The purpose of this study was to investigate the influence of an afterschool sport program on adolescents’ life skills development and to identify which characteristics of the program would have an influence on their life skills acquisition. The participants were six children  who participated in a 12-week afterschool program implemented in two elementary schools, as well as the two program instructors who implemented the afterschool sport program. Data were collected from individual interviews with program participants and instructors. The inductive analysis of data revealed four categories of life skills developed through program participation: (1) playing well and being more active, (2) connecting well and having better social skills, (3) coping well and becoming a better problem solver, and (4) dreaming well and having a better sense of purpose. Regarding the characteristics of the program that influenced life skills development, three themes emerged: (1) having a clear goal and building consensus with stakeholders, (2) establishing a firm yet flexible structure, and (3) instructors’ use of effective strategies for teaching life skills. Afterschool hours have been considered as both risk and opportunity for the health and wellbeing of adolescents. The rise of youth risk behaviors such as violence, smoking, drinking, and substance use  approach can be a framework that guides the development of adolescents in sport-based afterschool programs. The PYD is a strength-based approach, focusing on strengths, assets, and competencies rather than focusing on reducing deficits or problem behavior Lerner, . Damon  highlighIn order to capitalize on afterschool sport programs as a context for PYD, the program should have a specific focus and structured opportunity for skill-building in order to develop appropriate relationships with adults , competing player skills , and thriving player skills . The first phase of the program (sessions 1–3) focused on developing life skills for individual students , and then it moved toward the second phase of the program (sessions 4–6), which focused on team-related life skills . After sessions 1–6 were completed, participants learned how to handle pressure, stress, and conflicts in the third phase of the program (sessions 7–9), and completed the program by exploring future plans and setting short and long-term goals (sessions 10–12).A 12-week afterschool sport program called Playing for Fun and Life was designed to teach both life skills and sport skills to adolescents. Given that soccer was one of the most popular sports among Korean adolescents, the program selected soccer as an avenue and context to teach the four areas of life skills: individual player skills , team player skills  overview and purpose of the study, (2) procedure of data collection , (3) risks and benefits, (4) assurance of confidentiality , (5) right to withdraw from the study at any time, and (6) contact details of the primary investigator. The children were also provided with the same information using a child-friendly verbal explanation. Children were informed as to why we were doing this study, what were the positives or negatives that might occur during the study, who would be told the things we learned about them and their peers, what they should do if they changed their mind about participating in the study, and who they should contact if they had any questions. When children agreed to participate, they provided us with their own consent.A total of six children , three from each school, agreed to participate in the study. The average age of the participants was 11.5 years old, and they were fourth and fifth graders in elementary school. In addition, the two program instructors also participated in the study. One of the instructors, Mr. Lee, was a former soccer player and had worked as part of the staff for a youth sport program for life skills development with student athletes as well as a community-based sport mentoring program. The other instructor, Mr. Kim, was an elementary school teacher who had seven years of teaching experience in elementary school and three years of afterschool sport program teaching experience. The two instructors strongly agreed with implementing a sport-based life skills development program in an afterschool setting.Data were collected from individual interviews with children and program instructors and observations of the afterschool program sessions. Children were interviewed twice, before and after their participation in the program. The pre-implementation interview focused on the children’s afterschool activities, motivations to participate in the program, and key personal details. The post-interview focused on children’s life skills outcomes and the factors that influenced their life skills development. The questions for the pre-and post-implementation interviews are presented in The two program instructors were also interviewed pre- and post-implementation of the program. The pre-implementation questions included: (1) specific life skills needs for adolescents, (2) instructors’ philosophy of the program, (3) instructors’ perceived competency in implementing the program, and (4) expected outcomes for the adolescent through program participation. The post-implementation questions focused on identifying: (1) any critical incidents that happened during program implementation, (2) changes of adolescents’ behaviors and attitudes through program participation, and (3) specific strategies used by instructors for teaching life skills. All interviews were recorded on a digital voice recorder and transcribed verbatim.The researchers read the interview transcripts repeatedly and made marginal notes to facilitate the initial interpretation of the data. After the initial understanding of the data had been reached, the researchers segmented relevant parts of the data for coding  types of life skills developed in an afterschool sport program and (2) characteristics of the program that influenced adolescents’ life skills development. All names used in the Findings section are pseudonyms to protect the identity of the participants.The findings revealed that the afterschool program facilitated the adolescents’ life skills development in the following four areas: playing well, connecting well, coping well, and dreaming well.playing well, refers to skills that deal with being more physically active, improving levels of sport skills, and having fun and enjoying physical activities and sport. Given that sport-based programs emphasize learning about and learning through sport, participants’ commitment to sport is a prerequisite for developing other areas of life skills. The findings revealed that the program changed participants’ use of afterschool hours in more physically active ways by providing structured alternative activities.The first theme, I would say enjoyment is the most important thing. I couldn’t enjoy playing soccer because I was not good at it. I once mistakenly shot the ball into our own team’s goal, and my friends blamed me a lot for that. But here I learned skills like dribbling, passing, and shooting, and I found that it was really fun to play soccer with friends because I can play better than before.For example, when asked about his typical afterschool activity, a fifth-grade boy, Yubin, said, “I play computer games or play games with my smartphone because I don’t have anything special to do.” Through participating in the program, the inactive and unproductive use of his afterschool hours has been substituted with sport-related activities. In addition, participants perceived that their skill level had improved and they came to enjoy sport because their enhanced skill levels gave them better chances of playing sport with others. When asked what she learned in the program, a fourth grade girl, Chaemin said:The acquisition of “playing well” skills was facilitated by creating synergies between sport skills and life skills. For example, a fifth-grade boy, JaeYoung, commented on the benefit of learning life skills integrated activities: “Here I was more into soccer and had more fun because each week we have a theme to learn, like a life skill, and it gave me the feeling that I was learning something important besides soccer skills.” In addition, participants had a better chance of practice within a more positive program atmosphere due to the fact that the program emphasized life skills such as respect, teamwork, and fair play.Before I came to the program I just played the game without thinking. When the teacher asked me to meditate with my eyes closed, I used to chat with others with my eyes open. After I learned how to stay focused, I kept repeating what I should do as I learned here, and it worked even during PE classes.The program instructors emphasized the importance of feeling deep enjoyment and staying focused on the activities as a way to teach “playing well” skills. At first, students were easily distracted from the program and they checked their smartphones even during the game. The program instructors asked the students to recite the goal of the task and verbally repeat the cues of skills in order to enhance the concentration of the participants. A participant, Donghan, reported that these techniques not only helped him to stay focused on the task but they also helped him transfer these skills into a different, but similar context:Developing the skills for playing well was also related to the contextual characteristics of afterschool programs. For instance, the instructors would say, “We don’t have a test or exam here” and “We have more freedom here than in school PE.” Unlike regular curricular activities, the afterschool program had more flexibility in terms of structure and choice of content. These contextual characteristics helped the students be more committed to the program and be more motivated to learn and enjoy the program.connecting well, refers to the skills related to working with and working for other people. Given that most of sport activities require teamwork and intensive interaction with other people, sport worked as a good medium to teach life skills. For example, Ingang explained how he learned the importance of caring for others when he learned passing skills:When we practiced passing skills, Mr. Lee said, “Passing is the act of caring. You have to think where your teammate is and show that you care for him so that he can receive it well.” If I give a good pass, then my friend will give me back a good pass. It is same when we talk to other people. We have to think about other people’s feelings before we say something. When we pass along some nice words to others, then they will return nice words to us. I think it is the key to getting along with others.The second theme, I used to play just to win, but here we were supposed to help others and pass the ball to others before shooting for a goal. It made me feel closer to my friends and I learned the importance of working together.Participants also reported that they learned the importance of teamwork and cooperation through soccer activities. It is achieved through emphasizing the value of teamwork and cooperation rather than competition and winning. Regarding this, JaeYoung, a fifth grade boy, commented:In order to connect well with others, participants also learned how to communicate with others through a structured game play provided by the instructor. For