Basic Emergency Care (BEC): Approach to the acutely ill and injured, a multi-day, open-source course for healthcare workers in low-resource settings. Building on the BEC foundation, this study uses an implementation science (IS) lens to develop, implement, and evaluate a comprehensive emergency care curriculum in a single emergency facility in Liberia.Emergency care is vital in low- and middle-income countries (LMICs) but many frontline healthcare workers in low-resource settings have no formal training in emergency care. To address this gap, the World Health Organization (WHO) developed BEC content, standardized WHO clinical documentation forms, African Federation of Emergency Medicine (AFEM) didactics, and clinical mentorship by visiting emergency medicine (EM) faculty was designed and implemented using IS frameworks at Redemption Hospital, a low-resource public referral hospital in Monrovia, the capital of Liberia. Healthcare worker performance on validated knowledge-based exams during pre- and post-intervention testing, post-course surveys, and patient outcomes were used to evaluate the program.A six-month emergency care curriculum consisting of Nine visiting EM physicians provided 1400 hours of clinical mentorship and 560 hours of didactic training to fifty-six Redemption Hospital staff over six-months. Median test scores improved 20.0% (p<0.001) among the forty-three healthcare workers who took both the pre- and post-intervention tests. Participants reported increased confidence in caring for medical and trauma patients and comfort performing emergency care tasks on post-course surveys. Emergency unit (EU)/Isolation unit (IU) mortality decreased during the six-month implementation period, albeit non-significantly. Course satisfaction was high across multiple domains.BEC implementation over a six-month timeframe using IS principles is an effective alternative strategy for facilities in resource-constrained environments wishing to strengthen emergency care delivery.This study builds on prior research supporting WHO efforts to improve emergency care globally.  Disease Control Priorities 3rd edition (DCP3) estimates that emergency care can address the conditions that account for approximately half of deaths in LMICs such as diarrheal diseases, lower respiratory infections, and trauma [Emergency care is a vital part of effective healthcare systems. In low- and middle-income countries (LMICs) identification and treatment of life-threatening conditions are critical because of the high burden of time-sensitive injuries and illnesses . Diseased trauma , but frod trauma ,3,4. Emed trauma –12. Othed trauma .Basic Emergency Care (BEC): Approach to the acutely ill and injured, an open-source emergency care training program for frontline healthcare workers in low-resource settings [BEC is an important resource for frontline healthcare workers in low-resource settings, but may need to be augmented for individuals with limited prior emergency care training or experience. As such, there is a significant opportunity to develop more robust and comprehensive programs by building on the BEC foundation.To address the need for context-specific and accessible emergency care education, the World Health Organization (WHO), International Committee of the Red Cross (ICRC), and International Federation of Emergency Medicine (IFEM) developed settings . The fivsettings . EffectsLiberia is a low-income nation in West Africa  that hasBEC implementation over a six-month timeframe as part of a robust program is an effective alternative strategy for facilities in resource-constrained environments wishing to strengthen emergency care delivery.Given these unique historical gaps in emergency care training in Liberia, an implementation science (IS) framework was used to develop, implement, and evaluate a comprehensive emergency care program based on open-source WHO and African Federation of Emergency Medicine (AFEM) curricula in order to support frontline healthcare workers in a single emergency facility in Liberia. Here, we describe the development, implementation strategy, and preliminary outcomes of the program. We demonstrate that Redemption Hospital is a 175-bed secondary level referral center and the only public hospital serving Monrovia, the capital of Liberia. It has a 10-bed emergency unit (EU), a small isolation unit (IU), maternal and pediatric wards, a general inpatient medical ward, and outpatient services. In June 2014, Redemption Hospital was closed to prevent EVD transmission after twenty staff were infected, twelve of whom died from the disease . The hosReach, Effectiveness, Adoption, Implementation, and Maintenance framework (RE-AIM) [To understand why gaps in emergency care knowledge and practice existed after the implementation of SQS, the flexible, non-linear approach of IS was used to design and implement a comprehensive six-month emergency care program. IS strategies, including an Implementation Research Logic Model (IRLM)  and the (RE-AIM) ,26 were The emergency care program was created over a one-year span in 2018. Initial planning of the intervention focused on engaging key stakeholders and identifying barriers to healthcare worker behavior change. The WHO in-country lead, Minister of Health, County Chief Medical Officer, Chief Medical Officer at Redemption Hospital, Emergency Unit Nursing Director, and hospital administration were all involved in the programmatic planning and implementation. Feedback from frontline healthcare workers was also solicited during discussions of the intended impacts of the program on clinical documentation, patient care, and patient mortality. All key stakeholders took part in developing the program and helped ensure it met healthcare worker needs, was appropriate for implementation, and did not interfere with patient care. Initial meetings addressed gaps in education based on both anecdotal information and data from previous program implementation. Taking this information into account, the program implemented was designed to address these gaps and meet the local needs of the hospital and frontline workers. Key stakeholders were involved in each step of programming from deciding how to implement the curriculum, to specific curriculum supplemented and taught via AFEM open source lectures. Regular updates were relayed to all stakeholders and final data was shared upon completion of the program. All healthcare workers consented for voluntary participation in the program.BEC content and lectures from the African Federation of Emergency Medicine (AFEM) open-source lecture bank [BEC implementation period was adapted based on the clinical environment at Redemption Hospital. Given that there were few healthcare workers, short, on shift clinical didactic sessions were held two to three times a day to minimize disruptions to patient care. BEC was supplemented with AFEM content based on stakeholder requests for further educational material on common disease entities in Liberia. To facilitate shorter didactic sessions and additional AFEM content, the curated didactic curriculum for Redemption Hospital spanned over six-months broken into monthly blocks based on organ system and common chief complaints seen in Liberia. Triage had a dedicated curriculum integrated into the monthly content to ensure continual reinforcement and practice.WHO ure bank  were selThe WHO Standardized Clinical Forms for Medical and Trauma Patients  and RedeBEC and AFEM curricula. Visiting EM faculty were oriented via a series of phone calls and written guidelines, had frequent check-ins with the principal investigators while in-country, and 24-hour access to an in-country research assistant. While on-site, visiting faculty worked between five and six, eight-hour shifts per week for two to four weeks in the EU and IU at Redemption Hospital, conducting daily didactic sessions and providing clinical mentorship. When problems or delays occurred in teaching schedules or clinical shifts, the curriculum was adjusted to accommodate for unforeseen events. Visiting faculty members functioned as teachers and mentors to healthcare workers and were not intended to primarily care for patients presenting to the EU. They delivered the curriculum and worked alongside providers helping them make clinical decisions, utilize critical thinking, practice implementing knowledge and skills, and deliver adequate care based on the curriculum being taught. Once visiting EM physicians returned from Liberia, feedback was solicited through exit interviews to improve programming.At the time of program development, there were no long-standing board-certified EM physicians working in Liberia. Nine visiting board-certified EM faculty were selected to facilitate the program based on their experience working clinically in low-income countries and their comfort with The RE-AIM framework ,26 was uBEC knowledge-based exam was administered prior to program implementation to assess baseline emergency care knowledge. After completion of the program, a distinct post-course WHO BEC knowledge-based exam was proctored to assess emergency care knowledge acquisition. A survey was also administered to all participants to assess course satisfaction, confidence treating emergency conditions, comfort performing emergency care skills, and gather feedback for future programming  and in the six months during course implementation (January 2019—June 2019) was performed to compare EU/IU mortality. Patient disposition was stored on a password-protected Excel sheet with encryption for analysis.The study, including chart review, was reviewed and deemed exempt by the National Research Ethics Board of the Liberian Ministry of Health and Social Welfare and the Institutional Review Board of the University of California San Francisco. All participants gave oral consent to participate in the course. Patient consent was waived for the chart review portion of the study.Descriptive and exploratory data analyses, not presented here, were conducted prior to program implementation to determine the most common patient chief complaint and available medical equipment and infrastructure to drive overall program content. Descriptive data on program provider enrollment is presented as numbers and percentages. Provider self-assessments of knowledge and comfort with emergency care tasks, are reported as means with standard deviations and compared using paired t-tests. Scores on pre- and post-implementation validated exams are compared by Wilcoxon Rank Sum Tests, and stratified by provider type, location, and question category. Clinical outcomes are limited to EU/IU mortality, with additional clinical metrics, such as time to antibiotic administration, reported in a subsequent study. EU/IU mortality was calculated as the number of adult patients who died in the EU or IU, not including those who died before arrival, divided by the total number of adult patients seen in the EU or IU in the given study period as measured by EU/IU ledger records. EU/IU mortality was compared pre-implementation and cumulatively during implementation, via the chi-square (χ2) statistic. Course satisfaction surveys  are presented as means and standard deviations. Statistical analyses were performed using STATA 17 .A total of fifty-six frontline healthcare workers participated in the 6-month course. The majority of participating staff were nurses or physician assistants ; additional staff included hygienists and nursing assistants . Emergency and acute care at the facility under study included both an emergency (EU) and isolation unit (IU); over two-thirds of providers worked primarily in the EU  and 18 (32.1%) worked in the IU.Pre-implementation self-assessed knowledge and comfort with performing tasks associated with the key domains of the course ranged on average from 3.62–4.13  . On averOver the 6-month implementation period, nine visiting board-certified