Fellowship programs offer training in a subspecialty focusing on distinct and advanced clinical/academic skills. This advanced postgraduate training allows physicians, who desire a more specialized practice, to further develop clinical, academic, research, and leadership/administrative skills. The Aga Khan University (AKU) is one of the few institutes offering paediatric sub-specialty training in Pakistan. We aimed to evaluate the current Paediatric fellowship programs at AKU.Process evaluation of six paediatric fellowship programs  was conducted from September 2020 to April 2021 by senior clinicians and medical educationists. Evidence was collected through document review , observation of teaching and learning support, and focused group discussions/interviews with program faculty and fellows were conducted. A review of the evaluation report was done as part of this study. This study received an exemption from the ethical review committee. The quantitative data were analyzed using SPSS (22.0) while the reports of discussion with fellows and friends underwent content analysis.All fellowship programs met the criteria for having a robust competency-based fellowship curriculum as per the institutional and national guidelines. Formative assessment in the form of continuous evaluation was found to be integrated into all the fellowship programs, however, most of the programs were found to lack a summative assessment plan. Fellows in training and program faculty were satisfied with the opportunities for mentorship, teaching, and learning. Thematic analysis of the discussion reports with faculty and fellows revealed three key themes including, program aspects translating into strengthening the training, gaps in the training program in delivering the expectations, and making ways to reach par excellence.The process evaluation of paediatric fellowship programs provided an opportunity to holistically review the current strengths and quality of the training in individual programs along with the unmet needs of the trainees. This will help the program stakeholders to prioritize, align and allocate the resources to further enhance the quality of training and outcome of individual fellowship programs to ensure wider impacts at a regional, national, and international health system level. Fellowship is a training program, following core residency training, which focuses on the development of both clinical and non-clinical abilities at a subspecialist level . This adMedical programs are based on a non-linear training structure where there is constant evolution based on community needs as well as national and international benchmarks of quality in training. The evaluation of program elements and outcomes contribute to its continuing development and quality improvement thereby bringing forth excellence in patient care . AccrediThe Aga Khan University (AKU) is one of the few institutes offering paediatric sub-specialty training programs in Cardiology, Critical Care Medicine, Endocrinology, Infectious Diseases, Neurology, and Neonatology in Karachi, Pakistan. These training programs are in alignment with the mission of AKU, which is, “to prepare individuals for constructive and exemplary leadership roles, and shaping public and private policies, through strength in research and excellence in education, all dedicated to providing meaningful contributions to society”. The first paediatric fellowship programme in neonatology was birthed in 1996 and soon got recognition by the CPSP. These fellowship programmes follow the policies and standardized training requirements as set by the Postgraduate Medical Education (PGME) -AKU and CPSP.Although global data regarding evaluation of programs in different parts of the world is available, there is minimal literature describing the evaluation of fellowship training in our local context . ThroughThe program audit took place from September 2020 to April 2021 at the Department of Paediatrics and Child Health, AKU. This study has been given an exemption from AKU- ethical review committee (ERC# 2021-6847-19659).Multiple models exist in the literature for program evaluation , howeverSix teams were created for evaluating all the paediatric fellowship programs. The selection of evaluators in each team was guided by the following criteria: each individual had to be a faculty member with at least five years of experience in academia and had to have previously held an academic leadership position. Each team comprised of four members i.e., two clinicians  with over ten-year service experience, one clinician-educator , and a senior administrative support staff. The evaluators were not part of the faculty fellowship program being evaluated. A detailed briefing was given to the teams about the purpose of this evaluation ambiguities were removed. Each team was provided with some resource documents which are listed later in this text.The following resources were used for data collection.Document review.Each fellowship program has documents providing vital information about the program such as program curriculum, competency framework, program policies , trainees’ job description, and academic performance record. Evaluating teams utilized the PGME Program Information Form (PIF) for document review. This form has two parts. The first explores the demographic details of the program, including but not limited to CPSP approval status, number of faculty on board and number of fellows enrolled in each sub-specialty, attrition/year, and number of graduates. The second part confirms if the documentary evidence is met (80–100%), partially met (50–75%), or not met (< 50%) for each source including training curriculum , clinical responsibilities and caseload. Compilation of this information leads to a quantitative account of each fellowship program. The decision regarding the scoring of the met, un-met, or partially met criteria was made after discussion among the reviewers.2.Experiences of faculty members and fellows.Open-ended question guides were developed by the department’s medical educationist to explore the experiences of both the trainees and trainers in each fellowship program. For the fellows, the discussion was based on their experiences of clinical and academic learning, challenges in training, the support system in the fellowship program, supervision, and suggestions for improvement. A separate meeting was kept with program faculty who shared their opinions about the program outcome, strengths, limitations/challenges, support system, and suggestions for improvement in the quality of the training program.3.Observation of teaching session.After obtaining permission from the individual programs, the reviewers observed one to two academic teaching sessions to gauge the learning environment, fellow’s contribution, faculty contribution, and innovation, if any, used in the session.The reports compiled by the individual review committees of all six paediatric fellowship programs were presented to the department’s fellowship committee. The collated data were broadly divided into two categories for the purpose of analysis and ease of reporting.Data collected from the document review was analyzed using the Statistical Package for the Social Sciences (SPSS) version 22.0. Quantitative variables reported as percentages and frequency include, but are not limited to, the number of fellows in the training program, number of faculty in the training program, and percentage of documentary evidence met.Reports of discussions with faculty and fellows and teaching session observation of each fellowship program were transcribed and underwent thematic analysis. Data were condensed into codes, which were clumped together to yield categories or subcategories. Similar categories were merged to extract themes by two independent reviewers to ensure trustworthiness.The demographics of all the programs are shared in Table The key findings are reported below according to the various domains of medical education.The curriculum is the reconstruction of knowledge and experience that enables the learner to grow in exercising intelligent control of subsequent knowledge and experience . The stuEducational Strategies provide the means by which the curriculum’s objectives are achieved. These are considered the heart of the curriculum . During Assessments are crucial in judging learners’ competencies, assisting their performance improvement through feedback, providing guidance, and aiding in trainee selection for advanced training . All proOne of the gaps that were identified across all programs was an absence of opportunity for formal one-to-one feedback to fellows from program faculty Table . This coThematic analysis of the report of fellows and faculty discussion revealed three key themes as discussed below Table .The fellowship programs exhibited a sound structure, encompassing a comprehensive curriculum of academic, clinical, and research aspects, as well as honing leadership and presentation skills. Academically, trainees appreciated diverse learning tools and resources that included expertise from national and international platforms. Opportunities for formative assessment laid out in the programs and were deemed as thorough, informative, and divided well throughout the duration of the rotation. Clinical teaching was found to be continuous, occurring during in-service rounds and clinics. The programs effectively integrated research and statistical skills, covering clinical and basic research along with biostatistics. Fellows had ample research opportunities under excellent mentorship. Non-clinical training, including leadership, teaching, and presentation skills, were embedded in all programs and well-received by trainees, who expressed interest in further expanding these opportunities. This holistic approach to training coupled with close mentorship offered by the faculty resulted in confident, efficient trainees and visibly improved patient care.Despite the structured curriculum, the need for clearer, standardized tools was recognized to ensure fellowship graduates meet all competencies. Identified areas for improvement included limited feedback, lack of summative assessment opportunities, and undefined aims for external/internal rotations. Fellows noted the absence of formal assessment during these rotations. WPBA was seen as underutilized in many programs, while the imbalance between service care providers and workload was considered an issue. Faculty noted that the diverse sociocultural backgrounds of fellows can extend the learning curve for system-based practices. They advocated for expanding fellows’ exposure to national and international healthcare systems through electives. However, financial constraints pose a significant challenge to this effort. Finally, while formal research training existed, a gap was observed in translating these skills into actual publications. The CPSP mandates that to qualify for the fellowship certifying examination fellows must author and submit a research paper linked to their specific training program. However, variations were observed in the practices related to research across the fellowship programs, encompassing aspects such as the provision of mentorship, formal learning opportunities regarding research, and the dedication of specific time slots within the programs for research activities.Group discussions highlighted potential improvements in training quality. While the patient load is substantial for learning, there is a compelling need to branch out to other institutes during rotations. Rotations in public sector institutes can assist in understanding the needs of people in underdeveloped areas who lack financial support to reach private institutes. Due to the strength of the research training being offered, it was voiced that a certain period may be set solely dedicated to it. It was also noted that assessment methods need to be more focused and aligned with the curricular objectives and outcomes for each training program. Faculty also expressed their opinion on the need for trainees to get administrative exposure and involvement in quality improvement projects.Fellowship is intense training that follows certification in a primary specialty or subspecialty and focuses on distinct and advanced clinical and/or academic skills . ObjectiOur results, showed that the curriculum was extensive with an appropriate competency framework however, lacked focused teaching, aligning with the trainees’ objectives. There is a need to set clear and standardized assessment tools to ensure that our fellowship graduates meet all competencies. Similar findings were reported in an extensive study done by Constance D. Baldwin on the strengthening of the academic base of general paediatrics fellowship programs where the main problem highlighted was the efficient integration of learning objectives in the curriculum . In soluClinical teaching is the highlight of a fellowship program. Most clinical application is found to be through experiential learning, which has been known to be the most effective way of medical learning . A pressResearch emerged as one of the strongest domains, by both the faculty and the fellows in our analysis It is crucial to building this skill as the fellowship experience expands a physician’s abilities to pursue hypothesis-driven scientific inquiry resulting in evolving contributions to the medical literature and patient care. Fellows were given adequate opportunities to develop mentored relationships and built on an infrastructure that promotes collaborative research. However, as identified by the Dana-Farber Cancer Institute in Boston for their paediatric hematology/oncology fellowship program, there is a need to encourage an individualized training program when it comes to research , as eachThis study is the first of its kind in the region which reports the experience of the process evaluation of multiple paediatric fellowship training programs in a tertiary care center in a low-middle-income country. Methodical triangulation was utilized to explore the holistic quality of training programs which will facilitate the program evaluators to utilize this experience in national and international contexts. However, the scope of this study, conducted in a single private sector institute, presents certain limitations. The findings of our study may not be completely representative of other contexts, particularly programs in the public sector as well as other institutes operating under the umbrella of CPSP. As such, conducting a multi-center study would not only increase the generalizability of the results but enable greater understanding of the structure of fellowship programs across various settings and contexts. Thus, while acknowledging this limitation, it must also be recognized that this study is an avenue for future research to utilize the structured and robust mechanism of process evaluation we have proposed to present more comprehensive and contextually comparative evaluations of subspecialty fellowship programs.Evaluation of paediatric fellowship programs provided an opportunity to review not only the written curriculum but also informed the stakeholders about the strengths and gaps in the transfer of this curriculum. To ensure the optimum transfer of competencies, there is a need to create opportunities of formative as well as summative assessments in the program. The prospects include preparing these programs for accreditation by international bodies, for example, the Accreditation Council for Graduate Medical to enhance the quality and consistency of fellowships, increase their recognition, promote the academic vitality of future faculty, and make the discipline a more attractive career choice for outstanding residents.


