Mycobacterium tuberculosis (MTB) infection in isolated pulmonary nodules.Investigate the use of endobronchial ultrasonography with a guide sheath (EBUS-GS) combined with Gene Xpert MTB/RIF (Xpert) for diagnosis of Patients who had isolated pulmonary nodules and unknown diagnoses at our institution from October 2020 to December 2021 were prospectively examined using EBUS-GS and Xpert. The diagnostic values of using EBUS-GS or bronchoalveolar lavage fluid (BALF) with acid-fast staining, MGIT 960 culture, pathological examination, and Xpert for isolated pulmonary nodules caused by MTB infection were compared using receiver operating characteristic (ROC) analysis.There were 135 patients, 64 with isolated pulmonary tuberculomas and 71 with non-tuberculous lesions. The sensitivity of EBUS-GS with Xpert was significantly higher than BALF with Xpert . Use of EBUS-GS with Xpert and MGIT 960 culture further increased the sensitivity to 62.50% (95%CI 50.64–74.36) and increased the specificity to 100%. The AUC values of BALF with MGIT 960 culture was 0.663(95%CI 0.543–0.783) and BALF with Xpert was 0.674 (95%CI 0.556–0.792). The AUC values of EBUS-GS with MGIT 960 culture was 0.680 (95%CI 0.554–0.743), with pathological examination was 0.713 (95%CI 0.573–0.760), and with Xpert was 0.789 (95%CI 0.655–0.829).Use of EBUS-GS with Xpert had high sensitivity and specificity in the diagnosis of isolated pulmonary tuberculoma. This method has significant potential for use in clinical practice. Tuberculosis (TB) is a significant global public health problem. The 2021 Global Tuberculosis Report of the World Health Organization (WHO) concluded that about 9.9 million people were suffering from TB and 1.3 million died from TB during 2020. China had 841,500 newly diagnosed TB patients in 2020, accounting for 8.5% of the global total, second only to India [Pulmonary tuberculoma is a special type of secondary pulmonary TB that has no characteristic clinical manifestations, but has imaging manifestations of atypical non-calcified solitary pulmonary nodules . PulmonaMycobacterium tuberculosis (MTB) infection [rpoB gene [Mycobacterium tuberculosis complex (MTBC) and mutations conferring rifampicin resistance within 2 h [Endobronchial ultrasonography (EBUS) is an efficient and minimally invasive interventional bronchoscopic technique that is increasingly used because of its good performance in the diagnosis of pulmonary diseases, such as tumors –14. EBUSpoB gene . This methin 2 h . The Xpethin 2 h . In thisThis study selected patients with isolated pulmonary nodules and unclear diagnosis who were admitted to Shanghai Pulmonary Hospital, Tongji University affiliated, from October 2020 to December 2021. Case selection was based on inclusion criteria. All enrolled cases underwent comprehensive diagnostic examinations, including complete blood count, blood biochemistry, coagulation profile, QuantiFERON-TB Gold (QFT) test, rheumatologic immune markers, tumor markers, etc. After excluding contraindications such as bleeding tendency, acute coronary syndrome, severe hypertension, severe ventilatory dysfunction, etc., the patients underwent endobronchial ultrasound-guided transbronchial lung biopsy (EBUS-GS) under local anesthesia and bronchoalveolar lavage (BAL) under bronchoscopy. EBUS-GS was performed first, followed immediately by BAL. EBUS-GS biopsy samples were subjected to smear, culture, Xpert, liquid-based cytological test, and histopathological examinations, while BAL fluid samples were subjected to smear, culture, Xpert, and liquid-based cytological test. Patients diagnosed with tuberculoma were classified as the TB group, while those diagnosed with other diseases were classified as the non-TB pulmonary disease group. This study was approved by the Ethics Review Committee of Shanghai Pulmonary Hospital affiliated to Tongji University (Ethics No. K20-009). All patients signed informed consent documents prior to bronchial examination and biopsy.i) patient age from 16 to 80-years-old; (ii) at least two negative results for acid-fast bacilli and at least one negative molecular detection result for TB in sputum; (iii) isolated pulmonary nodules (≥ 10 mm and ≤ 30 mm in diameter) based on imaging of pulmonary lesions; and (iv) HIV negativity. The exclusion criteria were: (i) patient inability to cooperate; (ii) pulmonary nodules smaller than 10 mm in diameter, inability of the bronchoscope to reach the lesion, or failure of the EBUS-GS procedure; or (iii) unclear final diagnosis; or (iv) loss to follow up.The inclusion criteria were:  positive for MTB based on Bectec MGIT 960 culture in sputum, bronchoalveolar lavage fluid (BALF), or puncture fluid; (ii) positive for MTB based on molecular tests of BALF or puncture fluid; (iii) positive for MTB based on histopathological examination of puncture, biopsy, or surgical samples with granulomatous inflammation and epithelioid cells, caseous necrosis, and Langerhans cells in the lesions observed by microscopy, with positive TB-DNA-PCR results, with or without positive results from acid-fast staining.A patient clinically diagnosed with TB met all the following criteria: (i) positive in the interferon gamma (IFN-γ) release test; (ii) exclusion of non-tuberculous pulmonary diseases; (iii) efficacy of anti-TB treatment.The EBUS-GS used a xenon light source and image processing station , a flexible bronchoscope , an ultrasonic endoscope system , and a bronchial ultrasonic probe .Bronchoscopic alveolar lavage was performed basically based on the 2017 Chinese expert consensus on pathogen detection in bronchoalveolar lavage for infectious pulmonary diseases, published by the Chinese Medical Association, and the 2012 ATS clinical practice guideline [For EBUS-GS, the patient was given a local anesthesia, and then placed in a supine position on the examination bed. First, a routine bronchoscopy was performed to observe the mucosa and lumen of the bronchus. Then, the ultrasound probe was sent to the distal end of the bronchial branch of the lesion until it could not go further. The bronchus was scanned to determine the location of the lesion and the surrounding blood vessels. After the site for puncture was determined, the guiding sheath was fixed, and the ultrasonic probe was withdrawn. All lesions (3–5 samples per patient) were obtained using biopsy forceps and cell brushes and were routinely sent for pathological examination. At the end of biopsy and sampling, 10 mL of normal saline was injected into the guide sheath and recovered using negative pressure suction for further etiological examination Figs. .Fig. 1CaMycobacterium according to the instructions of the manufacturer.For acid-fast staining and Bactec MGIT 960 culturing, specimens were first smeared and dried. Then, acid-fast staining was performed, followed by microscopic examination. The BACTEC MGIT 960 automatic analyzer  was used for rapid culture of For pathological examination, biopsy specimens were fixed by formalin, embedded in paraffin, and then sectioned. Then hematoxylin–eosin staining and acid-fast staining were performed. Pathological diagnosis was based on the histopathological and immunohistochemical results. Real-time fluorescence quantitative PCR was used to detect specific MTB DNA fragments: IS6110 , RV0577,For the Xpert assay, sterile normal saline (1 mL) was added to the tissue samples, followed by centrifugation at 3000 rpm for 15 min. Then the supernatant was discarded and the remaining precipitate was used for the Xpert test. The automatic GeneXpert was used to detect positive MTB and Xpert  was used to test resistance to rifampin according to the instructions of the manufacturers.t-test. Categorical data were compared using the Chi-square test. The values of EBUS-GS and BALF when used with acid-fast staining, MGIT 960 culture, pathological examination, and Xpert for the diagnosis of pulmonary tuberculoma were compared by calculation of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and Youden's index. For each test, a receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was calculated. All tests were two-sided, and P value below 0.05 was considered statistically significant.All data were analyzed using SPSS version 24.0 . Continuous variables with normal distributions were expressed as means ± standard deviations (SDs) and groups were compared using Student’s We initially examined isolated pulmonary nodules from 201 patients who were admitted to the Tuberculosis Department between October 2020 and December 2021 Fig. . We exclvs. 49.30%, P < 0.001).We initially compared the baseline characteristics of the TB and non-TB groups Table . OverallWe performed EBUS-GS in all 135 patients, and then examined the samples using different methods Table . The resWe also performed bronchoalveolar lavage and collected BALF in 76 patients  within (94 cases) and 2) adjacent to (41 cases). Among the 94 cases, the sensitivity of EBUS GS + Xpert diagnosis was 61.5% (24/39). Although this sensitivity was higher than the 52% (13/25) observed in the 41 cases, the difference was not statistically significant (P = 0.451). The specificity in both groups was 100%.We then analyzed all 43 bacteriologically/histopathologically confirmed cases of TB based on EBUS-GS . The sensitivity of EBUS-GS with MGIT 960 culture (35.94%) was higher compared to BALF with MGIT 960 culture (32.61%); and the sensitivity of EBUS-GS with acid-fast staining (17.19%) was higher compared to BALF with acid-fast staining (8.69%). However, there was no statistical significance between them .The sensitivity of EBUS-GS with Xpert was significantly higher compared to BALF with Xpert  and granulomatous diseases of the lung, have clinical and pathological characteristics that are similar to pulmonary TB , 35. In In general, compared with conventional invasive examinations, EBUS-GS is characterized by smaller wounds and fewer complications, and Xpert has a high diagnostic rate and is relatively rapid. The combined use of these two methods led to good diagnostic efficacy in isolated pulmonary nodules caused by MTB, and was also useful in the differential diagnosis of non-tuberculous pulmonary diseases.There were some limitations in this study. Firstly, it was a single-center prospective study with a small sample size. Thus, the diagnostic value of EBUS-GS with Xpert for isolated pulmonary nodules caused by MTB needs verification by large multi-center studies. Secondly, the operators of EBUS-GS must have a relatively high level of technical expertise, and considering the angle of the bronchoscope, some lesions may not be reached or puncture failure might occur.EBUS-GS combined with Xpert has great clinical value in the diagnosis of isolated pulmonary tuberculoma based on its moderate sensitivity and high specificity. The sensitivity of EBUS-GS is greater when used with Xpert. Thus, use of this method in clinical practice may help to provide early diagnosis pulmonary tuberculoma so that these patients can avoid misdiagnosis and receive prompt treatment.