EM faculty presented 560 hours of didactic content to Redemption Hospital staff and provided 1,400 hours of bedside clinical teaching and mentorship. In total, sixty individual lectures were presented to EU staff and fifty-two to IU staff.Overall, the median score on validated pre-course assessments was 48.0 (IQR: 36.0–52.0) among fifty-three individuals. The median score on a distinct validated post-course assessment was 68.0 (IQR: 48.0–80.0) among forty-six participants . SignifiPre- and post-course test scores were also stratified by question type. There were significant improvements across all domains, with the largest median difference in pre- and post-course scores in questions about difficulty in breathing .Overall course satisfaction was high across multiple domains .Those with a post-course test score greater than 60% were more likely to strongly agree that the quality of emergency care at Redemption Hospital improved ; and more likely to strongly hypothesize that EU/IU mortality improved , though this association was not significant. Participants also provided free-response comments to aid in future course development and EU/IU improvements. In general, comments suggested increased training and support for systems improvements.Comprehensive evaluation of the program was conducted using the IS RE-AIM framework . OverallExcluding patients who died prior to arrival, 1,958 and 1,523 patient encounters recorded in the EU/IU ledger were reviewed in the pre-implementation and during-implementation study periods respectively. EU/IU adult mortality did not change during course implementation .BEC content, AFEM lectures, standardized documentation with existing and modified WHO clinical forms, and clinical mentorship by visiting EM faculty. Overall, the program increased healthcare worker performance on validated knowledge assessments, confidence in treating critically ill medical and trauma patients, and comfort with performing all emergency care tasks. Emergency Unit (EU) and Isolation Unit (IU) mortality decreased during the course implementation period, although not significantly. This program offers an alternative implementation strategy for the WHO BEC toolkit that allows for curriculum adjuncts and further clinical support over a longer period. Implementing such a program under the frameworks of IS ensured continual assessment of factors that contributed to the translation of evidence-based practices into clinical practice.The goal of this study was to develop, implement, and evaluate a comprehensive emergency care program to support frontline healthcare workers in a single public hospital in Liberia. Several IS concepts including an Implementation Science Logic Model (ISLR) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework were used for planning and evaluation of the six-month program. The program incorporated open-source resources including WHO BEC in Zambia, Tanzania, and Uganda [BEC participants, 48.0% as compared to 60.5%, likely due to the lower degree of existing emergency care training in Liberia. Physician assistants and nurses had higher pre-course test scores than participants with lower levels of training, but all providers had significant improvement on post-course exams, which suggests that the program was relevant for the wide variability in the level of training and experience at Redemption Hospital. When stratified by practice setting, IU staff performed better on post-course exams than did EU staff. Multiple factors may have contributed to this finding including better testing conditions in the IU, which often had fewer patients and disruptions than the EU, in addition to a more consistent learning environment over the course of the curriculum.The effectiveness of the program was assessed first by healthcare worker knowledge acquisition, as measured by differences in validated pre- and post-course exams. Improvement in performance on knowledge-based assessments was comparable to pilot programs of d Uganda . In thesBEC programs in Zambia, Tanzania, and Uganda, additional iterations have been implemented in emergency facilities in Nigeria, Sierra Leone, Ukraine, and Kiribati and adapted for each clinical context [In addition to the pilot  context –33. In t context ,35.BEC into a longer, comprehensive program delivered over a six-month period. Additionally, this is the first BEC implementation in Liberia, either as a standalone program or as part of a larger initiative. Besides the country-wide SQS program, only a few emergency care training courses in Liberia have been described. Basic life support (BLS), advanced cardiovascular life support (ACLS), pediatric advanced life support (PALS), and a modified neonatal resuscitation (NRP) curriculum were previously taught by American Heart Association healthcare providers during a two-day program at a rural hospital in Liberia [BEC as part of a comprehensive emergency care program to achieve this aim in Liberia.To our knowledge, this is the first program to incorporate  Liberia . Several Liberia . As manyClinical outcomes associated with educational interventions are infrequently reported in existing literature. A recent study in Uganda demonstrated that three-day patient mortality during the implementation of a two-year emergency care training program for nurses in a rural emergency facility was 2.0%; however, the study did not assess mortality before program implementation for comparison . A signiThis research also adds to the existing knowledge base, because emergency facility mortality in Liberia has not been previously reported. Mortality in emergency facilities in other Sub-Saharan LMICs is estimated to be 3.4% . In otheThis study was implemented in a single center in Sub-Saharan Africa and the program was adapted to the specific needs of Redemption Hospital; therefore, the exact contents and outcomes of the program may not be generalizable to other LMIC emergency facilities. Additionally, the course relied on partnerships with visiting EM physicians, which may not be a sustainable model for longer term programming. A train the trainer model was intended, but unfortunately was not feasible during this pilot study due to unit leadership changes. As a pilot project we were limited in our scope. Future iterations must include a train the trainer model. Additionally the advent of COVID-19 made measures of sustainability and follow-up challenging. Despite these limitations, the general framework of this program is applicable to a wide variety of low-resource settings and is an important example of how basic concepts in emergency care can be implemented as part of a comprehensive curriculum using IS concepts.Despite efforts to standardize data collection methods, inconsistent and missing records limited the quality of patient outcome data collected and may have introduced bias that affect the validity of the patient data. For example, not all patient charts were reported in the ledger introducing sampling bias. Several months of pre-course ledger data was missing and not included in analysis. Additionally, in this preliminary analysis possible confounders such as demographics, initial vitals, and chief complaint were not adjusted for due to the limitations of the existing data.We also recognize that there is a significant risk of Hawthorne effect as the presence of having visiting faculty in the EU may have substantially led to behavior change on behalf of the participants. This effect, however, was intentional and served as a key driver of modeling behavior change. Additionally, while no substantial changes in infrastructure or personnel occurred over the study period, we also did not specifically collect and are not thought to have impacted the data in a meaningful way. Other factors may have limited the validity of the outcome measures for participant knowledge. Attendance at on-shift lectures was below 100% due to various reasons. Despite lectures being repeated several times and given at various times throughout the day to accommodate staff availability and schedules, staff were still not able to attend lectures due to low staffing in the EU and IU and importance of not disrupting patient care. In creating the program we understood that this was a potential limitation of the implementation plan and attempted to mitigate this through supplying staff with BEC workbooks and on-line AFEM lectures so they had access to all the material to review on their own. Additionally, not every visiting physician was as diligent at taking attendance during lectures and unfortunately, sign-in sheets were sometimes not utilized. Lastly, there was a component of burn-out among frontline healthcare workers as the program proceeded and they chose not to attend lectures despite being available. As participation in this program was voluntary, visiting professors tried to motivate such staff through encouragement and making the lectures engaging; however, these tactics did not always lead to participation.BEC. Therefore, we cannot comment on the cost-benefit analysis of this program as compared to BEC as a standalone program.Quantitative self-assessment of comfort performing emergency care tasks was used to assess programming instead of skill-based scenarios, which may have introduced bias and limited validity of the data. Skill based testing is a more objective measure, but unfortunately was not feasible given time and personnel restraints. The post-course qualitative survey was written in such a way that some of the questions could be construed as being leading to participants. This was not done intentionally and the survey questions followed a format previously used to assess self-reported knowledge and skills of healthcare workers in Liberia. Additionally, this paper does not report on overall costs related to this program and costing analysis has not been reported for Lastly, many frontline healthcare workers expressed that they lacked resources to change their practice in the EU and IU at Redemption Hospital. Although we did not report or collect data on physical resources, qualitative participant feedback suggests that investment in infrastructure and medical equipment may be needed to see additional benefits of emergency care training at Redemption Hospital.Implementation of a comprehensive six-month emergency care program specific to the local needs of a single public hospital in Liberia, using open-source AFEM and WHO tools, was feasible using an IS framework to ensure appropriate translation of evidence-based practices into the clinical environment. Using an ISLR model helped to identify key stakeholders and the RE-AIM framework grounded assessment of the program. The program was sustainable and scalable because smaller elements were taught on a repeating basis with continual assessment and improvement. Using IS frameworks, EM faculty helped evaluate and improve programming after every teaching block. Imperative next steps include making the program sustainable by training local stakeholders who can continue the iterative improvement cycle in a train the trainer model.BEC and additional WHO tools provides lessons for facilities in resource-constrained environments wishing to strengthen emergency care delivery.In summary, the course increased provider performance on validated knowledge-based exams, confidence in treating critically ill medical and trauma patients, and comfort with performing emergency care skills. EU/IU adult mortality decreased during the program implementation period, albeit not significantly. Due to the COVID-19 pandemic, longer term maintenance of the effects of this program could not be studied. This study builds on previous research supporting efforts to improve emergency care globally. Sharing these novel, adaptable strategies for implementing S1 Appendix(TIF)Click here for additional data file.S2 Appendix(TIF)Click here for additional data file.