example, Mr. Kim designed a game called silent soccer so that participants could experience the importance of active listening and respecting other people’s feelings and thoughts. Commenting on how she learned communication skills, a fourth-grade girl, JS said, “When we played silent soccer, it was really frustrating because we couldn’t talk. We had to focus on other people’s gestures and signals and become more sensitive to other people’s feelings to work as a team.”I learned how to get along with others here. I felt like, “Aha! This is the way to get along with others.” I had to listen to others, show that I cared for them, and be a good example. When I became a class president, I took the role just like playing a soccer game in the field. I closely observed my friends, listened to them, and did something when it was needed before being asked to do. When I acted like that, they liked me and happily followed me.The skills of connecting well with others have been transferred to participants’ other areas of life such as school. For example, Ingang reported how he found the applicability of life skills learned in the sport context to the classroom as follows:Given that participants spent their afterschool hours in individualistic activities such as watching TV or playing computer games before they joined the program, the development of connection skills has crucial importance in adolescents’ lives. The participants’ acquisition of connection skills was related to (1) the characteristics of afterschool programs, which provided ample opportunities to interact with participants from diverse age groups, and (2) the characteristics of a team sport and the instructors’ intentional use of specific strategies, such as structured game play to develop life skills.coping well, refers to the life skill required to deal with stress, problems, or conflict in a constructive way. The pre-implementation interview with participants showed that participants’ coping with stress was rather destructive and lacked specific strategies. For example, when asked how he responded to stressful situations, Yubin said, “I yelled at others and showed my anger so that they wouldn’t talk to me anymore.” The rest of the participants reported that they responded to stress by crying, punching pillows, or eating sweets.The third theme, When we practiced soccer shooting, Mr. Kim asked us to shout, “Stress, kick out!” whenever we kicked the ball. It made me feel better and I decided to play sport when I get stressed rather than playing a computer game. I also learned to use deep breathing and say a positive thing to myself, such as “All is well” when I was stressed with a math exam.However, participants reported that they came to have better coping skills through afterschool sport program participation. The program not only provided specific tools but also provided an alternative context and activities to deal with stress and problems. For example, when they were stressed with an exam or test, participants applied specific coping strategies such as deep breathing or self-talk, which were both learned in the program, to handle their stress. In addition, they used sport as an alternative activity to release stress rather than eating or playing computer games. Regarding how she changed her approach in dealing with stress, Chaemin commented:When people made mistakes, I used to blame others for not doing well, and sometimes it ended up with a fight. Mr. Lee taught us how to build up others instead of blaming them. He said, “Build up others, don’t blame others.” We repeatedly practiced, “It’s OK. You can do better next time” whenever someone made a mistake. I used it in my PE class when a friend ran to the third base instead of the second base. Although he made three outs, I said, “It’s all right. It’s just a game. You will do better next time.” I found that it made me feel better and my friend also thanked me for my encouragement. When I made a mistake, I said the same thing to myself and it made me feel more comfortable.Participants also reported that they learned how to respond to their mistakes or the mistakes of others in a more constructive way. Given that sport experience provided vivid examples of dealing with mistakes and failures, the instructors used these opportunities to teach how to encourage others as well to be resilient in the face of their own failures or mistakes. Regarding how he learned and applied coping skills to a similar context, Ingang said:In addition, participants developed coping skills, which were related to dealing with winning or losing in competition. Initially, they equated winning with success and losing with failure. However, their perceptions have now changed because they have been exposed to the idea of learning how to be a good loser and a humble winner. Regarding how he changed his attitude to deal with win and loss in the game, Donghan said, “I always wanted to win because winning tastes sweet and losing tastes bitter. But Mr. Lee said we should put forth our best effort and should not lose heart because there will always be other games.”In order to develop adolescents’ coping skills, the program instructors put a strong emphasis on life skill development rather than just teaching how to play sport well. Regarding the importance of coping skills, Mr. Lee said, “For these children, learning about how to resolve conflicts or cope with difficult situations is more important than winning the game because they are not elite athletes. They need life lessons, not victories.” The adolescents’ acquisition of coping skills was possible when the instructor had the clear philosophy and intention to teach life skills in the sport program.dreaming well, refers to skills that are related to exploring future lives and setting specific goals to achieve a future dream. The pre-implementation interview revealed that participants had a very vague notion of a future image of their lives. For example, when asked to list a few career options, Donghan said, “I wanted to be a police officer, but now I want to be a president.…I want to be in the highest position and make lots of money.” Yubin’s description of his future dream was not much different: “I want to be a pro-gamer because it looks cool to be a good gamer and they make lots of money.” These comments showed that participants did not have the structured opportunities and appropriate information needed to explore their future careers.The fourth theme, Although it was a basic level of exploration, participants reported that they had an opportunity to think more specifically by examining their own strengths and weaknesses. For example, Chaemin reported:I only thought that I should study hard to achieve a dream. But here we were asked to think about our strengths and weakness, and Mr. Kim said that we need to turn our weakness into a strength in order to achieve a dream.Another participant, Ingang, also addressed the importance of specific efforts to explore self and future careers by stating that, “I learned that preparing for a job means more than studying hard. I should know what I do well, what I like, and what kind of jobs are out there.”Because the goal of this program is to develop life skills rather than win at the competition, I was able to share with them their future dreams, what they like, and what they can do well. I think asking them to write down their dreams, change the dreams into specific goals, and take time to think about what they should do, on a daily basis, was helpful to them.Unlike elite sport programs, which pressure students to win in the competition, the afterschool sport program provided an opportunity for the participants to share their lives and future dreams, which facilitated career exploration skills. Given that participants had limited social capital to explore future lives, the afterschool sport program instructors played an important role in helping them transform their vague and simple notions of future aspirations into more specific life skills. Regarding this Mr. Kim said:Three themes emerged regarding the characteristics of the program that influenced adolescents’ life skills development: having a clear goal and building consensus with stakeholders, establishing firm yet flexible structure, and instructors’ use of specific teaching strategies.Although it is offered during afterschool hours, afterschool sport programs are definitely an educational activity. I have a firm belief that students should learn life skills because those are what they need in their lives. They need skills for promoting health, having empathy toward their friends, and getting along with others. I focus on long-term goals so that they can obtain and use life skills in their future lives.The two program instructors commonly reported that they had a clear goal in teaching life skills in an afterschool sport program. For example, Mr. Lee, expressed his opinion that afterschool programs should be both educational and life skills oriented so that it can have transferrable and sustainable impacts on adolescents’ future lives. Explaining his teaching philosophy in the afterschool program, Mr. Lee revealed:When I recruit members, I explained the goals and intention of the program. I want to recruit members who understand my philosophy. Parents showed more interest in the program when I told them I will focus on life skills as well as sport skills. Although they didn’t know exactly what life skills were, they seemed to understand the importance of developing positive qualities in addition to sport skills. When parents understand and have trust in the program, they tend to be more supportive of what we are doing here.Another instructor, Mr. Kim, reported that he clearly communicated his intention and program philosophy with parents and adolescents in order to build a consensus with them. The program instructor perceived that teaching life skills should be intentional and also require mutual understanding both from parents and adolescents in order to obtain appropriate support. Commenting on how he built a consensus with stakeholders, Mr. Kim said:In addition, the program instructors constantly emphasized the goal of the program so that participants internalized the value of learning life skills. The instructors admitted that implementing the life skills oriented program took time because participants were accustomed to traditional sport programs organized around game play and skill practice. Regarding this, Mr. Lee said, “At first, children wanted to play games rather than learn life skills. Although it was difficult, I constantly emphasized life skills. Eventually, they took pride in themselves because they were learning these life skills.”When program goals and philosophy were clearly communicated, participants reached a consensus with program instructors. For example, when asked what was the most important thing learned in the program, a fifth-grade girl, Chaemin, said, “Mr. Kim used to say that when we learned only sport skills, we got only a half out of the program. He told us we have to learn life skills so that we can use them anywhere and anytime.”The two program instructors commonly addressed the importance of a systematic and structured experience for adolescents’ life skills development. To establish a program structure, the program instructors reported that they clearly communicated what was expected by setting up rules in the