We generated descriptive analysis of the findings across the sub-region.the 20 program reviews included field observations to the subnational levels as well as interviews with program staff and stakeholders. At the time of the reviews, only 11 countries had functional National Immunisation Technical Advisory Groups. Operational funding was inadequate in half of the countries. The reviews documented the cancellation of outreach services, supportive supervision visits and maintenance of cold chain equipment due to the lack of fuel or operational funding. Immunisation programs in 10 countries had major human resource gaps. Vaccine stock management tools were not effectively used in 10 countries, and stock out of vaccines and supplies was documented in 9 countries during the review. The full components of the RED strategy were implemented in only 3 of the 20 countries. Twelve countries reported challenges with the availability and accuracy of target populations. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews.the reviews demonstrated challenges in various aspects of the programs in different countries. The implementation of the review recommendations should be built into the annual program plans, as well as into coasted multi-year plans, in order to address the gaps and helps the program to attain the set targets. With the rapid evolution of the scope and complexity of the immunisation programs in recent years, countries should invest their efforts in building the capacity of their human resources as well as updating their logistics and data systems. In May 2012, the World Health Assembly (WHA) endorsed the Global Vaccine Action Plan (GVAP) -5.On the operational aspects, WHO advises countries to implement the Reaching Every District (RED) approach to be able to reach all communities and all children, including those who normally do not access health services, and thus to assure equity in immunisation service delivery. The RED approach comprises of establishing outreach services; conducting regular supportive supervision; linking services with communities; monitoring and using data for action; and the management of resources . The monThe World Health Organisation (WHO) recommends the periodic conduct of comprehensive national immunisation Program reviews (EPI reviews) to help countries identify system-wide barriers or gaps, monitor performance against the set targets, and develop strategic direction to remove these barriers or gaps towards the development of a more robust and resilient program . These pThe Eastern and Southern African sub-region of the WHO consists of 20 member states, a subset of the 47-member State of the WHO African region. These countries are Botswana, Comoros, Eritrea, Eswatini, Ethiopia, Lesotho, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Tanzania, Uganda, Zambia, and Zimbabwe. Between the years 2014 - 2018, all of the twenty countries in the sub-region conducted at least one comprehensive immunisation program review. This manuscript attempts to summarize the strengths and weaknesses of the immunisation programs in the countries in the sub-region, as documented in the program reviews, with a view to highlight actions required for countries to progress towards the programmatic targets.Comprehensive immunisation program reviews are cross-sectional program assessments that are conducted through the review of documents and data, the interview of immunisation program staff at national and subnational levels, as well as field visits to provinces, districts and to service delivery sites. The data from the program review is collected using standardized data collection tools developed by WHO AFRO, which are adapted to the individual country context. The tool includes sections that cover the following thematic areas: (i) leadership, governance and coordination; (ii) human resource management, capacity building and supervision; (iii) vaccine supply quality, logistics and cold chain; (iv) service delivery; (v) data monitoring, immunisation quality and vaccine preventable diseases surveillance; (vi) demand generation, social mobilization and advocacy. At the end of a program review, the findings and the recommendations are compiled by the review team in a formal report and presented to the respective Ministry of Health. We reviewed the detailed narrative technical reports generated from each of the national immunisation program reviews conducted in the 20 countries in the sub-region in the course of 2014-2018. We conducted a descriptive analysis of the findings from the review exercises and attempted to do a summary of the findings by thematic areas.Each of the 20 countries conducted at one national immunisation program review between 2012 and 2018 . These 2Leadership, governance and coordination: at the time of the program reviews, 16 of the countries (80%) had some sort of legislation promoting immunisation, and 13(65%) had updated immunisation policy documents. All except one country had updated comprehensive multi-year plans for immunisation (cMYPs). Full government financing of the immunisation program was documented in the 6 countries while 14 countries (which were GAVI eligible) depended on complementary support from partners such as Gavi for new and underutilized vaccines and UNICEF for the purchase of traditional vaccines. Immunisation services were provided free of charge in public health institutions in all countries. In the area of coordination, only 11 countries had functional National Immunisation Technical Advisory Groups (NITAG), while 17 countries had National Regulatory Authorities (NRA) at the time of the review. The 6 self-financing countries did not have functioning Inter-Agency Coordination committees (ICC), while in 10 of the remaining 14 countries; the ICC was playing a key role in the coordination of partner support to the national immunisation program. The level of coordination between the immunisation program and the unit responsible for disease surveillance was limited in 8 of the 20 countries. Operational funding was inadequate in half of the countries in the sub-region. The reviews documented the cancellation of outreach services as well as the regular conduct of supportive supervision and maintenance of cold chain capacity at sub national level in these countries, mainly related to the lack of fuel or funds to rent vehicles.Human resources management, capacity building and supportive supervision: ten (50%) countries had gaps in the number of staff and the skill mix required to run an efficient immunisation program at national and sub-national levels. These countries also lacked clear terms of reference or job descriptions for the assigned focal persons who were engaged in the day-to-day management of the immunisation program at different levels. Seventeen countries (85%) had clear plans for program supervision. However, supervisory visits to the subnational levels were inadequate or irregular in 4 of these 17 countries, due to limitations in funding and means of transport. Standardized tools for the supervision of immunisation services were available in only 14 of the 20 countries.Vaccine and cold chain logistics: vaccine stock management tools were not effectively used in 10 (50%) countries, with tools lacking or outdated or not used regularly to monitor vaccine stocks at the health facility levels. Stock out of vaccines and supplies at the sub national level, lasting more than 3 months, was documented in 9 (45.0%) countries during the review. It was documented that 4 countries had frequent power interruptions and inadequate backup generators. Five countries did not have an updated cold chain equipment inventory system and no cold chain rehabilitation / replacement plan at the time of the review. The cold chain capacity was considered inadequate according to the reviews in 4 countries mainly at the sub national level . At the time of the reviews, 14 countries (70%) did not have up-to-date operational level micro-plans for routine immunisation services. In addition, 9 (45.0%) countries were not able to organize outreach services as planned due to transport and field staff constraints. Five (25.0%) countries also did not have enough cold chain equipment to run outreach services. At the time of the reviews, three countries had not yet introduced AD syringes for use in their immunisation programs. Defaulter tracing mechanisms were available in only 12 (60%) countries  out of the 20 countries. Besides, the review in ten countries detected gaps in the systematic use of data for decision making, especially at the district and Health Facility levels, linked mostly due to knowledge gaps and limited resources. Data quality review and data harmonization meetings were held regularly in 13 (65%) countries. Seven countries reported major challenges with their monitoring systems. These included denominators projected from outdated census causing significant over or under-estimation of the real target population, too many monitoring tools, discrepancies in the data across different administrative levels, as well as limited time and capacity to analyze and use data for decision making  countries. In 5 countries, it was noted that communication efforts were well developed for new vaccines introduction and supplemental immunisation activities (SIA) but quite weak in promoting routine immunisation and community surveillance. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews. Four (20%) of the 20 countries did not have communication messages tailored to address specific groups.The findings in this summary have been aggregated and no specific country detail is given, since the main objective of the study was to demonstrate the challenges countries face in general. Moreover, since the reviews took place in the years 2012-2018, it is expected that any gaps have been addressed by the specific countries following the review exercise. While 12 of the 20 reviews were conducted in the last 5 years, 40% were conducted more than 5 years ago indicating the need for timely program reviews to steer the programs in the right direction. Immunisation program reviews cover a broad scope of program area but may not always achieve the necessary depth given the limited time allocated to the exercise . When inThe 20 program reviews covered in this study indicated that some countries did not have any legislation or policy framework for immunisation. Having the appropriate legislative framework helps countries to protect national immunisation budgets and also to address community demand for vaccines . SimilarIn the 20 program reviews in this sub-region, capacity gaps are also reflected in the lack of clear managerial tools . Inadequate supportive supervision and the absence of standard supervisory tools are other common challenges. Supportive supervision has been shown to be an important component in immunisation programs . Regardiet al. have identified six common drivers of routine immunisation coverage improvement. These include the presence of a cadre of community-centered health workers, health system and community partnership, regular review of health workers performance, the delivery of immunisation services tailored to community needs, political commitment to routine immunisation, and the actions of development partners. The study claimed that the presence of all six factors together was found to have positive impact in terms of coverage improvements [et al. have found that geographic inaccessibility of services, vaccine stock-outs and/or cold chain problems accounted for the majority of missed opportunities for the