Since 2003, the MLA Membership Committee has facilitated an in-person mentoring program called Colleague Connection at the annual meeting. The program hinged on meeting attendance, so members who could not attend were excluded. The 2020 virtual meeting created an opportunity to rethink the Colleague Connection experience. Three members of the Membership Committee developed an expanded and virtual version of the mentoring program.Colleague Connection was promoted via the MLA ’20 vConference Welcome Event, MLAConnect, and email lists. The 134 participants were matched based on same-chapter preference, library type, practice area interest, and years of experience. Mentees chose mentor-mentee or peer pairs, resulting in 4 peer matchings and 65 mentor-mentee matchings. Pairs were encouraged to meet monthly, and conversation prompts were provided. A Wrap-Up Event was held for participants to talk about their experiences and network. A survey evaluated the program and sought suggestions for improvement.The online format boosted participation, and the format change was well received. In the future, a formal orientation meeting and communication plan can ensure pairs make their initial connections and provide clarity about program details, expectations, timelines, and contact information. The type of pairings and size of the program are important considerations for the feasibility and sustainability of a virtual mentoring program. Mentoring programs are a common feature of professional library organizations. Organizations such as the Australian Library and Information Association (ALIA) , 2, the A variety of mentoring opportunities have existed through the Medical Library Association (MLA). Past annual meetings have provided interactive mentoring sessions , 16. OthThe Colleague Connection initiative began in 2003 as a mentoring program for first time MLA annual meeting attendees. Led by the MLA Membership Committee with support from MLA staff, the goals of Colleague Connection are to strengthen relationships between MLA members and promote awareness of opportunities to grow within the organization. By introducing new members to the MLA structure and possibilities for involvement with groups or service roles, the Colleague Connection event, as the only MLA-wide mentoring program, supports retention and development of a “professional home” for MLA members. In past years of the program, a first-time MLA annual meeting attendee was paired with a more experienced attendee. The connection focused on the one-time, in-person meeting and helped new attendees navigate the meeting. Since the connection hinged on annual meeting attendance, members who could not attend the meeting were excluded. The mentoring relationships were generally short-lived and were limited to the parameters of what mentors' and mentees' conference schedules allowed.In the spring of 2020, as MLA and other organizations began to shift to online-only programming due to the COVID-19 pandemic, we (three MLA Membership Committee members) decided to plan an extended online Colleague Connection program. Several articles and meeting abstracts detail the challenges and benefits of developing online mentoring programs through professional organizations , 25–27. As MLA and other organizations moved programming online, the MLA Membership Committee made quick plans to offer an online mentoring program. We held a planning meeting in mid-July 2020 to devise the overall structure, map out a timeline, and assign responsibilities for recruitment, matching, and communicating with participants.The new virtual Colleague Connection program was announced on July 27, 2020, during the MLA vConference Welcome Event. To reach members who did not attend the Welcome Event, weekly MLAConnect emails advertised the program from late July through mid-September. Colleague Connection was also promoted via the MLA Community Council and through chapter email lists.We marketed the program as a way for both new and experienced members to expand their professional networks. Mentors were also told that mentoring a colleague would help someone navigate a new organization and profession. The program dates were advertised as October 2020 to January 2021. Anyone interested in participating in the program signed up via an online form on the MLA website.One hundred thirty-four people signed up, including MLA members from the United States, Canada, and 3 other countries. This represents approximately 5.4% of MLA's total membership of 2,469, as reported in the 2020-2021 MLA Headquarters Annual Report . SeventyMentees could choose to be matched with either a fellow new member or a mentor. Participants provided their name, email address, institutional affiliation, geographic location, years in librarianship, librarian type, chapter affiliation, preference for a same-chapter match, and primary interest by practice area. We also asked mentors if they would be willing to mentor more than one person.Most participants came from academic libraries, followed by hospital libraries. Mentees averaged six years of experience. Fifty-seven percent of mentees (n=42/74) had 1 to 3 years of experience. Mentors averaged 15 years of experience, and 70% of mentors (n=42/60) had more than 10 years of experience in librarianship. Sixteen mentees and 6 mentors wanted to be matched with someone from their own region or chapter, but most did not express a preference. Education  and Information Services  were the two most frequently selected areas of practice.Matching was based on preference for same-chapter match, type of library served, primary interest by practice area, and years of experience. Once completed, sixty-five mentees were matched with a mentor. Since there were more mentees than mentors, five mentors were assigned two mentees. Nine mentees opted to connect with a peer, forming three pairs and one trio.All participants were notified of their matches by early October 2020 and were encouraged to meet for the first time that month. It was up to the pairs to establish their own meeting times and frequency and to determine the meeting format. We hoped pairs would meet at least once a month during the four-month program.Email messages sent at the beginning of each month provided some structure to the program and served as a reminder to meet. The initial email shared some conversation prompts to help get things started. Prompts included questions like “How did you get where you are career-wise?,” “How are you involved in MLA?,” and “What do you wish you had known earlier in your career?” November's email highlighted volunteering to serve on a jury or committee, joining a caucus, presenting at the annual meeting, or applying for the MLA Rising Stars program. In December, we included a recap of questions from the October email. In January, we suggested pairs discuss how they keep up with the literature and how they create and maintain CVs and resumes. We also promoted a Wrap-Up Event and asked for volunteers to share their experiences from the program.The Wrap-Up Event, held on January 28, 2021, marked the official end of the program. More than forty people attended the forty-five-minute event. The MLA Membership Committee Chair and the MLA President each gave introductory remarks. Three mentorship pairs talked about their experiences with the program before we offered two rounds of small group networking in breakout rooms. Pairs expressed that they were glad to get the chance to connect with another MLA member. Other attendees mentioned in the chat that they enjoyed the program.In early February 2021, we surveyed participants about their experience in the virtual Colleague Connection program (Appendix A.) The survey was open for one week, from February 4 to February 11, 2021. The online survey was generated using Qualtrics through the University of Iowa. The University of Iowa Human Subjects Office determined the survey did meet the regulatory definition of human subjects research and therefore did not require IRB review. After an introductory question about how the survey respondent participated in Colleague Connection, there were two versions of the survey—one for mentors and one for mentees and peer pairs. After the survey closed, results were exported to Microsoft Excel. Qualtrics provided minimums, maximums, means, standard deviations, variances, count data, and percentages. In some cases, we combined the responses for mentors and mentees. Responses to the open-ended question were grouped thematically.The survey asked about the number of times participants met and if that was sufficient, whether they planned to continue meeting, if the frequency of communications was sufficient, if mentors would participate again, if mentees felt the program was beneficial, and if mentees would recommend it to another new member. Fifty-four percent of participants (n=73/134) completed the survey, including 62% of mentors (n=37/60) and 49% of mentees (n=36/74).Most participants reported meeting 3 to 4 times during the 4-month program. During that time, the mean for mentors was 3.5 meetings and the mean for mentees was 3.8 meetings. More than half of the survey respondents  indicated that they would continue to meet with their mentor/mentee after the formal program concluded, while 29% (n=21/73) said they might meet, and 15% (n=11/73) reported that they did not plan to meet in the future.Seventy-four percent of respondents (n=54/73) indicated the 4-month program was an appropriate length of time. Fourteen percent of mentors (n=5/37) and a third of the mentees (n=12/36) said the program was too short. None of the mentors thought the program was too long, but two mentees  would have preferred a shorter program duration.When asked whether the communication frequency was sufficient, 90% of respondents (n=66/73) indicated the 1 email per month from coordinators was sufficient. Five people (7%) indicated the question was “not applicable” to them, and 2 (3%) answered “no.” Unfortunately, the peer pairs were inadvertently left off the email lists. These peer groups received an initial email with their matches; however, they did not receive any further communication from