It is well established that behavioral lifestyle interventions resulting in modest weight reduction in adults can prevent or delay type 2 diabetes mellitus; however in children, successful weight management interventions are rarely found outside of controlled clinical settings. The lack of effective community-based programs is a barrier to reducing obesity prevalence and diabetes risk in children. The objective of our study is to develop and test a group-randomized family-centered community-based type 2 diabetes prevention intervention targeting at-risk children, 9- to 12-years-old.Using participatory methods, the adult-focused YMCA Diabetes Prevention Program was adapted for families, creating a novel lifestyle behavior change program focused on healthy eating, physical activity, and a supportive home environment. The program will be tested in sixty 9- to 12-year-old children at risk of diabetes and sixty parents over 12 consecutive weeks with two intervention formats randomized by location: a face-to-face instructor-led program, or a hybrid program with alternating face-to-face and mobile technology-delivered content. Anthropometric, behavioral, psychosocial and physiological outcomes will be assessed at baseline, post-intervention (12 weeks), and follow-up (24 weeks). Secondary outcomes are participant acceptability, feasibility, and adherence. The RE-AIM framework  will guide intervention implementation and evaluation. Changes at 12 weeks will be assessed using a paired t-test combining both delivery formats. Exploratory models using linear regression analysis will estimate the magnitude of the difference between the face-to-face and hybrid format. The sample size of 60 children, informed by a previous YMCA intervention in which −4.3 % change in overweight (SE = 1.1) was observed over 6 months, will give us 80 % power to detect an effect size of this magnitude, assuming a one-sided test at alpha = 0.05.The proposed study capitalizes on a partnership with the YMCA, a popular and widespread community organization, and uses mobile technologies to extend program reach while potentially reducing burden associated with weekly attendance. The long-term goal is to create a scalable, replicable, and sustainable pediatric “diabesity” prevention program that overcomes existing barriers to the translation of efficacious interventions into effective community programs.NCT02421198 on April 15, 2015ClinicalTrials.gov,  The statistics are startling: nearly one-third of U.S. children and adolescents are overweight and one in five are obese . Given tIn adults, behavioral interventions have proved more efficacious than pharmacological interventions for T2D prevention  with estThe proposed program - EPIC Kids (Encourage - Practice - Inspire - Change) will provide critical infrastructure to support youth and families in making lifestyle changes by adapting the successful adult YMCA Diabetes Prevention Program (YDPP) , 16 for Adapt the efficacious Diabetes Prevention Program (DPP) in adults – the adult YMCA DPP – for delivery to children, ages 9-12-years-old, and their familiesTest the impact of the program on child anthropometric, behavioral, physiological, and psychosocial outcomesAssess feasibility, participant acceptance (child and parent), and retention rates of the program using two delivery formats randomized by YMCA location: a 12-week face-to-face program and a 12-week hybrid face-to-face and mobile device-based programThe EPIC Kids Study has the following objectives:Herein we describe the design and evaluation of the EPIC Kids Study, a family-focused, YMCA-based diabetes prevention program specifically designed for at-risk children and their families.The impact of the EPIC Kids intervention will be evaluated using a group-randomized, non-inferiority trial design with three data collection points: baseline, post-intervention (immediately post program completion at 12 weeks), and follow-up (24 weeks) , and follow-up (24 weeks) measures will assess changes in child anthropometric, behavioral, psychosocial, and physiological outcomes. We will also determine whether the two delivery formats are acceptable and feasible, and if the use of technology reduces participant burden and improves adherence for the ‘hybrid’ condition. The study protocol was approved by the University of Arizona Institutional Review Board, and is registered with ClinicalTrials.gov (NCT02421198).Eligible participants are 9 to 12-years-old at study enrollment, have a BMI at or greater than the 85th percentile for age and sex, and have one or more of the following T2D risk factors: ethnic minority, first or second degree relative with T2D, conditions associated with insulin resistance or metabolic syndrome . EligibParticipants will be recruited through pediatric and family medicine practices, the Southern Arizona YMCA membership, and the Tucson community  using electronic announcements, flyers, posters, and word-of-mouth between May and August 2015, and between October 2015 and January 2016. Respondents will be invited to attend study information sessions held at participating YMCA locations where eligibility will be confirmed. Interested and eligible respondents will complete the informed consent process following University of Arizona Institutional Review Board-approved materials and methods and assigned a study location based on geographical proximity. Written consent will be obtained from parents; verbal assent will be obtained from youth and documented in writing by study staff. Families who are not yet YMCA members will be provided access to YMCA facilities free of charge for the duration of the study, with an opportunity to continue at a reduced rate after the study has concluded.The primary outcome is change in percent overweight. Our estimated sample size was informed by the results of Foster et al.  who obseThe YMCA of Southern Arizona (YMCA-SAZ) will play a significant role in the intervention. As a certified training center for the Y-USA Diabetes Prevention Program (YDPP), YMCA-SAZ administrators and staff have experience delivering the successful adult-focused YMCA Diabetes Prevention Program , 16. TwoThe YMCA’s (adult-focused) Diabetes Prevention Program (YDPP) served as a guide for the development of the EPIC Kids program. The YDPP consists of a series of weekly lessons delivered by trained paraprofessionals at the YMCA over 4 months. Program goals are weight loss through healthy eating and increased physical activity; all activities provide opportunities to learn and practice lifestyle behaviors . EPIC Kids was designed to retain the relevant, evidence-based features and structural elements of the successful adult-focused program, with two key adaptations related to content and delivery - content specific to youth and families and delivery of content using mobile devices - both designed to address and overcome potential barriers to implementation unique to youth and families.Congruent with the 2012 IOM Report  and guidAnticipating a ‘hybrid’ intervention format with an alternating face-to-face/digital delivery, five out of twelve EPIC Kids sessions (40 %) were adapted for delivery through the study-provided tablet . Best practices for mobile content design and delivery informed these adaptations, with a focus on the persuasive design elements associated with mobile health behavior change   Table 11.Table 1Participatory methods were used to refine intervention content and delivery methods. Formative research partners included an external advisory board comprised of experts in diet, physical activity, youth development, diabetes, mobile technologies, and pediatric medicine; youth in the target age range (9- to 12-years-old); administrators and program staff at the YMCA of Southern Arizona and Y of the USA, and staff from The University of Arizona Cooperative Extension’s Garden Kitchen, a seed-to-table nutrition education program serving the City of South Tucson.In September and October 2014, in-depth interviews were conducted with two YMCA administrators and four staff to explore factors influencing local adoption and delivery of EPIC Kids. Discussion topics included branding and licensing issues, and ongoing costs and resources associated with training, implementation, and evaluation. Interviews also explored resources needed to conduct the future large-scale study. Two researchers trained in qualitative procedures conducted the interviews, which were audio-recorded, transcribed, and coded to identify salient issues.In October 2014 and March 2015, advisory board members reviewed intervention materials and assessed whether proposed topics and activities aligned with program goals, rated the potential of each topic and activity to influence obesogenic behaviors, and insured the proposed activities fostered skill acquisition and provided opportunities for further practice. Following advisory board review, content was revised and further refined by the research team during a series of user tests conducted February to April 2015 with five children aged 9- to 12-years-old recruited from the YMCA. Participants met with the research team during six, 1.5-hour sessions held every other week for twelve weeks. At each session, participants were asked to complete a series of scripted activities mimicking study engagement  and verbalize their reactions  as they completed the activities. Participants also viewed sample content from weekly sessions and rated its acceptability, their comprehension, and enjoyment. Following recommended guidelines for qualitative data collection , sessionEach EPIC Kids session is 1.5 h in length; sessions are delivered weekly over 12 consecutive weeks. In addition to incorporating structural elements that promote fun, activity, and interactivity  among children, family members and coaches; content is focused on impacting modifiable diabetes risk factors including the home environment, parenting practices, diet quality, physical activity, screen media use, and sleep. Sessions are structured to foster skill building and provide repeated opportunities to practice healthy lifestyle behaviors. Each week has a similar format, beginning with family physical activity, and concluding with goal setting , and organizational skills/time management . TraininThe intervention will be conducted over 12 weeks at two YMCA locations. Each location will engage up to thirty children and their parents. The program duration is informed by the length of the YMCA adult-focused Diabetes Prevention Program, as well as studies in adults , 32 and Two YMCA sites, [A] and [B], were randomly assigned to face-to-face versus hybrid intervention formats using a random number table. Based on alphabetical order and an even number selected, [A] was assigned to receive the face-to-face