Information on the prevention of earthquakes in Peru, a high-risk country, is still emerging. We determined the frequency and factors associated with knowledge of evacuation routes and the use of emergency backpacks in people affected by a major earthquake. A cross-sectional study using secondary data was conducted from August–December 2021 on people that experienced the 6.1 magnitude earthquake that occurred in Piura, Peru on 30 July 2021. The outcome was self-reported knowledge of evacuation routes and the use of emergency backpacks. The association with self-reported earthquake preparation training, use of sources of information on earthquakes, and sociodemographic variables was investigated. A total of 69.5% of participants knew evacuation routes, and 46.3% had an emergency backpack. A higher frequency of knowledge of evacuation routes was associated with previous training , use of the media , having received information from the COEN , and with a greater number of household members . There is a high frequency of knowledge of evacuation routes among participants. However, basic notions of prevention culture are still needed. This research contributes to policy development on earthquake preparation at the community level. Earthquakes are unpredictable natural disasters that have a great impact on people’s health and can also cause material losses ,2. It isExposure to relevant information is a motivator for promoting household emergency preparation . TelevisTherefore, this study aimed to determine the frequency and factors associated with the self-reported knowledge of earthquake evacuation routes and having an emergency backpack in the population affected by a 6.1 earthquake in Piura, Peru. This paper will describe the study materials and methods , results , discussion of main results , limitations and strengths of the study, and conclusions.Procedures section).This was a cross-sectional analytical study based on data from a previous study conducted in the resident population of Piura, Peru, which experienced a 6.1 magnitude earthquake on the Richter scale on 30 July 2021 . The stuThe population consisted of adults who experienced the earthquake that occurred on 30 July 2021 in Piura and reported being residents of one of the 38 districts of Piura declared in a state of emergency due to the impact of damage caused by the occurrence of seismic movement . The priThe data were collected and managed using the Research Electronic Data Capture system (REDCap). REDCap is a secure online platform for designing, managing, entering, and rigorously capturing surveys and online databases for research ,25. To dThen, we used the Survey Queue tool. This tool allowed us to combine the list of all questionnaires into one single form for each participant. To combine all questionnaires into this single form, we activated the Survey Queue in the REDCap project; we then navigated to “Online Designer” and clicked on the Survey Queue icon located above the data collection instruments. Immediately, a “Set up Survey Queue” box appeared. Next, we clicked the Enable icon for each questionnaire we wanted to set up. Under the “Show survey in survey queue when.” column, we used the drop-down menu to indicate when each questionnaire should be shown to the participant. We used the Branching Logic tool in the Survey Queue to display the questions in the questionnaires. The Branching Logic tool allowed us to display the questionnaires to the participants compiled on a single form automatically, only if the participant provided informed consent.In addition, we used other tools in the REDCap project to ensure the correct arrangement, provision, and completion of questionnaires: unique and anonymized identifiers on each form, questionnaires ordered in a consistent way ((1) informed consent, (2) general data, (3) sources of information on earthquakes, and (4) culture of earthquake prevention), use of conditional logic for skip questions, mandatory fields in questions to avoid missing, minimum and maximum ranges in numerical variables, and use of group matrix tool for Likert scale responses. Finally, a public survey link was created using the Manage Survey Participants tool. Before starting the study, the survey link and form were verified to work correctly.Subsequently, we began the dissemination of the virtual questionnaire through infographics on social networks of universities, academic-scientific institutions, and the media in Piura. The questionnaire began its dissemination in August 2021 and ended on 30 September 2021.The questionnaire consisted of 3 sections:Age in years;Single marital status ;Level of education ;Type of work ;Monthly household income in Peruvian currency ;Number of family members in the household, report of having comorbidity .oMedia;o[National Civil Defense Institute]—INDECI;Instituto Nacional de Defensa Civil o[National Emergency Operations Center]—COEN;Centro de Operaciones de Emergencia Nacional o[National Disaster Risk Management System]—SINAGERD;Sistema Nacional de Gestión de Riesgo de Desastres oMinistry of Health—MINSA;o[Geophysical Institute of Peru]—IGP;Instituto Geofísico del Perú oFamily, colleagues, or friends.Self-report on the sources of information that the participant used to find out about the earthquake that occurred:Self-report on having received earthquake preparation training ;Self-report on knowing evacuation routes and safe zones at home and/or workplace ;Self-report on having an emergency backpack for earthquakes .The dependent variables were (1) report knowing evacuation routes and safe zones in their home and/or workplace through the question “Do you know evacuation routes and safe zones in your home and/or workplace?” and (2) report having an emergency backpack for earthquakes with the question “Do you have an emergency backpack for earthquakes”?The independent variables were report having received earthquake preparation training with the question “Have you received earthquake preparation training?”, use of information sources used to learn about the earthquake, and sociodemographic data .Statistical analysis was performed in Stata 17.0  after exporting the database from the REDCap data entry system.In the descriptive analysis, we reported absolute and relative frequencies for categorical variables and the best measure of central tendency and dispersion for numerical variables, previously evaluating the normal distribution numerically, graphically, and analytically.t-test was useful; otherwise, the nonparametric Mann–Whitney U test was used.In the bivariate analysis, we identified the factors associated with knowledge of earthquake evacuation routes and having an earthquake emergency backpack using the chi-square test of independence after analyzing the expected frequency assumption. In the case of numerical variables, the parametric Student’s Poisson distribution family, log link function, and cluster by the district of origin. Significant variables (p < 0.05) in the simple model entered the final multiple-variable model. p-values less than 0.05 were reported as statistically significant.In simple and multiple regression, we estimated prevalence ratios (PR) and 95% confidence intervals (95% CI). We used generalized linear models (GLM), Of the 177 participants, the mean age was 22 years, 56% were female, 63.8% had a university education, and 28.3% were working at the time of their participation; We found that 89.8% of the participants reported using social networks to receive information about the earthquake. In addition, the other most frequently reported sources of information were the media (80.1%), the Geophysical Institute of Peru-IGP (73.9%), and the National Institute of Civil Defense-INDECI (51.7%). Only 17.6% and 18.8% of the participants reported using the National Emergency Operations Center (COEN) and the National Disaster Risk Management System (SINAGERD) as a source of information about the earthquake; Here, 63.3% reported having received earthquake preparation training, while 69.5% mentioned knowing evacuation routes and safe zones in their home and/or workplace. In addition, slightly less than half (46.3%) mentioned having an earthquake emergency backpack at home; p = 0.003), IGP (p = 0.029), and family (p = 0.001) as sources of information for earthquakes. In addition, participants who reported having received earthquake preparation training had a higher frequency of knowing evacuation routes ; In the bivariate analysis, we found that the variables significantly associated with knowledge of earthquake evacuation routes were using the media , the factors associated with a higher frequency of knowledge of earthquake evacuation routes were reporting having received earthquake preparation training , using the media as a source of information about the earthquake , getting information through the COEN , and having more members in the household . On the contrary, being a student reduces by 18% the frequency of knowing evacuation routes and safe zones in their home or workplace ; The factors associated with having an emergency backpack were reporting the MINSA as a source of earthquake information  and having a family income greater than PEN 3000 , as found in the multiple regression analysis adjusted for household income and MINSA as a source of information (the only two significant variables in the simple regression model); Earthquakes, one of the most damaging natural disasters, leave a large number of people injured, disabled, or dead . Taking In our research, it was found that the most used source of information to be informed about earthquake news was social networks (89.8%), mass media (80.1%), the Geophysical Institute of Peru-IGP (73.9%), and the National Institute of Civil Defense-INDECI (51.7%). In contrast, the least reported sources of information were the National Disaster Risk Management System-SINAGERD (18.8%) and COEN (17.6%). Similar to this was the study after the 2011 earthquake in Japan (8.9°), in which the population used social networks, especially Twitter, and traditional media such as television and newspapers to stay informed . HoweverWe found that nearly 6 out of 10 participants reported having received earthquake preparation training. This is similar to that reported by Ozdemir, Raziye et al. in Turkey, where 61.4% of Karabuk University faculty members reported reading tutorials on earthquake preparation, and 