Tu Salud ¡Si Cuenta! (TSSC), to augment fruit and vegetable (FV) consumption and physical activity (PA) engagement among low-income Latinos of Mexican descent living along the U.S.-Mexico Border in Texas. TSSC used longitudinal community health worker (CHW) home visits as a core vehicle to enact positive change across all socioecological levels to induce behavioral change. TSSC’s reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) was examined. A dietary questionnaire and the Godin-Shepherd Exercise Questionnaire measured program effectiveness on mean daily FV consumption and weekly PA engagement, respectively. Participants were classified based on CHW home visits into “low exposure” (2–3 visits) and “high exposure” (4–5 visits) groups. The TSSC program reached low-income Latinos (n = 5686) across twelve locations. TSSC demonstrated effectiveness as, compared to the low exposure group, the high exposure group had a greater FV intake  and an increased PA  from baseline to the last follow-up on a multivariable linear regression analysis. Multivariable logistic regression revealed that the high exposure group had higher odds of meeting both FV guidelines (adjusted odds ratio (AOR) = 2.03, 95% CI: 1.65–2.47) and PA guidelines  at the last follow-up. The program had a 92.3% adoption rate, with 58.3% of adopting communities meeting implementation fidelity, and 91.7% of communities maintaining TSSC. TSSC improved FV consumption and PA engagement behaviors among low-income Latinos region wide. CHW delivery and implementation funding positively influenced reach, effectiveness, adoption, and maintenance, while lack of qualified CHWs negatively impacted fidelity.This study evaluated the dissemination and implementation of a culturally tailored community-wide campaign (CWC),  American Latinos have lower rates of fruit and vegetable (FV) consumption ,2 and phTu Salud ¡Si Cuenta!  (TSSC) program, which adapts a CWC model for Latinos of Mexican descent living along the U.S.-Mexico border in Texas [A cost-effective and evidence-based manner to address health behaviors are community-wide campaigns (CWC), which take a holistic approach to target factors influencing behavior across all socioecological levels, ranging from individualized risk factor screening to interpersonal social support to environmental infrastructure improvements ,17. CWCsin Texas ,30. In iWhile CWCs are effective in improving outcomes, the adoption and scale up of these programs at the population level can take decades . DissemiThe translational science-derived RE-AIM  framework provides a structured manner to evaluate the public health impact of an intervention’s dissemination and informed future program implementation and adaptation through iterative reflection . AccordiWe hypothesized that adapting a CWC model would appeal to and reach our priority population, that with increasing CHW home visits there would be significantly increased levels of FV consumption and PA engagement aggregately and by location, that most locations offered the program would adopt it given the TSSC’s prior successes in health behavior uptake ,18, and With the goal of combining an effectiveness study and implementation research, we conducted an Effectiveness-Implementation Hybrid Type I study design . To evalp = 0.019) and a 14.8% compliance rate with FV guidelines compared to 21.93% for Latinos nationally (p < 0.0001) [TSSC took place in the U.S.-Mexico border region of the lower Rio Grande Valley, which is young (mean age of 45 years)  and rapi 0.0001) . We thusFrom 2014–2019, the TSSC program was disseminated and implemented in 12 locations in Texas’ Rio Grande Valley, neighboring Mexico. The location included two county precincts (“Precinct”) and two urban areas (“City”) with a population of over 75,000 each, two small towns with a population of 10,000 to 70,000 (“Town”), and six rural areas each with populations <5000   as shownpromotoras, who are lay neighborhood-based health workers trained to provide health information to their community to combat systemic healthcare inaccessibility [TSSC culturally tailored the CWC model to the U.S.-Mexico border Latino population to address their lack of social support and community- and environmental-level facilitators for healthy behaviors . TSSC hasibility ,49. CHWssibility ,30. CHWssibility ,51, withsibility ,17,30 ansibility . TSSC ussibility .The TSSC recruitment and enrollment process is presented in CHW home visit procedures have been detailed elsewhere  and are The TSSC program was initially designed for Latinos in one border city  to targeSociodemographic characteristics collected from the sample included: sex , age (as a continuous variable), Latino (yes/no), health insurance , and income . Incomep < 0.001) and a fair agreement for vegetables  among the local Latino population [The validated Two-item Dietary Questionnaire for Adults was used to assess FV consumption among participants, asking “How many portions of fruit, of any sort, do you eat on a typical day?” and “How many portions of vegetables, excluding potatoes do you eat on a typical day?” , with pipulation , using spulation . Validatp < 0.05) and moderate agreement when compared to an accelerometer  [p < 0.05) when compared to an objective pedometer measure for classifying participants as “physically active” in meeting PA guidelines or not [The Godin-Shepherd Leisure-Time Exercise Questionnaire instrument ,63 was u < 0.05) , with fas or not . Weekly s or not , in tands or not ,30,53,54Participants were classified by the geographic location they received the TSSC program services. Almost exclusively, participants were seen within the jurisdictional boundaries of the CHW paid by that municipality or precinct. In addition to community CHWs, three CHWs were hired by the university to deliver services across multiple locations; their participants were grouped by the participant’s primary residence.All participants who qualified for and received follow-up CHW home visits formed our initial sampling frame, from which we drew our study population for analysis. Guided by the RE-AIM Framework  for progReach: Reach was measured as the percentage of the total population living in the program locations with CHW follow-up visits to address risk factors. The total population of the municipalities/precincts (“locations”) was 718,647 based on the 2018 American Community Survey [y Survey . For refy Survey ,47, withEffectiveness: This study used CHW-delivered home visits to quantify individual program exposure because eligibility for home visits was predicated on abnormal vital signs at screening, thus suggesting unhealthy blood pressure and/or weight status in these participants. Among the participants who met the inclusion criteria for analysis, including those identifying as Latino and having at least two CHW visits for change measurements, we assessed the effectiveness of TSSC program exposure to change in self-reported measurements of daily FV consumption and weekly PA. We operationalized exposure to TSSC by the quantity of CHW home visit encounters received by each participant. We classified the participants into “low exposure” (2–3 CHW visits) and “high exposure” (4–5 CHW visits) groups based on a prior pilot study [t-test or its non-parametric equivalent  for continuous variables and Chi-square test for categorical variables. The program effect was measured by comparing the changes from baseline to the last CHW visit on FV servings consumption and MET-minutes of PA between the low and high exposure groups using two separate multivariable linear regression models.ot study , which fot study . The proFor those who did not meet daily FV consumption or weekly PA guidelines at baseline, logistic regression models assessed whether program exposure is associated with newly complying with FV or PA guidelines by the last CHW visit. Our focus, while building logistic regression models, was on understanding the association between variables and meeting FV/PA guidelines, and not on predictions or the evaluation of discrimination performance, which may require a validation process to make predictions on new data. We also assessed the program effects by each location. Potential confounding effects based on patient demographics were evaluated and adjusted accordingly in multivariable models. To account for heterogeneity among participants in their baseline measurement and duration of total follow-up, we adjusted for these variables in our models. We tested for effect modification to assess whether the program effects on behavior changes were modified by the interaction of other variables , although no significant effects were found. Underlying assumptions of linear regression and logistic regression were evaluated while developing final multivariable models. For the analysis, we used SAS  statistical software with a statistical significance level of 0.05.Adoption: We examined historical records of meetings to calculate the number of municipalities/precincts offered the TSSC program for implementation (the denominator). We then examined the number of unique municipalities/precincts that implemented the program between January 2014–November 2019 as evidenced by documented CHW home visits and other TSSC programming that was performed (the numerator). This metric was thus defined as the percentage of total municipalities/precincts in the region that were offered to the program who adopted TSSC during this time frame.Implementation: As aforementioned, the program defined “high exposure” based on a pilot study [ot study , as partMaintenance: This was defined as the percent of locations that adopted the program and had active ongoing CHW home visits as of November 2019.n = 8225) were aligned with our priority population of Latinos with a low income.Between January 2014 and November 2019, a total of 15,870 participants were recruited by TSSC, or about 2.21% of the entire population of the 12 partnering locations. Among participants who provided ethnicity data, 12,304 (93.25%) identified as Latino. 