Undergraduate medical learners from historically marginalized groups face significant barriers, which was made concrete at our institution when a student presented her research indicating that Black students felt unsure about which faculty members to approach. To better support our students, we used Kern’s model for curriculum development and a critical pedagogy approach to create a Faculty Allyship Curriculum (FAC). A total of 790 individuals attended 90 workshops across 16 months and 20 individuals have completed the FAC. A majority of participants reported they felt at least moderately confident in their ability to teach learners who are underrepresented in medicine, mentor learners who are different than they are, and teach allyship topics. An informal content analysis of open-ended responses indicated changes in awareness, attitude, insight, and use of language and being more likely to display advocacy. For others considering creating a similar program, partnering with an existing program allows for rapid implementation and reach to a wide audience. We also recommend: beginning with a coalition of willing learners to quickly build community and culture change; ensuring that the curriculum supports ongoing personal commitment and change for the learners; and supporting facilitators in modeling imperfection and upstanding, ‘calling in’ rather than ‘calling out’ learners. Making Allyship Visible: Evaluation of a Faculty Development DEI Curriculum Jessica Bunin, Jonathan Scott, Ryan Landoll, Jessica Servey, Abigail Konopaskyvisible group of faculty who are ‘safe’ for historically marginalized learners at our institution. Below, we outline our approach to this problem, our intervention outcomes, and lessons learned.Undergraduate medical learners from historically marginalized groups like Black, Indigenous, and People of Color (BIPOC); Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersexual, Asexual and other sexual and gender minorities (LGBTQIA+); persons with disabilities; and women face more barriers than white, heterosexual, cisgender, or male students . A studeUsing Kern’s model for curriculum development , the intA total of 90 FAC workshops covering 11 topics were offered over the 16 months of this evaluation. Forty of those workshops were offered virtually during the first week of each month to accommodate a geographically dispersed National Faculty. A total of 790 unique individuals attended at least one workshop, live or virtually. To date, 20 individuals have completed the FAC. Formative assessments, including written evaluations, were distributed immediately following each workshop and a summative program evaluation was completed 16 months after the first faculty development workshop .Of the 40 workshops offered virtually, there were 773 learners . There was a 39% (301/773) response rate on the individual workshop evaluations. Of these 99% (299/301) of respondents reported that workshops were excellent or good.For the overall program evaluation, there was a 10% (75/790) response rate. We conducted an informal inductive content analysis of responses to open-ended questions, guided by Elo and Kyngas . When asThe Allyship curriculum continues to be a driving force for social justice at our institution; faculty regularly comment to us what a difference these spaces to discuss and enact equity make in their practice as teachers, colleagues, and clinicians. For others considering creating a similar program, beginning with a coalition of willing learners (versus mandatory training), as we did, quickly builds community and culture change across the institution. However, participants have noted informally and through the evaluation that our next step must be creating materials for more resistant faculty members. Another lesson learned includes the importance of starting with the voices of historically marginalized students – beginning with learners’ lived experiences grounded the design in their needs and guided our ongoing curriculum development and evaluation. We also strongly recommend partnering with a robust and well-respected program that already exists  to reach a wide audience, ease the administrative burden, and promote rapid implementation. Finally, we have recognized the importance of ensuring the curriculum is focused on facilitating ongoing personal commitment and change. To avoid concerns about the curriculum and its associated visible recognition program as performative, the requirements to participate in a journal club and self-reflection in addition to longitudinal course attendance helped to promote authentic learning.Critical to our intervention were the workshop facilitators, who we trained to ensure psychological safety both for learners from marginalized groups and for all levels of FAC learners. We struck this difficult balance by modeling imperfection and upstanding as facilitators, letting learners know that we were aiming for progress rather than perfection. This accommodating ‘calling in’ versus non-accommodating ‘calling out’ is a cornerstone of our approach . Like otA limitation to the evaluation of this curriculum was the 10% response rate on the 16-month program evaluation. This was due in part to the frequent turnover of faculty at our institution (most faculty in the military transition to different institutions every 3 years). As such, we are unsure that our survey reached all participants. Additionally, only one reminder was sent for survey completion. In the future, we would send out more reminders.As we move forward with our curriculum, we are updating and adding workshop topics, broadening our facilitator pool using a train-the-trainer model, improving our assessment methods, and broadening advertisement of the program.Click here for additional data file.


