N = 189 healthy adults participated in a 12-week interactive (intervention) or non-interactive (control) web-based health program. The intervention provided a web-based lifestyle intervention to promote physical activity and fitness through individualized activities as part of a fully automated, multimodal health program. The control intervention included health information. Cardiorespiratory fitness measured as maximum oxygen uptake (VO2max) was the primary outcome, while musculoskeletal fitness, physical activity and dietary behavior, and physiological health outcomes were assessed as secondary outcomes . Statistical analysis was performed with robust linear mixed models. There were significant time effects in the primary outcome (VO2max) (t0–t1: p = 0.018) and individual secondary outcomes for the interactive web-based health program, but no significant interaction effects in any of the outcomes between the interactive and non-interactive web-based health program. This study did not demonstrate the effectiveness of an interactive compared with a non-interactive web-based health program in physically inactive adults. Future research should further develop the evidence on web-based lifestyle interventions.Web-based lifestyle interventions are a new area of health research. This randomized controlled trial evaluated the effectiveness of an interactive web-based health program on physical fitness and health.  Physical inactivity is one of the most important risk factors for noncommunicable diseases (NCDs) . The latHowever, the global burden of physical inactivity can be addressed through the wide-ranging health-promoting potential of a physically active lifestyle. The health benefits of physical activity, as well as of physical fitness as a component of physical activity, have been well documented for both the prevention and treatment of many NCDs, such as obesity, type 2 diabetes mellitus, and metabolic syndrome, and for individual related health outcomes, such as anthropometry, blood pressure, blood levels, and vascular health ,7,8. ThuPrevious research has shown that face-to-face interventions can be successful in managing NCDs ,13,14. AThis study evaluated a web-based lifestyle intervention promoting physical activity and fitness as part of a multimodal health program offered by a national statutory health insurance fund . This 12-week interactive web-based health program  aims to achieve prioritized health goals  through individualized health coaching for primary prevention of NCDs . The preThe objective of this study was to investigate the effectiveness of a 12-week interactive web-based health program (TK-HC) on physical fitness and health in physically inactive adults. The program was compared with a 12-week non-interactive web-based health program. For this investigation, we defined three hypotheses focusing on long-term effects. Short- and medium-term effects were additionally considered. We hypothesized that the interactive web-based health program would significantly improve primary and secondary outcomes with small to medium effect sizes (time effect). We further postulated that these improvements would be more significant than those of the non-interactive web-based health program (interaction effect). Moreover, we expected that higher program use of the interactive web-based health program would result in better program effectiveness than lower program use (dose–response relationship) .https://drks.de, DRKS00020249, accessed on 11 December 2019). The study protocol has already been published [This study was part of a nationwide evaluation project of the TK-HC, in which the health goal “Increasing Fitness” was evaluated in a randomized controlled online trial and the present randomized controlled trial. The online trial assessed self-reported outcomes from online questionnaires of participants across Germany and was conducted by the Section of Health Care Research and Rehabilitation Research at the Medical Center of the University of Freiburg (SEVERA) . In addiublished . This arublished .2 and a physical activity level of ≤60 min/week. They also had to be willing to be randomized and predominantly healthy. If subjects had any health problems or diseases, they were asked to have a medical certificate for study participation. Internet literacy was not specified as an inclusion criterion but was strongly recommended. Pregnancy was a criterion for exclusion [To register for the study, subjects had to be participants of the online trial living in southwest Germany (postcode area: 79). Male, female, and diverse adults (18–65 years) were included if they had a body mass index (BMI) between 18.5 and 34.9 kg/mxclusion .Subjects were recruited through various online and offline media, including Google advertisements, websites, newsletters, and social media, as well as local press, radio, and flyers. All recruitment tools led to an open-access landing page where interested subjects were provided with study information and asked to give their written informed consent by ticking a box. The study information and consent form could then be downloaded. The information provided in these documents can be viewed together with the published study protocol. Upon study registration, participants were randomized and contacted by study staff to receive additional study information, assess eligibility, and arrange an appointment for the first medical examination. As part of the first medical examination, participants were reinformed, reassessed against the inclusion and exclusion criteria, and given the opportunity to discuss any remaining concerns. Participants were finally enrolled in the study after successful completion of the first medical examination. The face-to-face assessments during the medical examinations on-site allowed the study staff to get to know the participants over time. Further information on the enrollment process, particularly in relation to the online trial, can be found in the study protocol .The program assigned to the intervention group was the TK-HC. This fully automated, web-based health program provides interactive, multimodal health coaching tailored to personal health goals and profiles. Based on motivational psychology, users are expected to achieve sustainable lifestyle changes in a self-directed and flexible way within 12 weeks . As the To start the program, users had to pass a multistep anamnesis and were then guided to the program platform, which was structured into three areas. In the first area , users could access a personal dashboard with a weekly and an overall 12-week coaching plan of individual activities A. Users Furthermore, users were allowed to choose activities from other coaching modules, such as weight loss activities from the “TK-WeightLossCoaching” (TK-WC), and connect an activity tracker to the program to send their daily step count. Users were asked to log all their activities on a daily or weekly basis and could flexibly adjust them to their individual needs. In addition to the activities, the dashboard included a barrier management tool, customized tips and notifications, support options, and a visualization of the current personal health goal achievement .The second area of the program (“Knowledge”) assisted users with evidence-based background information about physical activity and fitness and other health-related topics. The contents were taught through interactive knowledge courses prepared in small articles with texts, videos, tools, and tests. One course  was automatically scheduled weekly in the coaching plan. In the third area (“My data”), users could find an analysis profile of their logged activities, their health profile and personal data, as well as the study information and consent form. Moreover, they could withdraw participation from the study and the health program. Once users had completed the program, they received a coaching summary .The control group was offered a 12-week non-interactive web-based health program. This program was a simple online platform designed to help users promote their physical activity and fitness. The program initially required users to log in without providing any anamnesis in order to tailor the health program to personal health goals or profiles. The first area  provided only non-interactive health information on physical activity and fitness. Users could select and read short articles from standardized texts, but these articles did not include interactive elements such as videos, tools, or tests. In contrast to the interactive web-based health program, users also did not have access to health information on other health goals, for example, weight loss. There were also no daily or weekly activities to promote their physical activity and fitness, and they could not link an activity tracker to the program. In the second area (“My data”), users could view their personal data, the study information, and the consent form and could withdraw participation from the study and the health program. The program did not comprise an individual analysis profile or user feedback mechanisms .Both interventions were scientifically developed by TK in collaboration with health professionals and Vilua Healthcare GmbH (VHG). The interventions were accessible as desktop and mobile versions for unlimited use on computers, tablets, and smartphones and were delivered as web-based interventions without human involvement. A support team from VHG was available by phone or e-mail to answer questions about the content and technical aspects of the health programs as needed. No instructions or recommendations were given to users on program use. The interactive web-based health program (TK-HC) was