In many countries, life expectancy has increased considerably in past years, and the importance of finding ways to ensure good levels of wellbeing through aging has become more important than ever. Arts based interventions are promising in this respect, and the literature suggests that musical activities can reduce isolation and anxiety and foster feelings of achievement and self-confidence. The present study examined the effects of group music making programs on the health and wellbeing of nursing home residents in Southern Switzerland. A team of professional and student musicians delivered 10 weekly music sessions in four nursing homes, focusing on singing, rhythm-based activities with percussion instruments, and listening to short, live performances. 22 participants  were recruited to take part in the study and were interviewed after the last music session. The data were analyzed with thematic analysis to investigate how residents experienced group music making and its effects. The findings show that the music programs were beneficial for residents’ wellbeing. Music plays an important role in their lives, both in their pasts and presently, and being involved in musical activities offers engagement and novelty in daily life, providing learning opportunities and facilitating interpersonal relationships. Moreover, these results were due to interactions with the musicians involved. Residents particularly appreciated the opportunity to listen to live performances as part of the sessions. This study suggests that nursing home residents value music and that music based interventions play an important and direct role in enhancing their wellbeing. The total number of music students involved was 9, with 4–5 per team and some, on voluntary basis, involved in more than one nursing home. Students, who already possessed skills of advanced instrumental performance, were specifically trained to act as facilitators of the music workshops. The training consisted of being able to direct small groups of residents in singing, using the percussion instruments employed , and to support learning in an appropriate and effective manner throughout the sessions. As a consequence of a quarantine for a serious influenza outbreak, the ten-week program was interrupted for seven weeks in one nursing home.This study arises from Each music team delivered a public event in their assigned nursing home to introduce the musical activities proposed to residents. Each resident was offered the opportunity to participate in the program, and at the end of each session, the number of participants was noted by the staff of the home. The inclusion criteria for this study considered only residents who attended at least 8 sessions and who were able  to be interviewed. Forty-one residents  met the first requirement, and from them, 22  met both criteria.Each group music making session lasted 45 min. The musicians performed some live music both at the beginning and during the sessions, which was designed to engage participants and to make their experience as enjoyable as possible. The program for each nursing home was refined by the workshop leader as the 10-week period progressed, and the repertoire included songs requested by residents. Even though each music team delivered its own program, the overall approach and musical activities were common to all programs and included agreed songs at the beginning and at the end, musical warm-up exercises, and the practice of a varying between new songs and the revision of previous songs. During the sessions, residents were able at any time to choose whether or not to take part in each song or exercise proposed by singing, by accompanying with the instruments reported in the study design, or by listening.Data were collected through individual semi-structured interviews conducted by the researcher (first author), who was known to participants as a member of the music team. The interviews took place in Italian either in residents’ private rooms or in common spaces of the nursing home during the week following the last music session. Inspired by a phenomenological approach, the questions invited interviewees to evaluate the program, to talk about its effects on themselves and on their relationships with other people involved in the sessions, and to provide a self-evaluation of their musical abilities. The full list of questions is provided in The study was granted ethical approval by the Ethical Committee of Canton Ticino (CE 3030-2016-00193).The first author transcribed verbatim the interviews, and then thematic analysis  was appl•role attributed to music,•changes of the role of music due to the program,•nature, intensity and duration of the effects of the sessions,•overall evaluation of the program,•interpersonal relationships,•experience of making vs. experience of listening to music during the sessions,•peculiarities .Grouping rich accounts of data in this way allowed for a deeper and more detailed understanding of the complexity and the nuances implied by each criterion. In order to reconstruct individual experiences of the program, each interview was then analyzed again observing for each participant the interactions of these criteria. This analysis was discussed within the research team and led to the elaboration of a summary of the results.As shown in The effects described by participants belong to the dimension of mood and emotions, and taking part in the program evoked happiness and other positive feelings. It emerged from interviews that this was mostly due to how the overall program was carried out, rather than to its specific aspects.