program. The rules provided a boundary of acceptable behavior and also helped participants establish a positive atmosphere in the program. When asked what is expected in the program, a fifth grade girl, JS, commented, “Here we can do whatever we want, but there are some rules to follow such as no trash talking, playing fair, and always encouraging and respecting others.”Because sport is very dynamic and active, children can easily get excited and lose self-control. That’s why we need a clear boundary here. When they break the rules, I usually go back to the rules of the program and asked them to think about what rules they broke and to think about the consequences of their behavior. Sitting down and having time to talk with children helped them cool down and also reminded them of the importance of the rules of the program. I think there is actually a good chance to teach life skills because some of the rules are very similar to the life skills.The program instructors not merely established the rules but also constantly reminded them of the guidelines during the program. When participants broke the rules, the instructors revisited the rules and provided an opportunity to reflect on their behavior. Consequently, the instructors used this process as a teachable moment for teaching life skills. Regarding how he used the rules as a tool for teaching life skills, Mr. Lee said:I think an afterschool sport program is the best place to learn autonomy. I can decide what to do and how to do it with my students. In this sport program, we have regular meetings and they decide who will draw lines on the playground, who will lead the warm-up exercise, and who will manage the equipment. All these are great opportunities to experience feelings of autonomy.Besides setting up a clear boundary, the program instructor also provided adolescents with an opportunity to take responsibility and experience a sense of autonomy. Given that this afterschool program had more flexibility in terms of content and structure, the program instructor capitalized on it to promote adolescents’ sense of autonomy. Regarding this, Mr. Kim said:I learned soccer in other places but they did not give me many choices. Here I had more freedom and fun. We could choose either to practice alone or work with others. I found that I learned better when I worked with others with encouragement and cooperation. I would never know that I was good with friends if I did not have a chance like this.When adolescents were provided with a sense of autonomy, they used this opportunity to explore how they could learn life skills better. In addition, the participants developed positive reactions such as happiness, encouragement, and cooperation within the context of the autonomous program. The following comments from Ingang showed that adding choices and flexibility to program structure strengthened and deepened his life skills acquisition through self-discovery:The findings indicated that adolescents needed a firm structure guiding their expected behaviors as well as a flexible and autonomous atmosphere in order to take ownership of their life skills learning experiences.I usually make a short and simple phrase to make it easier to understand. For example, when I teach a life skill such as team spirit, I ask them to recite “One for all, all for one.” By reciting the phrase while they practiced, they came to understand not only the meaning of it but also when and how to use it.The program instructors applied various strategies for adolescents’ life skills development. In order to teach life skills, the program instructors translated the meaning of life skills into the children’s level of language. Providing a simple yet clear definition of life skills through a one-liner turned out to be helpful. For example, when teaching the importance of caring, Mr. Lee repeatedly used the phrase, “Passing is the act of caring.” Participants were asked to repeat the phrase when they practiced soccer passing skills, and they were asked to be considerate and to think of the other peoples’ positions so that they could easily pass the ball. Using a one-liner helped participants understand the meaning of life skills and facilitated the practice of life skills in sport contexts. Regarding the use of a one-liner, Mr. Lee stated:Mr. Lee used to say, “Coming passes will be nice if gone passes were nice.” Likewise, when I give a good word to my friend, then he will return a good word to me. Mr. Lee said that relationship and communication are the same as passing skills. When I encourage other people and say something nice, they will also be nice to me.In addition, the program instructors used sport metaphors to teach life skills. Given that sport settings have many similarities to real life situations, the program instructors used sport-related metaphors and stories to teach life skills. Regarding how he learned the importance of good communication skills in relation to soccer passing skills, Ingang explained:When I close each session, I sit down with them and have reflection time with them. I usually ask, “What did you learn today? How can you work on these in your school or home life?” Initially, children talked about sport skills, but as time went on they talked about life skills such as taking care of their health or dealing with stress. I asked them to write a short journal to record what they learned, how they learned, and how to work on it in their school or home. Filling out a simple format of a journal made it easier for them to remember what they learned and how to set goals.The program instructors also used reflection as a strategy to facilitate the transfer of life skills beyond sport contexts. Reflection not only reminded them of what they learned but also facilitated participants’ thinking about how they can transfer it to real life contexts. Regarding how he used reflection to promote life skill learning Mr. Kim commented:Teaching these life skills to the participants was possible due to the instructors’ specific and intentional instructional strategies. The instructors adopted various strategies to clarify the meaning of life skills, help them recite and practice during sport play, and also to facilitate transference of life skills beyond a sport setting.This study examined adolescents’ life skills development in a sport-based afterschool program and the characteristics of a program that influenced their life skills development. The findings of this study showed that adolescents’ participation in an afterschool sport program enhanced life skills in the four domains: playing well, connecting well, coping well, and dreaming well.First, the afterschool sport program facilitated the adolescents’ healthy and active lifestyle by providing a structured opportunity to develop sport skills. The enhancement of sport skills and the feeling of joy through play worked as assets for the adolescents as they extended their participation beyond the program setting to maintain active lifestyles. The literature also supports the theory that participation in sport and physical activity programs promotes diverse health benefits, and provides a foundation for future engagement in active lifestyles (Beets, Beighle, Erwin, & Huberty, Second, the findings revealed that playing sport and improving sport skills was not an ultimate outcome of the afterschool sport program, but it also worked as a vehicle to develop other life skills such as social and coping skills. It supports that sport is a viable tool to teach social skills, coping skills, and future exploration skills by providing active and dynamic contexts for practicing teamwork, cooperation, problem-solving, and goal-setting skills (Holt, Tamminen, Tink, & Black, The current study also identified characteristics of programs that facilitated adolescents’ life skills development. The program instructors’ clear philosophy on the importance of life skills and their effort to build a consensus with students and parents turned out to be important. Considering that adolescents are navigating multiple contexts such as home, school, and community, clear communication of a program’s philosophy is critical in building a consensus among people in diverse developmental contexts. Additionally, this approach helps to support the adolescents’ transfer of program values to other developmental contexts (Lee & Martinek, Another characteristic was establishing a clear boundary yet providing a flexible structure to practice a sense of autonomy in the program. The findings are similar to the features of positive youth development such as use of appropriate structure with clear rules and expectations, use of positive social norms, and empowering youth to take responsibility and have ownership of the program (Catalano, Berglund, Ryan, Lonczak, & Hawkins, Finally, the instructors’ teaching strategies, such as use of short phrases, sport-related metaphors, and reflection, turned out to be effective. The use of a one-liner and sport-related metaphors facilitated adolescents’ cognitive understanding of life skills as well as a contextualized understanding of life skills during sport play. In addition, reflection helped adolescents identity what life skills they learned and how to transfer them to other domains of life (Jones et al., Afterschool hours have been considered as a contested context for adolescents’ development, both as a risk and opportunity. This study showed that the sport-based afterschool program can be an important context for life skills development such as playing well, connecting well, coping well, and dreaming well in adolescents’ lives. In addition, it provides information on program characteristics such as having a clear goal and building a consensus with stakeholders, establishing a firm yet flexible program structure, and use of specific and intentional strategies for life skills development. These characteristics should be considered not only for designing an afterschool sport program, but also should be emphasized for staff training so that the program staff fully capitalize on the power of sport for life skills development.The study has limitations in that only six children in two schools, three children in each, were interviewed. Coupled with the small number of study participants, the low age of the subjects can be seen as a limitation of the study. Because the young participants were limited in their abilities to articulate their thoughts and feelings, the transferability of this study may be somewhat restricted. In order to overcome this weakness, future studies should explore children’s life skills development by combining the observation of participants’ behaviors along with individual interviews. In addition, this study does not provide detailed explanations on how life skills acquired in sport programs were applied to different contexts such as home or school. Given that the ultimate goal of the life skills program lies in the transference of the lessons beyond the sport program setting (Danish et al.,