tested and revised in advance, including usability tests and two randomized controlled pilot trials. The program was then frozen and used throughout the study period without any changes in software development that could have influenced the results . As the TM)  [After completing the first medical examination, participants were given access to the interactive or non-interactive web-based health program. They were authorized to log in to the respective health program for free via the project’s landing page using a personal study account. During the study period, participants received regular e-mail reminders to participate in the health programs, which could be run as often as desired until the end of the study. Participants were asked not to take part in any other physical activity or fitness studies. For successfully completing the study, participants received free medical examinations, an activity tracker  , free acCA, USA) .2max) (mL/min/kg) using the Cooper 12-min run test [2max was calculated from the maximum distance (m) achieved on a 400 m running track with the formula “2max (mL·kg−1·min−1) = (distance in meters − 504.9)/44.73” [To evaluate health goal achievement, we defined physical fitness, specifically cardiorespiratory fitness, as the primary outcome, which was assessed by maximum oxygen uptake (VOrun test . VO2max )/44.73”  (p. 118))/44.73” .As another component of physical fitness, musculoskeletal fitness was determined as a secondary outcome. It was evaluated by maximum isometric strength  with an isometric leg press ,39 and aTM [®Plus software (version 4.8) [TM and dietary records [Behavioral health outcomes were further included as secondary outcomes. Physical activity was analyzed by daily step count (steps/day), sedentary behavior (min/day), and light, moderate, and vigorous intensity physical activity (min/week) via the Fitbit Charge 3TM  and the TM . DietaryTM ,43 by 7-ion 4.8) . As part records .2), fat mass and fat-free mass (kg), and waist circumference (cm) were measured standardized with a stadiometer (seca 274) [Moreover, secondary physiological health outcomes were obtained. For anthropometry, body weight (kg), body height (m), BMI (kg/meca 274) , a bioeleca 274) , and a meca 274) . Waist ceca 274) .1c) (%)) and blood lipids  cholesterol, low-density lipoprotein (LDL) cholesterol (mg/dL)) [In addition, systolic and diastolic blood pressure (mmHg) and heart rate (bpm) were recorded with an electronic blood pressure device  on the l(mg/dL)) .TM system [TM (VAC) software (version 4.0.8) [As a final outcome, vascular health was assessed in terms of endothelial function by flow-mediated dilatation (FMD) (%) with the non-invasive AngioDefenderM system . The 8-mn 4.0.8)  with then 4.0.8) .All outcomes were collected at four medical examinations  (approximately 4–5 h each) with standardized procedures by trained and qualified staff in separated and protected premises of the DSS. For all medical examinations, participants had to appear fasting  with sufficient sleep the night before and in good health. This was asked at each medical examination within an anamnesis completed by the study director, which included documentation of diseases, medication, and adverse events. Data were discussed with the principal medical investigator and used to review the inclusion and exclusion criteria and further study participation. Participants were thoroughly introduced to each examination. If they could not fulfill the examination criteria or complete an examination as required, the examination was repeated. There were no specific risks associated with the medical examinations or the health programs in advance. The availability of the principal medical investigator ensured that immediate care could be taken on-site if needed. He could also stop participation if any health problems arose that precluded further participation in the study. Additional information on all primary and secondary outcomes can be taken from the study protocol .Usage data of the interactive web-based health program were monitored during the intervention and follow-up phase (logins/week) to analyze the effect of program use on program effectiveness. Data were assessed by VHG and sent to the DSS .2max). The calculation required a case number of n = 79 for each study group and, with an additional dropout rate of 15%, a total number of n = 186 (93 + 93). Recruitment activities were stopped when this total sample size was reached [Sample size calculation was performed by SEVERA with the use of G*Power software (version 3.1)  for the  reached ,33.Randomization was performed as permuted block randomization with variable block sizes of 4, 6, and 8 and an allocation ratio of 1:1. Randomization sequences were prepared by SEVERA with RITA software (version 1.50)  and tranParticipants were told about the intervention character of the interactive and non-interactive web-based health program as part of the study information for ethical reasons. They were then able to identify the allocated health program after their first program login and therefore could not be blinded. Blinding of recruiters and outcome assessors was possible by providing information on group allocation only after completion of all medical examinations. In addition, participants were advised not to disclose their group allocation to outcome assessors during the medical examinations on-site. However, it was possible for them to do so. Data monitors and analysts could not be blinded because conclusions about group allocation could be drawn from the data ,33.d was calculated as the effect size with a 95% CI  [Data analysis was performed with R software (version 4.0.5) . Primary effect) . Outcome effect) . As the  effect) .Data collection and storage were done in pseudonymized form and publication in aggregated form. Personal data were kept secure and separate from research data. There was no data transfer to third parties. Deletion of all personal data will occur after three years, and deletion of all research data after ten years. Participants took part in the study and the health programs voluntarily and could withdraw participation anytime through the health programs, the DSS, or VHG. They were briefed on all privacy issues in the study information and gave their written informed consent. In case of withdrawal, the consent form and personal data were deleted, and research data were stored anonymously. Further details are described in the study protocol .N = 318 subjects registered for the study, of which n = 189 were finally included in the medical examinations. The medical examinations took place from January 2020 to December 2021. Thus, the study was conducted during the coronavirus disease 2019 (COVID-19) pandemic. Throughout the study period, n = 83 dropouts and no intervention-related serious adverse events were reported. As an additional n = 10 participants paused individual medical examinations due to the COVID-19 pandemic, n = 96 participants were included in the PP analysis. Fewer subjects were considered if missing data were available for the relevant outcome. For the ITT analysis, all n = 189 participants were analyzed. The detailed flow of participants is visualized in Participants were recruited between January and September 2020. A total of 2max in both study groups over the course of the study is illustrated in 2max improved from 25.94 ± 6.29 to 27.52 ± 5.38 mL/min/kg  in the intervention group and from 26.64 ± 5.77 to 27.80 ± 4.96 mL/min/kg  in the control group  (The change in VOol group . Statist = 0.33) . There w = 0.33) .TM are presented in p < 0.001, d = 0.52; t0–t2: p = 0.008, d = 0.47). No other significant time or interaction effects were found . Otherwise, no significant time or interaction effects were detected  and the control group from 10,110.05 ± 2934.87 to 10,425.40 ± 3059.40 steps/day . In addition, total physical activity decreased from 2276.06 ± 572.77 to 2259.61 ± 511.09 min/week  in the intervention group and increased from 2229.46 ± 423.58 to 2257.68 ± 423.92 min/week  (t0-t3) in the control group . These cre found . Regardidetected .p = 0.039, d = −0.27). For diastolic blood pressure, there was a significant medium-term time effect with a small effect size for the intervention group  and a significant medium-term interaction effect in favor of the control group (t0–t2: p = 0.023) (p = 0.023), so this interaction effect was not considered as given. Furthermore, a significant medium- and long-term time effect with very small to small effect sizes for triglycerides  and a significant short- and medium-term time effect with small effect sizes for LDL cholesterol  were found for the intervention group  . Howeveron group . There won group .n = 104) were classified into the following user types: regular users , half-time users , partial users , rare users , and one-time users . 