A major employer implemented a change to its employee health benefits program to allow beneficiaries with diabetes or high cholesterol to obtain preselected generic antidiabetic or generic antihyperlipidemic medications with a zero dollar copayment. To receive this benefit, plan beneficiaries were required to participate in a contracted vendor’s case management and/or wellness program.To assess changes in medication adherence and the costs for generic antidiabetic and generic antihyperlipidemic medications resulting from participation in a zero copay (ZCP) program.This was a retrospective pre-post comparison group study, evaluating adherence and cost. Participants using an antihyperlipidemic and/or antidiabetic medication during the study identification period and post-implementation period for the program were considered eligible for the study. Eligible beneficiaries who enrolled in the ZCP program during the post-implementation period were considered participants, while those who did not enroll during this period were considered nonparticipants. ZCP program participants and nonparticipants were matched via a 1-to-1 propensity scoring method using age, gender, comorbidity count, medication type , and baseline adherence as matching criteria. The proportion of days covered (PDC) metric expressed as a mean percentage was used to assess adherence to medication therapy, while payer cost was examined using prescription drug utilization expressed as per member per year (PMPY) and cost change per 30 days of medication expressed in dollars.Among participants who were users of antidiabetic medications, the mean adherence rate was sustained from pre- to post-implementation (81.8% vs. 81.9%); however, it decreased in the matched nonparticipant group (81.9% vs. 73.1%). This difference in mean adherence over time between the participants and nonparticipants was statistically significant . Similar results were found among users of antihyperlipidemics. The mean adherence rate was sustained over time for participants (77.7% vs. 78.3%) but declined over time for nonparticipants (77.6% vs. 70.8%). The difference in mean change over time was statistically significant between participants and nonparticipants . Average prescription costs PMPY increased for participants of the ZCP program during the post-implementation period; however, the increase was not larger than the cost increase among nonparticipants . Furthermore, among antihyperlipidemics the cost increase post-implementation was actually significantly less for participants than nonparticipants .Plan sponsors are increasingly evaluating the use of value-based benefit design (VBBD) to change member behavior. This ZCP program used a reduction in cost sharing to incentivize members to use more generic drugs and to enroll in a care management coaching program. The study also demonstrated that a VBBD program can have a positive impact on adherence and cost outcomes among those who participate compared with nonparticipants.


To assess the effect of an virtual speech-language orientation program, as well as the prevention of orofacial myofunctional alterations.Fifty-five volunteer residents aged between 18 and 50 years of age residents of Federal District participated in the study, 14 men and 41 women with an average of 28. The orientation program was divided into five stages (1) The preparation of material to be used in the orientation program, (2) The completion of a semi-structured questionnaire made available through Google Forms, (3) Completion of a pre-orientation program questionnaire, (4) utilization of the speech therapy orientation program, (5) Completion of the post-orientation program questionnaire. To analyze the results the McNemar statistical test was used considering the absolute frequency (N), enabling comparison through a paired sample. The significance level adopted was 5%.Statistically significant differences were seen in 10 of the 19 questions asked in the pre and post-orientation program questionnaires, proving the effect of the orientation program and improvement in participants’ knowledge. In addition the participants were satisfied with the program and the content.The orientation program focused on health promotion and prevention of orofacial myofunctional alterations and combined with telehealth brought significant changes to the reality of the participants, favoring the quality of life of these individuals and changing their reality. On the other hand when there is a change in the organism, be it structural, morphological or psychological, harmful patterns may arise called deleterious habits. Some of the more common habits such as pacifiers and/or bottle usage, finger sucking, onychophagy (nail biting), atypical tongue pressing during speech, lip sucking, mouth breathing, bruxism and object-biting habits,3, can become harmful in the long term due to extended duration, high frequency and intensity of the habit resulting in overloading of the stomatognathic system (SE),4.Throughout life we adopt various habits and types of behavior according to our experiences and our body's requirements. Among these are oral habits, which are defined as learned neuromuscular habits that become unconscious.Deleterious oral habits can cause changes in orofacial functions, such as chewing, swallowing, breathing and speech, in addition to changes in the temporomandibular joint (TMJ), resulting in a temporomandibular disorder (TMD), especially during increased periods of apprehension and anxiety resulted in a growth of psychological disorders and consequently an increase in anxiety, depression and post-traumatic stress. These disorders can lead to an increase in deleterious oral habits and consequently changes in orofacial functions,4.The emergence of the coronavirus pandemic and the requirements for social distancing and self isolation to help halt the advance of the virus.Social isolation can lead to changes in sleep patterns caused by a lack of daily routines, which can change sleeping and waking times, and in the long term these changes in sleep patterns can provoke sleep disorders, consequently care is needed in this area to ensure essential and proper bodily function. Speech-language pathology and audiology, resolution No. 580 of August 20, 2020 established guidelines for carrying out teleservices and the use of services such as tele-education.Telehealth has emerged as an effective way of distributing health-related services and information during the pandemic and allows for long-distance consultations, care and disease prevention measuresSocial isolation is a factor which can contribute to changes or the worsening of habits that impair adequate performance of orofacial functions and these are related to a person’s quality of life. Health promotion and education have the purpose of promoting progress and social transformation so that individuals become active members in the process of health improvement.The objective of this study was to verify the effect of a virtual speech therapy program, as well as to prevent orofacial myofunctional alterations.This study was approved by the Research Ethics Committee of Faculdade de Ceilândia – Universidade de Brasília, protocol number 4.341.780.This is an observational, cross-sectional and quantitative carried out in 2021 during the COVID-19 pandemic with residents of the District Federal, who were required to have access to WhatsApp  and as well as be aged between 18 and 50 years old. The following participants were excluded from the research, speech-language therapists and students of speech-language pathology courses, as well as participants who did not have internet access and who did not complete all the stages of the study. In addition when considering the questionnaires used for the study, participants with literacy problems were also were excluded from the research. All the volunteers agreed to participate in the research by signing a consent form (FICT).To prepare the materials used in this research, a bibliographic search was carried out of scientific literature in the PubMed and Scielo databases, according to each theme, as shown in 1. Definition2. Etiology3. Classification4. Diagnosis and treatment5. Professionals involved in the treatment6. Preventive MeasuresFor each theme 3 types of learning material were made available, in the following order. A video of a maximum duration of 10 minutes containing the definition, etiology and consequence of each habit or behavior. A PDF booklet pointing out the main points of each subject, prevention measures and professionals involved in the treatment of orofacial myofunctional alterations, in addition to specific topics on each subject and a short video covering trivia about the topic of the day, called “Minute Health”. At the end of the second day of each topic a specific time was chosen for the participants to ask question or resolve any queries .For the recruitment of participants, an initial semi-structured questionnaire was published on social networks such as Instagram, WhatsApp and Facebook and made available on Google forms and prepared according to the content of the speech therapy program and comprised of sociodemographic questions for the purposes of sample characterization and identification of participants, in addition to the FICT and their WhatsApp contact details. Then, 223 individuals were contacted through their WhatsApp number which they provided in the initial questionnaire, inviting them to participate in the speech-language pathology orientation program, as well as providing the access link to the pre-test questionnaire speech therapy program.After completing this stage, only 55 volunteers accessed the pre-program questionnaire, and were included in the WhatsApp groups to receive the material prepared for the speech-language pathology guidance program. The 55 volunteers were divided into two groups just to highlight that they were allocated into two different groups in WhatsApp. Group A consisted of 7 men and 22 women, totaling 29 participants and group B consisted of 7 men and 19 women, totaling 26 participants. The average age remained at 28 for both groups. A total of ten days was given to each group to complete the orientation program of which two days were allocated to each subject.When