We describe the lessons learned in building nutrition capacity through the development and implementation of the first dietetics training program in Malawi. We developed the first-ever clinical dietetics program in Malawi to equip students with knowledge, attitudes, and skills in nutrition support, health promotion, and disease prevention at the community and health facility levels.We addressed challenges in curriculum implementation, lack of supervision, and lack of capacity-building resources by using unique approaches and building partnerships with existing programs and professionals.Building a dietitian workforce to serve the needs of the population requires a commitment to funding the program, building research capacity, and developing regulatory and practice guidelines. The current nutrition situation in Malawi, characterized by high rates of malnutrition in communities and hospitals and a rapidly increasing burden of overweight/obesity and diet-related noncommunicable diseases, highlights the urgent need for registered dietitians, who have a proven track record in the prevention and management of all forms of malnutrition and improving patient outcomes. However, dietetics practice has been described as underdeveloped and fragmented in many parts of Africa, exacerbated by a severe and chronic shortage of dietetics professionals and a lack of nutrition and dietetic education programs in most African countries.We share early lessons learned in the development and implementation of the first dietetics program in Malawi. Within 6 years, the program produced 10 graduate dietitians who have filled the first clinical dietitian posts in Malawian public hospitals. This early success can be attributed to the model used to develop and implement the program, which included early stakeholder engagement to define the priority skills and competencies of a Malawian dietitian, the use of internationally recognized training standards, and the development of strategic institutional partnerships that brought together complementary skills and expertise. Furthermore, using existing resources and recruiting students with a nutrition and health background accelerated implementation. The current dietetics curriculum responds to the national nutrition and health policy direction and strategic objectives. Early and sustained government engagement was crucial in creating demand and securing career prospects for graduates. Although still in its infancy, dietitians in Malawi are poised to contribute significantly to alleviating the country's complex nutrition challenges. More than 60% of African countries do not have academic programs for training dietitians and the “registered dietitian” title is not protected by law in many African countries.Despite a globally observed exponential growth in the dietetics profession, the dietitian's role remains underdeveloped and fragmented across Africa.Moreover, most nutrition professionals in Africa receive education and skills largely focused on public health and community nutrition. This nutritionist cadre is critical and has been at the forefront of combating undernutrition, which persists as a major contributor to morbidity and mortality in sub-Saharan Africa. However, management of malnutrition in clinical settings, whose etiologies and treatment are often specific to underlying disease processes, which is just as critical and requires strong integration of medicine and nutrition, is largely underdeveloped. Dietitians specialize in the integration of medical nutrition therapy in individualized patient management plans, while also being adept in working in community-based/public health interventions. Considering the need for developing the dietetics profession, we share the experience and lessons learned in developing and implementing the first dietetics training program in Malawi.,,,Malawi is a low-income country with a population of approximately 17 million people, 82% of whom are rural and have a national life expectancy of 61 years.Concurrently, Malawi's burden of undernutrition in communities remains high, with 37% of children aged under 5 years stunted and 12% underweight.,,Driven by unhealthy diets/lifestyles and overweight/obesity, NCDs are now the leading cause of death globally and show no signs of abating, especially in low and middle-income countries.Having access to adequate food for the promotion of good health and self-sufficiency is a human right and a central feature of key national documents, including the “National Multi-Sector Nutrition Policy 2018–2022” and its accompanying “National Multisector Nutrition Strategic Plan.”We outline the process to determine the need for the program along with discrete steps in the development and implementation of the program. We also identify lessons learned and future directions for the continued growth of dietetics training and the profession in Malawi.We conducted several scoping exercises aimed at understanding the context in Malawi and identifying resources available for running a quality dietetics training program. We identified institutional strengths to implement quality training and key stakeholders that included government officials, whose support was essential to implement the program and promote dietetics practice .In 2012, we undertook a needs assessment that highlighted the lack of dietitians in Malawi and determined gaps in the health care team that needed to be filled.We undertook a needs assessment that highlighted the lack of dietitians in Malawi and determined what gaps would be filled through the development of this cadre of health care workers.–,We reviewed the existing Bachelor of Science degree in nutrition and food science at Lilongwe University of Agriculture and Natural Resources (LUANAR) to determine areas where course content merged with the minimum requirements for dietetics and gaps that needed to be filled by the dietetics curriculum. The areas of convergence became the prerequisite requirements for entry into dietetics training . In someThe first Malawian clinical dietetics program was created in collaboration with LUANAR, the Feed the Future Innovation Lab for Nutrition based at Tufts University, and the Kamuzu University of Health Sciences (KUHeS) in Blantyre, Malawi . The Malawi Mission of the United States Agency for International Development  provided funding for the program.The program equips students with knowledge, attitudes, and skills in nutrition support, health promotion, and disease prevention at the community and health facility levels. During the first 12 months of didactic instruction, students take courses in biomedical sciences, medical nutrition therapy, human behavioral sciences, and research methods . In the Both the diploma and master's programs were approved by the LUANAR senate (as the host institution of the program), the Malawi Medical Council, and the National Council for Higher Education. In April 2016, the first cohort of 6 students was admitted; a second cohort of 10 students was admitted in 2018. At the time of writing this article, 10 students have completed all requirements for registration as dietitians. Of the 16 students in the first and second cohorts, 6 either failed to meet pass requirements or dropped out of the program before completion.Curriculum implementation relied heavily on leveraging the strengths of a strategic partnership between LUANAR, KUHeS, and Tufts University. As an agricultural university with a vibrant and nationally recognized department of human nutrition, LUANAR's expertise and postgraduate courses in food science, public health nutrition, and nutrition epidemiology were adapted to meet dietetics core competencies. Tufts University and KUHeS provided teaching support in core dietetics courses, medical nutrition therapy, nutrition counseling and behavior change, and nutritional biochemistry. Tufts provided technical leadership and ensured the benchmarking of the program to quality standards. KUHeS was also central in providing the platform and supervision for clinical practice.Considering the lack of dietetics expertise and supervision capacity in Malawi, we identified 2 positions, supervising dietitian and clinical coordinator, that were critical for the daily management of the program, teaching, and supervision. A content expert in clinical dietetics, the supervising dietitian had an advanced degree in dietetics and extensive clinical experience. The clinical coordinator, a Malawian trained medical doctor, brought medical expertise coupled with knowledge and experience on Malawian health care delivery.Considering the lack of dietetics expertise and supervision capacity in Malawi, we identified 2 positions, supervising dietitian and clinical coordinator, that were critical for the daily management of the program, teaching, and supervision.An evaluation of dietetics practical training needs against the available resources revealed the lack of adequate critical care nutrition resources . In light of this need, the University of Cape Town (UCT) hosted Malawian students for a 6-week exchange program in critical care and surgical nutrition support. The exchange program was critical in building capacity and fulfilling competencies in critical care nutrition support and surgery for the Malawian students, who would have otherwise not been exposed to these resources.,Approaches to providing adequate supervision focused on self-directed methods of learning, which included problem-based learning, peer supervision, and role emerging placements. Because of the lack of dietitians to shadow in Malawian hospitals, role emerging placements were particularly useful, and have gained global traction in allied health care professional training as a viable solution for balancing competing demands of providing quality practical training with limitations in supervisor coverage.While developing the program with various stakeholders, we encountered some barriers that included inadequate knowledge of dietitians' roles, lack of recognition, and low acceptance of the dietitian's role in health care. We actively worked on promoting the new dietetics cadre at the government policy level and to fellow clinicians in hospitals through frequent stakeholder engagements that took many forms.These stakeholder engagements included aligning the program's aims and objectives to the strategic nutrition and