2max over the course of the study in each type of user compared to the control group. From t0 to t3, data did not indicate a consistent dose–response relationship (regular users: +1.49 mL/min/kg (+6.02%), half-time users: +0.96 mL/min/kg (+3.56%), partial users: +1.52 mL/min/kg (+5.68%), rare users: +1.79 mL/min/kg (+6.19%), one-time users: +4.29 mL/min/kg (+17.32%), control group: +1.16 mL/min/kg (+4.35%)) ) .This study aimed to investigate the effectiveness of a 12-week interactive web-based health program (TK-HC) on physical fitness and health in physically inactive adults. For this purpose, the program was compared with a 12-week non-interactive web-based health program. The effectiveness of the interactive web-based health program in terms of superiority over the non-interactive web-based health program was not proven. Significant time effects were found in the primary outcome and individual secondary outcomes for the interactive web-based health program, but there were no significant interaction effects in any of the primary or secondary outcomes between the interactive and non-interactive web-based health program. There was also no consistent dose–response relationship between different user types of the interactive web-based health program.Web-based lifestyle interventions have emerged as an attractive approach to the prevention and treatment of NCDs due to their compelling advantages ,18,19. Mn = 6055) received a physical activity website, and the control group (n = 6232) was not exposed to any intervention. A subsample (n = 1190) of these participants, who were part of a nationwide survey, was also invited to health examinations. After three months, there were no significant improvements in cardiorespiratory fitness assessed by a watt-max or sub-max test on a bicycle ergometer (−0.40 mL/min/kg vs. +0.30 mL/min/kg) or musculoskeletal fitness assessed by a hand grip test (+0.60 kg vs. −2.40 kg) in the intervention and control group. Additionally, no significant improvements in BMI (−0.10 kg/m2 vs. ±0.00 kg/m2), waist circumference (−0.10 cm vs. −0.50 cm), fat mass (±0.00% vs. ±0.00%), or systolic (+0.10 mmHg vs. ±0.00 mmHg) and diastolic blood pressure (−0.30 mmHg vs. −0.40 mmHg) were observed in both study groups. Our results were almost consistent with this study and revealed only a significant time effect in cardiorespiratory fitness in the intervention group  was provided with a pedometer, an information booklet, and computer-tailored step advice, while the control group (n = 137) was given no intervention. After three months, pedometer-based daily step count increased significantly by 1064.91 steps/day in the intervention group, compared with a decrease of 24.72 steps/day in the control group. Our results showed a non-significant increase of steps/day measured by the Fitbit Charge 3TM in the intervention and control group after three months (see n = 119) was offered a web-based physical activity program (Philips DirectLife), and the control group (n = 116) was assigned to a waiting list. After three months, there was a significant increase in daily moderate-to-vigorous intensity physical activity, as measured by a wrist accelerometer, of 11.10 min/day in the intervention group, compared with a decrease of 0.10 min/day in the control group. Moreover, body weight (−1.49 kg vs. −0.82 kg), waist circumference (−2.33 cm vs. −1.29 cm), fat mass (−0.64% vs. +0.07%), and HbA1c (−0.05% vs. −0.01%) improved significantly more in the intervention group than in the control group. In our study, there was a non-significant decrease in weekly moderate and vigorous intensity physical activity measured by the Fitbit Charge 3TM in the intervention and control group after three months. Furthermore, improvements in body weight, waist circumference, fat mass, and HbA1c were also not significant in both study groups after three months  participants of the intervention group were classified as regular users, but there was no consistent dose–response relationship between the different categorized user types. As our analysis was based only on the weekly login behavior of the users, a more detailed analysis and, thus, a better control on the part of the study may have provided further information on whether participants were using the intervention appropriately, e.g., considering endurance and strength activities. In addition, our study participants had the opportunity to give open, qualitative feedback on the interactive and non-interactive web-based health program within each anamnesis, which was noted by the study director. Feedback from participants of our intervention group indicated that the interactive web-based health program may not have been sufficiently developed. Participants reported that the program was very well-founded and interesting but that its usability could be improved. The program was further perceived as complex and time-consuming. Participants also asked for more guidance within the program and more suitability for everyday use, e.g., through an app. Particularly during the COVID-19 pandemic, with high levels of personal and work-related stress, it was challenging for participants to use the program.Possible explanations for our study results may be found within the current scientific literature. Eysenbach  describeTM to achieve their personal health goals. However, this feedback was open and voluntary, so it should be treated with caution. A standardized evaluation of the activities of the control group participants may have provided more reliable information. Taken together, these two issues of the intervention and control group may have led to what is known as “bias towards the null” [On the other hand, it is difficult in evaluating web-based interventions to ensure that the control group is really a control group and not using other web-based interventions out of disappointment at not receiving the intervention. It is therefore recommended to assess the use of other web-based interventions among control group participants . Qualitahe null”  (p. 2), 2max) were performed, which are not presented in this article. These analyses showed that age and gender did not affect the results. This study also had a high dropout rate, so the calculated sample size could not be maintained until the end of the study. The ITT analysis was performed to account for this. In addition, it was not possible to blind participants, which is common in eHealth trials [In addition to these difficulties, namely the two issues of the intervention and control group, this study had further methodological limitations that may have influenced the results. First, it should be noted that the study population was defined very broadly. However, it had to correspond to the target group of the interactive web-based health program. To assess potential influence of age and gender, additional adjusted PP and ITT analyses for the primary outcome  was measured using the Cooper 12-min run test, which has been shown to be a valid field test for estimating cardiorespiratory fitness [TM as a measurement tool for both study groups, but there is evidence that Fitbit-based interventions can increase physical activity behavior [Moreover, from a measurement perspective, our study participants may have been more motivated due to the face-to-face assessments on-site than participants of the online trial or other purely web-based trials. However, this was not seen in our data. Further, it was challenging to provide a feasible and standardized assessment of physical activity and fitness in our large sample size. The primary outcome (VO fitness ,65. Musc fitness ,67. Howe fitness , as strebehavior . Despitebehavior ,71, sevebehavior .Finally, it needs to be mentioned that this study was conducted during the COVID-19 pandemic. Studies have shown that this pandemic had a negative impact on physical activity behavior worldwide . As mentTaken together, these limitations may reduce the generalizability of our study results. Given the methodological approach and the difficulties encountered, our study could not provide evidence of the superiority of an interactive web-based health program over a non-interactive web-based health program. For future studies, we would like to suggest several recommendations. Studies evaluating web-based lifestyle interventions to promote physical activity and fitness should establish more pronounced differences between the intervention and control group. For the intervention group, it is essential to ensure that the intervention is used appropriately. To verify this, detailed usage data should be collected. For the control group, it should be considered whether a waiting list would be better than a control intervention, and the use of other web-based interventions should be evaluated. A high level of control of the intervention and control group with reliable data may provide helpful information to justify the study results. Furthermore, the study population should be narrowly defined to minimize variability in the data, and the study sample should be large enough to achieve the required sample size despite a high dropout rate. Attention should also be paid to the specificity of training and testing methods used to assess physical fitness. In addition, it is important to differentiate between the intervention itself and the measurement tool used to assess physical activity. With regard to the health program being evaluated, it is important that the program has been sufficiently developed and previously tested. On the one hand, it should offer a high level of usability, and on the other hand, it should guide the user through the program in a targeted and close way to achieve health-promoting effects. Overall, we definitely need more randomized controlled trials to evaluate the effectiveness of web-based lifestyle interventions.This study examined a 12-week web-based lifestyle intervention to promote physical activity and fitness as part of a multimodal health program. The effectiveness of this interactive web-based health program in comparison with a non-interactive web-based health program on physical fitness and health in physically inactive adults was not demonstrated. However, this study included an elaborate assessment of objectively measured health outcomes and was part of a nationwide evaluation project during the COVID-19 pandemic. Further research is needed to extend the available evidence on web-based lifestyle interventions to promote physical activity and fitness.