Genetics and genomic medicine in Cuba. Its geographic location includes 19°49′ and 23°16′N and 74°08′ and 84°57′W, from the Greenwich meridian; that places it north of the Caribbean Sea and south of the Tropic of Cancer, at the entrance to the Gulf of Mexico .The surface area of the Cuban archipelago is 109,884.01 kmhttp://www.one.cu).Cuba is recognized internationally for its high educational and cultural levels, as well as for the qualified provision of its health services. The infant mortality rate was 4.3 per thousand live births at the end of 2016, which places the island in the vanguard of America and among the first 20 nations of the world. Life expectancy at birth is 78.45 years for both sexes (76.5 for men and 80.45 for women)  in Havana. The national program is coordinated by the NCMG; the national reference center is also responsible for undergraduate and postgraduate training, research, and introduction of new technologies in this field  by detecting carriers and prenatal diagnosis began in 1983. It is based on HbSS and HbSC screening, providing the study of hemoglobin electrophoresis to all pregnant women in the first trimester of pregnancy. The program includes procedures for the identification of high‐ risk couples, the provision of genetic counseling, and the availability of prenatal diagnosis for molecular studies of the gene. Couples at high risk of having children affected by this disease, can obtain information, have access to services and the necessary resources to adopt reproductive behavior appropriate to their interests  in the Cuban population was reported at 3% and the trait for Hemoglobin C (HbAC) at 0.7% , which includes the use of ultrasound for the study of cases with elevated values. The determination of AFP is made during gestational age 15–19 weeks  .The five labs  of the National Center of Medical Genetics, the leading institution of the genetics program, use the most advanced technology available in the country, to guarantee the diagnosis of more than 150 genetic diseases  were 72%, 20% and 8%, respectively  has been used as a research program for congenital defects that allows establishing a system of clinical and epidemiological surveillance of the same in the hospital births. This record includes all live births or stillbirths of babies weighing 500 grams or more that have one or more birth defects. This is a specialized and highly complex data file  were investigated, taking into account the ethnic origin of the Cuban population which is mainly influenced by Spanish and sub‐Sahara African contributions. All but p.N1303K were detected in the patients, the p.F508del being the most prevalent (37.9%). Overall, six mutations showed frequencies above 1% accounting for 55.5% of the Cuban CF alleles . Specifically, spinocerebellar ataxia type 2 (SCA2) reaches the highest prevalence rate in the world. The first epidemiological observations were made between the decades of the 60s and 70s of the last century, and since then a predominance has been identified in the eastern region of the country. The investigations carried out in Cuba and specifically in the CIRAH have been of great importance for the study of the genetic and molecular characteristics of the SCA2 . (Rojas‐Betancourt et al. Ministerial Resolution 219 of 2007, published in the Official Gazette of the Republic of Cuba, establishes the Ethical Norms for the protection of genetic information of Cuban citizens who participate in investigations or who are diagnosed with a condition in which access to data relating to the individual and their families, as well as biological material from which DNA can be obtained (The main strength of Genetics in Cuba, a low income country whose health expenditures consume a significant proportion of the annual budget, is the community approach, which has allowed strategies to be established for the detection and prevention of genetic risk. This has favored a progressive decrease in infant mortality due to birth defects, at values below 1 per 1000 live births from 2008 to date.On the other hand, research in this field is aimed at the progressive introduction of applications in the clinical practice of genomics and related technologies, always complying with the principle of introducing their results for the benefit of the Cuban population.Cuba has highly trained human resources in medical genetics, so that the generalization of genomic technologies and, fundamentally, the reduction in production costs, will allow, within a medium period of time, quicker transfer of the actions of personalized medicine to clinical practice.


Many continuing professional development (CPD) Web-based programs are not explicit about underlying theory and fail to demonstrate impact.The aim of this study was to develop and apply an aggregate mixed-methods evaluation model to describe the paradigm, theoretical framework, and methodological approaches used to evaluate a CPD course in tobacco dependence treatment, the Training Enhancement in Applied Cessation Counseling and Health (TEACH) project.t tests for quantitative analysis.We evaluated the effectiveness of the 5-week TEACH Web-based Core Course in October 2015. The model of evaluation was derived using a critical realist lens to incorporate a dimension of utilitarian to intuitionist approaches. In addition, we mapped our findings to models described by Fitzpatrick et al, Moore et al, and Kirkpatrick. We used inductive and deductive approaches for thematic analysis of qualitative feedback and dependent samples P ˂.001) in knowledge and skills (objective-oriented approach), and (3) high motivation (78.90% of participants) to change and sustain practice change (management-oriented approach). Through the intuitionist lens, inductive and deductive qualitative thematic analysis highlighted three central themes focused on (1) knowledge acquisition, (2) recommendations to enhance learning for future participants, and (3) plans for practice change in the formative assessment, and five major themes emerged from the summative assessment: (1) learning objectives, (2) interprofessional collaboration, (3) future topics of relevance, (4) overall modification, and (5) overall satisfaction.A total of 59 participants registered for the course, and 48/59 participants (81%) completed all course requirements. Quantitative analysis indicated that TEACH participants reported (1) high ratings  for instructional content and overall satisfaction of the course (expertise and consumer-oriented approach), (2) a significant increase (In the current aggregate model to evaluate CPD Web-based training, evaluators have been influenced by different paradigms, theoretical lenses, methodological approaches, and data collection methods to address and respond to different needs of stakeholders impacted by the training outcomes. Web-based courses for busy health care providers (HCPs) allow for iterative knowledge acquisition and application in real-world practice settings at a relatively low cost. A variety of different online tobacco dependence treatment training programs and evaluation methods for HCPs have been used ; howeverThe goal of this study was to develop a comprehensive, aggregate, and conceptual evaluation framework focusing on the use of paradigm, theory, and methodology for a Web-based training program. The embodiment of a critical realist lens, characterized through a dimension of utilitarian (the greatest good for the greatest number) to intuitionist  , formed Over the past decade, the TEACH Project at the Centre for Addiction and Mental Health (CAMH), has become a benchmark training program for health care providers (HCPs) at local, national, and international levels . The TEAHow will I do it?) [How will I know when I have done it?). This framework is one of the most well-known and widely used evaluation models in assessing the effectiveness of training and learning [What am I doing and why am I doing this?) [The TEACH Project based their evaluation approach on Moore et al’s and Kirkpatrick’s frameworks to evaluate continuing professional development (CPD) education ,7,9,10.  do it?) ,10. Alsolearning  to creatg this?) . Fitzpatg this?)  of utilig this?) ,13 throuWe developed an aggregate evaluation framework , adoptedTaken together, this aggregate evaluation model can elicit the following primary factors: (1) direct instructional design strategies during educational planning, organizing, implementing, and evaluating, (2) identify how HCPs learn, (3) determine how and where assessment can be used to measure progress of the program, and (4) identify ways to inform decision makers regarding evaluation outcomes.We examined the aggregate model’s feasibility by evaluating the data which has been collected through one of our cohorts of the TEACH Web-based Core Course in October 2015 with a total of 48 participants. We measured training effectiveness through the following four evaluation approaches, developed based on the aggregate model:). This approach focuses on the number of participants (learner-oriented) who completed the training, overall satisfaction, the degree to which participant’s expectations of the quality of the training were met, and quality of the program as compared with other existing programs. We capture participation and satisfaction through the registration database, formative evaluations administered throughout the training, and a summative evaluation administered at the end of the training. We measure quality of the program through evidence of accreditation by an external body. This is aligned with an expertise- and consumer/learned-oriented approach in which participants make valuable judgments based on training credibility .Approach 1 is based on Fitzpatrick et al’s expertise and consumer/learner-oriented approaches, Moore et al’s Levels 1 and 2 (Participation and Satisfaction), and Kirkpatrick’s Level 1 , and Kirkpatrick’s Level 2 (Learning). This approach focuses on the impact of training on participants involved  state what the training intended them to know and (2) state how to do what the training intended them to know). To achieve this, an evaluator needs to determine the extent to which clearly defined course objectives have been met immediately post course. We capture declarative and procedural knowledge through pre- and postcourse assessments. This approach helps instructional designers, evaluators, and other stakeholders judge the training’s success or shortcomings through some of the trainings immediate outcomes . We also capture participant learning through the administration of a competency-based exam administered post course. Participants are required to achieve a grade of 70% or higher in order to pass the course. Additionally, participants are able to provide free text comments and open-ended feedback questions for course development to enhance learning for future participants in the formative evaluations administered during the course.Approach 3 is based on Fitzpatrick et al’s management-oriented approach, Moore et al’s Levels 4 and 5 (Competence and Performance), and Kirkpatrick’s Level 3 (Behavior). The central concern for this approach is to identify and meet the information needs of managerial decision makers, evaluate self-assessed practice change, and implementation of knowledge and skills . We measure competence and performance through follow-up surveys administered 3- and 6- months post training. Quantitative data collected 3- and 6- months post training can provide decision makers with evaluation data that demonstrates program effectiveness over a longer period, which can be helpful in guiding decisions for program continuation or expansion. To ensure an intuitionist approach to evaluation, 3- and 6-month surveys should include qualitative response options to capture participants’ experience