81.91% of those who provided both ethnicity and income data , or those eligible but declining to have follow-up CHW home visits  were excluded. Those with only an initial CHW visit, despite being eligible for follow-up , were also excluded from the analysis, as there was no measurement of FV consumption and PA change from baseline. Non-Latinos, or those who did not disclose their ethnicity , were excluded from the analysis given the study’s emphasis on investigating the effect and implementation of TSSC on Latinos, specifically given the paucity of research for this population. Therefore, a total of 5686 (35.8%) participants were included in our analysis and were classified into “low exposure” (n = 4639) and “high exposure” (n = 1047) groups for analytical comparisons. The mean number of total CHW visits did not differ by sex  or by 10-year age groups (range between 2.5–2.8) (not shown in p = 0.0008) and less likely to be in poverty . At baseline, the high exposure group had a significantly higher mean MET-minutes , mean FV consumption , and people who met the PA guidelines , and FV guidelines   .p < 0.0001) based on a multivariable adjusted model (p < 0.0001) (Unadjusted results of mean change in FV consumption from baseline to the last CHW visit was similar to the adjusted multivariable model . Both exed model . Additio 0.0001) .p < 0.0001) based on the adjusted multivariate model (p < 0.0001), and having health insurance  significantly increased the odds of meeting FV guidelines by the last CHW visit  met the FV guidelines by their last CHW visit . The higte model . Each adHW visit .p < 0.0001) (p < 0.0001), younger age , and having health insurance  significantly increased the PA level from baseline (Both exposure groups had a significantly increased mean change from baseline to the last CHW visit in PA (in MET-minutes per week) based on unadjusted and multivariable linear regression models across all 12 locations . In the  0.0001) . A highebaseline .p = 0.0046) (p < 0.0001), female sex , and having health insurance  significantly increased the odds of complying with PA guidelines at the last visit. Older age  and being in poverty  significantly lowered the odds of meeting PA guidelines  met PA guidelines by their last CHW visit . The adj 0.0046) . Increasidelines .n ≥ 35) in the high exposure group for stable regression analysis and were excluded from the location-level program effectiveness analysis. The adjusted mean changes in FV consumption and PA levels from baseline to the last CHW visit were compared between the low and high exposure groups in seven location—one urban area (City A), two towns , and four rural areas . The proportion of their sample in the high exposure group varied greatly across locations: 27.7% of n = 1251 (City A); 7.4% of n = 457 (Town A); 11.0% of n = 747 (Town B); 56.7% of n = 702 ; 15.4% of n = 540 ; 7.7% of n = 467 ; 6.6% of n = 587 .In a location-specific analysis , one citp < 0.0001) (Based on  0.0001) . The hig 0.0001) .p < 0.0001) (p = 0.0061)  . The hig 0.0001) . Six loc 0.0061) .During the first two-thirds of the study period (January 2014–December 2017), nine locations were offered the program and all nine adopted it (100% adoption rate). Beginning August 2017, four more locations were approached, with three accepting the program. The overall adoption rate across the region (12 adopted/13 approached) was therefore 92.3%.Of the 12 locations that were adopted, seven (58.3%) were implemented with fidelity in terms of providing a sufficient number of participants (≥35) sufficiently exposed to the program at a high dose of CHW home visits (≥4 home visits). The five locations that did not implement with fidelity included two locations with personnel issues , delayed administrative setbacks, and a lack of certified CHWs in the community willing to participate in providing home visits for TSSC . These factors delayed the program’s CHW home visit implementation and thus, insufficient numbers of participants received the required CHW home visit curriculum.All but one location maintained the program (91.7%) with active CHW home visits up until November 2019. Rural E discontinued the program due to a lack of a consistently available CHW for employment despite the funding being available.TSSC, in leveraging the community asset of CHWs to perform home visits in a culturally tailored manner for the local Latino population , reachedOverall, we enrolled 2.2% of the total population of the participating locations for an initial CHW home visit and 81.91% of our sample was our priority population of low-income Latinos. This indicates that the CWC model can effectively enroll the priority population for which programming services were designed, even in a resource-scarce region. This study contrasts with the concern from prior community interventions on the rare reporting of priority population reach and that minorities are less likely to enroll in and benefit from community health interventions ,72. IncrTSSC is the first CWC intervention in the literature that examined the program effects on both FV consumption and PA engagement. We found a significant improvement in FV consumption and PA aggregately across locations, with a greater improvement in the high compared to the low exposure group, but with significant increases, even with 1–2 CHW follow-up visits. Our findings parallel CHW-based Latino community interventions that improved behavioral outcomes ,17,18,30In a location-specific analysis, the effect size difference by location is wide, differs by outcome, and is partially explained by individual and organizational capacity factors. The community CHWs differed individually in their professional backgrounds and approach to follow-up visits. Each municipality had varying levels of priority placed on this program as evidenced by the varied time spent in an administrative setup by different municipalities before initiating CHW home visits. As the CHWs balanced municipal and program demands, their emphasis on providing CHW home visits may have diverged. Future research should examine factors associated with RE-AIM’s Implementation and Maintenance dimensions  to comprIn line with our study, CWCs, through targeting multiple levels of the ecological environment, have shown significant effects in improving PA across different adult populations globally ,24,81, aMoreover, no prior CWC had published PA effects by socioeconomic status or other markers of equity . This stThe TSSC program was adopted by 92.3% of locations to which it was promoted. Our study reflects high motivation to adopt the program in a high need region. Enthusiasm for adoption was likely influenced by the presence of grant funding to cover annual program costs. Over time, the local municipalities were able to leverage this core funding into additional programming and infrastructure improvements, which built enthusiasm. Generally, past research has indicated that community-based interventions are not adopted because health issues are not perceived by key stakeholders and municipal decision-makers as relevant ,89,90. NThe goal of TSSC was to have as many participants have longitudinal CHW home visit follow-ups to address the socioecological factors that preclude FV and PA behavioral uptake in the priority population. There was some lack of fidelity in program implementation as 39% of those eligible for follow-up CHW home visits based on abnormal BP and/or BMI did not engage in the home visits or any other TSSC component. Moreover, seven of twelve locations (58.3%) reached a minimum threshold of implementation where a sufficient dose of monthly CHW home visits was provided. Incentivizing participant engagement in follow-up CHW home visits could also be considered in the future.In general, locations that adopted TSSC with fidelity generally expeditiously identified community CHWs with experience and capacity to implement the home visits and program components. Several sites had difficulties in finding qualified CHWs, which curtailed the number of follow-up visits performed at those locations. These challenges were seen in prior Texas Latino CHW-based interventions in which their implementation and effect success was mitigated by CHWs’ supply shortages, their lack of continuing training opportunities, and their heavy workload ,91,92. TMaintenance was high, but like adoption, it was influenced by the presence of an ongoing grant funding to support the intervention activities. As the program has future expansion planned, more knowledge about maintenance will come over time, as seen in the original CWC program implementation in Finland, which has been maintained for 40 years ,35. TSSCThe limitations to our study include a lack of control communities. However, several previous studies with control groups on the TSSC program have shown evidence of efficacy ,18,30, aAnother limitation is the differential sample size between the low and high exposure groups. The unequal sample size between these groups may have weakened the statistical power and resulted in the exclusion of five of the twelve implementing locations from the analysis. As more participants are followed for a longer timeframe, the program effect and maintenance can be examined using longitudinal analysis. The outcome variables were measured through self-reported measures subject to a intervention-induced social desirability bias that can cause over-reporting of the participant-reported measures in FV and PA with resultant differential misclassification of these measures and over-estimation of the true effect size of behavior change in our study . The twoMoreover, FV consumption and PA engagement behavioral changes are not just due to the CHW home visits by itself, but the delivery of the entire multimodal components of TSSC. The synergy of all these different facets, each impacting various socioecological levels of influence, is likely what ultimately yields FV consumption and PA behavioral changes. Our analysis quantified program exposure based on CHW home visits given its primacy in the TSSC curriculum with a regression covariate established for program components received. However, future programmatic enhancements can include enhancing the tracking of participant engagement with each component of TSSC to better quantify the isolated effect of each individual program component on behavior.This study’s strength rests with its large sample of 5686 predominately low-income Latino adults along the U.S.-Mexico border who at baseline have disproportionately low uptake of FV consumption and PA engagement ,13,15,45Other CWCs have examined effectiveness, but rarely have dissemination and implementation been studied. We discovered novel evidence that the broad dissemination and implementation of a CWC in a low-resource region is related to enhanced uptake of FV and PA behaviors in thousands of Latinos in diverse, real-world settings regionally. However, we went further and examined facilitating and inhibiting factors that influenced our scaled-up dissemination and implementation of TSSC to inform and improve next generation implementation efforts of TSSC and CWCs in general. It would be of interest to frame CWCs as a modality for advancing health equity, and thus the intersectionality of socioeconomic status and health behavior uptake in community interventions and the sustainability of FV and PA behavioral changes should be explored. Public health initiatives will continue to benefit from the explication of implementation efforts based on the RE-AIM framework because practitioners generate insight into how to practically disseminate and implement evidence-based interventions into tangible community settings.This Effectiveness-Implementation Hybrid Type I study used the RE-AIM Framework  to evaluThe study implementation revealed high adoption, moderate fidelity, and high maintenance across a variety of settings ranging from major urban to rural communities. CHW delivery and implementation funding positively influenced reach, effectiveness, adoption, and maintenance. At the organizational level, a lack of qualified CHWs and differential proactiveness to conduct longitudinal home visits among CHWs negatively impacted the fidelity of implementation in some locations. Evidence-based health behavior promotion interventions in Latino communities rarely analyze the reach, adoption, implementation, or sustainability of interventions ; accordi