Child Life Specialists (CLSs) are psychosocial care professionals of child development and health who focus on the individual needs and rights of young patients. CLSs accompany sick children and focus on the children's perspective and their reality of life. CLS programs are already established in clinical settings in the United States and other Anglophone countries but have not yet been piloted in the German health care setting, neither has their implementation been evaluated in this context. This study aimed to explore the factors influencing the implementation of a pilot CLS program in pediatric inpatient care at the Dr. von Hauner Children's Hospital at the University Hospital of Munich, Germany.Building on methods commonly employed in the evaluation of complex interventions, we developed a logic model to guide the process evaluation of our program. Semi-structured interviews with four groups of stakeholders were conducted in person or via videoconferencing between June 2021 and January 2022. Data was analyzed collectively using the method of qualitative content analysis by Mayring.n = 4), parents (n = 4), CLSs (n = 4) and other health professionals (n = 3). Factors influencing the implementation were identified on three levels: system, staff and intervention. On the system level, a clearer definition of CLSs’ tasks and responsibilities was perceived as important and would likely lead to a delineation from other  professions and a reduction of potential resistances. On the staff level, lacking training opportunities and feelings of being insufficiently skilled were limiting the CLSs professional self-confidence. On the intervention level, the emergence of a unique characteristic of the CLSs’ work  supported the acceptance of the new program.Fifteen individual interviews were conducted with patients (children aged 5–17 years, The implementation of a CLS program into an established hospital system with existing psychosocial care services is challenging. Our results contribute to a better understanding of implementation processes of such an additional psychosocial care approach and provide recommendations for addressing upcoming challenges. Leaving their home and familiar surroundings, dealing with illness, and potentially experiencing pain- and anxiety-inducing procedures are only some of the numerous stressors children face in hospitals. Anxiety and stress symptoms during hospitalization can disrupt children's development and lead some to experience posttraumatic stress symptoms after they have been discharged –4. ChildOne approach to increasingly embrace the children's perspectives in pediatric health care is the implementation of Child Life Specialist (CLS) programs. CLSs are psychosocial care professionals of child development and health who strive to change perspectives in the hospital system by focusing on the needs and rights of children and respecting their individual reality of life. CLSs accompany and support children during their hospital stay and integrate children's perspectives into processes and structures in hospitals . CLSs seDr. von Hauner Children's Hospital, the children's hospital and polyclinic at the University Hospital of the Ludwig-Maximilians-Universität (LMU) in Munich. The Dr. von Hauner Children's Hospital is one of the biggest children's hospitals in Germany with 108 beds and approximately 5,000 inpatients per year .2.2.1.The evaluation concept was based on the guidance of the Medical Research Council (MRC) on “developing and evaluating complex interventions” . The CLSBased on these findings, we developed an a-priori, system-based logic model  of the C2.2.A process evaluation examines mechanisms during the implementation of an intervention, takes a closer look if and how an intervention reaches its goals, or explores which factors contribute to or interfere with an intervention's success , 23. In This study was conducted by researchers of the Chair of Public Health and Health Services Research at LMU Munich. The ethical standards of the Declaration of Helsinki  were tak2.2.1.Dr. von Hauner Children's Hospital, the children's hospital and polyclinic at the University Hospital of LMU in Munich, one of the biggest pediatric hospitals in Germany. The pilot CLS program was initiated in May 2020 by the hospital's director and the leader of the hospital's psychosocial team. The latter interned at an established CLS program in the United States before starting the implementation in Germany. Additionally, regular exchange meetings with leaders of CLS programs in the United States were installed. Four CLSs (full-time positions) with different professional backgrounds  were employed as psychosocial health care providers. Until January 2022 three more part-time positions were added . All of them were recruited internally within the hospital as well as externally. Since in Germany at that time no institutionalized training opportunities for the CLS profession existed, nor were there any German-speaking CLSs who could assist, CLSs were trained by a Certified Child Life Specialist (CCLS) from the United States before being installed on wards. The intensive training (facilitated in English) consisted of input on CLS theory and supervised practical exercises. Furthermore, an ongoing training schedule has been implemented which covers theoretical input and practical sessions. CLSs were installed on wards with a focus on gastroenterological, metabolic, neurological and pulmonary diseases, as well as on the pediatric intensive care unit. Each CLS was assigned to one ward where s/he contacted and cared for patients and families. CLSs worked together with medical, nursing, and psychosocial employees (mainly educators and psychologists) and primarily undertook the following interventions: medical education and preparation, teaching of coping strategies, providing distraction and therapeutic play. The introduction of the CLS program was accompanied by information events outside the hospital  as well as by regular meetings with physicians and nurses to inform about the new professional group. Overall, the implementation of the CLS program was prepared based on the experiences reported in model CLS programs from the United States and was constantly being adapted to the clinical hospital setting. The primary goal was to test and adapt the introduction of a pilot CLS program into the German health care system which could lead to a long-term and up-scaled introduction of such programs in Germany.This study was conducted at 2.2.2.We recruited four groups of stakeholders for individual interviews: (i) patients (children 4–17 years), (ii) their parents, (iii) CLSs, and (iv) other health professionals with contact to the CLS program, e.g., physicians, nurses, educators. During recruitment, educators were identified as professionals with regular and close contact to CLSs: educators were present on all wards where CLSs worked and were discussing individual patient cases with CLSs in psychosocial team meetings. The psychosocial team in the hospital served as a gatekeeper for recruiting and provided the research team with a list of contact details of potential participants. Members of the psychosocial team were the only ones who had an overview of patients, parents and health professionals who already knew the CLS program. From this list, participants were recruited according to a purposeful and maximum variation sampling technique: patients from different age groups, with different diagnoses and on different wards; and health professionals with different professional backgrounds. CLSs were seen as multi-professionals who combined the experiences from their former professional background with their view in their new role as CLS. Due to contact and access restrictions during the COVID-19 pandemic, not all participants were contacted in person by the interviewer (JH), but via telephone or email. The researcher was already known to participants from the CLS team but had no contact to the other participants before the interviews. All participants were provided with extensive information concerning the purpose and procedure of the interview, the handling of the data, the interviewer's role in the project and her professional background. Age-appropriate information sheets and consent forms were used for children . All participants provided their written consent; for minors, the additional consent of their parents was required.2.2.3.Semi-structured, guided interviews were conducted by one member of the research team (JH) between June 2021 and January 2022. For each group of participants  specific interview guides were developed based on the research aims, the CLS literature, the logic model and first practical experiences with the program see  dependin2.2.4.Data was analyzed using qualitative content analysis following Mayring's systematic approach to the interpretation of qualitative material based on defined analysis rules and steps . In this3.3.1.n = 4), the parents of these patients (n = 4), CLSs (n = 4), and other health professionals . To maintain data protection and anonymity of one educator and two physicians interviewed, these professional groups were summarized under the term “health professional”. n = 9) took place face-to-face. The interviews with patients lasted between 15 and 20 min for younger children (5 and 8 years) and 45 min for the adolescent (17 years). The average duration of an interview with an adult was 44 min.Fifteen individual interviews were conducted with patients  should be clearly defined, and the scope of the new CLS program should be determined, preferably already before starting the implementation. In their opinion this had not happened to a sufficient extent.“It would have been helpful to consider what services were already being offered on the wards. We wanted to introduce something new but did not think about how our goals may coincide with others. The best strategy would have been to survey existing services and then work to complement them.” “We needed more clarification regarding our offer of interventions in order to be more self-confident on the wards and to be able to say: ‘This is how we can help support the patient’.” (CLS 4)Additionally, participants reflected that the CLSs’ tasks should be more clearly delineated from those of other professional groups in the hospital. CLSs and health professionals pointed out that a lack of a clear distinction can result in an inefficient use of human resources by either not employing available CLS competencies or by certain activities being carried out by several professionals at the same time.“At the beginning it was difficult because no one knew who I was or what I was responsible for. I always waited for a call, but nothing ever came.” (CLS 3)“It took some time before we were able to work together because our scope of activities seemingly overlapped. Initially, we were two people sitting there with two children trying to achieve similar goals and it was too much.” CLSs described the initial phase of the program as a challenging period. Feelings of being insufficiently prepared, not having enough knowledge as well as missing social networks led to stress. Getting to know the profession and the hospital's procedures were perceived as the main challenges when the CLS program started.“It was as if we had been abandoned on a desert island. We didn't know anyone on the wards because we did not have any contacts or previous relationships.” (CLS 4)3.2.1.2.The material in the interviews suggests that the attitudes of stakeholders about the profession of CLSs and the CLS program negatively impacted the implementation of the program. CLSs reported that they experienced refusal or negative remarks from other hospital employees during their visits on the wards. It was pointed out that the information on the CLS program which was disseminated before the actual program's launch created certain assumptions concerning the program and caused resistance in some hospital employees towards the CLS team and their work.“The others were thinking: ‘And what have we done so far? Where is the recognition for us?’ […] We want to work together and not against each other. That came across wrong. This immediately created resistance from the staff on the wards and made it difficult for others to accept us.” (CLS 3)“One problem is that [the CLS program] is not accepted by everyone. […] I have noticed that some doctors and nurses do not see the benefit [of the CLS program] or do not value it as much.” Furthermore, CLSs were excluded from internal teams due to missing knowledge about or acceptance of the program.“There was limited communication and understanding about what our role was on the wards or how to reach us. Many asked questions like: ‘What are you doing here again?’, and when we informed them, they told us: ‘You will just have to wait and see how to get involved because we don't have time to call you’.” (CLS 4)CLSs tried to explain negative attitudes with a fear of losing competencies: other professional groups may have concerns about having to hand over their own activities and areas of responsibility to CLSs which is why they may have been reluctant to integrate CLSs in internal networks or share knowledge and experiences.“We were attempting to integrate a new service into a long-standing system, which I think is always difficult, regardless of the hospital. Our scope of practice needed to be better defined in order for others to understand how we could help and to reduce concerns about losing own responsibilities.” (CLS 1)According to CLSs, refusing attitudes concerning the CLS program could be reduced by the perception of the program as relevant and meaningful. CLSs stated that the other health professionals first needed to make their own experiences with CLSs’ work. When there was an understanding of the goals of the program as well as a perception of possible benefits, acceptance of the CLS program could be achieved.“Thank goodness [the resistance] lifted after they realized what we do and that it can positively make a difference. This helped us work together without conflict and it works quite well now.” (CLS 3)3.2.1.3.According to participants, the collaboration with other hospital employees affected the integration of the CLS program into the hospital. Almost all interviewed professionals noted that good communication  is an important requirement for the integration of the CLS program into the hospital. The exchange of information can reduce prejudices and resistance. Furthermore, participants thought that communicating responsibilities could strengthen mutual support between CLSs and other hospital employees so that tasks would be divided, and the workload would be reduced.“If you communicate well, then it doesn't matter which professional group you work with. It’s just a question of communication. (…) It’s always like that when something new comes along, but I think you can solve that by establishing a good contact and by communicating areas of responsibility.” (CLS 2)“Clear communication can make a big difference. When they realize we have a clear goal, are following a plan and document our interventions in the patient’s chart for them to read, then they know: ‘Aha, the CLS is providing a specific service, which is not my job at all and it’s good this gap is being filled.’ I think with time they will understand.” (CLS 3)Although communication and integration processes had already started, CLSs expressed their wish for expanding this development and being more directly involved with other professional groups.“Success is when you are asked in advance to support a child on the ward. For example: ‘Could you provide medical education for…?’, or: ‘We are having this problem with this child, can you assist?’. This would prove that we are more accepted and more involved.” (CLS 2)3.2.2.Factors influencing the implementation on a staff-level relate to the personal characteristics and skills of those who carry out the CLS program, that is the CLSs themselves .3.2.2.1.Although various positive experiences in the interaction with CLSs were reported, the CLSs themselves felt they had not been trained appropriately. CLSs didn't feel sufficiently skilled and described that they mainly had to rely on their previous personal and professional competencies. The interviewed CLSs expressed their wish for (more) training sessions and further CLS-specific qualification.“We didn’t have any guidelines to follow. We had to build everything ourselves: develop concepts and prepare ourselves.” (CLS 3)“Because CLS is a new professional field in Germany, there was no available fixed training, so sometimes we lacked education for simple situations.” (CLS 1)3.2.2.2.In general, patients and parents valued the CLSs’ interaction with patients and felt CLSs were able to build reliable relationships with them and their families. According to patients and parents, compared to other health professionals CLSs obtained more information and were provided with deeper insights into patients’ and parents’ needs and worries.“[The CLS] is very close to the children, much closer than a doctor, and most of the time even closer than the nurses. This is because [the CLS] spends so much time with the children, plays with them, and talks with them in a language they understand. She notices what they are afraid of.” (Child 4)“[The CLS] came and started playing [the patient’s] favorite game half an hour before the blood draw, so that he was already into the game during the blood draw. That was great. Because the [other professionals have] no time for that.” (Mother 2)3.2.3.Factors influencing the implementation on an intervention-level relate to the characteristics and components of the intervention that support or hinder the implementation of the CLS program .3.2.3.1.The characteristic of the CLS program as being new and unknown within the hospital context was commented on by many interviewees. Patients and parents reported that they were neither familiar with the term “Child Life Specialist” nor with the associated tasks of a CLS. Furthermore, the English term “Child Life Specialist” was difficult to pronounce and remember for a German speaker, especially for children. One patient, although having a close relationship to a CLS, did not use the term “Child Life Specialist”.Interviewer: “Do you know what kind of job [the CLS] has here?”Child: “She is a child guardian [literally “Kinderbetreuerin”], right?” (Child 3)Parents pointed out that for them it was difficult to understand the CLSs’ role, particularly at the beginning of the hospital stay when they needed to gain a general understanding of the hospital's routines and when their stress-level was especially high. It took time to locate the CLSs and their tasks within the hospital context.“At the beginning, I couldn’t tell what [the CLS] was responsible for. Everyone introduces themselves, but you don’t really know who they are and what they do at first.” (Mother 1)The lack of knowledge on the work of CLSs did not only apply to patients and parents, but also to the employees in the hospital, as one CLS stated.“I once sent the doctors a list of my areas of responsibility and when I was available because they didn’t seem to know what my role was. Now they know when they can reach me, and that I will come right away, but many things are still unclear.” (CLS 3)3.2.3.2.When asked about the CLSs’ tasks, patients, and parents as well as other health professionals answered that CLSs were responsible for preparing patients for medical procedures. According to participants, the ability to prepare patients for medical procedures using methods that are appropriate to the patient's age and developmental stage is a unique characteristic of CLSs which delineates them from other employees in the hospital. Generally, parents felt CLSs had specific competencies and medical knowledge that other psychosocial professionals did not have.“We should pay more attention to the fact that it is not only the parents who need to be educated and prepared for medical procedures, but also the children. […]. In my opinion, that is the goal of the CLSs’ work.” “The CLS can fill the gap, if for example, we don’t understand something or if we don’t dare to ask the doctor, [the CLS] can often help. […] In my experience, she has a deeper understanding about medical procedures than the educators or psychologists.” (Father 1)3.2.3.3.The CLS program being flexible and individualized increased the acceptance for the program. Patients and parents strongly valued that the CLSs were to a large extent able to consider patients’ needs and adapt their work to them. CLSs seemed to constantly evaluate the patients’ individual situations and to adopt the frequency of their contacts and the kind of intervention depending on what was needed most. Parents perceived this flexibility in the CLSs’ work, which contrasts the work of other health professionals, as a significant advantage. They felt CLSs were more detached from hospital structures and tight schedules and therefore more independent to fill emerging gaps in health care. Additionally, according to patients and parents, CLSs seemed to dispose of more time and appeared less stressed than other health care professionals which further supported the CLSs’ flexible and independent mode of working.“[The CLS] has always tried to visit me as often as possible. Even if it was only for a short time. Then she came in and said: ‘I don't have much time now, but I'll come again this afternoon.’ […] And she has the possibility to adapt her program or what she does to the age [of patients].” (Child 4)“Perceived from the outside, [the CLSs] have a bit more freedom, what they take care of, where and when. This may also give them the opportunity to fill gaps that may otherwise occur in the patients’ care […]. I think it’s important to have someone not so strictly tied into the structures as the others who work [in the hospital]. Someone who can act a bit more flexibly.” (Father 2)Similarly, a CLS, formerly working as a children’s nurse, defined the higher amount of time available for CLSs as an essential and differentiating aspect of CLSs’ work.“In general, I think that [the CLS tasks] would be what I have been doing all along as a children’s nurse, except that I simply have more time for it, because that’s what’s missing in nursing. That you can simply take your time with the patients to work out solutions to problems, have conversations, or have the time to distract them during difficult examinations.” (CLS 2)3.2.3.4.per se were not sufficiently present within the hospital. According to the interviewees, a constant and reliable availability could hardly be established due to a small number of employees, frequent changes in staffing and long periods of time when a CLS was either not available at all on a ward or only available for a very short period of time and thus unable to address all demands. CLSs and other health professionals felt that this could have caused resentment, weakened professional networks, and consequently reduced the program's acceptance.CLSs and other health professionals reported that the CLS program and the profession of CLSs “If there are lean periods, this is bad for the [CLS] project. If a structure to which one has become accustomed changes constantly or if a CLS is sometimes present and sometimes not at all, then one cannot rely on them.” “We need more staff to succeed. The current situation doesn’t allow us to do anything well and because we are always in short supply, it creates difficult situations because we were somehow not there for half a day or a day again. People are extremely demotivated because of this.” (CLS 4)4.4.1.This process evaluation of a newly introduced pilot CLS program in a German children's hospital revealed key factors influencing the implementation on three levels . On the system level, a clearer definition of CLSs’ tasks was perceived as important and would likely lead to a delineation from other professions and to a reduction of potential resistances towards the new program. On the staff level, lacking training opportunities and feelings of being insufficiently skilled were limiting the CLSs professional self-confidence. Finally, on the intervention level, the emergence of a unique characteristic of the CLSs’ work  supported the acceptance of the new program.4.1.1.acceptability of a new program is important to assess and can strongly influence implementation.Since there is not much research on the implementation of CLS or other pediatric psychosocial care programs in children's hospitals, we compared