health objectives of the Malawian government through multiple consultations with the government at key points, starting with scoping visits, the needs assessment, and regular program updates to senior Ministry of Health officials. During this process, we identified a need to create demand for dietitians as part of the health care teams. We worked closely with the Department of Clinical Services to establish the first clinical dietetics posts in civil service.To immerse key government decision makers in clinical dietitians' roles, we invited senior government officials, comprising directors of clinical services, nutrition, and human resources, to visit both a Malawian hospital and UCT teaching hospitals, where students completed their critical care and surgery rotations. This “show, tell, and involve” strategy was instrumental in fast tracking a roadmap for recruiting and integrating dietitians into Malawian clinical services. Although the full integration of dietitians is a long-term goal, the government has shown strong commitment by creating posts and hiring the first graduate registered dietitians. The visits also helped orient the stakeholders on resources needed for optimal practice. We supported the government with mapping the resources needed for optimal practice including procurement needs for specialized enteral and parenteral nutrition support and the development of national hospital food service guidelines. For the first time, these guidelines quantify and standardize the nutritional content of meals served to patients and have therapeutic adaptations for common conditions, such as diabetes and chronic kidney failure, in hospitalized patients.We used a “show, tell, and involve” strategy with key government decision makers to fast track a roadmap for recruiting and integrating dietitians into Malawian clinical services.To further address the barrier of inadequate knowledge of dietitians' roles in clinical care, we facilitated clinical nutrition training for doctors and nurses at 2 major referral hospitals in Malawi. Thirty-five critical care nurses and doctors attended a hands-on short course in enteral and parenteral nutrition support administration. This was a precursor to the introduction of ready-to-hang, pump-assisted enteral nutrition administration at 2 of the largest critical care units in Malawi.The need for dietetic professionals to join health care teams to combat both forms of malnutrition and tackle the rising prevalence of NCDs in developing countries is urgent. Since 60% of African countries were in a similar situation as Malawi before the introduction of the dietetics program, we believe that several lessons can be drawn from the experience in Malawi that may apply to other countries.First, engaging with stakeholders from the beginning at both the policy and implementation level garnered government support and drove demand for dietitians in government health services. Sustained engagement efforts with key government stakeholders including sharing regular updates/progress reports, sensitizing them to dietitian roles, and involving senior government management in training students and career development, was crucial in creating a program that developed competencies and skills that responded directly to the country's needs. This response, in turn, was a key factor in gaining high-level government support.The creation of the first-ever posts for dietitians and subsequent deployment of both cohorts of graduates within months of their graduation was a major achievement considering that more than 50% of existing health care professional posts in Malawi are vacant.We believe that securing employment prospects and career paths for dietitians early in the training program has been and will continue to be a crucial enticing factor for recruiting students.At the implementation level, we found that continuous benchmarking of courses, rotation sites, and competencies was critical in identifying gaps in dietetics training and developing quick remedies for such gaps. For example, the UCT exchange program was a stop-gap remedy that improved the quality of critical care nutrition support training to a level that was not possible in Malawi given the available resources levels there.Since there were few dietitians in Malawi, the quality of training and exposure relied heavily on leveraging the strengths of partnerships and multiple stakeholder engagement. The medical school partnership was crucial to implementing clinical rotations and gaining quick acceptance and recognition of dietitians in the hospital. The UCT exchange program exposure was also very valuable for Malawian students and preceptors. Students gained confidence in resources for nutrition support that were not available in Malawi and were exposed to an established clinical nutrition service operation, which can be modeled in Malawi. Malawian preceptors also learned about supervision and assessment of students in practical rotations, leading to improved quality in training.This also highlights the importance of building strong networks with regional dietetics experts who assisted with strengthening our program by vetting examinations and performing a curriculum review. The continued fostering of relationships with regional experts has also opened doors for institutional collaborations in capacity building and research. Two program graduates have completed master's degrees in nutrition with the North-West University, South Africa, for example. In addition, networking with local Malawian dietitians also contributed vastly to improved preceptor support. The preceptors were role models to students and brought extensive practical experience in the Malawian context. Another successful strategy for dietetics clinical practice was a series of dietetics-orientated capacity-building workshops and seminars for other health care professionals. These efforts raised the awareness of the role of the dietitian and advanced multidisciplinary collaboration.This program was built on maximizing existing capacity for nutrition training by reviewing, adopting, and adapting existing nutrition coursework and matching with dietetics competencies, then filling the gaps with new course content. The recruitment of qualified nutritionists and people with biomedical backgrounds meant that a significant portion of dietetics coursework needs and competencies had already been fulfilled in the student's undergraduate degrees. This led to a shorter program and fast-tracked graduate output. However, through early and continuous evaluation of student performance, we observed many students, particularly those with a nutrition background, struggled to transition from their undergraduate biomedical science knowledge base to the expectations of the dietetics program. This may explain the 37.5% average failure rate observed in both cohorts. Hence, we designed an 8-week “bridging course” to mitigate this gap in nutritional biochemistry, nutrition in the lifecycle, and medical terminology. We hoped that this would lead to a smoother transition between the student's prior knowledge and the rigor of the dietetics program. This may be applicable in other countries, especially in Africa where there are more nutritionist training programs than dietetics.,.There remained an acute shortage of supervision capacity for students during clinical placements/rotations, a high supervisor-to-student ratio, and no established role for dietitians in clinical placements. We had anticipated this problem given the limitations in dietetics practice in Malawi. Nonetheless, this shortage posed a serious threat to quality training that will likely continue until a critical mass of dietetics educators/instructors exists. We used a role emerging placements model, which works ideally in places where there are no structures and roles for dietitians,We used a role emerging placements model, which works ideally in places where there are no structures and roles for dietitians.A strong case has been made for registered dietitians as an essential piece in solving the nutrition challenges in Malawi. We describe how capacity for the dietetics professional practice has been built thus far. We believe that our case study can be extended to other developing countries that are undergoing similar epidemiological transitions with similar resource constraints impeding the quality of health care professional training.A major priority for the program going forward is to increase graduate output and build a critical mass of dietitians to sustain the practice. To that end, LUANAR has secured an additional 5-year USAID grant to provide scholarship support for about 25 more students and sustain the program for an additional 5 years. Through this grant, LUANAR will prioritize training dietitian educators through mentorship with regional and international experts. There is a need to secure more sustainable sources of funding from the government and diversify sources of funding by securing research grants and competitive tuition rates.Efforts to build the national research agenda are underway with 90% of the graduates of the program now pursuing Masters in Dietetics degrees and undertaking groundbreaking research on nutrition outcomes in clinical care. The new grant is also set to bolster the research capacity through training more master's students and funding research. Evidence will ultimately inform practice, improve the quality of care, and justify the role of dietitians in Malawi.Important steps in promoting professional dietetics practice made thus far have included advocacy, forming a dietetic association, drafting regulatory guidelines that define the scope of dietetics practice and have credentialing requirements for both individuals and training institutions, and engaging national regulators for enacting the guidelines and drafting practice guidelines. These are all structural priorities that protect the registered dietitian title and the public from imposters. Future priorities should focus on strengthening regulation of practice and the association as key bodies promoting practice.The development and implementation of the first academic program for dietitians marks the genesis of the profession in Malawi. However, sustained investment in the expansion and improvement of practice conditions is needed for dietitians to realize their full potential.