47.7% received first aid training . HoweverNearly 7 out of 10 participants reported knowing evacuation routes and safe zones in their homes and/or workplaces. This is similar to that reported by Gallegos C. R. in students in Lima, 74% knew about protective places inside the classroom, and 65%  about evOur study found that nearly 4 out of 10 participants have an emergency backpack in the event of an earthquake. This is similar to that reported in the 2021 National Household Survey in the United States, where 45% reported preparing supplies . HoweverPeople who reported having received earthquake preparation training were 47% more likely to know evacuation routes and safe zones in their homes or workplaces. This is similar to that reported by a quasi-experimental study in Turkey, where students who received an educational intervention had a 48.5% increase in determining how to leave their homes during an earthquake . A studyUsing the media as a source of information about the earthquake increased 53% the frequency of knowing evacuation routes and safe zones in their home or workplace. This is similar to what was reported in Indonesia, where the media, such as television and radio, proved to be effective in transmitting information about the earthquakes that occurred . This fiPeople who were informed through the COEN are 20% more likely to know evacuation routes and safe zones in their homes or workplace. A study conducted in Hong Kong found that only 2.9% of participants used state websites as a source of disaster information . AnotherThe greater the number of household members, the greater the frequency of knowing evacuation routes and safe zones in their homes or workplaces. This is similar to what was reported in Hong Kong, where a higher number of household members was associated with good household disaster preparation . HoweverStudents were 18% less likely to know evacuation routes and safe zones in their homes or workplace. This is similar to what was reported in Iran, where less knowledge about disaster preparation was found in students and self-employed workers , and anoWe found that people who used the Ministry of Health (MINSA) as a source of earthquake information had a 24% higher frequency of having an emergency backpack. Moran Bodas et al. in their study reported that the frequency of searching for information on earthquakes represented 79.1%  and accoIn addition, those with a family income of more than PEN 3000 were 58% more likely to have an emergency backpack. This is similar to that reported in Taiwanese families by Ziqiang Han et al., in which the frequency of having an emergency preparation backpack is higher in families with higher average monthly household income  . This fiThrough this research, we have studied the factors associated with the culture of prevention in risk situations such as earthquakes. Our findings indicate that more than half of the population knew the evacuation routes and safe zones 69.49%), which was related to having received previous training .49%, whi,47. GiveTraining should be considered among the main strategies for the mitigation of damage caused by natural disasters according to their magnitude , althougIn our study, approximately half of the participants did not have an emergency backpack (53.67%), as recommended by the Ministry of Health (MINSA) ; therefoConcerning the health problems framed by the study, it is important to understand that the effects of the earthquake on public health began to be studied both in the early stages and in terms of medium–long-term effects . These nOur research has some limitations. First, there is a selection bias since we conducted a non-probabilistic sampling; therefore, it is not possible to generalize findings to the population of interest. Second, due to the cross-sectional design, it is not possible to attribute causality between the variables that were associated with a better culture of earthquake prevention. Third, there could be an information bias because the variables were measured by self-reporting of the participants; however, to reduce this, we collected information up to a maximum of two months after the earthquake. However, our study highlights as its main strength the fact that the results found are consistent with the literature and with earthquake preparation, a crucial stage in natural disasters to mitigate possible aftereffects as much as possible. In addition, our research addresses an issue that is scarcely studied in northern Peru. Finally, this study shows solid and well-documented evidence to prepare better community policies that are efficient, culturally adapted to our context, and serve as a niche for future research aimed at strengthening the preventive culture in the face of natural disasters.We found a high frequency of knowledge about evacuation routes and safe zones at home or workplace in the participants exposed to the strong earthquake. However, slightly less than half reported having an emergency backpack in the event of an earthquake. In addition, the factors associated with a better culture of earthquake prevention were being informed of the earthquake by the media, COEN, and family. Participants with higher income and those who were informed about the earthquake by MINSA reported a higher frequency of having an emergency backpack in the event of an earthquake. These findings suggest that there is still a need to increase awareness of the culture of earthquake prevention and that this depends on focused interventions by authorities, in which the participation of institutions and media may play a fundamental role. Our study will contribute to the development of policies focused on earthquake preparation, as well as to the elaboration of future research on preventive culture in the face of natural disasters and their impact on different aspects of health. Recommendations for future studies comprise the inclusion of a random sample, the development of cohort studies that measure the actual practice of evacuation routes and the use of emergency backpacks, and the establishment of interventions that effectively promote these practices.It is recommended to design and implement interventions to improve earthquake preparedness based on self-efficacy, perceived benefits, and action cues. Planning, preparing, and practicing what you would do in the event of an earthquake will help you learn to react appropriately and naturally when the shaking begins. This will increase the chances of surviving an earthquake and reduce the danger of injury. In addition, it is vital to stock up on emergency supplies that can be used after an earthquake, including a first aid kit and emergency supply kits for the house and car with water and food, and stocking up on products that will last at least three days. In addition, you should gather necessary documentation and compile a list of crucial details, such as emergency contact information and relevant medical information , and store these items in a safe place, such as a fireproof or airtight safe.


Peer support has been an undeveloped pathway for filling the service gap and to generate employment opportunities for autistic individuals. Peer supports have been deployed widely in mental health and among veterans and understanding the utility of this service modality among autistic individuals illuminates opportunities for research, policy, and practice. This study examined characteristics of participants in an autistic-delivered peer support program and reports on use of and satisfaction with the program. Half of autistic participants had a co-occurring mental health diagnosis. Participants reported multiple areas of unmet needs and participant satisfaction with the program was high (90%). The findings of this study point toward autistic-delivered peer support as a promising avenue for future development.The online version contains supplementary material available at 10.1007/s10803-022-05816-4. A robust and growing evidence base has identified gaps in services and supports available to autistic adolescents and adults  of an autistic-delivered peer support program aimed at enhancing self-identified goals for community outcomes among autistic adolescents and adults. The overall goal of the initiative, the Community Autism Peer Specialist (CAPS), is to promote independent living, participation, and social relationships of autistic youth and adults by addressing individual-identified needs and goals. The CAPS initiative involved the development of a first of its kind peer specialist training program designed by and for autistic peers, which we describe briefly, followed by a description of the CAPS program itself that employed some of the trained peer specialists. We examine the level of utilization of the CAPS services and characteristics of those who have participated in the CAPS program, such as age, co-occurring conditions, social functioning, and unmet needs, with a particular interest in assessing whether autistic individuals with more service needs are willing to seek autistic-delivered peer support services. We also demonstrate practicality through self-reported relationships between peer specialists and program participants in agreement on the goals and tasks and development of bond. Moreover, we evaluate acceptability by assessing both participants and peer specialists’ satisfaction with the program. This information is critical to informing future efforts aimed at expanding the availability of similar peer support initiatives for autistic individuals focused on enhancing community outcomes.Medicaid-reimbursed peer support services delivered by individuals with mental health diagnoses to others with mental health diagnoses require peer specialists to receive specialized peer support training Salzer, . TraininThe training curriculum was facilitated by a consultant group comprised of neurodiverse individuals to ensure that culture, the nuance of language, and content were reflective of autistic individuals’ perspectives. Specifically, the consultant group led the process of seeking feedback from an Advisory Board and Curriculum Committee on the development of the training curriculum materials and content formatting . Committee members completed a survey that asked whether certain content should be included or not and changes that they would recommend. Furthermore, the peer support curriculum used in