format and [B] was assigned the hybrid format.Anthropometric, behavioral, psychosocial and physiological outcomes will be evaluated at baseline, immediately following the 12-week intervention, and at follow-up (24 weeks). At each of these time points, weight will be measured using an electronic calibrated scale  and rounded to the nearest 0.1 kg with participants wearing light clothing and no shoes. Height will be measured by a portable stadiometer  and rounded19 to the nearest 0.1 cm. Waist circumference, linked to metabolic syndrome in children , will bePsychosocial measures will be evaluated to assess mediators of behavior change using validated questionnaires for youth including self-efficacy related to nutrition , 40 and Physiological outcomes will be assessed through 12-hour fasting insulin, glucose, and lipids drawn at J2 Laboratories, Tucson, Arizona, by a trained phlebotomist and placed into serum separator vacuum tubes. Insulin resistance (IR) will be assessed using HOMA , shown tFeasibility data will include recruitment, enrollment, and retention rates, program attendance and engagement, and delivery costs. Program satisfaction will be self-reported by participants (parents and children) using brief surveys that inquire about relevance of content, promoters and barriers to attendance and engagement, and degree to which the family applied the intervention to lifestyle behavior changes. Adherence data will include attendance logs and time spent with mobile content (hybrid condition), and completion of self-monitoring and goal-setting activities (both conditions). Importantly, our mobile infrastructure  permits Data collection and entry, and statistical analyses will be conducted by research staff who are blinded to treatment allocation. Participants will be assigned a study identification number upon enrollment. Study personnel involved in data collection will follow a strict written protocol that describes study measures for protecting confidentiality and privacy. All aspects of data collection and storage will be carefully monitored to ensure rapid detection of errors, inconsistencies or other problems. Data will be double entered with third party verification to insure data integrity, and kept in locked files and on a dedicated study computer and secure network. Access will be restricted to the principal investigator and designated staff. Files with information linking names and other personal data to participant identification numbers will be deleted at the end of the study, and written copies will be shredded.Outcome measures will be stratified by delivery format to assess whether the mobile technology-supported delivery of the intervention is as efficacious as the face-to-face format. Descriptive statistics for change in endpoints  between baseline and 12-week measurements will be computed separately for each program format (face-to-face or hybrid mobile technology-supported program). The statistical significance of the change at 12 weeks will be assessed using a paired t-test combining both formats. One-sided statistical tests will be used, as the interventions approaches are of interest only if they decrease the percentage overweight and lead to improvements in diabetes risk factors. Statistical significance is set at alpha = 0.05. Sample size constraints do not allow adequate statistical power to formally test for differences between the two formats. However, exploratory models using linear regression analysis will estimate the magnitude of the difference between the face-to-face and combined formats, adjusted for baseline levels and the potential correlation between the participants within a given YMCA . These parameter estimates will provide effect sizes to appropriately power a larger study comparing the two formats. Since this is a randomized comparison, confounding is not an issue as long as there is non-differential dropout between the two formats. Differential dropout between the two formats will be assessed using a Fisher’s Exact Test. Similar analyses will assess whether improvements are maintained after the intervention ends, by comparing the 24-week versus 12-week values. We acknowledge the potential for differential loss to follow-up and missing data. Baseline values of those who complete the study versus those who do not will be compared using two sample independent t tests and Fisher’s Exact Tests, as appropriate. Additional sensitivity analyses will use multiple imputation for missing values and an intent-to-treat analysis with baseline values carried forward.We expect four to seven percent reduction in the percent of overweight youth after 12 weeks, similar to behavioral interventions in clinics , 53, 54;The intervention has an a priori focus on scalability, replication, dissemination, and sustainability. Process evaluation and monitoring plans were created using the RE-AIM framework, a tool to assess the public health impact of health promotion interventions as described by Glasgow et al. . RE-AIM Obesity prevalence among U.S. youth remains high  heraldinEPIC Kids is an intervention that adapted the successful adult YMCA DPP to include evidence-based behavioral change strategies , while


A randomized control trial demonstrated that a computerized cognitive behavioral therapy (cCBT) program  was an appealing and efficacious treatment for depression for adolescents in New Zealand. Little is known about the acceptability of computerized therapy programs for rural Australians and the suitability of computerized programs developed in one cultural context when used in another country. Issues such as accents and local differences in health care access might mean adjustments to programs are required.This study sought to explore the acceptability of SPARX by youth in rural Australia and to explore whether and how young people would wish to access such a program.Focus groups and semistructured interviews were conducted with 16 young people attending two youth-focused community services in a small, rural Tasmanian town. An inductive data-driven approach was used to identify themes using the interview transcripts as the primary data source. Interpretation was supported by demographic data, observer notes, and content analysis.Participants reported that young people want help for mental health issues but they have an even stronger need for controlling how they access services. In particular, they considered protecting their privacy in their small community to be paramount. Participants thought computerized therapy was a promising way to increase access to treatment for youth in rural and remote areas if offered with or without therapist support and via settings other than school. The design features of SPARX that were perceived to be useful, included the narrative structure of the program, the use of different characters, the personalization of an avatar, “socialization” with the Guide character, optional journaling, and the use of encouraging feedback. Participants did not consider  accents off-putting. Young people believed the SPARX program would appeal to those who play computer games generally, but may be less appealing for those who do not.The findings suggest that computerized therapy offered in ways that support privacy and choice can improve access to treatment for rural youth. Foreign accents and style may not be off-putting to teenage users when the program uses a playful fantasy genre, as it is consistent with their expectation of fantasy worlds, and it is in a medium with which they already have a level of competence. Rather, issues of engaging design and confidential access appeared to be more important. These findings suggest a proven tool once formally assessed at a local level can be adopted cross-nationally. Northwest Tasmania is characterized by mountainous terrain, a rugged coastline, and small, sparsely populated settlements with economies reliant on agriculture, mining, and forestry. These communities are too small to individually host a full range of community health services and in winter they are often isolated due to flooding, high winds, snow fall, and icy roads. It is these smaller towns and settlements where social determinants associated with health inequity are most evident, that have reduced access to health services, have a higher proportion of Aboriginal Australians, lower socioeconomic status (SES), and are under-represented in post school education statistics ,2. RecenThe impact of child and adolescent mental health disorders on individuals, families, and communities is significant ,4. Loss Traditional approaches to translating evidence-based interventions into practice have failed to substantially close the gaps in service quality or reduce disparities -18. AlegComputerized therapies have been shown to be effective in alleviating depression and anxiety symptoms in adults, adolescents, and children -22. MostSmart, positive, active, realistic, X-factor thoughts, or SPARX, is a cCBT program that uses a bicentric frame of reference ; it combThis research project was undertaken as a first step in exploring the “translation” of a computer program developed for New Zealand youth, for use by young people in rural Australia. Issues such as accents and local differences in health care access might mean adjustments to programs are required. Given that (un)acceptability of Web-based programs is a significant factor in attenuating the effectiveness of services delivered in real world settings as compared with efficacy shown in clinical trials it is an important component to assess for methodological and pragmatic reasons . While tTo engage with the community to assess the acceptability of the SPARX cCBT program  to Australian youth, a naturalistic ontological view was adopted. A naturalistic, or subjective ontology, considers the researcher part of the same experience as the research participants, not discrete from the inquiry. The nature of the research is exploratory; the researcher seeks to understand the reality, actions, and perceptions of individual participants. This is not assumed to be value-free, but interpreted by the researcher , an apprA decision to adapt the program would incur cost, thus evidence to support the decision required a degree of impartiality by the researcher. On this basis, a positivist epistemology was applied. Positivist epistemology asserts the researcher has a priori relationships with phenomena, which may be identified and tested by logic and deduction . That isAs only a small window into local youth opinion was required, both to suit the nature of the inquiry and the way young people were most likely to interact, short focus groups were selected as the primary data collection method, supported by demographic information, observer notes, and content