The challenges faced by the low and middle-income countries (LMIC) in the field of public health management calls for the capacity building of qualified and trained public health managers in order to improve the effectiveness and efficiency of the health care delivery system. Most of the existing training programs for public health management are based in the settings of developed countries, which hinders their application in LMIC countries. The objective of this paper is to document the process of development and evaluation of a capacity building program for public health managers of various LMICs.A training program was developed using Kern’s six-step framework with several innovative learning and assessment methodologies and evaluation using Kirkpatrick training evaluation model. Delphi technique was used for program development.This five to ten-day partly/fully funded six International Public Health Management Development Programs (IPHMDP) programs was conceptualized which enrolled 178 participants from 42 countries between years 2016 and 2019. Based upon the elaborative discussion in four rounds of Delphi technique, the problem and challenges faced by public health mangers and eight key competencies  were identified. The group consensually agree upon a blended teaching methodology comprising of chalk and talk approach, inquiry based learning, participatory student based learning, small group instructions, gamification, project-based learning and field-based learning. There was a significant increase in participants’ knowledge score (P<0.0001) after all programs especially in the competencies of monitoring and evaluation, followed by project/ program planning, supply chain management and quality management. The majority (90%) submitted their action plan one week following the program, out of which 64% implemented their action plans within six months. A majority (54.7%) of participants were able to implement their learning once they went back by conducting similar training/ workshop/webinars in their settings.The comprehensive public health management program in LMIC settings strengthens the competencies of public health managers which can be replicated in similar settings across LMIC to mitigate diverse challenges in public health management. Public health management workforce is defined as “the stock of all individuals engaged primarily in the improvement of the health of populations” . These aCapacity building in managing public health has been a mandate of various development organizations. For example, World Health Organization (WHO) has emphasized giving the right training to the right people to create an effective workforce for the delivery of healthcare . SimilarVarious developing economies have made significant progress in the last two decades in the realm of public health management. However, there has been the poor quality of service delivery, inefficient recruitment and retention system, lack of skill-based training of program managers leading to a critical shortage of trained human resources . FurtherIn addition to this, most of the existing programs on public health management for Low and Middle income countries (LMIC), which have poorer health indicators as compared to high-income countries, are based in the settings of developed countries, which hinder their application in LMIC countries as they may theoretically train the participants in tools and techniques but fails to instill confidence in their application in respective countries. Svadzian A, et al. in their recent article has also advocated for having programs in LMIC settings and had put forth their perspective that “we should still ask why an African trainee must go to London or Boston to learn about control of sleeping sickness or malaria (and pay top dollars for such training)” . The traTo address these gaps, there is a need to devise a comprehensive public health management program in LMIC settings that can build the competencies of public health managers of LMIC to manage the existing and emerging public health challenges effectively. After undergoing such a program, it is expected that the public health managers should be able to effectively contribute towards the overall improvement of the health care delivery system to achieve SDGs in limited-resource settings . The objThe Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India, is an autonomous “Institute of National Importance” by an Act of Parliament of India functioning directly under the Ministry of Health and Family Welfare, Government of India. The institute is rated second best for medical education, training, and research in India. Department of Community Medicine, instituted in 1977, has been a pioneer in teaching, training and research activities. To address emerging challenges in public health training and education, the department was upgraded to School of Public Health (SPH) in the Tenth Five Year Plan of India (2002–06) . The depThe five days (later became ten days after request from participants) biannual International Public Health Management Development Program (IPHMDP) was conceived in the year 2016 in technical collaboration with the developmental partners the International Against Tuberculosis and Lung Diseases (The Union) and Chitkara University, Punjab India, with an overall goal of building the capacity of public health managers working at the sub-national and national level of LMIC, who can improve management processes and practices within their organizations. The specific objectives were: change in the knowledge about various managerial competencies, satisfaction score of participants on program logistics and technical learning, and implementation of learning of program in their program setting.Before the actual conduct of the program, the program took three months for its development, including finalization of the course content, flow, methodology, course design, and faculty. Kern’s six steps framework guided the development process. The model was initially developed to provide a practical, theoretically sound approach to developing, implementing, evaluating and continually improving educational experiences in medical sciences; however, later it has been applied to several other health science curriculum –34. The “S1 Annexure” Besides, the national health plan and SDG indicators of the participating countries were accessed and discussed. Thereafter list of competencies were presented to experts which was followed by extensive discussion on competencies required by a public health manager along with gaps in existing management and leadership programme across the globe. Then, the first author (SG), build consensus on the competencies to be included. In the second round the experts revisited the competencies. Based upon the competencies finalized by the experts, the tool (e.g.: knowledge questionnaire) to access them were developed. Further, the feedback questions about the program along with an action plan format (viz. a detailed plan outlining the action to be implemented at their workplace) were evolved. An agreement to list of questions in the various tools were reached after two rounds of Delphi technique.The Delphi technique is a group consensus for developing new concepts . Around In the third round, the goals and objectives of the program were developed. During this phase, the experts were instructed to compile prospective goal and objectives through the competencies finalized in earlier rounds, supplemented with literature search. The list of objectives were then presented in third round which was followed with discussions which led to their finalization. The discussion led to one goals and seven possible objectives. Thereafter these objectives were placed against the predefined competencies finalized during second round of Delphi technique. Two objectives were eliminated after detecting duplications whereas two were eliminated as they were quite narrow and just related to single competency desired for the program. During this round, the educational approach for conducting the program was also finalized wherein the expert shared their experiences with attending or conducting prior similar programs by them. Thereafter, during the fourth round, the program faculty along with dissemination policy was discussed and finalized.The evaluation of the training program is done based upon Kirkpatrick training evaluation model. The 4 level model is described as ‘the worldwide standard for evaluation of training effectiveness’ and its use has been documented in several healthcare training programs –41. LeveData on various tools of program  was collected through Google Forms which was exported to MS Excel followed by. For each pre- and post-question, a correct response was scored “one” and an incorrect response was scored “zero.” The difference between pre and post mean competency score was calculated for all modules in the program. The feedback of program was assessed for parameters using the five-point Likert scale . The analysis was done using the Statistical Package for Social Sciences (SPSS) version 20.The institutional review board of Postgraduate Institute of Medical Education and Research exempted this study from ethical review (IEC-08/2020/ 1743).A total of 6 IPHMDPs were conducted between the years 2016–2019, in which 178 participants from 42 countries attended the programs, 36 participants in first program, 27 in second, 35 in third, 24 in fourth, 24 in fifth and 32 in sixth. Out of total, there were 69 (38.7%) females and 109 (61.2%) males. Majority of participants were post graduates . Out of total, 87 were from India, and the remaining 91 participants were from Africa, South America, Asia, and Europe regions. The results of the study are presented through the Kern’s six steps and Kirkpatrick 4 step frameworks. The primary problems and challenges of public health managers identified by Delphi panel were the poor capacity to plan, impalement and evaluate programs or initiatives, inadequate supplies, and logistics, limited knowledge on financial management, poor health information management systems, lacking communication skills, lack of human resources along with limitations on effective leadership. Besides, the experts cited that lack of formal management training along with their theoretical and extensively elaborative curriculums are primary barriers to effective public health management. Based upon the consensus, it was felt that the creation of a well-designed public health management program is an opportunity to build management competencies of public health managers of LMIC for the overall improvement of health indicators of the country. A list of eight key competencies to address the felt need of participants were then finalized which were: leadership and governance, project/ program planning, financial management, supply chain management, quality management, human resource management, monitoring and evaluation, and communication. Based upon the competencies, a total of 8 modules were proposed for the entire program.Based upon the discussion during Delphi technique, 100% expert agreement was reached for three objectives which were: change in the knowledge about various managerial competencies, satisfaction score of participant on program logistics and technical learning, and implementation of program in their setting.During third round of Delphi discussion, various teaching and learning techniques were discussed. The majority of Delphi members reached to the consensus on following methods: chalk and talk approach, inquiry based learning, participatory student based learning, small group instructions, gamification, project-based learning and field-based learning. The experts were in the agreement that selected participants should undergo e-mentoring before the actual course, where pre-reading material should be shared to familiarize them with the program’s content. During the course, the 2–3 day field-based assignments pertaining to core competencies of program were proposed in the nearby jurisdictions (of program settings) for demonstration of the good and replicable practices relevant and contextual for LMIC settings. For this, experts reviewed and finalized possible good and replicable practices based upon the listed competencies which can be demonstrated to the participants.  