vaccination of children in many countries [In a study focused on the district level in 3 African countries, LaFond ovements . The finountries . A lot oountries .The reviews documented serious gaps in the surveillance for vaccine preventable diseases (VPDs) related to limited knowledge of health workers, inadequate resources and programmatic focus. Gaps were documented in the prioritization for active surveillance, as well as in the monitoring and use of surveillance data, as reported in other studies in the African region ,27. The Limitations of the study: these national immunisation program reviews were conducted using similar approaches and tools, but the review was conducted by different teams, and using tools adopted for the national context. This may result in differences in the formulation of the review questions and interpretation of data. During these reviews, the sampling of subnational units was done purposively to strike a balance between urban and rural districts as well as strong performing and weaker districts. Therefore, all the results may not be comparable across the countries. In addition, it is expected that the countries will have acted upon the review findings and made the necessary program changes since the reviews, and so the results may not reflect the current situation at country level at the time of publication.The national immunisation program reviews in the sub-region have been useful tools to identify barriers or program gaps and generate recommendations for the national program and local partners to address the barriers or gaps. The reviews in the subregion have demonstrated challenges with regards to various aspects of the programs in different countries and unless addressed they will fail short to ensure provision of equitable immunisation service delivery. The follow-up of recommendations to address the challenges and gaps constitutes an essential component of the review exercise aiming to enable them to attain the set targets. Countries should invest in continuous and systematic capacity building, in the context of the continuously evolving and expanding immunisation program. in this context, we also recommend that countries should plan for and conduct EPI program reviews at least every 4-5 years, preferably timed to provide inputs into program plans along with setting up mechanisms to regularly monitor program performance and address gaps, as well as to follow-up and implement recommendations from review exercises. These EPI reviews may not constitute an in-depth evaluation of all program components, indicating the need to tailor the implementation of the reviews towards specific aspects of the program, based on the country context and preliminary findings. In addition, as necessary, countries may plan to conduct in-depth evaluations, and root cause analyses.Comprehensive national immunisation program reviews are conducted once every 4 to 5 years in low-and middle-income countries, in order to identify program areas for improvement, realign program focus as necessary and prepare the program for the introduction of additional program elements;Comprehensive program reviews are complementary to reviews with in-depth focus on specific program components;Recommendations generated by program reviews help countries to focus their efforts to address major program gaps.With the rapid evolution of the scope and complexity of the immunisation programs across the region, countries should build in methods to regularly review program performance and develop their strategic directions with the required investments for program sustainability and also invest in capacity building;A significant proportion of national immunisation programs in the sub-region continue to have gaps in their implementation of the reaching every district approach, in their human resource capacity, as well as in their logistics and data management systems;The follow-up of the review recommendations will be critical to address the identified system-wide barriers or gaps in order to strengthen the immunisation program and enable it to attain the objectives.


Background: This study tested the feasibility of implementing Healthy Hearts for an Abundant Life (HHAL), a cultural adaptation for African American (AA) women of the evidence-based cardiovascular disease prevention program Strong Women-Healthy Hearts (SWHH).Methods: Using a quasi-experimental pre-post study design, this 12-week program was implemented in four faith-based organizations between 2017 and 2018. Eligible participants were AA women between 40 and 65 years who had a body mass index of 25 or higher and were currently sedentary. HHAL program participants met weekly for 2-h sessions led by program leaders. The curriculum has four modules: total health; relationships, family, and networks; material security and the environment; and emotional wellness. Each class included walking for 30 min, goal-setting session, and a group dialog called “making it work” for building collective efficacy.Results: Of the 27 participants (mean age=54.2±5.9), 24 completed postassessments (93% retention rate). All outcome measures proved feasible and weekly program attendance was 73%. Findings from in-depth interviews show high satisfaction with the program and suggest extending the class time and adding cooking demonstrations.Conclusions: The culturally adapted HHAL proved feasible and was positively received by the participants. Future studies will evaluate the effectiveness of the program. The prevalence of CVD among AA women is 57% compared to 43% for White women.5 This program was designed for women aged 40 years and older, a group for whom targeted interventions are lacking even though behavioral modifications can reduce risk at any age, including older adults.6 In the national dissemination study,5 AA women enrolled at rates proportional to their representation in the counties where the program was run; however, they withdrew at twice the rate as White women (36% vs. 17%), and if they completed the program, they did not realize the significant benefits experienced by their counterparts.5 Together, these data suggest that program leaders were reasonably successful at outreach to AA women, as evidenced by the interest and response. However, once in the program, AA women's needs were not met, as evidenced by their withdrawal rates.Strong Women-Healthy Hearts (SWHH) is a 12-week community-based program that has previously demonstrated both effectiveness in decreasing body weight and waist circumference and success at reaching women across the United States.8The relatively few CVD-related interventions developed specifically for AA women indicate that it is possible to achieve significant improvements in risk behaviors and biological parameters when culture, values, beliefs, and unique barriers are considered.9 which provides a framework for understanding “deep structure” factors—psychological, cultural, social, historical, and environmental—considered to be critical for maximum salience and effectiveness in cultural adaptations of health programs.7Based on this evidence and anecdotal reports from program leaders, we hypothesized that a culturally adapted version of the SWHH program might better meet the needs of AA women. We conducted formative research using the African American Collaborative Obesity Research Network (AACORN) paradigm,10 Briefly, participants shared the importance of social support in providing comradery, accountability, and motivation. Structural barriers and sources of stress included racism and a lack of access to healthy food to feed a family. They discussed strategies such as goal-setting and self-care.In the formative work, we assessed perspectives of AA women regarding CVD prevention barriers and facilitators, and these insights were used to develop the adapted curriculum entitled Healthy Hearts for Abundant Life (HHAL).9 These shaped the framing of the core content on diet, physical activity, and heart disease prevention from the original SWHH curriculum.The HHAL adapted curriculum incorporated themes from our formative work using the AACORN expanded knowledge domains. These included stress-reducing activities, tools for self-care, metaphorical language based in spirituality, acknowledgement of the role of racism, and strategies and tools consistent with available resources.To help address gaps in the nutrition intervention literature for AA women, we conducted a pilot study to determine the feasibility of implementing the HHAL program and collecting outcome measurements and to assess whether the adaptation would be a cultural fit. Another goal was to calculate effect sizes and intraclass correlation coefficients (ICCs), which are necessary to design a fully powered randomized controlled trial.11 Furthermore, the study team had pre-existing relationships with several predominantly AA churches and utilized these connections to recruit churches. Each church received $500 for hosting the program. The two program leaders were community-based nutrition professionals recruited through a professional organization designed for nutritionists and dietitians of color.This pilot was designed as a quasi-experimental pre-post study. The 12-week program was implemented between November 2017 and April 2018 in four predominately AA churches in the northeastern United States. The program was conducted in churches because 62% of AA women report an affiliation with an historically Black church, with most attending at least weekly.To be eligible to teach HHAL, the program leaders attended a 5-h training workshop. They received $25 per hour for administering the program. The Tufts University Social, Behavioral, and Educational Research Institutional Review Board approved all study procedures.Both SWHH and HHAL class topics have been included (Appendices A1 and A2). HHAL group members met for 2 h every week and were led by the trained program leaders. The HHAL curriculum had four modules: total health; relationships, family, and networks; material security and the environment; and emotional wellness. Each class included six components: (1) an introduction to the session's topic, (2) a leader-led discussion for knowledge dissemination, (3) walking for ∼30 min, (4) a group dialog called “making it work” to build collective efficacy and to discuss common barriers, (5) a journaling and goal-setting session to help participants integrate behaviors into their everyday lives, and (6) a wrap-up. While the intervention included some metaphorical language based in spirituality, it was fundamentally secular in nature. A recipe booklet with culturally appropriate recipes was developed for the program.12 Two coders worked on the analysis, and intercoder-reliability was established at 80% agreement or greater. NVivo Pro 11 software  was used during analysis.13Participants and program leaders were interviewed after program completion using semi-structured interview guides to better understand the resonance of the program within AA culture. The key topic areas for the interviews were (1) overall experience, program curriculum, and structure; (2) curriculum modules and understandability of materials and handouts; and (3) perceptions of participants' own abilities to make the suggested behavior changes given the resources available in their environment. Three participants from each group were randomly selected and invited to participate in a phone interview administered by research assistants. Participants gave verbal consent at the beginning of the call to be interviewed and recorded, and all interviews were transcribed. The