The nutrition education program was also successful in reducing the consumption of sweets. Children’s education improved the parents’ knowledge about dietary sources of fiber and the recommended fiber intake, and it contributed to the awareness that breakfast is the most important meal of the day. The program did not enhance the parents’ knowledge about snacking between meals or the role of sweetened beverages in dental caries, overweight and obesity. Conclusions: Long-term multi-stage nutrition education for children aged 3 to 6 years can be helpful in shaping families’ eating habits and improving parental nutrition knowledge. However, the program was less effective in eliminating the respondents’ preference for sweet-tasting foods.Background: Effective strategies for improving eating habits and dietary intake in preschoolers are essential for reducing the risk of chronic non-infectious diseases in later life. The aim of this study was to evaluate the effect of long-term nutrition education for 3- to 6-year-olds on parental nutrition knowledge. Methods: The study was conducted as part of the “Colorful Eating is Healthy Eating” nutrition education program that has been implemented in kindergartens in Lublin since 2016. A total of 11 kindergartens were involved in this stage of the program, and 733 parents consented to participate in the project. The study was divided into three stages. In the first stage all parents completed a questionnaire containing 54 items. In the next stage, 211 children from four randomly selected kindergartens participated in the “Colorful Eating Is Healthy Eating” educational program that lasted 7 months. In the third stage of the study, the parents of children who had completed the 7-month educational program and the parents of control group children once again completed the questionnaire. Results: A positive outcome of the educational program was that it contributed to a decrease in the consumption of sweetened hot beverages ( Effective strategies for improving eating habits and dietary intake in toddlers and preschoolers are essential for reducing the risk of chronic non-infectious diseases in later life ,2. UnheaParents and caretakers should instill healthy eating habits in their children, and they should receive support in the process of preparing and eating healthy meals in the family setting ,6,7,8. NAccording to most researchers, parents’ nutritional knowledge significantly influences children’s eating behaviors and food choices ,16,17. MTherefore, the aim of this study was to evaluate the effect of long-term nutrition education for 3- to 6-year-olds on parental nutrition knowledge. The nutrition education program lasted 7 months and comprised six meetings dedicated to different topics. An attempt was made to determine whether long-term multi-stage nutrition education programs that are adapted to the cognitive abilities of preschoolers from different age groups  can contThe study was conducted as part of the “Colorful Eating is Healthy Eating” nutrition education program that has been implemented in kindergartens in Lublin, a city in south-eastern Poland, since 2016 . The proThe third part of the questionnaire was composed of 15 items analyzing parental nutrition knowledge. The respondents could answer each item with one of three options: true, false or don’t know. One point was awarded for each correct answer, and no points were given for incorrect answers or “don’t know” responses. Points were summed up for each respondent (range 0 to 15 points). Based on the distribution of points, the respondents were divided into three nutrition knowledge categories: low (0–7 points), average (8–11 points) and high (12–15 points).The study was divided into three stages. In the first stage (September–October 2018), all parents (733 persons) who consented to participate in the project completed a questionnaire containing 54 items. The respondents returned 521 correctly filled questionnaires; 175 respondents did not return the questionnaire or filled it in incorrectly, and 36 respondents withdrew from the project.In the next stage, 211 children from 4 randomly selected kindergartens participated in the “Colorful Eating Is Healthy Eating” educational program. The program consisted of 6 meetings between November 2018 and May 2019. Each month, preschoolers attended one meeting lasting 30–60 min . The meeIn the third stage of the study (June 2019), the parents (521 persons) of children participating in the educational program and control group children once again completed the 54-item questionnaire. An additional workshop on the healthy food and lifestyle pyramid was held in June 2019 for all children who had not participated in the educational program.Categorical variables were presented as sample percentages (%), and continuous variables were expressed by median values and the interquartile range (IQR). The differences between groups were analyzed in the chi-squared test . The Wilcoxon signed-rank test for two dependent samples was used to comprehensively compare test data and retest data and to verify differences in mean food consumption frequency between the test and the retest.Eating habits and food consumption were presented with the use of qualitative data, and the frequency with which different foods were consumed was expressed on a scale of “never” to “several times a day”. Identical ranks and/or indicators of daily consumption frequency (times/day) were applied to process and interpret the results .p < 0.05. Data were processed in the Statistica program .The odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. The reference categories (OR = 1.00) were the child’s age (5–6 years), parents’ age (26–35 years), education (university education), professional status (permanently employed) and parental nutrition knowledge scores (8–11 points). The ORs were adjusted for parental knowledge about healthy nutrition and the role of nutrients in health maintenance. The significance of ORs was assessed by Wald’s statistics. The results of all tests were regarded as statistically significant at The respondents returned 521 fully and correctly completed questionnaires. In the studied population, 83.7% of the respondents were female .The families’ eating habits and intake of different food products were compared before and after the 6-month educational program for children. The comparison revealed that the educational program induced minor changes in the parents’ dietary preferences.p < 0.05) (p < 0.05), but the consumption of pickled and fermented vegetables decreased despite the fact that the health benefits of fermented foods had been discussed during the workshops and that the children consume such products in the kindergarten. A significant (p < 0.05) increase was noted in the consumption of fruit and vegetable juice which should be part of a diversified diet, but should not be consumed in quantities exceeding 220 mL/day. A positive outcome of the educational program was that it contributed to a decrease in the consumption of sweetened hot beverages (p = 0.014) and an increase in water intake (p = 0.001). Before the program, average water intake was 237 ± 254 mL/day in the entire population. In the surveyed group, water intake increased from 311 ± 231 mL/day before the program to 467 ± 313 mL/day after the program. None of the children drank water less than several times a week (the water intake coefficient increased from 0.14 before the program (once a week) to 0.5 after the program , which suggests that some children had been drinking water only once a week before the program). The nutrition education program was also successful in reducing the consumption of sweets. Before the program, more than half of the children from the surveyed group (52.3%) ate sweets once a day on average, 45% ate sweets several times a day and only 2.7% ate sweets less than once a week. This percentage was reduced to 34% after the program (p < 0.05).The consumption of white bread and fine groats decreased ( < 0.05) . After tThe parents’ knowledge about healthy dietary patterns and the role of nutrition in maintaining health, as well as changes in parental nutrition knowledge after the educational program were analyzed in the control group and in the surveyed group .p < 0.01). After the program, 72% of control group parents demonstrated high levels of nutrition knowledge with an average score of 12.6 ± 1.1 points, whereas 37.4% of the parents from the surveyed group had high levels of nutrition knowledge with an average score of 13.9 ± 0.6 points.The average score was significantly lower in the control group after the educational program than in the surveyed group (p = 0.0011). The parents’ educational attainment was also a significant contributing factor. Better educated parents had significantly higher nutrition knowledge scores (p = 0.021), and 74% of the parents in the surveyed group had high scores (p = 0.0008) after the program.The child’s age was a factor that significantly contributed to the parents’ nutritional knowledge after the program. Five- to 6-year-olds who participated in the program probably conveyed more information to their parents, made better use of the acquired skills, knowledge and recipes, and their parents had higher nutrition knowledge scores  than the parents of younger children , parents older than 35  and parents with high nutrition knowledge scores  were familiar with dairy intake recommendations for preschoolers.The influence of parental factors on the parents’ knowledge about food products and dietary guidelines for preschool children was analyzed . Both bep < 0.05). After the program, 71% of parents from the above group correctly indicated that fast foods should not be incorporated into their children’s diets.Before the program, a higher number of parents with primary school education were of the opinion that fast foods can be introduced to their children’s diets similarly to other supplementary foods without increasing the risk of lifestyle diseases , unemployed parents who were homemakers  and parents with low nutrition knowledge scores . After the program, significantly fewer parents with vocational education  and unemployed parents/homemakers  declared that they did not read food labels and that nutritional information was not important for the child’s health.Nutrition fact labels provide consumers with important information about the quality of consumed foods. Food labels were very rarely or never read by parents with vocational education .Children’s education also improved the parents’ knowledge about dietary sources of fiber and the recommended fiber intake, and it contributed to the awareness that breakfast is the most important meal of the day. The program did not enhance the parents’ knowledge about snacking between meals or the role of sweetened beverages in dental caries, overweight and obesity. The parents’ knowledge about the recommended number of fruit and vegetable servings per day was similar in all groups before and after the educational program , which enables the educators to introduce new topics gradually and systematize the imparted knowledge ,39,40. AStory telling is one of the most effective teaching methods in preschool education. Stories and characters that relate to children’s daily experiences promote better understanding of the imparted knowledge, and visual aids such as a health food pyramid or a healthy eating plate help children to remember and recall the learned content ,42. EducWell-designed nutrition education for young children can improve a family’s eating habits. Nutrition education classes for 3- to 6-year-olds that are held in the kindergarten setting do not require parents’ or caretakers’ involvement, and the imparted knowledge can be reinforced through various activities. Young children are highly susceptible to the content of educational curricula, and they are not yet highly influenced by their peers and the environment. The knowledge imparted during educational programs in kindergartens reaches the parents indirectly, and it can improve eating habits in families that do not have healthy dietary behaviors and are unaware that they require assistance in this respect.In children aged 3 to 6 years, higher water intake could be helpful in reducing the consumption of sweetened hot beverages, fruit juice and carbonated drinks, thus decreasing preschoolers’ daily calorie intake ,45,46. AOne of the greatest strengths of this study is that the type of activities in the nutrition education program and class time were adapted to the learning capabilities of 3- to 6-year-olds. All educational materials were approved by preschool educators who also assisted the researchers in selecting the most appropriate expository teaching methods. Educational materials were further refined during the program, and they were handed over to the teachers for use in groups that did not participate in the project. Ready-made class scenarios and teaching aids can be helpful in expanding the content of standard preschool curricula relating to healthy nutrition and the promotion of healthy eating habits.The study also has several weaknesses. The number of respondents who participated in the nutrition education program was relatively small, and the program consisted of only 6 meetings. Kindergarten principals were unable to incorporate more than one nutrition class per month in their schedules, and the number of researchers participating in the project was insufficient to teach more classes.Long-term multi-stage nutrition education for children aged 3 to 6 years can be helpful in shaping families’ eating habits and improving parental nutrition knowledge.Nutrition education programs that rely on expository teaching methods can be effective tools for instilling healthy eating habits in preschoolers and shaping their food preferences provided that class time and the volume of imparted knowledge are adapted to the learning characteristics of children at different developmental levels.Age is an important factor that significantly influences a child’s ability to transfer the acquired knowledge and skills to the home environment. After the program, the parents of older children had higher nutrition knowledge scores than the parents of younger children.The nutrition education program contributed to more frequent choices of health-promoting food products and increased water intake in families. However, the program was less effective in eliminating the respondents’ preference for sweet-tasting foods.Educational campaigns on how to use nutrition fact labels should also target children who have not yet learned to read to promote healthy food buying habits and raise awareness that food products differ in quality and health safety.