analysis.One of the small rural towns of northwest Tasmania was selected for the study, which is characteristic of the vulnerable, small communities described. There is one General Practice in the town, no resident psychological service, with a visiting mental health practitioner hosted 1 day per week at a local organization. The nearest regional town with psychology services is over 80 km (50 miles) away; the nearest Headspace office  is over 200 km (125 miles) away. According to the 2011 Australian Bureau of Statistics Census data , the towThe two community-based organizations in the town offering a variety of community programs aimed at improving the towns’ health and well-being supported this study. These organizations focus on early intervention and preventative measures to encourage and enhance healthy life and seek to improve quality of life and wellbeing for individuals and families. A range of services are available, including mental health support, health promotion and education, and youth health. One organization supports all persons in the community regardless of their social, mental, or physical condition and generally operates as a self-referral service, although troubled youth are steered to these services through school programs. The other organization specifically targets services to meet the needs of the local Aboriginal community, but also includes referrals from police to youth prevention and diversion programs. The visiting mental health practitioner is hosted by this organization through a Medical Specialist Outreach Assistance Program. As such, these organizations do not represent the broader community of young people, but provide a more purposive sample for assessing an adolescent mental health intervention by means of a focus group interview. Ethics approval for conducting this research was obtained from the Tasmanian Social Sciences Human Research Ethics Committee.Both organizations preferred to recruit potential participants themselves, and arrange groups to optimize dynamics based on their knowledge of the individuals. Three participants were recruited from one of the organizations, 2 males and 1 female . The research team determined it was important to capture the views of marginalized individuals and we were, therefore, keen to accommodate these preferences. Hence, semistructured interviews were carried out with the 2 male and 1 female participants.The second organization recruited 10 males and 3 females. Again, this organization’s staff felt the individuals would best participate in groups according to gender, and organized their participants into a younger male group (with participants 12- to 15-years old), an older male group (with participants 16- to 18-years old), and a group for females.The focus groups were held at the participating organizations in consecutive weeks, with an information session held the day before each focus group. At the beginning of the focus group sessions participants were asked to record their age, gender, ethnicity, and whether or not they played computer games.The SPARX program was introduced by using a short (5 minute) video trailer of the program. The trailer included audio of the Guide character supporting a program user, avatar customization, and the visual effects of being transported into the SPARX fantasy world  and 2. FThe clinical psychologist of the research team (HB) acted as the Facilitator, while another member played the role of Observer (CC). Neither were known to participants prior to the information sessions.1. What do you think of the way SPARX looks?2. What do you think of the way SPARX sounds?3. Do you think young people around this area might be interested in using the program? If so, why? If not, what about if they were feeling down or depressed?4. If young people were to use SPARX, where might they use it ?5. What do you think might get in the way of young people using SPARX?6. Do you think any changes need to be made to SPARX so that young people would like to use it? If so what could be changed? How important would it be to make these changes?7. What do you think about the use of the word “Depression”?As this was a small study, a hybrid approach in developing a data-driven code was followed as described by Boyatzis . In the Thus, to systematically conduct thematic analysis, the procedure followed in this study was in two stages:Identification of the dependent variable and use of all 5 focus groups/interviewsDevelopment of themes and codesReduction of the raw dataIdentifying themes within samplesComparison of themes to own theories and research literatureCreation of a codeChecking reliability by revision and refinement of category systemAudio recordings of the interviews were transcribed using Olympus Sonority v1.2.0 voice recording software. The transcripts were entered into Microsoft Excel 2010 software for organization, identifying the group, gender, and age of participants. Observer notes and content analysis were added at the appropriate questions. Blocks of text were summarized according to the specific interview question and research aim . TranscrEmerging themes were identified through repetition of a common word or action, for example “privacy” or “using it in private/at home/where no one else can see”. The views of gamers were subsequently compared with nongamers to understand how a prior interest in computer gaming might affect their view of SPARX, and within the context of the personal sphere of participation for meaningful use of technology in health .Sixteen codes were generated. To identify categories, an iterative grouping process was used where the codes were at times split, and regrouped with indicators and text fragments as examples to find where they best represented the themes and data within, and to select category labels that best represented these. Once these categories were established as nodes and subnodes within nVivo software, the transcripts were recoded according to this framework by members of the research team individually . This double-coding technique sought to test the reliability of the coding framework. Reports were compared and reviewed collectively to discuss and resolve differences. The revised final category system, themes, and transcripts were reviewed (TF) and found to be similar to information derived from SPARX-related focus groups previously conducted with young people in alternative education programs .Five focus group/interview sessions were held with a total of 16 participants,  between the ages of 13- and 18-years old. Four participants reported their ethnicity as Aboriginal, 5 as Australian, while 7 reported none or left this field blank. Thirteen of the 16 participants identified themselves as a computer gamer .The categories derived from thematic analysis of the data were personalization, engagement, and stigma..” Having options to make personal choices was consistently valued across all groups with all participants, “because everyone’s really differentAdditionally, the participants accepted that while some people would value being able to use the program in private, without telling anyone, others would prefer to use it with a counselor, to augment counseling sessions, or to use the program in a group therapy session, “It’d probably be like a bit of a first step, like they go through that [SPARX], then they they’d go to a counselor sort of thing.” The personalization of the program itself was also seen to be important. This was strongly represented in comments relating to the choice of gender of the avatar, with both males and females suggesting making the gender of the guide a choice for users. The importance of this choice was not just for aesthetics, but because the young person might not relate well to the gender seen as being the cause of, or contributing to, the young person’s issues in real life.The ability to recommend this program to friends who might not otherwise agree to see someone for help was also valued by the groups.This theme referred to young people’s access to and use of computers in general and their acceptance of the SPARX computer game as a tool to deliver health care. All participants used computers, and some specifically identified they used computers when they were feeling down. Participants either identified as people who usually played computer games or not. Most (13 of 16 participants) played computer games. Those who played computer games were very accepting of this program:It's just cool… it's a different way... because you know, you go to a counselor and stuff and they have all these different ways of doing things but like, nobody’s ever really thought of a computer game or something. It's usually like “tell me how you're feeling”, or “write it down” and stuff, but not “play it”.Female, 14-years old, “To be honest, I hate computer games. Some people like me—I wouldn't want to play a game.” Those who did not play computer games said they would be less likely to engage with the SPARX program. One nongamer was quite vocal within her group and open about her lack of interest in this medium as a way of getting helpThis allowed comparison of her responses to others. For example, her view of a fantasy-based genre was different than others, which is outlined in While some recognized that the Guide had a New Zealand (“Kiwi”) accent, they also stated that this was not important . The mosSchool was not favored by any group as a place to use SPARX for fear of school peers finding out that a young person was having personal problems and reacting in a negative way. The fear of reprisal was so large some participants stated they would not stop to read posters advertising the program around their school because of its focus on mental health-related issues:Not a lot of people would want to stop there, if it was something like that [SPARX]. Someone will say, “Why are you looking at that?”, “Why do you need that?” There’s a lot of bullying around.Female, 13- to 14-years oldWhile most reported that they would use SPARX in the privacy of their own home:Yeah because if it’s fully online – people don’t like people knowing about their problems, so they’ll be judged. So we’d do it in private [at home].Male, 15- to 18-years oldSome identified alternative safe places in the community:The Online center; somewhere like that but with a bit more privacy.Male, 13-years oldFemales stated that boys did not like to talk explicitly about their feelings, so this medium potentially offered them an alternative way to explore their feelings safely without having to talk to others, and get the help they needed . Boys did comment that some people didn’t like talking about their problems, and that the program would be easier than going to a counselor. While the cCBT medium allowed users to get help