The expeThe expert’s selection dwelled upon the selection of participants and resource faculty along with dissemination strategies of the program. They consensually opined that the persons who have been working for the effective and efficient delivery of healthcare programs and projects should be the participants. A written commitment about replication of the program’s learning was sought to be taken prior to the selection of participants. The resource persons were selected from leading public and private healthcare organizations, national and international developmental agencies, academic institutes, and non-governmental organizations working at the grass-root level, who have prior experience and expertise in delivering the competencies of the program.For the national courses , the selection of participants was sought to be made one-two month prior to the program through an open call for applications and wider circulation through major professional groups, letters of nomination to government organizations, emails to professionals, and technical partners and postings on various social media handles including the institute websites. The international participants from LMIC were nominated by their respective governments through the Indian Technical and Economic Cooperation (ITEC) programme under the Ministry of External Affairs, Government of India. These programs are designed to build the capacity of professionals from 161 countries in Asia, Africa, East Europe, Latin America, the Caribbean, and Pacific and Small Island countries in demand-driven emerging areas of shared concern along with the development of mutual cooperation and partnerships. A group of 20–40 participants were pronounced to be selected by taking representations from different states of country/other countries, gender, academic profile, organization, and experience.The evaluation of the training program was also done in four stages of Kirkpatrick’s model viz. reaction, learning, behavior and results .The satisfaction regarding the logistics of the program and information sharing with them prior to the program was reported as “good” by 160(89.8%) participants, whereas 14(7.7%) and 4(2.5%) rated it as ‘average’ and ‘poor’ respectively. 158 (90.1%) responded that the venue had all requisite facilities and necessary comforts. The presentations prepared and the pace and the sequencing of the sessions was reported as “good” by majority of the participants  and  respectively.The following quotes express the participants’ opinions regarding satisfaction or favorable component of reaction.The planning and designing of the program as wonderful. It was time bound and systematically managed but can be extended to 2 weeks for better learningLearning environment through management games and videos during the break was very innovative. They helped us to practically apply the learnings at our workplace.Accommodation, transport, training hall were very well organized. The stay was very pleasant & comfortableIn engagement, 161(90.6%) of the participants responded ‘good’ on the effectiveness of the mix of methodologies and 170(89.9%) participants said they were engaged in active learning. 171 (93.6%) agreed to the appropriate number of participants in the program, whereas 169(95.3%) and 170(94.2%) responded faculty and support team of the program were effective.Regarding the program’s ‘relevance’, most participants opined that they had prior knowledge regarding the takeaway" from the program. 173 (97.3%) respondents agreed to the relevance of program to their work setting while  agreed to the fact that such training programs should be incorporated into their routine practice for professional development. 168(93.6%) participants said the program met its stated objectives, and 148(92.5%) believed the program was relevant to their job responsibilities. The majority, 165 (96.6%), agreed that the resources/material provided would be helpful in their program settings.The following quotes express the participants’ opinions regarding ‘engagement’ component of reactionThe speakers from various backgrounds were very good, highly experienced and motivating. They have well-prepared presentations, case scenarios, and group activities.A systematic approach of organizers, blended with personal attention was outstanding.Perfect blend of innovative teaching methodologies was the USP of the program. Action plan and Field tours are real learning sources in the programThe program helped in my personal development & my career and will be role model to other programs in India and Globally.167(96.1%) participants opined that they strengthened the knowledge and competencies in the selected area of public health management. 160(82.9%) participants felt that the program increased their familiarity with ‘state of the art and good practices’ in public health management. The confidence was reported by 160 (90.9%) participants who overcame language & other barriers for better understanding during the program. The majority  agreed to the fact that the programs helped them in developing networks & relationships with other participants. Also, there was a significant increase  in their knowledge and skills for countering the public health problems in the country after attending the course. The commitment to apply the learning’s at work was quoted by 167(94.9%) participants, whereas 172(95.8%) assured to recommend the program to their colleagues on going back to their respective countries.The learning was also evaluated through pre post-examination conducted at the beginning and end of the program. The figure shows the difference of mean competency score of the participants attended 6 IPHMDPs.  There waThe following quotes express the participants’ opinions: regarding the ‘learning’ level of Kirkpatrick model:The content and flow of presentations were simple and understandable. Pre-read material and reading materials were very informative and interestingInteractive sessions, including role-plays and games were very productive. They added flavours to teachingPractical information imparted was of utmost relevant to our work areas.160(90%) of the participants submitted their action plan about one topic following one week of the program in the behavior level. Of these, 115(64.6%) reported the implementation of their action plans within six months. The majority 63(54.7%) participants conducted similar training/ workshop/webinars in their settings, while rest were engaged in health promotional activities 4(3.47%), collaboration 7(6.08%), and implementing knowledge learnt in academic/program settings 24(20.8%) .We learned the theoretical concepts of public health management and now we can implement them with determination in our organization.The program helped me in designing and implementation of health activities in our day to day settingsA total of 165(92.9%) rated the program as “good”, 8(4.6%) rated it as ‘average’ and 4(2.5%) reported it as ‘poor’.Public health management training is often being overlooked by organisation of LMIC but has shown a significant difference in operational efficiency, staff satisfaction and effectiveness, and quality improvement ,43. The The study has several strengths. Firstly, a well-designed comprehensive curriculum enabled participants to develop competencies for designing, implementing, monitoring, and evaluating program/ project operations in their respective countries. It equipped participants in leadership competencies and on appreciating gaps in current health scenarios in their countries and envision future trends in health care management for effective decision making. Second, the two validated frameworks  were used to diagnose the existing problem and need of LMIC and further evaluate the implemented program. Third, the continuous quality improvement of the subsequent training programs was done by incorporating feedback of stakeholders. For each programme appropriate changes were incorporated. For example, the feedback from participants and alumni lead to increased number of training days from 5 to 10 days. Also, e-mentoring was proposed in later programs to the participants. Further, the change based on feedback from resource persons leads to the development of country-specific case studies as a resource material; which lead to cross culture learning and the sharing of ideas and strategies. This continuous improvement through the course amplified the relevance of the program and the sustainability of the program. Fourth, the output-oriented curriculum lead to application of learning’s in their respective settings which boosted the confidence of the participant, eventually leading to increased performance and productivity of the organization.The study’s key findings were its uniqueness in production and implementation of a need-based curriculum for public health mangers demonstrating enhanced satisfaction of training, relevance, and adequacy at LMIC settings. This curriculum was purposively developed to let the participant have an exposure of adult learning methodology along with application-based learning. The schedule not only demonstrated the development process of the curriculum which could be implemented by other LMIC, but additionally present findings regarding participant engagement, satisfaction, and relevance. The highlight of current capacity building program in terms of information dissemination, selection of participants, selection criteria was found similar to the study by Ramsay et al. . The traThe model used in the study has a few limitations. The model measures what participants have learned, but does not measure the involved interest and motivation factors behind the learning. During subsequent programs the perceived motivation of participants could be sought. The model does not talk about the impact of skills demonstrated during the program or the program’s long-term effects on change in moral behavior, or the program’s financial impact. We are working upon to access the long term changes on their moral behavior and program outcomes. Besides the model, the study also has few limitations. The current study has a relatively small number of participants in a particular geographical region and health system context. This can be eliminated by enrolling an almost similar number of participant’s different WHO regions. Further the participants demanded translating lectures in their respective languages, which was not feasible due to the increased cost. In future, recorded lectures can be uploaded on some modern IT software where different languages are available The other challenge was the dropout rate from a long-term follow-up on the action plan implementation. Without a separate financial support in place, it becomes difficult to continuously follow up with the participants in terms of long-term outcomes, post-program implementation of the learning’s from the program. The effort can be put into developing the curriculum having an online version of the course would help to reach more people across boundaries.The current public health management program was effectively developed and implemented in LMIC settings to enhance the knowledge, competencies, and self-sufficiency of global participants of LMIC settings for strengthening their country’s health systems. The organizations, government, and non-government should carefully adopt the interventions in the program for individual and organizational growth based upon their contextual settings. The study also suggests a few recommendations and way forward for conducing similar programs. First, the LMIC based public health management programs will have a more significant impact from an implementation point of view due to the application of contextual learning back at the workplace. Second, the curriculum of the public health management program should be integrated with graduate and postgraduate education systems in strengthening public health management. Third, the integration of PHM alumni for training the upcoming programs will enhance the competencies and confidence of the participants. Fourth, the program’s reach can be increased by providing an online platform to facilitate the participation of more countries who cannot attend because of time and resource constraints. Fifth, collaboration with various stakeholders-nationally and internationally is needed for increasing visibility and robustness to the program. The financial or/and technical support for its sustenance is required to strengthen global health systems.S1 Annexure(PDF)Click here for additional data file.