Effective and scalable mental health programs are greatly needed for older adults, given the vast majority in need do not receive formal mental health services. In this study, we adapted Mood Lifters—a peer-led, community-based program promoting mental well-being—to address the unique needs of older adults. The 14 weekly program sessions were delivered via Zoom. Twelve older adults  enrolled; 9 completed the program . A battery of validated measures administered within one week before and after the program assessed domains including depression and anxiety, stress management, and health behaviors. Compared to baseline, participants who completed the program showed significant improvements in perceived stress (p=0.03), sleep quality (p=0.02), and emotion regulation via cognitive reappraisal (p=0.06). Depression and anxiety symptoms  were lower at program completion, although improvements were not statistically significant. No significant changes from pre- to post-test were reported in loneliness and health behaviors. Participant ratings of program satisfaction were very high . Results from this pilot test of Mood Lifters for Seniors suggest it is feasible and acceptable for outreach to older adults, with preliminary evidence of benefits in several domains related to mental health and wellness. Future randomized trials with larger, more diverse samples will be necessary to confirm program benefits.


The Senior Community Service Employment Program (SCSEP), the only federal workforce-training program that targets older adults, engages people aged 55 years and older with incomes at or below 125% of the federal poverty level with multiple barriers to employment. This study examined SCSEP’s role in participant financial, physical, and mental well-being. To do so, we held five sessions  over a combined nine hours in August and September 2020 using a form of participatory research called community-based system dynamics with 15 Massachusetts SCSEP participants and case managers. Through structured activities, respondents identified how program, policy, and organizational factors influence and are influenced by participant well-being  as well as program and policy recommendations to strengthen the program . These findings highlight the benefits and potential of this long-running program.


Teaching point: Idiopathic granulomatous mastitis is a rare disease that may present as breast abscesses and may mimic other inflammatory, infectious, or neoplastic disorders on imaging. A 43-year-old woman presented with erythema and swelling of the areola and the peri-areolar area of both breasts. She did not have any relevant clinical history.Figure 1A and 1B, white arrows). Ultrasound confirmed bilateral well-delineated, heterogeneous hypoechoic collections with posterior acoustic enhancement in the retroareolar area .Digital breast tomosynthesis demonstrated well-delineated retroareolar lesions in both breasts, with central lucency and a dense periphery in the right breast and a radiodense lesion in the left breast . Diffusion restriction was observed in all lesions . The overlying skin and areola were thickened.Magnetic resonance imaging (MRI) demonstrated round and oval masses with smooth margins and peripheral enhancement in both breasts on contrast-enhanced subtraction images  is a rare chronic benign inflammatory breast disease. There are two subtypes. Specific granulomatous mastitis (SGM) is associated with systemic granulomatous disease, including sarcoidosis and granulomatosis with polyangiitis (Wegener disease), or chronic granulomatous infections such as tuberculosis, fungal infections, or histoplasmosis. In idiopathic granulomatous mastitis (IGM), no underlying etiology is identifiable. IGM occurs more frequently in women of childbearing age with elevated hormonal states, such as contraceptive medication and lactation. The most common clinical presentation is a tender retro-areolar mass. Nipple retraction, erythema, swelling, axillary lymphadenopathy may be present .Imaging features of IGM are often nonspecific. The most common mammographic finding is a focal or regional asymmetric density, with potential architectural distortion or skin thickening. MRI shows heterogeneous non-mass-like enhancement. Sometimes, IGM may manifest with abscess formation . An abscOn imaging, IGM abscess formation may mimic an invasive breast carcinoma with central necrosis or abscesses in SGM or non-granulomatous infection .The initial treatment of IGM is abscess drainage and immune modulation with a corticosteroid regimen. A methotrexate regimen or surgery may be considered in refractory cases .


The model includes the following steps: (1) Parameters of a pretrained ResNet model are initialized using transfer learning. (2) Samples are divided into three different sample spaces  based on the differences in multimodal medical images PET/CT, and ROI of the lesion was extracted. (3) The ResNet neural network was used to extract ROI features and obtain feature vectors. (4) Individual classifier ResNet-NRC was constructed with nonnegative representation NRC at a fully connected layer. (5) Ensemble classifier E-ResNet-NRC was constructed using the “relative majority voting method.” Finally, two network models, AlexNet and ResNet-50, and three classification algorithms, nearest neighbor classification algorithm (NNC), softmax, and nonnegative representation classification algorithm (NRC), were combined to compare with the E-ResNet-NRC model in this paper. The experimental results show that the overall classification performance of the Ensemble E-ResNet-NRC model is better than the individual ResNet-NRC, and specificity and sensitivity are more higher; the E-ResNet-NRC has better robustness and generalization ability.Under the background of  Through the ResNet-50 feature extraction, the training sample matrix of the feature space is obtained as X′ = , with a test sample matrix y′ = .Taking the Sample-CT-ROI as an example, for the training samples (4)X′ and query sample y′ are normalized to unit L2 standard:Each column of the matrix (5)X′ in the feature space y′ is nonnegative. Therefore, the nonnegative coefficient The training sample (6)Training samples are used to classify the nonnegative representations of the test samples based on their similarity as(7)Finally, the label category of the residual output result is defined asThe process to obtain these is as follows. Software environment is as follows: Windows10 operating system, MatlabR2019a; hardware environment is as follows: Intel(R)Core(TM)i5-7200U CPU @2.50GHz 2.70GHz, 4.0GB memory, 500GB hard drive.F-score value, and Matthews correlation coefficient (MCC), which are described as follows:In this paper, the evaluation metrics include accuracy, sensitivity, specificity, Accuracy, sensitivity, and specificity were calculated by true-positive (TP), false-positive (FP), true-negative (TN), and false-negative (FN). TP indicates a benign tumor was predicted correctly, FP indicates a malignant tumor was predicted incorrectly, TN indicates a malignant image was predicted correctly, and FN indicates that benign tumors were predicted incorrectly. They are calculated by the following formulae:F-value is a summed average of the percentages of completeness and accuracy. It is used as a trade-off between accuracy and recall. The calculation formula is as follows:The MCC is a more comprehensive evaluation metric that reflects the reliability of the algorithm. When the number of categories is different, the value of the measure is considered balanced ranging from -1 to +1. The MCC takes the value of 1 when the prediction error is 0 for both FP and FN, which means that the classification is completely correct; when the prediction error is 0 for both TP and TN, the MCC takes the value of -1, which means that the classification is completely wrong. It is calculated as follows:The experiments were performed using a 5-fold cross-validation for training. The final results were averaged over five experiments. 2400 training samples and 600 test samples were used. The experiments were carried out in CT, PET, and PET/CT trimodal datasets. AlexNet and ResNet-50 were used for comparison. Classification was achieved through the nearest neighbor classification (NNC), softmax, and nonnegative representation classification (NRC) algorithms. The algorithms were pairings were as follows: AlexNet+NNC, AlexNet+Softmax, AlexNet+NRC, ResNet-50+NNC, ResNet-50+Softmax, and ResNet-50+NRC.This experiment explored the effects of different network models, classification algorithms, and sample spaces on the ResNet recognition rate and training time. The following six combinations of algorithms were examined: AlexNet+NNC, AlexNet+Softmax, AlexNet+NRC, ResNet-50+NNC, ResNet-50+Softmax, and ResNet-50+NRC. The recognition accuracy, running time for training, and standard deviation (SD) in the sample space of CT, PET, and PET/CT are shown in (1) Not Using Ensemble Learning. The experiment was also carried out without using ensemble learning. In the first scenario, different network models with the same classification algorithms were used. As in Experiment 1, three groups of comparative experiments were performed, namely, AlexNet+NNC and ResNet-50+NNC, AlexNet+Softmax, and ResNet-50+Softmax, as well as AlexNet+NRC and ResNet-50+NRC.Taking the third group as an example, in the CT sample space, the accuracy of the proposed ResNet-50+NRC model was 0.27% higher than that of the AlexNet+NRC model with a training time of 1019.04 seconds. It is noted that the ResNet is deeper when compared with the AlexNet; for this reason, the extracted image features are richer, and the classification accuracy is higher; however, the training time is greatly increased, in this case, by 648.14%. The results of the other two groups were similar (data not shown).In the second scenario, the same network with different classification algorithms was used. In Experiment 1, there were three groups of comparative experiments, namely, AlexNet+NNC and AlexNet+Softmax, AlexNet+NRC and ResNet-50+NNC, and ResNet-50+Softmax and ResNet-50+NRC. Taking the second group as an example, in the CT sample space, the classification accuracy of the individual classifier ResNet-50+NRC was 2.07% and 0.94% higher than that of the ResNet-50+NNC and ResNet-50+Softmax, respectively. In terms of the training times, Net-50+NRC was 28.04 and 22.67 seconds faster than the ResNet-50+NNC and ResNet-50+Softmax models, respectively. Compared with the first scenario, the overall training time was greatly improved; however, after the network model was determined, the increase in training time was not significant. It is noted that when using the same network architecture, the NRC model exhibits a better classification accuracy when compared with the NNC and Softmax models. This algorithm also proved suitable for handling high-dimensional data and reduced training times significantly.(2) Using Ensemble Learning. In this experiment, the same network architecture and classification algorithms under different sample spaces were used. Six groups of comparative experiments were considered: AlexNet+NNC and E-AlexNet+NNC, AlexNet+Softmax and E-AlexNet+Softmax, AlexNet+NRC and E-AlexNet+NRC, ResNet-50+NNC and E-ResNet-50+NNC, ResNet-50+Softmax and E-ResNet-50+Softmax, and ResNet-50+NRC and E-ResNet-50+NRC.Taking the third group in the three different sample spaces as an example, the classification accuracy of E-AlexNet+NRC model was 0.63% and 1.46% higher than that of the AlexNet+NRC in the CT and PET/CT sample spaces, respectively. When taking the sixth group in the three sample spaces as an example, the classification accuracy of the proposed E-ResNet-50+NRC model was 0.50% and 1.24% higher than that of the ResNet-50+NRC model in the sample space of CT and PET/CT, respectively. Meanwhile, the training time was improved by 1974.43 and 1992.16 seconds, respectively. It is noted that when using the same network model and classification algorithm on different sample spaces, ensemble learning can improve the classification accuracy at the expense of substantially increased training times. From the comparative experiments in Experiment 1, namely, E-AlexNet+NNC, E-AlexNet+Softmax, E-AlexNet+NRC, E-ResNet-50+NNC, E-ResNet-50+Softmax, and E-ResNet-50+NRC, the classification accuracy of the proposed E-ResNet-50+NRC model was 99.57%—the highest among the six tested models.F-value, and MCC  according to the different medical imaging techniques. The ResNet extracts the ROI features and uses them to construct feature vectors. Then, an individual classifier, ResNet-NRC, was constructed by employing nonnegative NRC at the fully connected layer. Finally, the ensemble classifier E-ResNet-NRC was achieved by employing relative majority voting. The experimental results showed that the overall classification performance of the proposed E-NRC-ResNet model was better than that of the individual classifier. Its specificity and sensitivity were also higher, while possessing good robustness and generalizability.