codebook used for qualitative data analysis was initially based on the interview guide; it was then refined in an iterative process based on the initial interviews. Standard qualitative methods were used.14 and could safely engage in moderate physical activity according to the Physical Activity Readiness Questionnaire (PAR-Q).15 Participants were excluded if they failed to provide informed consent, were regularly participating in any other lifestyle modification program, were pregnant, or were planning to move outside the area within 5 months. Women deemed eligible during the telephone screening were invited to a preintervention assessment session. Informed consent was obtained during this session before assessment. The study's participant flow is depicted in In collaboration with the host churches, participants were recruited through posting promotional flyers on-site, using the churches' email lists, and conducting informational on-site visits where research personnel provided sign-up sheets for interested church attendees. Research assistants called potential participants from the sign-up sheets to assess their eligibility. The inclusion criteria were women aged 40–65 years who self-identified as AA, spoke English, had a body mass index (BMI) of 25 or higher, were currently sedentary and not meeting the Physical Activity Guidelines for Americans,All measurements were taken at the preintervention assessment session, which occurred within 2 weeks of the intervention start, and again at the postintervention assessment session, which occurred within 2 weeks after the final class.16 Trained research assistants performed anthropometric measurements in triplicate.17 These measurements comprised body weight to the nearest 0.5 kg and height to the nearest 0.5 cm, and both were used to calculate BMI. Body fat percentage was assessed using bioelectric impedance (Tanita DC-430 MAP), and blood pressure was measured to the nearest 5 mmHg using an automated monitor.19 Dietary intakes were measured by three 24-h recalls (2 weekdays and 1 weekend day) using the ASA24® dietary assessment tool.20 Participants received text messages from the study team on randomly assigned days that reminded them to log into ASA24 and report their intake. Physical activity was assessed by administering the International Physical Activity Questionnaire (IPAQ) long form, which has been validated in multiethnic populations.21 Cardiorespiratory fitness, which is strongly associated with decreased CVD risk, was measured using the Siconolfi step test since this method has been validated for the estimation of VO2 max in very-low-fitness populations.22 Participants were asked to step up and down on a 10-inch bench, and their heart rates were monitored and recorded at the end of each of the test's three phases. The ICC was estimated for body weight, systolic blood pressure, and diastolic blood pressure using cluster-adjusted paired t-tests.Demographic information included age, marital status, occupational status, education, and income level.24 Perceived social support was assessed using the 23-item Sallis Social Support Scales for Eating and Exercise Behavior.25Psychosocial factors were assessed using validated instruments that were compiled and administered via an online survey during the pre- and postintervention assessments. To assess self-efficacy for eating and exercise behaviors, both the 20-item Weight Efficacy Lifestyle Scale and the 5-item Exercise Self-Efficacy Scale were used.Descriptive statistics of the demographic information and baseline values were compiled and tabulated. Changes in body weight, dietary intake, physical activity duration and frequency, blood pressure, cardiorespiratory fitness, and psychosocial factors were assessed using paired t-tests or Wilcoxon signed-rank tests for participants with both timepoints (pre-post). All statistical analyses were performed in SAS 9.3 . As per the goal of acquiring information to design a randomized, controlled trial, the ICC for body weight was determined, which will be the main outcome in future trials.Program leaders were asked to complete weekly online questionnaires about their class teaching experience and document any challenges they faced as a measure of dose and fidelity to the program. Program participants were asked to complete a midpoint online assessment at the 6-week mark to assess any changes in health status (such as recent injuries or illnesses) and program satisfaction. Adherence was operationalized as the number of sessions attended by each participant, as measured with the class attendance sheets completed by the program leaders. Retention was defined as the number of participants who completed postassessments. Reach into the target population was estimated from the number of people who signed up to be screened yet did not participate in or were not eligible for the study.Baseline data were obtained from 27 study participants. The mean age of the sample was 54.2 years (with ages ranging from 40 to 61 years); 64% had a bachelor's degree or above, 44% had an income of $75,000 or more, and 68% were employed full time .The two program leaders and 10 participants took part in the telephone interviews. Overall, the program leaders and participants had a positive experience with the program. Several themes emerged . The proThe program participants appreciated building on shared lived experiences and knowledge. They discussed how the relationships cultivated during the program kept motivation and accountability high. They also described incorporating dietary changes at home and reading food labels more consciously. The participants specifically referenced how the class on built environment heightened their awareness of targeted marketing in AA communities.2 (standard deviation [SD]: 6.7), and the mean pre-post change was 0.3 kg/m2 . The mean percent body fat at baseline was 45.6% (SD: 5), and the mean pre-post change was −0.1% (95% CI: −0.8 to 3). Mean systolic blood pressure at baseline was 138.4 mmHg (SD: 18.16), and the mean pre-post change was 4.8 mmHg (95% CI: −0.9 to 7.2); mean diastolic blood pressure was 83.1 mmHg (SD: 7.8), and the mean pre-post change was 0.6 mmHg (95% CI: −0.8 to 3). For cardiorespiratory fitness, the participants' mean VO2 max estimate was 17.8 (SD: 3.4), and the mean pre-post change was 0.9 (95% CI: −2.2 to 0.3). Participants' median self-reported Metabolic Equivalent of task minutes per week of physical activity was 2934 (interquartile range [IQR] 6263), and the mean pre-post change was 610 (IQR 5457). For dietary intake, participants reported a mean intake of ∼2 cups of fruit (SD: 1.3) and vegetables (SD: 1) per day; the mean pre-post changes were −0.5 cups of fruit per day (95% CI: −1.1 to 0.3) and 0.1 cups of vegetables per day (95% CI: −0.6 to 1.1). The ICC for body weight was between 0.025 at baseline and 0.086 at follow-up.As shown in p-value=0.029). Friends' discouragement to exercise declined significantly . The pre-post change in all remaining psychosocial and outcome measures were non-significant.Among psychosocial measures, within the Social Support for Diet and Exercise Behavior Scale, there was a significant pre-post decline in participants' ratings of family members complaining or criticizing them for exercising , and weekly class attendance (adherence) was 73%. During the midpoint satisfaction survey, all participants were “very satisfied” or “generally satisfied” with their overall experience in the program (100%), and the majority were “very satisfied” or “generally satisfied” with the progress they made because of their participation in the program (95%). The majority of study participants (83%) rated the program's effectiveness as “excellent” or “very good” in meeting the needs of group members for making lifestyle changes and fostering relationships between group members. The program leaders in their weekly online reflections documented the dose and fidelity of the program delivered. This included how certain class topics created robust conversations among participants that caused them to shorten or postpone some content. Additionally, program leaders highlighted the difficulty of completing both the exercise component and the classroom content within the allotted 2 h, partly due to delays in participant arrival to the classroom and delayed walking sessions. One leader rescheduled the exercise component to occur at the beginning of class to adjust for shortened daylight during winter. Overall, program leaders had to cancel 2–3 classes because of inclement weather, but they were able to combine sessions and meet with their groups on alternative days. Our target enrollment sample was 30 across all sites. Recruitment through churches took ∼1 month and led to 56 participants signing up for screening, 13 of whom were subsequently unreachable (23%) and 16 of whom (28%) were ineligible. We concluded enrollment at 27 participants, close to our goal, for logistical reasons. This indicates there was interest in the program, but that we may need to reconsider aspects of the recruitment process, for example by requiring that multiple forms of contact information are provided.Using the ASA24 dietary recall tool proved a challenge. Only half of the study participants completed both pre- and postintervention 24-h recalls (13 out of 27). The participants were invited to participate in an additional feedback interview to better understand their challenges via ASA24; four participants gave 20-min interviews and received an additional $25 gift card each. Overall, they expressed frustration with the website, the length and repetition of the questions, and an inability to complete the recalls immediately after receiving the text message reminders . The Siconolfi step test presented some technical difficulties with the heart rate monitor, which prevented us from reaching the full sample (13 out of 27).26–31 HHAL experienced a retention rate of 93%; of eight similar studies, only two reported retention rates greater than 90%.26–33 While other CVD interventions for AA women focused on diet and physical activity,8 HHAL adopted a total health approach and addressed cardiorespiratory health, stress reduction, and the built environment. Additionally, the program used multiple cultural adaptation levels.34This pilot study demonstrated the feasibility of implementing HHAL in church settings and supports the validity of HHAL, a culturally adapted evidence-based program designed for AA women. The participants' adherence and retention rates were within the range of those observed in similar studies, which supports the program's feasibility. The adherence rate in HHAL was 73%, and six similar group-based community CVD programs for AA women reported adherence rates of 53% to 89%.8 Furthermore, the program recognized the role of AA women as caretakers and incorporates self-care tools. Additionally, knowledge sharing was built into the program in recognition of the importance of personal experience to leverage behavior changes among AA women.34The program was delivered by two AA women of similar age to the participants. Each program leader led two of the groups separately (they did not co-teach). The material and recipes were designed to reflect the target population. We implemented the program in church settings to incorporate aspects of the communal identity frame in an attempt to increase the effectiveness of interventions.35The findings from the in-depth qualitative interviews with the program leaders and study participants showed an overall positive program experience. Specifically, the