without having to divulge their thoughts and feelings to others, the narrative of the game and use of different characters was identified as providing an element of socialization and “life” to the program:I like how you've got that Guide and that you can personalize yourself. Like the journal thing - that's pretty cool.Male, 15- to 18-years oldThe stigma of depression and fear of being judged negatively by others was very apparent across all groups/sessions in this study. It was described by participants as the reason young people do not accept they have symptoms and need help, and as preventing them from asking for assistance:Some people don’t like to talk about [depression or mental health issues], to people about their problems. It’s too embarrassing… like they’re useless.Male, 15- to 18-years old, “Because different professionals sometimes, sometimes they’re in denial, because they don’t think you’re depressed at all.” Participants also commented that health professionals were sometimes reluctant to accept a young person had a problem and needed help, further limiting the young person’s confidence in asking for help, “That doesn’t always help.” The effect of stigma and their visibility in a small town was evident at a manifest and latent level. In response to a comment that there were free counselors available, a participant commentedAnother participant related her experience of using online chat sites instead of using local practitioners, “because it's not in the town where everyone can just tell everyone.” In this exploratory focus-group study, we found that participants wanted help for mental health issues, but there is a stronger need to have choices available to them and to control how they access services. They considered protecting their privacy and visibility in their small community to be paramount. They saw online therapy as providing a number of features that promise this control, getting help without having to tell anyone, and getting help without physically seeing a person or attending a place known in the community. Participants considered the SPARX cCBT program to be appealing and engaging to young people. Design features such as the personalization of an avatar, the socialization with the Guide and other characters, journaling, and the use of encouraging feedback were seen as engaging and helpful. Despite the fact that it was not an Australian program it was considered to be appropriate for local youth. SPARX, in a “playful” medium and using a fantasy-based genre, is a format like other computer games, which many young people like to play and are likely with which to have a level of competence. In this format, young people are accepting of differences in the look and sound of characters.Previous research has identified that young people often do not seek help from health providers for mental health concerns even if they are concerned about these issues -40. The It is of interest that young people wished to be able to use the program in private or to be able to use it with a counselor or in a group. In a domain in which an empathetic and supportive relationship with a counselor is a mainstay of therapy, computerized therapies have been regarded warily by practitioners ,41,42. ISchool is considered an important part of the social life of young Australians; playing a key role in providing help services and the opportunity to use select interventions with extensive reach . The vieThe finding that the SPARX program was appealing is consistent with the popularity of computer games using a fantasy-based genre, which has been reported to comprise over 80% of the gaming market ,44. HoweWhere community participation is considered important, introducing some bias may be a trade-off. While participants were not selected on the basis of any objective mood measure, the youth workers did know the individual participants better than the research team, and as such were able to seek out a purposive sample. Most participants said they had felt down in recent weeks. As a step in translating evidence-based therapy into practice, it relies on finding evidence of meaningful use and advocating value from the perspective of vulnerable groups, rather than performing dispassionate science. Nevertheless, quantitative measures were used to support or refute interpretations, and accepted methods of systematic process and analysis were employed and explained.The small sample size and single-community setting for this research makes this study just a small window into the views of local youth; the focus groups were exploratory and as such the findings of this research do not profess generalizability or offer authority.This research has demonstrated that a proven tool can be adopted when the context has changed. Limitations such as accent have little effect when the medium is known and the tool has high fidelity. Young people like computer games. This playful medium offers a nonthreatening way to explore identity and express feelings, in a format that is hugely popular and could overcome literacy barriers and cultural specificity through narration and fantasy-based worlds.In spite of recent investment in local Internet infrastructure, in 2011 only 65% of northwest Tasmanian dwellings were connected to the Internet, falling to 62% in some west coast towns, in comparison with 74% of Australia . While yAdolescents have strong views about the dissemination and content of mental health treatments and these views should be considered in the development of services. Computerized CBT therapy offered with and without therapist support and via settings other than school was seen by young people as a promising way to increase access to treatment for rural and remote youth. The game-like interface offered by the SPARX cCBT program was appealing to Tasmanian youth and making the program available was seen as more important than making any modifications to it. It may be an interesting coincidence that fantasy-based computer games have world-wide appeal, but it is an exciting prospect for expanding the reach of evidence-based therapies to more communities.


Objective: To assess effects of a two year intensive, multidisciplinary rehabilitation program for patients with early- to mid-stage Huntington’s disease.Design: A prospective intervention study.Setting: One inpatient rehabilitation center in Norway.Subjects: 10 patients, with early- to mid-stage Huntington’s disease.Interventions: A two year rehabilitation program, consisting of six admissions of three weeks each, and two evaluation stays approximately three months after the third and sixth rehabilitation admission. The program focused on physical exercise, social activities, and group/teaching sessions.Main outcome measures: Standard measures for motor function, including gait and balance, cognitive function, including MMSE and UHDRS cognitive assessment, anxiety and depression, activities of daily living (ADL), health related quality of life (QoL) and Body Mass Index (BMI).Results: Six out of ten patients completed the full program. Slight, but non-significant, decline was observed for gait and balance from baseline to the evaluation stay after two years. Non-significant improvements were observed in physical QoL, anxiety and depression, and BMI. ADL-function remained stable with no significant decline. None of the cognitive measures showed a significant decline. An analysis of individual cases revealed that four out of the six participants who completed the program sustained or improved their motor function, while motor function declined in two participants. All the six patients who completed the program reported improved or stable QoL throughout the study period.Conclusion: Our findings suggest that participation in an intensive rehabilitation program is well tolerated among motivated patients with early to mid-stage HD. The findings should be interpreted with caution due to the small sample size in this study.  Several studies of treatment with physiotherapy suggest beneficial effects when using sensitive standard physiotherapy outcome measuresZinzi et al 5] described that early to mid-stage HD patients were able to preserve or improve cognitive and motor function after participating in a two year intensive multidisciplinary rehabilitation program that included six in-patient stays, of three weeks each, in a rehabilitation center describeIn 2009, The Norwegian Directorate of Health funded a pilot project to investigate effects of an intensive multidisciplinary rehabilitation program for patients with HD. The primary aim of the project was to replicate the results reported by Zinzi et al.Subjects. Ten of 20 HD patients who completed a one year program at the rehabilitation center in Tromsø agreed to continue for an additional year. They were already included in the program based on inclusion criteria in the beginning of the first year of the study: 1) age >18 years, 2) known genetic diagnosis of Huntington´s disease, 3) early to mid-stage HD, equivalent to stages I-III on Shoulson & Fahn rating scale, 4) no diagnoses of severe psychiatric disease, 5) no apparent severe impairment in general cognitive function at the time of first admission.Procedures. Patients were recruited from the same rehabilitation center during the first year of the rehabilitation program. The project was submitted to the Regional committee for medical and health research ethics who considered this to be a clinical quality improvement project (ref. 2010/2629-7), exempt from approval by the ethics committee, and therefore referred the project to the Norwegian Social Science Data Services which granted approval (ref. 26587). Unified Huntington´s Disease Rating Scale (UHDRS)Patients were admitted in two groups of four to six persons each during 2011-2013. All patients and their family members received written and oral information, and gave their informed consent to participate in the project during the first year and consented to continue for an additional year. The first consent was considered sufficient for the second year since it was not registered as a second study. For all patients, the following demographic information was collected from the medical records at the time of the first admission: age, gender, marital status, estimated disease duration. Furthermore, baseline clinical characteristics were recorded using the standardized assessments of theDescription of the rehabilitation program. The structure of the rehabilitation program was similar to the first year program. In the two year program each participant completed six admissions of in-patient stays of three weeks each. The program included up to eight hours of various activities during weekdays Monday to Friday, and four hours of supervised activities during the