the mental health field was compared to areas where autism-specific content would need to be newly created or modified from a mental health-specific lens.The intention of the CAPS program was to structure training and service delivery to be positioned to obtain approval as a Medicaid billable service similar to what is required for billing for peer support for individuals with mental health diagnoses. In parallel to the required length of typical Certified Peer Specialist training in mental health in Pennsylvania  providing peer support , 2) promoting community participation, (3) promoting capabilities and independence, (4) supporting education on autism characteristics , (5) awareness and practice of self-care, (6) building cognitive flexibility skills, and (7) focusing on relationships. The short-term, intermediate, and long-term outcomes associated with each activity were also identified, including hope, enhanced self-concept and empowerment, increased participation, better relationships, and improved sense of well-being  diagnosis and being eligible for Medicaid. Individuals were enrolled through referrals by licensed treatment providers. After the referral, interested participants completed an intake evaluation form. This was reviewed by the CAPS program leadership who matched the individual to a peer specialist based on their availability, shared interests, and preferences of the individual, including gender preferences , location , and transportation use to ease travel for the participants and CAPS.A set of measures were established by members of the outcomes evaluation subcommittee of the Steering Committee. Measures were compiled into an online survey tool (REDCap) , and the average age was 19.7 (SD = 6.1), with a range of 14–41. Eleven participants were 19 years old and older. Most participants identified as white (44.8%) or Black (41.1%), and 13.8% were Hispanic Table . SpecifiIn order to receive the CAPS training, peer specialists must be: (1) being 18 years of age or older with an autism diagnosis, (2) having a high school diploma or GED from an accredited institution, and (3) having engaged in employment or education within the past three years . A total of six peer specialists were employed to provide CAPS services during the course of this study. The average age of the peer specialists was 29.7  and four (66.7%) were female. Three were Non-Hispanic white, one Black, one Native Hawaiian or Other Pacific Islander, and one other race/ethnicity. Four out of the six peer specialist had at least one mental health diagnosis. Specifically, two peer specialists had ADHD, two had depression, and two had anxiety. No peer specialists in this study reported an intellectual disability diagnosis.The following measures were used to assess feasibility of the CAPS program. First, to assess the demand of the program, we used demographic and clinical information, Social Responsiveness Scale 2nd edition (SRS-2), and Camberwell Assessment of Needs to examine the characteristics of those who participated in the program. We also used utilization of the CAPS services to assess the demand. Second, to assess the practicality, we used the Working Alliance Inventory-Short Form to measure the level of agreement on the goals and tasks and development of bond. Third, to measure the acceptability, we asked participants and peer specialists to rate their satisfaction with the program.Self-reported gender, race and ethnicity, and age were collected at baseline and co-occurring psychiatric diagnoses collected included diagnoses of Attention Deficit Hyperactivity disorder (ADHD), Depression, Anxiety, Post Traumatic Stress disorder (PTSD), Bipolar disorder, or Intellectual Disability (ID). Crisis service use history was captured by asking participants to enter the number of times they had gone to an emergency room, hospital, or crisis center for mental health, psychiatric or emotional help in their lifetime and within the last 12 months. Employment status was identified by asking whether participants had a job where they were earning at least minimum wage.The SRS-2 Adult Self Report was used at the baseline to measure the ASD traits. This 65-item instrument was scored on a 4-point Likert scale, from Not True to Almost Always True. The total score measures social deficits, with T-scores of l Bruni, .A modified version of the Camberwell Assessment of Needs  reported going to an emergency room, hospital, or crisis center for mental health, psychiatric or emotional help in their lifetime, with an average of 2.9 visits over their lifetime. Approximately 14% of participants had gone to an emergency room, hospital, or crisis center for mental health, psychiatric or emotional help at least once in the past year with an average of 1.3 visits.Among the 28 CAPS participants who responded to the SRS-2, six (21.4%) were in the Severe category of social impairment, 13 (46.4%) in the Moderate category, seven (25.0%) in the Mild category, and two (7.1%) in the Normal category.On average, participants indicated having a need in 9.4 out of the 23 domains  meetings with a CAPS peer specialist in the first three months that they participated in the program. In a typical week, program participants reported that they met with a CAPS peer specialist for about 2.59 h . Program participants most frequently met with a CAPS peer specialist at their home  followed by meetings in the community  or at the CAPS program location .Among the 19 participants who responded to the WAI-S at the 3-month follow-up, the mean of the WAI-S total scores was 4.07  out of a possible 5, which corresponded to “very often” on the Likert-like scale. Similarly, high scores were also observed in the Bond, Goal, and Task subscales. The descriptive statistics for the subscales are presented in Table The overwhelming majority of CAPS participants  reported overall satisfaction  with the program Fig. . Most ofThe perceived satisfaction of peer specialists is presented in Fig. Autistic-delivered peer support is a promising new service option for autistic adolescents and adults. Using a program modeled from peer support services widely established for individuals with mental health diagnoses, the Community Autism Peer Support (CAPS) program is among the first to develop a specialized peer support training program for autistic individuals and implement an autistic-delivered peer support program. The co-development of CAPS with autistic individuals substantively enriched the program content, evaluation, and sustainability. The ability for autistic-delivered peer support to be implemented in one of the largest cities in the US with among the highest proportion of the population living in poverty underscores the versatility of and demand for service options that are developed based on the needs of the communities they intend to serve.We provide empirical data about the feasibility and acceptability of an autistic-delivered peer support intervention for transition-age youth and adults. Data from 29 participants who were referred to the program suggest that autistic-delivered peer support services using the CAPS model are feasible for autistic adults with multiple and intensive service and support needs. Participants were generally highly engaged in the services and reported high levels of satisfaction with most aspects of the program.CAPS can be delivered to autistic youth and adults with complex, significant needs, including many with co-occurring mental health diagnoses and social communication needs. About half of the program participants reported at least one mental health diagnosis. Most of the adult program participants (67.8%) in our sample were in the moderate to severe deficiency range defined by the SRS. Program participants had a wide range and high number of needs in their social lives, physical activity, mental health service and supports, and daytime activities. More than half of the participants also reported autism treatment, transportation, finance, and education support needs. Future research should examine the relationship between services received and needs of program participants, as well as identify the impact of the CAPS program on community functioning that autistic individuals prioritize.CAPS participants, again, many with complex needs, were also fairly engaged in the program. The median number of contacts was 9 and the mean was 12.9. Reasons for varied engagement need to be further studied and could reflect the continuum of needs across the autism spectrum, fluctuation in needs across the lifespan, participants’ satisfaction with the support received, or practical barriers to meeting more frequently. Given CAPS is a self-directed treatment service, variability in service use and service delivery is not uncommon. CAPS is intended to address geographical barriers by maximizing flexibility for meeting times and locations . Due to the COVID-19 pandemic, CAPS contacts with participants were predominantly virtual beginning in March 2020. The modality of service delivery should be examined in the future. Research on the use of telehealth among autistic individuals has primarily been limited to children and to diagnostic and assessment services  program participants would recommend this program to a friend or a family member, which is very high, but did fall below our desired benchmark . Unfortunately, due to a lack of qualitative data, we could not determine the specific reasons given by a few participants for not recommending participating in CAPS. Future research should consider a mixed-method approach to further explore potential weaknesses and strengths of the program. Responses to questions about cultural sensitivity or ethnic background were also below the desired satisfaction levels . The establishment of CAPS was at all phases proactive in seeking to engage diverse groups, which is a departure from most autism intervention research conducted with less heterogenous groups  and peer specialists (n = 4) that completed measures at the 3-month timepoint. To date, CAPS has included only one participant with an intellectual disability, and it does not provide tailored services for non-speaking individuals or those who use non-traditional communication methods. In alignment with the recent call to action around including individuals with the highest support needs Below is the link to the electronic supplementary material.