with practice change post course. This cohort study did not include qualitative response options in the 3- and 6-month follow-up surveys; however, our revised tools will incorporate this approach.Approach 4 is based on Fitzpatrick et al’s stakeholder-oriented approach, Moore et al’s Levels 6 and 7 , and Kirkpatrick’s Level 3 (Results). This approach focuses on a practical participatory evaluation approach, the long-term outcome in job-related performance, and institutional and community level changes as a result of the training program. Patient and community health outcomes are measured through connecting previous evaluation data with the current health outcomes and subsequent linkage with population health data. However, practice change and implementation is dynamic and complex behavior. Additionally, connecting previous evaluation data to patient and community health outcomes is not always easy, feasible, and will only be able to show a marginal effect of the training because of competing factors. Accordingly, a more intuitionist approach rooted in subjectivist epistemology is required for Approach 4. Long-term follow-up through qualitative inductive and/or deductive approaches should involve multiple stakeholders  in determining the program’s success and shortcomings . This cohort study did not include Approach 4 in the protocol; however, our future evaluation research will explore this level.t tests, analysis of variance (ANOVA) and CI were calculated to test the difference between and within the groups with a probability level of .05. Missing data were replaced with grand mean or modal responses for continuous and categorical variables. To gather qualitative data, the formative and summative questionnaires with extensive qualitative comments used thematic analysis to present participant’s evaluation of the course. SPSS 24 and NVivo 11  were used to perform analysis of quantitative and qualitative data. At the time this study was designed, the CAMH Research Ethics Board deemed that formal review and approval was not required for the study.A mixed-methods design was undertaken using data collected through formative evaluations administered following each Web-based module and a summative evaluation administered post course, which collected both quantitative and qualitative feedback, pre-and postcourse assessments of knowledge and skills, a competency-based exam administered post course, and 3- and 6-month follow-up surveys measuring self-reported practice change. Accordingly, we were able to pilot Approaches 1 to 3 of our aggregate model. The numeric data were summarized as descriptive statistics using IBM SPSS Statistic 24 for analysis. Simple frequencies and percentages were calculated; additionally, means and standard deviation for the pre- and postcourse assessments were obtained. Paired Following expertise-oriented approach, TEACH is accredited by the University of Toronto’s Faculty of Medicine CPD program, as well as the College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Addiction Counsellors Certification Federation, and Royal College of Dental Surgeons of Ontario. A total of 59 participants registered for the course, and 48 participants (81%) completed all course requirements. t tests were undertaken. Z=6.03, P<.005.The pre- and postcourse assessments consisting of 29 closed-ended questions related to course competencies were used to collect quantitative data, and paired samples P<.001) for the importance variable. A nonparametric approach was used to support the analysis of the Likert scale responses of feasibility, confidence, and importance  was used. Data normality can be observed in the analysis of feasibility and confidence with the Kolmogorov-Sminrov & Lilliefors test (95% CI). However, data normality was not observed  recommendations to enhance learning for future participants, and (3) plans for practice change  interprofessional collaboration, (3) future topics of relevance, (4) overall modification, and (5) overall satisfaction.The percentage distribution for the competency-based exam indicates successful achievement of intended outcomes whereby 47 out of 48 participants received a passing grade (n=10 between 80%-90% and n=37 between 90%-100%), with only one participant receiving a failing grade below 70%. Finally, thematic content analysis was conducted for the qualitative comments provided by participants in the formative (34 comments) evaluations which were related to the three themes: (1) e change . To follmore practice was identified as the major barrier at the 3-month follow-up point. At 6-month follow-up, 64% of respondents still identified the need for more practice as a barrier. Three additional barriers were identified at the 6-month follow-up and included finding the time to offer tobacco cessation counseling (an average of 71%), struggling with patients’ motivation to attend cessation sessions and wanting more financial support for cessation programs and services (50% for each). Another important outcome from using a utilitarian lens through a management–oriented approach relates to the dissemination of tobacco cessation knowledge and skills to other providers. At both follow-up time points, participants were asked whether they had communicated any of the knowledge or skills they had learned to colleagues since completing the course. At the 6-month follow-up time point, 78.90% of participants indicated that they had been involved in informal discussion/information sharing with colleagues; 32.90% indicated that they had offered brief presentations (up to 1 hour) with colleagues; and 8.11% indicated that they had written articles or reports to share with colleagues.Follow-up surveys administered 3- and 6-months post training were analyzed with a management-oriented approach. We evaluated participant’s self-reported implementation of tobacco cessation knowledge and skills, the number of clients seen, the dissemination of program material to other providers, barriers to change, and future intentions to implement knowledge and skill into practice. The average response rate for the 3-month follow-up survey was 27.08% and 29.17% for the 6-month follow-up survey. Responses indicate that at 3-month follow-up, 76.9% of participants were offering individual tobacco cessation sessions with clients, which increased to 85.7% at the time of 6-month follow-up. Participants provided information on what they perceived to be barriers to changing their practice and implementing new cessation programming post course. The need for Previously, the TEACH project was introduced as the first university-accredited continuing education certificate program in Canada that focused on evidence-based research for intensive cessation training, leading to enhanced system capacity. Study findings suggest that the certificate program impacted clinical practice, highlighting successful knowledge transfer from research to practice . With itApproach 1 of our evaluation model directs us to a comprehensive judgment of the quality of the program, which includes expertise-oriented and consumer-oriented evaluation. They are the oldest approaches in evaluation, directing evaluators to focus on valuing or judging the quality of the program they are evaluating ,16. ScriApproach 2 of our evaluation model helps us to determine the extent to which our training objectives have been achieved. Bloom et al  not onlyApproach 3, which is oriented to decision making, focuses on how evaluation outcomes can support decision makers  in making judgments regarding program improvements and continuation. On the basis of a review of studies on commitment to change  ,22, we cThe application of the entire aggregate model through Approach 4 has the potential to involve different stakeholders, including those directly impacted by training  rather than leaving decision making of program changes and implementation to training participants and program managers. Future directions of our program evaluation will involve a long-term evaluation of TEACH through administration of in-depth interviews with previous participants, their patients, and their managers in order to fully capture the intuitionist approach to program evaluation. This evaluation will also connect participant previous evaluation data to patient health outcomes in order to determine training impact beyond the participant . This agAnother limitation of this study was that we performed our pilot study through the Web-based version of the TEACH course in 2015 with 48 participants. This was done to assess the feasibility of the new evaluation model that required a redesign of evaluation questions and approaches. We were consequently unable to utilize our available, large-scaled data from our previous study  since thAnother limitation of the aggregate model is applied in its entirety —the evaluation can be complex and resource intensive. To address this limitation, evaluators need to consider the resources and time they have available and if Approach 4 fits within a feasible scope of work. Also, we achieved 27% and 29% response rates for the 3-month and the 6-month Web-based follow-up surveys despite subsequent mailing reminders to nonrespondents. Although we hoped for a better response, other surveys of HCPs also have tended to generate low response rates ,29.Using a mixed-methods approach that balances both quantitative and qualitative data as equally valuable in evaluation is consistent with using a realist approach to identify the contextual factors of successful training programs, since these factors are intimately connected to the success or failure of a training . The quaImplementation models for dynamic human behaviors , such as the KTA cycle, require a comprehensive evaluation framework with different approaches that can inform future decision making. Some evaluators have lamented the proliferation of evaluation models and urged that an effort be made to synthesize existing models . ConversIn this evaluation study, different approaches helped us to comprehend the wide range of needs related to evaluating the Web-based TEACH Core Course. Our predispositions and preferences on philosophical and methodological dimensions led us to choose different models, methodologies, data collection tools, analysis methods, and interpretive techniques. As we move forward, we must identify what is useful in each approach when faced with a specific evaluation need. This study also helped to demonstrate that the aggregate model can detect the effects and impact of Web-based courses because of the richness of data collected in each approach impacting different stakeholders. This comprehensive evaluation approach appears compatible and applicable to other programs based on implementation frameworks . Some of the key features and major characteristics of the aggregate model are as follows:When developing an evaluation model, one must consider paradigm, theoretical framework, methodological approach, and data collection methods.A comprehensive evaluation model should include qualitative (deductive or inductive) and quantitative approaches for data collection, analysis, and interpretation.Utilitarian approaches to evaluation can be helpful in identifying impact through a more objective lens. However, an intuitionist approach, through a subjectivist lens, can uncover information to guide program improvements, beyond what may have been originally expected.