The Bruins-in-Genomics Summer program represents an example of how a combined didactic-research program structure can make computational biology accessible to a wide range of undergraduates and increase participation in quantitative biosciences.Recruiting, training and retaining scientists in computational biology is necessary to develop a workforce that can lead the quantitative biology revolution. Yet, African-American/Black, Hispanic/Latinx, Native Americans, and women are severely underrepresented in computational biosciences. We established the UCLA Bruins-in-Genomics Summer Research Program to provide training and research experiences in quantitative biology and bioinformatics to undergraduate students with an emphasis on students from backgrounds underrepresented in computational biology. Program assessment was based on number of applicants, alumni surveys and comparison of post-graduate educational choices for participants and a control group of students who were accepted but declined to participate. We hypothesized that participation in the Bruins-in-Genomics program would increase the likelihood that students would pursue post-graduate education in a related field. Our surveys revealed that 75% of Bruins-in-Genomics Summer participants were enrolled in graduate school. Logistic regression analysis revealed that women who participated in the program were significantly more likely to pursue a Ph.D. than a matched control group (group x woman interaction term of  Our nation has been challenged to add one million STEM-trained individuals to the workforce  because Despite these needs, students from Black/African-American, Hispanic/Latinx and Native-American backgrounds are severely underrepresented in graduate programs in STEM fields . AlthougIt is critical that life scientists receive quantitative training that will allow them to fully participate in the bio-data science revolution , 9, 10. There is substantial evidence that providing research opportunities to undergraduates has a significant impact on their careers. Undergraduates who participate in research are more likely to persist in STEM majors, identify as scientists, maintain interest in STEM-related careers, and attend a graduate program in the sciences –19. AttrIn addition to research experiences, other critical factors can contribute to the likelihood that a program will have short and long-term positive outcomes for its participants , 31, 32.We designed the UCLA Bruins-in-Genomics (BIG) Summer undergraduate research program, launched in 2016, to address the specific need for a more robust and diverse pipeline of computational and quantitative biologists. The aim of BIG Summer is to provide a diverse group of undergraduates with training in quantitative analysis of genomic data, an inquiry-based research experience, a sense of community and scientific identity, mentorship from a faculty member, and support for professional development. We anticipated that a program with these elements would have a strong impact on the students’ career paths, and we specifically hypothesized that program participants would be more likely than controls to enter graduate programs in bioinformatics and related fields. Here we describe the features of the BIG Summer program and our analyses of its impacts on the participating students. We found that among the students who had received their bachelor’s degree and for whom we have data on their career paths, 75% of all students and 69% of URM students had entered post-undergraduate degree programs. A logistic regression analysis revealed that for women in particular, participating in the program was associated with a higher likelihood of enrolling in a PhD program.In developing and assessing the BIG Summer undergraduate research program, we relied on the Tripartite Integration Model of Social Influences (TIMSI), which describes three fundamental developmental processes that promote student integration into STEM careers . Guided Within the context of undergraduate STEM education, specific training environments, co-curricular opportunities, and members of the scientific community such as faculty mentors can act as social influence agents that affect the development of these three key social influence processes . While sThe components of the BIG Summer program were developed in a way that positions them as social influence agents that simultaneously target the fundamental social influence processes predicted to be important for positive longitudinal outcomes for a diverse group of students . These cAll studies were approved by the University of California Institutional Research Board as having minimal risk. The IRB determined that it was not necessary to obtain signed informed consent from participants. The IRB determined that the recruitment email could serve as the informed consent form. All relevant federal and institutional guidelines were followed. Graduates of the BIG Summer program were contacted by email and asked to participate in surveys administered through Google forms. Of the 187 alumni of the program that were emailed, 70 responded. Emails to the students explained that the data generated would be part of our research on the summer program and could be published in research journals. Student alumni were told that they could address any questions about the survey to program administrators. The survey that was administered via Google docs is provided as a pdf as Supplementary Information Document 1 in To assess the current status of BIG Summer alumni, web-based searches were performed through Google, LinkedIn and other publicly accessible websites. These searches resulted in information about whether the students had matriculated in a graduate program and if so, in what field. The data abstraction document is provided as Supplementary Information Document 2 in BIG Summer is an 8-10-week program that provides undergraduate students an opportunity to gain skills in performing research in computational biology. The program has five components : (1) A dThe goals of the program, as described in detail below, are focused on the undergraduate student participants, which on their own justify the investment in faculty time and funds. However, over the past years it has become clear that the outcomes of the program are broader. Faculty mentors report that undergraduate program participants are making important contributions to their research projects. Postdoctoral and doctoral trainees report improved skills in mentoring and project management, while faculty and departments note an improved institutional climate when community members engage in a shared focus on furthering diversity and mentoring. These latter outcomes help to sustain enthusiasm among the available faculty pool to serve as mentors in BIG Summer. The five components of the program were designed to address six program goals, as described below, through a variety of activities .The BIG Summer program is advertised through in-person and electronic advertising beginning in the fall of the previous calendar year . AffiliaIn 2017 and 2018, the BIG Summer program received 110 and 116 applicants, respectively. In subsequent years the number tripled, reflecting improved recruitment efforts and program reputation . In eachWith this advertising plan and applicant pool, the BIG Summer Program was able to establish diverse cohorts of students . In 2019While in the first year of the program many of the students came from UCLA (63%), the number of students from other institutions increased over time as the reputation of the program spread throughout the country . In 2019Applicants to the program were consistently very strong academically. The average GPA of the applicants was 3.6 each year of the program. Most of the applicants are majoring in biology, bioinformatics, computer science or related fields.Scientific self-efficacy is one of the cornerstones of the TIMSI and has been demonstrated to be a particularly important component of scientific integration for undergraduate students . TherefoThe first two weeks of the BIG Summer program involves didactic training with hands-on workshops in Next Generation Sequencing data analysis taught through QCBio . In the These classes also introduce students to their fellow BIG Summer students, and foster community building within the summer cohort. The Collaboratory workshops provide students with training in the Unix operating system and programming in Python and R.  .As discussed above, prior research has demonstrated the efficacy of authentic research experiences in promoting the development of scientific identity in students –19. By pTo help the students achieve the learning goal of increased fluency in evaluating the primary literature, students participate in a mentored, weekly journal club. The faculty leaders assign a paper each week, and work with each group of students to develop the presentation and lead a discussion . These jStudents perform research projects in the laboratories of faculty mentors starting in week 3 of the program . FacultyToward the end of the summer, faculty mentors and daily mentors support the students as they write an abstract that summarizes the problem they were investigating, their specific hypothesis, their results, and their conclusions . The proStudents who self-identify as scientists are more likely to apply to graduate school and continue on an academic path . ScienceTo foster continuity in the quantitative biology training pipeline, BIG Summer provides students with structured programs for career development . Summer After the summer ends, faculty mentors are encouraged to continue their relationships with their students, and students are encouraged to apply for conferences and graduate school. Students often continue to be engaged in their projects or in the PI’s other research. Many students contribute to manuscripts for publication. QCBio provides funding for students to present their research at national conferences.To assess the impact of the BIG Summer Program on the students’ career development, we asked whether participation in the BIG Summer Program affected their interest in attending graduate school. Two-thirds of participants responded that the program inspired them to attend graduate school  and chooPrevious studies report that educational programs that engage students in inquiry-driven research, encourage self-identification as a scientist, and provide mentorship and professional development, can achieve outcomes that include increased attendance at graduate school –48. As tDue to the nature of the BIG Summer program and the intensive time commitment required from participants, it is likely that there is a degree of self-selection for participants who are inclined to attend graduate school. To disentangle the impact of participation in BIG Summer on its participants, we used two approaches. First, we compared the outcome for BIG Summer with other similar programs. A study of the Meyerhoff Scholars Program reports that almost half of the