The purpose of this commentary is to highlight the lessons our team learned through transitioning a university campus’ therapy dog program from being delivered in-person to a novel online format during the COVID-19 pandemic. By connecting therapy dog teams virtually with program participants, we aimed for participants to continue to experience feelings of love, comfort and support as occurred in in-person programming, and gain knowledge about the best evidence surrounding mental health care during a pandemic. Through a combined process-outcome evaluation and subsequent needs assessment of the online program, and reflecting on our collective experiences, we learned several lessons regarding program personnel needs, therapy dog handler training and support requirements, and online programming prerequisites. These learning experiences continue to inform our current delivery of the program online and are applicable to other programs considering the same.In 2015, the University of Saskatchewan PAWS Your Stress Therapy Dog program partnered with St. John Ambulance for therapy dog teams to visit our campus and offer attendees love, comfort and support. We recognized at the start of the COVID-19 pandemic that students, staff and faculty may require mental health support, particularly with the challenges of isolation and loneliness. In response, our team transitioned from an in-person to a novel online format at the start of the COVID-19 pandemic. We designed online content for participants to (1) connect with therapy dogs and experience feelings of love, comfort and support as occurred in in-person programming, and (2) learn about pandemic-specific, evidence-informed mental health knowledge. Our unique approach highlighted what dogs can teach humans about health through their own care and daily activities. From April to June 2020, we developed a website, created 28 Facebook livestreams and 60 pre-recorded videos which featured therapy dogs and handlers, and cross-promoted on various social media platforms. Over three months, first a combined process-outcome evaluation helped us determine whether our activities contributed to the program’s goals. A subsequent needs assessment allowed us to elicit participant preferences for the program moving forward. This commentary reflects on these findings and our teams’ collective experiences to share our key lessons learned related to program personnel needs, therapy dog handler training and support requirements, and online programming prerequisites. This combined understanding is informing our current activities with the virtual program and should be of interest to other therapy dog programs transitioning online. The PAWS Your Stress Therapy Dog program is a partnership between the University of Saskatchewan (USask) and St. John Ambulance (StJA), an international humanitarian organization . The proDespite our team’s lack of preparation for these changes, we quickly transitioned the PAWS Your Stress Therapy Dog program into a novel virtual format with one-time funding from the Saskatchewan Health Research Foundation Research Connections COVID-19 fund. We recognized within a month of the start of the pandemic that USask students, staff, and faculty may require mental health supports, particularly with the challenges of isolation and loneliness because of various federally and provincially enacted physical distancing measures. At the same time, the pandemic occurred in an era when social media is a key source of knowledge exchange. Our unique online format was designed for the USask community, and all Saskatchewanians, to virtually connect with the therapy dogs and acquire evidence-informed information about pandemic-specific mental health self-care tips. Unique to our approach of knowledge dissemination was highlighting what dogs can potentially teach humans about health through their own care and daily activities. For example, our team leader and therapy dog handler, Colleen Dell, live-streamed a video of a therapy dog, Anna-Belle, enjoying skateboarding, and linked that to doing outdoor activities and hobbies which are important for mental health.Guidance for Handlers of Service and Therapy Animals ny engagement opportunity that allows participants the benefits of the human–animal bond by encouraging the remembrance of feelings that are commonly associated with interaction with an animal” . With ouhttps://www.flipsnack.com/harperg/animal-memories-fcfexaf97/full-view.html accessed on 22 March 2021) and used virtual technology to connect with prison sites across the country to share these memories eterans”  (p. 83).memories . www.therapydogs.ca accessed on 22 March 2021) to serve as a central hub to collate our varied online activities, posting social media content, as well as sharing information about scheduled activities. We also expanded our existing and adopted new social media platforms, including Facebook and Facebook Live (@PawsYourStress), Instagram (PawsYourStress), Twitter (PawsStress), Flipgrid (https://flipgrid.com/therapydogs accessed on 22 March 2021) and YouTube (https://www.youtube.com/channel/UCktTwbHipNjEReDp9IahWhQ/videos accessed on 22 March 2021). We intentionally chose online platforms that could store our program content to ensure we were participant centered; that is, meeting individuals where they are at, so they can view the content at their convenience. At all times, participants were encouraged to post questions and offer feedback. For this reason, Facebook and Instagram were specifically focussed on during the transition as we had an existing account with some followers to build upon. Facebook and Instagram were also experienced as popular social media on the university campus by our team and our program partner, Peer Health.Our team began transitioning its in-person program to an online format by developing a website , USask Peer Health (1k followers), and Colleen Dell’s Anna-Belle and Subie’s Adventures (2k followers) with hashtags . Several of our therapy dog handlers cross-promoted our program on their Instagram, Twitter and Facebook accounts, and all team members and participants were encouraged to share the posts on their personal social media platforms. We also promoted the therapy dogs via internal USask communications. Efforts were also dedicated to advertising the visits to Saskatchewanians and other university therapy dog programs in Canada, including using paid Facebook advertisements, emails to social networks, press releases, and news articles  and which were picked up by various groups .Our live and pre-recorded videos featured the therapy dogs and handlers engaging in various activities they regularly engaged in and linked these activities to an evidence-based pandemic-specific mental health self-care tip, such as going for a walk. Additional activities that the dogs and handlers engaged in ranged from a healthy food taste test between a therapy dog in training and a therapy dog, training with a Canadian Kennel Club recognized trainer, grooming for a dog show, taking photos outdoors, and a dog skin care tutorial. Rarely, if ever, were the dogs asked to engage in activities they were not already familiar with.The Facebook live visits were on average 15 min, mirroring the typical length of a participant’s in-person therapy dog visit. The pre-recorded videos varied in length, with some as short as 2 min and were more of a greeting style. The Instagram videos were typically a maximum of 1 min, adhering to the site format, unless we uploaded to the specific Instagram TV feature. Several special videos were compiled of various canine companion animals of members of our team to advertise the program. There were also regular social media posts with photos of the therapy dogs staying healthy and active, and again linked with a positive and encouraging mental health message. It is important to note that in the period of time before we began the recordings, our team posted regularly on social media with updates from the therapy dog handler teams. These “check-ins” took the form of pictures and stories regarding what the dogs were up to while unable to visit in person. This was met with positive follower engagement. We also posted pre-recorded children’s stories read to therapy dogs by their handlers, in partnership with Scholastic Canada and authors Nicole Petroski and Jane Smith.As a university-based program, our team is well aware of the need and equipped to design and undertake planning and evaluation of the PAWS Your Stress Therapy Dog program, including during the rapid online transition. Given the novelty of the online program and urgency with which the pandemic was experienced, it was important to offer the programming swiftly, as well as undertake evaluation, and document our team’s reflections about key lessons learned.39 pandemic-specific mental health videos;10 storybook reading videos (English or French);28 Facebook Live videos and 11 pre-recorded videos containing pandemic-specific mental health self-care tips;One podcast episode with Be Well at USask (aired 22 May 2020);One infographic co-designed and promoted with the Canadian Centre on Substance Use and Addiction and the Mental Health Commission of Canada, titled Coping with Stress, Anxiety, and Substance Use During COVID-19: How Animals Can Help.Our PAWS Your Stress program output between 22 April and 31 July 2020 included:There were nine additional book readings and 23 videos created between these dates, but they did not include pandemic-specific mental health tips. As such, they are not reflected on in this commentary.A combined process-outcome evaluation followed by a needs assessment was undertaken over a three-month period to determine whether our team’s activities contributed to achieving the program’s goals. That is, we wanted to know whether program participants: (1) experienced feelings of love, comfort, and support; and (2) learned about pandemic-specific mental health self-care knowledge. Contrary to the program’s history, we separated the terms love and comfort for this evaluation to respond to the unique on-line nature of the program and increased awareness of love being a therapy dog program goal since it was incepted in 2015. Unfortunately, due to time constraints based on our COVID-specific funding, we were unable to compare multiple time points to determine participant change. As such, we only assessed perceptions/opinions at a single time point. Quantitative and qualitative data were collected from the target population, USask students and community, as well as participating Saskatchewanians, with two online questionnaires . Given the online and public nature of the program, it was not feasible to exclude non-USask community members from participating, although their participation was determined to be limited. We recognize that our on-line sampling approach was not