our results with studies examining factors influencing the implementation of new interventions in a broader hospital setting. As in our findings, other qualitative studies report negative attitudes of hospital employees towards new interventions either based on resistance due to misinterpretations, on fatigue towards new initiatives, or on role conflicts and competing priorities , 32. NegSupport and commitment from the hospital's management can facilitate the implementation of new interventions, which is also shown in a systematic review on the diffusion of innovations in healthcare . Additio4.1.2.A lack of confidence and skills of employees can impede the implementation process of new interventions which is also shown in a qualitative study on the implementation of a new outcome measure in palliative care in the United Kingdom . This fi4.1.3.Participants in our study reported that CLSs had a positive impact on patients, parents and health care professionals, but CLSs themselves did not perceive this as such. According to patients and parents, CLSs were particularly competent in building trustful relationships and collecting relevant information on individual patients, often going beyond the information available for other professional groups. Furthermore, the CLSs’ ability to provide medical education and preparation was particularly appreciated by patients and parents. A positive impact of CLSs on different stakeholders is reported in a qualitative study on nurses’ perceptions on the CLSs’ influence on their work . Nurses appropriateness of the CLS program  was limited particularly at the beginning of the program which was a barrier for the implementation. This is in line with other qualitative studies highlighting that a successful implementation of a new program requires a good fit between the program and existing hospital structures , as well as to adapt the program to the specific organizational context in a hospital. The variety of role titles, responsibilities and specific interventions undertaken by CLSs (and comparable professions) identified in a scoping review  may indiOur findings indicate that the implementation of a new complex CLS program is a challenging process. Therefore, implementation strategies of reducing complexity of the intervention itself and the CLS program as a whole may be facilitators. For instance, each CLS could be firmly assigned to a specific unit and integrated into all processes. This could provide clarity about the CLSs’ scope of action and facilitate better integration within the team due to constant availability and increased contact. A further reduction of complexity could be achieved if CLSs were not only assigned to a specific job site but if they also focused on distinct interventions. These should be selected based on an analysis of needs and demands, with the aim to strengthen children's perspectives as well as in distinction to existing services. A reduction of CLSs’ scope of action to a certain site and to specific tasks could sharpen the CLSs’ job profile and raise the confidence of CLSs in their own work. The range of tasks and responsibilities can be expanded in a next step when awareness and acceptance for the new program are established, and first implementation processes proved to be successful.The difficulties in introducing a CLS program into the German pediatric health care system may be due to the fact that other pediatric psychosocial care services already exist. In the current care system considering children's needs in all clinical processes is not sufficiently taken into account , and oth4.3.Our study had several strengths. The interview guide was (i) developed according to rigorous methodological approaches and finalized based on consensual decisions within the research team, (ii) discussed in an interdisciplinary method's workshop, and (iii) piloted with regards to its appropriateness, particularly for use with children. A range of different stakeholders were interviewed, also including the perspective of children and adolescents in their role as patients, as well as CLSs as multi-professionals who combined the experiences from their former professional background with their view in their new role as CLSs. Data analysis was conducted in accordance with established methods of qualitative content analysis . The codOur study also has limitations. The recruitment was based on contacts of the psychosocial team in the hospital which may have led to sampling biases. However, this couldn't be avoided since members of the psychosocial team were the only ones who had an overview of potential participants who already had contact to the CLS program. The research team who conducted the process evaluation was in regular contact and exchange with the hospital team responsible for the implementation of the CLS pilot. Therefore, the research team was informed about the ongoing implementation process and associated challenges while designing the process evaluation. Additionally, the interviewer (JH) already knew the interviewed CLSs before the study. While facilitating recruitment and an open communication, prior personal relationships may also have influenced the interviewees’ responses. On the other hand, there was no personal contact prior to the study to the other interviewees . The researchers tried to mitigate the effects of potential biases through regular reflections and discussions in the interdisciplinary team with extensive experiences in qualitative methods. Moreover, interviews were conducted during contact restrictions due to the COVID-19 pandemic which (in some cases) limited possibilities for relationship building. Particularly, the interviews with younger children would have benefited from personal interactions (in presence) before starting the conversation. The COVID-19 pandemic additionally complicated the recruitment of hospital employees. In the highly structured hospital routine with an extreme workload, which was exacerbated by the COVID-19 pandemic, three health professionals  were available for interviews, and no participant could be recruited from the nursing professions, despite several attempts to make contact. However, two of the interviewed CLSs had a professional background as children's nurses which we consider representatives of this perspectives in our material. Nevertheless, we reached data saturation during coding and data analyses.5.The implementation of a new professional service focusing on pedagogical aspects and the respect for children into an established hospital system is challenging and supporting structural guidelines are lacking. Our data highlights the importance of preparing the context as well as developing a clear job description. This should be based on the needs of the target groups and identified gaps in the health care system. Our results contribute to a better understanding of processes during the implementation of a new professional service and provide practical recommendations for meeting emerging challenges. The experiences of this pilot CLS program could support a structured implementation of (long-term and larger) CLS programs in Germany and other contexts. More research in other settings is needed to consolidate our results and extend scientific knowledge on implementing complex interventions into hospital settings.


These factors can negatively affect their cognitive function and symptoms of depression. This study aimed to introduce an evidence-based online dementia prevention program in the South Korean context and to identify its effect on cognitive function and symptoms of depression in community-dwelling older adults during the COVID-19 pandemic. (2) Methods: One hundred and one community-dwelling older adults without dementia participated in twelve sessions of an online dementia prevention program designed by occupational therapists. Cognitive function and symptoms of depression were assessed before and after the program. Cognitive function was tested using the Cognitive Impairment Screening Test and symptoms of depression were assessed using the Korean version of the Short Geriatric Depression Scale. The participants’ opinions were gathered using open-ended questions. (3) Results: After the program, according to the raw score, orientation was maintained and attention, visuospatial function, executive function, memory, and language function increased. The memory and total cognitive score was improved significantly. Symptoms of depression significantly decreased. The program’s benefits according to the participants were participation in new activities, boredom reduction, online communication, and reminiscence. (4) Conclusions: An online dementia prevention program is effective in maintaining and increasing cognitive function and preventing depression in community-dwelling older adults. An online dementia prevention program is a useful method in providing opportunities to participate in cognitive training and continuous daily activities during the COVID-19 pandemic. Face-to-face rehabilitation was commonly used before the coronavirus disease COVID-19) pandemic. However, during the COVID-19 pandemic, community-dwelling older adults have limited access to public health services and limited participation in classic face-to-face rehabilitation and community treatment services 9 pandemi. These sOnline rehabilitation is a useful treatment strategy during the COVID-19 pandemic. Continuous participation in rehabilitation, cognitive therapy, and community services are essential for the older adults and those with mild cognitive impairment (MCI), dementia, and stroke . ParticiOnline dementia prevention programs are effective in maintaining cognitive function, and in preventing and delaying cognitive impairment in older adults with MCI and dementia ,8,9,10. Online rehabilitation therapy is a useful method for managing depression in community-dwelling older adults. Communication with others can decrease depression levels ,12. TherEvidence-based online dementia prevention programs are important. The American Psychiatric Association (APA) suggested a comprehensive dementia prevention program that includes behavioral, emotional, cognitive, and stimulus-oriented approaches . TherefoPrevious studies have demonstrated the effectiveness of online cognitive rehabilitation in older adults and those with MCI and dementia. In South Korea, face-to-face dementia prevention programs are usually conducted at public health centers. In particular, OTs play a major role in designing and performing dementia prevention programs for community-dwelling older adults in the Korean context. Dementia prevention programs are a major element in Korean public health centers. Therefore, sharing and introducing ideas of evidence-based dementia prevention programs is important. However, studies about identifying the effectiveness of online dementia prevention programs through participation in daily activities and cognitive activities for healthy older adults in a community environment are insufficient.The aims of this study were to introduce an online dementia prevention program based on the APA guidelines and to identify the effect of online dementia prevention programs on cognitive function and depression in community-dwelling older adults in the Korean context. One hundred and one community-dwelling older adults participated in this study at a public health center in Gyeonggi-do, Korea. Before the program, they received a sufficient explanation about their participation in the dementia prevention program and research. All participants provided written informed consent. The inclusion criteria were age >60 years, normal cognitive function, mild cognitive impairment (MCI), ability to use smartphones, ability to read and write, Internet installation at home, and no hearing or visual limitations. The exclusion criteria were dementia, difficulties in using smartphones, inability to read and write, hearing and visual limitations, and no Internet connection at home. There were no dropouts in the middle of the program.The online dementia prevention program was conducted once a week, 1 hour a day, for 12 weeks (12 sessions) from April to June 2021. All community activities and gatherings were banned by the Korean government during the study period to protect against the spread of COVID-19. This