considering the level of education of the participants in this research, there was a higher frequency of participants who were graduating (46.1%), followed by those who had completed higher education (38.5%) and others who had completed high school (15.4%).The questionnaire contained 21 questions, of which 18 questions about the contents that would be covered in the proposed orientation program, which were performed again at the end of the program for the purpose of comparing the answers after the program, and a further 3 questions regarding the degree of satisfaction of the participants with the orientation program.After completing the speech therapy orientation program, the post-program questionnaire was given to the participants, this questionnaire contained the same questions as the pre-program questionnaire and additionally contained questions about satisfaction with the program . was used, considering the absolute frequency (N), with the answers “no” and “don't know” being grouped together. The significance level was set at 5%. The descriptive questions were considered invalid for this test, for analysis the answers were categorized and gathered according to the main message of each answer given by the participants.For statistical analysis of the questions, the McNemar testAfter completing the program and statistical analysis of the absolute and relative frequencies , it was Question four about ideal breathing (Q4), had a higher frequency of the alternative “nose”, followed by the “nose and mouth” alternative in both questionnaires, which showed a similar frequency for all alternatives in the comparison between the pre- and post-orientation program questionnaires .When asked about the multidisciplinary team involved in the treatment of mouth breathing, the speech therapist, otolaryngologist and the dentist were the most mentioned professionals, respectively. In addition in the post-program questionnaire, there was an increase in the mention of these professionals, with emphasis on the dentist, which increased by 41% .In question 10  there weThe orientation program satisfaction questions (Q19 to Q21), 65% of the participants were very satisfied, 33% satisfied and 2% not very satisfied. When asked about the guidelines provided in the program and their daily lives, 60% reported “very likely”, 29% answered “likely” and 11% indicated “unlikely”.The last question (Q21) gave the participants the opportunity to express their opinions about the orientation program. Forty participants praised the program in terms of organization, quality of materials and content, preparation by the researchers, how queries and doubts were handled and finally didactics and reception.Prevention is the best way to avoid prejudice occurring. In this context, the guidance program in this study aimed to prevent orofacial myofunctional changes resulting from harmful oral habits and other such behavior, which increased significantly due to COVID-19 social isolation measures. carried out an educational program in schools aimed at preventing and improving knowledge about mouth breathing and its causes and consequences with an objective and results similar to this study. This reaffirms the relevance of speech therapy orientation programs.This type of program disseminates fundamental information for the prevention of diseases. The study by Guimarães and Picinato-Pirola,14, which reaffirms that multimedia can be used successfully as a learning medium.This study used telehealth as the method for health promotion through awareness and dissemination of information about the proposed themes. In addition the technological resources used such as videos, pdf booklets and WhatsApp, were based on information and communication technology,16 that investigated the prevalence of sleep alterations in the Brazilian population, emphasizing that those who exercise minimize the chances of suffering from sleep disorders. In addition, a team is needed to treat this condition (Q3), so the participants indicated that speech therapists should be an integral part of this team and can perform myofunctional therapy to adjust muscle tension, mobility and posture of organs phonoarticulatory organs, decrease apnea and hypopnea indexes, the awakening index, excessive daytime sleepiness, as well as improve sleep quality and quality of life.Considering the questions about sleep (Q2 and Q3), there were statistically significant differences when comparing the pre and post questionnaires. We noted that the study audience already had prior knowledge about the need for lifestyle changes in cases of Obstructive Sleep Apnea (OSA), this data corroborates studies,18, the participants already knew about about this information . In this study, the same thing happened, with a 41% increase in the citing of dentists.In cases of treatment of mouth breathers, a multidisciplinary team is required, which must consist of a speech therapist, otorhinolaryngologist and dentist, among others. However most people are unaware of the professionals who should carry out the treatment in these cases, but with guidance this can be changed, as demonstrated in the study by Guimarães and Picinato-Pirola,21. When asked we found that the participants learned about this after the speech-language pathology orientation program. However, if the individual has a chewing preference, there may be an alteration in the facial muscles, requiring an intervention to adjust mobility and muscle tension, which may be carried out by the speech therapist. The participants showed they already knew about this subject.Regarding chewing (Q7 to Q9), it is a well known fact that the ideal masticatory pattern is the alternating bilateral one and a preference for a different form of mastication, can impair the function with possible consequences of TMD and an asymmetrical faceTMD can cause symptoms such as earache, pain and popping of the ears when opening and closing the mouth and pain when chewing, however quite often an individual with these symptoms may not be aware of this dysfunction as demonstrated by the results of the pre-program questionnaire (Q10), it is extremely important to promote health in Speech-Language Pathology and Audiology about issues that can be prevented, making society able to identify the symptoms of this change and to seek specialized help.. This information was successfully conveyed to the participants (Q13) as seen by analyzing the statistical analysis.The speech therapist is an integral member of the multidisciplinary team and is responsible for the treatment of TMD. The role of the speech therapist is crucial in carrying out myofunctional therapy (OMT) and utilizes resources such as laser therapy to adapt orofacial structures, as well as balance the orofacial functions,4. The structures that make up this system work together in a balanced and controlled manner and are responsible for the vital functions of breathing, sucking, chewing and swallowing, in addition to speech. Consequently if there is a change in these structures, the functions can also undergo changes,3, and as a way of preserving these structures, prevention is considered in order to provide the balance of the stomatognathic system through awareness of the harm that can be caused by harmful habits,3. This issue was addressed during the program developed in this study and comparing the pre and post-program responses (Q14 to Q17), some participants' already knew of the damage caused by harmful oral habits, specifically the use of pacifiers, bottle feeding and onychophagy, chewing, breathing and speaking. When studying the answers in the post questionnaire 100% of the answers in Q15 and 16 were correct, as well as a 26% increase in the post-program answers of Q17, which confirms acquisition of knowledge of this topic in the program.The presence of deleterious oral habits can be harmful due to their long duration, high frequency and intensity, which can overload the stomatognathic system.The last question subject to statistical analysis using the test adopted in this study refers to the difference between speech, voice and language. There was a significant increase in the answers referring to the “yes” alternative, which shows the 100% effectiveness of the content in the post-program questionnaire. This result can be justified by the type of material used to disseminate this content. It was a short video, therefore it does not require a greater attentional focus to understand the information, enhancing the transmission of knowledgeThe groups in this study were satisfied with the information in the orientation program (Q19 to Q21) and with the quality of material and content, handling of queries, didactics and reception being pointed out as factors that potentiated the propagation of the orientations..This study demonstrated positive results about the telehealth orientation, and it was possible to see that the program proved to be effective and fulfilled its purpose of educating, as well as informing the adult population of the Federal District, corroborating the results found in another studyAmong Speech-Language Pathology research, there are still very few studies that aim to promote health and prevent orofacial myofunctional alterations, deleterious oral habits and improve sleep behavior, so the purpose of this research was to encourage such actions in order to promote and increase studies on the theme.It is worth mentioning that the limitations of this study were the low adherence of the participants and the lack of control over the studies of the program content by the participants. A further orientation program is recommended in a controlled access virtual environment.In view of the findings in this research, the orientation program focused on health promotion and prevention of orofacial myofunctional alterations combined with telehealth bringing significant changes to the reality of the research participants during a critical period of the pandemic and helped to minimize the conditions that favor and intensify orofacial myofunctional changes, making it possible to use the autonomy of individuals to disseminate information and guidelines that are capable of transforming reality and favoring a better quality of life using technological resources associated with health.