ideal, but it is what we had access to doing at the time. Human Research Ethics Board approval was not required given the evaluative focus of our work.The first process-outcome evaluation questionnaire was designed to assess participant opinion and experiences with the PAWS Your Stress online program. The questionnaire was accessible via Facebook, Instagram posts/stories and through the therapydogs.ca home webpage, and a total of 94 participants completed it, nearing our anticipated goal of 100. Most participants were registered students (26%), 18–25 years old (23%), self-identified as a woman (92%), resided in Saskatoon, Saskatchewan (65%), and currently had a pet (88%). In brief, we found the following: Related to Goal 1, participants were asked using a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree) whether they felt comforted, loved by, connected to, and supported by the therapy dogs online. We decided to include the concept of connection given the growing emergence of it in the AAI field  and its possible linkage to memories. The majority of participants strongly or somewhat agreed that they felt comforted by (90%), loved by (63%), connected to (86%), and/or supported by (83%) the therapy dogs. Participants were also asked using a 5-point Likert-type scale (1 = A lot less to 5 = A lot more), compared to other sources of connection, love, comfort, and support in their lives, how much did they experience these feelings generally from watching the therapy dogs online. Most participants reported that they experienced these feelings a little bit more (39%) or about the same (30%) from watching the therapy dogs online . In order to feel more connection, love, comfort, and/or support from the therapy dogs online, participants suggested providing more information about the dogs (“It would be nice to know their birthdays and favourite toys”—participant) and having the dogs engage more and in different activities (“Learn tricks as suggested by viewers”—participant). Related to Goal 2, most participants (68%) reported “yes” to learning about pandemic-specific mental health self-care tips from the handlers and therapy dogs online . Using a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree), participants were asked whether they were more aware about evidence-informed, pandemic-specific mental health self-care knowledge after watching the online videos and whether they were using the tips they learned from the online videos. The majority of participants strongly or somewhat agreed that they were more aware about (83%) and were using (85%) the pandemic-specific mental health self-care tips from the therapy dog online videos. We also asked participants what made the pandemic-specific mental health self-care tips easy for them to apply. Participants indicated that the mental health tips were easy for them to apply because they felt inspired by the video content , and also identified them as good reminders (“They were reminders to take breaks and take care of yourself”—participant). The tips were recognized as simple, clearly explained, affordable, and attainable . While many individuals noted that they needed to figure out for themselves how to increase their motivation and the likelihood that they would apply the self-care tips , some suggested that the tips needed to be communicated differently  and that even more or different tips could be offered .www.therapydogs.ca (accessed on 22 March 2021). Most participants were full-time students (50%), between 21 and 25 years old (26%), self-identified as a woman (82%), and currently had a pet (72%). Findings from this questionnaire also supported the two main outcomes we sought to measure. In line with Goal 1, participants were asked using a checklist of possible response options  why they want to visit with the therapy dogs online. Participants primarily visited the therapy dogs online to reduce stress (48%), to learn about the therapy dogs’ lives (37%), and because they missed the therapy dogs (29%) (“Just seeing the dogs do their thing brings me joy”—participant). There was no specific data collected in our second questionnaire pertaining to our Second Goal about increasing pandemic-specific knowledge, however, 16% (58) of respondents indicated that they wanted to visit the therapy dogs online “to learn how to stay healthy during the COVID-19 pandemic” [The second needs assessment questionnaire assessed participant needs and preferences regarding program implementation to help inform future programming. The questionnaire was again advertised through Facebook, Instagram, and the therapydogs.ca home page, and had a total response of 372 participants. We anticipate the increased response compared to the first survey was due to broader awareness and engagement with apy dogs % , and putting it all into action in the program. While the team lead spent considerable time upfront, this decreased as the program established itself.There was likewise participation of the therapy dog teams to consider. The PAWS Your Stress program typically had 35 handler and therapy dog teams to draw from to visit campus. With the transition to an online format, we learned that the majority of handlers were reluctant to the change to an online format, some were hesitant, and some were very excited for the new program. The primary reason for handlers’ resistance was the permanence of online platforms. In retrospect, we recognize that Instagram may have been a more compatible choice for some as the platform does not store live video content online after 24 h. Additionally, without all of the regular therapy dogs participating, some students were unable to continue connections with dogs that had visited in-person. However, we chose the platforms we did so individuals could access them when they wanted to. In the end, we had a total of 17 handlers participating in the Facebook Live events, 18 in posting photos, and 24 in recorded greetings and story book readings. For the participating handlers, their openness to technology and desire to connect with students and the broader community through their therapy dog drove their decision to participate. The number of handler/dog teams ended up being enough to post live videos 2–5 times per week at the beginning of the project, and this reduced as we transitioned from spring to summer months, which is typical for the program. The amount of content produced at the beginning of the project was not limited by handler engagement.We recognized early on that for handlers to participate comfortably and effectively online they required training with the technology we were using. When we started the online platforms, two of our research assistants connected individually and over Zoom with the handlers to do introductory training on how to use Facebook Live and Zoom as well as how to install the necessary applications on their device and establish user accounts. This was generally done by a staff member and 2–3 therapy dog teams at a time online or over the phone. Sessions generally lasted 1 h and handler confidence increased as they engaged with the technology. A research assistant was also available via text to assist with technological difficulties whenever a handler was livestreaming on Facebook Live. Difficulties that arose ranged from holding the camera sideways through to poor sound quality in a windy environment. We also recognized that access to online connections varied for participants. The ease and quality of online work can depend on the device being used , and access to technology .Handlers also required support with navigating their therapy dogs’ role during online visits. Consulting periodically with an established dog trainer to include their expertise, we shared with the handlers that while the dogs were not able to recognize the technology or that there is a camera on them, they do recognize voices or audio output from the devices . We suggested that the handlers establish an enjoyable routine with and for their dog while being in front of the camera. Depending on the handler and dog, this may involve, for example, cuddles, treats and/or clicker training. This was explained as an indirect connection with the audience by the dog, and more directly by the handler; this is a role reversal from in-person visits. Many of the handlers reported that the dogs began to recognize and appreciate the routine during the online visits. Animal welfare is the cornerstone of the PAWS Your Stress program, and we navigated this carefully with the on-line transition, encouraging handlers to be involved in activities with their dogs that they typically do. This was relatively easy to accomplish with our initial COVID-19 focus and messaging being specific to the dogs engaging in daily activities that they enjoyed for their own care. This includes recognition of the reciprocal relationship the dog and handler posses. Consideration of the dogs’ perspectives is inline with attention to animal welfare, ethics and needs in the new e-resource Alternatives to Traditional Animal Assisted Interventions: Expanding Our Toolkit (2020) .Our team anticipated the need to collate evidence-informed mental health tips for the therapy dog handlers to relay. Doing so also ensured that the shared tips were clear, consistent and “on script.” We considered this to be important during the pandemic and did all we could to ensure supportive and evidence-informed messaging was being shared. Our team had access to and examined peer-reviewed and grey literature focused on pandemic-specific mental health tips from various health organizations. These included the World Health Organization , Public Our team chose to begin the online transition of the PAWS Your Stress program by engaging with platforms we had some collective experience with, as the stress of the pandemic on other aspects of our lives, jobs and education was not conducive to doing otherwise. We used GoDaddy to build the website because it does not require a website design background and is moderately priced. That said, developing website content that is easy to navigate is a skill that none of our team had expertise in and we could still benefit from. We used YouTube as a hub for all the videos we produced. The platform allows for multiple users and unlimited storage of videos, and videos in the production phase could be designated as private or “unpublished” for all team members to access without being seen by the general public. We also used Facebook, Twitter, Instagram, and Flipgrid because these were believed to be most popular amongst the USask community, and again, we were familiar with them to some extent. However, each platform had its drawbacks. For example, a downfall of using YouTube as our video hub was that it required significant time to convert the videos to store there. Additionally, Twitter had limited use by our audience