program was designed by two authors (first and second) based on the APA guidelines. The second author recorded all program videos, which were 30–40 min long, and uploaded them on the NAVER BAND application (app) once a week. NAVER BAND app is a commercial communication app that allows subscribers to communicate and upload files. Participants watched the program videos and performed daily tasks by keeping a diary and a brain health book. Program videos were uploaded to the NAVER BAND app during the program period. They watched the videos whenever they wanted during the program. Subsequently, they uploaded their weekly tasks to the NAVER BAND app. The authors communicated with participants through text messages. Before and after the program, cognitive functions and symptoms of depression were assessed. Participants visited a public health center before the start of the program. All participants were retired. Cognitive function and symptoms of depression were assessed directly by the second author. Education and training on how to use the NAVER BAND app were provided to participants and their caregivers. After the program, participants visited a public health center to be assessed for cognitive function and symptoms of depression directly. Every participant uploaded their tasks on time. The CIST is a cognitive function screening test developed by the Ministry of Health and Welfare and the Central Dementia Center in South Korea . It consThe SGDS-K is the Korean version of the Elderly Depression Scale  based onSubjective opinions were collected using open-ended questions after the program. Questions were “How was the dementia prevention program?”, “What did you like in this program?”, “What was difficult?”, and “Is there anything you want from the program?”The online dementia prevention program was designed by two authors based on the APA Dementia Clinical Practice Guidelines. The guidelines include behavior, emotion, cognition, and stimulus-oriented approaches. The program consisted of 12 weekly sessions, including daily participation and occupational activities . Particit-tests to compare the results before and after the program. Statistical significance was set at p < 0.05. Windows SPSS version 24.0 software was used for all analyses.Descriptive statistical analyses  were conducted to obtain general information about the subjects. The effects of the program were evaluated using paired Based on the raw CIST score, orientation was maintained. Attention, visuospatial function, executive function, memory, and language function were improved . Memory p = 0.000) according to the SGDS-K after the dementia prevention program.The result indicated that symptoms of depression were significantly reduced from 3.35 ± 3.09 to 2.15 ± 3.06  meaning in the activity itself, (2) cognitive stimulation, (3) reminiscence, and (4) challenges and achievements from the acquisition of new skills . Some paContinuous community participation and performance of meaningful daily tasks are important for maintaining and improving the cognitive function and mental health of community-dwelling older adults. During the COVID-19 pandemic, opportunities to participate in community activities and daily tasks have decreased significantly in South Korea. This study introduced a daily activity-based online dementia prevention program and investigated the program’s effectiveness on cognitive function and symptoms of depression of community-dwelling older adults. This program was designed based on the APA Dementia Clinical Practice Guidelines and consisted of daily tasks using a cognitive activity diary and a brain health playbook. The program gave community-dwelling older adults a chance to participate in daily tasks and to communicate with others. The program was effective in maintaining and improving their cognitive function and symptoms of depression. In particular, two out of five participants with MCI in the initial assessment improved to normal cognitive levels after the program. Therefore, a continuous dementia prevention program is essential for the community-dwelling older adults during the COVID-19 pandemic.A comprehensive dementia prevention program is effective for older adults. The dementia prevention program in this study was designed comprehensively based on APA Dementia Clinical Practice Guidelines. In this study, we designed 12 online dementia prevention program sessions. The program consisted of four parts: cognitive, behavior, emotion, and stimulation approaches. Therefore, to design a dementia prevention program, clinicians should consider various areas to improve the cognitive function and emotional status of community-dwelling older adults. In the previous study, ten sessions of a non-face-to-face dementia prevention program were effective in twenty-six older adults  in day and night care facilities . CognitiIn another study, the effectiveness of a 14-week comprehensive cognitive training program in five older adults with mild dementia was investigated [Participation in daily tasks effectively improves cognitive function and reduces depression. In the previous study, an 8-week daily task participation program improved daily life, cognitive ability, satisfaction, and orientation in forty-three subjects with early dementia . RepetitSocial engagement and participation in daily tasks decreased symptoms of depression ,14,22. IMany kinds of online rehabilitation and cognitive training programs have been introduced ,23,24. OOnline dementia prevention programs have several strengths over face-to-face programs. First, protection from infection is increased in online situations, which is important during the COVID-19 pandemic. Second, many people, especially those who suffer from locomotion difficulties, can participate in the same manner as in the videos at home. Third, participants can participate in the program anywhere and at any time, even if they live far away from a public health center. Finally, community-dwelling older adults can keep in touch with therapists weekly, so they can maintain their social relationships. In our opinion, these benefits have positive effects on cognition and depression among community-dwelling older adults.However, difficulties in direct management and treatment, the need for trained helpers or facilitators, safety issues, and difficulties in checking treatment adherence are limitations of online dementia prevention programs. It is still necessary to visit in person when a detailed assessment or diagnosis is required. In this study, participants needed to travel twice for evaluation before and after treatment. Therefore, professionals should choose appropriate approaches depending on the settings or situations.The strengths of this study were that it used a large sample size. Secondly, the effectiveness of an online dementia prevention program for normal community-dwelling older adults was investigated in community-based rehabilitation settings. Third, the program in this study was evidence-based, based on the APA Dementia Prevention Guidelines. Finally, the program was comprehensive, including cognition-, emotion-, behavior-, and stimulation-oriented factors. Therefore, we found great value in online dementia prevention programs for improving cognitive function and depression in community-dwelling older adults.A limitation of this study is that generalization is difficult because the participants were recruited from one public health center. In addition, this study was not a randomized controlled study and there was no control group. Our program consisted of several programs. Therefore, determining which factors were the most influential is difficult. However, we found the comprehensive dementia prevention program used in our study to be effective for improving cognitive function and depression in community-dwelling older adults. Even though the authors checked the results of the participants weekly on the NAVER BAND apps, it was difficult to ascertain whether subjects watched the videos to the end.In previous studies, effectiveness of the application of an online dementia prevention or cognitive treatment program for patients with MCI and dementia in various areas such as daily life, performance function, quality of life, and stress was identified. However, in this study, only cognitive function and symptoms of depression were assessed. Therefore, identifying the effects in various areas is necessary for future research. Furthermore, specialized online dementia prevention programs must be developed.The online dementia prevention program was effective in improving cognitive function and symptoms of depression in healthy community-dwelling older adults and those older adults with MCI during the COVID-19 pandemic. Participation in meaningful daily occupational tasks, including keeping a diary and using a cognitive health playbook, is a useful method for improving cognitive function and decreasing symptoms of depression. Regular online communication with occupational therapists positively affects depression management. A dementia prevention program for community-dwelling older adults is important for community-based occupational therapy in Korea. Clinicians in community rehabilitation settings should be more interested in online dementia prevention programs and provide evidence-based programs.


To (1) evaluate the prevalence and types of disease management (DM) programs provided by independent and chain community pharmacies in the state of California, (2) examine the interest among community pharmacists in establishing programs, and (3) assess perceived barriers to developing a successful DM program in community pharmacy.An exploratory telephone survey was conducted from February 2003 to February 2004 to collect data from community (primarily independent and chainstore) pharmacies across California. The survey evaluated existence (or lack of) and types of DM programs in community pharmacies in California. Pharmacies that did not have a DM program were queried on their interest and decision-making authority in establishing new programs. Pharmacies that had existing DM programs were sent a follow-up survey to determine the details of the DM programs, including challenges in establishing DM programs, reimbursement issues, and program effectiveness.The sample comprised 1,875 pharmacies, 60 (3.2%) of which had existing DM programs. There were significantly more independent pharmacies (37) with DM programs than chain-store pharmacies (23), P less than 0.001. There was a statistically significant difference between independent and chain pharmacies in operating hours, number of pharmacist and nonpharmacist staff members per day, and proximity to a clinic or hospital (P less than 0.05). The most common type of DM program was diabetes, and the second most common type was asthma. Limited time, limited staff, and limited reimbursement were the 3 most commonly reported barriers to establishing new DM programs. About 20% of the sample that did not have a DM program reported interest in developing DM programs, and an equal percentage reported having the decision-making authority to start a program. There were no differences between independent and chain pharmacies on interest (P=0.234); however, there were significantly more chain pharmacists that did not have the decision-making authority. Of the 18 of 60 pharmacies (30%) that had DM programs and responded to the follow-up survey, 9 respondents (50%) reported monitoring medications as part of their DM program. Fifteen of 18 (83%) perceived lack of reimbursement as a challenge to implementing DM programs. Only 2 pharmacies reported an increase in revenue as a gain from the program, and 2 reported cost savings. Improved patient satisfaction was reported by 16 of 18 respondents (89%) with DM programs, but only 8 (44%) reported that patient satisfaction was being measured.The study found that the prevalence of DM programs was very low among California community pharmacies and the interest in developing these programs moderate, attributable to several barriers such as lack of time, lack of reimbursement, and lack of trained personnel. Some of these barriers could be addressed to encourage the development and proliferation of DM programs that would improve patient outcomes and expand practice roles of pharmacists.