Rural residents generally lack adequate physical activity to benefit health and reduce disparities in chronic diseases, such as cardiovascular disease and certain cancers. The Socioecological Model describes physical activity as involving a dynamic and reciprocal interaction between individual, social, and community factors. Community group-based walking programs and civic engagement interventions aimed at enhancing physical activity have been successful in rural communities but have not targeted all three socioecological levels. Public libraries can act as innovative public health partners in rural communities. However, challenges remain because rural libraries often lack the capacity to implement evidence-based health promotion programming. The goals of this study are (1) build the capacity for rural libraries to implement evidence-based health promotion programs, (2) compare changes in physical activity between a group-based walking program and a combined group-based walking and civic engagement program with rural residents, and (3) conduct an implementation evaluation.We will conduct a comparative effectiveness study of a group-based walking (standard approach) versus a group-based walking plus civic engagement program (combined approach) aimed at enhancing walkability to increase physical activity among rural adults. Key mediators between the program effects and change in outcomes will also be identified. Finally, we will evaluate program implementation, conduct a cost effectiveness evaluation, and use a positive deviance analysis to understand experiences of high and low changers on key outcomes. Twenty towns will be matched and randomized to one of the two conditions and our aim is to enroll a total of 350–400 rural residents (15–20 per town). Study outcomes will be assessed at baseline, and 6, 12, and 24 months.This study will build the capacity of rural libraries to implement evidence-based walking programs as well as other health promotion programs in their communities. The study results will answer questions regarding the relative effectiveness and cost effectiveness of two multilevel physical activity interventions targeting rural communities. We will learn what works and how these multilevel interventions can be implemented in rural populations.ClinicalTrials.gov Identifier: NCT05677906.The online version contains supplementary material available at 10.1186/s12889-023-16788-0. Engaging in the recommended amount of physical activity (150 min per week of moderate level activity) has numerous health benefits, including lower risk of chronic diseases, such as heart disease and diabetes and some types of cancer . DespiteCall to Action to promote walking and walkable communities highlighting the importance of walking and having safe places to walk [The Socioecological Model (SEM) is a framework for understanding determinants of health behaviors including physical activity. The model emphasizes the reciprocal interplay among multiple levels of influence: individual, social, and community . The SEM to walk . Recogni to walk .Community group-based walking programs have been shown to increase walking, physical activity, and fitness and improve health outcomes, including with rural communities –18. WalkCivic engagement is one approach to built environment change, such as enhancing walkability. Civic engagement refers to individuals participating in the community in order to improve the conditions of the community . Civic eRelative to urban communities, rural communities generally lack the necessary resources to implement public health programming. An innovative public health partner in rural communities is public libraries, which are increasingly offering a multitude of programs –43. A 20Although rural residents face greater health disparities compared to urban residents in terms of chronic disease, there is a major gap in achieving reach and sustainable impact in behavior changes to reduce the risk of these diseases. Multilevel physical activity interventions are likely to be more effective, but there is limited evidence on how they work with rural communities, which often lack the capacity to conduct and sustain these interventions. Thus, disparities in rural physical activity persist. This study addresses this gap by comparing the effectiveness of multilevel physical activity programs that promote walking in rural communities and identifying key mediators of the program. The aims of this study are (1) increase the capacity of rural libraires to deliver evidence-based health promotion programs, (2) compare the effects of a group-based walking program with a combined group-based plus civic engagement program on physical activity, cardiovascular fitness and collective efficacy among rural residents, 2a) identify key mediators between the intervention program effects and change in physical activity, fitness, and collective efficacy, and (3) evaluate program implementation and cost effectiveness.This study is a comparative effectiveness experiment of a group-based walking program, Step It Up!, versus a combined program of both Step It Up! (SIU) and a civic engagement program aimed at walkability, the Change Club. We also will conduct a mixed-method implementation evaluation. At the organizational level (library), a prospective convergent parallel mixed methods design  will be This study will take place in 20 rural communities in Oregon. The US Institute of Museum & Library Services (IMLS) classifies libraries as serving urban, suburban, town, or rural areas using the National Center for Education Statistics (NCES) definitions for each classification . The libThe rural communities in which the libraries are located will be matched on population, median household income, percent of residents who identify as white, walk score, rate of violent crime, percent of population 65 years or older, employment rate, percent residents without health insurance, and area deprivation index. Matched pairs will then be randomized to either a group-based walking program, Step It Up! (SIU) or the combined program (Combined) that includes both SIU and a civic engagement program, Change Club. Cluster (pairs) randomization will be implemented using the Goldilocks approach . This apWe will disseminate results to the scientific community through peer reviewed publications and presentations and to the communities through presentations and written materials, such as an infographic.Increase the capacity of rural libraries to deliver evidence-based health promotion programsCapacity building will start pre-program implementation to get the libraries ready for implementation and will continue throughout implementation. We will provide the 20 librarians with technical assistance on program implementation and $5,000 stipends to support program implementation. Librarians will be divided in two groups based on the randomization, a SIU group and a Combined group and will attend trainings and webinars with their group. We will hold two 60-minute trainings for the SIU program and an additional 60-minute training for the Combined program prior to program implementation. All librarians will receive a SIU Toolkit that provides information on how to set up and deliver a group-based walking program as well as handouts for participants. Librarians in the Combined Program will be given a facilitator guide and curriculum for the Change Club and handouts for participants. Additionally, the Change Club groups will be awarded $5,000 after submitting a budget for use of the funds. We will hold monthly webinars to provide an opportunity for the librarians to learn from and support each other as they plan for and implement the programs. The research team will be available via phone calls or email to librarians throughout the study for questions or individualized support as needed. Each librarian will complete the Public Health Professional Competency Assessment  prior toCompare the effects of a group-based walking program with a combined group-based plus civic engagement program on physical activity, cardiovascular fitness, and collective efficacy among rural residents.Identify key mediators between the intervention program effects and change in physical activity, fitness, and collective efficacy.The objective for Aim 2 is to determine the amplified effects of the combined program on outcomes. Our working hypothesis is that participants in the Combined program will have greater improvement in outcomes compared with SIU program alone because participants in the Combined Program will engage in activities directed at individual, social, and community factors.Librarians, with assistance from the research team, will recruit 15–20 participants. Inclusion criteria are age 18 or older, inactive , ability to walk for at least 20 min, living within the rural community served by the local library, and ability to travel to the local library/location of walking group. Each potential participant will complete the Physical Activity Readiness-Questionnaire (PAR-Q)  as part Recruitment methods will include fliers/postcards/business cards and bookmarks placed at community locations, such as grocery stores, banks, and retail establishments; word of mouth; radio and/or newspaper ads; and press releases sent to local newspapers. Fliers/postcards/business cards or information as worded on the fliers /post cards/business cards may also be posted on the library or city/town government websites and included in printed and electronic versions of library or community organization newsletters.The Socioecological Model and Social Cognitive Theory serve as the theoretical foundation for both SIU and the Change Club. We hypothesize that program effects are mediated by increased self-efficacy, social support, group cohesion, and perceived environment resulting in increased physical activity, fitness, and collective efficacy  . Rural lGroup walks will occur weekly for 60 min. Participants will progressively build up to walking for 45 min at a brisk pace. The first walk will start with setting group norms, building rapport, and developing Specific Measurable Attainable Relevant Timely (SMART) physical activity goals and a short walk. For the next four weeks, the walk will start with a check-in, followed by a 30-minute walk and end with brief stretching. Thereafter, the walks will start with a check-in followed by a 45-minute walk and end with brief stretching. The librarian will use behavior change strategies Table  and willThe SIU group walk will be implemented as described above. The group will meet for the Change Club for 30 min after the group walk. The Change Club curriculum has been revised to be implemented in 30-minute sessions and to focus on walkability. The first month topics include building group rapport and identity and establishing group norms, as well as assessment of community walkability assets Table . Months Data will be collected at four timepoints  by trained research staff. Data collection events will be scheduled at each library at each of the timepoints. The SPIRIT flow diagram , worn on the non-dominant wrist for seven consecutive days. Raw accelerometer data collected at 30 Hz will be processed into physical activity metrics using a machine-learned random forest classifier specifically designed and validated for assessing movement behaviors in free living adults . The ranThe six-minute walk test will measure cardiorespiratory fitness . ParticiThe Collective Efficacy Scale will be used to measure collective efficacy . This suWe will measure height, weight, waist and hip circumference, blood pressure, and resting pulse. Each measurement will be taken twice. Participants will complete surveys that include individual, social, and community level questionaries Table .Results of multiple studies have shown that walking group interventions have small to large effects on physical activity. What is unclear is how much advantage can be gained by combining the walking group and civic engagement interventions. To be conservative, we chose to power this study to detect small effect sizes (Cohen’s d ~ 0.20). We calculated the minimum detectable effect (MDE) for the primary cross-level interaction effect testing whether outcome