and so was slowly phased out of use during the program, Instagram showed but did not store our live videos, handlers found Flipgrid challenging to use, and not all handlers were willing to acquire a Facebook account for principle-based or personal reasons.Our team also used YouTube to search for videos to learn about the social media platforms we were using. This included learning how to cross-post to multiple platforms to save time and reach diverse audiences . Using multiple platforms was important because it allowed for varied reach as well as diverse forms of audience engagement . We also searched for the prime times to post content . Additionally, we learned how to edit a recorded Facebook Live video before they were posted to our website  to remove, for example, political content or the home address of a handler that was mistakenly shown. We quickly learned too that technology was constantly changing, including YouTube and other social media, and this was especially true during the pandemic as the platforms competed to secure users.Our team learned that managing social media is time intensive. One example is trying to ensure consistency in the look, feel, and content of our messaging , especially when multiple team members are involved in developing it. The hiring of a digital marketer would be extremely useful. We also rarely engaged with social media on the weekends or in the evenings. This could be revisited, given our survey finding that participants indicated they would like to visit the therapy dogs on weekday evenings, as well as the weekend . We alsoOur team also learned that interpreting social media “analytics” or “insights” is not straightforward and most often cannot be compared across platforms. From what we could determine, on all of the platforms that the PAWS your Stress program engaged with, we were able to increase subscribers and views over time. It is not clear from the available analytics, however, how long individuals engaged with each view . Due to the varied analytics across platforms and other factors, we were not able to determine which advertising techniques were most effective at gaining subscribers or views. We relied on data from Google Analytics for our website, which does not have analytics embedded in it from GoDaddy.Analytics we found meaningful include the following. Across all the pandemic-specific videos, there were 587 comments from viewers over the three-month period. Types of comments included: questions/comments regarding general and therapy-specific dog training; questions/comments about the dog, including in-person time spent with the dogs and sharing special memories; compliments for the handler and expressions of gratitude for making the video; greetings for the therapy dog team; non-specific compliments and expressions of gratitude; and, comments about how the videos made viewers feel. Facebook Page likes increased from 199 on 13 April to 705 on 31 July 2020, with an average of 7 new page likes per day, and followers increased from 209 on 13 April to 789 on 31 July 2020. As another example, there was a total of 21 Flipgrid videos, 6 pandemic-specific, with 1183 views that translated into 33.9 h of total viewing. Our YouTube videos had an average of 130 views. It is important to mention though that most of our viewers were tuning in to videos specifically through Facebook Live or Instagram (after the fact), and so are not recorded on YouTube analytics. Our videos with the most views on YouTube included “Anna-Belle the therapy dog reads Birthday Party Pandemonium” (330 views), “Kisbey the therapy dog reads Three Easy Steps to Getting a Dog” (221 views), and “Murphy the therapy dog reads Murphy Mondays!”, which is a book written about him (148 views). We recognize that these analytics may not be impressive in comparison to other social media sites and activity but given the growth from the beginning to end points for this paper we are happy with what we achieved given that we are still in what is arguably the establishment phase of the online program and amidst a pandemic.Our team also used more “traditional” media to market our program, including local news media and newsletters as well as information sharing technologies within our university . We tried to pay attention to the audience’s preferred formats  and culture. This included advertising techniques that used the USask channels focused on stresses experienced by this population, used language commonly applied across university communications, and referred to the in-person therapy dog program that would normally be available. For advertising efforts beyond the university environment, more general COVID-19-related stressors were acknowledged and evidence of the efficacy of therapy dogs was highlighted. Social media posts regularly used informal language and utilized humour to engage all of our audiences.This commentary has documented highlights of our team’s transition from an in-person to an online therapy dog program, while also reflecting upon evaluation outcomes and multiple lessons learned throughout the transition and implementation of the virtual program. These are in the key areas of program personnel needs, therapy dog handler training and support requirements, and online programming prerequisites. It is clear to our team that individuals enjoy and want to connect with the therapy dogs online as physical distancing mandates remain in place. While there is no substitute for touching and interacting with the therapy dogs in-person, attendees reported to enjoy seeing the dogs, connecting with or maintaining connections with them, learning about them, and gain cognitive/emotional benefits . Many attendees have also reported feelings of comfort, love, connection, and support from the therapy dogs in our on-line evaluations, similar to in-person findings. These findings support the 2015 in-person program evaluation and the 2017 in-person PAWS Your Stress study that reported students identified the program as providing opportunities to be in-the-moment , facilitate social connections , and complemented their existing healthy coping skills .Moving forward, we understand from our reflective experiences and evaluations that most participants of the PAWS Your Stress program would like to learn more about the dogs’ lives and therapy dog training in general. Some also suggested more audience participation, having less focus on the handlers with more focus on the dogs, and requested for the video and sound quality to be improved. They indicated that Instagram, Facebook, YouTube, and therapydogs.ca are the preferred platforms for accessing therapy dog videos and photos. Videos should be brief (between 1 and 5 min), and if online meetings are offered via Zoom, they should be a maximum of 20-min sessions. We also noted that Facebook boosts should be utilized as they greatly increased video views (though may not translate into followers), and that there is no need to include pandemic-specific mental health information in our videos as audiences were most interested in simply seeing and connecting with the therapy dogs.www.therapydogs.ca (accessed on 22 March 2021) while in-person visiting is prohibited. Throughout online delivery, we will continue with our process and outcome evaluation, through which we will pay particular attention to whether there is a downside to reconnecting with dogs that were once visited with in-person . Fourth, our team will begin to explore designing a project to directly compare on-line versus in-person therapy dog visiting for when in-person visiting resumes, noting the two programs varied significantly in their formats. We are particularly interested in the role of the handler, which has received limited attention generally within the therapy dog research realm. We are also interested in learning how participants experience love and comfort as distinct concepts, as well as their understanding and experience of connection (with both the therapy dogs and handlers) and a possible linkage with memories. Finally, we will continue our evaluation of the PAWS Your Stress program and for various demographics , including assessing for participant cognitive and emotional changes by comparing multiple time points, which we were unable to do for this evaluation due to time and resource constraints. In response, our team is undertaking the following next steps. First, we will revise our social media platform focus. This will include transitioning to non-COVID-19 specific Facebook Live streams and photo posts on Facebook and Instagram, while continuing to transition away from using Twitter and Flipgrid due to low response, and reducing the number of Live videos. We will also attempt to draw upon a social media expert to best target and offer the program, keep up with the rapidly changing technology, and participants’ online “overload.” Second, we will host Zoom sessions for the USask and broader Saskatchewan community. These will follow a conference call format with the Zoom Breakout Rooms feature, which allows for attendees to split off into a separate session from the main meeting and interact with the therapy dogs in a more intimate format . They caAs shared, it is anticipated that therapy dogs will not be back on the USask campus until the province fully reopens, and this is not expected to be in the near future. We understand many therapy dog programs are in the same position, although some have started revisiting outside of our province of Saskatchewan. We offered our key lessons learned through uniquely transitioning the PAWS Your Stress program online and our plans for moving forward in the hope that they will be useful for other therapy dog programs, and possibly even AAI clinicians who have, or are considering, facilitating AAIs in virtual settings during this time when many people are experiencing increased isolation and stress, or beyond. In particular, we suggest that involving animals in online therapy sessions could positively impact therapeutic relationships between the clinician and client, given that existing research has demonstrated that animal involvement in therapeutic settings can facilitate the establishment of a stronger therapeutic alliance ,39. ReseWhile we transitioned the PAWS Your Stress program online due to necessity, this novel experience has highlighted the potential for online engagement with AAIs beyond the pandemic: to reach individuals living in rural and remote communities, individuals who are immunocompromised, and individuals whose allergies interfere with them being in the same room with certain animals. This is likely something our team will continue to explore and engage in. The lessons learned will have implications as we move forward dealing with the pandemic and afterward, as the greater society gains increased experience and comfort with the online world.