us. Respondents who answered “no” to this question were mentees and not members of peer pairs.Since the program was designed to support new members, we asked the mentees if the number of times they met was sufficient and whether the program was beneficial to them. Three-quarters of mentees (n=27/36) felt the number of times they met with their mentor or fellow new member was sufficient. Concerning the program's benefit, 31 mentees  indicated the program was “definitely” or “mostly” beneficial.Most mentors  replied that they would participate in the program again, while the rest  said “maybe.” Similarly, we were curious whether the mentees would recommend the program to other new MLA members. Most mentees  selected “yes.”At the end of the survey, we asked an open-ended question to determine how the program could be improved. Thirty-six respondents provided additional feedback. The following themes emerged: expressions of thanks; comments about communication; suggestions and observations about the program format, frequency, length, and timing; examples of pairings that were not as successful; cases of scheduling difficulties; and explanations of program benefits.Regarding program format, frequency, length, and timing, a couple of mentors commented that they were usually very busy during the annual meeting and appreciated that this more flexible schedule allowed them to spend more time getting to know their mentee. Three mentees felt an introductory meeting would improve their experience. One person offered that the program could run year-round, while another felt that offering it twice a year would allow more people to participate. Four respondents suggested the program should be longer than four months. One person proposed the timing could overlap with the annual conference to give participants the opportunity to meet beforehand and discuss their experiences at the annual conference afterwards.Communication was another theme that surfaced in the open-ended comments. One person mentioned sending an email after the initial pairing to make sure everyone successfully connected with their mentor or fellow new member. In addition, four people commented they did not receive the monthly emails.In terms of reception, ten respondents provided notes of thanks or mentioned that they thought the new version of Colleague Connection went well. Four mentees highlighted program benefits. For example, a recent MLS graduate explained that their mentor helped them become “a better medical librarian,” gave them resume advice, and prompted them to join a caucus.Due to the COVID-19 pandemic, we moved the Colleague Connection program online. We recognized that moving to an online format provided an opportunity to improve and expand the program. Since the event previously occurred during the in-person MLA annual meeting, most pairs only had time to meet once, given the limited meeting time and competing demands on their attention. Aware of these limitations, we hoped to offer an online mentoring experience that met the program goals and offered more flexibility to participants to decide when and how often to meet. We also sought to help foster connection between MLA members several months into a stressful global pandemic.We attribute the success of the 2020 Colleague Connection event to several factors.The virtual format enabled more people to participate since the program was open to all MLA members and participation was not tied to annual meeting attendance. In 2019, there were 66 participants in the in-person program, and the virtual version in 2020 saw the number of participants double to 134.The event was spread over four months, allowing participants more time for discussion and the opportunity to meet more than once. We hoped that participants would meet once a month, and most survey respondents indicated they met three to four times.The timing of the mentoring session did not overlap with the annual meeting, allowing mentors and mentees to discuss meeting participation ahead of the May 2021 virtual conference. One conversation prompt encouraged participation in the meeting by preparing an abstract for submission. During the Wrap-Up Event, we heard of an instance where a mentor encouraged a mentee to submit an abstract for MLA.Although the first iteration of the new Colleague Connection program went well, we know it could be better. Potential improvements center on orientation, communication, and value. The kickoff was all done via email: we did not offer orientation meetings. In hindsight, we could have held a virtual meeting at the start so all participants could mingle and meet their mentors or mentees for the first time. At the Wrap-Up Event, some participants mentioned they had not participated in a professional mentoring program before and may not have known what to expect. Outlining basic expectations, the timeline, and program communication could have helped people feel ready to participate sooner and more fully.An orientation would also help ensure pairs met at least once. Not all participants found the time to meet due to busy schedules and different time zones. In addition, a few matches never connected, which was evident in some of the survey responses and in our experience hearing from participants during the program. Hines reported similar issues, noting in that program that a survey respondent explained that she “never received the contact info for her protégé” but neither party reached out to organizers for help . In futuThis case study provides a window into one online mentoring program, but it has some limitations. Half of the 2020 Colleague Connection participants did not fill out the survey, so we do not know about their experience. We do not have historical information about participants or outcomes of the in-person Colleague Connection events. Participants were not specifically asked about the relationship they developed with their matches and whether their participation in the program led to more engagement; however, we received some feedback about this during the live Wrap-Up Event.Although participants were asked whether they would continue to meet after the official program ended, they were not asked to elaborate on their responses. Asking this question could have given some additional insight into the connections. Additionally, we did not set out to discover or follow known best practices as we transitioned from in-person to online. Like many other groups, we quickly pivoted and drew on our collective experiences with the Colleague Connection program to provide the best program under the circumstances.We suggest future post-event survey questions could offer choices of specific potential benefits of the program and goals of the MLA Membership Committee, such as more engagement in the organization or a higher comfort level with certain aspects of their work.Despite this, a few open-ended responses yielded important information about program benefits. Respondents also offered constructive feedback about how to strengthen the program. Hines reported a similar experience with their survey, noting “the open-response questions were the most valuable and informative” . IntentiWe offer the following recommendations for future events or others planning similar virtual mentoring programs for their professional organization. The first three recommendations build on survey respondents' answers to the open-ended question that asked them how future iterations of Colleague Connection could be improved.Hold an online orientation at the outset of the program.In-person events at annual meetings should correspond with a virtual component before or after the in-person meeting.Consistent communication is important. Participants should be informed about program details and expectations, the timeline, and how to reach organizers if they encounter any issues. Along the same lines, Hines proposed that feedback should be solicited “at a halfway point through the program to catch problems … before they become big issues later” .A discussion board could broaden and deepen the experience and allow for more connections. Ma and Wong and Hines describe this communication piece as a potential supplement to meetings among the pairs , 27.Limit pairings to mentor-mentee pairings only, reserving peer-to-peer mentoring for another program. More experienced mentors have more insight into the organization, and since one objective of Colleague Connection is to increase engagement in MLA, a mentee-mentor match is best in this context. The single option also simplifies coordination for organizers.Consider matching based on areas of need or interest—for example, job and resume support; solo librarianship; tenure-track positions; or liaison-specific roles.Other MLA groups offer dedicated mentoring programs. MLA's Rising Stars program, which accepts four mentees per year, is currently the most supported. Chapter and caucus-specific mentoring efforts are not standard across groups or years; hence, the MLA Membership Committee's Colleague Connection is the longest running, all-MLA mentorship offering. Other MLA groups might be able to match participants by identity or background more than our MLA-wide initiative and could offer peer-to-peer connections.In this initiative, the Colleague Connection program could be sustained in a virtual or hybrid format with continued leadership from the MLA Membership Committee and MLA staff. The virtual program was coordinated by three MLA Membership Committee members; one MLA staff member coordinated the virtual program. If Colleague Connection program demand increases or the scope of the mentoring offered by the Membership Committee grows, program support will need to increase. Some survey respondents suggested lengthening the program or offering it more than once during the year; however, the small number of people serving on the Membership Committee would need assistance from other groups to implement those changes.Overall, participants who completed our survey were pleased with the virtual Colleague Connection program. Though necessitated by the pandemic, it brought about positive changes to a long-running Membership Committee initiative.