Additionally, the participants’ body images were improved, the participants disrupted their stereotypes about makeup, and they were willing to gradually maintain their appearance. Overall, the beauty program was effective for enhancing the self-perceptions of aging and reducing depression in older adults in rural Taiwan. Further research with a larger population of older individuals, male older adults, or frail older adults is needed to examine the specific effects of the beauty program.This study aimed to investigate the effects of a beauty program on the self-perception of aging and depression among the community-dwelling older adults in an agricultural area in Taiwan. Twenty-nine older adults aged 65 and above in one agricultural community care center completed the program. Based on cosmetic therapy, the beauty program consisted of 13 sessions focused on facial skin care, make-up application, and massage with essential oils. Each 90 min session of the program was conducted in groups once a week for 13 weeks. This study applied the mixed methods approach, and data were gathered through questionnaire surveys, interviews, and observation. Before and after the beauty program, the elderly individuals’ self-perceptions of aging and depression were assessed using the Attitudes towards Old People Scale (ATOPS) and Taiwanese Depression Questionnaire (TDQ), respectively. The participants’ ATOPS scores after the program were significantly higher than those examined before the program ( As the population of older adults worldwide continues to grow, international organizations, governments, scholars, and practitioners across the world are promoting the health of older adults to help them live better lives while reducing the burden on care services for older people .Due to the deterioration of their physical health, discontinuity of their social lives, changes in appearance, and degradation of cognitive function, older adults are usually unable to live normal or independent lives, which significantly affects their psychological health and causes low self-esteem or even depression ,3. Many Additionally, many elderly people suffer from depression due to the deterioration of their physical and psychological functions. For the aging population, depression may cause disabilities, which can interfere with the treatment of chronic diseases and increase medical costs . ElderlyIn recent years, health promotion activities for older individuals launched in many countries have focused on physical exercise, music therapy, board games, gardening, animal therapy, and so on ,18,19,20Recently, Korean and Japanese researchers have explored improving the cognitive functions, interpersonal relationships, life satisfaction, and emotions of older adults through beauty programs. Studies have shown that beauty programs can significantly facilitate cognitive functions in older adults, including orientation, attention, and arithmetic abilities, immediate and short-term memory, language ability, and visual spatial abilities ,26,27. AThis study, with a convenience sample of older adults aged 65 and above, was conducted at a community care center in a rural town in Pingtung, Taiwan. In recent years, the Taiwanese government has built many local nonprofit care centers for elderly people to attend all kinds of activities in their communities to facilitate their physical and mental health. Over 70% of seniors aged 65 or above in Pingtung made a living by farming when they were young. Thus, agricultural work is a shared life experience of these participants.The research was approved by the review committee of the Pingtung County Government. Following approval by the administrators of a community care center in an agricultural town in Pingtung, the researchers individually contacted the potential participants in the community center who were aged 65 and above. The recruitment criteria for the participants included being aged 65 and over, never having participated in similar beauty programs, not being diagnosed with or suspected of having dementia, and being independent in self-care.n = 1), fear of COVID-19 infection (n = 5), lack of interest (n = 1), and injury or sickness (n = 3). The average age of the 29 participants who completed the intervention was 78.6 years (SD = 5.5); most of them were aged from 76 to 80 years (34.5%). Most of the participants were females (89.7%), lived with their family (84.6%), and had received primary education or less (72.4%). All of the participants were married, and 55.2% of them had a spouse who was deceased. The average attendance rate of the program was 74%.A total of 39 participants were recruited at the community care center and written informed consent was obtained from all of the participants. Finally, of the participants, 29 completed the beauty program, and 10 withdrew due to death  to 27 July 2022, except the 3rd week of April and the 2nd week of July because of COVID-19 lockdowns. The beauty program intervention was conducted once a week during the 13 study weeks, and each weekly session lasted for 90 min.The beauty program targeted older adults aged 65 and above in rural areas; its aim was for elderly participants to be able to take care of their skin, apply simple make-up on their own, perform self-massage with essential oils, have a positive self-perception of aging, and maintain positive emotions. The beauty program consisted of 13 sessions involved self-skin care, make-up application, and body massage with essential oils. The program was developed by 3 licensed beauticians, 1 registered nurse, 1 occupational therapist, and 1 health promotion expert; it was then verified by 1 licensed beautician, 2 beauty majors with master’s degrees, and 1 specialist in health promotion with a doctoral degree. The protocol of the program is shown in The beauty program was conducted by an experienced beauty training instructor with the assistance of the two assistants in this study and two community care center volunteers who had completed training by the instructor. Before and after each of the sessions, except for the last one, the researchers took pictures of each participant and put the pictures in their personal photo albums. At the beginning of every session (except the first session), the participants were encouraged to look at their own albums to observe their appearances.Each session of the program included three phases and the participants learned in groups. In the first phase, the instructor invited the participants to recall the learning experiences in the previous session and to share their cosmetic practices at home. In the second phase, the instructor explained and demonstrated the cosmetic activities, and then the participants practiced. Each group was supported by one volunteer or assistant. In the third phase, the instructor guided the participants to observe the changes in their own and their group members’ appearances, to give feedback to one another and to share their afterthoughts on learning.To encourage the participants to practice what they learned in the beauty program in their daily life, easily accessible beauty products of high quality and low cost, such as lotion that could be bought in supermarkets, were applied. In addition, the instructor made good use of daily necessities, such as porcelain spoons and plastic combs, as massage tools and encouraged the participants to bring and use their own tools. Additionally, to facilitate the participants’ interest in the beauty program, the beauty operation procedures were simplified, and the male participants were provided with multiple alternative activities, such as applying masks instead of putting on make-up and wearing clear lip balms instead of lipsticks. Furthermore, rather than the standard make-up, the importance of personal preferences and experiences of beauty were emphasized.In this study, the data were collected through questionnaire surveys, semi-structured interviews, and observation.Before and after the intervention, the participants were assessed through individual interviews that the researchers administered. These two scales, which have acceptable psychometric properties, have been applied by researchers and clinicians.Self-perception of aging (SPA) among the participants was measured using the Attitudes towards Old People Scale (ATOPS) (α = 0.94), which was developed by Lu and Kao [ and Kao  especialDepression among the participants was measured by the Taiwanese Depression Questionnaire (TDQ) (α = 0.90), a culturally relevant instrument for screening depressive symptoms in Taiwan [n Taiwan . TDQ is n Taiwan   version 22.0 was used to analyze the questionnaire data. Descriptive statistics were used to describe the participants’ backgrounds. The dependent sample t test was used to examine the changes in SPA and depression scores as the effects of the interventions with a significance level of 0.05.The interview transcripts and observation records were analyzed by applying thematic analyses . First, t tests indicate that the scores of all of the variables of SPA significantly increased from before the intervention to after the intervention (p < 0.001).As seen in t = −10.37, p = 0.000), self-perceptions of appearance and physical characteristics , self-perceptions of psychological and cognitive characteristics , self-perceptions of interpersonal relations and social engagement , and self-perceptions of work and economic safety  all significantly improved. Namely, the participants’ perceptions of and attitudes toward their aging were significantly improved: their late life experiences were more positive.After the beauty program, the participants’ overall SPA  to after the intervention  (p < 0.001). Namely, after the beauty program, the participants’ level of depression  significantly decreased.As shown in The results of the qualitative data analysis indicated that, through the beauty program, the participants’ self-perceptions of aging became more positive in the physical, psychological, and social aspects.The older adults said that, due to the beauty program, which involved facial cleaning and care, eyebrow shaping, and makeup application, they perceived a significant improvement in their appearance, including looking younger, having clearer skin and fewer wrinkles, becoming beautiful or handsome, and even discovering a different version of themselves. As Elly said, “I never applied makeup before, and I just felt ugly… but after putting on makeup during the beauty program, I was surprised to find myself a different person.” The male participants also noted an improvement in their appearance. “In the beauty program, after the makeup application, I found the dark spots on my face had faded, and my friends said that I looked like a teenager,” Dick said. The older adults also found themselves more energetic after practicing skincare and applying makeup. “After taking the beauty program, the older adults looked much better than before and became more enthusiastic about beauty, like lipstick application or eyebrow penciling,” the volunteer Jenny noted.The beauty program encouraged the participants to observe their appearance, which accordingly led them to appreciate themselves after applying makeup. At the beginning, the female participants mostly failed to accept their own appearance and thus disliked taking photos or viewing their own photos. However, during the beauty program, in addition to guiding the participants in cleaning and caring for their faces and applying makeup, the instructor showed the participants photos of themselves before and after the makeup application to encourage them to observe themselves and each other, give mutual positive feedback, and gradually accept and even appreciate their appearance. As Candy said, “I’m not going to take my makeup off after class today. Rather, I will leave this makeup on when going home and show it to my neighbors