Frontotemporal dementia (FTD) includes a group of clinically, genetically, and pathologically heterogeneous neurodegenerative disorders, affecting the fronto-insular-temporal regions of the brain. Clinically, FTD is characterized by progressive deficits in behavior, executive function, and language and its diagnosis relies mainly on the clinical expertise of the physician/consensus group and the use of neuropsychological tests and/or structural/functional neuroimaging, depending on local availability. The modest correlation between clinical findings and FTD neuropathology makes the diagnosis difficult using clinical criteria and often leads to underdiagnosis or misdiagnosis, primarily due to lack of recognition or awareness of FTD as a disease and symptom overlap with psychiatric disorders. Despite advances in understanding the underlying neuropathology of FTD, accurate and sensitive diagnosis for this disease is still lacking. One of the major challenges is to improve diagnosis in FTD patients as early as possible. In this context, biomarkers have emerged as useful methods to provide and/or complement clinical diagnosis for this complex syndrome, although more evidence is needed to incorporate most of them into clinical practice. However, most biomarker studies have been performed using North American or European populations, with little representation of the Latin American and the Caribbean (LAC) region. In the LAC region, there are additional challenges, particularly the lack of awareness and knowledge about FTD, even in specialists. Also, LAC genetic heritage and cultures are complex, and both likely influence clinical presentations and may modify baseline biomarker levels. Even more, due to diagnostic delay, the clinical presentation might be further complicated by both neurological and psychiatric comorbidity, such as vascular brain damage, substance abuse, mood disorders, among others. This systematic review provides a brief update and an overview of the current knowledge on genetic, neuroimaging, and fluid biomarkers for FTD in LAC countries. Our review highlights the need for extensive research on biomarkers in FTD in LAC to contribute to a more comprehensive understanding of the disease and its associated biomarkers. Dementia research is certainly reduced in the LAC region, highlighting an urgent need for harmonized, innovative, and cross-regional studies with a global perspective across multiple areas of dementia knowledge. Dementia in Latin America and the Caribbean (LAC) countries has become a major challenge –3. The WEpidemiological studies from the LAC region are scarce and existing evidence is limited, nevertheless making only modest contributions to global prevalence figures . Most ofFTD is an insidious neurodegenerative clinical syndrome characterized by progressive deficits in behavior, executive function, and language , 18, 19.C9orf72 (chromosome 9 open reading frame 72), MAPT (microtubule-associated protein tau), and GRN (progranulin) discussed below in this review.Regarding clinical diagnosis, as mentioned, FTD is often underdiagnosed , 20, 21.Biomarkers, defined as a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes , have emThe study of biomarkers in FTD requires sophisticated procedures that only a few research centers have access to in LAC. Moreover, biomarker measurements or research are not funded by public health , 3. In tConsidering the impact of FTD on LAC and the barriers to diagnosis of this progressive neurodegenerative disease, the advent of promising biomarkers  that can enhance diagnostic accuracy and help overcome outstanding needs could have a significant impact on this region. This review aims to update the knowledge base on biomarker development for FTD, with an emphasis on published studies from LAC and highlights the need for further development of FTD biomarkers that can be generalized to broader settings and diverse populations.A systematic search of the online literature was carried out targeting journals indexed by PubMed Central, Redalyc, Scopus, and SciElo databases. Pub-Med Central corresponds to the digital archive of the United States National Institutes of Health and it was selected for its scope and importance in the biomedical and life sciences; this database allows access to free material but the use of the material is subject to copyright and/or license terms. Redalyc is an academic project promoted by the Autonomous University of Mexico, in collaboration with other institutions, for the dissemination in Open Access of the scientific publishing activity that occurs in and on Ibero-America; and it was selected for its reach in regional populations. Scopus is a bibliographic database of abstracts and citations of scientific journal articles, which are peer-reviewed. This database was selected for its antiquity (1966) and scope since it is sponsored by Elsevier. SciELO is a Brazilian project that promotes the development and operation of Latin American collections for all areas of knowledge, with publications preferably in English, but also in other languages. It was elected for indexing many national and Latin American journals.To identify potentially eligible studies related to FTD cognitive dysfunction biomarkers, the PRISMA Checklist and PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses was followed, to have a validated and consensual research methodology . Two of Studies were considered eligible for data extraction if they meet the following inclusion criteria: original peer-reviewed articles  written in Spanish, English or Portuguese; published between January 2000 until November 2020, based on human Latin American populations, considering samples with FTD pathological characteristics, which their contents were about genetic, neuroimaging and fluid biomarkers. If some of the results found were still in press and could be checked by title and abstract, they were included too for the full-text review, by contacting the authors. No particular diagnostic criteria were required for the samples to be included because the main objectives of some potential results might be comparing them.The exclusion criteria considered were: studies with no LA population samples, studies conducted with non-human animals, and studies written in a language other than those previously referred. We considered excluded from our investigation model: prospective studies, interview studies, retrospective studies, clinical and treatment trials, qualitative studies, mathematical modeling, experimental replications, scientific simulations, field studies, focus groups, non-clinical case studies, literature reviews, systematic reviews, and meta-analyses.In the first stage, MFA and PO searched for the selected keywords using boolean operators. With these first results, in a second stage, the articles were reviewed and selected according to their titles; from here, those who met the search words and/or the eligibility inclusion criteria were considered for the next stage. In the third stage, the abstracts and the full texts were read by PO and MFA to ensure papers met the criteria for sample descriptors, language, type of study, and contents. When the third stage was completed, the exhaustive review of each paper for the final selection was made by three authors . Disagreements were resolved by discussion between the three authors and, in case of disagreement, a fourth opinion was sought from the other authors for a final decision. Finally, the resulting sample of papers was divided between the other authors for the data analysis and synthesis. The flowchart in MFA recorded specific data for each study  includinAfter performing the PRISMA analysis, our search identified 21 studies on FTD and biomarkers in the LAC region. The selection process is depicted in the flowchart in A biomarker is defined as an objectively measurable indicator of a biological state or pathological condition. A biomarker must be reproducible, stable, available to a large part of the population and reflect relevant disease processes . BiomarkC9orf72, GRN, and MAPT  expansion in chromosome 9 open reading frame 72 (C9orf72) [GenBank: JN681271] was discovered to likely be the most frequent genetic cause of bvFTD, FTD with motor neuron disease (FTD-MND), and amyotrophic lateral sclerosis (ALS) in some populations  encodes tau proteins involved in microtubule stabilization and assembly. Mutations in this gene cause tau splicing alterations, promote tau cytoplasmic aggregation, or cause tau hyperphosphorylation, which generates microtubule instability . This protein has functions such as RNA transcription, splicing, transport, and stability –82. MutaPSN-1 gene is frequently mutated in familial AD , 90, howHomozygous or compound heterozygous mutations of TREM2 have been associted to Nasu-Hakola disease which is characterized by bone involvement with an early-onset FTD phenotype , 94. TheClassically, FTD cases show frontotemporal and insular atrophy in structural neuroimaging, with Magnetic Resonance Imaging (MRI) . In funcThe neuroanatomical correlates of different cognitive tasks were used to evaluate specific symptoms of FTD, to look for the pathogenic substrate of that clinical manifestation. A multinational team of researchers, including participants from Chile and France, aimed to identify and discriminate the structural anatomical markers of episodic memory impairment in bvFTD, comparing those patients with AD patients and healthy controls, finding that impairment of medial/lateral temporal atrophy is associated with memory deficits .Social cognition deficits seem to be a critical marker of the disease. Reports from LAC in this domain have shown neurocognitive deficits in FTD related tofacial emotion recognition –109, empA multinational team of researchers from Argentina, Chile, and Colombia looked for a structural correlate of the moral judgment impairment often seen in bvFTD, finding that in bvFTD patients, judge harm permissible had an inverted relationship with the gray matter volume in the precuneus, thus implying that processing intentions and outcomes for moral judgments rely on regions beyond the Ventromedial Pre-frontal Cortex . The samThe contextual fluctuation different social abilities seems to be a hallmark of FTD –120, repResearch that used machine-learning algorithms  to identify bvFTD and AD, was carried out by a team from Argentina and Colombia, in collaboration with one team from Australia . This teIn the field of neuroimaging, functional connectivity is a very sensitive tool that is becoming increasingly popular. Functional connectivity is defined by Friston “as the temporal coincidence of spatially distant neurophysiological events” . In LAC,in vivo imaging of proteins, DTI allowing to evaluate the connection between lobes, among others  inspired by EEG studies and based on machine learning, proved to be superior to linear measurements (R Pearson) widely used in the identification of functional connectivity in patients with bvFTD , 47. AnoCerebrospinal fluid (CSF) and blood are the most frequent fluids which have been described or studied as a diagnostic tool in dementias . Here, wGRN, C9orf72, and MAPT)  . In a lond MAPT) . Anothernd MAPT) –146. Thend MAPT) , which hnd MAPT) , 148.GRN cause disease through haploinsufficiency and CSF and plasma progranulin concentrations are reduced in GRN mutation carriers 1–42, total tau (T-Tau), and phosphorylated tau (p-Tau) ratios, showed their clinical utility for differentiating AD from non-AD neurodegenerative dementias, distinguishing AD from both bvFTD and semantic dementia  . In a sipatients . This st from AD , 170. Th from AD . In a re from AD . Another from AD . In Braz from AD . Importa from AD .C9orf72, GRN and, MAPT in both symptomatic and pre-symptomatic subjects  is a protein widely expressed by numerous cell types of CNS, including astrocytes , 175. GFsubjects . Increassurvival . In our It has been suggested that immune activation may be an early cause of neurodegeneration  or that GRN mutation carriers, an apparent CSF profile of elevated CXCL10 and decreased levels of TNF-α, IL-15, and CCL5 have been described  was performed and identified 20 differentially abundant proteins between symptomatic GRN mutation carriers and 24 non-carriers and 9 between 19 symptomatic and 9 pre-symptomatic mutation carriers. These results were validated in subjects symptomatic and pre-symptomatic mutation carriers of C9orf72 and MAPT, in addition to GRN carriers . A validC9orf72 gene is widely represented in familial and sporadic cases from Chile, Brazil and Argentina, followed by MAPT and GRN genes, as described in HIC. Several neuroimaging techniques are being used, however, most of the LAC research described in our review is based on structural neuroimaging, functional imaging, and EEG. In this context, further research is needed to expand these biomarkers across LAC, allowing a better and accurate diagnosis.FTD, like the rest of dementias, is a public health problem, often underdiagnosed, undertreated, and not fully understood. This situation is especially relevant in LAC, presenting several barriers to diagnosis, treatment, and further research on FTD. In this review, we showed local efforts to make research on biomarkers in the LAC region. Until today most of the knowledge about FTD comes from North America and Europe cohorts, providing guidelines and descriptions that do not necessarily capture the local reality in terms of psychopathology, genetics, or diagnostic tools. Aligned with that, our current analysis in this systematic review revealed only 21 articles published between January 2000 until November 2020 in LAC, considering FTD participants and genetic, neuroimaging, or fluid biomarkers studies . InteresImportant to emphasize, studies on fluid biomarkers also proceeded exclusively from Brazil and Argentina , 51, 52.Knowledge of the clinical manifestation of FTD has progressed exponentially over the past 20 years . HoweverRecent years have seen a rapid development of biomarkers for FTD and other dementias –31. LAC Recently, multiple regional research efforts have been developed in LAC countries focused on the use of machine learning for the combination of neuroimaging modalities as well as behavioral/cognitive assessment to a better understanding of different dementias in our region , 215–219The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.CD-A and AS designed the proposal. PO and MA-P performed PRISMA analysis. CD-A, PO, TL, FH, VC, TE, MP, and AS wrote the drafts, discussed contributions from all co-authors. All authors searched the literature, participated in discussing the contents of the paper, contributed to editing, and approved the final version of the article.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.