The aim of this study is to examine gifted students' evaluations of their education programs in terms of their project production and management by considering the basic principles of gifted education and training programs. In evaluating the effectiveness of programs for gifted students, it is regarded as important to consider the evaluations of the individuals for whom the programs are implemented. Project production and management was taken as the basis for the principles and guidelines of the programs implemented for gifted students. A mixed research design was used in the study. In the quantitative part of the research, the views of 300 randomly selected gifted students, who were attending the project production and management (PPM) and special talent development (STD) programs at Science and Art Centers (SACs) throughout Turkey, regarding their evaluation of the education programs, were analyzed. In the qualitative part of the research, the project production and management of the gifted individuals in the upper and lower groups according to their program evaluations were evaluated descriptively by examining the project proposals they developed. In the analysis of the quantitative data, it was determined that the participants had positive views about the effectiveness of the program, but that there was a significant difference between the upper and lower groups in terms of program evaluation scores. Considering this situation, the data of 10 participants in total (five participants included in each of the upper and lower groups) were subjected to qualitative analysis in the second stage. As a result of the study, it was determined that all of the gifted students in the upper and lower groups were able to produce projects, but that in the categories specified in their projects, there were differences in favor of the upper group in terms of depth, originality, taking their talents into account, acting consciously, acting in accordance with the plan, participating in more prestigious competitions, and quality. Evaluation of the education program aimed at gifted individuals is important in terms of revealing the effectiveness of the program. The effectiveness of the training program is determined according to the change in the skill  are institutions where gifted individuals receive education in order to develop their talents, skills, competencies and potentials in the fields of science and art, based on their educational needs according to the fields in which they are identified MoNe, . In the When the advancement process in the programs is examined, it is seen that by starting from the establishment of interdisciplinary relationships with basic skills, individuals first identify all fields and determine their own talents, then develop their special talents in a field or fields, and as a result, are able to create original projects in line with their interests and wishes in their area of expertise. In this context, it can be stated that advancement in the programs is in a pyramidal structure, which gradually narrows from the general to the specific in line with the individual's abilities, and that it is based on the creation of projects by specializing in one or more fields MoNe, , 2019. IDifferentiation of gifted education programs is defined as shaping education programs according to individual differences in gifted education, and for this purpose, curriculum differentiation models are developed  program in SACs are examined, it is stated that each individual who attends this program is expected to prepare at least one project for each academic year, that the consultant teacher should prepare at least two progress reports during the project development process, and that information about the completed projects should be processed into the SAC program MoNe, , 2019. IIn the literature evaluating the effectiveness of education and training programs implemented not only for gifted students, but also for other individuals, there are studies examining students' model creation statuses  continue their project production and management (PPM) and special talent development (STD) programs throughout Turkey, and 300 randomly selected gifted students make up the quantitative research group. The Science and Art Centers (SACs) continue their project production and management (PPM) and special talent development (STD) programs throughout Turkey, and 300 randomly selected gifted students make up the quantitative research group. Participants consider as gifted who passed and received high scores through three-stage identification process are selected for education at SACs. In the first stage, students who are gifted are nominated by their class teacher by filling out the “Primary Education-Age Teacher Observation Form.” In the second stage, the Basic Abilities Test is applied to the students nominated. Candidates who show high performance in this test are taken into individual evaluation at the third stage  SAC attended; (2) Type of school (public-private); (3) Program level ; (4) Skill area ; (5) Grade; (6) Geographical area of residence; (7) Age; (8) Years of experience at SAC.The Gifted Education Program Evaluations-Student Form (GEPE-SF), which was revised and whose psychometric properties were determined, was used Sak, . It is s2 = 3,147.55, df = 1,127, p = 0.000, χ2/df = 2.79, GFI = 0.96, IFI = 0.96, NFI = 0.94, NNFI = 0.96, CFI = 0.96, AGFI = 0.93, SRMR = 0.05, RMSR = 0.08, and RMSEA = 0.08) were calculated and evidence was obtained that the scale has a valid structure for this sample  that the project was entered in and the placings it received:....”This form consists of 3 parts . There are 21 items in the second part. Some of the items are: “It applies for a patent related to its original product” and “It converts project results into products.”This form consists of 3 parts . In the second part, there are sections about the dates when checks were made in stages from the start date of the project, the stage that was reached in the checks, the result of the check, and whether it was completed or not. Some of the items in the statements in the third part are: “Making a plan according to the project, preparing a timeline: …” and “Carrying out the project according to the plan: ….”During the data collection, the identity information of the participants was kept confidential, and they were allowed to voluntarily participate in the research and fill in the consent form. The research was carried out in two stages. In the first stage, the quantitative data of the research were obtained by administering the GEPE-SF scale and the personal information form to participants throughout Turkey.In the second stage, regarding the program in which project production is the basis, data were collected about the project production statuses as well as the program evaluations of gifted students throughout Turkey. The aim of the research was taken into account in making the decision about which participants to collect these data from. In addition to the aim of the research, the points taken into account in the collection of these data were: (1) to determine and examine the project productions of the participants in the upper and lower groups in terms of program evaluations, (2) to determine the province with the highest number of participants in the first stage and gather qualitative data from this participant group. From among the participants, data on the project productions and management of a total of 10 participants, five each in the upper and lower groups in terms of program evaluations, were collected with the program forms of these participants.Data entry was made during the fall and spring academic semesters to 3 different data sources related to the project production and management processes of the upper and lower group participants according to their program evaluations. Data entries were made in line with progress in the project stages. The fact that project production requires a long time, that there are annual periods for applications for dissemination, and that on the basis of the special talents program, individuals who are in the PPM program are expected to carry out project production during the academic year MoNe, , 2019 coTable 4). Descriptive statistics were calculated for each score. Considering ranking of the program evaluation scores of the participants, lower 27%-upper 27% groups were determined. T-test was employed to determine the differences between the scores of the participants in the lower 27%-upper 27% groups. It is suggested that upper and lower groups consisting of 27% from the extremes of the criterion score distribution are optimal for the study of test items  in the GEPE-SF scale were reverse coded. Before beginning the analysis, missing values and extreme values were examined. There were no missing values in the data set. As a result of the extreme value analyses, 8 individuals  were removed from the data set and the analyses were continued in this way. Then, the normality of the distributions of the total scores obtained from the scales and the homogeneity of the groups  were examined for parametric techniques  scores are summarized in X = 230.51).When As stated in the problem situation of the research, the principles and guidelines of the program implemented for gifted students are based on project production and management. In the analysis of the quantitative data, it was determined that the participants had positive views about the effectiveness of the program, but that there was a significant difference between the upper and lower groups in terms of program evaluation scores. Considering this situation, it was decided to examine the findings for project production and management according to the program evaluations of the participants in the upper-lower groups. According to the gifted students' program evaluations, the data of 10 participants in total, five participants each in the upper and lower groups, were subjected to qualitative analysis in the second stage.The project production and management findings of the upper and lower group participants are summarized in As a result of the literature review, questions were encountered about how many different ways the pieces can be placed on the chessboard according to a certain rule and what is the largest square