Repeat firing produces uncertainty about stabilizing lithium disilicate glass-ceramic (LDGC) material properties, even though prolonged holding time can enhance the mechanical property of LDGC during a single firing cycle. However, the effect of prolonged holding time and repeat firing on the mechanical property and microstructure of LDGC is not fully understood. In the present study, three groups of LDGC material were created: (i) extension of holding time (7 vs. 14 vs. 28 min) at 780–800 °C; (ii) holding time extension (7 vs. 14 min) and dual sintering at 800–820 °C, respectively; (iii) dual sintering with prolonged holding time (7 vs. 14 min) at 820–840 °C. The nano-indenter test revealed that prolonged holding time (14 and 28 min) promoted the enhancement of LDGC hardness and Young’s modulus. X-ray photoelectron spectroscopy, X-ray diffraction and Fourier transform infrared spectroscopy confirmed that prolonged holding time increased and stabilized LD phase in LDGC, as well as induced residual compressive stress. Scanning electron microscopy showed that prolonged holding time increased LD crystal grains homogeneously and facilitated LDGC to form dense interlocking structure without enlarging crystal size grains significantly. In contrast, LDGC that dual sintered alone at 820–840 °C possessed inferior mechanical properties, coupled with heterogeneous crystal phases, residual tensile stress, and melted crystals grains in the porous microstructure. Interestingly, these deteriorated properties of LDGC caused by dual sintering alone could be counteracted by prolonging the holding time. Nevertheless, the LDGC materials displayed an excellent biocompatibility throughout the study. This study identified that prolonged holding time during repeated firing cycles stabilized LD phase and crystal grain size of LDGC, thus enhanced the mechanical properties, which provided a new insight to extend the repeat fired restoration longevity of LDGC. The inception of “digital dentistry” and advances in computer-aided design (CAD) and computer-aided manufacturing technology has revolutionized dentistry. Lithium disilicate glass ceramic (LDGC) material was introduced to maximize the quality and efficiency of prostheses manufacture, and showed exceptional mechanical and esthetic properties , 2. HoweFor LDGC materials, the conventional wisdom is that excellent mechanical properties match “ideal” microstructures which have been formed by “interlocked” lithium disilicate (LD) grains, and show the best balance of the conflicting effects of crystallinity degree, grain size, and residual stress . To achi2-bearing LDGC materials fabricated by pressure-less sintering and spark plasma sintering, and minor alterations of chemical bonds were identified by Fourier transform infrared (FTIR) spectroscopy [According to literatures, X-ray diffraction (XRD) shows good sensitivity for identifying phase transformations , 9. Howetroscopy . These sWith these premises in mind, we investigated the effect of the holding time, and dual sintering on the mechanical properties and corresponding phase transformation of an LDGC block. Nanoindentation, XRD, XPS, FTIR spectroscopy, and field emission scanning electron microscopy (FESEM) were employed concomitantly to investigate the mechanical properties and microstructure in detail, the biocompatibility of LDGC materials with different treatments were evaluated as well. In this way, information on the heating schedule could be used to optimize the mechanical properties of LDGC prostheses for dental application.3) by a liner precision saw . Then, they were polished gradually by silicon-carbide paper of 600-, 800-, 1000-, 1200-, 1500- and 2000 girt  under running water at 500 rpm on a polishing machine . Then, the specimens were rinsed with deionized water  and stored dry before processing and tests.Commercially available dental-grade LDGC blocks  were machined into slides  of 20 mN, which was followed by a pause time of 2 s. Hardness and Young’s modulus were calculated from the unloading segment of the load–displacement curve using the Oliver–Pharr method [Nanoindentation testing was used to assess the Young’s modulus and hardness of the material. Load-controlled nanoindentation measurements were undertaken by a Nano Hardness Tester (NHT) nanoindenter . A diamond Berkovich pyramidal tip was employed for all measurements under a trapezoidal loading function, and was calibrated using a fused silica standard. The constant loading rate and constant unloading rate were 40 mN/min, and the corresponding time was 30 s, respectively. The material was indented with a maximum load  with monochromatic Al Kα (1486.6 eV) irradiation was employed for XPS. Spectra were calibrated using the C 1 s (284.6 eV) peak of the hydrocarbon remaining in the XPS analysis chamber as a contaminant. All 10 slices of each group were analyzed randomly in five regions. Removal of the Shirley background was followed by element identification and processing of peak deconvolutions using Multipak V6.1 A  and XPSPEAK 41 . The full width at half-maximum for peak deconvolution was kept constant in 1.6 eV for Si2p. The Lorentzian–Gaussian ratio was fixed at 80%.https://www.icdd.com/mdi-jade/) as well for the reference data to enable interpretation of the XRD patterns obtained from Joint Committee on Powder Diffraction Standards (JCPDS) patterns. Residual stress measurements were conducted by PANalytical X-Pert Pro materials research diffraction (MRD) system  using Cu Kα X-rays with a wavelength of 1.56 Å in a 2θ range of 68–72°. The lattice spacing was measured in 6Ψ tilts . The calculations were performed using “X’Pert Stress 1.1a” XRD software module.Slices were placed in the holder of an XRD system  and scanned using Cu Kα X-rays with a step size of 0.02° in a 2θ range of 10–90°. Phase development analyses were undertaken by Jade 6  with an attenuated total reflectance accessory in the range 400–4000 cmLDGC samples were etched with hydrofluoric acid (5 vol%) for 3 min and then rinsed with deionized water. Slices were coated with platinum and examined by FESEM using a S4800 system  operating at 10 kV for microstructural observation.4 cells per well and cultured for 2 and 5 days. The α-MEM  supplemented with 10% FBS  was refreshed every 2 days. A cell proliferation colorimetric assay was conducted with the Cell Counting Kit-8  for 2 and 5 days, according to the manufacturer’s instructions. After 2 h reaction, 100 µl of the above medium containing CCK-8 solution was transferred into a 96 well cell culturing plate. Optical absorbance of reaction solution was recorded using a plate reader  equipped with a 450 nm filter.A preosteoblast MC3T3-E1 cell line was obtained from the Cell Resource Center, Peking Union Medical College . MC3T3-E1 cells were seeded on the sterile LDGC discs in a 12-well cell culture plate at a density of 5 × 10LDGC samples cultured with MC3T3-E1 cells for 5 days were fixed in 2.5% glutaraldehyde and 1.5% paraformaldehyde at 4 °C for 1 h. The specimens were then dehydrated in ascending grades of ethanol and tertiary butanol. After drying with 100% tertiary butanol, specimens were coated with sputtered gold for further SEM  analysis.q (SNK-q) tests were done for multiple comparisons at a significance level of p = 0.05.Data were analyzed with SPSS 22 . One-way analysis of variance followed by Student–Newman–Keuls-Figure 2 and pre-crystallized LM, in which silicon was bound to two oxygen atoms [2 crystals were signatures of Si4+, in which silicon can connect to four oxygen atoms [The narrow-scan XPS spectrum of the Si2p region in each group was decomposed into three contributions . The average residual stresses were displayed in Table Phases of LDGC samples were qualitatively determined by XRD Fig. . The maj−1 were attributed to LM [−1 are intrinsic for LD [−1 was assigned to vibration of pyro-silicates (Si2O7)6− as Q1 [−1 was caused by the vibration of SiO2 [−1 was related to Li3PO4 [3PO4 phases were detected in the non-fired, 780–800 °C, 780–800 °C (H14), 800–820 °C, 800–820 °C (H14), and 820–840 °C (D) groups. The characteristic peaks of LD were the primary components in the 780–800 °C (H28), 800–820 °C (D), 820–840 °C, and 820–840 °C (H14/D) groups. A prolonged holding time promoted the generation of the LD phase at 780–800 °C and showed stabilized effect on the LD phase at 820–840 °C during dual sintering. LD could be generated by dual sintering at a temperature below 820 °C but lose its phase stability when the LDGC was dual sintered above 840 °C, thus multiple crystal phases could be identified in 820–840 °C (D) group.As a supplement, the FTIR spectra of LDGC block exhibited various features which suggested that temperature, the holding time, and dual sintering could contribute to alterations in Si-related components Fig. . Bands ned to LM , 18. Peac for LD –19. The 6− as Q1 . The kin of SiO2 . The fluo Li3PO4 . GeneralBefore firing, the fine crystal grains were compressed to form a dense structure Fig. , “platelConsistent with the SEM results, XPS, XRD and FTIR also highlighted that the LD phase was the predominant component in LDGC when the holding time was prolonged enough below 800 °C, showing corresponding characteristic spectra Figs. . Dual siAs shown in Fig. We demonstrated that dual sintering and holding time had a significant impact on regulating the mechanical properties and microstructure of LDGC material, and the alterations could be regulated by the temperature as well. Little negative impacts on biocompatible stability of LDGC material emanated from the fluctuation of these heating parameters. The corresponding alterations in mechanical properties were highly relevant to microstructure evolution, including surficial chemical alteration, crystal phases, residual stress and morphology.The way that LD crystals strengthen the glass-ceramic is thought to aid the formation of an interlocking structure with rational crystal size and shape of LD . Well-siStudies have shown that increasing the number of firing cycles adversely affects the mechanical properties of LDGC materials , 24. Tho−1 peaks upon extension of the holding time, as shown in 780–800 °C (H28) group  and 800–820 °C (D), even though the crystal phase and microstructure in both groups were close to 820–840 °C group. These results appeared to be in good agreement with previous studies. Heat treatment at a low temperature resulted in multi-phase crystallization for Liretained . The hetretained , 32. Cryretained , 25, 26.In summary Fig. An interlocking structure with homogeneity of crystal phase and size facilitated the strengthening of mechanical properties of LDGC material. Dual sintering alone at 840 °C caused adverse alterations in the microstructure and crystal phase of LDGC, as well as transferred residual stress from compression to tension, resulting in inferior mechanical properties of materials. A prolonged holding time promoted the crystallization and stability of LD crystal grains without increasing the grain size significantly, and showed an antagonistic effect to the mechanical-property weakening of the LDGC material caused by dual sintering alone at 840 °C. For extending the restoration longevity of LDGC, prolongation of the holding time at the second stage of a standard firing cycle could be considered when dual sintering is inevitable or predictable.