changes across time differs between intervention groups. MDE was estimated using a multi-level framework using Optimal Design software  for the Survey data will be collected via REDCap, a highly secure and robust web-based research data collection and management system . AnthropStandard descriptive statistics of frequency, central tendency, and dispersion will be used to describe the sample and standard psychometric analyses  will be used to assess the reliability of all self-report measures. Before formal modeling, we will identify any departures from statistical assumptions . All primary analyses for each aim will be conducted ITT . In addition, we will explore adherence-based analyses in which we will compare groups including only participants who completed 70% or more of the intervention after controlling for any covariates related to adherence.Our primary aim will be tested with a linear mixed-effects (multi-level) modeling approach implemented in the lmer package in R. Within this framework, the level-1 and level-2 models will include within-person  and between-person  variables, respectively. An additional level will be added to the model to account for nesting within town. Changes in outcomes across time will be modeled as a fixed time effect and model testing will be conducted to determine how best to represent change in each outcome . Intervention effects will be examined by specifying fixed-effect dummy variables that compare the intervention groups. Specific hypothesis testing will be by specifying cross-level interactions (time x group contrasts) to determine whether differences across time  significantly vary between intervention groups. Model testing will be used to determine the appropriate random effects structure for each outcome, with the default model including random slopes and intercepts. We will evaluate primary hypothesis tests at traditional significance levels  and use modern methods to control for false discovery rate  for postWe will examine dropout and patterns of missing data to determine mechanisms  . In the Mediation hypotheses (sub-aim 2a) will be tested within a structural equation modeling framework in a series of latent growth longitudinal mediation models . The strEvaluate program implementation and cost-effectivenessThe implementation evaluation is based upon the Consolidated Framework for Implementation Research (CFIR) and the Socioecological Model (SEM). The CFIR, derived through a comprehensive synthesis of the implementation literature , has fivWe will select a sample of participants in three waves for audio-recorded 40-60-minute semi-structured interviews. In wave 1 we will focus on adoption. After six months, we will identify 10 participants with positive deviance , high changers, and compare them with 10 participants who have lower changes in these outcomes, low changers. Participants will be selected to maximize variation in location, arm, and attendance to ensure greatest learning. In wave 2, we will focus on understanding sustainability. We will select participants with positive deviance at six months who sustained changes at 12 months, and participants with positive deviance at six months but who did not sustain changes. In wave 3, we will select participants who have sustained change for 24 months. Interviews will explore participants’ experiences with the program, asking open-ended questions about participant, program, and contextual factors that influenced engagement, behavior change, and sustainability of changes. Interviews will explore barriers and facilitators for engaging in the program, social influences , environmental influences , what was most useful and why, what was liked least and most, and what behavior changes were made and why. For civic engagement, we will also ask about approaches to the identified project.For quantitative data we will calculate standard descriptive statistics of frequency, percentages, central tendency, and dispersion.Qualitative analysis will follow an immersion-crystallization approach , using MCost-effectiveness analysis (CEA) will be conducted to evaluate and compare the costs and health gains among different arms. The CEA will utilize the incremental cost-effectiveness ratios (ICERs), defined as the incremental costs of implementing the intervention program over the improvement in the health outcomes in the community, as the primary measure for comparing the interventions. For the incremental costs, we will collect costs directly related to the program intervention excluding research-specific costs. The costs of each component, including recruitment, intervention, retention, and maintenance, of the program will be calculated separately. Improvement in health outcomes will be measured in both natural units  as well as quality-adjusted life year (QALY). We will conduct probabilistic sensitivity analysis to characterize parameter uncertainty in the calculation of ICERs and QALYs. Monte Carlo simulations based on those probability distributions will be used to obtain a joint distribution of costs and impacts in different scenarios in order to calculate ICERs and QALYs. We will use the simulated results to generate a cost-effectiveness acceptability curve to compare the probability that an intervention is acceptable for different range of willingness-to-pay thresholds and identify which intervention program is best in this particular rural population setting. CEAs will be conducted from program, healthcare sector, and societal perspectives. We will measure costs of resources used in intervention administration and implementation. Cost categories include facilities (meeting space), wages, supplies, travel, and training. For the societal perspective, we will measure direct costs included in the payer-perspective cost analysis, plus the opportunity costs, including those that impact participants.Although rural residents face health disparities compared to urban residents in terms of chronic disease, there is a major gap in achieving reach and sustainable impact in behavior changes to reduce the risk of these diseases. Multilevel physical activity interventions are likely to be more effective, but there is limited evidence on how they work with rural communities, which often lack the capacity to conduct and sustain these interventions. Thus, disparities in rural physical activity persist. In this regard, the proposed study will (1) create synergy by combining two interventions to address individual, social, and community factors of physical activity; (2) conduct a mediation analysis to understand underlying mechanisms for behavior change; (3) build capacity of rural libraries for implementation and assessing this sustainable model of implementation, and (4) conduct a positive deviance analysis to understand experiences of high and low changers on key outcomes and using comparative analysis to identify factors that influence outcomes. These approaches will provide insight into how multilevel physical activity interventions work with rural residents and how they can be sustained in rural communities.This study has several strengths. It is building the capacity of rural libraries to implement an evidence-based walking program as well as other health promotion programs in their rural communities. We will build evidence regarding the cost effectiveness of multilevel physical activity interventions targeting rural communities. We will learn what works and how these multilevel interventions work with rural populations, which experience health inequities.There are potential limitations to this study. Recruitment and retention of rural populations can be challenging; however, we will use best practices that have been successful with rural populations –94. TherBelow is the link to the electronic supplementary material.Supplementary Material 1


The practice of medicine faces a mounting burnout crisis. Physician burnout leads to worse mental health outcomes, provider turnover, and decreased quality of care. Peer support, a viable strategy to combat burnout, has been shown to be well received by physicians.This study evaluates the Peer Outreach Support Team (POST) program, a physician-focused peer support initiative established in a 2-hospital system, using descriptive statistical methodologies. We evaluate the POST program using the Practical Robust Implementation and Sustainability Model (PRISM) framework to describe important contextual factors including characteristics of the intervention, recipients, implementation and sustainability infrastructure, and external environment, and to assess RE-AIM outcomes including reach, effectiveness, adoption, implementation, and maintenance.This program successfully trained 59 peer supporters across 11 departments in a 2-hospital system over a 3-year period. Trained supporters unanimously felt the training was useful and aided in general departmental culture shift (100% of respondents). After 3 years, 48.5% of physician survey respondents across 5 active departments had had a peer support interaction, with 306 successful interactions recorded. The rate of interactions increased over the 3-year study period, and the program was adopted by 11 departments, representing approximately 60% of all physicians in the 2-hospital system. Important implementation barriers and facilitators were identified. Physician recipients of peer support reported improved well-being, decreased negative emotions and stigma, and perceived positive cultural changes within their departments.We found that POST, a physician-focused peer support program, had widespread reach and a positive effect on perceived physician well-being and departmental culture. This analysis outlines a viable approach to support physicians and suggests future studies considering direct effectiveness measures and programmatic adaptations. Our findings can inform and guide other healthcare systems striving to establish peer support initiatives to improve physician well-being. Burnout is an existential threat to the field of medicine. Burnout and secondary trauma erode providers’ competency, physical and mental health, and morale –3. The hPerfectionism and mental toughness–reinforced during medical school and residency–pervade the culture of medicine. Emotional reactions to adverse events are seldom acknowledged or discussed. Physicians may feel unable to ask for help, leaving them isolated and ashamed . Many heMedice, cura te ipsum.” However, stigma, isolation, and time constraints pose significant barriers to physicians accessing self-care resources after a traumatic incident [Commonly recommended strategies rely on the individual to perform self-care or seek mental health resources : “Mediceincident . Proactiincident ,19.We describe a novel physician-focused peer support program developed within Kaiser Permanente Northern California (KPNC). While previously described healthcare and physician peer support programs have been studied, the POST model is distinct in its focus on physicians, a robust third-party referral structure, a hyperlocal framework, and strong institutional support.Previously described models of peer support programs in healthcare have reported relatively low physician utilization –23, withHerein we apply descriptive statistical methodologies to evaluate the POST program using the Practical Robust Implementation and Sustainability Model (PRISM) framework . Our priThe Practical Robust Implementation and Sustainability Model (PRISM) was developed to provide a practical, actionable model that could be used to plan and guide interventions and their implementation . PRISM iApplying the PRISM framework, we describe the intervention, the recipients of the intervention, implementation and sustainability infrastructure, and the external environment (PRISM factors), and evaluate reach, effectiveness, adoption, implementation, and maintenance (RE-AIM outcomes). A group of KPNC physician leaders and key stakeholders–front-line providers in high-risk specialties, operational leads, and experts from medical-legal, human resources, patient safety, and physician wellness departments–convened to address the gap in support for physicians. This group designed the Peer Outreach Support Team (POST) program