Students who are targets of bullying and who witness bullying are at high risk for negative mental health outcomes. Bystander training is essential to reduce bullying and the negative associated consequences for targets and bystanders. Resources necessary for program delivery, however, pose significant barriers for schools, particularly those in rural, low-income communities. Technology-based programs can reduce health disparities for students in these communities through cost-effective, easy-to-disseminate programming.The aim of this study is to conduct usability testing of a bystander bullying web app prototype, STAC-T  as an initial step in the development of a full-scale STAC-T intervention. Objectives include assessing usability and acceptability of the STAC-T prototype, understanding school needs and barriers to program implementation, and assessing differences in usability between school personnel and students.t tests, and consensual qualitative research were used to assess usability and program satisfaction and to extract themes related to acceptability, feasibility, needs, barriers, and feedback for intervention development.A sample of 16 participants, including school personnel and students recruited from 3 middle schools in rural, low-income communities, completed usability testing followed by a qualitative interview. Descriptive statistics, 2-tailed independent sample Usability testing indicated that the app was easy to use, acceptable, and feasible. Both school personnel  and students  rated the app well above the standard cutoff score for above-average usability , and both school personnel  and students  gave the app high user-friendliness ratings . The overall ratings also suggested that school personnel and students were satisfied with the program. Of the 6 school personnel who said they would recommend the program, 1 (17%), 4 (66%), and 1 (17%) rated the program as 3, 4, and 5 stars, respectively; 80% (8/10) of students said they would recommend the program; and 60% (6/10) and 40% (4/10) rated the program as 4 stars and 5 stars, respectively. Qualitative data revealed that school personnel and students found the STAC-T app to be useful, user-friendly, and relevant, while providing feedback related to the importance of digital learning activities that engage the user. Data from school personnel also indicated positive perceptions regarding program feasibility and probability of program adoption, with the most significant barrier being cost, suggesting the importance of considering the financial resources available to schools in rural, low-income communities when setting the price point for the full-scale STAC-T intervention.This study provides support for the full-scale development of the STAC-T app and provides key information for revision to enhance used engagement.ClinicalTrials.gov NCT04681495; https://clinicaltrials.gov/ct2/show/NCT04681495 Bullying is a national public health issue in the United States, with 20.2% of students aged 12 to 18 years reporting being bullied at school and 15.3% reporting being cyberbullied in the previous year , anxietyYouth in rural -17 and lNegative consequences are not only limited to targets of bullying but also extend to students who witness bullying ,22 and cdefenders is an important component of comprehensive school-based bullying programs  of the world.Participants were also asked to share their thoughts regarding the relevance and appropriateness of the program content for students at their school and their community. School personnel indicated that the program is relevant and can help increase students’ understanding of relationships. For example, a school counselor stated, “I definitively think that it’s relevant, just like we talked about, especially the online portion.”Another school counselor indicated that the program helps “...kids to continue to understand the differences...” (between people). Students also indicated that the program was age-appropriate. One student said:I think it is very appropriate and relevant. I think it’s a great idea, and it has great examples so kids can see [bullying] if they haven’t seen it before or see different situations it [bullying] could be in.Another student shared:Yeah I think it’s really good cause I’ve had some programs that use really big words, and so you can’t understand, or it explains every word like you’re a little child. Your program was perfect, like right at my level.When asked for feedback regarding how to improve the program, school personnel suggested that it is important to follow through while making the program interactive. One teacher stated:I’d have to kind of see how all of the avatars work together, how the animation works together, how relevant that would work with keeping students’ attention. Because right now currently I’d have to read everything and know students aren’t going to read everything.A school counselor said, “I definitely think having, like you already talked about, the piece of it being interactive, definitely needs to have that.”Students suggested adding colors, including realistic pictures. One student stated:I would definitely add color to the pictures, that’s one thing. I bet that would catch somebody’s eye. I know people who have more creative minds tend to pay attention to color more, cause I’m one of those people.School personnel were also asked to speak about the feasibility of the program implementation. Participants provided positive responses indicating that the program was user-friendly and would align with existing programs that address social and emotional development. One school counselor indicated:...it’s very user-friendly, even for me who had struggles getting going. It really gives you very clear, concise steps to be able to move forward and directions of what you need to do.A teacher stated, “So, for me I can easily put it into the current curriculum or the current places in which we are but I think that would be up to individual teachers.”Finally, when asked about the likelihood of program adoption, the school personnel indicated that their school would be open to using this program. One teacher stated: “I know I would really enjoy it personally because I think it’s the strategies that are important for kids to understand and be able to use and apply.”A school counselor indicated, “I think our school has been pretty open to learning new or picking up new tools that would enrich out student population.”The school personnel indicated that resource constraints were the major barriers to adopting the program. A school counselor shared:Money, money, and cost. But honestly, as far as implementation, it’s simple because it’s online. It really does come down to the time and how much does it cost.This study aims to examine the usability of a technology-based bystander bullying intervention designed specifically for middle schools in rural, low-income communities. We were particularly interested in perspectives from both middle school personnel and students, as these participant groups represent key stakeholders who are in the position of making decisions regarding bullying programming and are the end users of the program. We aimed to test the usability of the STAC-T prototype; assess program utility, user-friendliness, and relevance; and gain an in-depth understanding of the needs and challenges related to program adoption and feedback regarding program content and delivery. Quantitative analysis of the survey data demonstrated a very positive response to the program, which was supported by qualitative data from individual interviews. Overall, the results indicate that participants perceived the STAC-T app to be useful, user-friendly, and appropriate for students at their schools and reported high levels of satisfaction with the program. Findings from this study indicate that the STAC-T app is relevant and feasible for implementation in middle schools in rural, low-income communities.The findings of this study support the usability of the STAC-T app. For both school personnel  and students , scores on the SUS indicated a very high level of usability, well exceeding the standard cutoff score of 68 . The useRegarding feasibility of implementation, school personnel indicated that they believed that their school would use the STAC-T app if the intervention was cost-effective. This finding is consistent with research indicating that administrators in rural middle schools would support a technology-based bullying program  and paraBoth school personnel and students discussed STAC-T program strengths and considerations for increasing user engagement. Qualitative findings suggested that participants perceived the STAC-T app to be useful and helpful in addressing the problem of bullying. They also indicated that the content of the program was appropriate for their schools, confirming the need for bullying programming that teaches students skills to use to intervene in bullying situations. This finding is consistent with previous research in which school personnel in rural, low-income communities indicated a need for bystander training that teaches students strategies to intervene on behalf of targets of bullying and includes having students actively practice these strategies across different scenarios . RegardiThis study supports the usability, relevance, and feasibility of the STAC-T prototype, providing valuable information for the development of a full-scale STAC-T app. However, certain limitations of this study must be noted. Participants were recruited from 3 schools in rural, low-income areas from 1 state in the Northwestern region of the United States. Although participants were recruited from 3 different counties to increase generalizability, school personnel and students from different regions of the country may have a different perspective. Furthermore, most participants in this study were female, further limiting the generalizability of the study. Although variability was low in the quantitative data and we did not identify divergent responses among participant interview responses, interpretation of the results for males should be made cautiously as females comprised approximately 81% (13/16) of the sample. Further formative research conducted during the development of the full-scale STAC app should include purposeful sampling to ensure appropriate representation of male participants. Furthermore, although most participants were White , this parallels the ethnic and racial composition of rural communities in the United States . It is aThis study has important implications for the development of a technology-based bullying intervention that addresses the needs and challenges specific to middle schools in rural, low-income communities. First, participants provided very high usability ratings for the STAC-T prototype, with qualitative data supporting the usability, utility, and relevance of the program. In addition, participants indicated that program implementation is feasible as long as the program is cost-effective. These findings support the development of the full-scale STAC-T app, while keeping the price point as an important consideration. Program cost considerations are particularly important in rural schools, as they face significant financial challenges due to a lower tax base for funding programs . Furtherbadges , which are highly effective gaming tools used to encourage user engagement and build game loyalty [The findings from this study provide a strong scientific premise for moving forward with a full-scale production of the STAC-T app and have implications for program development. The full-scale STAC-T app will include 3 core modules, including strategy training, in which students select customized avatars as they move through role-plays in which they practice the STAC strategies. On the basis of participant feedback on the STAC-T prototype, all core modules will be built to include gaming and features requiring user input . Real instances of game dynamics and mechanics will include several options, such as badges, leaderboards, levels, points, achievements, avatars, content unlocking, quests, social recognition, teams, and tokens. These items target the social cognitive theory components of modeling, outcome expectancies, self-efficacy, self-regulation, identification, and reciprocity. Consistent with research on mobile health strategies for adolescents -80, this loyalty ,88, willBullying is a significant public health issue for middle schools in rural, low-income communities. Schools in these communities face multiple and competing demands on their time and have limited access to training, funding, and mental health professionals to implement bullying programming. The findings of this study demonstrate the usability, relevance, and feasibility of a brief, technology-based bystander bullying intervention. This study provides support for the development of the full-scale development of the STAC-T app and provides information that can be used to enhance program usability while addressing the unique needs of schools in rural, low-income communities.