students went on to STEM graduate school . OutcomeAs a second approach to evaluate the impact of BIG Summer on its participants, we identified a control group of students who applied to BIG Summer and were accepted, but chose not to attend. The GPA’s for the participant (3.6) and control (3.7) groups were not statistically significantly different based on Student’s t-test. The fraction that are women  is not significantly different by chi-square analysis. The fraction that are URM students  is not significantly different by chi-square test . Among tAmong the participants, 75%  (69/92) of those who had completed their bachelor’s degree and for whom we had data on their post-graduate plans chose to continue to graduate school . Our rubAmong women students, 38 out of 50 BIG Summer students who completed their bachelor’s degree and for whom we have information, continued to graduate school  , Fig 5. p = 0.024). While our primary hypothesis that participation in BIG Summer would result in more women entering a PhD program was not statistically significant, this secondary hypothesis, that participation in BIG Summer would result in more women entering a PhD program in a related field was significant. These findings are hypothesis generating and can be tested further in future studies.We investigated in more detail the field of study for students who went on to graduate work. Among all BIG Summer alumni, 30% (21–39%) continued to graduate school in bioinformatics, 14% (8–22%) continued in biology and related fields, and 14% (8–22%) continued in computer science, math or statistics , Fig 6. Finally, we investigated the types of jobs that the BIG Summer alumni and controls pursued after graduation. Among the 27 students with jobs in the participant group, 6 (22%) were involved in academic research, 4 (15%) were involved in bioinformatics, 8 (30%) were employed in programming, and 4 (15%) held jobs associated with data analysis . For BIGp = 0.005) at α = 0.05 for predicting likelihood of obtaining a Ph.D., suggesting that for women, participation in BIG Summer affected whether or not they enrolled in a PhD or MD/PhD program  by woman  interaction term had a statistically significant coefficient  provided funding for students from Historically Black Colleges and Universities. This grant supported partnerships with Fisk University, Florida A&M, and Spelman. The National Science Foundation (NSF) Research Experiences for Undergraduates (REU) program included the program on its website, increasing visibility. The NSF program is focused on supporting students from diverse backgrounds, students who are the first generation to attend college, students with disabilities, and students from schools that do not have a PhD program in bioinformatics.Undergraduate research experiences and faculty mentorship are important for encouraging students with an interest in STEM to continue their education and remain in STEM-related fields. Previous studies have shown that students are more likely to persist in the sciences if they identify as a scientist, feel that the work is aligned with their values, and have a sense of scientific efficacy , 43, 51.In the first five years of BIG Summer, the program developed a national reputation resulting in a strong and large application pool. Alumni who responded to our follow-up survey overwhelmingly reported that their participation in the program provided skills that were valuable for their career, influenced their research interests, and introduced them to the new scientific areas. Alumni reported that participation in the program allowed them to make connections that were useful in their careers, inspired them to go to graduate school, and helped them select the right graduate program. We compared the post-graduate career choices of students who attended BIG Summer with a control group of students who applied to BIG Summer and were accepted but chose another summer plan. Women who participated were more likely than women in the control group to attend graduate school, supporting the hypothesis that participating in BIG Summer increased the likelihood that women participants would continue to graduate school. Fully 30% of BIG Summer participants, and 20% of the control group, elected to continue with postgraduate education in bioinformatics or a closely related field. The percentage of students in graduate school for Bioinformatics and related fields was similar for students from underrepresented backgrounds (28% for BIG Summer participants and 19% of the control group) and for women (32% for BIG Summer participants and 9.4% of the control group). Of the BIG Summer students who had secured employment, a high fraction was employed in a field related to bioinformatics . In the control group, 63% (43–79%) were employed in bioinformatics or a similar field.Our data did not reveal an increase in the fraction of URM BIG Summer students who entered PhD or MD/PhD programs compared with our control group of students who had also taken the initiative to apply to BIG Summer, were accepted, but declined. A much larger study revealed that participation in the four-year spanning Meyerhoff Program was associated with an increased fraction of students entering a PhD program in a STEM field, with the control being students who were invited to participate in the Meyerhoff Program but did not . WhetherWe believe that other institutions can develop programs similar to the Bruins-in-Genomics Program and offer some advice based on our observations. First, we suggest advertising the program at conferences such as ABRCMS and SACNAS. Students presenting posters and winning awards at such conferences were effective methods for advertising the BIG Summer program. Second, we highly recommend an application for the program that asks questions about the applicants’ courses, their research experience, their research interests, and their contributions to diversity. The BIG Summer application form is included as Supplementary Information Document 5 in Overall, students who attended BIG Summer overwhelmingly reported that they had learned skills that were valuable for their careers or studies. For women, who are nationally less likely to enter graduate school in quantitative fields, we observed an increased likelihood that the participants would continue to graduate school in a related field than student in a control group. These results attest to the effectiveness of our program in addressing the need for an increased and more diverse pool of STEM-trained individuals.S1 Data(XLSX)Click here for additional data file.S1 File(PDF)Click here for additional data file.


BackgroundThe objective of this study was to assess the accessibility and content of the Accreditation Council for Graduate Medical Education (ACGME)-accredited general cardiology fellowship websites.MethodsUsing the online information provided by the Electronic Residency Application Services (ERAS), we compiled a list of ACGME-accredited cardiac fellowship programs. The program links on ERAS were evaluated followed by a standard Google search of the program name + “cardiology fellowship”. Each program website was evaluated on the basis of program content, applying/recruiting and education.ResultsAt the time of this study, we reviewed 231 general cardiology fellowship programs provided through ERAS. Of the 231 programs, 12 were excluded due to broken links, repeated links on ERAS, and websites with a general lack of content. We analyzed the data collected from the remaining 219 programs to assess the availability and general content of those websites. Data collected revealed a general lack of information regarding application processing and educational services but were sufficient in providing program descriptions and contact information.ConclusionsERAS can be used to locate general cardiology fellowships participating in the current match; however, the links provided by the program websites on ERAS are lacking in general content and accessibility. Although most websites did contain enough information about their program, there was a distinct lack of key information provided typically in the education services and application process. General cardiology fellowship is mediated by the American College of Cardiology (ACC) and the American Heart Association (AHA). The ACC/AHA accreditation is “a single source of state-of-the-art process improvement tools to bridge gaps and integrate evidence-based science, quality initiatives, clinical best practices, and the latest ACC/AHA guidelines,” and serves as a guideline for cardiology fellowship program structure . In 2015In our current climate of social distancing and virtual interviews, it is critical for fellowship programs to have working links, easy access, and adequate information on their web pages. A 2011 study by Chu  reportedWebsite access and content have been previously studied for a variety of other fellowships, with a similar conclusion that the content of most programs does not provide an adequate amount of information for prospective applicants on their websites. A 2018 study by Shaath  demonstrThe purpose of this study is to assess the content of ACGME-accredited general cardiology fellowship websites and the accessibility of that content.The current list of general cardiology fellowships was taken from the Electronic Residency Application Services (ERAS) website . The felThe program websites were then evaluated by a number of parameters, starting with the hyperlink, google location, program statement, program director, address, email and contact information, application information, and links to the ACC or AHA websites. The information obtained was then cross-referenced against the other 218 programs available: whether the links were present, present but not working, and not present. Once the hyperlinks were assessed, we also checked the program accessibility through Google. A specific Google search was performed for each program: [Program name as seen on ERAS] + “cardiology fellowship”, and the location of the link for the program was recorded as its location on Google. The content gathered from the program websites were evaluated for program overview, application process, and education. Program overview included the program description, the program director's name, address, email, phone number, current and previous fellows, and current employment of alumni. Application information included access to either the ACC or AHA with current guidelines, application process including the number of recommendations needed, deadlines, and salaries/benefits. Educational content included didactics, journal club, rotation/curriculum information, research requirements prior to entering the program, previous program research, any ongoing clinical trials occurring at the program, clinic/call responsibilities, case log requirements, and international opportunities. Of the total 231 general cardiology fellowships, we discounted 12 websites due to a total lack of any content, i.e., missing/no information at all, broken links, and inability to access the website or repeated links from ERAS. In total, we assessed the content and general accessibility