and family members. I feel pretty after the makeup, rather than looking like an old woman in her 80s.” Ida also noted, “I appreciate myself with light makeup. The more I look at myself with makeup, the more I like myself”.In the beauty program, most of the participants felt that they were more outgoing and willing to help each other in the group. As Yuki said, “Lyn’s son recently passed away. While learning about skincare and massage in class, we talked and laughed together hoping to comfort and encourage Lyn.” The volunteer Kyle noted, “Although they have been neighbors for a long time, these older participants are shy to serve each other. However, mutual massage in this beauty program can gradually make them open to massaging each other.”The older adults and volunteers said that the beauty program had direct positive effects on the moods of the older adults by improving their appearances. Most of the participants said that they became happy after applying makeup. In addition to looking at themselves in the mirror to identify changes in their appearance, they also felt cheerful when receiving positive feedback from their partners. As Betty mentioned, “I never applied makeup before, but after this program, I realized that applying makeup or not makes a world of difference. I like my appearance with light makeup. When going out, I really feel joyful when I am praised for becoming more beautiful”.Moreover, the use of aromatherapy together with essential oil massage relaxed the participants by smelling and massaging with essential oils. Hebe said, “Essential oil massage, together with hot compresses, can unwind my body, especially the shoulder and neck, making me in a good mood”.The participants attending the beauty program drew more attention from their neighbors, friends, and family, which generated more interaction among them. As Apple mentioned, “When I got home with makeup from the beauty program session, my friends and neighbors usually asked me where I went and why I applied such exquisite makeup, which always led to a lively conversation about my makeup and the beauty program.” Additionally, the participants’ families, such as their spouses, children, and grandchildren, also noticed the changes in their appearances when the participants returned home after the beauty program session. Furthermore, some of them uploaded their photos taken during the beauty program to social media, eliciting warm and positive responses from their family. Dick said, “My son usually told me that I looked more handsome and younger and often discussed my learning in the care center! Before, he seldom paid attention to my activity”.It was found that older females in the agricultural community, which is characterized by a conservative social atmosphere, were not encouraged to practice skincare or apply makeup when they were young, “Because we had been taught to keep our look as simple as possible and to be busy farming or doing work instead of dressing up ourselves,” Ida said. Hence, they tended to believe that makeup was necessary only for important activities and worried that makeup would cause others to think they were too flashy. As the researcher observed, “Jade requested that her eyebrows be returned to normal immediately after eyebrow penciling, even though she admitted that her eyes looked brighter with eyebrow penciling. This is because she was not accustomed to eyebrow penciling and was afraid of being criticized by her husband or laughed at by neighbors.” However, in the beauty program, the participants were encouraged to implement facial care, put on makeup, and observe the continued improvement of their facial appearance. Furthermore, the instructor continued to reinforce the idea that regardless of their age, the individuals should accept and care for their appearance and that applying makeup can prevent dementia ,26,27. GDuring the implementation of the beauty program, even the three male participants engaged in the beauty activities. Dick said that the facial care and makeup activities made him happy and, without being restricted by the traditional stereotype that makeup is only for females, he was willing to participate in the beauty program. Furthermore, some female elderly participants even encouraged the male older adults to attend the beauty program. Betty noted, “I believe the men will also feel happy when learning to apply makeup, including putting lipstick on their lips”.Overall, the beauty program in this study could improve self-perception of aging and alleviate depression among the older adults living in a rural area. Moreover, through the beauty program, the older adults could better accept and appreciate their own appearances, thus contributing to the improvement of their social lives. Both the male and female participants managed to disrupt stereotypes about makeup and viewed maintaining and improving their appearance as being normal and natural.In this study, the quantitative results show that the participants’ overall self-perceptions of aging were significantly improved after the beauty program, and the qualitative results further indicated that the program could promote their self-perceptions of aging in the physical, psychological, and social aspects. Specifically, the participants believed that their appearance was significantly improved through the beauty program, including by looking younger, more beautiful, and elegant. In fact, the improvement of physical appearance is essential for older women’s quality of life. Research has suggested that female older adults who perceive themselves as being physically attractive and young tend to feel healthy, happy, optimistic, and socially connected; to adjust to the environment well; to be satisfied with life; and to be willing to attend social activities ,35,36.The beauty program in this study, which emphasized facial cleaning and care, makeup application, and aromatherapy, and which was implemented in groups, was likely to have impacts on physical, psychological, and social aspects of the participants’ aging experiences. However, the results of the questionnaire surveys indicate that the older adults’ perceptions of aging in terms of job and economic security were also improved. Clearly, their perceptions of their work and economic security were not only affected by objective life indicators but also closely related to their psychological feelings ,37. HencThe quantitative results of this study indicate that the beauty program significantly alleviated depression among the participants, and the qualitative results also show that the participants felt happier and more relaxed after participating in the beauty program. This may be explained by the fact that positive peer interaction in the beauty program, positive feedback from friends and family members, and active social engagement in the beauty program could improve the psychological health of the older participants. Moreover, the improvement in their physical appearances may also have had positive psychological effects on the participants’ emotions. Clinical studies have found that beauty programs can effectively improve the mental health of patients with cancer, dementia, or psychological illnesses .Empowering older adults is one of the key objectives of health promotion programs for the aging population. Namely, older adults are encouraged to realize their potential and gradually become confident and independent through continuous learning ,13. In tFurthermore, maintaining and pursuing an attractive appearance plays a key role in the later lives of older adults because having an optimal appearance indicates that older adults can effectively manage their aging bodies. Additionally, positive feedback from themselves and others about their physical appearances can boost their self-confidence and then contribute to their empowerment .This study reveals that the beauty program could provide older adults with new learning experiences and lead them to find a different version of themselves and further appreciate themselves. Elderly people in rural areas may rarely apply facial makeup or practice aromatherapy in their lifetime due to their heavy workload or the conservative social atmosphere. As Hebe noted, “In my lifetime, I only applied makeup when getting married, so it was not until at this age that I learned applying makeup at the center.” Additionally, the participants could see a different version of themselves through applying makeup in the beauty program. “I can hardly imagine how beautiful I could be after applying makeup,” Elly said. This was an unexpected result of the beauty program. Most participants who seldom wore makeup were so surprised at the improvement in their appearance that they could not help but repeatedly observe their faces in a mirror for a long time after applying makeup. However, this finding has rarely been mentioned in previous studies . This maThe study also found that the beauty program could reverse the female participants’ negative body images and help them maintain and pursue an attractive appearance. At the beginning of the program, most of the female participants had negative self-appraisals of their appearances. This may be explained by the traditional Chinese social practice of replacing modesty with self-deprecation, which is especially common in rural areas . MeanwhiIt was found that the beauty program in this study could disrupt the older adults’ stereotype that “makeup is only for females” and attract the older men to participate in beauty activities. In the beauty program, there were three male participants who actively and willingly participated in beauty activities, such as applying makeup, lipstick, and facial masks, as well as practicing essential oil massage, and warmly praised the group members’ appearances after practicing skincare and applying makeup. One of the male participants, Dick, always left the center with applied red lipstick; he said, “I would like to show my good looks to my friends and family.” He usually encouraged his older male friends to visit the beauty program. Additionally, in the end, even the female participants suggested that males should also attend the beauty program. This finding could be explained by the fact that the beauty program provided varied activities for the male older adults to choose from to achieve similar skincare effects ,22. For It is important to acknowledge some limitations of this study. First, the participants consisted of elderly adults in good health, who may be different from the general aging population in some respects. Therefore, the generalizability of the results is limited. Second, the beauty program in this study was multidimensional in nature; therefore, we can tentatively conclude that the effects of self-perception of aging and depression resulted from the cosmetic treatments. Third, a small number of the participants withdrew from the study, and they might have had different reactions toward the beauty program from the participants who completed the program. These differences might have influenced the results and warrant further examination. Fourth, the beauty program in this study comprised three parts, including skin care, make-up application, and massage with essential oils, and the specific effects of each part of the beauty program warrant further investigation.The results revealed that the beauty program in this study was effective for improving the self-perceptions of aging and reducing depression among the community-dwelling older adults in an agricultural area in Taiwan. Additionally, the older participants’ body images were improved, the participants disrupted their stereotypes about makeup, and they were willing to gradually maintain their appearance. Further research with a larger population of aging people, male older adults, or frail older people is needed to examine the specific effects of the beauty program.