weekend. Daily activities included training with physio-, occupational- and speech therapists, group training in the gym and/or in the swimming pool. There were patient education sessions and group discussions as well. Family members were also included in the program. For a detailed description of the program see our earlier report Outcome measures. The same outcome measures as described in our previous report were used, including the a) Timed-up-and-go test (TUG): the time the participant uses to stand up from a chair, walk 3 meters, turn around, walk back and sit down on the chair;,,,,,ADL function was assessed using The Barthel index, a 10-item rating scale, evaluating the level of assistance needed by a participant to perform basic activities of daily livingMini Mental State Examination (MMSE)UHDRS Cognitive Assessment, comprising the following tests: a) Verbal Fluency Test containing letters F, A and S (generating as many words as possible starting with these letters), b) Stroop colour-word test, including three conditions: Stroop colour (naming colour blocks), Stroop Word (reading colour words printed in black ink), Stroop interference (naming the ink colour of incompatible colour words), c) Symbol Digit Modalities Test (SDMT) (the patient has to pair digits to assigned symbols with help of a reference key)The Hospital Anxiety and Depression Scale(HADS), in order to assess symptoms of anxiety and depression,General Cognitive function was measured by the Short Form-36 (SF-36) a self-reported questionnaire with two component scores, for physical and mental quality of lifeParticipants´ quality of life was assessed using the Assessments. Gait and balance assessments were completed at the beginning and end of each admission, resulting in a total of 14 assessment points during the two year period. ABC scale, Barthel index, MMSE, HADS and SF-36 were completed at the beginning of each admission, generating a total of eight assessment points during the two year period. UHDRS Cognitive Assessment was used three times; baseline, 15 months and the evaluation after two years. All assessments were conducted by experienced and trained staff and, if possible by the same staff member during the full two year program.Statistical analysis. Due to small sample size and non-normal distributions, the non-parametric Friedman’s ANOVA was used to calculate the overall mean change effect from baseline (admission 1), the 15th month evaluation and the final evaluation stay for all the variables. Confidence Intervals (CI) were calculated and reported for all measures at the three measure points. For post hoc procedures, pairwise comparisons between baseline, 15 months evaluation and the final evaluation after two years were performed using the Wilcoxon Signed Rank test. The family wise error rate was controlled for by Bonferoni correction. The SPSS software, version 21 was used for all statistical analyses. Level of significance was set at p<0.05. We will report assessments at the time of the first admission at baseline, and again at 15 months and two years at group level. Additionally, we will report on the individual baseline and final evaluation stay scores for gait, balance and quality of life for the 10 participant who entered the second year of the program for a total eight measure points.Characterization of the sample. Baseline demographic and other characteristics of these 10 patients were the following: the mean age was 50.0 (SD±14.0) years with 50% (n=5) of the patients being women; 60% (n=6) was married and 90% (n=9) had children. Only one patient  smoked. All patients had initiated or established an individual plan for coordinated health care prior to entering to the second year of the rehabilitation program, and 60% (n=6) had some professional home assistance. The mean BMI was 23.6 (SD±2.8). Mean time from the baseline to the two year evaluation was 783.0 days (SD±28.0). Mean symptom duration was 6.6 (SD±4.3) years and mean total functional capacity (TFC) score was 8.7 (SD±2.5).The mean scores for the UHDRS motor and behavioral scales were 47.4 (SD±9.8) and 7.4 (SD±6.9), respectively. Mean MMSE score was 23.5 (SD±4.1).Motor function. Results showed a slight decline or stable function in gait  from baseline to the 15 month evaluation and to the two year evaluation (see Table 1). The mean changes in gait assessments from baseline to the evaluation after two years were small and not statistically significant: TUG + 2.5 seconds, 10MWT – 0.17 m/s and 6MWT + 4.3 meters. Minor declines in balance was detected  with a mean change of – 1.4 points for BBS and of 8.7 points for the ABC scale. These changes were not statistically significant. ADL-function as measured by Barthel Index showed a non-significant minor change of -0.2 points from baseline to the two year evaluation.Analysis of the individual cases showed that, among the six participants who completed the two year program, four had stable or improved gait measured by TUG from baseline to the last measurement point  (see figure 1). Two participants, cases 5 and 7, showed a clinically meaningful decline exceeding 2.98 secSimilar findings were found for balance. In general, BBS scores were stable or improved for four individuals throughout the study period. Changes in BBS from the baseline to the measurement were ±0; +3; ±0 and +2 points, respectively for cases 2, 5, 8 and 9. Cases 3 and 7 experienced a decline in balance fig. 4) with changes in score from baseline to the last measurements of -3 and -6 units, respectively. Only case 7 had a clinically meaningful change in BSS that exceed 5 points with chaCognitive function. The MMSE mean score showed a small improvement of +1.3 points from baseline to the evaluation after two years. The mean scores on the UHDRS Cognitive assessment also showed declines between baseline and the two year evaluation. These declines were -1.0 points for the FAS test (cognitive regulation), -3.3 points for the Stroop color naming task , -5.6 points for the Stroop interference test , -5.0 points for the SDMT . The Stroop word reading task  showed virtually no change in score with a 0.3 change. None of these changes were statistically significant. The results are shown in Table 1.Anxiety and depression. Although patients initially were only slightly affected by anxiety and depression, symptoms of anxiety and depression were reduced from baseline to the evaluation stay (Table 1), and showed a continuous reduction throughout the whole project.Quality of life. Patients reported improvement in both the physical component score (13.0 points) and mental component score (10.3 points) from baseline to the two years evaluation (Table 1), but these changes were non-significant. Only participant 7 had a slightly lower physical QoL score from the baseline to the final assessment point change, – 3 units, and cases 2, 3, 5, 8 and 9 reported improved or stable QoL . Also change in Mental QoL scores for the individual cases 2, 3, 5, 7 and 8 were positive and only case 9 had a minor reduction of -2 units in QoL scores . The participants that did not complete the full two-year program  did have improvement in QoL until they left the program (shown in figures 6 and 7).BMI. Patients gained some weight during the project period, as seen by an increase in BMI of 2.4 units from baseline to evaluation. The mean BMI at the end of the evaluation stay lies slightly above the normal range (BMI 18-25) indicating a mean weight somewhat above normal.Main findings. The present follow-up study found that six out of ten patients completed the full program. Slight, but non-significant, decline was observed for gait and balance from baseline to the evaluation stay after two years. Non-significant improvements were observed in physical QoL, anxiety and depression, and BMI. ADL-function remained stable with no significant decline. None of the cognitive measures showed a significant decline. An analysis of individual cases revealed that four out of the six participants who completed the program sustained or improved their motor function, while motor function declined in two participants. All the six patients who completed the program reported improved or stable QoL throughout the study period. The participants who were able to complete the two year rehabilitation program showed greater individual variation in function than results at the group level indicated. It seems that individuals with better functional levels at the start, as measured by higher/better scores in gait and balance, are able to sustain achieved results over longer time.Participation and drop-out. Our findings suggest that participation in an intensive rehabilitation program is well tolerated among motivated patients in early- to mid-stages of HD. Six of the 10 patients completed the entire two-year program as planned. We found that dropout rate among participation in an intensive long-term rehabilitation program will increase over time, similarly to what was found in an earlier study by Zinzi et al.,Since HD patients have complex disabilities, including cognitive challenges, rehabilitation programs require intensive multidisciplinary effort to provide the best possible rehabilitation. Overall, we have positive experiences with the implementation of the rehabilitation program for HD patientsMethodological considerations. This study is not a randomized clinical trial, but a descriptive intervention study over a two year period for a small number of participants. Interpretation of our findings should thus be done carefully due to small sample size and lack of a control group. The program included standardized protocols and systematically executed multidisciplinary approaches, which have been carefully planned in terms of use of assessments, measurement points aiming to have the same experienced rater at both baseline and the final evaluation. The assessment for UHDRS motor function and behavior were not conducted at the final evaluation so we have not been able to detect any changes in these scores. Changes in medication were not studied. Whether and how long the observed beneficial effects of intensive rehabilitation can be sustained among HD patients, needs to be assessed with longer follow-up. There is also a need for randomized clinical trials to study the effect of multidisciplinary intensive rehabilitation intervention on progression of HD. Further, it is important to investigate which patients profit most from such intensive rehabilitation.Our findings suggest that participation in an intensive rehabilitation program is well tolerated among motivated patients with early to mid-stage HD. The findings should be interpreted with caution due to the small sample size in this study.The authors have declared that no competing interests exist.


Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services.Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs  matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level.The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs . Eighty-five providers held ‘any qualified provider’ contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings.Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services. Smoking is a leading cause of premature mortality and morbidity in developed countries . In 1998Payment incentives influence the behaviour of healthcare providers . Policy In April 2010, commissioners from eight PCTs in one region volunteered to collaborate with their host health authority  and take a unified approach to piloting new contracts for stop smoking services. They adopted qualification-based provider regulations known as ‘any qualified provider’ regulations, which allowed any providers to deliver services that met specified criteria, including adhering to NHS service quality requirements and accepting new payment, contractual and reporting obligations ,3. This The objective of this study was to evaluate the impact of the stop smoking intervention and this study is the first to report the impact of commissioning NHS treatment using payment incentives based solely on achieving specific clinical outcomes combined with opening the provider market using qualification-based regulations .We used a cluster controlled study design in which the eight intervention PCTs were retrospectively matched to a control group of the 64 PCTs with similar demographics which did not implement the outcome-based payment system. The Office for National Statistics (ONS) has categorised geographic areas of the UK based on similar local population characteristics using census data . Each ofOur outcome measures are 1) The number of enrolled smokers per 1,000 adult population. 2) The number of four-week quits per 1,000 adult population. A four-week quit is defined as a treated smoker self-reporting continuous abstinence from smoking from day 14 post-quit date whose quit status within 25 to 42 days of the quit date has been assessed  ,23. Two Our main analysis used published PCT-level data on stop smoking services for the years 2009/10 to 2012/13 . Data onWe began with exploratory plots of the outcome variables over time for each PCT nested within clusters. We used mixed effects Poisson regression models to account for “clustering” effects, with repeated measures nested within PCTs and PCTs nested within clusters (n = 6). PCTs and clusters (n = 6) had random intercept terms and PCTs had a random slope term. The response variable was a given smoking cessation outcome measure (e.g. the estimated number of four-week quits), with an exposure variable reflecting the area of opportunity (e.g. adult population). The model had three covariates—pilot PCT (yes/no), years  and their interaction. The hypothesis of interest (i.e. "effect-size") was represented by the interaction term (rate of change of the incidence rate ratio). If the interaction term was significantly greater than 1 then we can conclude that the intervention PCTs have a higher rate of change than controls. Statistical significance was set at 5%. Plots were produced in the lattice package  in R 2828 and moWe have undertaken sensitivity analysis at an aggregate level to explore whether changing our measure of quits or controls altered the findings. Our baseline analysis assumed that 16% of quits not confirmed by CO testing should be excluded, and we varied this by plus or minus 8%, (a) and (b) respectively, as well including all self-reported quits (c) and only CO-verified quits (d). We made three changes to the control. We reran the analysis taking account of the presence of the pre-existing ‘spearhead’ localities (e). The spearhead group was announced by the Department of Health in 2004, and comprised the 20% of local authorities in England facing the greatest health challenges . The aimThe intervention PCTs experienced an increase in the number of enrolled smokers per 1,000 adult population of 5.5% per year on average compared to a decrease of 2.5% per year in the control PCTs . The intThe number of quits per 1,000 adult population increased by 9.6% per year on average in the intervention PCTs, compared with a decrease of 1.1% per year in the control PCTs, and the difference in the ratio of rates was statistically significant  .The approximately tenfold better rate of improvement in performance of the intervention PCTs compared to the control PCTs was maintained when we varied the percentage of excluded quits not confirmed by CO testing by plus or minus 8%, as well including all self-reported quits and only CO-verified quits . The finThe four-week quit rate used by the Department of Health to monitor performance, defined as the number of CO-validated four-week quits as a percentage of the number of enrolled smokers, increased by 6.8% per year on average in the intervention PCTs and 2.8% per year in the control PCTs, and the difference in change was not statistically significant  . By 2012In 2011/12, 85 providers held stop smoking services contracts in the intervention PCTs under the ‘any qualified provider’ regulations . Six of The intervention’s data on ‘any qualified provider’ contracts show that six providers were the largest PCT-level providers across the intervention, and they accounted for 75% of the total intervention quits in 2011/12 . In fiveA measure of the quality of smoking cessation services is the percentage of self-reported quits validated by CO testing, which increased by 3.0% per year on average in the intervention PCTs compared to 1.3% per year in the control PCTs. Although this difference was not statistically significant  , the intAs noted above, providers in the intervention PCTs increased reach to smokers by getting more individuals to set a quit date. However, they did not maintain contact with the larger group of individuals attempting to quit. The difference in change in the number of individuals not lost to follow-up per 1,000 adult population for intervention PCTs and control PCTs  was not statistically significant . InsteadThe intervention PCTs that adopted novel commissioning policies, comprising pay-for-outcomes and opening the market to new providers, experienced substantial increases in quits compared to the controls: the number of four-week quits per 1,000 adult population increased by 9.6% per year on average in the intervention PCTs, compared with a decrease of 1.1% per year in the control PCTs. This finding is important because despite the growth in stop smoking services, which are viewed as cost-effective, the scale of these services remains small in the face of the challenge to reduce smoking prevalence . The larThe wider adoption of the novel commissioning policies described in our study is being pursued in the NHS and other public sectors ,18, despOur cluster controlled study provides an appropriate quasi-experimental design for this type of policy intervention . Our appBy adjusting the recorded quit data for the over-reporting of non-validated quits, we have attempted to improve the basis for making comparisons over time and between localities. As noted above, we did not use CO-validated quits only in our main analysis because changes in this measure may reflect changes in CO-verification activity rather than changes in the number of smokers quitting. Furthermore, although CO verification is viewed as an important quality indicator, and a comparatively high proportion of four-week quits in the intervention PCTs were validated by CO testing 86% in 2012/13), the test does not provide assurance that abstinence has occurred beyond a few hours, and certainly not since two weeks of the quit dates. To the extent that the intervention introduced a new incentive for providers to overstate four-week quits achieved in order to increase income, caution is appropriate when considering the findings. However, this incentive may have been moderated through the introduction of random audits of cases carried out by commissioners in the intervention PCTs, and this activity suggests that the outcome of the intervention should not be attributed to gaming or changes in record-keeping. The requirement to monitor data supplied by providers paid for successful quit data was recognised as being “especially important” in national guidance . Nationa012/13, tAnother measure of the reported impact of stop smoking services is the number of CO-validated four-week quits beyond those estimated to have occurred with only a prescription for smoking cessation medication and no behavioural support . For theThe intervention PCTs introduced enhanced payments for providers achieving quits in a range of target subpopulations, the assessment of which is constrained by limited relevant published data. Nevertheless, further analysis should explore whether the intervention was associated with ‘cream-skimming’ by providers seeking to avoid treating patients with more complex needs . The intIntervention PCT C in cluster 2 had a comparatively low baseline enrolment rate, and it could be argued that this made it comparatively easy to improve its performance. This may be so, but the majority of intervention PCTs were not in this situation, and it is also apparent that enrolment across the intervention PCTs and controls was typically very low in relation to the 20% of the adult population who smoke . It is pOur findings suggest that the novel commissioning arrangements can improve the effectiveness and supply of the NHS stop smoking services. As the international policy momentum in payment-for-outcomes builds, this large-scale example of its application has relevance for policy makers and clinicians working in a range of healthcare settings and systems.Several aspects of the intervention merit further study. 1) The changes in quits, enrolment and follow-up suggest that practice has changed in the intervention PCTs, but the precise mechanisms associated with the change in financial incentives, remain unclear. 2) We have focused on aggregate results, and study of individual clusters may provide useful insight into implementation of the intervention in local contexts. 3) By introducing payment incentives to achieve 12-week quits, the intervention PCTs have started to explore the provision of longer term support for smokers beyond the four-week threshold used by the Department of Health. This is important because about three-quarters of smokers who have quit at four weeks will relapse within one year . HoweverS1 Box(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S9 Table(DOCX)Click here for additional data file.S10 Table(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.S2 Fig(DOCX)Click here for additional data file.S3 Fig(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Clinician educators face barriers to scholarship including lack of time, insufficient skills, and access to mentoring. An urban department of family medicine implemented a federally funded Scholars Program to increase the participants’ perceived confidence, knowledge and skills to conduct educational research.A part-time faculty development model provided modest protected time for one year to busy clinician educators. Scholars focused on designing, implementing, and writing about a scholarly project. Scholars participated in skill seminars, cohort and individual meetings, an educational poster fair and an annual writing retreat with consultation from a visiting professor. We assessed the increases in the quantity and quality of peer reviewed education scholarship. Data included pre- and post-program self-assessed research skills and confidence and semi-structured interviews. Further, data were collected longitudinally through a survey conducted three years after program participation to assess continued involvement in educational scholarship, academic presentations and publications.Ten scholars completed the program. Scholars reported that protected time, coaching by a coordinator, peer mentoring, engagement of project leaders, and involvement of a visiting professor increased confidence and ability to apply research skills. Participation resulted in academic presentations and publications and new educational leadership positions for several of the participants.A faculty scholars program emphasizing multi-level mentoring and focused protected time can result in increased confidence, skills and scholarly outcomes at modest cost. In the context of shrinking hospital and federal support for education, academic departments and residency training programs must produce scholarship that critically evaluates and studies educational programs.A number of interventions promoting scholarship among clinician educators demonstrate modest but significant gains in faculty publications related to education. Typically, in the reported experience of authors cited in this paragraph, 30 to 50% of participants improve their publication record while