Falls among older people are a major global health concern. This process evaluation investigates the experience of participants aged 60+ in a yoga program aimed at preventing falls which transitioned from studio-based classes to online classes in response to COVID-19 restrictions. We sought to understand how the Successful AGEing (SAGE) yoga program functioned in both settings and as a hybrid program, and to explain why it worked well for most participants.n = 21) and yoga instructors (n = 3), self-report feedback forms (n = 46), observation of classes and routine process measures.Realist process evaluation was used to explore the factors that facilitated a successful transition for most participants, and to consider why it did not work for a minority. This approach develops program theories that describe which mechanisms an intervention is (or is not) activating, and how this is mediated by context to generate process outcomes. Data included interviews with participants , 3. A communal experience , 4. Putting yoga within reach , 5. Building yoga habits , and 6. Yoga’s special properties (embodiment and mindfulness).This study showed that online delivery of a yoga program for people aged 60+ retained much of the value of a face-to-face program for the majority of participants, and increased the value for some. The structured, communal nature of an organised group program delivered by a skilled instructor, together with yoga’s intrinsic focus on mindfulness, facilitated continued engagement and perceived health benefits, despite the change in delivery mode.The online version contains supplementary material available at 10.1186/s12889-022-12818-5. Falls among older people are a major global health concern with profound impacts on health and wellbeing. One in three people aged 65 and over fall every year, often causing serious injuries and ongoing disability . WorldwiExercise programs involving balance and functional activities are effective at preventing falls in older people . Most foYoga also offers many benefits for older adults. A recent meta-analysis and systematic review of the effects of yoga on people aged 60+ found significant positive outcomes compared with inactive controls in physical function , depression, perceived mental health, perceived physical health, sleep quality and vitality . Yoga haIncreasingly, yoga is used in the management of specific health conditions that affect many older people. These include chronic obstructive pulmonary disease , cardiovA number of studies suggest that yoga may be superior to conventional physical activity programs (such as aerobic exercise) in improving health-related outcomes for older people . TraditiThe global shift from face-to-face to online programs and services as a means of increasing reach and reducing costs, supported by technological innovation and widespread access to technology, has been accelerated by the COVID-19 pandemic. Telehealth can widen access for many, including people who have poor mobility, lack of transport options, caring roles or live outside of service areas . TeleyogThe Successful AGEing (SAGE) yoga trial is a randomised controlled trial testing the effect of a yoga-based exercise program on the primary outcome of falls among 700 community-dwelling people aged 60+ years. To our knowledge, SAGE is the first trial of this size to test the impact of yoga on falls. Participants are randomised to either: (1) the SAGE yoga program involving 40 weeks of supervised twice-weekly yoga-based exercise designed to prevent falls with the availability of flexible ‘make up’ classes, plus goal-setting and unsupervised homework using specially designed yoga resources, or (2) a seated yoga relaxation program taught over two group-based workshops and then undertaken individually as often as participants choose. Trial participants are recruited via local newspapers, community centres and through social media. The primary outcome is rate of falls in the 12 months following randomisation, measured on a monthly basis via self-report. Secondary outcomes include mental well-being, physical activity, health-related quality of life, balance self-confidence, physical function, pain, goal attainment and sleep quality. An economic analysis will compare the cost-effectiveness and cost-utility of the two yoga programs. Details are available elsewhere  she has a toolkit at her disposal that she can deploy as needed.” (P5)Many mentioned specific teaching techniques such as encouraging people to work to their own limits, checking in with individuals (e.g. asking about the state of an injured knee), and highlighting the group’s progress, for example, by revisiting a pose towards the end of the class so participants could see in-class improvements.In addition to the overall design of the program, the quality of yoga instructors was an essential ingredient to the appeal of the program. Key instructor attributes were: credibility as a yoga practitioner; empathy and other interpersonal skills; and excellent teaching skills including the ability to lead a whole class while simultaneously attending to the needs of individuals,“that’s why I think [Instructor 1] was such a good teacher because she never gave you a feeling that your different ability was an impediment, and she helped everyone at all levels” (P1).This program theory is supported by adult learning  and coacThis program theory was initially about social interaction (which was an incentive for a minority) but evolved to focus on the concept of shared experience or solidarity which enhanced the experience of yoga practise for all but one of our interviewees, regardless of how much they wanted to interact with the other group members, “[It’s] the feel of having other people around you, the feel of working together” (P14). When in the studio, the group setting also supported two other mechanisms: many interviewees said they liked to benchmark or compare their physical functioning against others in their peers, and others described checking the person next to them to see if they were interpreting an instruction correctly. Outside of classes the WhatsApp forum was used to advise instructors about absences but was seldom used for other social interaction, suggesting that the incidental nature of conversation enjoyed by many in the studio classes was not well served by this platform. The exception was one group who arranged a get-together after the program had finished. They were in the class with the longest pre- COVID-19 studio time (17 weeks), suggesting that increased face-to-face contact creates stronger social bonds which may be maintained when classes move online. However, interviewees mentioned this as a pleasant outcome of SAGE rather than a factor in their perseverance with the program.Our theory of communal experience is supported by: the upward spiral theory of lifestyle change  , self-deThis program theory focuses on the accessibility and convenience of SAGE classes, both studio-based and online. Free classes were appreciated by all interviewees and acted as an enrolment incentive for those who were unsure about the value of yoga. For some on pensions or low incomes, free classes put quality yoga instruction within their reach. Many expressed gratitude about this, “... I feel terribly lucky to have it” (P21) which extended to the physical location of participating yoga studios being close to interviewees homes. Online classes increased convenience substantially for most, but many participants (and instructors) initially struggled with technology. Transition was smoothest for those who were accustomed to using technology and felt confident in navigating its challenges, but it also worked for those who were inexperienced but open to trying online classes with support from the SAGE team or their family members. All interviewees had prior access to appropriate devices so there was minimal indication of digital inequities, but one said she struggled with the costs of maintaining connectivity.This program theory was supported by the ‘zero price effect’ on value expectancy , studiesThe structure of the SAGE program supported participants to build and embed yoga as a habit. Interviewees were adamant that twice-weekly classes were essential for maximising health benefits but also explained that the regular schedule helped to shape their week  and created a sense of momentum, “Once a week it starts to disappear out of your head and then you start again, whereas twice a week, you’re in this routine” (P16). However, this relied on willingness to prioritise SAGE and sufficient flexibility to do so (requiring family support in some cases). Flexible ‘make up’ classes were valued by interviewees with carer commitments, travel plans, or other unforeseen demands on their time, and were frequently used to catch up on classes missed due to injury or illness. SAGE’s homework tools (program specific videos and handouts) and encouragement by instructors to do homework seemed to work best for those who were keenest on progressing and/or liked their instructor’s approval. The latter worked because instructors made it clear they could tell who was doing homework which some participants found “... highly motivating!” (P5). This form of accountability was seen to motivate routine practise and “then you eventually become self-accountable” (P7). This theory is supported by habit formation theories , 54, theThe SAGE program is balance-focused but utilises core Iyengar yoga practices including sequences that focus on precise bodily alignment using poses (asanas), breathwork and the use of props . Interviewees described being uniquely engaged with these practices in a way that they did not associate with other forms of exercise or recreation. They found yoga to be calming and “almost meditational” (P1), but also “stimulating and energising” P18). The literature offered several plausible explanatory (and complementary) theories. Embodiment theory . The lit, 97, 98 “... often as we get older, we come to be much more in our head and we almost disconnect from our physical bodies and I think that’s why so many people fall, because they’re not really in their bodies anymore as much, especially in the legs. And so, with yoga and the way the program is being set out, it’s very much legwork orientated ... so it is forcing them to bring that awareness into their legs.” (I2)Spirituality was highlighted in some studies of yoga, particularly in the US  I trusted when she did push a bit more that it was going to be achievable” (P12). The sense of mastery of core yoga practices and ‘being known’ by the instructor meant that less intense observation and correction online was generally acceptable. However, a few participants suggested they might not work as hard in online classes as a result of less intense observation.