participants highlighted how they appreciated the sense of comradery from the group and being able to share experiences and learn from other AA women. Social relationships and connectedness are known protective factors for CVD risk among AA women.9 Recommendations from the qualitative interviews, such as having more support for ASA24 dietary recalls, will be considered in future HHAL iterations.The core content related to nutrition and physical activity education for HHAL was the same as for SWHH; however, in HHAL, where both deep and surface structural factors were incorporated, the program was better received and resonated more with AA women, as evidenced through their higher attendance and adherence rates. These results are encouraging given the evidence that taking culture, values, and beliefs into account can significantly improve modifiable risk factors among this group.26 Although ASA24 is a cost-effective and reliable instrument,36 its usability should be tested in the study population. In this study, only half of the participants completed all three recalls. The majority of these recalls occurred 1 or 2 days after the unannounced reminder text messages, leading to reactivity bias in reported diet intake. While three recalls is the gold standard, other studies found more than two recalls burdensome for this population.37 Future studies should hire staff, preferably nutrition professionals, to administer the ASA24 to ensure the accuracy of the collected dietary data and to reduce participant burden.39This study had several strengths. The adaptation was based on a “deep structure” cultural framework and formative research, and the overall study and the intervention were led by AA women. This helped ensure that the adapted curriculum was grounded in lived experiences. The curriculum structure and outcome measures proved feasible. Specifically, the Siconolfi step test captured cardio fitness health and produced reasonable VO2 max estimates, unlike the 1-mile Rockport test. In a previous study with a similar group of midlife Black/AA women, the 1-mile Rockport test's average walk times were too long for an accurate estimation formula.This study has several limitations. Several dietary intake data were missing because of technical difficulties with ASA24, as described above. Another potential limitation is that in one of the groups, only one person participated in the interview, potentially biasing responses from that group. Furthermore, the participants were relatively more educated and had a higher income compared to the national average, which might have affected adherence to the program. Finally, all the churches were in a northeastern American city, and participants were compensated for their participation, which might have affected generalizability.HHAL, a cultural adaptation of the evidence based program SWHH. Culturally adapted programs can lead to significant improvements in diet and weight outcomes among AA women.40 Cultural considerations differ across AA women.8HHAL specifically targets midlife AA women and used formative work to incorporate their preferences and needs that may differ from other subgroups.34 The high hypertension rate observed among our participants further emphasized the importance of addressing CVD risk among AA women. Such programs could potentially reduce CVD morbidity and mortality in this underserved population with pronounced health disparities. Future work will investigate the effectiveness of HHAL and demonstrate the link between cultural variables and health outcomes.Overall, this pilot study showed the feasibility and acceptability of


In recent years, veterinary education has begun the transition to competency-based models, recognizing that, like medical education, our goals include improved patient and client outcomes and the importance of learner-centered methods in education. Given that implementation of competency-based veterinary education (CBVE) is still in its relative infancy across many veterinary programs, we stand to gain from a unified approach to its implementation. As a guideline, the five core components of competency-based medical education (CBME) should serve to ensure and maintain fidelity of the original design of outcomes-based education during implementation of CBVE. Identified the essential and indispensable elements of CBME which include 1) clearly articulated outcome competencies required for practice, 2) sequenced progression of competencies and their developmental markers, 3) tailored learning experiences that facilitate the acquisition of competencies, 4) competency-focused instruction that promotes the acquisition of competencies, and 5) programmatic assessment. This review advocates the adoption of the principles contained in the five core components of CBME, outlines the approach to implementation of CBVE based upon the five core components, and addresses the key differences between veterinary and medical education which may serve as challenges to ensuring fidelity of CBVE during implementation. A new educational paradigm known as competency-based medical education (CBME) has emerged over the past 20 years and has been adopted by many healthcare training programs around the world. The goal of CBME is to develop “a health professional who can practice medicine at a defined level of proficiency, in accord with local conditions, to meet local needs” . This apAs more and more health care programs shifted to adopt this model of education, it became clear there was often an inconsistent process for implementation of CBME among training programs due to either a lack of understanding of what constitutes a true competency-based program or an incomplete process of implementation. An unintended consequence of the inconsistencies in adoption left some programs believing CBME failed to meet expectations –5. In reIn recent years, veterinary education has begun the transition to competency-based models, recognizing that, like medical education, our goals include improved patient and client outcomes and the importance of learner-centered methods in education . Given tAs with any innovation, standardization of language is critical for adaptive change , 9. DeveSequencing learner progression within an educational program involves designing curricula and assessments that are more deliberate and explicitly developmental , 11. In Tailoring learning experiences to the individual learner is a mechanism that allows time to be utilized as a resource by the learner. To achieve this goal, programs must consider removing time-based training and providing opportunities for learners to progress toward competency at their individual pace within a given timeframe. In medical education, an excellent example of time-variable training may be found in the Education in Pediatrics Across the Continuum (EPAC) program which was designed to advance learners from undergraduate medical education to graduate training based on competence rather than time spent in training . OriginaThere are inherent challenges associated with adoption of a new model of education, especially when faculty are comfortable in the perceived “stability” of the current system . As the To further mitigate skepticism and apprehension, it is essential that programs provide teachers with the faculty development necessary to prepare them to confidently meet the requirements of the new educational paradigm.of learning to the assessment for learning (Programmatic assessment (PA) is an approach in which assessment is seen as a system, or a program, of assessments . Many edlearning . To assilearning .Five core components have been identified as necessary to ensure fidelity of implementation in CBME. We believe veterinary education can and should follow these five core components as more and more educational programs move to accept and transition to outcomes-based training. Adherence to these five core components can support veterinary programs during implementation and with modifications to address the differences and/or challenges associated with veterinary vs. medical education as well as local context and needs, we believe veterinary programs can successfully adopt and implement CBVE.A number of competency frameworks have been developed for veterinary education . The mosThe CBVE Framework is intended to be utilized widely without alteration to preserve the ability of programs to communicate and share assessments, content, and activities related to the outcomes as published. To better reflect local context and regional content, individual programs may choose to modify and adapt the framework by including additional illustrative sub-competencies or nested sub-competencies that are identified during the process of CBVE adoption and subsequent implementation , 23. DefRecently, and following publication of the AAVMC CBVE Framework, multiple groups in veterinary education have developed, or are in the process of developing competencies related to specific subject area disciplines such as pharmacology, dentistry, informatics, emergency and critical care, and anesthesia. We offer a word of caution: while there are many 1,000s of competencies that could be developed in addition to those published with the CBVE Framework, this could cause the framework to become overwhelming for both educators and learners and act as a barrier for implementation. We advocate keeping the hierarchical structure of the CBVE Framework as published, leaving the newly developed “competencies” identified by different interest groups as illustrative subcompetencies to be mapped to individual CBVE competencies and associated domains of competence. The specific subcompetencies identified by each specialty group are intended for use within each group and not for the veterinary educational programs implementing the CBVE Framework. Again, maintaining fidelity of CBVE during implementation is critical for success of global adoption of outcomes-based education in veterinary medicine.To assist sequenced training and learner progress in competency-based training in veterinary education, the AAVMC has published a series of milestones which align with the CBVE Framework  and are It should be noted that although the milestones as published are written with the novice level designed for entry into clinical service of the training program, moving the continuum of learning backwards into the preclinical program through the establishment of pre-clinical milestones can guide course development and establish outcomes related to discipline-specific or basic science course content. In this way, pre-clinical milestones can provide the outcomes for each competency at varying training stages of preclinical training essentially creating a roadmap for faculty as they design specific course and session learning outcomes to ensure learner achievement and acquisition of competencies prior to entry into clinics .A preclinical milestones example for CBVE competency 1.1 is provided in Arguably, tailoring learning experiences and altering the length of the training program may be the most difficult barrier for implementation of competency-based training in veterinary education. The reality of converting time into a resource is challenging due to the current guidelines outlined in the American Veterinary Medical Association's (AVMA's) Policies and Procedures  which reIs it possible to develop a hybrid model of “time and achievement” for veterinary education? For example, using modules of practice, learners could spend the time necessary to ensure achievement of outcomes/competencies and when combined with a variety of