greater than 50% present educational research or scholarship in peer reviewed settings. Peer writing groups are associated with increasing the number of presentations, peer-reviewed publications and collaborative projects.27To address barriers to educational scholarship in the Department of Family and Social Medicine at the Albert Einstein College of Medicine and Montefiore Medical Center, education division directors, including a family physician (JT) and an educator (AF), sought and received federal funding to implement a faculty development program designed to support busy clinician educator faculty in conducting educational scholarship. Specific aims of the grant funded project were to: 1) increase department-wide faculty development activities in educational research and writing skills, and 2) increase the quantity and quality of peer-reviewed educational scholarship by departmental clinician educator faculty that addresses health disparities and Healthy People 2010 Objectives. This paper describes a Faculty Scholars program developed to meet the aims of the grant project, carried out between 2005 and 2009, reports on its successes and challenges, and provides recommendations for future research.The program leadership team  designed an evaluation strategy that included qualitative and quantitative methods to answer the following questions:Could a part-time faculty development program designed for clinician educator faculty with heavy patient care and teaching loads contribute to:enhanced skills in educational scholarship and dissemination?increased quantity and quality of peer reviewed publications of education research and innovations?In what ways would the program elements contribute to participants’ perception of their confidence, knowledge and skills to disseminate educational scholarship as part of their career trajectory?The program leadership team  chose to use a logic model  to clear29Our design for this evaluative study of a faculty development intervention included quantitative and qualitative methods. We collected quantitative data through pre and post participation surveys of self-assessed skills with anchors that described the confidence level of participants as well as a follow-up questionnaire, conducted three years after program completion, about outcomes such as continued educational scholarship activity and dissemination of education scholarship. We conducted a qualitative assessment through semi-structured interviews regarding faculty scholar experiences including their self-perceived confidence, knowledge, and skills as well as reflections on their experiences and on strengths and weaknesses of the program. Our intent was to explore the change process for participating faculty. We chose these two types of data collection methods to have a richer data set and to assure that skills, knowledge and attitudes of participants were reflected in the data.Our study was carried out at the Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx, New York. The large, urban department’s responsibilities included medical student education, residency and fellowship training, clinical care, research and community service.The program leadership team  recruited ten clinician educator scholars, based on a formal application and recommendations from supervisors, to participate in a part-time faculty development program with the goal of increasing educational scholarship skills and outcomes. The application process assessed the project plan, career goals, and scholarship development needs. Our selection criteria included relevance to the departmental mission of improving health in underserved communities and training physicians for practice in such communities.As a structured faculty development program with necessary evaluation, our project met exempt criteria of the Institutional Review Boards of the medical college and teaching hospital. We confirmed the exempt status eligibility through inquiry to the IRB. We informed all participants in the program of the planned evaluation activities. During the application and orientation process, we informed each cohort about the evaluation plans, which included data collection and dissemination of results, and we reminded participants of the evaluation plan at the time of the follow up survey. In addition, participants gave implicit consent by completion of pre, post and follow-up surveys as well as participation in interviews. We deemed the risks for program participation to be minimal, with potentially significant benefits for career development. Because of the small size of the program and the need to understand the outcome for each scholar, which was an obligation of the funder for the principal investigators of the grant, we treated survey data and qualitative interviews confidentially. A trained staff person, who was not affiliated with the program or funded on the grant, conducted all qualitative interviews. We stored all follow-up data  in secure, locked computers or cabinets, assuring privacy. Our selection process was equitable as all department faculty members were offered the opportunity to apply and applicants were supported in developing their application materials through meetings with grant faculty and review of draft materials.We tested a part-time faculty development intervention, which is described as follows:Our program was organized into three cohorts, with three application cycles, over the span of three years. This structure minimized the impact on clinical care at department practices and made best use of grant resources. Each cohort of 3–4 scholars actively participated for approximately 14 months. Each participant received protected time of 26 half-days for one year. Scholars received skills training through workshops and consultations with a visiting professor, the latter of which occurred both during and beyond their cohort cycle.The grant team  included two principal investigators  and a master’s trained project coordinator hired specifically to support both aims of the grant. The grant team reviewed the learning needs of the participants and considered their limited time availability. The grant team members therefore devised a multi-pronged approach to enhance the confidence, knowledge and skills of the participants and to achieve an outcome of increased educational scholarship. The grant team structured program activities in a part-time model that was feasible given the busy schedules of clinician educator participants and limited departmental resources . Scholar30Each cohort met monthly to discuss project plans, participate in project updates, present manuscript drafts, and to discuss challenges with projects. These meetings provided support, review and feedback from peers and faculty. The grant team designed monthly seminars and two half-day workshops to aid project development and writing; topics were tailored to address the immediate learning needs of each cohort. The master’s prepared coordinator (SS) met frequently with the scholars providing continuous project coaching and task management. She monitored their progress on project completion and provided support by using follow-up reminder emails that delineated next steps.An annual two-day writing retreat focused on the scholars’ projects and dedicated project work time during which a visiting professor with expertise in educational research and scholarship development provided individual project consultation with each scholar. She also presented seminars on strategies for education project design, evaluation and writing for the scholars. For continuity, the same visiting professor returned each year. The visiting professor also gave Grand Rounds, other presentations and met with additional department faculty members during each annual visit, thus addressing the first grant aim of development of scholarship in the entire department.An annual departmental Educational Scholarship Poster Session, introduced as part of this program, provided a capstone experience for the participants. Scholars designed and presented an academic poster on their individual projects. Poster design workshops were held beforehand to provide skills and content organization necessary for academic poster preparation.Core project faculty met weekly to coordinate seminars and workshops, determine logistics, and develop strategies to assist in scholar learning and project needs. In addition, senior faculty members from the department’s Community, Clinical, Education and Research divisions provided periodic individual project consultation, scholar mentoring, and supported skill development through presentations to the group.To inform program evaluation strategies, we created a logic model, previously described, to determine specific inputs and outputs of the Faculty Scholars Program , in an aThe surveys included a self-assessment skills based questionnaire with anchors that describe confidence level of the participants, administered pre and immediately post participation in the program and a follow-up questionnaire, the administered 3–5 years after program completion to ascertain outcomes such as academic presentations, published scholarly products and continued application of skills in educational scholarship. Formative evaluation took place during the program in the form of informal scholar feedback, which assessed the content, presentations, and applicability of the seminars, workshops, and retreats.We framed the interview guide for the qualitative semi-structured interviews from short- and medium-term outcomes of the program logic model, employing primarily open-ended questions with prompts. A trained research assistant conducted the interviews with each scholar, who had no affiliation with the scholars program, within one year of program completion. The interviews lasted between 30 and 60 minutes. Interviews for Cohorts 1 and 2 were conducted in person, tape recorded and transcribed verbatim. Interviews for Cohort 3 were conducted by phone with detailed field notes recorded.n = 10) was not sufficient to provide reliable inferential analyses of change over time, so descriptive summaries were generated to examine improvement in self-reported ability in selected skill areas. Summaries included frequencies and percentages of responses in each category prior to intervention . Improvement in skills areas was summarized in two ways: as the percentage of scholars who could not do the selected skill independently at pre-test, but showed any improvement  at post-test, and also as the percentage of all respondents who could do the skill independently prior to and following the intervention. We generated summaries using SPSS .We used descriptive statistics to summarize our findings. We found that the small sample size , an educator who had not participated in the program, reviewed the transcripts and field notes, categorized themes, and concurred with the group’s findings.The scholars (eight women and two men) ranged in age from 32 to 54 years (mean 45) and described themselves as novice researchers . Eight pScholars’ self-reported ability in research skills areas are shown in We conducted semi-structured interviews with all ten scholars after participation in the program. The emergent themes we found and exemplars are listed in Finally, the scholars reported that the visiting professor lent external validation to their work. The scholars utilized sessions with the visiting professor for various purposes such as obtaining feedback, discussing professional aspirations and learning about current national research priorities and funding sources.Scholars noted that the project leadership and research faculty mentors provided strong mentorship. As one scholar mentioned,“They provided moral support, which is actually very important to me when I am engaged in something that I really don’t have a lot of experience with.”Another stated that mentorship “…helped me focus my energies and produce what I need to produce.”We found several other factors were important to the scholars’ success. For example, most scholars viewed the program’s didactic sessions as helpful for completing their current project and acquiring a skill set applicable to future academic scholarship. The most useful presentations focused on conducting a literature review, designing survey methodology and managing references. The value of peer interaction emerged as another consistent theme. Many of the scholars found that participating as a cohort provided structure, concrete and moral support, and confidence in their work. Some scholars noted that working collaboratively with peers expanded their perception of educational scholarship.One scholar reported that,“Before I became a scholar, I had tunnel vision and really had not thought seriously about getting involved, collaborating with others around educational scholarship. This really enlightened me, brightened my future, allowed me to make connections that I needed and more importantly, it made me self-reflect.”Peer review of work also allowed