of 219 general cardiology fellowships. Of the total amount of links provided, we were able to assess 94.8% for content of program overview, application process, and educational services. Google links provided by ERAS worked for 94.8% of the provided links. Using the standard search approach described above, we found general cardiology fellowship websites were the first available link on Google 83.5% of the time, with an average position for those websites on Google at 1.25.Program informationNearly all fellowship programs provided a program description (95.4%) and most of those programs also included a program director (92.6%). However, contact information and available access to the program was lacking. The phone number was widely given (96.3%); however, the hospital address was given by only 195 of the 219 (89%), and email information was only given by 204 (93.1%). When evaluating the data for current and past fellows, we found that programs provided their current fellows 68% of the time, and only 64 programs discussed past alumni (29.2%). Table Application processWhen evaluating the number of programs that provided links to the ACC or AHA websites, only 47 of the programs provided us with a link 21.4%). Of the 219, 195 provided information on the application process (89%) and 147 programs provided a deadline (67.1%). Fellowship salary was provided in 64 of the programs (29.2%). Table 1.4%. Of Education servicesDidactics were provided by 170 of the programs (77.6%) and a rotation schedule of some kind was provided by 139 programs (63.4%). Only 128 programs mentioned/provided links to current clinical trials or current program research (58.4%) and information regarding journal club was provided by 153 programs (69.8%). Information regarding research meetings and conferences was available in 139 programs (63.4%). Table Cardiovascular disease is currently the leading cause of mortality in the US, with the current estimation by the CDC being 610,000 deaths per year, roughly one in four deaths in the US . AccordiUsing ERAS, we evaluated 219 general cardiology fellowships after dismissing 12 websites for broken links and general lack of any content available (5.2%). Google search proved to be the best way to locate available programs (95.4%), with the average position of the program link at 1.24. Of the programs that were available to review for content, we learned that a majority of those programs included a program description (95.4%) and program director (92.6%). Contact information was generally available, as either a phone number or email was provided. However, even though the program director’s name was generally available, current and past fellows were not . Similar studies in other specialties, including orthopedic trauma surgery, abdominal transplant surgery, and abdominal radiology fellowships, also demonstrated a lack of key information on their program websites. The number of applicants finding their information online is increasing, and this lack of content may prove deleterious to programs attempting to recruit the best applicants. When compared to our study on cardiology websites, this lack of information appears to trend through the studies previously described. A total of 17% of abdominal transplant surgery websites lacked contact details like phone numbers and emails  when comProgram websites lacked general content and provided minimal information about their application process or educational services for prospective applicants. Application process was discussed by 89% of websites but only 21.4% of those websites provided a link to the ACC/AHA websites. Deadlines for applications were only provided by 67.1% of websites. Other data collected included educational services and research opportunities provided. Didactics and clinical schedules were provided in less than 80% of the programs listed. Much of the content regarding didactics and information on included board prep had minimal. Research meetings and conference was provided by 63.4% of programs and only 58.4% of programs included current research/clinical trials.Our data does not show a total lack of general content provided by program websites, especially when compared to other fellowships reviewed in this paper. However, this study does highlight the discrepancies in information that exist. There is potential for access to better information in application processing and educational services.Based on these analyses, we have developed a series of proposals to aid prospective fellows and fellowship program choose their desired applicant and program. First, websites should contain a description of the program followed by a picture and contact information of the program director. This will ensure that applicants know what the program is offering as well as the ability to contact the program director easily from the home page. Too often contact information is hidden behind multiple pages or links that limit ease of access for applicants with poor internet connections. Second, tabs/links about applications and requirements should be provided on one page. This decreases the amount of time applicants will be changing pages and increases ease of access to program content. Third, programs should inform applicants of the research opportunities that will be provided. This increases the likelihood of highly qualified applicants passionate about clinical research applying once they recognize a program's participation in research. Lastly, we do not recommend having a single page with all the program information as it increases website load time, increases clutter, and decreases accessibility to find specific information. A study by Portnet on e-commercial retail found that after the first one to two seconds, the conversion rate (buying a product) decreases by 0.3% per second and that "load speed for product category pages has the most impact on sales" . For loaIn conclusion, these data suggest general cardiology fellowships have a paucity of general content and accessibility provided online, which may pose a challenge to match applicants with desired programs. Multiple studies have shown that applicants find a majority of their fellowship information online and use that information to decide where to apply. Due to the ongoing pandemic it is vital that fellowship programs, including cardiology programs, have a strong online presence to recruit prospective fellows.


The prevalence of anxiety, depression, and general distress has risen in recent years. Mobile mental health programs have been found to provide support to nonclinical populations and may overcome some of the barriers associated with traditional in-person treatment; however, researchers have voiced concerns that many publicly available mobile mental health programs lack evidence-based theoretical foundations, peer-reviewed research, and sufficient engagement from the public.This study aimed to evaluate the feasibility, acceptability, and preliminary outcomes of Noom Mood, a commercial mobile cognitive behavioral therapy– and mindfulness-based program.In this single-arm prospective cohort study, individuals who joined Noom Mood between August and October 2021 completed surveys at baseline and 4-week follow-up. Per-protocol analyses included those who completed both surveys (n=113), and intention-to-treat analyses included all participants (N=185).P<.001). Participants reported benefiting most from learning skills , interacting with the program features, and gaining awareness of their emotions and thought patterns. Participants also made a number of suggestions to improve product functionality and usability.A majority of the sample reported that the program is easy to use, they felt confident recommending the program to a friend, and they perceived the program to be effective at improving stress and anxiety. There were significant improvements in anxiety symptoms, perceived stress, depressive feelings, emotion regulation, and optimism in both the per-protocol and intention-to-treat analyses (all Results suggest that Noom Mood is feasible and acceptable to participants, with promising preliminary outcomes. Future studies should build on these results to evaluate the effects of Noom Mood using more rigorous designs. The World Health Organization stresses the importance of mental health, which they broadly define as a state of “well-being in which an individual realizes his or her own abilities and can cope with the normal stresses of life” . Many inAlthough a number of empirically supported treatments for mental health difficulties are available, myriad barriers exist that make it difficult for many people to access traditional in-person support, including cost, long waiting times to see providers, and limited provider availability, especially for individuals living in remote areas -15. The In recent years, there has been a proliferation of interest in and development of mobile mental health programs. Use of these programs has tripled in recent years , and mulDespite this proliferation of readily accessible mobile mental health programs, researchers have raised several concerns that merit attention and that can be viewed through the lens of implementation science  ) -43. Impo [MBSR]) ,44; howe [MBSR]) . More sp [MBSR]) ,46,47, N [MBSR]) . Noom Mo [MBSR]) -50. Spec [MBSR]) ,51,52. O [MBSR]) .The first step in evaluating any new mHealth platform is to investigate stakeholders’ views on the feasibility and acceptability of the proposed product ,50. FeasThe primary goal of this study was to evaluate the feasibility and acceptability of Noom Mood, as well as to gather preliminary data on whether the program might be associated with improved well-being. We hypothesized that users would find the platform to be feasible and acceptable. Furthermore, we hypothesized that participants who used the program would report some benefit in terms of improved anxiety symptoms, stress, depressive feelings, emotion regulation, and optimism by the end of the 4-week study.A single-arm prospective cohort design was used to test feasibility and acceptability of Noom Mood, as well as initial symptom and well-being outcomes.The study was approved by the Advarra Institutional Review Board (protocol No. 00055306).Participants were recruited from the pool of individuals who had voluntarily signed up for the Noom Mood program. A randomly selected subset of adults who voluntarily enrolled in the Noom Mood program between August and October 2021 were invited to participate. All participants provided informed consent prior to participation. Inclusion criteria for participants were as follows: located within the United States, English speaking, and aged 18 years or older. Participants were invited to complete the baseline questionnaire within 1 business day of signing up for the Noom Mood program. Those who completed the baseline questionnaire were invited to complete the follow-up survey 4 weeks later. Study completers were compensated with a US $20 gift card for their participation. Participants did not receive the program for free during or after the study. The entire study occurred remotely, including online administration of surveys