used to compare our sample with the target population were drawn from Butler County, Nebraska. However, the clinic from which we recruited participants may draw patients from outside Butler County, and comparisons may not directly align. However, when our sample is compared with the demographic characteristics of all adjacent counties , it remains a representative sample. Indeed, our study has several strengths. Our sample was 59% female, which is a higher proportion of male participants than typical community weight loss programs . Our samWe conclude that primary care physicians serving a rural community are capable of referring patients to a digitally delivered behavioral weight management intervention through in-person and population health record–generated letter referrals. When compared with POC methods, letter referrals were more effective at achieving high penetration in the target population and had a slightly higher yield of enrolled patients in this study. However, POC referrals yielded a considerably higher proportion of enrollees from those who received a referral. Participants who received ATF were more likely to be screened and enrolled in the program. These results suggest that either a letter or POC referral strategy can be effective with ATF; however, when resource costs are considered, POC with ATF may be the best method to engage rural primary care patients in a weight management program.


Providing Burn Care is a physically and emotionally demanding job. AND, it is a rewarding and inspiring profession. 2020 and 2021 saw unprecedented rates of burn out and turn over in staff. Our concern for the well being of staff as well as our need to increase retention motivated our desire to provide staff with tools to build resiliency and coping strategies. Traditionally, this education comes in the form of teaching mindfulness, breathing exercises or self care outside of the burn center. We recognized that while these approaches are important and effective, they are not the right fit for everyone. The current times require us to use a multipronged approach to the tools we offer our burn teams.Our regional burn center partnered with a community based arts education nonprofit to re-think how we provide staff with tools for adaptability. A curriculum was formulated that provided therapeutic art to nursing staff via four weekly zoom meetings. This resulted in a novel approach to resiliency building and self care.The program was opened to all burn center staff members. Staff registered in advance for the four week program; the arts organization mailed each participant a box containing all the supplies they would for need. Each week, a different art modality/artist was paired with therapeutic discussions grounded in a trauma informed approach. Discussions focused on emotional and physical safety, building a community of support, finding balance between work and home and identifying coping skills to use to help ground ourselves during times of stress.Seven burn center staff members signed up for this program. Weekly attendance averaged 6-7. A program evaluation was completed by participants at the end of the final session. Questions were divided into three sections: program logistics, community building and the artistic process. Results indicated that this was an extremely valuable experience for participants. In addition, staff made comments such as "allowing myself to be vulnerable in the process has built trust and connection between myself and the other participants", "I don't remember the last time I did something like this just for myself", "I feel like I can add art to my list of coping strategies, despite never thinking of myself as an artist".Offering burn center staff with an alternative program to help build resiliency resulted in an increased sense of trust between staff members, provided one more outlet for self care and allowed participants to build resiliency in a new way.