In diffuse large B-cell lymphoma (DLBCL), a positive interim positron emission tomography (PET) scan predicts treatment failure, but the proportion of high-risk patients thus identified is small. To improve prediction, we combined the interim PET result with the presence or absence of an associated IgM gammopathy. Of 108 DLBCL patients participating in a prospective trial, nine (8%) were interim PET positive and 19 (18%) had an IgM gammopathy. The monoclonal protein was not associated with distinguishing genetic features, and its light chain restriction was not always concordant with the light chain restriction of the lymphoma. The information provided by interim PET and IgM gammopathy was combined to dichotomize the population into sizeable high-risk (1–2 adverse factors) and low-risk groups (no adverse factor) with widely different outcomes . Multivariable analyses including established risk factors revealed the interim PET result and the IgM gammopathy status to be the only factors significantly associated with outcome. Information about interim PET response and IgM gammopathy may be useful in studies testing risk-adapted treatment strategies.The online version contains supplementary material available at 10.1007/s00277-023-05393-1. Diffuse large B-cell lymphoma (DLBCL) is the most common cancer of the immune system. It can be cured by immunochemotherapy in about two-thirds of cases . Prognos18[F] Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is the imaging modality of choice to define pretreatment lymphoma dissemination and post-treatment remission status. It can also be used to predict outcome. Baseline total metabolic tumor volume (TMTV), largely representing tumor mass, is of paramount importance, outperforming the IPI , 4. EarlTM assay that allows distinction between μ heavy chains linked to κ as opposed to λ light chains [TM assay measuring unbound κ and λ light chains [κ and IgM-λ outside the reference range indicate a monoclonal gammopathy [Similar to other types of B-cell lymphoma, DLBCL can be associated with a monoclonal immunoglobulin. The most common type in Western Europe, IgM gammopathy, has been associated with poor outcome –10. It it chains . Similart chains , 13, calmmopathy .Interim PET is a suitable method to identify chemotherapy-refractory patients , but theClinicalTrials.gov NCT00554164; EudraCT 2006-001641-33) was a multicenter study for newly diagnosed aggressive non-Hodgkin lymphomas [The PETAL trial  received four more cycles of R-CHOP or the same treatment plus two extra doses of rituximab. Patients with an unfavorable response (“positive” PET scan) were randomly assigned to receive six additional cycles of R-CHOP or six blocks of a more intense, methotrexate- and hyperfractionated alkylator–based protocol originally developed for the treatment of Burkitt’s lymphoma . RadiothProspective collection of baseline blood samples for scientific analyses was restricted to patients recruited in the final two years of the trial.max) of the hottest residual lesion on the interim scan by the SUVmax of the hottest lesion on the baseline scan (ΔSUVmax). Negative scans were defined by complete disappearance of all non-physiological FDG activity or SUVmax reduction by >66% [max procedure proved highly reproducible [max procedure with a cut-off value of 66%, considering scores 4 and 5 of the Deauville scale as high risk yields a higher proportion of false positive results and considering only score 5 as high risk yields a lower number of high-risk patients [max method [The imaging conditions have been described previously . The tre by >66% . In the oducible  which waoducible . Comparepatients , 17. TMTx method . Becausex method .TM and HevyliteTM assays  were performed at the Central Laboratory of the University Hospital of Essen to measure serum free κ, free λ, IgM-κ, and IgM-λ concentrations and calculate the respective ratios [κ, 3.3–19.4 mg/L; λ, 5.7–26.3 mg/L; κ:λ ratio, 0.26–1.65; IgM-κ, 0.19–1.63 g/L; IgM-κ, 0.12–1.01 g/L; IgM-κ:IgM-λ ratio, 1.18–2.74).The Freelitee ratios , 11–13. κ, clone A0191, dilution 1:15,000; λ, clone A0193, dilution 1:14,000; all from DAKO, Glostrup, Denmark) and evaluated visually by an experienced hematopathologist (WK) for specific cytoplasmic and/or membranous staining, with tonsil tissue serving as a positive control. MYC, BCL2, and BCL6 translocations were assessed by fluorescence in situ hybridization  [To group the lymphomas according to the cell-of-origin (COO) classification , availabIL, USA) . ChromosIL, USA) , and mutctDNA was isolated from pretreatment plasma samples using Qiagen’s QIAamp Circulating Nucleic Acid Kit  and evaluated by CAPP-Seq as previously described –26. Quanhttps://llmpp.nih.gov/lymphgen/index.php) from targeted sequencing of either tumor or plasma specimens. CAPP-Seq-derived mutation calls were generated using a 608 kb targeted sequencing panel suitable for genetic subclassification [LymphGen subtypes  were inffication , 29. Genfication , 31.2 test or—in case of low numbers—Fisher’s exact test, and continuous variables were compared using the Mann-Whitney U test. Time-to-event end-points were analyzed using the Kaplan-Meier estimator, the log-rank test, and, when adjusting for covariates, Cox proportional hazards regression [All analyses were exploratory, applying a two-sided alpha of 0.05. Frequencies were compared using the chigression . All anaOf 609 DLBCL patients participating in the PETAL trial, 108 had pretreatment blood samples available for immunoglobulin analyses. Patient, lymphoma, and treatment characteristics were typical of DLBCL (Tables κ), and 19 (18%) had an IgM monoclonal protein   had elevated concentrations of one or both free immunoglobulin light chains, 23 21%) had a monoclonal free light chain , we focused our analysis on IgM monoclonal gammopathy. IgM gammopathy tended to be associated with old age and unfavorable risk factors, with a statistically significant increase in the proportion of patients with high-intermediate or high IPI risk Table . A largeMYC translocations between IgM gammopathy–positive and IgM gammopathy–negative lymphomas (Table n=8) or plasma specimens with sufficiently high ctDNA levels (n=53). In univariable analysis, no individual gene was significantly differentially mutated between patients with or without IgM gammopathy . Of note, mutations in TP53 or MYD88 recently reported to occur in 31% and 31% of IgM gammopathy–positive DLBCL [CD79B reported to occur in 23% of IgM gammopathy–positive DLBCL [There were no statistically significant differences in histomorphology, COO subtype, or as Table . ctDNA las Table , left. Cve DLBCL , were obve DLBCL , were fove DLBCL . There wκ, 1 λ). In only one case was the light chain restriction in the lymphoma concordant with the light chain of the monoclonal serum protein (κ).By immunohistochemistry, four of seven available biopsies from patients with IgM gammopathy expressed IgM and three expressed light chains (2 n=3) was restricted to patients with IgM gammopathy.The PET response to the first 2 cycles of R-CHOP did not significantly differ between patients with or without IgM gammopathy Table . The intAmong IgM gammopathy–positive patients, only one of 19 had a positive interim PET scan. Outcome of interim PET-negative patients with IgM gammopathy was as poor as outcome of interim PET-positive patients without IgM gammopathy Fig. , top. ThTo identify factors impacting outcome systematically, time to progression and overall survival were subjected to univariable Cox regression analysis. Among nine dichotomous variables investigated, only IgM gammopathy, interim PET, and TMTV were statistically significantly associated with outcome Table . The IPIBecause of low numbers of events, multivariable Cox regression analyses were restricted to three variables at a time . When thElevated free light chains and monoclonal free light chains were associated with reduced time to progression and overall survival, but this association failed to reach statistical significance Table .Efforts to improve the identification of high-risk patients for risk-adapted therapies have been hampered by the fact that a more precise definition of risk is generally paralleled by a decrease in the number of patients at risk. Models predicting a 50% risk of progression at 3 years often pertain to only 5–15% of patients, with the majority of patients eventually progressing remaining unidentified , 6, 33. MYC translocation [MYC translocation. In the PETAL trial, MYC translocations were found to be statistically significantly associated with a positive interim PET scan [The major reason for the good performance of the combination is the fact that, except for one patient, the populations identified by a positive interim scan or an IgM gammopathy did not overlap. Despite a negative interim PET scan, the outcome of IgM gammopathy–positive patients was poor. Failure of interim PET to predict outcome has also been reported for lymphomas harboring a location  whose frlocation , 34. Thelocation , only onPET scan .The frequency of IgM gammopathy among DLBCL patients observed in our study 18%) was in the same range as described previously 13-19%) , 8, 10. % was in -19% , 8,To identify the origin of the monoclonal protein, we performed IgM and light chain staining in a limited number of available tumor specimens. Immunohistochemistry revealed IgM expression in four, concordant light chain restriction in tumor and monoclonal serum protein in one, and discordant restriction in two of seven samples studied. In two earlier studies, concordant light chain restriction, always associated with IgM expression, was found in 17 of 19 89%) and 6 of 6 samples , respectively 9% and 6 , the proIn contrast to other studies , 12, 13,The major limitation of our study is its small size. Progression, relapse, or death occurred in a limited number of patients, precluding more extensive multivariable analyses . The obsIn conclusion, interim PET and IgM gammopathy can be combined to dichotomize the DLBCL population into sizeable groups with excellent or poor prognosis. If confirmed in an independent cohort, the interim PET/IgM gammopathy combination may be useful in studies testing risk-adapted treatment strategies.ESM 1(PDF 295 MB)Below is the link to the electronic supplementary material.