assessment modalities throughout the curriculum , proficiency of individual learners could be assessed and confirmed prior to graduation, which is currently used as the endpoint. In addition, it could be envisioned that completion of the series of “basic” or “core” modules would then allow learners to move to “advanced modules” or “career-focused” modules based upon professional interests. This type of hybrid model of CBVE could be supported using block-chain technology  by issuiWe believe that successful implementation of CBVE related to competency-focused instruction relies upon faculty development opportunities to help align goals of the competency-based training program with the ability of educators to meet the goals of the new outcomes-based model. Providing opportunities for faculty to learn, practice, and reflect on their progress and development as educators within the new curricular model is essential for its acceptance and successful implementation. Assisting faculty development in the transition to competency-focused training should be a priority when implementing CBVE. The success of outcomes-based training relies on the transition of faculty to understand the difference between simply delivering content and that of developing a partnership of learning with trainees. Students must transition away from knowledge acquisition to knowledge application. These changes mirror recommendations regarding adoption of a growth mindset model in health professions education where the benefits to learners include increased reception to feedback while the benefits to educators focus on supporting collaborative relationships in safe learning environments .Competency-focused instruction requires educators to understand a basic level of curriculum development and course design. The backwards course design model can assist faculty in building outcomes-based educational opportunities  and can www.cbve.org).Another faculty development module used in medical education is the Fundamental Teaching Activities (FTA) Framework for CBME . These tImplementing programmatic assessment (PA) is one of the challenges currently facing physician-educators in CBME. Medical education programs that have designed successful PA strategies have included the following elements: (1) the creation of a program of assessments that represent all domains of competence within the competency framework, (2) the use of multiple raters/observers using multiple methods over time in formative-type low-stakes assessments, (3) the development of assessments that follow the shared mental model for progression toward achievement/competency, (4) the creation of assessments for learning using coaching feedback, (5) the design of assessments that include direct observation of activities performed by the learner in either simulated or workplace-based environments, and (6) the summative assessments that include multiple decisions by educators, using an aggregate to form a holistic vision of a learners achievement  .The concept of EPAs, introduced by Ten Cate, provides the means to evaluate performance of everyday activities of a practicing clinician and supports longitudinal data collection on learner performance. EPAs are defined as an essential task of a discipline  that an individual can be trusted to perform without direct supervision in a given health care context, once sufficient competence has been demonstrated . EPAs opIn many instances, collecting longitudinal data on trainee performance data is possible, but translating that data into a useful format may be problematic. It is understood that learners should have access to their longitudinal data to better understand how their performance compares to their cohort and informs their future goal-directed performance. Educators and administrators can use longitudinal data as a mechanism to assess learner competency across the continuum of the program and use the data to inform decisions related to trainee progress within the program. Determining the best process for utilizing data collected can be the rate limiting step in fully embracing PA in health care education.In recent years, CBME competency committees have gained more favor in guiding decision making on learner progress across the training program , 40. IntThe five core components of CBME can serve as a checklist for veterinary programs who are implementing CBVE to ensure fidelity to the competency-based model of education as it was originally designed. The components do not need to be implemented simultaneously as each training program should consider their individualized starting point for redesigning or updating their current program to adopt competency-based outcomes. Despite the starting point for implementation, we maintain that all five components are required to maximize the benefits and standardize the use and sharing of information across veterinary programs. With modifications to address the differences and/or challenges associated with veterinary vs. medical education within the five core components we believe veterinary programs can successfully adopt and implement this emerging model of education.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Non-communicable diseases (NCDs) have become the main cause of mortality in China. In 2009, the Chinese government introduced the Basic Public Health Service (BPHS) program to relieve the rising burden of NCDs through public health measures and delivery of essential medical care. The primary aim of this study was to evaluate the impact of the BPHS program on hypertension control.The China National Health Development Research Center (CNHDRC) undertook a Cross-sectional Health Service Interview Survey (CHSIS) of 62,097 people from primary healthcare reform pilot areas across 17 provinces from eastern, central, and western parts of China in 2014. The current study is based on responses to the CHSIS survey from 7,867 participants, who had been diagnosed with hypertension. Multi-variable mixed logit regression analysis was used to estimate the association between BPHS management and uncontrolled hypertension. In a follow-up analysis, generalized structural equation modelling (GSEM) was used to test for mediation of the BPHS program effect through patient compliance with medication.The estimated proportion of patients with uncontrolled hypertension was 30% lower (23.2% vs 31.5%) in those participants who were adequately managed under the BPHS program. Other predictors of hypertension control included compliance with medication, self-reported wellbeing, income, educational attainment and exercise; smoking was associated with reduced hypertension control. The significant inverse association between uncontrolled hypertension and age indicates poor outcomes for younger patients. Additional testing suggested that nearly 40% of the effect of BPHS management (95% CI: 28.2 to 51.7) could be mediated by improved compliance with medication; there was also an indication that the effect of management was 30% stronger in districts/counties with established digital information management systems (IMS).Hypertension control improved markedly following active management through the BPHS program. Some of that improvement could be explained by greater compliance with medication among program participants. This study also identified the need to tailor the BPHS program to the needs of younger patients to achieve higher levels of control in this population. Future investigations should explore ways in which existing healthcare management influences the success of the BPHS program. The leading causes of mortality in China have shifted relatively quickly from infectious diseases and perinatal conditions to chronic diseases and injuries ,2. This Funding for the program was provided by the Government initially on the basis of 15 Chinese yuan (CNY) per capita each year, which was increased to 20 CNY in 2011 and 50 CNY in 2017 . From 20A longitudinal cohort study of the Chinese population, the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2015 demonstrated that factors such as age, sex, smoking habits, drinking habits, household income, health insurance, BMI, residential region, marital status, educational level, and nationality were significantly associated with levels of awareness, treatment, and control among people with hypertension . A recenAlthough primary care in low-resource settings is the backbone for implementation of essential NCD interventions ,14, very12 factors in three categories were considered as determinants of hypertension control in this study. The first category consists of socio-demographic factors influencing adherence to medication, including age, gender, geographical region, health insurance, financial difficulties, and education level. The second category includes disease-related factors, such as smoking, drinking, and exercise. The third factor is hypertension management, denoting medical support and follow-up by a specialist, and is the factor considered as the effect of the BPHS program.Therefore, this study was to evaluate the effectiveness of the BPHS program in reducing the incidence of uncontrolled hypertension among participants and explore how to optimize the BPHS outcome.The ethics committee of the China National Health Development Research Centre reviewed and approved the present study, and the written informed consent was obtained from each participant before data collection.The primary research question in this study was to evaluate the effectiveness of the BPHS program (Management) in reducing the incidence of uncontrolled hypertension among BPHS participants.The secondary aim of this study was to explore factors which could influence the success of the BPHS program to gain insight into its processes and to provide guidance on ways to optimize BPHS outcomes. This was done by testing the impact of BPHS across demographic and regional groups. We also explored at the mechanism of BPHS action by testing whether the effect of BPHS would be mediated through patient compliance with medication. Finally, we examined the possibility that the success of the BHPS program could also depend on effective integration of existing health services though digital information management systems (IMS), which are currently available in some, but not all districts across China. The results of the secondary analysis are presented in the Supplementary Information and described in the Discussion of this manuscript.The Cross-sectional Health Service Interview Survey (CHSIS) used in this study was conducted in 2014 by the China National Health Development Research Center (CNHDRC) and was funded by the National Health Commission of the People’s Republic of China (NHC) and the China National Natural Science Foundation. The primary objective of the program was to monitor the implementation of primary care reform in China in chosen pilot areas, to use the experience gained to promote the integration of the health care system, and to disseminate this experience across the nation.Of the 32 provinces in the mainland of China, 17 were chosen to participate in the reform based on their representativeness and willingness to participate, These provinces cover all three regions of Chinal , and the rural-urban divide. One municipality was chosen in each of the 17 provinces as the basis for the program. A municipality in China denotes a large area encompassing both urban areas called urban districts, and rural areas called rural counties. As these are the basic administrative units of the financial and tax system in China, one urban district and one rural