The Florida-California Cancer Research, Education and Engagement (CaRE2) Health Equity Center is a tri-institutional, bicoastal center created to eliminate cancer health disparities among Black/African American and Hispanic/Latino/a populations living in California and in Florida. The CaRE2 Center created a Community Scientist Research Advocacy (CSRA) training program for community members to become cancer research advocates. The CSRA program is currently a 13-week program conducted 100% virtually with all materials provided in English and Spanish for participants to learn more about prostate, lung, and pancreas cancers, ongoing research at CaRE2, and ways to share cancer research throughout their communities. Participants attend didactic lectures on cancer research during weeks 1–5. In week 4, participants join CSRA self-selected groups based on cancer-related topics of interest. Each group presents their cancer-related advocacy project developed during weeks 5–12 at the final session. In this paper, we describe the CaRE2 Health Equity Center’s CSRA program, share results, and discuss opportunities for improvement in future program evaluation as well as replication of this model in other communities.The Community Scientist Program (CSP), a model connecting researchers with community members, is effective to inform and involve the general population in health-related clinical research. Given the existing cancer disparities among Black/African American and Hispanic/Latino/a populations, more models describing how The online version contains supplementary material available at 10.1007/s13187-023-02351-3. Community Scientist Programs (CSPs) have been valuable in increasing community engagement, knowledge, and awareness of research, trust in scientific research, and the quality of research conducted. CSPs help train community advocates in cancer research, providing them with necessary tools to help bridge the gap between scientists and the community at large. Trained community scientists can contribute to cancer research by serving on advisory boards, disseminating information, helping recruit participants, and serving as a bi-directional voice of the community in research. The application of a CSP model within diverse communities is relatively recent with a small body of peer-reviewed literature describing programs that share evidenced-based information about cancer prevention, screening, and treatment, tailored to populations at-risk for cancer , 2. The Dissemination of cancer research and participation in cancer research among B/AA and H/L populations present several challenges, including structural barriers to participation , fatalistic attitudes about cancer prognosis, and mistrust of clinical trial and healthcare systems , 11. TheThere is an increase in community-level engagement models being used  to creat2 Health Equity Center Community Scientist Research Advocacy (CSRA) training program, with the goals of informing, educating, and empowering community members to become cancer research advocates in FL and CA. The CSRA program is modeled after a successful educational program from the American Association for Cancer Research (AACR), the Scientist→Survivor Program (SSP) ), with 30% being from FL , and 5% from Georgia (Gwinnett County [N = 1]). Participants reported learning about our program by the following methods: Twitter, community organizations, or referrals from a CaRE2 Center member, family, and/or friend. The program launched on March 21, 2022, with 18/20 participants who met the requirement of attending at least 80% (10 weeks) of virtual training sessions. All of the CSRA participants identified areas for advocacy, resulting in at least 4 working groups that examined breast, lung, pancreas, or prostate cancer.All applicants N = 0 who appp = 0.2). Participants had a mean (SD) score on knowledge questions of 60.0 (14.6) when assessed mid-way through the program and a mean score of 68.2 (11.0) when assessed at the end of the program (post-survey) (p = 0.13). Tables There were 20 responses at the start of the program, whereas 16 responses were received at mid- and post-program due to attrition of two participants and no response from two other participants. Overall, across all knowledge questions, participants had a mean (SD) of 67.9 (7.9) at pre-survey and a mean of 71.4 (9.0) at post-survey  p = 0.1. Tables Participants’ knowledge regarding aspects of prostate cancer such as whether African American men are more likely to develop prostate cancer, what does the prostate do, what is prostate cancer, as well as the meaning of a high prostate-specific antigen (PSA) test was higher at the end of the program  compared with responses midway through the program Table . WhereasThe percentages of participants answering correctly about laryngeal cancer, squamous cell carcinomas, as well as the purposes and types of biorepositories used to collect samples increased by program end with significant increases observed for knowing what types of samples are collected and stored in biorepositories. On the other hand, the percentages of participants answering correctly on questions related to Social Determinants of Health (SDOH) were lower at program end compared with the percentages of participants answering correctly on SDOH questions midway through the program Table .p = 0.5). Overall, the percentages at the end of the program were not statistically significant compared to at the start of the program. Shown in Table We used a Likert scale to evaluate program expectations, which resulted in a mean (SD) of 94.0 (8.8) of participants who “agreed” that they were satisfied with the program at the start compared to a mean (SD) of 91.0 (12.9) of participants who “agreed” that they were satisfied with the program at the end  was in English and Spanish via translated materials or using synchronous translators, thus allowing monolingual Spanish-speaking participants (N = 2) to fully participate. Also innovative was the fact that the program was implemented in a 100% virtual environment, which allowed for each participant to interact and subsequently present their cancer research advocacy projects bicoastally in FL and CA. Offering the CSRA program through a virtual environment allowed for increased participation and program completion across the three institutions’ bicoastal locations and allowed for interactions between cancer advocates across the two coasts. Finally, we highlight the innovation that the CSRA program faculty and staff provided mentorship and guidance to teams as they worked to complete their advocacy projects, such as inviting experts, promoting their advocacy projects, and identifying required resources from evidence-based resources .Our CSRA model has several innovative aspects compared to other cancer community scientist programs –17. HaviUnderstanding Pancreatic Cancer (June 2022) and Breast Cancer Research (July 2022). Since our 2022 program, a program alumnus was selected to be a Breast Cancer Research Advocate for Susan G. Komen in Washington, DC, in June 2023 at the Advocacy Summit on Capitol Hill.Key strengths of the program include recruitment of participants that exceeded expectations, participation of guest speakers who presented on cancer research  related topics, repeated evaluations focused on knowledge, and program expectations throughout the program. Importantly, all participants agreed that they would make a greater impact in their communities given their participation in the CSRA program. Moreover, the CSRA program advocates successfully implemented their advocacy projects. For example, two webinars with both CA and FL participant collaboration included We recognize the opportunity to reassess our curriculum and evaluation processes to see a clearer trend within our program results about the overall program training approach. We recognize that a cohort of 20 participants is a limited number of respondents to detect significant differences in knowledge or program effectiveness and that our knowledge questions need to be more rigorous to avoid a ceiling effect at the beginning of the program, which reduces the potential to show a significant increase. Unfortunately, the cohort size is limited by grant funds and available team members. To achieve greater survey rigor, we will ask our didactic lecture speakers to provide learning objectives/goals and questions for their presentations, add questions related to our self-guided learning materials, and provide each participant with a code number to identify responses over time. Finally, we will assess each participant’s application, such as education level and primary language, to assure we are tailoring the content to the correct audience and using better targeted survey questions.2 Center labs at respective institutions. Switching to a virtual platform required a learning curve among participants on how to use Zoom, including use by our Spanish translators. In addition, internet or Wi-Fi sometimes failed for CSRA program participants and faculty. Other challenges included time management across three bicoastal institutions in different time zones. Despite these challenges, the CaRE2 Health Equity Center CSRA Program is a unique and effective health promotion model where participants learn about cancer research. They also gain skills in planning, developing, and implementing an advocacy project, as well as presenting projects to their community members and cancer scientists. Another setback of our program results is attrition and/or not completing the surveys, which affected the analysis of the pre-knowledge survey (N = 20) and post-knowledge survey (N = 16). Moving forward, we plan to measure longitudinal reach and impact of CSRA alumni through biannual contact that assesses advocates’ ongoing cancer-related activities and involvement resulting from CSRA program completion.Implementation of the CSRA program was met with several challenges. For example, the COVID-19 pandemic introduced setbacks given that we were not able to offer the planned in-person experience in CaREWe have taken our lessons learned to restructure our program for the new 2023 cohort, in hopes for a more accurate measurement of increase in knowledge and program expectations. We have additionally taken into consideration participant feedback from our program evaluation survey. As we evaluate our program further, we continue to include our Community Advisory Board in participant selection, as well as biostatistics experts in our ongoing program planning. To strengthen our program, we look to add the involvement of program alumni to help with feedback and evaluation for our program. These planned changes are consistent with the increased attention to patient public involvement (PPI) in research design and recruitment  in cancer programs, which we may find useful as our program continues to develop and is evaluated each year , 26.A key recommendation for replication of our program is emphasizing the need to tailor the program to the population in the corresponding catchment area. This includes the use of simultaneous session translators, material translations, and materials that accompany the training, as well as consideration of literacy level of participants. Other recommendations include, effective evaluation methods, advance program planning, time management, and a well-versed implementation team. Our program was bicoastally implemented, which takes successful coordination as well as considering the program teams’ different time zones. We recommend obtaining materials from an accredited institution(s) or organization(s) via online, in-person, or mail, such as but not limited to the NCI or American Cancer Society, that best serves your program structure and participants.In summary, we present an innovative community scientist research advocacy training program, uniquely developed for B/AA and H/L communities with a focus on disseminating information about cancer health disparities in these communities. We achieved our goal to train a workforce of trained advocates that can serve as a bidirectional bridge between cancer scientists and the community at large. Our program can be adapted to serve the needs of different communities.Supplementary file1 (PDF 101 KB)Supplementary file2 (PDF 264 KB)Supplementary file3 (PDF 319 KB)Below is the link to the electronic supplementary material.