The COVID-19 pandemic has caused a great deal of mortality and morbidity worldwide with 431.5 million cases and 5.9 million deaths as of February 25, 2022 [In Somalia, the United Nations Children’s Fund (UNICEF) implemented the Somali Health and Nutrition Programme (SHINE) from October 2019 to March 2022 as one of the three organizations to manage funding from the UK Government . The maiThe total SHINE program funding from the UK Government was reduced by 30% from GBP 20 million (approximately US$25.6 million) in 2020 to GBP 14 million (approximately US$19.18 million) in 2021, which compelled the SHINE program to revise its geographic and programmatic scope. UNICEF closely worked with the UK Government and the other fund managers to complete the SHINE program transition and identified many lessons to inform future program planning. The aim of this field note is 2-fold: 1) to summarize the practical steps that UNICEF followed to reduce the scope of a multi-year health program with reduced financial resources, and 2) to describe lessons learned from the SHINE program transition to inform how humanitarian and development programs may adapt to the COVID-19 induced economic environment.The first step for the SHINE program transition was to reduce program coverage in phases with available financial resources. In early 2020, the UK Government communicated with three fund managing organizations – Mott MacDonald (Mott), Population Services International (PSI), and UNICEF – regarding the phased reduction of SHINE program funding in 2021. The UK Government also announced that UNICEF would be the only fund managing organization from July 2021 to complete this multi-year program in September 2021. Based on these announcements and available financial resources, UNICEF implemented SHINE program activities through 95 service delivery points  from October 2019 to June 2020, 86 service delivery points  from July 2020 to March 2021, and 50 service delivery points  from April to June 2021.The second step was to consolidate SHINE-supported health facilities by three fund managers, review program data, financial resources, and supply availability, and determine the revised SHINE program coverage from July 2021. The SHINE program coverage was reviewed and adjusted in accordance with the following guiding principles: 1) achieving the optimal health outcomes possible with available funds; 2) standardizing program activities; 3) minimizing the risk of duplicative efforts with other donors and partners; 4) maintaining the operational presence in the current SHINE-supported districts; 5) keeping the existing partners; and 6) continuing the essential package of health services (EPHS) at health facilities; 7) maintaining basic emergency obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care (CEmONC) in designated health facilities; and 8) providing the same level of program supervision as before.Using these guiding principles, Ministries of Health, the UK Government, three fund managing organizations, and implementing partners reviewed the health service utilization data to assess the performance of health facilities in service provision, geographic locations of SHINE-supported health facilities, historical contexts of program locations, and available funding per implementing partner. A list of factors considered to identify priority health facilities for the updated SHINE program are presented in Facility-level data were retrieved from the District Health Information System 2 (DHIS2) for the period from January 2020 to March 2021. The criteria for identifying low-performing health facilities were the following: 1) less than 10 outpatient department (OPD) consultations per day for health centers and hospitals or 3 consultations per day for primary health units; 2) less than 3 vaccinations per day; 3) less than 3 antenatal care (ANC) consultations per day; or 4) less than 6 deliveries with skilled birth attendance per day. Additionally, UNICEF estimated the average number of consultations or services provided per health staff . Based on the health service utilization analysis, geographic factors, and financial factors, UNICEF and implementing partners determined priority health facilities and retained them for the revised SHINE program. Overall, the total number of SHINE service delivery points decreased from 267  by three fund managers in June 2021 to 192  by UNICEF from July 2021.The third step was to prepare program documents  with implementing partners. While the initial plan was to continue the SHINE program only up to September 2021, UNICEF prepared the program documents with the implementation period up to March 2022 in anticipation of the SHINE program extension. Each program document indicated that the program implementation beyond September 2021 was subject to the availability of funding. As the only fund manager, UNICEF activated program partnerships with six non-government organizations (NGOs) with this funding condition. The SHINE program was later extended up to March 2021 with some additional funding from the UK Government, and UNICEF also mobilized other financial resources to maintain the same condensed program level from July 2021 to March 2022.The process of SHINE program transition generated several lessons. First, revising the scope of a large development program may require a great deal of time from donors, fund managers, and implementing partners. The SHINE program transition took nine-month-long coordination, data review, and program partnership development among key stakeholders to implement activities with a revised scope. When existing development programs need to modify the financial and programmatic scope due to reduced funding availability, adequate planning time may need to be allocated in preparation for the anticipated changes. Second, development programs with uncertain funding availability may set a flexible program implementation period. UNICEF activated program partnerships with implementing partners for nine months without a firm confirmation of additional funding from the UK Government. This approach contributed to minimizing the risk of program implementation gaps from the time-intensive partnership amendment or extension process. Future development programs may consider activating partnerships with implementing partners with a buffer implementation period with a note that the program continuation is subject to the availability of funding. Third, the sustainability of development programs remains in question in Somalia. The SHINE program transition highlighted that the cessation of funding may stop essential quality health service provision in many health facilities where the government budget cannot cover supply and personnel costs.This field note summarized the three major steps followed by UNICEF to revise the financial and programmatic scope of a major health program in Somalia and highlighted key lessons learned. In the era of reduced funding availability for development programs, allocating adequate time for the transition process, ensuring flexible program arrangements, and using data and contextual information to inform the decision-making process are vital. A key recommendation for the future is to consolidate available resources and implement multi-sectoral and multi-year interventions to respond to the needs of vulnerable populations on health, nutrition, water, sanitation, and hygiene (WASH) and other humanitarian assistance. By overcoming siloed approaches, development interventions may maintain a major impact even with reduced funding availability.