space in these positions” and “Within the scope of the project, it was inspired by a problem posed in the internationally held olympiad named the International Mathematical Olympiad (IMO)….” It was concluded that the same participant determined the problem situation in line with his/her talent and knowledge. The statement related to this finding is “Based on the problem, new problems were created according to the rules for moving the pieces and the size of the board on which they are placed. …the new problems that were created and the generalization of the solutions given to these problems were worked on.” It was determined that the participant worked on the project by doing planning and in accordance with the scientific research in the project field. The statement related to this is “The largest square space formed in the placement of the chess pieces and newly identified types of pieces on the chessboard according to the rules for moving them was examined. It was noticed that these spaces and the number of dimensions are in a certain order. This perceived order was studied. It was investigated whether this order is valid in different dimensions and for different pieces that were identified.” It was determined that the participant carried out and finalized the project he/she planned by achieving mathematical generalization. The related statement is “In the solution of the problems, equations were obtained that ensured that the appropriate k values were found for each n. This condition was not provided for k + 1; on the contrary, it was proven by way of exemplification.” It was determined that the participant disseminated his/her project by participating in project-based competitions, and the finding related to this was obtained from the statement “Salih Zeki Mathematics Research Projects Competition” in the section “Competitions (if any) that the project was entered in and the placings it received.” It was determined that the participant made an original and scientific contribution to the field he/she was doing a project in by making mathematical generalizations as a project/product, and the statement regarding one of the generalizations related to this is “The existence ofk × ksquares without a rook in them and the existence of at least one rook in any (k + 1) × (k + 1) square was proven. Therefore, it was concluded that the answer is.”When It was inspired by a project in which a model was created using the geometric properties of the equilateral triangle and the circle for the design of the system” and “Different usage areas for the developed model were considered.” It was concluded that the same participant determined the problem situation for the application of the developed model to different areas. The statement regarding this finding is “The circularity of the geometric surface and how the developed model can be utilized in energy production can be determined by surface calculations related to it.” It was determined that the participant worked on the project by gathering data. The related statement is “Different results were transferred to the table by calculating the areas of the circle segments and equilateral triangles with the aid of the expressionsM = A + B = π.x2.1/6 and, respectively. The obtained data were compared.” The result statement stating that the participant expanded the application area of an already existing model is “The optimum value was calculated according to the variables. It was demonstrated that the model can also be used in energy production.” It was determined that the participant disseminated his/her project all around the center, and the relevant finding was obtained from the expression “The poster prepared was presented at the science fair” in the section “Whether the project was presented or not.” It was determined that the participant expanded the application area of the existing model as a project/product, and the statement regarding this is “The scope of the model was expanded in terms of area of use.”When When the project production and management processes of the participants in the upper and lower groups were compared according to the categories specified in the first line of When the problem situation specifications of the upper group participants summarized in From the analysis of the gifted students' program evaluation scores, it was concluded that they had positive views about the effectiveness of the implemented program. With this result, the research results related to the gifted students' program satisfaction were confirmed in a sense (Kayişdag and Melekoglu, When the results presented in In the literature, the findings obtained from studies conducted on the effectiveness of programs for the gifted support the conclusion that the project production and management of gifted individuals is associated with the quality of the programs implemented (Manuel and Freiman, The main objectives determined in the gifted education program model are that the program fosters inquisitive and creative thinking, the content of the program is related to daily life, it contributes to the course success of students at school, the lessons are interesting and supported by different methods, how to be a good person is taught, high-level topics are taught, teachers are well-qualified, and the program contributes to the student in different ways Sak, . When thToday, due to the fact that the individuals who shape the societies are among the gifted students, developed countries attach great importance to the education of gifted students and the development of programs for gifted students so that these students can develop their talents and use their capacities efficiently (Ayvaci and Bebek, For example; the objectives of the “Gifted Education Program, GEP” implemented in Singapore, which is located in the upper row in international tests OECD, , are as Based on the similarity between the main objectives of the gifted education program and the student outcomes expected to be gained in the project production and management process, it can be said that the students who find the gifted program to be effective and of good quality can achieve the specified program objectives more than the students who do not find it to be of good quality, and that consequently, they are more effective and competent in project production and management. It has been determined that students who deal with independent and small group projects, which are at the center of the gifted education program, perceive their projects as interesting and useful and believe that they contribute to their continuing interests and perceptions of pleasure in the future (Reis et al., For future researches, it would be suggesting to study if gifted students' demographic information influence the answers to the Gifted Education Program Evaluations Form and the differences that may exit in the points of view that are given in it. Because; in the quantitative dimension, especially their ages, grade levels, and years of experience at SACs may influence the students' perception of the program and their opinion of it. In the qualitative dimension, in addition to observing the comparisons with the lower group, it is recommended to interpret the project production and management results according to the demographic characteristics of the gifted students. Moreover, it can be recommended that more studies should be conducted on the evaluation of the existing program based on the opinions of gifted individuals. Project-based education programs aim to develop students' high-level thinking and research skills through the projects related to real-life problems that they produce. Therefore, studies should be carried out for the effective use of programs that focus on project production and management aimed at developing the skills of gifted individuals in formal institutions as well as in SACs. Gifted individuals are educated in mixed classes in Turkey. In order for the teaching-learning process in mixed classes to be effective, it can be recommended that teachers should be directed to in-service training related to project production. It can be recommended that pre-service teachers studying at education faculties should be enabled to develop projects or directed to project development courses so that they can support the gifted students they will encounter when they begin their profession. It can be recommended that the programs implemented for gifted students should be designed for normal students as well.The participants are limited to the gifted students who attended the PPM and STD programs at SACs in Turkey and who are at secondary and high school level as a requirement of these programs. Also, since the participants' project production fields are mathematics, it is recommended that the limitation of the research in terms of field should be taken into account in further researches on project production.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Akdeniz University Rectorate Social and Human Sciences Scientific Research and Publication Ethics Committee Decision. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.MD and GÖ contributed to conception and design of the study and wrote sections of the manuscript. GÖ organized the database and performed the qualitative analysis. MD performed the statistical analysis. Both authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study compares behavioral health and most-interested topics among older adults in three aging-in-community (AIC) programs: a university-based lifelong learning program , a county neighborhood lunch program , and a village program sample (33%) . Mean age was 72.4 (SD=8.68) years. Although perceived health was similar (mean=3.76), LLP and village members reported higher quality of life than NLP participants (p=.004). Two-thirds of the participants indicated at least half of their daily plates filled with fruits and vegetables, and at least 10 min. walking in 4.5 days during a typical week. The duration of each walking was lower among NLP members (23 min.), compared with village (31 min.) or LLP members (35 min.) (p=.002). The top three most interested topics were brain health, giving back, and keep community healthy. Older adults in AIC programs were overall healthy and active. Results have implication on tailored program development.