Background: Existing efforts to understand school-based child sexual abuse (CSA) prevention programs mainly focus on the effectiveness of these programs in increasing participants’ CSA knowledge and self-protective skills. There are currently no reviews addressing the underpinning pathways leading to these outcomes. In order to increase our understanding about the underpinning causal and contextual factors and inform the further development of school-based CSA prevention programs, a realist review was conducted to synthesize existing evidence from a broad range of data. Methods: An iterative search of electronic databases and grey literature was conducted, supplemented with citation tracking to locate relevant literature. For quantitative evidence, we considered evaluation studies that focused on students aged 5–18 years, who were enrolled in primary or secondary schools; for other types/formats of studies/documents, no population restrictions were applied. We included school-based CSA prevention programs that focused on improving knowledge of CSA or self-protective skills. Outcomes of interest included knowledge of CSA or self-protective skills. We did not apply methodological filters in terms of the types of studies to be included. Thematic content analysis was conducted to synthesize data. Results: Sixty-two studies were included. Five themes and five overarching Context-Strategy-Mechanism-Outcome configurations (CSMOs) that contributed to the success of school-based CSA interventions were identified, including tailoring programs to participants’ cognitive developmental levels, repeated exposure of key concepts and skills, utilization of interactive delivery methods and positive feedback, delivery of positive information and application of the ‘train-the-trainer’ model. Implications: Findings from this realist review provide insights into the underlying program theory of school-based CSA prevention programs, which can aid in the development and implementation of these programs in the future. The most recent meta-analysis of 55 studies from 24 countries showed the prevalence of CSA  to range from 8% to 31% for girls and 3% to 17% for boys . CSA is lt women . The recvary considerably depending on who delivers it, to which learners, in which circumstances, and with which tools and techniques’  as well. Thus, all coded components were aligned using a Context-Strategy-Mechanism-Outcome (CSMO) configuration framework, which was further translated to an ‘tatement . This retatement .Figure 1In order to develop an initial program theory, a scoping review of the literature was conducted. The initial scoping phase was intended to serve as a foundation for locating or developing the initial program theory. We examined both included and excluded studies of a systematic review of school-based CSA prevention programs , and an th 2020: EMBASE, Medline, ERIC, EMBASE, the Cochrane Database of Systematic Reviews, PsycINFO, CINAHL, Campbell Database of Systematic Reviews, China Academic Journals Full-text Database and Wanfang Database. We also completed forward and backward citation tracking, contacted authors and searched grey literature such as OpenGrey, abstracts from ProQuest, WHO child maltreatment database, ClinicalTrials.gov and organization websites such as UNICEF and Save the Children. Initial and final search strategies are described in Supplementary Appendix A. We ceased the search when there was sufficient evidence to refine the final program theory.We then systematically searched the following electronic databases from inception to March 30Supplementary Appendix F for the examples of data extraction). This was because more distal outcomes, such as decrease of CSA prevalence would require longitudinal data  in the refined program theory , presence of a supportive family  and social environment  and key strategies  are applied to the program implementation process (S), then participants’ knowledge of CSA or self-protection skills will increase (O), because the programs increase their motivation and interest in learning about personal safety, and empower them to learn more about CSA prevention knowledge (M). As a result, their understanding of CSA will change.A total of 44 studies were included to develop the initial program theory. The characteristics of included studies are listed in Supplementary Appendix B.Supplementary Appendix D.Included studies were published between 1987 and 2020. The included English-language studies were mainly published in the United States, with a small number of studies published in Australia, Canada, China, Ecuador, Germany, Indonesia, the Netherlands, New Zealand, South Korea and the United Kingdom. Among the included studies, there were seven Chinese-language studies. A wide range of documents were included, 57 of which were journal articles, including 38 quantitative studies , three qualitative studies (e.g. interviews), 15 reviews  and one mixed methods study. In addition, we included two commentaries, one critique, one magazine article and one book chapter. Details of the characteristics of the included documents are presented in Before discussing the CSMO configurations, we first present two overarching concepts that emerged from the thematic content analysis of the included studies.empowerment was frequently used in the included documents as the underlying theoretical basis guiding the development and implementation of school-based CSA prevention programs. Empowerment is a process by which individuals and groups gain greater control of issues of concern to them  when programs take children’s different cognitive developmental levels (C) into consideration. It is also important to tailor the program to children’s various needs, including 1) special needs for children with disabilities and 2) different age groups (S) such that participants are able to integrate CSA concepts and self-protective skills into their cognitive repertoire and learning processes (M).Evidence: Ten included studies supported this CSMO and Piaget’s cognitive development theory was frequently referenced as being core to the success of school-based CSA prevention programs   . In addige arts) , and thage arts) .Second, age was also identified as an important factor that contributes to better knowledge outcomes. For example, one study which reviewed CSA prevention programs noted that for complex concepts, older students obtained higher knowledge scores than younger students on questionnaires . InsteadCSMO 2: Participants’ knowledge of CSA and self-protection skills will increase (O) when the program involves repeated exposure to the key concepts (S), which will enhance participants’ understanding of program materials and reinforce key concepts and skills taught in the program (M). The contextual factors (C) that appears to influence this configuration are parental involvement and socio-economic status (SES).Evidence: We identified 18 studies that provided support for this CSMO. Included studies showed that repetition and reinforcement were necessary to optimize program effectiveness and improve participants’ knowledge outcomes. For example, one study found that there was a need to deliver the program ‘in a powerful manner’  found that students should not attend programs for one brief session only and that one single session may not be appropriate for all ages  involving parents during the program implementation process, such as providing training for parents or informing them of what children have been taught at school  provool e.g. . It is aool e.g. . Moreoveool e.g. .Involving the family in the educational process may help reduce the secrecy surrounding the topic of CSA, and may stimulate parent-child discussions about sexuality in general…Children trained by their parents would also receive repeated exposure to prevention information in their natural environment, thus providing a series of “booster sessions” to enhance generalization’ .‘The mechanism underlying this intervention strategy was described in one included study as follows:The supportive environment was also viewed in included studies to create a safe space for children to disclose CSA that has already taken place or if it occurs in the future. This is discussed further in CSMO 4 below.SES status was found to be another contextual factor contributing to differences in children’s knowledge gains. In particular, children from lower SES communities were identified in two studies as being at greater risk of CSA due to their lower knowledge and skill base, and as experiencing fewer gains from CSA prevention programs e.g. . InteresCSMO 3: When the program utilizes interactive delivery approaches and positive feedback (S), children will obtain more knowledge of CSA and self-protective skills (O) through imitation (M). The contextual factor concerning this configuration is participants’ cognitive developmental level (C).Evidence: Interactive delivery approaches were identified in 18 included studies as being important factors influencing whether the intended outcomes were achieved. One evaluation study of a CSA prevention program conducted in Indonesia, for example, concluded that the success of the intervention depended on the extent to which the intervention model was designed with the characteristics of primary school aged children in mind  and the program consistently delivers messages, such as experiencing CSA is not children’s fault, identifying trusted adults that children could disclose CSA to, and that it’s never too late to disclose (S), participants tend to disclose past or ongoing CSA (O) because they become empowered and therefore are more willing to talk about negative experiences (M).Evidence: Seven included studies supported this CSMO. Disclosure was found to be the most unambiguous outcome of CSA prevention programs , participants’ knowledge and skill gains increase (O) as it enhances trainers’ competence and ownership of the program (M), thus allowing for further reinforcement of concepts beyond the study. The contexts (C) under which this CSMO is most effective include but is not limited to settings where resources are