Ethiopia recently introduced the Doctor of Physiotherapy (DPT) degree at Addis Ababa University as a mechanism to increase the work force capacity of primary care providers in the health sector. The DPT program was supported by an international academic partnership and was designed to empower physiotherapists as leaders to move the profession forward. The curriculum was framed by core pedagogical principles and strategies and was phased into two programs. First, the 4-year Advanced Standing DPT program focused on developing registered Ethiopian physiotherapists with Bachelor of Science degrees as academic faculty. Second, these new faculty would then sustain a 6-year Generic DPT program that would matriculate students upon graduation from high school. The curriculum represented depth and breadth of foundation and clinical sciences, evidence-based practice, clinical reasoning skills, and interprofessional education opportunities. A leadership thread provided opportunities to develop skills necessary to effectively navigate and manage the challenges faced by the profession. The main outcomes included (1) an 8-year international partnership, (2) the academic performance of students, and (3) and leadership capabilities as demonstrated through activities and assignments. While the program has been criticized as an unnecessary extravagance for Ethiopia, the advantages of the DPT degree were revealed in a direct comparison to other academic physiotherapy programs in Ethiopia. In the end, because the DPT is new to the country, it will take time to fully understand the true impact within the Ethiopian health system. The PT profession in Ethiopia is relatively new when compared to the history of the profession in other countries . The modAt the beginning of the twenty-first century, Ethiopia had only13 PTs registered to serve an estimated 15 million Ethiopians living with disabilities .The BSc curriculum Table  integratAs with the introduction of any new health profession, Ethiopian PTs have met professional challenges within the health sector, which has impacted the general motivation by some to pursue or continue a career in PT. Thus, despite the development of the University of Gondar programs, Ethiopia continues to experience limitations in human resource capacity to meet the demand for rehabilitation services. There are a number of potential causes for the limitations.First, there is a lack of overt public and government support for the physical therapists, possibly due to a limited understanding of this relatively new Ethiopian profession. Second, the Ministry of Education assigns post-high school students to the academic program based on their interests in health care and on their performance on the Ethiopian Higher Education Entrance Certificate Examination. It is perceived that some of those assigned to PT programs would prefer to seek opportunities in other health professions. Third, while Ethiopian physicians have opportunities for continued professional development, the PT profession has extremely limited opportunity in this area. Thus, the growth and development of individual practitioners and the profession as a whole is limited by this void. Fourth, poor salary compensation may cause PTs to seek additional ways to supplement their income, or they choose to leave the profession altogether. Fifth, a shortage of qualified local PT faculty limits the ability to sustain the academic programs without international support. In addition, local faculty may not be fully qualified for academic roles as they often receive little to no formal training in teaching pedagogy, nor advanced PT skill sets to optimally integrate into the academy. Finally, Ethiopia has a broad Scope of Practice for the PT profession that is dependent upon the level of academic preparation. This leads to disparities in the delivery of patient care among PT providers.The sum of the limitations greatly impacts the profession throughout the country. Therefore, the focus of this special topic paper is to describe the development of the DPT program at Addis Ababa University (AAU) as a potential strategy to alleviate the impact of the many limitations on the PT work force capacity in Ethiopia.The DPT was introduced to Ethiopia at AAU in 2008. The program defined the vision to “be recognized in Sub-Saharan Africa as a center of excellence for education and service provision by doctors of physiotherapy. These doctors will be physical medicine experts who deliver optimal patient care and contribute to the goals of the health sector.” The development of the DPT program was planned in a partnership between AAU, Regis University , the Jackson Clinics Foundation, LLC . Over the 6-year planning period, the partnership developed relationships with several Ethiopian stakeholders that played critical roles in the formation and approval of the DPT program at AAU Figure . The parThe introduction of the DPT at AAU was designed to occur in two phases as follows: (1) the Advanced Standing DPT Program and (2) the Generic DPT Program.The Advanced Standing DPT program was developed with consideration of the (1) social and economic development level of the country, 2) analysis of history, development, and present status of the PT profession in Ethiopia and in other countries, (3) educational sector development plan of Federal Democratic Republic of Ethiopia (FDRE), (4) health sector development plan of FDRE, (5) standards of admission, program design, licensing, and accreditation needs for the education of PT professionals, and (6) new developments in research within the profession of PT. The scope of the 4-year Advanced Standing curriculum  program within the AAU School of Medicine. The curriculum was expanded from the Advanced Standing program by incorporating the first 2 years of the medical school foundational curriculum Table .In addition to the benefits cited for the Advanced Standing DPT program, the Generic DPT program will promote IPE collaboration in the classroom and in clinical practice and, thereby, expand potential for improved patient outcomes. Ultimately, the Generic DPT program will be fully sustained by PT faculty developed in the Advanced Standing program in coordination with the AAU medical school faculty. International faculty will not be needed to sustain the Generic DPT program. AAU plans to matriculate the first cohort of Generic DPT students in Fall 2017.The development of the DPT curriculum was guided by six core pedagogical principles that emphasized empowerment, leadership, relationships, active engagement, reflection, and innovation.Principle 1: empowerment through learning is the path to the future.Principle 2: leaders dwell within everyone.Principle 3: relationships form the basis of all learning.Principle 4: students achieve growth by challenging the process and modeling the way.Principle 5: active engagement amplifies learning achievement.Principle 6: reflective processes inspire innovation.The pedagogical framework was designed to build upon the six core principles while acknowledging the local context of the physical medicine and rehabilitation needs of Ethiopia, the Scope of Practice, and the constraints of a resource-limited health environment Figure . The DPTThe framework required a thorough understanding of the vision of the PT profession in Ethiopia and was, thus, guided by the Scope of Practice. The Ethiopian Physiotherapy Association and the Ethiopian Food, Medicine and Health Care Administration and Control Authority jointly wrote the Scope of Practice. The academic degree determines the scope of duties that a PT can perform, e.g., technician, BSC, MSc, and DPT. Ethiopian DPT practitioners have the highest capacity of all academic PT degrees to deliver primary care services.As previously stated, the Advanced Standing DPT and Generic DPT programs curricula were specifically designed to meet the unique needs of Ethiopia. Ethiopia aimed to increase the workforce capacity by including PTs as primary care providers in the health system. Thus, the DPT curriculum had to expand its scope beyond the BSc and MSc to meet the expectations and responsibilities that accompany the provision of primary care. For example, Ethiopian DPTs needed training to order medically relevant diagnostic tests, participate in the management of medical/surgical emergencies or trauma, perform specialty interventions such as mechanical decompression, plastering techniques, joint and soft tissue injections, prescribe neuromusculoskeletal medications, perform minor trauma suturing, reduce and stabilize minor fractures and dislocations, and perform electromyography, lower extremity Doppler tests, and stress tests. The curriculum also included a leadership thread to cultivate and empower leaders for the PT profession. A teaching and learning thread was also woven throughout the curriculum to develop Ethiopian faculty that could independently sustain the academic programs. Finally, the curriculum was taught with IPE collaboration among the faculty and students from other health professions to facilitate networking and teamwork among health professionals.The curriculum was delivered in accordance with the guidelines for AAU College of Health Sciences, School of Medicine modular undergraduate curriculum. The Advanced Standing DPT program included 51 courses Table  that werHuman Anatomy and DevelopmentPhysiology