Background. Recovery orientation is a movement in mental health practice. Although general mental health services have taken the lead in promoting recovery, forensic psychiatric systems have lagged behind because of the need to reconcile recovery principles with the complexities of legal mandates. Advocating recovery and making systemic changes can be challenging because they require seeking a balance between the competing duties to the patient and the public. This paper used a logic model framework to demonstrate a cohabitation program that placed a woman and her newborn infant in a secure forensic rehabilitation unit, and analyzed the key assumptions of recovery upon which it was based. Methods. This was a qualitative program evaluation. Data collection involved individual interviews with the woman, the infant’s father, five primary healthcare providers, and five system administrators, and 11 focus groups with unit staff and other patients. Content analysis was used to guide the data analysis and develop the critical components of the program logic model. Results. A logic model that consists of input , output , and outcome  components was developed. Conclusions. This study demonstrates a recovery-oriented program for a woman cohabitating with her baby in a secure forensic psychiatric rehabilitation unit. The logic model provided a comprehensive understanding of the way the recovery principles, such as shared decision-making, positive risk-taking, informed choices, and relational security, were implemented. Recovery-oriented practice has become a focus in mental health systems. “Recovery” refers to the ways in which a person with a mental illness experiences and manages a disorder in the process of reclaiming their meaningful life in the community . ContempIn this paper, we used a logic model framework to demonstrate the way that a cohabitation program for a woman and her newborn, in a secure forensic psychiatric rehabilitation unit, can be developed, and we evaluated whether the process and outcome promoted recovery in order to inform future practice.Building a logic model is a method for designing, planning, evaluating, and implementing programs and it has been applied across diverse settings and disciplines ,4,5,6. AWe begin our paper with a brief overview of the program, followed by the methods, which outline the development of the logic model framework. Next, we present the program logic model, including what we invested, performed, and achieved. Finally, we discuss recovery orientation using the logic model to identify the assumptions, activities, and outcomes indicative of recovery-oriented practice, and the factors that facilitated and impeded the process and goal achievement.The cohabitation program was developed within the Northern Alberta Forensic Program, Alberta Hospital Edmonton, Canada, which operates at the interface of psychiatry and the law. It provides assessment and treatment services for individuals with unmet mental health needs who come in contact with the law, and the services include assessments for courts and rehabilitation under the auspices of the Alberta Review Board. A large part of the forensic program consists of rehabilitating individuals who have been found “not criminally responsible” (NCR) by reason of mental disorder. An NCR verdict is neither a conviction nor an acquittal, but, rather, it is a third alternative for the courts . The larThe legal expectation is that NCR patients are to be gradually reintegrated back into society, which involves transitioning to a conditional discharge, and, eventually, an “absolute discharge” from all legal obligations. This legal journey is overseen by the provincial Review Boards, which are quasi-judicial bodies that are required to review NCR patients, usually annually, in order to consider granting an absolute discharge if they are no longer a “significant threat the safety of the public”  , in the unit town hall meetings (for inpatients), and in the system administration meetings (for administrators). Those who were interested in participation would contact the researchers directly. The purpose of the interviews is to understand the social climate, the therapeutic regimes, and the program impacts. We seek to build on and promote further successful cohabitation programs by not only considering the patient’s perspective, but, more explicitly, also by exploring the experiences of and impacts on providers, system administrators, and other patients in the unit. The intention is to answer the following questions: (1) What is the understanding and impact of the cohabitation program from the perspectives of all stakeholders at the system, staff, patient, and environmental levels? (2) How do they see the benefits and challenges in cohabitating the mother and newborn in the unit?Each interview lasted approximately 60 min, and each focus group interview lasted approximately 60–75 min. Their purposes were to understand the cohabitation program’s effects on all of the unit stakeholders. All interviews were audio-recorded and transcribed verbatim. The Research Ethics Board of the university approved the study procedure (Study ID: Pro00084270). Written informed consent was obtained after the procedure had been fully explained.The following procedures were used to analyze the data from the individual and focus group interviews to develop the program logic model. First, we used open and incident-by-incident coding to label opinions, events, conditions, or phenomena, on the basis of the recovery concepts. Second, we used categorizing and axial coding to group conceptually similar codes to form categories and subcategories using more abstract headings. Third, relevant categories were organized to develop the structural and process components with a description of the program’s operational practices, with a specific focus on recovery-oriented practice. These critical components were integrated into a logic model diagram. Lastly, a member-checking exercise was used to establish the model’s credibility and face validity. This process occurred when the analytic categories and interpretations were tested with certain members of the groups who generated the data originally. A preliminary description of the program model and its critical domains were discussed in a meeting in which the participants were invited to share their opinions on the model’s structure and content. The final critical components were amended on the basis of this exercise.Five system administrators, the woman, the infant’s father, and five primary care providers—three nurses, a psychiatrist, and an occupational therapist—were interviewed individually. Three focus groups, which consisted of 12 inpatients in the unit, and eight groups, which consisted of 21 multidisciplinary frontline providers, were conducted as well. The input aspects, which represented what we invested before the program, consisted of five components: (1) Team building; (2) Program planning; (3) Staff preparation; (4) Patient preparation, and (5) Resource management. Team building was the first step to reaching a collective agreement, identifying the key values and beliefs of the cohabitation program, and establishing a decision-making process. During the team-building process, recovery was identified as the core value and philosophy that guided the program’s direction. As an administrator highlighted: “Our ethics of being least onerous, but also being recovery oriented, we felt that we needed to explore this option [recovery]” (ADMIN 3). A provider also echoed: “We’re promoting recovery and this is a unique situation where recovery for this individual is very important in a special way and that requires us as a treatment team to actually facility that” (PHP 4). Effective communication was key at this stage to reach common agreement, as ADMIN 5 shared: “It was more tweaking and communication and making sure that what we were doing was still recovery-based and within the values of [the system], … So, it was a lot of stakeholder engagement and communication.” The identification of recovery as a core value was a key determinant in the program’s advancement.In the program planning, it was necessary to first review, adjust, or develop new policies, procedures, or guidelines in order to implement the recovery-oriented cohabitation program. Further, the program planning involved a feasibility evaluation, risk assessments, and a plan for any logistics that adhered to the recovery principles. Provider 5 commented: “In fact, when the plan was actually put to management, all of the comments I got was that, ‘Well it seems very recovery-oriented.’ So that was the language that was used and so that was what was driving [the program].” In the program preparation stage, it was crucial to prepare the staff by providing support and education to enhance their experience and understanding of recovery in a forensic context. A provider noted:We’re moving more towards a patient-centered approach to forensic care, a more recovery orientated approach towards forensic care which is driven by the goals of the patient, and the fact that the clinical staff on the unit are moving more towards that and there’s been, in recent years, a lot of education about recovery and what it means in forensic; and so that’s kind of laid the groundwork for people to start thinking outside of the box.(PHP 4)In addition to education about recovery, the staff also received support and training to equip them with the skills to manage new issues, such as pediatric-related critical responses, which are usually outside the practice of mental health professionals.I think for the patients it was empowering to know that when you trust your treatment team and you work with them and say, this is something that’s important to my recovery, they hear you. They don’t just say no because logistically it’s challenging and no because it hasn’t been done before. They hear you, they work with you and they help you achieve your goals.(ADMIN 3)Other patients on the forensic unit were undergoing their own unique recovery journeys, and it was important to ensure the quality and safety of their individual rehabilitation and reintegration into the community. Therefore, it was essential to have an open conversation and ongoing communication with other patients on the unit and provide support to address their potential anxiety and concerns, as well as to minimize any tensions or misunderstandings that may arise between people on the unit. An administrator shared:With respect to resource management and attention to results, it was essential to ensure that frontline staff, all physicians, community partners, and other stakeholders were committed to the program and that they worked as a cohesive team.The output aspects, which represented what we performed during the program, consisted of five activities, conducted in two phases: (1) Logistic activities; (2) Risk management; (3) Mental health care; (4) Staff/other patient support; and (5) Discharge preparation. When the baby arrived on the unit, the first 2–3 weeks of the program were identified as the first phase, during which daily conflicts occurred and problems were solved. The second phase began when daily routines were established, harmony was achieved, and the transition plan was initiated.I think yes, we did take risks, that we did need to take risks to promote recovery, and at the same time I think what really made it work was there was a lot of trust between all the parties; so, I think that really helped.Logistic activities included, but were not limited to, establishing a daily routine/schedule, coordinating services in the first phase, and developing guidelines and documents as required in the second phase. Positive risk-taking is one of the recovery principles. As ADMIN 3 explained: “We’ve always had, in my opinion, a group that really had a strong understanding of recovery-oriented principles and really had a strong understanding of positive risk taking and also a willingness to try.” Therefore, risk management and risk mitigation plans were a key consideration in the program. These needed to be in place and implemented when possible, and the staff needed to be trained as well to prepare for emergent situations. As Provider 4 noted:The other significant activity during the program was providing mental health care to the woman. In addition to delivering client-centered and recovery-oriented care throughout the program, it was particularly important to monitor potential relapse and postpartum symptoms during the first phase.I trusted in the actual assessment of the treatment team… they know each patient individually quite well. So, I trusted that they had appropriate amount of patients and the right patients on the unit. And I felt that when the baby was actually around that everybody was on their best behaviour, almost, yes. There was, there was just like a calmness and peace to the unit that I haven’t felt before, and I’ve been in the system for five years.