[The program] had very positive effects on me because I liked very much everything you did. […] I was very happy! I was really happy! [Every time] I spent a lovely lovely lovely hour. These positive feelings may have been linked to the novelty introduced by the program in the everyday life of residents or to the activation of ties with their own life experiences.You came here and made us spend an hour in happiness, with something different from what we do every day. It is a wonderful thing to have something engaging us and able to change our day. I have been happy because [the program] is something enabling me to be myself again, namely to listen again to music that I did not listen to for a long time. Every time I saw you [the researcher] coming with your double bass…I liked it! I was seeing my father [who was double bass player]! For these reasons, the session day was anticipated with happiness.I was always waiting for […] Wednesdays, then I was waiting for 10.30. It was almost a sort of romantic relationship. We were looking forward only to Fridays because it was the lesson day! It was something enjoyable for us, and when you like something, you are looking forward to that day. In only two cases, the effects on mood were not positive. In detail, it emerged that memories recalled by music provoked melancholy for a participant, while in two cases expectations were not met because the goals of the program were unclear or because its contents did not develop the participant’s own musical competences.My character is a little melancholic. If I listen to music, or maybe if you get out unintentionally some music related to my youth, this makes me sad. I found [the program] almost pointless…because it left me indifferent. I just laughed while we were using the basket making “tac tac, tic tic.” And I was wondering “What is the point?” The analysis revealed that the aforementioned effects are related to four themes. The first is connected to the importance of music in the life of residents, the second with the learning opportunities offered by the sessions, the third with the interpersonal relations experienced during the program, and the fourth to the usefulness of the program in coping with recurrent feelings and concerns.Although the interviews revealed diversity among residents regarding their musical backgrounds and their involvement in music, it emerged almost unanimously that music was an important and valued art form, able to induce emotions and affect mood.I like everything related to music and to musical instruments. It makes me happy! I think it benefits the spirit. For me, music is life! I think music is very important for elderly people. If you listen to a song or sing, you feel younger, you feel more alive. For me music is art, so I feel grateful when it is available. Everything related to art and able to reach your hearth is always welcome… If we take art away from life, what’s left? I could say music is a relevant part of my life, definitely, even though I never played an instrument. Music tells me something! It really does that! I am not indifferent to music, but I am not used to sitting down just to listen to music. This interest in music manifested itself through the regular use of radio and similar devices. However, listening to music autonomously was not always completely satisfying because the impact on the mood may have been negative.Every night I always listening to Rete2, always hoping to listen to good music to take me to sleep. Music gave a lot to me! And it still does! I can’t read anymore, and often I don’t like television broadcasting. There are songs that give me joy and songs that give me sadness. Besides the benefits associated with music listening, music was also relevant because someone important in their life had been actively involved in music, or because they themselves used to sing.My brother worked in an orchestra… In Switzerland we have the Suisse Romande Orchestra, which broadcasted concerts on the radio, and he worked there. Consequently, some interest in music remains. I still remember singing with my husband when traveling by car. When leaving for holidays, we would sing mountain songs along with our children. Beyond that, singing was still an important resource, and residents who used to sing maintained their music making because they were, to some extent, aware that it was beneficial and kept negative feelings away. It emerged that some residents accessed these benefits irrespective of their abilities, while others, concerned about their limits in singing, would sing only in specific conditions.For me, music is a great support for the spirit! While you are singing you don’t have sad thoughts, or perhaps you do, because you remember someone you loved. Singing is good for me, I sing gladly. When you sing a song, even though you didn’t compose it, you sing it gladly because it is something that awakens you. It wakes the body and soul. Furthermore, it keeps away some thoughts like: “Now I just have to wait to die”…no! If there is a singing group, I also sing because I still have the voice to sing. But I don’t sing alone! I always sang at home. But now I don’t anymore have my past voice, and this make me laugh because I think: “Gosh, if someone heard me singing he would throttle me!” But I sing anyway! Cases reflecting active involvement with musical instruments referred only to the distant past. Nevertheless, it emerged from the interviews that this kind of musical activity, no matter whether actual or contemplated, was still in the thoughts and desires of residents.I began to play piano in early childhood. My sister played violin, and we performed duets… Now I can’t play because my hands don’t work anymore. Furthermore, here it is impossible to play piano. I always liked music. Sadly, I wasn’t able to study it. I liked the piano, but I could not afford to study it… In my village a guy owned an accordion, and sometimes he allowed me to play, and I quickly learned to play the melody by ear. Afterwards, you know, you leave [the village] for work, and you don’t stay in touch anymore. After all, I miss an instrument. My mother was right: “You could at least study piano!” Now it is too late (smiling). The positive emotions reported by participants are also related to the numerous learning opportunities offered by the program.Taking part allowed residents both to receive information and instructions from the musicians and to manipulate the instruments used. With reference to the latter point, the opportunity to play percussion instruments, exploring the diverse sounds in