“I know that if a person was in front of me and I had a 360° view of what was going on in their body I would be able to pinpoint, adjust and correct far better than I can on the screen.” (I1)Consequently, they adapted their teaching style to address some of the main challenges. For example, painting the studio wall so they could be seen more clearly, asking students to turn so poses could be observed from different angles, more demonstration and step-by-step instruction, encouraging hand signals by the group (thumbs up/down), more time for questions, and the creative use of household items as alternatives to formal props. However, the extra activities resulted in slower progress online which frustrated some of the more advanced participants.Instructors tended to agree that observation was constrained online,The online platform prevented incidental chat and laughter between group members so this worked best for those with less desire for social connection, but the period of studio-based classes had already established some group camaraderie and the sense of SAGE as a shared experience continued online. Muted classes aided quiet focus but made it hard to communicate with the instructor and so it worked best for people who didn’t want/need to ask questions during classes. Poor visibility of fellow students disadvantaged those who liked to benchmark physical competence or peer check poses.Despite these barriers to interaction, therapeutic alliance between instructors and our interviewees remained strong, aided by the instructors offering individualised greetings and instruction. Where instructors became aware of problems they also followed up with that person and offered 1:1 consultations which supported some participants who were struggling with an aspect of the program and needed reassurance or modified asanas. However, two disclosed in their interviews that although they were struggling they did not alert their instructor.We anticipated differences between the classes based on the duration of their studio-based vs online classes  but none were evident in our data other than the apparent stronger social bonds mentioned earlier in the class with the longest studio time.This realist process evaluation sought to understand the success of the SAGE yoga trial in maintaining older people’s commitment to a twice-weekly yoga exercise program that started in yoga studios but was forced online by COVID-19 restrictions. We identified six dominant program theories that pivot around 16 causal mechanisms.We focus next on the implications of these findings for program improvement and scale-up.Our findings highlight the role of context in engagement with the SAGE yoga program, with implications for the program’s promotion. Unsurprisingly, people enrolled in the SAGE trial because they regarded yoga as a suitable method for improving their health or balance  based on prior experiences of yoga or its “good PR”. Previous research has shown that older people tend to perceive yoga as beneficial , and an Our interviewees greatly valued access to teleyoga during the COVID-19 pandemic lockdown period and, afterwards, were able to attend classes while caring for grandchildren and, in one case, while in hospital. Telehealth interventions have been found effective at promoting physical activity in older people  and tendWhile there are undoubted benefits to online programs and services, there are also challenges, as our analysis confirms. First, telehealth may extend the overall reach of fall prevention and other physical activity programs while disadvantaging certain groups. Technology use is a determinant of health thus lack of digital access or the inability to use it effectively reinforces existing disparities in physical, mental and social health , 113. OlSecond, our interviewees felt teleyoga was less effective at facilitating connection with peers and their instructor. A recent systematic review of group therapy found small decreases in therapeutic alliance in teletherapy but high satisfaction rates despite technical challenges . The autLastly, teleyoga depends on a suitable home environment. Our interviewees reported a variety of challenges including space constraints, disruption and feelings of intrusion. Matsumoto et al.  note thaOur findings suggest that, where possible, a hybrid model of initial studio-based yoga classes followed by online classes might deliver the best value to participants as it increases access while reducing some of the most pronounced concerns about communication and effective observation and correction in teleyoga. Many older people have a preference for at-home exercise , howeverHowever, in weighing up the value of a hybrid model we note that SAGE’s hybrid program may have produced paradoxical findings. On the one hand, interviewees felt that the initial studio-based classes mitigated the impact of decreased interaction and observation online because they had already established relationships in the studio and had learnt and embedded core skills, suggesting the hybrid model is superior to an entirely online model. Yet interviewees did not describe a lack of interaction, observation or correction online (and none felt unsafe in this environment), simply a less effective experience compared to studio-based classes. Therefore, it is possible that studio-based classes set expectations about interactivity, observation and correction that those starting in online classes would not have, especially considering that most interviewees had no prior experience of yoga. Planned follow up with later classes in the SAGE trial which employed a teleyoga model throughout will provide greater insights.Lastly, although the SAGE program was delivered by different instructors with slightly different teaching styles, our interviewee data did not indicate any discernible difference in how their classes were experienced. This suggests that the program mechanisms were being activated consistently across the whole program. Hawe  reminds Realist evaluation’s pragmatic mixed methods approach to data collection is a strength. The use of different ‘lenses of inquiry’ inherent in mixed methods can reveal richer, more comprehensive insights into complex health phenomena . EvaluatA weakness in this study was our inability to purposively recruit interviewees from the whole cohort (we were limited to those who had given advance permission to be contacted) or to talk with participants who had withdrawn from the trial. Where reasons for withdrawal were given, they were health-related, but not all withdrawals offered reasons which may indicate undisclosed problems in their engagement with the program. We interviewed yoga program participants soon after they completed the program so recent yoga classes were likely to be fresh in their minds, but they may have had limited recall of earlier classes. Interviewees may have felt some pressure to give socially desirable answers given that the researchers were based in the same research group as the trial designers and implementers Lastly, it is important to consider the context of COVID-19 in interpreting these results: some interviewees suggested that social restrictions may have increased their engagement with SAGE and their acceptance of an online program.Our study investigated the transition of a yoga program aimed at preventing falls from studio-based group classes to online classes. The factors that facilitated a successful transition for most participants included the quality of the teaching, the yoga practise itself and the structure of the program. The increased accessibility and convenience of an online class was a benefit for those with transport and health issues but worked less well for those without an appropriate home environment or who had privacy concerns. Many felt that the online interface negatively impacted communication and the effectiveness of yoga instruction compared to face-to-face classes. Using a realist approach we identified causal mechanisms that may have generated these effects. Our results provide useful guidance for the delivery of online yoga classes to people aged 60 years and over.Additional file 1. Research rigour.


In an era of global health security challenges such as the COVID-19 pandemic, there is greater need for strong leadership. Over the past decades, significant investments have been made in global health leadership development programs by governments and philanthropic organizations to address this need. Evaluating the societal impact of these programs remains challenging, despite consensus on the importance of public health leadership.This article identifies the gaps and highlights the critical role of monitoring and evaluation approaches in assessing the impact of global health leadership programs. Importantly, we also propose the theory of change (TOC) as a common framework and identify a set of tools and indicators that leadership programs can adapt and use.We carried out an informal review of major global health leadership programs, including a literature review on leadership program evaluation approaches. Current practices in assessing the short- to long-term outcomes of leadership training programs were explored and synthesized. We also examined use of program theory frameworks, such as theory of change to guide the evaluation strategy. We find the TOC approach can be enhanced by integrating evaluation-specific frameworks and establishing broad stakeholder buy-in. We highlight measurement challenges, proposed outcome indicators and evaluation methodologies, and outline the future direction for such efforts.Most evaluation of current leadership programs is focused on short-term individual-level outcomes, while reports on long-term societal impact were limited. Reciprocal impacts on and benefits for the “host” organizations were not included in evaluation metrics. Most programs had program logic or result chains, but with no well-articulated program theories.Key stakeholders involved in leadership training programs benefit from the evidence of rigorous program evaluations to inform decisions that address barriers in fostering global health leadership and improving population health outcomes. Insight into reciprocal change in host organizations is important. Evaluation of global health leadership training must go beyond the individual trainee and encompass organizational and community-level impacts. Documentation of long-lasting organizational and societal impacts is essential for donors to appreciate the return on their investment.Evaluation plays an important role in understanding how leadership development takes place and how it contributes to improving public health outcomes.Making the case for investments in leadership development programs requires robust evidence from monitoring and evaluation strategies that link investments beyond the individual-level to longer-term societal impacts.The first critical step towards a strategy for success is for leadership programs to clearly build, articulate, share, and use their program theories or theories of change.Theories of change help identify the pathways  through which leadership development programs effect change at the individual, organizational and community levels.Evaluation methods that examine outcomes of leadership programs should be multi-method, multi-level, and where possible include counterfactual outcomes.Allocation of funds to evaluate on-going and long-lasting societal impact of leadership programs should be a routine practice. In today’s constantly changing landscape, new infectious, environmental, and behavioral challenges, such as COVID-19, Ebola and Zika, highlight the need for strong leadership. Significant investments have been made in leadership training and several training programs have emerged to address this need. Public health leadership has been identified as an imperative for global health security . More reMonitoring and Evaluation (M&E) is used to assess the performance of projects, institutions, and programs set up by governments, philanthropy, international organizations, and non-governmental organizations (NGOs). The goal of M&E is to improve current and future management of outputs, outcomes and impact. At the program level, the purpose of M&E is to track implementation and outputs systematically. At the donor/funder level, M&E reports are used to determine success or advocate for refunding and are an important part of accountability to funding agencies and stakeholders. Given the underlying objectives of many global health leadership programs, such as improved health equity and health outcomes, M&E strategies that focus on simple metrics, such as numbers trained, paint an overly simplified view of leadership program progress and success.The pathways through which the increased leadership capacity of individuals leads to organizational and ultimately societal impact are tenuous. Most programs measure the “success” of leadership programs, by measuring process outputs anchored to the program objectives and goals as opposed to the true long-term impact of the program on global health. These M&E efforts are typically immediate or short-term in nature. Few M&E frameworks capture the impact of the trainee on host institutions or global health outcomes more broadly.Identifying measures of downstream organizational or societal impact is essential to meaningful assessment and improvements in global health leadership training programs. This requires a thoughtful consideration of the catalytic impact a training program has on individuals, their institutional