drawing from literature review, psychological first-aid education, applied educational pedagogy, and expert opinion. Prior peer support programs had limited physician reach, institutional support, peer matching, and end-user evaluation, and these were barriers to the effectiveness of these programs. The POST program was purposefully designed to address these limitations. As we describe below, POST is unique among organizational peer support programs in its system of third-party referrals, robust peer supporter training, institutional support, and physician focus and reach.The stated purpose of POST is to leverage the shared experience of trained peers to provide physicians with connection and support for professional stress of any kind.All peer supporters undergo an initial 4-hour training including: understanding of burnout and peer support; confidentiality and risk concerns; program structure; the components of a peer support interaction ; identifTo protect peers and the institution in the case of future legal action, the training emphasizes the importance of maintaining confidentiality, avoiding discussion of case details, and pivoting towards emotional support, with scripting and practice provided. Like previous programs, local legal advisors agreed that peer support poses a very low risk of legal harm and offers crucial benefits for both physicians and patients .The program was initiated in 2 hospitals staffed by a shared physician group in June of 2019 and has continued to spread since then. See This program has benefited from robust institutional support. Peer supporters are paid for their time in training, regular professional development, and check-ins. Both the peer supporter and the physician being supported can bill time for the support interaction. This arrangement is a tacit acknowledgement that physician well-being is valued at an institutional level and addresses the burden of additional time commitments for peer supporters and front-line providers . BecauseOnce a department decides to launch POST, the program is promoted via email, posters, and departmental meetings, and encourages both self- and third-party referrals. Because physicians are often reluctant to reach out to support services, this third-party referral expands the reach of the program . ReferraThe success of POST rests critically on the trust each department vests in its peer supporters. To select the most respected and well-positioned supporters, an anonymous survey is sent to all physicians in a participating department to nominate their peers. Nominated physicians are then offered the position. We have found that a 10:1 ratio of front-line providers to trained peer supporters within departments optimizes capacity matching and potential for culture shift .While POST has strong institutional support and is regionally publicized, its adoption in individual departments and medical centers is voluntary and depends on these departments or hospitals to reach out to our regional team to initiate the steps of starting a program. This process depends on word of mouth and grassroots organizing around an identified need in each local environment. This allows a bottom-up approach which ensures buy-in and investment by local leaders.This program was implemented in a 2-hospital system with strong leadership support, manifesting as financial and institutional support, leadership promotion of the program, and time protection for POST leads. Environmental barriers included busy work schedules limiting time for POST interactions, and a national physician culture of toughness . BurnoutWe evaluate the POST program in two ways and among two populations: 1) we evaluate the POST provider training among trained peer support providers and 2) we evaluate the impact of the POST program among the 11 departments and approximately 530 front-line physicians who had access to the POST program during the study period. We included 3 separate sets of data, with study populations for each enumerated below.To assess program reach, we consider the number of physicians who completed the initial training to become peer supporters, and the number of successful POST interactions between June 2019 and May 2022. All peer supporters were asked to complete a de-identified record including date and length of each completed peer support interaction. If the support was declined, no record was completed. These records were initially kept on paper and the paper form did not collect length of encounter; starting in November 2020 this record-keeping form was transitioned to Microsoft Forms, and length of encounter was captured, thus average time spent was based on interactions recorded via the Microsoft Forms record keeping form between November 2020 –May 2022.We analyzed all recorded encounters from June of 2019 through April 2022. Descriptive statistics were used to summarize encounter data, including the number of interactions overall and by department, and the average time spent per interaction.To evaluate effectiveness of the POST program, we considered perceived effectiveness outcomes using peer supporter and end-user physician feedback. To evaluate the training, an anonymous feedback survey  was administered to all peer supporters who completed the virtual training from 9/2020-1/2022. These included 38 physicians from the following departments: Anesthesia (1), Intensive Care Unit (ICU) (3), Emergency Medicine (EM) (2), Head and Neck Surgery (1), Maxillofacial Surgery (1), Hospitalists (8), Geriatrics (2), Pediatric Hospitalists (2), Pediatric ICU (1), and Adult and Family Medicine (17). The survey included both categorical and open-ended questions designed to probe physicians’ overall impression of the training, confidence in navigating resources, perceived tool and knowledge acquisition, understanding of the referral process, and perception of the online training platform. The survey content was based on review of successes and limitations of earlier peer support programs.Descriptive statistics were used to summarize categorical variables. Content analysis was conducted for the open-ended responses. A team of 3 physician-investigators  applied the constant comparative method ,32, reviTo assess the perceived effectiveness of the POST program for front-line physicians, a department-wide anonymous survey was sent to all staff attending physicians in March of 2022 via email in the longest-running departments, including OBGYN, EM, Hospitalists, ICU, and Anesthesia, a total of 255 physicians. Only the longest-running departments, defined as active for 18 months or longer, were included to allow for the accumulation of a meaningful breadth of experience with the program and an adequate number of peer support interactions to speak meaningfully to the interactions themselves. Eighteen months was chosen as a cut off because previous studies have shown a gradual adoption and fewer referrals in the first year ; based oWe assess adoption at the hospital and health system level by considering the number of departments that adopted the POST program during the study and the number of hospitals who have adopted the program since its launch. We consider the proportion of total physicians in the two-hospital system with active POST teams in their departments. In the department-wide survey, we consider willingness to recommend the program to another department and the proportion who accepted peer support when offered.We assess implementation by describing the process of provider training and program spread, guided by the PRISM framework. We also consider satisfaction with the training and the virtual platform, satisfaction with the program, and reported barriers to use.We assess maintenance by reporting the proportion of peer supporters and departments that remained active and the total number and trend in rate over time of POST interactions since the program was launched. We also describe spread to additional medical centers and the institutionalization of the program.The Research Determination Committee for the KPNC has determined the project does not meet the regulatory definition of research involving human subjects per 45 CFR 46.102(d). Descriptions of the study and its purpose were included with the anonymous surveys, and participation was optional. All data were analyzed anonymously with no identifying information collected; thus, the informed consent requirement was waived.A total of 59 physicians underwent the initial 4-hour POST training to become peer supporters between May 2019 and May 2022, with 38 of these completing the virtual training. During the study period, a total of 11 departments launched POST teams.From June 2019 to May 2022, 306 POST interaction record keeping forms were completed. Of these, the highest utilizer was Emergency Medicine , followed by Anesthesia/ICU  and Hospitalists . Across the 11 active departments representing approximately 530 physicians, there were an average of 8.5 completed interactions per month over the 36-month period, with a range of 1 to 27, and a median of 8 interactions/month. Three departments had no referrals. The interactions took an average of 68 minutes, with a range of 10–180 minutes and a median of 60 minutes.Seventy-five physicians responded to the department-wide anonymous survey . Of the 75 respondents, 66 (88%) responded yes to being aware of the POST program. Of these, 30 (45.5%) had made a referral to the program and 16 (24.2%) had made a self-referral. Of those aware of the program, 32 (48.5%) had a POST interaction themselves; 26 (39.4%) had never had a peer supporter reach out; and 8 (12.1%) had had a peer supporter reach out but declined. Of those who had a peer support interaction, 18 (56.3%) had two or more interactions.Of the 38 trained providers, 37 (97%) responded to the training feedback survey. Of respondents, 100% described the training as good or excellent on a 5-point bimodal Likert scale and 100% agreed that the training gave them a framework and tools to promote a culture of mutual support within their department. For perceived effectiveness outcomes, we also considered results from the department-wide anonymous survey. Overall, physician respondents rated the program very favorably . The majWe received open-ended responses from 42 (63.6%) of the 66 respondents who were aware of the program and our study team identified 8 broad themes of program benefits and potential barriers to use. We then divided these into perceived effectiveness outcomes  and implOf the 40 respondents to the department-wide survey who had had a peer supporter reach out to them, 32 (80%) accepted the support. Of 66 respondents with awareness of the program, 55 (83.3%) would recommend the program to another department.Over the three years of study, 11 departments had voluntarily adopted the POST program. This represents approximately 530 physicians, or approximately 60% of all physicians in the 2-hospital system. By September of 2022, 3 years and 3 months after initial launch, 7 additional hospitals had successfully launched the POST program, with more expressing interest.Implementation of the POST program remained a grassroots approach, relying on word of mouth, leadership promotion, and interest and requests from local departments to start a program. This contributed to local momentum and greater ease of implementation. Small groups of peer supporters were trained at a time, maintaining an atmosphere of participation and interaction. Spread was a natural and gradual process spurred by increasing acceptance of peer support and cultural change. Facilitators as identified in the PRISM framework  includedDepartment-wide survey respondents reported high rates of awareness of and satisfaction with the program . A majorReported barriers to POST acceptance identified in the survey included lack of time to schedule a POST interaction , lack of perceived need , privacy concerns , not being comfortable talking about emotions with colleagues , and medical-legal concerns . Of survey physicians who rated their overall satisfaction with the program as neutral  or negatively , only 3 (15%) had had a POST interaction, whereas of those who rated their overall satisfaction as very satisfied  or