a friendly and playful environment, provoked curiosity and fun.Well, I liked the triangle very much, I really liked having that small object to beat! I also liked the small drums and the bells… We wanted to try them, and we really liked it! […] Playing those small instruments was really nice and enjoyable. We had fun, like a child provided with sticks and allowed to play… The musical interaction within the group was central to providing pleasure in producing sounds. That was engaging because, on the one hand, this interaction required attention and, on the other hand, the mistakes and the musical imperfections were funny and intriguing.I had also laughs, when someone made this and another made that [she mimes two uneven gestures]… It happens when one gets old, but it was funny for me. Having to concentrate was lovely too, whether we were playing drums or whatever else. It was also funny. Musical activities were experienced with happiness and engagement especially because they were considered ‘proper’ learning opportunities, relating to very diverse aspects connected to music. The interviews reveal positive thoughts about the overall design of the program and the progress made session after session. A resident expressed disappointment as the program ended without any special activity.For us it was a sort of learning through playing. I mean: as you teach children how to play, you also teach the elderly how to play… At the beginning we took it [the program] as a joke, as a way to have laughs. But, little by little, we understood that while having fun, we were learning something. At the beginning we did our tasks poorly, while now, at the end, we do them much better!… I just observed that… I was used to chatting a little with all of you [members of the music team], and I felt gradually more secure. Yes… making music together reduced the awe I felt, definitely…and it made everybody happier! I expected who knows what!… It was the same from the beginning to the end… We wanted something for the conclusion!… But it was good to take part in this program. The combination of musical instruments and playing music with common objects was especially appreciated and represented a surprising revelation and discovery.I didn’t believe one could make music using those [objects and small instruments], but it is possible. I heard, and I am happy for having observed and learned that. You taught us that actually there are situations where one can make music even with simple objects… Let’s consider the grater, for instance: who knew that with such a tool you could make music? Nobody!… And then we learned also that. If we consider more closely only the musical aspects, participants referred to their improved ability to keep rhythm, their understanding of processes related to music creation, and their new capacity to approach and appreciate unknown repertoires. The time devoted to anecdotes and information related to the biography of famous musicians was, in turn, appreciated.Now I would evaluate 8  because I just learned what it means to keep rhythm. It was really very interesting!… [A way to] discover that music is something different to what I believed. I could not understand how you musicians do it…and then, I learned how one can make music! Russian music, in particular, was unfamiliar for me, and I liked it very much. Every time we discussed something about the life of Mozart or somebody else, that was nice too! In the rhythm-based activities the learning opportunities were generally welcomed regardless of familiarity with the songs and activities proposed. However, the inclusion of unfamiliar songs in the singing-based activities required some effort for participants.Dealing with the songs you know is simpler. You go in effortlessly… It is a little more tough to deal with learning new songs because you have to study, you have to read… I preferred the songs I already knew. To sing the other [unfamiliar] songs, you have to learn them.[…] When they [the musical team] teach you, when they engage you in singing German songs, you never learn them completely, and this is a problem. I know, they give you also the sheet (with lyrics), but it becomes a little difficult! You have trouble. Taking part in the program had effects also on listening to music, making this activity more engaging.Before, I was used to listening to music ‘en passant’. Now, I listen to it differently… with more attention. Now I try to listen a little more deeply, and I find again information I was taught at school. I think that, now, I listen more to the music than to the lyrics. I mean, before, I was focused mostly on lyrics, now instead I am almost more focused on music than on lyrics… Before I listened to lyrics but not to the music! These days I think: “Gosh, this music is wonderful!” The effects reported by participants were related to interpersonal relationships in two respects: relationships with other residents and with members of the music team.In the context of nursing homes, the program constituted an opportunity to meet, consolidating relationships between residents and offering conversation starters, particularly about musical topics.I talked with other residents! Even last Friday, with the lady close to me. We talked about music and operatic arias. I talked mostly with my friend. Yes, we talked a lot, and we are very happy about the whole program. I would not say I previously had a direct relationship with other [residents]. But everybody knows better each other through making music! Definitely! In some cases the program promoted the mutual support and the sharing of impromptu and spontaneous musical activities.A person I became friends with, who also participated in the program, liked it too. She has some problems with memory, and she asked me: “Remind me when the music session is so I can join you”, and last time she went before me and kept the place for me. She liked a lot the program and taking part in it together made her happy. We all felt well, and sometime, in the evening, we sang that ritual opening song “Siamo qui siamo tutti qui” (singing). Nevertheless, the