Fibromyalgia syndrome (FMS) disrupts patients’ biopsychosocial spheres. A multicomponent intervention (MCI) program, which combined health education, cognitive behavioral therapy, and physical activity, was conducted in South Catalonia’s primary care centers with the aim of improving symptom self-management and quality of life. A qualitative interview study was carried out to understand patients’ lived experiences during the intervention program. Sampled purposively, 10 patients were interviewed via phone calls and face-to-face. The encounters were audio-recorded, verbatim transcribed, and analyzed through thematic analysis. As a result, four themes emerged: legitimizing fibromyalgia through the MCI, the MCI as a socializing experience, learning how to live with FMS through the MCI, and room for improving the MCI. Participants agreed on the program being an insightful experience that promoted illness knowledge and acceptance and that improved their coping skills and symptom self-management. The inclusion of additional psychological guidance, expressive psychological group therapy, and providing relatives with information were proposed for enhancing the program. Our findings have contributed to gaining insight into the subjective impact of the MCI and identifying new therapeutic targets to tailor the program to patients’ needs, which will hopefully increase its effectiveness and improve their quality of life. Fibromyalgia syndrome (FMS) is a chronic condition that impacts patients in multiple directions. It compromises their personal, social, working performance, and quality of life (QOL) and potentially leads to mental health problems and disability ,2. Its cThe burden on society seems undeniable in terms of healthcare services and productivity losses . Being cExisting research indicates that poor perception of illness, including perceiving a fluctuating and unpredictable illness course and a low emotional representation of FMS, which means not connecting emotionally with one’s health condition, is associated with higher medical costs . TherefoIn the literature on FMS illness experience, the most prevalent themes include the inauthenticity of the syndrome and the uncertainty about its prognosis, identity and family disruptions, distress, social stigma, pain management, illness acceptance, and alternative healthcare approaches ,22,23,24While there has been a great deal of research on FMS patients’ illness narratives, to the best of our knowledge, very few studies have been designed to assess FMS interventions implementing the qualitative methodology ,26. ReleAccording to international guidelines and reviews, multicomponent interventions (MCI) based on physical activity, cognitive behavioral therapy (CBT), health education, and pharmacotherapy are beneficial to addressing FMS ,29,30. AInitiatives for delivering interdisciplinary healthcare in Catalonia’s primary care sector (Spain) have been operating since 2016 . CurrentOur study aims to understand the structure and meanings of patients’ lived experiences during the proposed MCI program and to explore its subjective insight. Specifically, this study plans to identify informers’ overall perception of benefits from the MCI; to detect the extent to which the informers implement the coping strategies delivered during the program in their daily lives; and to explore to what degree this experience may have influenced informers’ psychological, physical, and social spheres and contributed to personal growth. Additionally, we aim to detect improvement aspects of the program according to participants’ views.The results will be helpful to adapt the intervention according to patients’ appraisals in order to reinforce its benefits. Furthermore, this study is expected to complement the quantitative results of the randomized controlled trial (RCT) linked to this MCI   and the The design of this work involves a qualitative interview study through thematic analysis .The MCI program includes a 12-week/2-h session group-based interdisciplinary program in addition to the usual clinical care (UCC). The latest is delivered cost-free by the public health system and is generally based on the screening of a general practitioner, the delivery of general information about the syndrome and coping strategies, and the prescription of symptom-control medication. Nonetheless, there is a health care gap in the provision of additional therapies that could complement the pharmacological treatment for FMS management. For this reason, the proposed program combines health education, physical exercise and CBT. It covers topics such as the neurophysiology and pharmacology of pain, postural hygiene, nutrition, insomnia management, memory, sexuality, breathing and relaxation techniques, stretching, coordination exercises and pain, attention, and emotional management. Participants were encouraged to practice what they learned during the sessions, such as walking for 6 to 20 min, at home. However, private practice was not formally registered. The healthcare team comprised female staff including a general practitioner, a physiotherapist, a psychologist, and each health center’s head nurse who delivered the sessions in the primary care centers. Further details of the intervention program can be found in the study protocols ,40 and AThe study sample includes 5 out of 11 primary care centers from the GTTE, south Catalonia, Spain. The MCI groups included in the sample consisted of between 9 and 18 participants. The informers were recruited through purposive heterogeneous sampling to achieve maximum discursive variability based on sociodemographic features  obtained from the regional digital medical history system for primary care (eCAP).All participants of the MCI program had a clinical diagnosis of FMS , were adults, had oral and writing skills in Spanish and/or Catalan, and had a phone contact number. Additionally, the inclusion criteria to participate in this qualitative study involved a minimum of 75% session attendance to the program , up to 12 months since receiving the MCI to avoid memory bias, voluntary participation in the study, and written informed consent. Accordingly, the recruitment process and the sample reached were impacted by informers’ availability within the study, as described in The recruitment was carried out via phone calls in June 2020, one week earlier than the interview. In order to prevent absenteeism, a reminder text message was delivered the previous day of the meeting. In addition, participants were provided with relevant information about the study’s aim, the interview, and the data protection protocol.A total of 10 in-depth interviews were conducted to explore patients’ experiences during the MCI program with a mean duration of 30 minCAP Baix Ebre de Tortosa) and six were conducted over telephone due to the COVID-19 pandemic recommendations. The first author (V.M.A.) was the sole interviewer and had no previous contact with the informers before the recruitment process. Only interviewer and interviewee were present during the discussion. The interviewer has an academic background in clinical psychotherapy (BMT) and public health (MPH), with previous experience in qualitative methods, and is currently working towards a PhD in biomedical research.The interviews were scheduled according to participants’ availability. Four of them were conducted face-to-face in the same primary care center  and a mean of 11 years with a diagnosis of FMS . In terms of its impact, the scores obtained at baseline from the Revised Fibromyalgia Impact Questionnaire (FIQR)  and the , max 73 As a result of the thematic analysis, four themes were identified from the data, as shown in According to our informers, the MCI legitimized FMS by validating patients’ illness accounts. Patients reported a sense of being cared about given the provided health education, psychological guidance, professional support, and continuous follow-up. As detected, the invalidation process linked to FMS diagnosis is experienced by patients both physically, due to the lack of medical evidence, and socially, due to the lack of social acknowledgement as a real health issue.In this regard, informers described hopelessness when their proprioceptive experience is overlooked by the biomedical field and the social network. Further discernment revealed how patients could have undergone emotional dejection, confusion, and doubts regarding their suffering, which led to a nihilistic attitude towards themselves and the healthcare services. While existing treatment strategies are essentially based on pharmacological symptom control and lifestyle changes, patients may not be willing to make any effort if they do not perceive their condition as a real and frequent health problem that requires being addressed to improve functionality and QOL and to prevent future complications. As the following quotes show, interviewees suggested that the proposed MCI contributed to providing clinical value to FMS and its patients, which encouraged them to adopt an active role in their health process:“The program represents the tranquility of having a point of reference. I used to think it was just my imagination or that I was a complaining person. However, it turns out that it is much more complex than that.”(P5)“This experience helped me to show all those people who did not believe me that I was not lying.”(P9)While there is no medical evidence for supporting FMS, it has been detected that peers’ illness experiences provide living testimony to support this health condition. Hence, the significant other seems to play a key role in making sense of one’s health experience and promoting the sense of belonging to a group. Indeed, this biomedical identification process may have facilitated FMS legitimization in the explored sample. We discovered throughout the informers’ accounts that when the different spheres of signification or influence in which they live  fail to provide meaning to their health experience, social identity groups offer a socially constructed answer and a sense of being understood. The quote below explains how the patient emotionally struggles when her health experience conflicts with the social and medical perception of FMS, and how the MCI program contributed to it be apprehensible in a context of social validation:“As this disease is not evident externally, only the person who has it can understand it. It affects you to the point that you cannot move, you do not want to talk, you do not even want to think. It has killed me, indeed. It is very frustrating as it is not reflected anywhere, neither in an analysis, resonance, or image. However, discussing with people who are going through the same thing, make you feel not so weird and shamed. Because this disease is incomprehensible. The program has helped me understand that I am not the only person who is going through it.”