via email.The Noom Mood program was deployed as described above. At the time of this study, approximately 15 psychoeducational articles were presented to participants each week. In addition to the curriculum, participants had access to mood-logging features, and they were encouraged by coaches to engage in the curriculum and to log their mood once per day.Feasibility was assessed at 4-week follow-up.The System Usability Scale (SUS)  is a 10-As in past work , feasibiAcceptability was assessed at 4-week follow-up. The Credibility and Expectancy Questionnaire (CEQ)  is a 6-iWe asked the following open-ended questions: (1) What is the main benefit you received from Noom’s stress and anxiety management program? (2) How can we improve Noom’s stress and anxiety management program for you? (3) What was the most helpful part of the program? and (4) What was the least helpful part of the program? Because of the variety of answers possible, content analysis was used to code each response into categories and calculate the percentage of responses allocated to each category. The categories were created using latent Dirichlet allocation (LDA), a machine learning approach for automatic clustering of text data . LDA is Symptom and well-being outcomes were assessed at baseline and 4-week follow-up.The 7-item Generalized Anxiety Disorder scale (GAD-7)  is a 7-iThe 4-item Perceived Stress Scale (PSS-4)  is a 4-iThe 8-item Patient Health Questionnaire depression scale (PHQ-8)  is an 8-The Difficulties in Emotion Regulation Scale–Short Form (DERS-SF) ,66 is anThe Life Orientation Test–Revised (LOT-R)  is a 10-t tests were conducted to evaluate changes on all quantitative variables from baseline to week 4. Both per-protocol and intention-to-treat analyses were conducted. The per-protocol sample consisted of participants who completed both assessments (n=113) and included those who started the program but stopped using it. Intention-to-treat analyses included data from all participants who began the study (N=185); baseline scores were carried forward for participants who did not complete the week-4 assessment. Effect sizes were calculated using Cohen d [Analyses were conducted in SPSS software . For acceptability and feasibility, survey responses were descriptively analyzed with mean scores and percentages of participants that chose each response. For open-ended acceptability responses, content-analyzed categories are presented descriptively with the percentage of responses that fall into each category. Descriptive statistics were also conducted for engagement measures to evaluate feasibility. For preliminary outcomes, paired 2-tailed  Cohen d .Participants’ demographic characteristics are presented in Responses to the SUS are presented in Program engagement data are presented in Responses to the CEQ are presented in Responses to the Program Satisfaction Questionnaire are presented in For potential areas of improvement, most participants did not provide a response or indicated that they had no suggested improvements . The next most common response was “other” , or participants requested a new feature or program idea . “Other” responses included increasing the frequency of reminders, expanding areas of content , and slowing the pace of tasks. Participants also preferred a lower cost , with some mentioning the potential to be reimbursed, as well as a more personalized experience  and greater flexibility , such as the ability to progress while skipping articles, accessing future articles, or repeating an activity for another week.When asked to describe the least helpful parts of Noom Mood, most participants did not provide a response . The next most common response was “other” ; responses noted that the program contained too much repetition and that the pacing of the program needed improvement. Lastly, some participants  described coaching as the least helpful aspect of the program, noting that they would prefer to interact with a coach with specialized expertise or to receive more personalized responses.112=10.92, P<.001, d=1.03) and intention-to-treat samples  with large and medium effect sizes, respectively. There was also a significant improvement in perceived stress  and depressive feelings  with medium effect sizes. Finally, there were significant improvements in emotion regulation  and optimism  with small to medium effect sizes. From baseline to 4 weeks, there was a significant reduction in anxiety symptoms for both per-protocol samples  and effective at reducing stress and anxiety (76%). Importantly, 81% of participants felt confident in recommending the program to a friend. These findings are similar to other studies of mobile mental health programs and suggest that the program was perceived to be acceptable to users ,70,73. AParticipants reported benefiting most from skills training; program features such as articles, activities, and coaching; learning to better manage their emotions; and reflective processes such as learning, reflecting, and increasing their awareness. Participants reported benefiting from taking the time to reflect on how they were feeling and increasingly becoming aware of their emotions and thought patterns. Many participants also mentioned benefiting from the structure and accountability of a designated program. Participants appreciated the overall tenor of the program; one participant reflected that “the attitude it strikes is a great balance of cheeky humor but realistic so it’s not overly strict nor overly cheesy. Makes me connect with it well and stick with it.” Other participants, however, reported that they hoped for a more serious tone to the articles. At the time of the study, the program incorporated jokes and hashtags for the sake of relatability, and has since been modified in response to participant feedback. Participants also indicated that the program could be improved to better help individuals progress in a way that best suits an individual’s idiosyncratic wants or needs. For example, some participants wanted a slower pace, whereas others requested more daily reminders. Additionally, some participants provided feedback that they wanted more specialized interactions with coaches. While individuals were informed that Noom Mood is not a replacement for therapy and does not provide clinical assessment or treatment, it is possible that participants were expecting the coaching feature to function more similarly to therapy. However, some participants provided feedback stating that responses given by coaches did not feel personalized and felt too generic. It is also possible that some participants may not have been good candidates for a self-help approach. As mentioned previously, in the literature, there is limited understanding of how participants would experience a commercial mobile mental health program with personal coaching, rather than therapy. This study contributes initial understanding that, in this context, coaching can be helpful, but it can also raise confusion about the role of a coach when providing guidance and support rather than therapy. Future iterations of the program should, thus, be sure to set expectations for this feature clearly. Participants also relayed some suggestions for program improvements that would provide support in varying environments or situations, such as support for moms with young children, skills to reduce procrastination, video and audio recordings, and easily accessible summaries of activities or articles, all of which should be considered in future programs. Since the time of the study, audio recordings have been added to the program. Some participants reported that they would prefer that the program be offered at a lower cost, and some mentioned they would like the program to be covered by health insurance plans. In order to increase accessibility, future initiatives and programs should consider efforts to provide reimbursable experiences .d=1.03) in per-protocol analyses and 23% (d=0.70) in intention-to-treat analyses. In addition, stress reductions were 21%  and 13% , and depressive feelings decreased by 33%  and 22% . These effect sizes are comparable to those reported in studies of other mobile mental health programs with the same study length and outcome measures [From baseline to 4 weeks, anxiety symptoms improved by 36%  and 8.6% . Emotion dysregulation is hypothesized to underpin a wide range of psychological difficulties [In this study, we found that emotion regulation improved by 14% . To our knowledge, this is the first mobile mental health study to measure changes in optimism, though some studies of mobile mental health programs have found improvements in other positive psychological constructs, such as life satisfaction, general mental well-being, or quality of life [We found significantly higher optimism at 4 weeks compared to baseline . In addition, other interventions were uncontrolled; that is, program participants may have been participating in active therapy or may have been taking psychotropic medications while they were participating in this study. Nevertheless, it is unlikely that these findings are purely spurious, as the effect sizes are similar to those found in active treatment groups in RCTs, and they are much larger than those found in control groups . Now thIn this study, we explored the usability, feasibility, acceptability, and preliminary effectiveness of Noom Mood, a publicly available, mobile mental well-being program based on CBT and MBSR with personal coaching. The program follows 11 of Bakker et al’s  evidence


Social medias are seen as a risk factor for mental health because they increase body dissatisfaction and decrease self-esteem. This program is based on alimentation and physical well-being by relying on integrated intuitive eating and physical self-esteem. This program, implemented in a community setting use social media (i.e. Instagram-Loricorps), is composed of 12 monthly 180-second video capsule that address themes related to the promotion of body sensations and intuitive movement.The main objective of this study is to evaluate the effects of the program into the physical environment targeting the physical self-perceptions (PSP). Specifically, this study evaluates whether the eSILENCE 1.0 Program improves the level of PSP related to nutrition and explores the changes in the level and variability of the PSP.This project is a mixed sequential explanatory study. 300 participants  are targeted. Online nomothetic questionnaires evaluate occupational changes and PSP in relation to alimentation and are completed by the EG and the CG at pre-test, mid-test and post-test. Online idiographic questionnaires assess PSP and are completed by the EG before and after each video capsule and by the CG once a month without viewing the capsules. Following a preliminary analysis, a focus group will be formed to explain and deepen these results. Participants (N=5) will be recruited voluntarily into the EG.to come.Analysis of quantitative data will be used to assess the effectiveness of the program and analysis of qualitative data will provide an in-depth understanding of the linkages between the variables.No significant relationships.