A randomised trial of European Fans in Training (EuroFIT), a 12-week healthy lifestyle program delivered in 15 professional football clubs in the Netherlands, Norway, Portugal, and the United Kingdom, successfully increased physical activity and improved diet but did not reduce sedentary time. To guide future implementation, this paper investigates how those effects were achieved. We ask: 1) how was EuroFIT implemented? 2) what were the processes through which outcomes were achieved?We analysed qualitative data implementation notes, observations of 29 of 180 weekly EuroFIT deliveries, semi-structured interviews with 16 coaches and 15 club representatives, and 30 focus group discussions with participants (15 post-program and 15 after 12 months). We descriptively analysed quantitative data on recruitment, attendance at sessions and logs of use of the technologies and survey data on the views of participants at baseline, post program and after 12 months. We used a triangulation protocol to investigate agreement between data from difference sources, organised around meeting 15 objectives within the two research questions.We successfully recruited clubs, coaches and men to EuroFIT though the draw of the football club seemed stronger in the UK and Portugal. Advertising that emphasized getting fitter, club-based deliveries, and not ‘standing out’ worked and attendance and fidelity were good, so that coaches in all countries were able to deliver EuroFIT flexibly as intended. Coaches in all 15 clubs facilitated the use of behaviour change techniques and interaction between men, which together enhanced motivation. Participants found it harder to change sedentary time than physical activity and diet. Fitting changes into daily routines, planning for setbacks and recognising the personal benefit of behaviour change were important to maintain changes. Bespoke technologies were valued, but technological hitches frustrated participants.EuroFIT was delivered as planned by trained club coaches working flexibly in all countries. It worked as expected to attract men and support initiation and maintenance of changes in physical activity and diet but the use of bespoke, unstable, technologies was frustrating. Future deliveries should eliminate the focus on sedentary time and should use only proven technologies to support self-monitoring and social interaction.ISRCTN81935608, registered 16/06/2015.The online version contains supplementary material available at 10.1186/s12889-023-15419-y. Low levels of physical activity and high levels spent in sedentary time are contributing to the increasing global prevalence of non-communicable diseases such as cardiovascular disease, type 2 diabetes and some cancers,  and innoOne approach to attracting men to lifestyle change is to offer programs in partnership with professional sports clubs, which is expected to attract men through the draw of the football club. –8 The fiOne adaptation of FFIT was the European Fans in Training (EuroFIT) program . EuroFITBefore recommending the widespread roll-out of EuroFIT, we wanted to investigate in more detail how it was implemented and whether it worked as we expected it to do. We thought this more detailed information could support future deliveries and add insight into how lifestyle change programs delivered in professional sports settings can work to both attract men and enable positive public health outcomes. Thus the aim of this paper is to examine the process through which EuroFIT achieved its effects. We do this by reporting a mixed-method process evaluation  designedBefore describing our methods, we outline the EuroFIT program and the theories underpinning it .The EuroFIT program was designed to support men to: become more physically active and less sedentary; improve their diets; and maintain these changes over the long term. It was delivered over 12, weekly, 90-min sessions that combined ‘classroom’ discussion, including ‘tools’ for behaviour change, with group-based physical activity. All sessions were led by football club community coaches. Full details of EuroFIT are published including a description of the program in the TIDieR template  and a suRelational, physical and financial resources are needed to implement EuroFIT, including professional football clubs with sufficient commitment to try delivering the program and to recruit coaches willing to take part in training. The program also requires access to club facilities and materials for the program, and funding to pay for materials such as manuals and t-shirts Fig. . FundingEuroFIT drew on theories derived from various schools of thought in psychology and sociology. From psychology, EuroFIT drew explicitly on contemporary theories of motivation specifically, self-determination theory  and achiwith and not against them. For example, we expected that EuroFIT would attract men because it was male-only and based in professional football clubs, a context which is recognised as symbolically valuable to many men , about the size of a matchbox, to self-monitor their daily step count  and time spent upright (for sedentary behaviour) , 25. TheFor the duration of the research, the country-based research teams provided implementation support for football clubs. This included funding to deliver the program, guidance on recruiting participants, provision of detailed manuals for coaches, a two-day training program for club coaches and support for trouble shooting problems during delivery. Full details of the implementation process and support offered to clubs are already published .The mixed methods process evaluation reported here was embedded in the EuroFIT RCT  “I liked the fact that we received a lot of relevant information. It gave me the confidence I needed. I wouldn’t have been the same with a manual only. I liked having the information up front, so I felt I knew what I was saying. It was good. Was positive. A good combination of theory and practice.” Analysis of interview data showed that coaches were generally positive about the training they received and felt it prepared them to use the tools they needed to be able to deliver the EuroFIT program. For example, one said:However, analysis of study implementation notes showed a high turnover of coaching staff at some clubs in the UK with some of the coaches originally trained to deliver to program leaving their posts before delivery or part-way through the program. As a result, the research team had to develop bespoke interim training (which took one instead of two days) for new UK-based coaches.In relation to the theory of change, the relational resources described as necessary for program delivery, were available in all countries, as were the financial resources (because they were covered by the research grant). We recruited clubs through professional networks, although additional efforts were needed to replace clubs that dropped out of the study in the Netherlands and Norway. program .Attracting men to theDo you want to become more active with [club name]? “and explained that “EuroFIT aims to help you increase your physical activity levels and to be less sedentary. The program will offer you a toolbox of skills and techniques for living a healthy life and a chance to get fitter and feel better in yourself.” Materials also highlighted that the program would be interactive, led by club coaches, and that they would be with like-minded people, saying; “Each session includes physical activity led by [CLUB] coaches at [YOUR STADIUM/TRAINING GROUND] as well as focusing on how to incorporate new skills and techniques into your everyday life. The sessions will also offer you the opportunity to meet like-minded people and share tips and advice.”To recruit participants, football clubs e-mailed invitations to fans and used club websites, social media posts, features in the local press, and match-day leafleting/announcements to advertise the program . RecruitN = 80), with the Portuguese clubs attracting particularly high levels of interest.Data from expressions of interest forms showed that advertisements proved attractive to men wanting to join the program particularly in the UK and Portugal. The mean number of men per club expressing an interest in joining was 200.2 (155–272) in the UK, 121.0 (87–187) in the Netherlands, 155.3 (128–205) in Norway, and 441.0 (333–616) in Portugal. In every club, expressions of interest exceeded the number of places available .Participation in the EuroFITCoach-reported mean attendance at the 12 EuroFIT sessions was comparable across the four countries: 8.7 sessions (SD 3.3) out of 12 sessions in the UK, 9.8 (SD 2.5) in the Netherlands, 8.1 (SD 3.0) in Norway and 8.7 (SD 3.2) in Portugal. Analysis of post program questionnaires showed, as reported previously . I looked at the group and knew they would not be interested in these glasses and discussing how many lumps of sugar would be in them, well you know. This pouring, it doesn’t fit with this group.” [C-NL1-INT]As reported previously,  fidelityIn relation to the theory of change, we presumed that fidelity in delivery would be important to initiate and maintain change and thus to achieve outcomes. Based on the analysis we can say that the program was largely delivered as intended because most of the key elements were delivered in the observed sessions and coaches described situations in which they were adapted the content to deliver flexibly as intended. 