(P3)Our interviewees acknowledged the benefits of the group setting leading to new encounters, identification processes, and social networks. Isolation was reported as one of the main consequences of FMS. As informed, patients tend to avoid social contact in order to save explanations on their health progression, changes in their physical performance, and feelings of shame and guilt. The group modality of the MCI offered them the opportunity to create new social networking with people diagnosed alike and who were facing similar challenges. In this regard, finding support from peers emerged as a psychological facilitator for the informers. One of the major strengths of the program transcended the sessions’ setting:“A very warm bond was born between the participants of the program. Having the opportunity to talk, exchange experiences, and obtain new information blessed me with relief.”(P6)“We have made very good friendships with people who suffer the same condition, and we are very fond of each other. We have had phone calls; we have met; we encourage one another daily. We know that we are there for each other and that we are not alone. Finally, someone understands and cares about us.”(P9)Additionally, the program has contributed beyond the intra-group relationships. The group effect was found to benefit patients’ self-confidence in social contexts as well as their social initiative. Analytically, as peers become significant others, patients’ self-worth grows and their social performance anxiety and low social perception decrease. Consequently, informers recovered the strength to re-connect with their social environment, which no longer seemed as frightening as before:“Socially, this experience (the MCI program) has also been beneficial since I no longer feel that I need to justify myself when I cannot do something. Now I relate with others differently because I feel more secure about my illness.”(P5)“The program has also helped us to be more sociable in general.”(P6)“Before the intervention, I was closed in on myself. There was a time when I practically did not relate to anyone.”(P9)Informers reported being poorly supported by family members, particularly by male partners. Patients revealed how their closest discredited FMS. Their need for regular breaks, rescheduling home and work routines, reducing and adapting physical activities, and avoiding intimacy, among others, were frequently taken with hesitancy and intolerance. Informers described this situation as their biggest burden and requested professional help to address it. As portrayed, experiencing one’s health needs being neglected entails a de-subjectivizing process, which impacts both the patient’s well-being and the relationship involved.Reflecting on these findings, the group effect could have found its ground in the limited family support, whereas peers fill the gap in social understanding. Moreover, given the high prevalence of FMS among women, patients might find more frequent empathy among female peers, a pattern that could have been reinforced by the fact that the MCI program was delivered entirely by female staff.The following quotes illustrate how FMS challenges the popular beliefs about health and disease within the household context and confronts patients with their partners' denial:“The only problem I have is that my partner does not understand it… Let’s see He does understand it, but sometimes he tells me “Well, that’s nothing.” He does not quite assimilate it yet.”(P4)“I have had a horrible time with this disease because nobody understood me, nobody knew what it was. My husband, for instance, is a person who has never understood it and does not want to; he does not want to believe that I am sick. Since he has cancer, my pain is irrelevant compared to his. And he cannot accept that I am not who I was anymore.”(P9)On the other hand, the group setting was also found to be a barrier to personal change. One of the participants who hid behind the group as a shield and due to feeling overwhelmed by other members’ experiences disclosed:“In the groups, for example, I always take the role of the funny guy. It is my shield. I am not that expressive. However, this experience was helpful to find out that there are many people in worse conditions than me. In this sense, I realized that I am not handling it as bad as I thought. Anyway, there were too many people in the group; too many problems to share; too many mouths to talk; too many thoughts to be said. It is complicated.”(P1)Likewise, social comparison processes were detected throughout the informers’ narratives, with a downward contrast. Informers reported gaining perspectives on their health situations in light of hearing about peers in a worse condition. In this line, a feeling of pity towards those peers emerged from their narratives, which helps them to cope with moments of discomfort:“My mood has improved since I had the opportunity to interact with people who experience the same condition as me or even more seriously. I feel sorry for them.”(P4)“Many times, you feel bad, but maybe next to you there is another person who is feeling worse than you. And then you think: ‘well, maybe my situation is not so terrible’. And this strengthens you and gives you a little more encouragement.”(P8)Participants’ accounts indicated that the MCI facilitated an unmasking and unveiling of their suffering for both themselves and others, a bridge between appearance and reality, and the promotion of understanding and self-acceptance. FMS is an invisible condition that confronts patients’ illness experiences against its social perception. However, supporting FMS legitimacy encouraged patients to open up about their vulnerability, limits, health needs, and emotions. As inferred, learning how to live with FMS includes accepting the condition and facing it beyond social roles and expectations:“‘Have they called you again?’ He asked, surprised. Since I have to act as Mrs. Strength, it looks like I am not that wounded. Right? But what the program does is show my suffering face. To give it a face […]. It is useful to make the rest of the world realize that something is happening to you. Now I can prove that something else is going on here. From my viewpoint, the experience of the program has been very positive.”(P1)“For many years I had had a terrible time with this disease. I did not talk to people. I used to not say what hurt me because everyone could be in pain except me. So, I learned not to say anything. But then, being surrounded by people in the same situation, opened the doors to a world where there were people like me.”(P9)Informers revealed having developed new coping skills and a healthier attitude toward FMS, which help them to overcome symptoms, stigma, and uncertainty about the prognosis. Patients gaining insight into their health processes were highlighted as part of the educational benefits of the MCI. In this vein, learning about FMS and coping techniques was highly regarded for symptom self-management. Reflectively, even though widespread pain seems to be still a challenge, adopting new perspectives in FMS may have moved patients beyond the persistent symptomatology and toward acceptance and change. Informers remarked having reduced medication intake; controlled emotional distress; implemented new coping strategies such as physical activity, nutrition, relaxation, and anxiety-control techniques; and adapted their daily activities and exercises to their capabilities. Furthermore, informers stressed the importance of daily exercising; maintaining a routine; following psychological and physical guidelines; or simply but not less important, giving patients something to engage in:“If I was able to quit the anxiolytics and reduce the panic attacks, it means that the program works.”(P4)“I was diagnosed when I was thirty years old, and I practically had to give up my entire life. I lost many friends along the way, and it has been very hard. In the program, I learned how to live with Fibromyalgia. Even though I still have pain, I don’t break down or cry like I used to anymore.”(P9)“I notice that even though the exercises we learned with the physiotherapist are quite simple, they make a difference if practicing regularly […]. In this sense, it has been very helpful to have received guidance to know what is particularly useful for us. The nutritional session was also interesting. I have noticed that when eating healthy, I have less muscular pain. Designing a schedule with the psychologist was also very helpful in my view since it encouraged me to keep going and have better track of my progress.”(P5)The MCI successfully promoted participants’ self-awareness, allowing them to acknowledge their physical and psychological needs. As understood, gaining insights into their health condition could have helped the participants to assess their symptoms and possibilities more accurately, to avoid under or overestimating their ailment, and to prioritize themselves. The following quote depicts to what extent FMS patients can experience bodily dissociation as a mechanism to cope with physical pain:“The program promotes awakening consciousness. For instance, I was not aware that I had so little resistance training capacity […]. Or sometimes, I did not even notice the tachycardias. I have also noticed that my sight is getting worse. Now I understand that I need more time for myself. I remember once when I went for a nail job, and the manicurist did not stop hitting my hands. I was not understanding why he was doing that until I realized that he just wanted me to relax my hands. I was completely unaware of the amount of tension in my hands.”(P1)“Thanks to the program, I have incorporated self-awareness. Particularly, I have learned to focus on positive aspects. It has been a valuable experience to me.”(P2)Furthermore, reflecting on the informers’ narratives revealed an improvement in their subjective embodiment, which entails connecting their symptoms to their emotional status. Approaching FMS as a complex chronic condition emerged as a key to symptom self-management. In this regard, the proposed MCI aims to address patients suffering holistically including physical, psychological, and social well-being. The metaphor of the fish chasing its tail described in the quote below illustrates the complexity that FMS patients face daily:“It is the story of the fish chasing its tail. Although we have learned physical techniques, our pain is also related to our emotions. Because in the end, the body retains everything. It is mainly Psychological. In my case, I have an unsolved  knot. But it refuses to be solved, and I can prove it with my weight raise.”