Remote cardiac rehabilitation (RCR) after myocardial infarction is an innovative Israeli national program in the field of telecardiology. RCR is included in the Israeli health coverage for all citizens. It is generally accepted that telemedicine programs better apply to younger patients because it is thought that they are more technologically literate than are older patients. It has also previously been thought that older patients have difficulty using technology-based programs and attaining program goals.The objectives of this study were as follows: to study patterns of physical activity, goal achievement, and improvement in functional capacity among patients undergoing RCR over 65 years old compared to those of younger patients; and to identify predictors of better adherence with the RCR program.A retrospective study of patients post–myocardial infarction were enrolled in a 6-month RCR program. The activity of the patients was monitored using a smartwatch. The data were collected and analyzed by a special telemedicine platform. RCR program goals were as follows: 150 minutes of aerobic activity per week, 120 minutes of the activity in the target heart rate recommended by the exercise physiologist, and 8000 steps per day. Models were created to evaluate variables predicting adherence with the program.P=.002). Specifically, the older adult group improved from a mean 8.1 (SD 2.8) to 11.2 (SD 12.6). The metabolic equivalents of task (METs) and final MET results were similar among older and younger patients. During the entire program period, the older adult group showed better achievement of program goals compared to younger patients (P=.03). Additionally, we found that younger patient age is an independent predictor of early dropout from the program and completion of program goals (P=.045); younger patients were more likely to experience early program dropout and to complete fewer program goals.Out of 306 patients, 80 were older adults . At the end of the program, there was a significant improvement in the functional capacity of all patients (Older adult patients demonstrated better compliance and achievement of the goals of the remote rehabilitation program in comparison with younger patients. We found that older age is not a limitation but rather a predictor of better RCR program compliance and program goal achievement. Cardiac rehabilitation (CR) is essential for comprehensive cardiac care, as it prevents future heart-related complications which often result in hospital readmissions and death ,2. DespiIt is generally believed that older adults (>65 years old) struggle to use newer technologies. Various factors such as age-related cognitive impairment, vision or hearing difficulties, short-term memory loss, and physical limitations contribute to this assumption. Additionally, older adult patients have a preference for in-person communication with their physicians, resulting in a lower rate of acceptance of new technological applications ,9. FurthHowever, in recent years, there has been an understanding that older people are also willing and able to manage their health using the newest technologies . AlthougIt is well known that CR is essential for older adult patients due to this population having a higher risk of complications from cardiac-related causes compared to younger patients. However, there are contrasting results in this field of research. Previous studies have shown that older age is associated with a lower likelihood of participation in remote CR , while oOur goal is to further expand this area of research by comparing the adherence and program goals achievements between older and younger patients. The objectives of this study were as follows: to study patterns of physical activity, goal achievement, and improvement in functional level among patients over 65 years old undergoing RCR and compare them to those of younger patients; and to identify predictors of better adherence with the RCR program.The CR program is based on national guidelines provided by the Israeli Heart Society, specifically for comprehensive CR and the specific goals. A detailed description of the program and the Datos Health platform powering our RCR program was published previously . In shorOver the 18 months of the program's existence, we collected data on behavior patterns, training, and goal achievements from the first low-risk group of 306 patients rehabilitating under the RCR program at Sheba Medical Center in Israel. The participants of the group were both young and older adult patients. The collection of information and analysis were carried out retrospectively. The program goals were the same for all individuals regarding monthly exercise minutes , and the exercise intensity was derived from the results of the exercise test reflecting the age-dependent maximal heart rate. Resistance training sessions and repetitions were similar but with individualized resistance. Basic characteristics, including a complete medical history, risk factors, and laboratory tests were collected. Training patterns were obtained by the smartwatch and then analyzed prospectively by the platform for 24 weeks. Improvement of an individual’s functional capacity was assessed as the change between the first (prerehabilitation) and the second (following 3 months of rehabilitation) exercise stress test (ergometry)–estimated metabolic equivalents of task (METs). Satisfaction with the program and the care received were assessed using a digital questionnaire.The primary end point of the study was to determine the difference in adherence to the RCR program goals among patients over 65 years of age compared with younger patients. The following variables were evaluated longitudinally in each month of the exercise program: the number of minutes of aerobic exercise (aerobic minutes), the number of aerobic minutes in the target heart rate, the assessment of perceived Borg scale, the number of daily steps, and the use of the RCR mobile app (number of weekly entries). Secondary end points included the improvement in functional capacity, the number of training sessions, and the satisfaction with the RCR program overall.All required ethics board approvals for this study have been given by the Sheba Medical Center committee .t test or Wilcoxon signed-rank test was used according to the data distribution to assess the differences between baseline and program completion values for the entire group and for age-stratified subgroups. A logistic regression model was constructed using the best subset method in order to determine independent predictors of selected program goals. The following covariables were introduced: age, sex, prerehabilitation METs, and indication for CR.Descriptive statistics are presented according to variable characteristics and normality assumption evaluation. Baseline characteristics are presented as median, mean and SD, or percentages as appropriate. Group comparisons were performed according to data type and its respective distribution. A paired sample P value <.05 was considered statistically significant. Tests were 2-sided. Statistical analyses were performed using R statistical software version 4.1.2 .A P=.01). The median number of total minutes of aerobic training for 6 months was 183 minutes per week in the entire population. The older adult group achieved 222 minutes, whereas the younger group achieved 168 minutes (P=.003). P=.007).The study included 306 patients, 26.1% (80/306) of whom were over 65 years old. Detailed characteristics of the group are summarized in P=.001). Interestingly, prior to RCR initiation, there was a significant difference between the older adult group and the younger group in the baseline exercise capacity as expressed by METs (P=.002). However, this difference disappeared after 3 months of RCR.P=.03). The basic characteristics of patients who achieved the main goals versus those who did not during the third month of the program were also evaluated. Other than age, there was no significant difference between the groups of those who achieved versus those who did not achieve these goals. Older patients had significantly better completion rates of the three program goals: (1) completion of the full 3 months of RCR—the average age in the group of those who completed the program was 58.5 years while the average age of those in the group who dropped out was 55.5 years (P=.044); (2) achieving at least 600 aerobic minutes per month—the age of those who achieved this goal was 60 years while the average age of those who did not achieve this goal was 55 years (P=.001); (3) achieving at least 400 minutes per month of training in the target heart rate—the average age of those who achieved this goal was 63.7 years while the average age of those who did not achieve this goal was 56.9 years (P=.001).P=.007) and completing at least 400 minutes per month of training in the target heart rate .A logistic regression model was constructed to predict each of the 3 main program goals. Higher age was consistently an independent predictor of achieving the RCR aerobic exercise goals of completing at least 600 aerobic minutes per month .There was no significant difference between older adult and younger patients in the number of daily steps or in the amount of weekly use of the mobile app. However, a significant difference was observed in the number of aerobic workouts per week: the median number of workouts per week in the older adult group was 6.7 versus 3.7 in the younger group (Over 85.9% (263/306) of patients reported feeling safe and satisfied with RCR, and 83.9% (257/306) of patients answered that the program helped them maintain a healthy lifestyle.The principal findings of our study are the following: participants of the RCR adhered to the program and most attained the prespecified goals, older adult patients had higher compliance and were more likely to reach RCR goals compared to younger participants, and older adult patients had a significant absolute improvement in functional capacity assessed objectively by the stress test.Previous studies have mentioned factors such as preexisting health conditions and lower physical functioning as additional barriers which make older adult patients unable to benefit from CR compared to younger patients . HoweverA common misperception is that older adult people (>65 years old) are hesitant to accept new technologies. Several studies state barriers such as lack of knowledge or fear of misusing remote CR technology . HoweverThe strength of this study is that it is the first and exclusive study of a new national telerehabilitation program fully subsidized by the Ministry of Health. Moreover, the analysis carried out in this study covered a relatively large cohort of patients and carefully analyzed multiple aspects of their performance over a 6-month period. Nevertheless, our study has a number of limitations. First, it used a retrospective design and included a relatively low risk population, with most of the participants being men. This is unsurprising, as secondary prevention treatments are underused in women with coronary heart disease . Second,Multicenter prospective research is necessary in order to assess the generalizability of these findings. Furthermore, now having an understanding of the successful implementation of the program even among low-tech older adult people, we further seek to expand the implementation of telerehabilitation usage among patients at medium and high risk, for example, patients with heart failure. The recent experience of the COVID-19 pandemic has further emphasized the importance of implementing telecare for all types of patients without exception.Our study showed that older adult patients demonstrated better compliance with the remote CR program in most aspects. Higher age was an independent predictor of better compliance with program goals. Given these results, we suggest that CR programs are more suitable for older adult patients than initially thought. However, due to the misconceptions about their ability to use technology, older adult patients remain underrepresented in current remote digital health studies. Future studies need to be conducted to understand this relationship and explore the potential benefit of remote rehabilitation in other fields of medicine among older adult patients.