county was selected within each of the 17 municipalities, which was also based on their representativeness and willingness to participate. The sampling scheme is described in detail in the Supplementary Information , socio-economic status , disease-related health behaviors , self-reported wellbeing, and compliance with medication. The questions used to measure these factors are listed in Management;Uncontrolled Hypertension was used as the outcome measure in this analysis.The primary aim of the study was to evaluate the impact of appropriate BPHS follow-up  tests. The process of model selection is described in detail in S3 Table in Multi-variable mixed logit regression analysis was used to adjust the association between g design : the levCompliance). Generalized Structural Equation Modelling (GSEM) was used to estimate direct and indirect (mediated) effects of Management, as described in S1 Fig and S4 Table in The BPHS program is not a single intervention, but a disease management pathway, and any number of practices could be responsible for its effectiveness. The secondary aim of the study was to explore possible mechanisms of BPHS action. One possibility was that improved hypertension control in well-managed patients was due to regular encouragement to take medication. In this scenario the effectiveness of BPHS would be mediated through better compliance with medication  have been only partially implemented in China, as shown in S5 Table in All analysis in this report was carried out using Stata 14.1.Compliance with medication every day (77.3% vs 84.9%), male Gender (48.6% vs 45.4%), Age (62.5 vs 63.5 years), Self-reported wellbeing (7.0% vs 7.1%), Smoking (22.7% vs 21.4%) and frequent Alcohol intake (12.8% vs 11.9%). There were also broad similarities in proportions across categories of Education, Income and Exercise. Even though strong statistical differences between management groups were detected for most of these characteristics, such differences arose not from meaningful disparities, but from the large sample size , which made tests of significance sensitive to relatively minor differences.Key demographic characteristics for managed and unmanaged survey participants are described in Management were observed among geographical characteristics: urban Hukou (68.7% vs. 48.2%), urban Residence (74.1% vs. 49.8%) and in the breakdown by District/County  = 44.7), along with Compliance (χ2(1) = 81.2) and Region (χ2(33) = 227.0). The significance of random effects (χ2(1) = 46.6, Uncontrolled Hypertension at the level of Neighbourhood committee /Village.Alcohol, Gender, Insurance, Hukou, or Urban/rural Residence. These variables were excluded from the final model.Uncontrolled Hypertension among adequately managed participants (23.2% vs 31.5%). The benefit of Management was highly significant (P<0.001), despite adjustment for Compliance, which was included in the regression model as an independent variable. This finding suggested that Management offered a benefit that was additional to the benefit of improved Compliance with medication.The results of regression modelling  predicteThe significance of the inverse association between uncontrolled hypertension and age points to poor hypertension control in younger people . The treCompliance, self-reported Wellbeing, Income, Educational attainment and three or more Exercise sessions per week, while smoking over 20 cigarettes per day was associated with reduced control. Levels of control also varied between Regions (Uncontrolled Hypertension), Yunhe (10.1%), Runzhou (11.3%), Changning (11.8%), Wuhou (14.7%), Yijiang (14.4%), Pudong (12.8%), Shengzhou (13.6%) and Xinjin (12.0%); while the least favourable were in Keshiketeng (54.0%) and Yinan (43.1%).The effects of most other independent variables were in line with expectations . Predict Regions , with thThis study examined the relationship between hypertension control and a disease management program, which was provided through the BPHS using data from the CHSIS. The current report provides strong evidence supporting the effectiveness of the BPHS program, which was associated with a 26% reduction in the incidence of Uncontrolled Hypertension.A number of factors could have contributed to the success of the program, since it does not consist of a single intervention, but a process of patient monitoring and follow-up. This study explored possible reasons behind the effectiveness of the BPHS program, in order to gain insight into its processes and to provide guidance for future efforts to optimize its outcomes.One possible explanation is that regular face-to-face follow-up with health professionals may encourage improved compliance with medication. The results of mediation analysis Click here for additional data file.S1 Data(CSV)Click here for additional data file.


Impact on psychosocial function was reflected by 22% of the participants. Comments related to impact on career function were indicated by 45% of the participants. Ninety-four percent provided positive comments about the program structure, and 74% responded with positive comments regarding content of the program. Positive outcomes were associated with this one mentorship program, suggesting a need for more in-person, structured mentored learning experiences. Mentorship is recommended as a method to address the growing need within the profession to support career development, build knowledge, skill and attitudes, and aspirations/commitment as well as enhance professionalism/professional development.Mentoring is essential at all stages of a professional career. However, little has been written about the effectiveness of programs for practicing clinicians. This study was designed to address the need for evidence about the effectiveness of formal mentorship programs by describing the impact of the STAR mentorship program on a group of clinicians specializing in sensory integration and processing challenges. This study utilized an exploratory, retrospective, survey research design. Course evaluations were examined from 240 subjects following participation in a one-week, small group mentorship training program. Qualitative methods were adapted for use in this study. Sixteen codes, with operational definitions, were developed to analyze the surveys. Ninety-six percent indicated that the program met or exceeded their expectations; only 12.5% had a negative comment.  Mentoring is an essential component of professional growth and development both in the early stages and later stages of a professional career. The importance of mentorship is recognized within health care professionals in general  as well Occupational therapy (OT) entry-level education is filled with opportunities for experiential learning. However, once one completes an academic program, fewer opportunities exist for participation in mentored experiences. Additionally, clinicians are increasingly more isolated because of service provision settings . Research suggests that rural health care providers have greater difficulty accessing educational opportunities thus impacting knowledge and skill development in these professions .Although mentoring within allied health professions is not a new concept, it has resurged over the past 10-15 years . Little Starting in 2007, the SPD Foundation (now known as STAR Institute) identified a need for mentoring opportunities for occupational therapists working in pediatric settings. These unique one-week mentorship training programs were initially designed for experienced clinicians specializing in sensory integration and relationship-based practices. Both sensory integration and relationship-based practices are specialized interventions for children with sensory processing challenges that impact a range of developmental disorders such as ADHD, autism, and learning disabilities. This integrated treatment approach is based on theories of sensory integration originating from the work of Dr. A. Jean Ayres . Level 1Mentorship is defined as a working alliance between individuals in which the more experienced people support the growth and development of those with less experience , 9. MentMentorship is based on a mutual desire for career development for the purpose of updating one's professional skills. It capitalizes on a nonreporting relationship, a relationship within which there is no accountability or performance evaluation. Conversely, the purpose of supervision is to ensure that an employee's service and performance are congruent with their job description. Supervision helps to shape one's behavior so that organizational and professional goals are met, regarding job identity, competence, skills, and ethics . Often scareer function by exposing the individual to new professional arenas, providing resources and new knowledge. It also has a psychosocial function by cultivating competencies, achievement, and motivation of the mentee through the mechanism of a supportive and caring relationship as well as creating opportunities for networking among colleagues [Mentorship is defined as a relationship that is close, personal, nurturing, and dynamic . It is nlleagues , 17.The literature points to mentoring as being essential to professional growth and development. It is a mechanism for establishing professional identify as well as a vehicle toward increasing job satisfaction and professional confidence. Importantly, as job satisfaction increases, so too does one's commitment to their career , 18, 19.The current state of knowledge in occupational therapy suggests that experiential opportunities are more abundant for entry-level clinicians, and that practicing therapists may be increasingly more isolated. Small group mentorship experiences are not often discussed in the literature. Programs that are described tend to fall into one of three areas: mentorship for occupational therapy students during fieldwork , 21, menHowever, less is written about mentorship for practicing occupational therapy clinicians. In fact, in a scoping review of mentorship programs for occupational therapists, only seven out of twenty articles reviewed described programs directed toward clinicians. Within those that were reviewed, only seven were clinician-focused programs, with even fewer focused on pediatric clinicians. Several utilized a peer comentoring structure rather than the more traditional hierarchical relationship where the mentor is more senior and more experienced in a particular area relevant to the career development of the mentee .There is recognition that those working in specialty practice areas such as sensory integration require further learning and clinical mentoring to become experts , 23. HowThis current study was designed to address the need for evidence about the effectiveness of formal mentorship programs, mentorship groups, and mentorship in occupational therapy.The STAR Institute established its mentorship program in 2007 under the name of the SPD Foundation. These small group experiences allowed for classroom instruction discussion and reflection. Each program lasted for one week and engaged between 12 and 14 learners/mentees in the program. The structure was both didactic and experiential with exposure to such topics as assessment of sensory integration and sensory processing, goal writing, clinical reasoning used in treatment planning, documentation, and caregiver education. When not in the classroom, learners were able to observe live treatment sessions through a one-way mirror with microphones to capture audio exchanges among therapist, child, and parent. During and following the observation sessions, mentors