or policy arena, and ultimately on health systems. Training leaders is complex and thus measuring evidence of their impact is challenging. This paper reviews the current practices of assessing the success of global health leadership programs and outlines potential strategies that go beyond assessment to measuring impact.This paper contributes to the limited body of research on measuring and assessing the impact of leadership training programs by proposing a common framework—theory of change (TOC)—and a set of tools and indicators that leadership program designers can adapt to fit across programs. We review a selected sample of leadership training programs that are either practice or policy focused and propose a set of anticipated outcomes, potential indicators, and methods of data collection. Lastly, we discuss the impediments and solutions to measuring long-term impact on and reciprocal benefits to organizations hosting these programs.In our review of the literature, we found that evaluation has focused on measuring individual-level outcomes with some recent attention to leadership outcomes at the organizational level . LeadersTable 1 presents a relevant overview of the major approaches to the measurement of impact of public health training programs.There are over 200 differing ideas and theories on leadership. The evaluation of leadership initiatives has varied greatly in design and approach. There is no “gold standard” by which to assess success. In an informal survey of the programs led by the study authors, we found that few metrics were used consistently, making it difficult to assess relative impact of leadership training across programs. However, we noted several trends: 1) Most programs had a heavy emphasis on short-term (1–2 year) outputs. These metrics often focused on individual trainees, with emphasis on new knowledge/skills gained and early accomplishments . Some focused on the program outputs as well . 2) As programs described their evaluation metrics over a lengthier time scale, however, the number and specificity of measurement indicators typically decreased. In the medium-term horizon , programs often focused on how individuals interacted with their work environment, including behavioral changes, performance, networking, and organizational capacity building. When the scope was extended to the long-term (>5 years), greater emphasis was placed on broader institutional changes across multiple institutions and sectors. 3) We identified only two projects that measured organizational level and/or societal level outcomes, but one is still in the early (1–2 year) stage.theory of change for leadership intervention, describing what the leadership training program is trying to achieve and how it hopes to get there. This is a crucial, antecedent step in designing an evaluation strategy and illustrative examples of effective logic models are included in Figure 1.There is a large body of literature that demonstrates the critical role of theories and frameworks in guiding and explaining how to evaluate the outcomes of complex public health leadership programs for improved global health 14. One oFigure 2 we present both a TOC framework and provide illustrative examples of measurement indicators  that could be applied.Once the leadership program’s key components have been identified and its theorized causal pathways articulated, decisions can be made about which components and pathways of the program are of most interest. A TOC can also facilitate broad stakeholder buy-in and agreement, as well as guide the allocation of evaluative resources. The challenge then lies in identifying and then applying measurable indicators to components identified as critical to the pathway of change. The field of implementation science has several established evaluation specific indicators that have well defined measurement metrics. In Table 2 we propose sample indicators and evaluation strategies.To understand the comprehensive effect of public health leadership programs, we need to invest in the measurement of both short-term and long-term outcomes. As an evaluation shifts from short-term to long term-outcomes, so does the socio-ecological level of measurement which will progress from the individual to organizational and community/societal levels. In Evaluating leadership programs is inherently complex. Leadership development and leadership impact are characterized by dynamic and interlinked processes of change. Leadership development—whether at the individual, organizational or societal level—is subject to multiple feedback loops that change the conditions in which the training operates. The leadership development process continues well beyond typical high-touch points of the intervention . While positive leadership development at the individual level may be evident/observable during a training program, greater individual leadership growth is likely to take place multiple years out. This is the result of the accelerator effect of better learning through successive leadership experiences, the cumulative effect of broader network development with similarly trained leaders, or the catalytic effect of engagement of additional leadership mentors.Leadership evaluation uses a number of methods to measure the immediate impact of leadership programs on individual leadership abilities, including the use of 360 evaluations, assessment of self-efficacy, pre-post training assessment based on the Kirkpatrick model. Leadership development, however, is also strongly impacted by an individual’s organizational environment, including the incentives of an organization and the type of leadership behaviors it rewards. Long-term leadership evaluation has often struggled to adequately specify and measure how context affects outcomes. Doing so can illuminate how and when improved leadership in individuals translates into improved organizational and system-level outcomes— the contextually situated process of leadership.Social network analysis can also expand the range of results beyond individual outcomes to reveal the pattern and strength of relationships formed as the result of a leadership training . NetworkEvaluation of leadership programs beyond the individual level tends to face several, inter-related challenges. The narrower and more upstream the evaluation focus, the easier and clearer the attribution of the leadership program . The further beyond the individual level of measurement one goes (the downstream impact), the longer the timeframe to see the intended changes the leadership program aimed for. Moreover, when leadership development programs aim to influence outcomes beyond the organizational level, the theory of change needs to articulate the specific changes intended at multiple levels, which might include community, network, field, movement, population, and systems. These intended changes would need to be explicitly aligned between the executing or “training” program and the organization to which the participant is returning. The further downstream one looks for impact, the wider the field of contributing factors to that impact . This challenge is inherent in evaluating any leadership program, most training programs, and other complex interventions. Given these challenges and complexities, funders and evaluators should not emphasize “attribution” which forces people to look for more arbitrary measures of success. They should instead embrace a perspective which evaluates the leadership’s program contribution  which enables program implementers and evaluators to focus attention where they are really hoping to see a difference.Typically, stronger impact evaluation designs are considered to be those which compare the results of the program to a counterfactual, a comparison which is usually done through experimental or quasi-experimental research designs 18. HowevThe field of global health is in agreement that leadership matters for strengthening health programs and improving public health outcomes. In this article we argue that evaluation plays an important role in understanding how leadership development takes place and how it contributes to strong institutions and better health. Making the case for investments in leadership development requires solid measurement and an on-going focus on evaluation that can credibly link investments to longer-term impacts. Ongoing attention to leadership evaluation is critical to the case for leadership development as an essential component of public health. Here we highlight gaps that need to be addressed and some ways forward.For individuals who pass through leadership development programs, there may be a tension between what their organizations measure  and the developmental outcomes that leadership programs may espouse. These organizational performance outcome measures may fail to include non-quantifiable metrics and fundamentally be less concerned with how leadership emerges and how it is mutually constructed. The result is that organizations are likely to under-value the contributions of leadership training programs.The first crucial step towards a strategy for success is for programs to clearly build, articulate, and share their theories of change. Stronger theories of change can support leadership development in ways that go beyond evaluative functions. They help develop and confirm a program’s leadership ideology so there is a consistent approach across delivery and evaluation. They also help identify the pathways and potential tensions that are believed to drive leadership development within a particular organizational and institutional context. They also help build the case to funders by telling a clear story of how leadership matters and what kinds of outcomes funders might expect from their investments.Given that we are now at a critical juncture for global health, where the conditions and needs for effective healthcare delivery are changing, addressing the ‘interpretation of leadership’ and ‘drivers of leadership’ evaluation gaps is vital. Left unaddressed, these evaluation gaps can hinder the ability to develop leaders with the capacity to establish and deliver both population-based and individually targeted solutions, which will be required from leaders in public health. Bridging the ‘interpretation of leadership’ evaluation gap requires recognition that while there are many definitions of leadership, leadership programs need to clearly identify the type(s) of leadership roles and responsibilities in global public health they are supporting.Making the case for investments in leadership development requires an approach to impact measurement that moves beyond individual leadership outcomes. Moving beyond individual outcomes requires a better understanding of how leadership development affects the performance of host organizations, as well as how feedback loops and network interactions can amplify the effects of original investments to improve community and population-level outcomes. Making this case requires funding for evaluations that are multi-method, longer-term and that focus on identifying causal effects where possible, yet pay close attention to credible contribution to organizational and societal outcomes.A thoughtful M&E strategy has the ability to not only harness meaningful indicators that seek to quantify the outcomes of a global health leadership training program, but also, when nested within a theory of change, allows for an understanding of the causal pathways that contribute to success. A holistic approach to M&E requires capture of both short and long-term indicators across socio-ecological levels, some of which are proposed in this paper. There is a greater need in the field of global health leadership training, however, to support the development and measurement of impact indicators that span beyond the program and the individual trainee, to also encompass the organization and community where that the trainee works. Leadership measurement that truly captures impact requires funding to support evaluation long after the training program is completed. Such an investment is necessary if donors are to identify and thus support programs that have the ability to make long-lasting sustainable impact.