Culturally grounded after‐school programs (ASPs), based on local cultural values and practices, are often developed and implemented by and for the local community. Culturally grounded programs promote health and well‐being for American Indian and Alaska Native (AI/AN) adolescents by allowing them to reconnect to cultural teachings that have faced attempted historical and contemporary erasure. This article is a first‐person account that describes the development and implementation of a culturally grounded ASP, Native Spirit (NS), for AI adolescents (grades 7–12) living on a Southwest urban‐based reservation. NS, a 13‐session culturally grounded ASP, was developed by an academic–community partnership that focuses on increasing cultural engagement as a form of positive youth development. Each session was guided by one to two local cultural practitioners and community leaders. The development of the NS program contributed to an Indigenous prevention science that emphasizes the positive impacts of Indigenous culture and community on health and well‐being. The use of the ASP format, in partnership with the Boys & Girls Club, increased the feasibility of dissemination and refinement of the NS program by tribal communities and organizations. This study expands the literature on culturally grounded health promotion programs for youth.The Native Spirit program increases cultural engagement as a form of positive youth development.An academic–community partnership developed a culturally grounded program for Indigenous youth.The Native Spirit program may be refined by other tribal communities throughout the United States. American Indian and Alaska Native (AI/AN) adolescents are vulnerable to experiencing health disparities that continue into adulthood , have led to a blatant disregard for AI/AN health promotion approaches, including engaging in cultural practices. In the late 1800s, the US government prohibited the practice of traditional AI/AN religions and thousands of AI/AN children were forced to attend boarding schools that used corporal punishment in an effort to erase AI/AN culture  to promote developmental assets in AI/AN adolescents. A recent literature review yielded 14 studies, published from 2009 to 2020, that evaluated culturally engaged ASPs for Indigenous youth , for AI adolescents living on a Southwest urban‐based reservation, the Salt River Pima‐Maricopa Indian Community (SRPMIC). The SRPMIC has agreed to be named in this article. It uses a first‐person account to detail the community and partnership contexts, program history, and the curriculum development process, and also describes program implementation and the proposed evaluation plan. Finally, this article describes challenges and recommendations to foster success for tribal communities, organizations, and researchers seeking to develop culturally‐grounded health promotion programs. Ultimately, this first‐person account contributes to the literature by detailing the amount of time and effort required to develop, implement, and evaluate a culturally grounded prevention program for AI/AN adolescents. The detailed description combats the narrative that community‐specific interventions are not rigorous and supports placing a higher value on external validity, especially for communities that have been historically underserved and are not regularly represented in research  of Greater Scottsdale in 2015. The BGC of America is a national organization that hosts ASPs to provide a safe and educational after‐school experience for children between the ages of six and 18 years. Of the 60 BGC locations in Arizona, 13 serve AI communities; each is directed either by the larger, local BGC chapter or has started its own free‐standing location under the national organization. In 2018, BGCs in Arizona served 112,883 youth; 10% were AI , a master's student at the time, helped develop the program in 2015. The program was named, “Native Spirit” by the youth and BGC staff. In 2018, the BGC of Greater Scottsdale expressed interest in refining the program to fit two of their urban‐based reservation locations (SRPMIC). Although the program curriculum was refined, the name of the program was not changed. The SRPMIC prioritized adolescent and community health by providing robust opportunities for cultural engagement. As a doctoral student, I initiated the research process with SRPMIC to begin refining the program. With a small amount of funding through scholarships, I provided meals during the in‐person Community Advisory Board (CAB) meetings and invited CAB members to the recognition ceremony at the end of the program. I also organized and facilitated CAB meetings, recorded the development of the NS curriculum, and developed the NS curriculum into a comprehensive handbook detailing the program's history, curriculum, and logistics. I also coordinated NS session logistics including contacting session leaders, securing locations, and purchasing supplies and food.The SRPMIC is comprised of two ancestral Indigenous groups, the Akimel O'odham (River People) and the Xalychidom Piipaash (People Who Live Toward the Water). The 52,600‐acre SRPMIC, located in Maricopa County in Arizona, was established by Executive Order on June 14, 1879 . Some community members wanted to contribute to the curriculum even if they were not able to serve as session leaders. The SRPMIC has a copy of the curriculum and can make changes as necessary as the community changes.The NS program emphasizes the importance of cultural engagement in health promotion and PYD for AI/AN youth. A PYD framework focuses on individual and community strengths, rather than individual psychopathologies, and adheres to six organizing principles , each community has a different story that is often intricately related to the local flora, fauna, and geographical landscape. The NS program model  can be used in AI/AN communities and remain culturally grounded with proper community refinement and specificity.The SRPMIC CAB started by reviewing the original NS curriculum. They kept all of the existing values but added three values that they wanted to pass on to the adolescents of the SRPMIC: responsibility, teamwork, and service. The CAB then identified local cultural practices that were associated with each cultural value; each cultural practice can be associated with multiple values. However, each program session focuses on one cultural value and one associated practice for the sake of organization and reproducibility in an after‐school format. CAB members then identified local cultural practitioners who would be comfortable leading each of the NS sessions.Language as the first session. This allows the participants to learn how to properly introduce themselves in their traditional language, a task that is considered respectful in many AI/AN communities, and to practice their introductions each week with a knowledgeable leader and with their peers for the duration of the program. The development of the NS curriculum was an iterative process that took place over a six month period during monthly meetings with detailed feedback from CAB members and additional input from session leaders, community members, and tribal council members. Table Finally, CAB members decided on the appropriate order of each session depending on the time of year and specific cultural practice. Although the session order is interchangeable, the CAB promoted NS was developed for use by local youth‐serving ASPs with middle school and high school‐aged adolescents. Each NS session ran for 1.5 hours each week except in weeks with a conflicting holiday or school event . Each NS session, of the 13 sessions available, is meant to be led by one to two people who are cultural knowledge holders and leaders in the SRPMIC. Middle and high school adolescents in the community are combined and regularly interact in ASPs.Recruiting cultural practitioners to serve as session leaders is integral to presenting culturally grounded interventions  assisted with qualitative data analysis, and as a member of the SRPMIC, with expertise in statistical methods, assisted with quantitative analysis. Findings from the Fall 2019 iteration of the NS program are forthcoming.This article describes the development, implementation strategy, and evaluation strategy of the culturally grounded NS program with AI/AN adolescents who are members of the SRPMIC. Throughout this discussion, we offer several takeaways that can be used by public health professionals who want to engage in similar partnerships and research. The use of cultural engagement as a form of PYD is the main focus and strength of the NS program. AI/AN communities share a common experience of traumatic loss of cultural practices, language, life, and land  for their time and expertise. Additionally, we must emphasize that the common goal of increasing cultural engagement in AI/AN communities is to ensure the proliferation of cultural values and practices. Examples of recently developed culturally grounded programs include the Elders' Resilience Curriculum, Ho'ouna Pono, and Qungasvik (Cwik et al., Another recommendation is to ensure there is a continuous effort to evaluate the NS program using Indigenous evaluation methods. The academic–community partnership was vital for developing the NS program and evaluation plan. CAB members who indicated a desire for this program had been identified in the past; however, there was always a need for extra assistance and resources to create a well‐documented program. The academic–community partnership produced some of the needed resources, including administrative support and experience in the creation of ASPs, and the use of evaluation methods. SRPMIC has been committed to sustaining the program since it began. It has coordinated efforts by SRPMIC tribal ASP for adolescents, social services, and the teen girls' program to share the responsibility of offering NS. As a result, more adolescents in the SRPMIC will have access to the program and resources for several years.At this point, NS is fairly small; it has been implemented twice in two tribal communities and has reached approximately 30 adolescents. Standards in prevention science marginalize Indigenous approaches by requiring sample sizes that are unrealistic for culturally grounded interventions (Flay et al., An academic–community partnership successfully developed and implemented a culturally grounded ASP for AI adolescents living on an urban‐based reservation in the Southwest. Documentation of the development and implementation of the NS program contributes to an Indigenous prevention science that examines the impacts of AI/AN culture on adolescent health and well‐being. The accessible and widely used format of ASPs provides opportunities for disseminating the culturally grounded and strengths‐based NS program to BGCs, ASPs in Indian Country, and urban AI/AN organizations across the country.