constrained (e.g. lower- and middle-income countries (LMICs)).Evidence: The ‘train-the-trainer’ model refers to experts in a particular field instructing others in the community, school or other settings on how to implement a prevention program . Similarly, Linkages between CSMOs: It should be noted that, while we did not examine the interactions across configurations, they appeared interrelated and could be present in one program in any combination. For example, ‘repeated exposure’ is proposed as a separate configuration but is also linked to CSMO 5, which discusses the train-the-trainer model. Similarly, CSMO 1 suggests that programs should be tailored to participants’ cognitive developmental levels, which echoes CSMO 3 which highlights the use of interactive delivery methods for different age groups.This realist review was the first attempt of which we are aware, to examine how, why and under what circumstances, school-based CSA prevention programs work in order to assess the extent to which they provide children with the knowledge about CSA prevention and self-protective skills. A range of study designs and publication types were included to deepen our understanding regarding the underlying program theory . FurtherThe initial program theory was developed in the first stage of the review based on studies included in an earlier review by We then identified two overarching concepts underlying these intervention programs that emerged from the included studies and documents, namely, ‘empowerment’ and ‘competence’. These were included in the final program theory as core underpinning concepts. Following this, we developed five CSMO trajectories that appear to underlie school-based CSA prevention programs. These highlight the importance of tailoring the program to the cognitive developmental level of the participants, repeated exposure to program material, the use of interactive delivery approaches and positive feedback, delivery of positive information and the utilization of the ‘train-the-trainer’ model.Our refined program theory not only substantiated the initial program theory, but also provided more nuanced configurations that were supported by the wider literature. First, we argued that participants are able to integrate the taught concepts regarding CSA and self-protective skills into their cognitive repertoire and learning processes when the intervention program is tailored to their cognitive developmental level, which will lead to the improvement of participants’ CSA knowledge and self-protective skills. Second, if participants are repeatedly exposed to CSA prevention knowledge and self-protective skills, the mechanism of knowledge reinforcement and knowledge enhancement can be triggered, thereby promoting achievement of the intended outcomes. We also identified that SES and parental involvement are two major contextual factors in which this configuration is likely to be activated.Third, we proposed that through the use of interactive delivery methods and positive feedback, participants are able to engage in a process of imitation that enables them to improve their overall performance. The contextual factor in which this configuration was more likely to be triggered included participants’ cognitive developmental levels. Fourth, we argued that when positive information is delivered, children will feel more empowered sharing negative experiences, thereby leading to the disclosure of CSA. A supportive environment was identified as being an important contextual factor for this configuration. Last but not least, we suggested that particularly with LMICs and resource-constrained settings, the use of the ‘train-the-trainer’ model ensures that more skilled providers such as teachers are able to deliver the CSA programs effectively.The main strength of this review was the use of a realist methodology. To the best of our knowledge, this is the first use of a realist review to explore the CSMOs that underpin school-based CSA prevention programs. Unlike conventional systematic reviews, which focus on the effectiveness of the programs, we included a wide range of study designs to deepen our understanding regarding contextual, strategic and mechanistic factors that lead to the success of these programs. By unpacking the program using a realist lens, we have identified some of the key features of CSA prevention programs. The included studies covered a range of diverse contexts and populations. Further, our review did not only include studies published in English, but also made use of studies published in the Chinese literature, highlighting the similarities in CSMOs across contexts.There are three major limitations of the review worth noting. First, in order to be comprehensive, we searched all databases and other sources from inception, and as a result, some of the programs in this review were unavailable or no longer accessible. Furthermore, it is possible that studies published in languages other than English and Chinese may have been missed. Second, it should be noted that the purpose of this review was not to provide a detailed account of all existing or potential relationships between CSMOs in school-based CSA prevention programs but rather to identify from the existing literature some of the key mechanisms; it was also not aimed at providing evidence of the effectiveness of the CSMOs identified and as such, this review is not conclusive and needs to be complemented with further studies to test and refine the program theories that we have developed here. Third, we generated our initial program theory by examining studies in two recent systematic reviews on this topic i.e. . We addrFirst, program developers should utilize the CSMOs derived from this realist review to inform future program development and implementation. CSA programs should be tailored to the cognitive developmental level of the targeted participants, using repeated exposure of key concepts and skills, and utilization of interactive delivery methods and positive feedback, and delivery of positive information. It is also important that policy makers in LMICs commission the delivery of programs that are optimized in terms of the needs of their particular populations, including the use of programs that can be delivered using ‘train the trainer’ models, particularly in settings where there is a shortage of program providers.Second, it should be noted that the current realist review included two most commonly used proximal outcomes measured by questionnaire-based and vignette-based instruments . There are, however, other child outcome measures used when evaluating the effectiveness of school-based CSA prevention programs, including children’s perception of safety, self-efficacy/confidence to act and harm . FurtherLast but not least, future research should ensure that the reporting of the study process provides a clear picture of the underlying program theory thereby allowing for a deeper understanding of whether the necessary program mechanisms are in place to achieve the desired outcomes. Future investigations should further explore the contextual factors that determine the success of the intervention programs.For LMICs context, there is a need for more rigorous studies to be conducted in the CSA prevention field, including high-quality qualitative studies that explore stakeholders’ perspectives on school-based CSA prevention programs, evaluation studies that rigorously examine the effectiveness of these programs and systematic reviews that examine the overall effectiveness of these programs. The proposed combination of qualitative and quantitative studies are necessary to develop a comprehensive understanding of the way in which school-based CSA prevention programs work in a LMICs context. Further, our findings suggest that teachers and parents can be effective agents of change to facilitate the delivery of school-based CSA prevention programs, which is important in LMICs and resource-constrained settings. Therefore, future practice in these settings should involve engaging teachers, as program providers. However, it should be noted that perpetrators maybe someone the child knows and/or may live in the household. In fact, previous research has suggested that up to one-third of CSA is perpetrated by family members . Last buAlthough school-based CSA prevention programs have been extensively researched since their development in the 1980s, there is still a lack of evidence regarding the theoretical underpinning in terms of how these interventions work, for whom and in what circumstances. This realist review has enabled us to identify key contextual factors, program strategies and program mechanisms that appear to be associated with improvements in CSA knowledge and self-protective skills in children. The implications for future policy, practice and research are identified.• Five CSMO trajectories appear to underlie school-based CSA prevention programs: tailoring programs to participants’ cognitive developmental levels, repeated exposure of key concepts and skills, utilization of interactive delivery methods and positive feedback, delivery of positive information and application of the ‘train-the-trainer’ model.• Program developers should utilize the CSMOs derived from this realist review in future program development and implementation.• Future research should ensure that the reporting process provides a clear picture of the underlying program theory thereby allowing for a deeper understanding of whether the necessary program mechanisms were in place to achieve the desired outcomes.• More rigorous studies need to be conducted in the CSA prevention field to develop a comprehensive understanding of the way in which school-based CSA prevention programs work. Practice in LMICs and resource-constrained settings should involve engaging teachers, as program providers.Click here for additional data file.Supplemental Material, sj-pdf-1-tva-10.1177_15248380221082153 for Unpacking School-Based Child Sexual Abuse Prevention Programs: A Realist Review by Mengyao Lu, Jane Barlow, Franziska Meinck and Lakshmi Neelakantan in Trauma, Violence, & Abuse