and Kinesiology of MovementClinical Decision MakingCardiovascular and Pulmonary System ManagementMovement SciencesDiagnosis—Electromyography StudiesNeurological Systems ManagementRadiologyMusculoskeletal Management I—ExtremitiesMusculoskeletal Management II—SpineSpecialized Medical Management of the Musculoskeletal SystemProfessional RolesPopulation HealthIntegumentary and EndocrinologyUrogenital/OB-GYNOncologyResearch MethodsScope of Physiotherapy PracticeAll courses were delivered in a blocked design, where students were required to take one course to completion before beginning the next course and subsequent module. The blocked design also accommodated the international faculty travel schedules.The Generic program will also be taught with a modular system but will be taught with a traditional distributed delivery model rather than a blocked model. In addition, the Generic program will expand the curriculum to 6-years; thus 21 new courses Table  will be Body Structure, Organization, and FunctionMetabolic Homeostasis and Molecular GeneticsBasic Concepts of Disease and TherapyBlood and ImmunityNeoplasia and the Molecular Basis of CancerMusculoskeletal and Integumentary SystemsCardiopulmonary SystemNutrition, Metabolic Diseases and GITExcretion and ToxicologyInfectious DiseaseEndocrinology and ReproductionNeuroscience and BehaviorThe additional 12 modules will be taught by AAU medical school faculty and represent the current foundational courses for medical students. The DPT students will take these courses alongside medical students during their first 2 years of the curriculum.The Advanced Standing DPT program employed several pedagogical strategies throughout the curriculum to meet the needs of diverse learners and to expose the students to a variety of strategies that would be available to them as they prepared for their roles as future faculty.The curriculum was delivered with a hybrid model that utilized ground-based and distance-based delivery models to accommodate the availability of experienced international faculty. Ground-based instruction incorporated both didactic and practical (action-based) skill development and was delivered in a traditional classroom on the AAU School of Medical campus. Distance-based was primarily utilized for the delivery of didactic content and was delivered through a Skype connection into the AAU classroom.Traditional lecture formats were utilized throughout the curriculum, but with intentional efforts to actively engage the student in dialog. Non-traditional lecture formats that utilized technology with audio-enhance lectures (flipped classroom concept) were also implemented when a faculty member could not be on-site or when students needed additional course review beyond the physical structure of the classroom.Many of the courses incorporated lab experiences to teach, learn, demonstrate, and practice practical skills.Clinical mentoring courses for experiential patient management were performed in small groups of 3–4 students. The curriculum included a series of nine clinical mentoring courses. A similar model will be incorporated into the Generic program.Adopting the model, “See One. Do One. Teach One,” the students were frequently encouraged to assume the role of instructor to gain experience for their future roles as faculty.Students completed individual readiness assurance tests and team readiness assurance tests on content assigned for specific days within selected courses. The TBL model encouraged learners to arrive to class fully prepared to engage in teamwork with other students.Contextual-based case scenarios were adapted for various courses to promote thoughtful reflection, dialog, critical thinking, problem solving, and group process.The students were assessed with a variety of methods, including written examinations, quizzes, practical examinations, written assignments, and oral presentations.As stated earlier, academic instruction for the Advanced Standing program was supported by an international partnership. The partnership was manifested through a complex network of relationships Figure  and a meThe DPT curriculum represented depth and breadth of both foundational and clinical sciences and was accompanied by competencies and objectives reflective of an entry-level DPT curriculum. In addition, a leadership thread was woven throughout the curriculum to develop leadership for the advancement of the profession in Ethiopia.Illustrate the social responsibilities of a doctoring profession.Advocate for patient and community needs.Commit to meet professional obligations.Consider the determinants that impact societal health and wellness.Adhere to high ethical principles and professional values and standards.Accept responsibility for roles, obligations, and actions of the physiotherapist.Consider social, emotional, and psychological components in patient care.Acknowledge that effective health care depends on a mutual understanding and relationship between the health-care team, patient, and the family with respect for the patient’s welfare, culture, identity, beliefs, and autonomy.Demonstrate patient-centered actions ahead of the self-interest of the physiotherapist by treating patients with politeness and consideration, respecting their dignity, privacy, and point of view without regard to background, culture, language, religion, race, and point of view.Participate in lifelong learning to ensure ongoing high levels of knowledge and clinical competence.Serve as leaders to elevate the standards of PT care in Ethiopia to best meet the needs of society.The leadership goals and objectives were unique to AAU’s DPT program and were not represented within the BSc program at the University of Gondar. They included the following:As stated previously, the partnership experienced significant turnover within the AAU academic administration. The Executive Director of the college of Health Sciences changed three times, the Academic Dean of the School of Medicine changed four times, the Associate Dean of the College of Health Sciences changed four times, the Director of Undergraduate Medical Education changed three times, and the Director of the Department of Orthopedics (where the Unit of Physiotherapy resides) changed five times. The instability and longevity of the higher education administration made the progression of the program difficult. Fortunately, the commitment of the DPT program Coordinator at AAU remained constant throughout all of the transitions in higher administration to sustain the partnership. All partners remain committed to the progression of the academic programs.The Generic DPT curriculum is currently in its final stage of development. The curriculum is scheduled for submission to the AAU Senate for review and approval in early 2017. Once it is approved, AAU will begin the process to matriculate post-high school students into the program in Fall 2017.The 17 DPT students that matriculated into the Advanced Standing DPT program are currently completing the third year of the curriculum. To date, 36 courses have been taught by a total of 29 faculty, including 14 different AAU faculty for 18 courses, 7 different Regis University faculty for 15 courses, and 8 Jackson Clinics Foundation clinicians for 3 courses.An extensive survey was administered to all students at the end of their first year. The survey addressed three primary areas and utilized a 4-point scale; 1 = novice: shows an understanding of the behavior but does not consistently act in this manner; 2 = competent: performs the behavior upon request, but not necessarily in every day activities; 3 = proficient: regularly acts in this manner and can provide recent examples; and 4 = expert: always behaves in this way and can illustrate with many recent examples.Professional behaviors, roles, and responsibilities of the DPT profession: the domains with an average score in the proficiency range  were leadership, collaboration and relations building, communication, and altruism. The domains in the competency range  were professional roles and behaviors, advocacy, social responsibility, accountability/ethical/legal issues, self-assessment/peer-assessment, education, evidence-based practice, and critical thinking/clinical reasoning.Principles for patient management: the domain with an average score in the proficiency range  was guiding principles for examination. The domains in the competency range  were guiding principles for diagnostic tests, evaluation, diagnosis, prognosis, plan of care, intervention, outcomes assessment, and education intervention.System and patient-specific management: the domain with an average score in the proficiency range  was musculoskeletal examination. The domains in the competency range  were cardiopulmonary, integumentary (examination only), musculoskeletal, neuromuscular, orthotic/prosthetic/protective devices, and assistive/adaptive devices. The domains with an average score in the novice range  were integumentary procedural interventions and special populations.The survey will be readministered at the completion of the 4-year Advanced Standing DPT program, and the results will be analyzed as a component of the overall assessment of the program.The critics of the AAU DPT degree argue that a change in academic degree will not resolve the challenges faced by the PT profession in Ethiopia. Indeed, they are probably