and mentees engaged in clinical reasoning discussions based on the child's symptom presentation relative to sensory-related behaviors impacting participation in daily life activities.Thus, the purpose of this study was to describe the impact of the STAR mentorship program on a group of pediatric occupational therapists. Specifically, the objective was to explore the perceptions of clinicians specializing in sensory integration and processing. Feedback from the learners was designed to tap both strengths and weaknesses of the mentorship program.This was an exploratory, retrospective, survey research design, which examined course evaluations following participation in a one-week, small group mentorship training program. The protocol was reviewed by the Rocky Mountain University of Health Professions, Provo, Utah Institutional Review Board who deemed it to be exempt.Participants were occupational therapy clinicians who completed the level 1 mentorship program at STAR Institute (previously known as SPD Foundation). All reported working with children or adults with sensory processing and integration challenges. Data is from 240 clinicians who attended the training from 2007 to 2014. This timeframe was selected for consistency of instructors, structure, and content. Surveys were completed anonymously so limited demographic data were collected; name, age, gender, and years in practice were unavailable. Additionally, a calculated response rate was not tracked as a part of this study.Did mentorship meet your expectations?Did you feel the mentorship was a good value for what you received?What other topics or subject matter would you have liked to see covered this week?What did you like best about the mentorship program?What did you like least about the mentorship program?What would you suggest we do differently in the future?Other comments about this programAt the end of each mentorship week, participants completed an overall course evaluation used for quality assurance/management at a program implementation level, which served as the research questionnaire survey for this study. Data were collected anonymously from participants. The survey contained seven open-ended questions that asked for participants' opinions of or perspectives on their learning experiences, strengths, and weaknesses of the program and suggested changes. The questions are listed below:Qualitative methods were adapted for use in this study. The two approaches used for coding were inductive and deductive methods. The first was an inductive process that was data driven. This approach involved looking at the feedback in the text without a predetermined conceptualization , e.g., lFifteen participant responses were first reviewed to get an overall sense of the data. From this review, a list of codes emerged based on this sample of the responses. The process of inductive coding followed recommended procedures . The datn = 24) were scored for interrater reliability. Interrater reliability was calculated using the following formula: agreement/(agreement + disagreement) × 100. Scores ranged from 75% to 97% across this sample. Frequencies of code endorsement by participant  were then calculated. Descriptive statistics were used to summarize and tabulate the data.Ten percent of the sample  whether the comment was positive or negative, and (3) if positive comments were related to the structure of the program versus those related to the content of the program. Frequencies for these category analyses were also calculated.We then applied a deductive process that was concept driven . These cResults are reported in Six broader categories were produced from the sixteen codes in career and psychosocial function, the following was found: impact on psychosocial function was reflected by 22.08% of the participants. Specific influences were reported on professional identity as well as notably that the mentorship program instilled confidence, positively affected their professional outlook, and that they appreciated networking with colleagues. Comments related to impact on career function indicated that 45.41% indicated that the training had a specific influence on clinical skills such as clinical observations, clinical reasoning, translating theory to practice, and access to resources.When examined with respect to Positive comments about the program structure were provided by 97.73% of participants reflecting the organization of materials, topics, and pace of interaction with participants and faculty. Positive comments regarding content of the program were expressed by 73.75% of the participants while negative comments were expressed by 12.5%., Those with negative comments felt that the program did not meet or partially met expectations, highlighting that the course was too expensive. Negative comments were related to both the structure of the program and program content. Specifically, suggestions were to restructure the program by changing the pace of lectures, grouping participants based on level of experience and more time for breaks. Suggestions also included revising contents by addressing specific content areas by either spending more time on some topics and less time on other topics. There were no negative statements related to professional identify or impact on clinical skills, although participants indicated wanting to schedule one to one meeting with mentors and to wanting more time to address issues related to interdisciplinary treatment.A sample of comments included: “mentors were great resources”; “the program facilitated clinical reasoning” and “supported integration of theory into practice”; “the environment welcomed discussion and expression of opinions,” and “it was a great opportunity for networking with other clinicians.” Areas for improvement included the addition of topics related to practice setting . Those with recommendations for change suggested more mentor-guided independent learning opportunities and smaller group analyses of videotaped treatment sessions.Overall, clinicians regarded this mentorship program as a positive and valuable experience. Mentees enjoyed the format of learning experiences and the unique opportunity to network with other practicing clinicians. Responses were similar to those expressed by occupational therapy students in a study at the University of Western Ontario, Canada , suggestThe program described in this study fulfilled many of the projected responsibilities of a successful mentor articulated by Roberson and Savlo  by fosteImplications can be gleaned from this study for both entry-level academic education and postgraduation professional development. In an age in which distance education via online synchronous or asynchronous learning is growing and technology is increasingly a part of educational experiences, there is a recognized need for in-person, structured mentored learning experiences that utilize a hybrid approach . ParticiBased upon the results of this study, small group mentoring seems to be beneficial at all stages of one's career. The mentorship provided through this program seemed to foster the development of professional expertise as well as instilling a sense of commitment among attendees to the profession. All participants described some benefit consistent with mentoring. Results suggest more mentorship programs like the one described in this article would be beneficial to the occupational therapy profession.As recognized in the existing literature , mentorsClearly, more research is needed into the efficacy of mentorship programs relative to their effectiveness in supporting the development of occupational therapy practitioners across clinical populations and settings. Current research advocates for studies to address methodological gaps, with a need for occupational therapy practitioners and researchers to continue researching mentoring experiences using more rigorous designs and standardized measures of program effectiveness .This study had several limitations. No demographic data was collected on the participants. Evaluations were completed anonymously so there was also a lack of information on experience levels, years in field of sensory integration and sensory processing, or years in the profession. Thus, there is no data about the characteristics of each mentorship small group cohort: specifically, it is unclear as to which groups had a more homogenous sample of participants.Additionally, all data were collected retrospectively. There was no scheduled opportunity to follow up with respondents to determine how the experience in mentorship has altered their professional life or what components of the program they were able to implement in their own practice. The survey tool that was used for data collection in this study was not developed for the purpose of research so questions may not have tapped all areas of interest to program development or the impact of the program on career or psychosocial functions specifically. Future prospective studies need to be designed to explore intended impact of the program and intended applications.Lastly, there were no questions related to the characteristics of the mentors that may have supported learning or differences across mentors responsible for teaching the content. A future topic of interest is to reflect on the benefits of being a mentor within such structured programs.As a result of this study there is a recognized need for small group learning with recognition that observations  in the clinic setting are beneficial. There is a clear benefit of mentoring opportunities for both novice and experienced health care professionals. Ultimately, mentorship strengthens the integrity and viability of specialty areas as well as to the profession as a whole.


ABSTRACT IMPACT: This work will help assess the effectiveness of the mentored career development programs. OBJECTIVES/GOALS: There is increased attention on assessing the impact of the CTSA in building a research workforce through mentored career development programs. We propose using data visualization to assess and communicate the impact of the programs on the scholars career development. METHODS/STUDY POPULATION: Evaluators from two CTSAs collaborated to visualize the KL2 data such as demographics, scholarly productivity , and time to promotion that is already tracked through REDCap at their institutions. Excel, Tableau, and Microsoft PowerBi were then used to generate trends in scholarly productivity over time. The goal was to compare how different tools can be used to visualize bibliometric data, based on what is available at the respective institutions. RESULTS/ANTICIPATED RESULTS: Longitudinal visual summary reports were produced for the entire program as well individual scholar progress. These reports can be used to identify trends such as how long after program completion do participants achieve their next milestone, what type of milestones are achieved, when in their career is their scholarly productivity the highest, etc. Answers to these questions could tell a story of the effectiveness of a mentored development program in the participants’ career. It can also highlight gaps and areas of opportunities that the program must address, either by adapting their curriculum or clarifying their intended outcomes. DISCUSSION/SIGNIFICANCE OF FINDINGS: Data visualization provides better understanding of the impact of the training programs on the scholars career development. Such insights are otherwise missing when evaluations are only focused on the percentage of scholars who were still engaged in research after completion of the program.