(P2-2)Addressing concerns, maintaining open communication, and debriefing and reflection were three critical aspects of providing support to staff and other patients in the unit. Such support played a key role in reducing the tension on the unit and improved the ward climate. For example, a patient shared:When the woman and her baby were ready for discharge, searching for potential resources and providing mutual support between the inpatient and outpatient teams were two main areas of discharge preparation.She’s [the mother] actually further along in her recovery journey, because she was able to achieve one of her major goals, which was being a mom. She says, “I want to be a mom,” then, you know what, we have to help you be a mom. So, I think that’s what we did. And, because we did that, she was able to continue her recovery in such a positive way.(ADMIN 5)The outcome aspects, which describe what we achieved, varied according to the stakeholders. For the woman herself, the cohabitation program helped her advance her recovery through her strong bond with her newborn and improved her mental health and sense of wellbeing. An administrator explained further:My recovery, my children have always been a protective factor for me. I fell into substance abuse when I didn’t have my daughter. So, being able to have a second chance and not make the same mistakes, he’s a huge protective factor, so, it’s been really good to have him [the baby], for sure, for my recovery.The woman herself reflected on the program, and shared:I just want to say that was a very good experience for me. Like taking care of the kid, and watching her take care of the kid, you kind of like learn a little bit of how to take care of kids and stuff, so it was a learning experience for me. (P3-1)Other patients in the unit also benefited from the program through their positive emotional, social, and behavioral responses to the patient, and gained a sense of being trusted as well. As one patient said: “It’ll be a lovely experience for everybody involved, right, so I figured that if, well the staff trusted us enough to have a baby on the unit, and that was pretty cool.” (P3-1). He emphasized:I guess maybe just the whole idea of how much the rehabilitation program here at the Hospital… how they actually do care for our wellbeing. It really opened up my eyes to the whole idea that, you know, they really do have our best interests at heart.(P2-2)Further, the patients trusted the psychiatric unit team to act in their best interests; as a patient expressed:I’m just so proud of my team for going above and beyond for the patient. They were—had their head so in the right place and their hearts, and this was purely about recovery and best practice for patient care.At the system level, the cohabitation program’s effects included the growth of the system’s capacity, flexibility, and risk tolerance, the creation of knowledge and a self-developed toolkit, and the patient and family-focused value-based practice. As ADMIN 1 shared, the lessons he learned were “…understanding how we can engage in client-centered recovery focused care in expanding the definitions and the roles and what we were able to do as a forensic service for our clients.” ADMIN 5 illustrated further the recovery-based values embedded in the program:I think it’s kind of created perhaps a self-awareness that we can do things differently … it’s demonstrated that the system is open to change and that it’s open to new ideas and innovation and particularly along the lines or recovery, promoting recovery. I don’t believe it’s been a shock to the system. I think that it’s been an awakening or an understanding what the system actually is like, you know that it’s much more flexible and much more positive and much more patient-centered.(P4-1)The frontline providers endorsed the sense of system flexibility and capacity building; as a provider expressed:Overall, the cohabitation program’s broader effects were that it showed the implementation of a client-centered, recovery-focused, and innovative program in forensic psychiatric services, as well as advocated for social justice and equity.I guess I just want to kind of recognize my own tension with being watched all the time. … it’s tough to deal with, you know, like a person you wouldn’t ever imagine—a regular human being observed all the time… You just want to, some days you just want to have your own space, your own time to yourself, and I do get it...”(P2-3)The issues and challenges in delivering recovery-oriented services in a forensic inpatient rehabilitation setting were also raised. As ADMIN 1 described the unit: “The context of that within forensics is actually very difficult, because client-centered and more specifically recovery oriented, some of the natural principles are in direct contradistinction to the actual structure of our program, you know, which is custodial and detainment.” This leads to problems in developing a shared meaning of recovery within the context. As we understand that fundamental components of recovery practice are person-centered and include empowerment, transferring these components of practice into an inpatient setting has certain difficulties. Tensions occurred between maintaining order on the unit and ensuring the choices, preferences, rights, and satisfaction of patients. As a provider shared her observation of the mother:All providers expressed the importance of the patients’ choices and decision making, but conceded that, in the real world, they have to manage potential risks to ensure patient safety and prevent any harmful consequences. During the program, it was found that frontline providers underwent a learning process that transformed their practice from risk-averse and custodial strategies into one that supported opportunities to engage and take responsibility. Another lesson the providers learned was to be more comfortable sharing power with patients. The majority of providers agreed that they were well-rounded in client-centered and recovery-oriented services by building “real, trustful relationships with patients” (P5-5), advocating for their patients, and resolving the conflicts raised in recovery-oriented daily practice.This paper describes a logic model for a cohabitation program that forensic psychiatric inpatient services throughout Canada can use. The qualitative data collected in this specific forensic psychiatric unit were instrumental in creating the logic model’s components and for achieving insight into the particular inputs, activities, outputs, and outcomes needed to reach the overarching goal.When considering both recovery and forensic settings, it is important to reveal both the individuals’ and the services’ perspectives on risk. Forensic service users have committed a crime that usually is considered sufficiently serious to require their confinement in a forensic service facility. They are often assumed to pose risks of harm to others, compromise security, and demonstrate a considerable level of aggression and violence. This stereotype has a profound effect on the design of the forensic mental health environment, which emphasizes security and risk prevention. In this respect, recovery constitutes challenges in forensic services . The wayFrom the personal perspective, moving beyond a criminal self-identity is key to the recovery of forensic service users ,20. In oServices users in forensic settings often perceive treatment as more coercive than in other mental health settings . BecauseRecovery is promoted when frontline providers are equipped with the ability to help patients become actively involved in their own lives. In this study, our providers built upon, and were motivated by, the belief that the woman was able to find a path to her recovery. They supported her aspirations, hopes, and needs to play the role of a mother. However, in the “investment” (input) stage of the program, the question about the workforce’s understanding of recovery principles was raised, and a series of education and empowerment activities was planned, in which staff had ample opportunity for discussion and questions. Particularly, the questions of risk and choice were debated hotly with concerns about “what if” scenarios. Nevertheless, these set the stage for staff acceptance and also highlighted the challenges in changing the practice culture. Thereafter, staff were able to identify recovery as the core of valued-based practice and to think of a “real” client-centered approach. They learned to be open, but clear, about limits. They appreciated the collaborative decision-making process and remained sensitive to the individual’s needs. Some staff in this study described the program as a personally meaningful and transformative learning process, in which changes in their attitude influenced their practice. We believe that building such awareness was fundamental to the program’s success.However, recovery-oriented practice at the provider-level cannot occur in the absence of broader organizational support and facilitation. In this study, we found that, although the clinical team became more educated and focused on recovery, the program could not have been implemented successfully had the same ethos not been embraced at the system level. Essentially, what occurred was that the system administration assigned an equal value to patient recovery. A single program cannot demonstrate full support for recovery. It involves reflecting on the way the entire system views mental health problems and the role of forensic psychiatric rehabilitation. To practice recovery-oriented services in forensic settings “safely” and effectively, it is necessary to reconceptualize service approaches fundamentally, at the system level. Hence, the organization’s role, new approaches to intervention planning and programming, and the evaluation of patient outcomes had to be redefined. Our program demonstrates leadership’s imperative role in promoting recovery by providing sufficient participation in decision making and access to resources.Organizational support, particularly for risk-management planning and new practice guidelines, must be clear and transparent and involve collaboration and discussion with frontline staff. A clear structure and support for staff on the part of all administrative levels is necessary to facilitate the adoption of the new recovery-oriented approaches.The overarching goal of developing this program logic model was to provide all of the inputs and implement the activities in order to achieve a series of outputs and outcomes for the cohabitation program. Notably, through this model, outpatient stakeholders, such as Forensic Assessment and Community Services (FACS), will be able to provide similar services in the community to support this woman’s wellbeing and recovery upon her transition from inpatient services. The model developed here can be used as a reference for future program development and implementation, as a tool to engage stakeholders, and as a framework to guide program evaluation. We illustrated how forensic psychiatric services can share recovery values and practices in inpatient contexts. To promote recovery movement, the future direction for forensic psychiatric services should address the ethical tensions between the fundamental principles of recovery and their moral considerations in practice.One limitation of this model is that the components were measured only qualitatively, while a more rigorous mixed-methods approach may have provided more detailed findings. In addition, it is critical to recognize that the components required may not be the same for all NCR patients. Future research should examine the differences in the logic model components’ results if a different research method is used. In summary, this model may serve as a framework to provide cohabitation services for both NCR pregnant patients and their infants.The process of providing recovery-oriented services in secure forensic settings is complex. This study demonstrates the ways that services could implement a recovery orientation through a cohabitation program model that reflects both recovery values and a forensic awareness of safety and security. The program provided the woman opportunities to build a life beyond illness and to find motherhood a meaningful occupation in her recovery journey. Although the recovery journey of people in forensic services differs somewhat from that of others, application of the recovery principles, such as patients’ participation in their care, shared and transparent decision making, positive risk taking, informed choices, and relational security among all stakeholders, were evident in the program logic model.