8, Table  theory of change – attract men).Participants’ reported reasons for joining, continuing with or opting out of the EuroFIT program  and Portugal (46.8%), than in the Netherlands (24.3%) and Norway (26.2%). This did not resonate with the post-program focus groups, which all mentioned the importance of the club as a draw. For example, in the Netherlands, one man explained how getting privileged access to valued parts of their club attracted him:P6:Meet similar people as well.I:Yeah.P6:The same age group, same interests and, you know, perhaps eating too many beefburgers and having too many pints [of beer], um, being able to relate and move forward together as a group. [P-UK5-PPFGD].In the baseline questionnaires, participants in Norway (46.9%) and the UK (34.7%) were more likely to report that being with men ‘like them’ was a reason for joining than participants in the Netherlands (12.9%) and Portugal (15.0%). Again, there was some dissonance between questionnaire and focus group data, with examples of wanting to be with men ‘like them’ emerging in focus groups in the UK, Netherlands, and Portugal. For example, in a post program discussion in one UK club, participants agreed why they were attracted to EuroFIT:I was thinking about that actually …. That it was only men [–-] If there had been women I wouldn’t have joined.’ [P-NL3-PPFGD]. In Portugal too, one man suggested: ‘I liked the idea of being with other men of my age and condition’ [P-PT1-PFGD].In the Netherlands, the importance of the program being men only was emphasised: ‘In relation to the theory of change, the assumption of multiple motivations for joining the program proved correct, with men in all countries commonly citing 'weight loss', 'desire to improve lifestyle' and 'getting fitter' as reasons to join and there was agreement between data sets .The coach then asks: “Have you guys been to the match?” “Yes,” said one of the men, “it was spectacular.” “I know right?” said the coach, “I saw you there!” “Yes, 4–3 hey?!”’ (OBS-NL1)We expected that interactions between men, and between coaches and men, would be important for group cohesion and success. The theory of change Fig.  suggesteThe way coaches valued participants was also made evident through ‘grand gestures.’ For example, in one club in the UK, a coach gave a teddy bear to a man who had just had a child. Participants in all four countries also commented on these exchanges and the welcoming nature of coaches Men’s enjoyment of the program was evidenced by observations that men’s interactions were often interspersed with jokes and banter, which contributed to the supportive environment, the fostering of relatedness and enjoyment of sessions. For example, observation of a physical activity session in the Netherlands recorded:In summary, in relation to the theory of change, the observations of sessions confirmed the assumptions we made about the importance of positive interactions in delivering outcomes .Our theory of change made the coaches’ role explicit only in relation to how they interacted with men and how they encouraged interactions. Implicit to the theory of change, however, is that coaches, through following the program manual and being well prepared for sessions, would be crucial in providing an excellent motivational environment to support change  which inThe coach manual was very handy. It was really nice to have these clear instructions” [C-NL4-INT].In interviews, coaches in all countries reported that they found the manual essential for delivering the program. For example, a coach in the Netherlands said: “Along with the other tools, then the SMART-goals have also been very good indeed, and those you link with the SitFIT and MatchFIT, and that is like, that you get to link those tools together has been a very good method [C-NOR2-INT]There was agreement between the observations and interviews that coaches did teach participants how to use of the ‘toolbox’ of BCTs. For example, a coach in Norway said: [training emphasised] you need to do that, erm, which, which definitely is good advice. Erm, so yeah, I think goal setting is very important. The guys did stick to it. [C-UK1-INT]Sometimes, the guys trying to make big targets, we'd try and calm them down. Which, again, theMany of the coaches played an important role in the repetition and practice of BCTs, and prompted men to set optimal challenges for themselves, building on their own progress, as one coach from the UK explained:“I think they also found it difficult, like how to choose something [a SMART goal] that is specific enough and that I can potentially accomplish.” [C-NL2-INT]However, other coach interviews showed that it could be hard to explain goal setting to participants, as one Dutch coach explained:“.. so at a certain moment, some of the men – not all of them—would go like ‘Yeah, I know by now!’ and they no longer felt like evaluating progress over and over again.” [C-NL4-INT]The repetition of goal setting each week could be experienced as boring, as a coach from another Dutch club explained, suggesting that goal setting may be important in initiating but not maintaining changes:I like very much that they [participants] set their own goals and that we get to choose the tools we need ourselves. We try, we give them many options to take those tools that fit into their everyday life and that we do not say that so and so and so, and if you do not do this, you fail. That you, that we make them aware, and that making your own choices is done every day, that we take those choices unconsciously in a way. [C-NOR2-INT]Coaches clearly understood that their role was to facilitate change having created an enabling motivational environment and taught the flexible use of BCTs. This is illustrated by an extract from a coach in Norway, who said:Consistent with our theory of change, analysis of observations of sessions and interviews with coaches confirmed that coaches used the manual as expected, creating an enabling environment for behaviour change by teaching BCTs. program and materials .Participants’ views and experiences of the EuroFITI think the great thing about the program was that it wasn't, you [didn’t have to] to make a massive amount of effort to make an improvement. It was small improvements, and you could measure them. And so, what I think was a great thing was that you learned about walking a little bit more, standing up a little bit more, just doing incremental things made you fitter. [P-UK1-PPFGD]As we have seen, our theory of change placed explicit emphasis on learning to use a ‘toolbox’ of BCTs to promote an agency- and competency-based approach to initiating and maintaining changes in physical activity, sedentary and dietary behaviours. Specifically, the ‘toolbox’ focused on: goal setting, problem solving, action planning, self-monitoring of behaviour and outcomes, and social support. Data from focus groups showed that, in all four countries, men engaged with the toolbox of BCTs. For example:Responses to post-program questionnaires supported these findings, with participants reporting high levels of engagement with SitFIT (self-monitoring) devices, SMART goal setting, planning for making cumulative small changes to their everyday lives and seeking social support see Fig. .Fig. 3Sep < 0·001) over and above the baseline average of 8,372 steps/day  to track my routines and progress regarding my almost daily walks and runs and my weight. I really like to fulfil it and think of ways to upgrade it… I put time, intensity [into it]… look (Participant shows interviewers some printed files)’ [P -POR2-PPFGD]Objective measurements of physical activity indicated that after completing EuroFIT, on average, men were walking an additional 1208 steps/day . Across the four countries, participants commonly reported routinely using their SitFIT for monitoring their physical activity, as this interaction from a post program focus group in the UK demonstrates:I think the thing as well that I noticed was I’d look at it and if it’d have, like our average would be like eighteen thousand steps, I’d look at it and go, I’m only on sixteen thousand, if I put mine, it’ll bring everybody down […] I felt bad if I plugged it in and then…then the [MatchFIT average] figure was less after I plugged in. [P-UK3-PPFGD]As described, we developed the SitFIT (and some aspects of the MatchFIT app) to support self-monitoring. Whilst most felt positive about the SitFIT and in some cases found sharing their steps either through MatchFIT, Facebook or WhatsApp motivating, one man in the UK described how he felt that sharing his steps on MatchFIT might let the other men in his group down if he had not achieved what he had hoped (men in this group were taking a lot of steps each day):While men spoke positively about the SitFIT, they also described challenges using the device. These were practical , technical  or mechanical .P5:I’ll look at it [upright time on SitFIT] and I’ll see what it is but I don’t kind of work towards it, do you know what I mean?P2:No.P4:It’s not…you can’t really quantify what you’re doing so…[UK3-PPFGD].While self-monitoring appeared to be a useful BCT for increasing physical activity (steps), men reported that they found decreasing their sedentary time more difficult. Post-program focus group data program suggested that, while participants internalised the message to stand more, they found it harder to use self-monitoring and goal setting to change their sitting behaviour:As part of the toolbox, EuroFIT aimed to encourage social support and relatedness through peer interaction. Participants responded well to encouragement to use social media for social support outside of EuroFIT sessions, using both WhatsApp and Facebook to support one another to be active, both during the program and up to 12 months afterwards .Another way that men were encouraged to engage with EuroFIT between sessions was through the MatchFIT app. As measured by server log data, the overall uptake (participants creating an account and using the app at least once) of MatchFIT across all countries was 63.5%. Uptake varied significantly across countries: in the UK it was 37.2%, in the Netherlands 65.2%, in Norway 78.7%, and in Portugal 82.8%. MatchFIT was introduced in week 4 of the program. About half of those who registered