satisfied , 30 (68.2%) had had a POST interaction. Difficulty accessing the program with time constraints was also identified as a barrier in open-ended responses .Of 37 trainee feedback survey respondents, 100% described the training as good or excellent on a 5-point bimodal Likert scale, with high perceptions of confidence and satisfaction with the training . We founThe number of successful interactions per year increased over the 3-year study period across all active departments, from 73 in the first year, to 109 in the 2nd year, to 124 in the third year of the study period. The average number of interactions per month increased from 6.1 in the first year of the program to 10.3 in its 3rd year.The program was able to achieve and maintain the target ratio of 1:10 peer supporters to physician staff in all departments . Of the We describe the development and key guiding principles of the POST program, a novel physician peer support program, and its implementation in our health system. Applying the PRISM framework, we identify important contextual factors that impacted the implementation of the program in a 2-hospital system. The success of the program can be seen in its substantial reach, perceived effectiveness, physician adoption, and continued spread to additional departments and hospitals. The use of PRISM and consideration of RE-AIM outcomes allows for important conclusions which may guide spread and local adaptations in future sites.Several contextual factors were key determinants in POST implementation. Key facilitators included optimal peer matching, institutional support, and financial support. The survey data confirmed that providers valued institutional and financial support as a positive implementation theme. Respondents also noted the importance of peers, allowing more profound understanding and connection. The departmental structure allowed true peer-to-peer matching, an aspect well-demonstrated in the literature as beneficial and most widely accepted by physicians . BarrierEarlier models of peer support programs in healthcare reported lower physician reach, with fewer referrals and more limited program spread –23. ShapOur survey data shows that physicians felt the POST program has been effective. As far as we know, this is the first evaluation of a peer support program to incorporate and report end-user feedback, which allowed individual and culture-level perceived effectiveness considerations. Physician recipients of peer support reported increases in well-being, mitigation of negative emotions and stigma, and beneficial cultural shifts within their departments. Respondents, even those who had not used the program, felt having the program available helped bring positive cultural shifts toward greater acceptance of self-care and mental health practices in their departments. Our findings suggest both individual and system-level benefits of an effective physician peer support program.We found that the POST program was adopted broadly across the 2-hospital system and has since successfully spread to other hospitals across the region, with high retention of peer supporters trained. A majority of respondents in active departments would recommend the program to another department, and this lends itself to further spread, as we rely on word of mouth and requests to bring the program to new locations. Acceptance was maintained over time, with annual rates of peer support interactions increasing each year over the 3-year period. These findings together suggest a successful bottom-up approach for rollout of a peer support program, relying on successful pilot departments, word of mouth, and gradual spread to departments and medical centers who are ready to adopt the program.Access to skilled peer supporters was identified as a key facilitator of the program. Positive reviews of the peer supporter training suggest that effective training enabled peer supporters to feel confident supporting their peers. Many peer supporters valued hands-on training and practice, including role-play and breakout sessions. Most trainees rated the virtual platform very highly, a potential leverage point to ensure consistent training standards and efficient, effective spread. We suspect there is an important relationship between the value of the training and the positive impact and perception of the program, and an emphasis on robust training may increase the success of any peer support initiative.While the POST program had positive impacts across multiple departments, EM had the highest number of referrals. This may be due to a high number of critical cases, a greater burden on front-line providers during the COVID-19 pandemic, and higher rates of burnout in this specialty . The morThe departmental survey was administered via email with only 1 reminder one week later. Limitations to response include lack of financial incentives, busy schedules, and full email inboxes. The number of physicians who opened the email and those who were on PTO or leave is not known, and these physicians were likely missed. Given these factors, we believe the response rate still provides a broad and diverse cross-section of the population of interest allowing meaningful conclusions. A future study may put into place financial incentives or a more direct survey measure to garner a higher response rate.This study considered perceived effectiveness for trained peer supporters and physician recipients of peer support. While meaningful measured outcomes included confidence and tool acquisition for peer supporters, positive psychological impacts of peer support, changes in wellbeing, and perceived cultural benefits, we did not measure direct effectiveness outcomes including direct quantitative measures of burnout, sick leave, extended time away from work, physician turnover, nor direct measures of departmental culture and psychological safety. The findings suggest future studies are needed that include rigorous direct effectiveness outcomes.Our study period included a 3-year period. We believe this allowed effective evaluation of the program’s reach, adoption, maintenance, and perceived cultural and individual well-being effects. A future study could consider a longer time period to measure and draw conclusions regarding the long-term effect of a peer support program on a living and evolving healthcare organization.This study was conducted in a unique clinical environment, a large integrated healthcare delivery system providing comprehensive inpatient, ED, and ambulatory care for over 4 million people, staffed by a multi-specialty group of physicians. The results from this study are not universally generalizable to other healthcare systems or physician groups. Future studies of peer support programs in a variety of healthcare models are needed to delineate the generalizability of these findings.Physician burnout impacts physician health, the effective functioning of our healthcare systems, and patient outcomes. We found that POST, a physician-focused peer support program, had widespread reach and a positive effect on perceived physician well-being and departmental culture. Several components of the POST program, including its physician and department-level focus, robust institutional support, third-party referrals, and value placed on effective peer supporter training, were identified as facilitators, and likely contributed to the program’s reach and perceived effectiveness. Our findings can inform and guide other healthcare systems striving to establish peer support initiatives to improve physician well-being.S1 Appendix(DOCX)Click here for additional data file.S1 File(XLSX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.S3 File(XLSX)Click here for additional data file.


The purpose of this study was to examine experiences and impacts from participating in an adult swim instruction program. We conducted 20 semi-structured interviews with adults aged 18 + who had participated in an adult learn to swim program. Participants were interviewed through a virtual platform using a semi-structured protocol. Data were coded individually by each member of the research team for emerging thematic outcomes with final consensus among all those involved in the analysis. Participants expressed adult learn to swim programs had an effect in three areas: (a) life affordance, (b) emotional affect, and (c) interpersonal relationships. Public health experts and aquatics leaders should consider targeting programs aimed at teaching adults to learn how to swim, especially to marginalized individuals and those who did not grow up in the United States. The authors highlight how these programs can create life affordances well beyond lap swimming and even water safety.The online version contains supplementary material available at 10.1186/s12889-023-17320-0. Aquatic activities are popular leisure pursuits across the globe, from swimming pools, oceans, lakes, and rivers, there is a water-based activity for all throughout the lifespan. Aquatic pursuits can also promote personal and population health through physical activity, social connections, and sense of wellbeing . AlthougThere are various reasons why adults do not learn to swim as children or identify with having low swimming competence . VariablAccess to drowning prevention resources is inequitably distributed within communities in the United States. For example, demographic factors are significant predictors of swimming ability. In a 2009 study, African American respondents reported a 57.5% “at risk” (unable to swim or uncomfortable in the deep end of the pool) swimming ability. Similarly, Hispanic/Latino children confirmed a 56.2% “at risk” level as compared with 30.9% for White subjects . FurtherIf an adult has a negative prior aquatic experience, they are more likely to have a fear of water and a lower achievement and progress during swim lessons . A 2021 andragogy, meaning “the art and science of helping adults learn” [Knowles proposed a theory of adult learning, called s learn” . Knowless learn” , 23. Ands learn” . We must understand the barriers that prevent individuals from learning to swim. Negative prior aquatic experiences as children is one important factor to be considered as they can affect one’s interest in learning to swim and perceived skill level. When adults have a negative aquatic experience there is an interplay between four psychological constructs: (a) past experiences, (b) difficulty or challenge associated with the outcome, (c) reinforcement and personal interactions with significant others, and (d) intrinsic motivation . Adult sIt is also important to acknowledge that not all hesitancy to swim is individual or related to negative prior aquatic experiences as children. In the United States, Jim Crow laws and racist practices created segregated pools leaving Black/African American children and families without access to most public pools for generations . During The purpose of this study was to examine experiences and impacts from participating in an adult swim instruction program. The United States Masters Swimming Adult Learn to Swim (ALTS) program is designed for community members who are interested in learning to swim. Instructors are generally member volunteers with a local master’s program. Adult swim instruction programs can help fill the gap of individuals who never had the opportunity to learn to swim as a child and would like to learn now as an adult and although not a requirement, many of the participants in the program are members of marginalized communities. The authors sought to understand the experiences and motivations of adults that learn to swim later in life. Our qualitative study employed semi-structured interviews as a basis for data collection. Qualitative interviews are a popular research method in social science research that aims to uncover participants’ experiences, attitudes, and beliefs about a particular phenomenon , 30. TheThe research team was comprised of four individuals with a background in social science research and qualitative research. Two faculty members, one from medicine and one from public health led the design and implementation of the study. Together, they have more than 30 years of experience as qualitative