(P1)Informers’ accounts revealed that the intervention program helped them to increase their autonomy by promoting physical and psychological independence. As experienced by the participants, FMS limits their basic daily activities regarding going out or commuting due to fear of physical impediments and social judgment. Recovering the strength and the courage to face daily life has been interpreted as a valuable experience:“The MCI encouraged me to be more independent. Before participating in the program, I could not go out alone since I was afraid of falling due to vertigo. I used to panic outdoors. But during the program, I discovered that I was not afraid of falling but of what people could think when they saw me walking with instability. I was ashamed of myself and felt limited. Now, I go everywhere by myself; I no longer care what others think or say.”(P4)“I live 12 km from the town where the program took place, and instead of asking my husband to drive me, I preferred to take the bus by myself. Despite my limitations, I used to get on and off the bus following the professionals’ advice about being proactive and increasing physical activity.”(P7)FMS was described as a life disruptor that leads to patients abandoning their life projects and losing enthusiasm. In this regard, the MCI program proved to provide patients with a sense of purpose and motivation to carry out new plans. Informers shared their experiences on taking new courses, keeping busy, and exercising daily:“I was feeling overwhelmed because I could not do anything. But one day the psychologist asked me what I would like to do. And I explained to her that I have always liked languages, but life circumstances had not been in my favor. Anyway, she encouraged me to try it out. Now I study English at a local academy, and I am doing great.”(P4)“The professionals encouraged us to keep our minds occupied with other things. For instance, I have signed up for an online course. Being partially disabled and not working, I have more free time to do other things.”(P5)Informers expressed satisfaction with the experience of the program as a whole and willingness to recommend it. However, they suggested some key points for improvement including more psychological guidance, expressive group therapy, and inviting family members to the sessions to help them to understand the diagnosis and its consequences:“I would have needed more psychological guidance and strategies. Especially to improve attention and relaxation. For instance, I practise creative meditation through drawing and music in my spare time. It would be interesting to include something like this in the program […]. Besides, some people also needed to talk about family and personal problems because they probably have no other place to do so.”(P1)“The staff insisted that the program was not a psychotherapy group. That was crystal clear. But it would have been nice to have a little space for sharing worries in life. They cut us short in this sense.”(P2)“The professionals had so little time that they had to explain everything very quickly, and there was no time for letting us express a little more about how we felt about the topic that was being discussed.”(P3)“I need someone to explain to my husband, to make him understand what I have because he doesn’t. That’s why it would help if at least one day we could invite our couples to the session. I would sign up right away for that because this is my biggest burden. I would add a bit of therapy so that people could express themselves. what I missed is exactly this, to be able to talk a little more between us.”(P4)In this qualitative study, four themes emerged when analyzing FMS patients’ experiences during the MCI program: legitimizing fibromyalgia through the MCI, the MCI as a socializing experience, learning how to live with FMS through the MCI, and room for improving the MCI. Overall, the MCI program was valued unanimously as a positive and insightful experience that should continue as part of the UCC. Another common denominator was the benefits of the social encounter with people with the same diagnosis who could truly understand their suffering without judging them.Our results provide insights into the role of social support in legitimizing FMS. As Cooper S. and Gilvert L.  have disOur informers showed a tendency to compare themselves with their peers. According to Festinger’s social comparison theory (SC) , humans Notably, our informers tended to make a downward contrast with their peers, which helped them to relativize their health condition in contrast to others perceived as equals (since they have the same diagnosis) but worse off and, consequently, allegedly different. Even though this phenomenon could temporarily improve self-esteem, it may redefine patients’ perception of well-being and promote remaining in conformity not visualizing their health needs. Hence, if SC is not skillfully monitored by healthcare professionals, the group effect could be iatrogenic. As a double-sided coin, group interventions can bring social support and belonging, facilitating patients’ health processes, but could also be used as a way to resist change by externalizing one’s health needs to others. Accordingly, the evidence shows that frequent SC can trigger destructive emotions and behaviors . FurtherThe proposed MCI proved to be a socializing experience for its participants. Nevertheless, preventing the drawbacks of a group setting is particularly important considering the high prevalence of alexithymia among FMS patients, which is characterized by difficulty in recognizing and expressing feelings, and it is correlated to psychological distress ,54. ContAccording to our results, health-related guilt emerged among the FMS patients’ accounts and lack of illness legitimacy was indicated as the reason behind it. Sebic et al.  found thFrom a gender perspective, guilt is women’s historically inherited burden related to the patriarchal social order . Guilt cOn the other hand, this sex bias may also affect men by being underdiagnosed which delays assessing the peculiarities of FMS in this population and its best treatment approach ,66. Studpatients must be encouraged to continue working”, since evidence suggests that FMS patients who do not leave their jobs show a promising prognosis. In addition, a recent review proposes that healthcare providers support employers with guidance about workplace accommodation [The gender bias in medicine and its gap in comprehensively addressing women’s health needs triggers further consequences. For instance, Shahvisi  demonstrmodation .In light of the evidence, healthcare professionals and intervention programs should contemplate patients’ subjective reports about their illness experiences and circumstances from a psychological and gender approach ,76. In tThe literature recommends that working on a positive body image can improve pain perception ,78,79. IThe proposed MCI program is in line with the latest trend of multidisciplinary approaches for FMS treatment combining pharmacological and non-pharmacological strategies . Even thOur study follows the consolidated criteria for reporting qualitative research (COREQ)  in orderMethodologically, the reported findings result from a non-linear interpretation process that intends to summarize the “essence” of the informers’ accounts by means of themes that recover the embodied lived experiences in their narratives. In this regard, themes within the context of hermeneutic phenomenology attempt to overcome a superficial description of patterns in the text, which is particularly suitable for modest samples.Notwithstanding the sample size, efforts were made to obtain quality data and to analyze it with reflexivity and rigor. As a result, this study pretends to understand the impact and benefits of an MCI program on patients’ subjectivity from a critical thinking perspective.Regarding the limitations, and since the interviewee sample only included those with high assistance records and willingness to participate in the study, the results could have overestimated the benefits of the program. However, the interview schedule included questions concerning improvement aspects for the MCI and interpretations were focused on the unveiled effects of the program.Moreover, the sample did not include men as the only two possible candidates did not agree to be interviewed. Women’s FMS high prevalence contributed to a limited number of men within the MCI program. Moreover, the data collection process was conducted during the COVID-19 pandemic, which could have affected participation. Future projects should make efforts to recruit this population group. Additionally, the informers included belonged to only 5 out of 11 primary care centers of the health region owing to inclusion criteria requirements and sample availability. Nevertheless, since the MCI was performed the same in every center, we do not consider that this aspect could have impacted the results significantly.Regarding the data collection, due to the COVID-19 outbreak telephonic interviews had to be conducted in some cases. Therefore, the interviewer–interviewee relationship could have been more impersonal than face-to-face interviews since it was the first contact between the informant and the researcher. However, the interviewer provided relevant information about her background to the participants and encouraged a natural and fluent conversation, including follow-up questions and promoting meaningful exchanges, in order to reduce this potential limitation.In addition, even though the results were not delivered to the informers for review and feedback, an outside research group was consulted for further validation.Lastly, our findings may not be generalizable beyond the study sample. Nevertheless, the MCI program could be tailored and assessed in other contexts.Our study has contributed to gaining novel insight into FMS patients’ lived experiences during an MCI in primary care. Informers agreed on the program as a revealing, insightful, and motivating experience that has facilitated illness knowledge and acceptance and improved their coping skills and self-management in daily life. Furthermore, peer support was emphasized as a key benefit, beyond clinical outcomes, due to the sense of comprehension, bonding, and encouragement that remains active post-intervention as a positive social network. Gender awareness and empowerment have also been observed as remarkable results. In this regard, including gender diversity within the staff might help patients to deliver information to their partners. Moreover, complex psychological mechanisms were identified intra-group level, which the professionals should skillfully monitor and intervene. In addition, the inclusion of expressive psychological group therapy and inviting relatives to the sessions were claimed as improvement aspects of the program. Nonetheless, our findings warrant further discussion. Finally, these results will allow for adjusting the program to patients’ health needs to broaden its benefits and to support the UCC.