had stopped using the app by week 10, and, by week 12, only a third were still using it. Qualitative data from participants suggested that, while the idea of MatchFIT was appealing in all countries, particularly in the Netherlands, the practical challenges of connecting the SitFIT and uploading data limited wider engagement  and that this was consistent across countries. Self-monitoring through the SitFIT worked well, although this was less successful for sedentary behaviour than for walking and men found making changes to sedentary behaviour difficult. The motivation strategies were effective, self-referenced goal setting enabled small cumulative changes in physical activity, and relatedness through social support was important for embedding change and MatchFIT demonstrated potential to encourage interaction in between sessions but technical difficulties uploading data made its use frustrating. changes and what was helpful in maintaining change .Participants’ experiences of maintaining (or not) any lifestyle [news]paper in the morning and stuff like that, and I’ve kept it going and it’s just because it gave me the push that I needed, basically. [P-UK4-12MFGD]I’ve got to enjoy it, my routine of walking around for theEuroFIT was designed to support men to make changes that they would be able to sustain beyond its 12-week delivery. As noted above, practising BCTs was helpful to participants in initiating and maintaining changes through the program, and men were encouraged to make small changes that could be accommodated within their daily routines. In the 12-month questionnaire, 71% of the intervention group said they became more active by making small changes to everyday life ‘often’ or ‘a great deal’. Focus group data from all countries confirmed this, with examples such as the following offered by participants:“I don't make an effort… this new way of behaving is like the normal me.” [P-POR3-12MFGD].The same pattern of convergence between qualitative and quantitative data was observed in relation to the routinisation of dietary changes, in all countries. Some described such routinisation in very direct terms e.g., At my home I think at least that previously when I confidently sat in the favourite chair with the remote control, then I think it is much nicer to see myself confident where I am active and that you do something with yourself to be more present at home both energy-wise and with the kids and, yeah – day-to-day stuff, really [P-NOR1-12MFGD]Our theory of change Fig.  suggestep = 0·008), but that this reduction was not maintained at 12 months .We have reported elsewhere that EuroFIT participants, on average, reduced their sedentary time post-program (i.e. at 12 week measures) by an estimated 14.4 min/day  and this made it hard to maintain their activity levels. They missed the group, the people and the weekly sessions they had together, and said that these things would have made it easier to maintain the activity long term. As one said ‘The mile is long if you are by yourself’ [In summary, men’s experience of the program suggests it largely worked as described by the theory of change, at least for those who maintained change – in that they recognised the personal benefits brought by relatively small, but cumulative, routinised, lifestyle changes, although not everyone had been able to keep those up. There was also evidence that men had learnt to avoid setbacks and plan for difficult encounters, although again not all participants were able to do this because of illness or other life events. Groups formed to continue exercise after the program were highly valued where they happened and were seen as motivational but, in their absence, as in Norway, it was harder to motivate ongoing physical activity.Our analysis shows that EuroFIT was largely implemented as planned in professional football clubs in four countries, that coaches delivered the program as intended and that the program worked largely as expected for participants.The research project paid for deliveries of EuroFIT within the trial context which facilitated recruitment of professional football clubs to deliver the program, although the fact that we had to identify additional clubs when three dropped out, suggests that it might be more difficult to recruit clubs if funding for deliveries was not readily available. Coaches responded well to the training provided in EuroFIT session delivery, although high turnover of staff was a problem in some clubs. Recruitment strategies proved successful in all countries, but especially Portugal and the UK and it is possible that the ‘draw’ of the football club was not so clear amongst men in the Netherlands and Norway. The UK has a long history of community development activity in professional football clubs , so footAttendance at program sessions, e assumed would be necessary to initiate change, was good. Fidelity, assumed necessary for successful outcomes, was also good; and coaches responded flexibly to participants’ perceived needs, a feature of the program we think it essential to retain in subsequent implementation . InteracEuroFIT was one of the first studies to deliberately engage motivation theory behaviour change strategies into the protocol. From both self-determination and achievement goal theories, we incorporated BCTs associated with autonomy, relatedness, competence, mastery and self-referenced goal strategies and coaches were very successful in using those strategies to foster behaviour change. Self-monitoring using the SitFIT and the setting of self-referenced goals were seen as particularly important by participants and coaches and reinforcement of BCTs was also important to maintain changes through the program. MatchFIT, on the other hand, did not seem to play an active role in encouraging maintenance of behaviour change in most countries, perhaps because of the technical difficulties encountered in its use, and unlike in the FFIT program few narrEuroFIT was not successful in supporting men to make long-term improvements to their sedentary behaviour. While there is good evidence for different approaches to, and the benefits of, becoming more active , less isThat said, the mechanisms through which changes in physical activity were likely produced – i.e. goal setting, self-monitoring, action planning, social support and problem solving – are consistent with both the theory of change and with literature relating to behaviour change for physical activity in men . In thisA novel feature of EuroFIT was its use of bespoke technologies. The SitFIT activity tracker  was wideOur study suggests that it is possible to implement EuroFIT in different club settings. It also indicates ways in which clubs tailor EuroFIT to their own contexts and characteristics. Future research and practice relating to the delivery of health interventions in professional sports settings should ensure programs are designed with flexibility in mind, to ensure that variations in resource availability do not present barriers to implementation, although the key elements of how the program functions should be maintained. Given the significant public health benefits that have been demonstrated by such interventions , 10, 41,A final point of discussion raised by our study relates to harnessing the appeal of professional sports club settings and in being with other like them to attract participants to health interventions. As we have reported, our findings generally support the body of literature which argues that professional sports club settings are a powerful motivator for intervention participants, and perhaps particularly men , 45, 46.A major strength of this study is that it analysed data from four countries, in fifteen club settings, and derived the findings from a large body of data collected through multiple methods, allowing for triangulation across data sources. The study also deliberately employed behaviour change strategies informed by contemporary motivation theories. These strengths and the findings from the study underpin our confidence in the utility of the EuroFIT theory of change as a representation of the program’s mechanisms of action for men in the four countries studied. A limitation is that although we went to considerable efforts to standardise qualitative data collection and analysis across countries it was conducted by multiple teams, with varying levels of experience, in four different languages. The research team which produced the convergence matrix had limited ability to go back to original sources to check interpretations for themselves. This was mitigated through extensive cross-country dialogue, but remains a shortcoming that is faced in all cross-cultural work in which all analysts are not poly-lingual .and sedentary time may have led participants to select the behaviour they found most easy to grasp and alter ; that bespoke technologies can be complex to implement and bespoke social support platforms may have low take up; and that the appeal of the club as a site for health-related change may be culturally-mediated. Future deliveries should consider whether the distinction between decreasing sedentary behaviour and increasing physical activity is worth pursuing, should use easily available technologies to support self-monitoring and social interaction and how different forms of football fandom can be exploited to attract participants.This paper has explored the processes through which EuroFIT achieved its outcomes and the extent to which the underpinning theory of change represented the program’s mechanisms of action. Through a mixed-methods approach, we have concluded that the theory of change is an effective representation of the EuroFIT program, with only three small areas of ambiguity. In relation to this latter point, we have suggested: that the dual focus on changing physical activity Additional file 1.