the scholars to learn about barriers encountered and skills needed for the projects of other cohort members. Scholars found that continuous redrafting of manuscripts for peers provided useful and comprehensive feedback on the writing process.Another scholar’s reflection supports these findings from the interviews:“The drafting portion [of the group meetings] for the manuscript …was really useful because that makes it a step by step process instead of a big intimidating thing. And then peer and faculty feedback just makes you … go through the stages of drafting and redrafting …much more quickly because of second eyes-sees much more easily what makes no sense at all.”After completing the fellowship, participants reported increased comfort, confidence and competence in conducting scholarly work, as noted in One significant challenge with program implementation identified by the scholars included difficulty in obtaining “true” protected time. Several scholars noted competing priorities especially lack of coverage when away from clinic.As one stated,“The expectation is that even though you are not at the health center, you’re still covering your patients so you are still liable to get phone calls, see patients in the hospital…”Other scholars reported difficulty scheduling protected time because administrative staff was not always supportive of the project. In addition, some participants noted initial difficulty transitioning between clinic and academic work, but over time learned to manage the transition better. Some scholars noted a decrease in the frequency of monthly small group meetings. This occurred due to competing schedule demands for participants, especially in finding a common time to meet. Scholars in one cohort noted a need for more efficient and effective meetings.As one scholar reported,“I didn’t feel the time was always well used…it might have been useful to have shorter time per project…and to focus the discussion on very real practical issues we were all facing.”Scholars suggested several approaches for the department to encourage faculty to engage in more scholarly work. Scholars felt it was imperative to have protected time to engage in scholarly activities, gain the skills needed to write grants and eventually secure funding for educational projects. Others suggested that encouraging ongoing collaboration within the department was absolutely necessary for career development. In addition, most scholars suggested the department fund both a dedicated staff person to assist with logistics and editing and mentoring time for the research faculty.Nine of 10 scholars responded to the follow-up questionnaire, conducted three years after program completion. Publications and presentations resulting from the faculty scholars’ projects are presented in In the follow-up survey all respondents reported benefitting from faculty and staff mentoring as well as from peer coaching and felt they gained positive momentum from departmental recognition of their work. All reported increased confidence in planning scholarly projects. Over half reported increased project management skills and a familiarity with qualitative and quantitative data analysis preparation of an academic poster, and preparation of a manuscript. In reflecting on the impact of the program, many of the participants felt the scholars program created a strong sense of collaboration and creativity. For example, one scholar stated,“One of the benefits of the … faculty scholars’ project is that it created a community of support for a variety of projects that faculty members felt passionately about. In doing so, it energized people to work on and complete projects. It also gave people ideas and stimulated creative approaches to their projects. It also fostered collegiality and a sense of common purpose, a healthy antidote to the isolation generated while working on scholarly endeavors”.One participant became the director of the department’s federally funded primary care faculty development program subsequent to her participation in the program. Another accepted a faculty leadership role in a new family medicine residency program in the region. The on-line journal initiated by another scholar has been very successful, offering a weekly venue for other educators and clinicians to publish peer reviewed reflections and led to two books of collected essays and poems from the journal. Another participant was recruited to be part of the core residency faculty in the department.Our findings are consistent with previous reports in the literature, which found that scholars’ programs that include protected time, mentoring, and active participation in a peer group support lead to progress in written scholarship and enhanced confidence and identity as scholars.31New contributions to the literature regarding such faculty development interventions reported in our study include the use of a consistent visiting professor over time, the integration of a master’s prepared coach who worked individually with faculty, and a program structure involving only modest protected time. In the following sections we will discuss the program elements associated with the achievement of short and medium term outcomes that we had delineated in the logic model, including increased confidence and skills, implementation of an educational scholarly project, building of internal and external professional networks, academic presentations and publications, and defining a line of scholarship.Scholars benefitted from multi-level mentoring and coaching from the project coordinator, project leadership, an external expert (a visiting professor), department research faculty, and peers. The role of the dedicated master’s prepared coordinator, who devoted fifty percent full time effort, proved to be invaluable. She provided individual task-focused coaching that reduced scholars’ projects down into small, discrete steps, allowed scholars to gain confidence and move forward. The guidance and follow-up on tasks provided through the coaching supports the findings of others regarding the necessity for a structure that supports accountability.Engaging a single visiting professor over the course of the program resulted in consistency and continuity of input. At each visit, the visiting professor’s individual consultations, feedback on projects and career goals, group meetings and formal presentations/workshops on research skills provided a sense of external validity to the scholar’s work, which inspired the scholars to continue their projects, despite competing demands.The didactic sessions leveraged departmental expertise of senior faculty members and were deemed crucial by the scholars as they increased scholars’ research and scholarly skills and provided confidence in their ability to complete their current projects and future academic work.Our study confirms the findings of others regarding the power of peer mentoring.Our experience regarding the value of mentoring from different individuals with various types of expertise and approaches to mentoring, including senior faculty, program staff and peers, is consistent with recent findings reported in the literature regarding the impact of networks of mentors and “horizontal mentoring” by peers.Funding allocations over 3 years limited the project to ten scholars, and thus, the impact of the program in the department. The diversity of scholars ready for scholarship development and their varying schedules made it difficult to plan content sessions and meetings, and thus to deliver a consistent set of learning activities to each scholar. As anticipated, participants reported the need for protected time to conduct educational research. Although the allotted time was modest, the scholars agreed it was essential to allow them to focus on their scholarship and achieve consistent progress. The lack of long term protected time past twelve months limited their ability to progress in their projects in an efficient way and therefore had an impact on definitive outcomes within the 3 years of grant funding. We were not surprised that scholars found their protected time frequently interrupted by clinical and teaching responsibilities, given the patient care and clinical teaching commitments of the sponsoring department and the multiple professional duties. This issue required early and repeated attention by program leadership to communicate and collaborate with clinical administrative staff to assure scheduling of protected time. In addition, several scholars discussed a preference for one specific mentor assigned to their entire project instead of mentoring by various program faculty and peers. Due to limited faculty resources the design of the program assured the workload of longitudinal mentoring was shared by a few expert faculty and the scholars’ peer group. Though several research faculty members volunteered their time by providing guidance to the scholars, scholars reported some difficulty in obtaining consistent assistance on research design and methods from these faculty members, due to their competing obligations.Our study has several limitations. The scholars selected for the program came from a defined pool of clinician educators in one clinical department, which has a focus on delivery of primary care in an urban underserved ambulatory setting and a parallel focus for residency/fellowship training, reducing the generalizability of our findings. Only 9 of 10 scholars responded to the 3-year follow-up survey. The data reported by the scholars of their pre and post confidence with research skills during the program and the additional data collected in 3 year follow-up surveys were both self-reported and may have reflect scholars’ omission of information or attributing the results to events that occurred outside of the funded fellowship. Several of the scholars projects had goals and outcomes that diverged somewhat from the intended outcomes of the program, such as creating curriculum and developing an on-line reflective journal, all relevant to the Department mission but less aligned with traditional mechanisms of publishing educational research; therefore some scholars were less focused on achieving a traditional peer reviewed publication as an outcome measure and resulted in projects that fulfilled a boarder definition of scholarship. This created some ambiguity about whether program objectives were met by these participants. The intended focus on health disparities was not fully achieved in that not all projects directly addressed the topic. The participants’ strong interest in their topic and ownership of their project proved most important in assuring progress and completion. A final limitation was a self-report survey to determine if the Scholars continued their research efforts post grant completion. This was the most efficient way to collect current data from the Scholars, as their CVs may not be current with their ongoing research efforts.Our experience demonstrates both the feasibility of and successes associated with a part-time scholars program in medical education research for teaching faculty as an alternative to a full fellowship that includes significantly more protected time and resources.Faculty members who previously had not engaged in medical education research and written scholarship represent an untapped resource of experience and perspective. Our experience demonstrates that it is possible to support scholarship by novice clinician educators, resulting in meaningful engagement, acquisition of relevant knowledge and skills, and measurable progress in producing scholarship. Engagement of a consistent external consultant and a dedicated master’s level coach added value and is relevant to departments wishing to embark on a similar endeavor. Our findings suggest that future programs may confer additional benefit if they provided a longer period of protected time and greater funding for scholars. It is essential for leaders of such programs to be proactive in scheduling true protected time for faculty to avoid distractions from competing demands and priorities. The importance of these infrastructure and support mechanisms was highlighted in the report by Simpson et al.Future research in this area might explore the use of technology, such as webinars with linked resources, to enable clinicians to participate from various clinical or teaching sites. Researching in more depth the experience and evolving identities of mid-career teaching faculty who embark on medical education scholarship might identify success factors and ways to address barriers. Testing the impact of implementing the unique components of our program, with cost/benefit analysis, might demonstrate the value of further iterations of our approach in this era of limited resources. Comparing the value of a single mentor who brokers input from other faculty members to a multi-mentor approach such as ours would be valuable, given the feedback from our scholars. O’Sullivan and Irby’s call for an expanded model of research