researchers. Additionally, two doctoral students participated in the interviews and analysis of the data. Our team was also diverse in terms of gender, age, and race/ethnicity.A local masters swimming program in the Midwest, operated by a member organization of United States Masters Swim (USMS), was used as the primary source for potential study participants. Contact information for pre-identifying program participants was obtained with consent of the study site organization with potential subjects receiving information about the study through email correspondence. Once participants expressed interest, a member of the research team coordinated the interviews.Semi-structured interviews were conducted by members of the research team and transcribed using Zoom. Interviews were held between February and June of 2022 and scheduled for 45-min. Permission was obtained from study subjects to record interviews. A recent study highlighted the benefits of using videoconferencing technology, which can overcome barriers to participation and reach a wider range of participants . Given tParticipants for this sample were recruited from a USMS Adult Learn-to-Swim program in the Midwest region of the US. Subjects included registered program participants between 2014–2021. Subjects were recruited from an existing registration database, contacted via email and invited to respond about participation. Participants were only contacted to participate after completing the swimming program. Based on the nature of the program described above, swim instructors do not have due influence over the participants.Participants who completed at least one session were recruited for interviews to understand their experiences, motivations, and outcomes of participating in an adult swim instruction program. Participants were asked to voluntarily share their age, gender and race/ethnicity. Among the participants, 11 self-identified as female and 9 as male. Furthermore, seven participants self-identified as Black/African American, five as White non-Hispanic, two as Hispanic/Latino, three as Indian, two as Asian, and one as Native American/White.The research team partnered with USMS swim program leaders who provided the roster and contact information for individuals who had previously participated in the program. The research team contacted individuals via e-mail and invited them to patriciate in a virtual interview. Before scheduling, participants were provided information about the study and were informed about a gift card incentive for participation.Inductive thematic analysis was used to construct a variety of themes from the data. The interview transcripts were read and a coding taxonomy was developed. Following two distinct readings of the transcript data, codes were identified and grouped, leading the creation of themes . Raw datThemes were grouped into three categories: (1) life affordance, (2) emotional affect, and (3) interpersonal relationships. Representative quotes are presented for each theme.For the purpose of this research study life affordance is defined as what the environment offers the individual, in this case the ability to swim can expand life experiences and opportunities that would otherwise be inaccessible. This section explores the pursuit of life affordances as a motivating factor for learning to swim. Learning to swim provided participants not only with swimming, but also a wide variety of water-based activities. For some, participating in the program went beyond just the water and reminded them of the importance of staying active and learning new things later in life. Many acknowledged their motivation to learn to swim was fueled by a desire to feel confident pursuing water-based recreation and leisure activities. For example, a participant, an Indian male in his 20s, described his motivation and life affordance this way, that they “want to do some enjoyable activities like scuba while I travel, that would be something I would want to pursue to enjoy my life.” Another participant, a White male in his 20s, explained how the program helped him overcome his fear, “the program helped me become more adventurous for sure, because I went from never being able to swim to doing shark cage diving at night and diving with manta rays in Hawaii.” Having swimming competence provided these participants with enjoyable life experiences they would not have otherwise been able to partake in. These life affordances can broaden horizons and open possibilities that were previously unavailable.Life affordances and motivations related to water-based physical activity opportunities were also referenced by participants. One participant, a Black/African American female in their 40s explained, “You know, with exercise I’m able to get exercise, and I could see myself doing like water aerobics at my gym and things that I maybe would not have been able to do…and I’m super proud of myself and that would not have happened if I hadn’t taken that course.” Another participant, a White female in their 30s said, “So I wanted an activity an exercise activity as well, so I did the lessons and then that winter I got a membership at the gym for the indoor pool, and I did swim all that winter.” These examples illustrate the impact feeling comfortable in the water can have on recreational and physical activity choices. Having the ability to participate in water-based physical activity, in addition to other life affordance opportunities, has the potential to positively impact additional health outcomes as well as behaviors, creating a ripple effect on personal wellbeing.Swimming or the idea of swimming and aquatics-based activities elicited many different emotions for participants. Participants reported their experience learning to swim as frustrating, nervous, anxious, and intimidating. Participants indicated that not knowing how to swim was often deeply rooted in visceral fear of water and drowning. As a result of the program, participants shared feelings of excitement, accomplishment, and confidence.Most participants shared emotions and beliefs about water that went back to childhood. Many of these participants shared some of the emotions that caused them to avoid swimming and water, often long into adulthood. For example, a participant, an Indian male participant in his 30s shared, “I think for me, as with a lot of other participants, it was a fear of swimming.” He went on to share his experience swimming as a child by saying, “I took some classes in high school, but I still had this pretty drastic fear of the water. So, that is what it was for me, I think, it was based on this inability that I felt I had, and I feel like the program helped.”For many, the program was transformational and altered for the better their perceptions A participant, a Black/African American male in his 20s explained, “I remember very vividly the instructor had taken us over to the deep end. He wanted us to jump into the water. I was like, I don’t know if I want to do this.” He went on to share that after going through a couple of classes he jumped into the deep end of the pool and said, “I remember jumping and was like ‘it’s not that bad.’ I won’t forget that. It was unreal. I have skydived before and all this other stuff. I don’t know what it was about it, but I did it. I think that helped me progress to another level.” For another participant, a White male in his 60s, the program helped him to gain confidence. He said, “if there is something you think you want to do then no matter how hard it is, you should go ahead and do it. For me there was a lot of confidence building (from completing the swim program).” This program not only helped participants overcome barriers, but it also built confidence for themselves and had a ripple effect on others in their lives.Participants’ interpersonal relationships served as a prominent reason for deciding to complete an adult swim instruction program. For many participants, having parents or family members who could not swim played a large role in them not learning how to swim as children. Participants indicated that swimming was rarely discussed in their families and communities. For example, a White and Native American male in their 60s shared, “as a kid, I had a father who was terrified of water. His mother was terrified of water too. My dad said that his mother was afraid even to let him or his brother take a bath because she was that terrified of water.” For many participants, they grew up in families where their parents, grandparents, and other adults in their life did not swim. As a result, they were not exposed to water-based activities or did not take swimming lessons.Interestingly, it was also interpersonal relationships that caused many adults to decide they wanted to learn how to swim. For example, one participant shared that she was now a grandmother and she wanted to feel comfortable taking her grandchildren to the pool to swim. Similarly, several participants were parents and they wanted to make sure their children could swim, so they could fully participate in social activities with their friends. For example, a Black female in her 40s, and a mother of four, shared how the experience influenced her adult cousin to decide to swim, “she doesn’t know how to swim very well either. On vacation I told her about my experience with my swim class and now she is into it (where she lives).” The experience also helped this participant connect with her adult children. “There was kind of trickle down and also my kids—I have four adult kids—they all know how to swim, and I was like the only one in the family that didn’t know how to swim. They were really proud of me for learning to swim and now we are talking about planning a vacation to beach as a family and enjoying the water together.” As she reflected on the past year she said, “You know I have done a lot of transformation this year so I am like a new mom.”The experiences and impacts of an adult swim instruction program were examined by conducting 20 semi-structured interviews with adults. The participants expressed that the program had a positive effect in three areas: life affordance, emotional affect, and interpersonal relationships. The intentional design of this programs acknowledges the unique needs highlighted in adult learning  .The results of this work may inform the importance of water safety programs directed towards teaching adults to swim. Regardless of whether they continued to swim as a form of exercise, the process of learning how to swim and overcoming the fear of water opened doors not only for participants but also for others in their lives . FurtherMany participants entered the program with previous experiences that influenced their emotional response to aquatic activity. Adult learning theory provides a framework for understanding internal motivation and readiness to learn . These eAlthough the goal of the Adult Learn to Swim program is to teach adults the skills to swim, the benefits of this program seem to span beyond the lane lines of the pool . In factA limitation of the study was the number of participants. Although this study was held over a 5-year period, consistent contact between participants and program leaders at the conclusion of the program was a challenge. Another limitation concerned our research team itself, which did not include anyone who was born out of the United States. Additionally, no one from Black/African American or Indigenous/Native American populations participated in the data collection or analysis, so our ability to understand the lived experiences of participants from these backgrounds was limited. Future studies could explore the experiences of the volunteers who teach this program, as well as replicate this study at various locations in the United States.This study provides valuable insights for program developers and public health officials on the potential benefits of adult swim instruction programs beyond just swimming skills and safety. The authors emphasize that these programs can create life affordances beyond lap swimming and water safety. Further research can expand on the study’s findings and explore other potential benefits of adult swim instruction programs.Additional file 1.