right. Taken at face value, the expansion of the curriculum with the DPT degree is evident. However, less obvious was how the leadership thread served as a potential mechanism to address the aforementioned limitations.The leadership thread was an integral part of the Advanced Standing program and will continue with the Generic DPT program. The thread exposed students to a variety of leadership theories, models, and assessment tools. It offered opportunities to engage in reflective processes and gain perspectives on personal leadership styles as well as the leadership traits of others. Students individually and jointly reflected on their personal and professional values and future roles and responsibilities in the Ethiopian health-care environment. They also deliberated on leadership topics in groups to identify core professional values that they believed could lead the profession forward in Ethiopia. The current cohort identified the core PT values as professionalism, timeliness, accountability, knowledge and skills, and transparency and coupled them with their personal values of compassion, integrity, love, kindness, and honesty. Finally, the cohort worked as a team to develop action verbs to accompany the personal and professional values that would enable them to act upon the identified values. They chose to empower, promote, work, demonstrate, strive, pursue, and engage.The thread required students to develop personal mission statements that could guide their journey as individual leaders in academia and clinical practice. General themes that emerged from the mission statements included statements to lead the PT profession forward through active involvement in policy making, to inspire and empower current and future PTs, to embrace altruism in practice, to advance the quality of patient care, and to be accountable to the profession and those that they served.The culminating activity within the leadership thread was the development and implementation of personal leadership projects. The projects were a mechanism to motivate and empower them to address the challenges in Ethiopia by engaging as positive change agents. The leadership projects reflected the added value of the leadership thread within the curriculum. The leadership project themes ranged from being able to more fully integrate PTs as leaders within the Ministry of Health and improving the awareness of the profession in the country to improving PT work efficiencies and physical environments in hospitals and clinics to increase job satisfaction and retention of PTs in the work force. The general feedback about the leadership thread from the current cohort was extremely positive, as many of them believed they could be positive change agents and lead the profession forward as a result of the leadership development process.Ethiopia has made great advances in developing academic programs to address the shortage of PTs in the workforce. Over the past 15 years, the contributions of Gondar University’s BSc and MSc programs have contributed over 200 PTs to the physical medicine and rehabilitation sector. The DPT programs at AAU were designed to address the mounting challenges of the profession by increasing the scope of the curriculum for primary care and developing leaders to move the profession forward.“Africa does not need doctoral education. They simply need basic training to meet the general growing needs of the population.” (USAID Representative)“Ethiopia does not need autonomous PTs, they need to work with the physicians as a team.” (European Physician)“The BSc degree works around the world. Does the world really need the American DPT?” (European PT)The DPT programs have been subjected to criticism, especially since the degree is new to Ethiopia and all of Africa. The harsh opinions have included statements such as:To the critics, it can be argued that the challenges will only continue to grow if innovation is not pursued. Examination of the different curricular models in Ethiopia revealed the advantages of DPT degree compared to the BSc and MSc degree. Benefits to the profession included developing leaders; advancing clinical reasoning skills and application of evidence-based practice beyond the technical skill sets associated with the BSc and MSc programs; broadening the depth of foundational and clinical practice knowledge to fully address the professional scope of practice in primary care; promoting a culture of lifelong learning and service to others; envisioning positive change for the future of the profession; instituting IPE in educational curricula and clinical practice for optimization of patient outcomes; developing local faculty to sustain academic programs; increasing the potential for greater income, as the DPT will be compensated on a doctoral scale like physicians; and improving the potential for greater recognition and sustained increased in work force capacity within the profession. While preliminary data have been collected related to professional behaviors, roles, and responsibilities of the DPT profession, principles for patient management, and system and patient-specific management, future analysis of data from graduation surveys will serve as quantitative markers of the impact of the program.The greatest limitation of the DPT program at AAU has been the inconsistencies of higher administration support due to the frequent turnover of personnel. It is strongly recommended that the primary coordinator/director of the program have a strong presence in the daily academic environment to ensure stability and sustainability of the program. Limitations were also noted in the availability of AAU medical school faculty and international PT faculty. The MOU designated courses to be taught by the AAU medical school faculty, but it was often difficult to secure the actual commitment of the faculty. The challenge was related to difficulties in communication and expectations between higher administration and the faculty. For almost all of the international faculty, they could only commit to teach in 2-week blocks due to ongoing responsibilities within their home institutions. Students reported that they would have preferred the courses to be taught over a 3- to 4-week timeframe to allow time to fully integrate the course materials. In addition, the expense to send international faculty to Ethiopia was quite high. The opportunities for external funding and grants were essentially non-existent for the DPT program, as most grants/funds directed to Africa targeted HIV/AIDS, TB, malaria, and other medical student education programs. Advocacy for the PT education and profession grants in Africa would be strongly encouraged. Finally, the DPT program at AAU was specifically designed to meet the unique needs of Ethiopia and, thus, the curriculum may not be fully generalizable to other countries. However, the degree has many benefits that warrant careful consideration as a potential mechanism to upgrade the diploma to a degree in Africa. With this in mind, the process by which the DPT was developed in Ethiopia is, indeed, generalizable. The process involved a grassroots movement of Ethiopian PTs, a collaborative partnership for expertise , support of internal (academic institution) and external governing bodies , and students willing to commit to a pioneering academic program. The process requires time to navigate necessary systems to launch the program. It is very important to be patient. Due diligence to complete all requirements to launch a new program is the ultimate key to facilitating the sustainability and success of the DPT degree.I never knew what it was to be a PT until I started the DPT program.Since the program is still very new, it will take time to understand the impact of the DPT in Ethiopia. The only marker that exists at this time is the performance of the 17 students currently enrolled in the Advanced Standing program, all of who graduated from the BSc program at Gondar University. One particular student comment stands out to reflect the value of the DPT program:So, the question to be asked is. “Can the DPT make a difference in Ethiopia?” If any credence is to be applied to the empowerment potential of the leaders being developed in the Advanced Standing DPT program, then the answer will hopefully emerge as, “Yes, the DPT can make a difference!”CF, the lead instructor for the Doctor of Physiotherapy program at Addis Ababa University, contributed historical knowledge of program development at Addis Ababa University as one of the international partners and also provided specific details of the history of PT profession development, curriculum design, and pedagogy. AD, the lead instructor for the leadership development component of the Doctor of Physiotherapy program at Addis Ababa University, contributed key knowledge of the curriculum design and pedagogy. HT contributed valued perspective as a student in the doctoral program at Addis Ababa University and also contributed knowledge of the challenges within the Ethiopian health sector. TY, WM, and TS contributed valued perspective as students in the doctoral program at Addis Ababa University. EA provided a voice as the President of the Ethiopian Physiotherapy Association and contributed rich knowledge of the historical perspective and future direction of physiotherapy in Ethiopia.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.