The prevalence of schizophrenia is gradually increasing worldwide. Many patients with schizophrenia have a diminished ability to empathize and to detect their own emotions or those of others, deteriorating their social functioning and their quality of life. Nonetheless, emotional management training may improve patients’ emotion recognition, emotional expression, and negative symptoms. Developing and applying a short but effective program that reflects the current medical environment, in which hospital stays are ever-diminishing, is warranted. This one-group, pretest–posttest, quasi-experimental pilot study aimed to examine the effects of a short emotional management program (EMP-S) on 17 patients with chronic schizophrenia. Participants were patients hospitalized in the National Center for Mental Health in Korea. After the completion of a twice-a-week, eight-session, four-week long EMP-S, participants showed improvements in emotion recognition, emotional expression, and negative symptoms. Our results suggest the applicability and potential effectiveness of the EMP-S, which takes the length of psychiatric hospital stay and the inpatient environment into consideration. To minimize any barriers to social functioning in the post-discharge lives of inpatients with chronic schizophrenia and enhance their social cognition—by improving their emotion recognition, emotional expression, and negative symptoms—we suggest the periodical administration of this EMP-S to these inpatients. Schizophrenia is a chronic and serious mental disorder affecting more than 19,776,900 people worldwide . MoreoveIn middle- and low-income countries, approximately 69% of patients with schizophrenia are not treated properly ; furtherAccording to some studies on the negative symptoms of schizophrenia ,11, factEmotion recognition refers to the ability to detect one’s or others’ inner emotions and to recognize and evaluate complex and subtle emotions ; emotionHerein, we present some of the evidence that can be found on the topic in the scientific literature. A study showed that emotion recognition and expression in patients with schizophrenia can be improved with professional training . FurtherPsychiatric institutions, under the influence of stringent utilization management, are beleaguered to reduce psychiatric inpatient length of stay to show that they are rapidly and cost-effectively treating patients ,25. HoweThus, considering the clinical feasibility of the program related to the length of stay of patients with schizophrenia in mental hospitals, we further reduced the duration of the shortened version of an EMP proposed in a prior study ; we modiThis study aimed to investigate the applicability of the EMP-S, expecting improvements in emotion recognition, emotional expression, and negative symptoms of inpatients with schizophrenia.This pilot study employed a one-group, pretest–posttest, quasi-experimental design. The sample size was determined using G-power 3.1.9; with reference to a previous study , the conadults aged 19–64 years;diagnosis of schizophrenia based on the DSM-5 and ICD-11 by a psychiatrist;absence of organic brain syndrome assessed through brain imaging, electroencephalography, and laboratory tests;ability to read and respond to the questionnaire and understand the contents of the program;a score of 40 or higher in the Global Assessment of Functioning (GAF) Scale—this scale was chosen by referencing the study by Fenger et al. , and serdeemed to be fit to participate in the program by their doctor;signing of the written informed consent.adults aged over 65 years;a score of under 40 on the GAF Scale;difficulty in reading and responding to the questionnaire and understanding the contents of the program;organic mental disorders or intellectual disability.Emotion recognition was measured using the self-reported, 22-item, short Korean version of the Trait Meta-Mood Scale. It comprises emotional attention and emotional clarity subscales. Responses are marked on a 5-point Likert-type scale, with total scores ranging from 22–110 and higher scores indicating a clearer recognition of, and focus on, one’s emotions. This scale has been validated for use among Korean patients with schizophrenia by Cha , and it Emotional expression was measured using the self-reported, 16-item Berkeley Expressivity Questionnaire . It compThis tool has been widely used for measuring emotional expression in patients with schizophrenia , and it Negative symptoms were measured using the 25-item Scale for the Assessment of Negative Symptoms (SANS) , which iThe intervention comprised eight sessions, with two sessions for each of the four aspects of emotion that were addressed , and was administered twice-a-week for four weeks; this modified procedure served to shorten the existing EMP, which administered one session per week for eight weeks . We alsoOf the 19 participants that were recruited, two withdrew from the study , resulting in 17 participants that were included in the EMP-S and whose data were analyzed. Considering the average days of hospital stay and the optimal number of participants required to be in the EMP-S—which was a group treatment intervention—we conducted a four-week program for different participants at different time points , forming two groups; each group comprised eight–nine participants. The EMP-S was conducted in these groups between November 2018 and January 2019. General characteristics, disease-related characteristics, and emotional cognition and emotional expression scores were measured using a self-report questionnaire that was administered immediately before beginning the program , two weeks into the program, and immediately after the completion of the program (post-test). The scores for the GAF and SANS were measured by a psychiatric nurse practitioner who was not involved in the conduction of this study.The collected data were statistically processed and analyzed using SPSS, version 24.0. After analyzing the general characteristics through descriptive statistics, we analyzed participants’ score changes during  the program and post-test by comparing them with pre-test scores using generalized estimating equations (GEEs) with an autoregressive correlation structure. The data were repeatedly measured, were clustered, and were correlated; however, the GEEs do not assume the independence and homogeneity of variance, so we can adjust for individual and interaction confounders . To testThis study was approved by the institutional review board of the National Center for Mental Health (116271-2018-50)—to which all authors are affiliated, except for SJJ—and the investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. All participants received the following information: study rationale, purpose, and procedure. They were guaranteed that the collected data would be processed anonymously, the data would be used solely for research purposes, and that they had the freedom to withdraw from the study at any time. Further, a written informed consent form was provided to all participants, and all were requested to sign it prior to participation.In total, 64.7% of the participants were women, and the most common age group was 50–59 years (58.5%). Most (53.9%) participants had an associate degree or higher, and the most common duration of disease was 10 years or longer (47.0%). In total, 70.6% of the participants had a history of four or fewer admissions to a psychiatric hospital. Regarding employment, 64.7% had never had a job and 17.6% had maintained a job for two years or longer. All of the participants’ duration of untreated psychosis was less than one month and timely medicated .t = 2.41, p = 0.031) and lower negative symptom scores  than those with a score of less than 50 for the GAF , 3.07(2.09) at two weeks and 7.00(2.60) post-test, showing that the estimated mean of the emotion recognition score increased by 3.07 at two weeks and by 7.00 at post-test compared with the pre-test. The score changes were statistically significant . The estimated mean increased by 1.48 at two weeks into the program (B[SE] = 1.79[1.48]), which was a statistically significant change . When the pre-test score was compared to the post-test score, however, there was no statistically significant change (B[SE] = 3.66[1.83])  .p < 0.001; Negative symptom scores significantly declined at two weeks into the program and at the post-test compared to the pre-test. The negative symptom score was B(SE), −24.20(3.11) at two weeks into the program and −44.87(4.31) at post-test, showing that the estimated mean decreased by 24.20 at two weeks into the program and by 44.87 at post-test compared with pre-test. The score changes were statistically significant  and at four weeks into the program  compared with baseline , and the changes were statistically significant. This is consistent with the findings of Cho and Jang , which sFurther, the emotional expression score tended to improve at two and at four weeks into the program, although these changes were, generally, not statistically significant. This contradicts the literature; studies by Won , and ChoAdditionally, negative symptoms gradually improved at two and at four weeks into the program compared with baseline, and the changes were statistically significant. Although we only used one group in this study—hindering our ability to directly confirm the potential effects of the EMP-S owing to the lack of a control group—negative symptoms in our sample seem to have been influenced by interactions with others whom patients encountered while participating in the program/intervention provided by the therapist. On the topic, a study showed that to improve negative symptoms, it is important to have patients express their emotions and increase their interactions with others through activities, such as role-play . AccordiAccording to a recent study , emotionFirst, the study included a very small sample with a one-group, pretest–posttest, quasi-experimental design as a pilot study. This is a significant limitation of this study; because there was no control group and participants were recruited from only one unit in one hospital, our results have limited generalizability. Although we applied GEE to control for potential confounders, we still strongly suggest the need for a future randomized controlled trial to investigate program effectiveness.Second, we did not examine the longitudinal changes after the program completion; future studies are warranted to collect data four–six times during different periods, placing some of these after program completion, to allow for longitudinal examinations of program effects.Third, a recent study  examinedFourth, as shown here, the proposed EMP-S is anticipated to be effective in improving emotion recognition, emotional expression, and negative symptoms in an inpatient setting for patients with schizophrenia; therefore, subsequent studies should investigate the long-term effects of the program in various clinical settings.Our results show that, even though the proposed EMP-S lasted half the time that prior existing interventions lasted for completion, it still showed improvements in emotion recognition and negative symptoms in patients with schizophrenia. Hence, the program is anticipated to be applicable for managing emotions and negative symptoms in patients with schizophrenia in modern hospital environments.