data also reveal that, due to individual attitudes or to the recent relocation to the nursing home, taking part did not affect their relationships with other residents.The relationships [with other residents] remained the same. After all, I am not a chatterbox. When I come across somebody I salute them; I chat with them. Well, it’s not been that long that I moved here, barely a year. Then I talked very little with other residents (with a sad tone). The interactions occurred during the sessions, and the concentration demanded by the activities also brought to the surface small frictions between residents.There was a lady in the group, odious and even ugly, who was always out of time. And when I looked at her, I went out of time too… When one makes music and brings the time, you can’t go out against the time! I don’t like people who always want to prevail. Unfortunately [in our group], there was a lady with this flaw, and this gets me nervous. She always prevails, always! Now I let go. Why should I get nervous? The encounters and interactions with music team were often positive. The interviews reveal feelings of warmth and gratitude.I bonded with each of you (smiling); you were lovely and kind. Did you notice I came to greet you at the end of each session?… Honestly I felt very well with you. First of all I was delighted to be acquainted with you, people taking care of me and my peers. The musicians avoided a formal and detached approach with residents, and this was unanimously appreciated. The friendly, serene atmosphere established throughout the program promoted empathy and triggered ties with residents’ life experiences. The encounter between different generations had an important role in this sense.I liked [the relation with musicians]! That reminds me of the time when my son was in high school, and I felt as I could feel their problems and share with them my problems. Do you know what I mean? The guys were very, very nice! They made themselves available to make us able to do a good work, and they achieved that! They were very lovely, yes – wonderful and lovely. The flower of youth! Due to personal habits or individual character, a few residents taking part in the program did not experience meaningful interactions with music team.I am not very sociable… I made my music, I followed the instructions, and that’s all. Besides personal interactions, the arrival at each nursing home of the music team offered an opportunity to see new faces and figures. Residents found it interesting to observe the personal and musical interaction within the team and appreciated the musicians’ commitment and energy in doing their work.I liked it very much because it was clear that there was a strong chemistry between you musicians and that you enjoyed making music together. I liked that opening ritual song because I thought: “It also is a sort of welcome”. [It expressed] your pleasure, the pleasure perhaps you had in the same way we had. The interviews offered room for thoughts related to the everyday life in the nursing homes and to the meaning of musical activities within this context. In this regard three subthemes emerged, offering further elements to understand the effects of group music making and how it was experienced. First of all, the opportunity to take part in the program represented a valuable opportunity to limit the feelings of isolation perceived when living in a nursing home.Your idea is very good, in that way we don’t feel completely lost, we [see] more people and [we have] more interactions… Here many [residents] cannot even move from their chairs. In my opinion music is extremely important for the elderly. If you listen to a song, or if you sing it, you feel younger, you feel more alive… Do you know what I mean? Because in being just nothing, one regresses. For residents strongly interested in specific music genres, the feeling of isolation was explicitly related to their musical tastes, as it may not have been possible to share with anyone their passion for specific repertoires.I like very much classical music too, but it’s not easy! Because…not everybody is used [to that]. I am talking about people living here… Here we are all old! Senile! (She laughs)…Believe me, it’s not easy to live here. I think people living here are not very musically cultivated. The only music they enjoy are the ditties, “La bella lavanderina” [a folk song], and that’s all… I like any kind of music, but to listen to a recording is not the same. With you musicians one can talk and share impressions about music and about the feelings it provokes. As we have already seen, the program was to a significant extent experienced as a learning opportunity. Nevertheless, some residents revealed doubts about their own cognitive abilities.I would like to study, but perhaps the brain regresses. [With regards to the possible changes and improvements of the program] I would not change it so much, no. We are quite limited, in the truest sense of the word. Beside the thoughts related to learning, the interviews reflected thoughts related to novelty and engagement, and in particular attention and imagination were considered under stimulated by some.[The program] was positive mainly because one learns to pay attention, which is not something we have to do so much here. I think that [during the sessions] our imagination is very stimulated. The program supports our imagination. This study suggests that the program of group music making had effects on the mood and emotions of participants and, to some extent, enhanced autobiographical memories. These effects were related to three elements: participants’ interest in music, their appreciation for the learning opportunities included in the program, and the interpersonal relationships promoted by it. The results are aligned with those of other studies  and are Residents reported mostly positive effects, and this was due to the fact that the program offered, in an environment where they sometimes lack a sense of novelty, a combination of receptive and active engagement with something they considered important. Thanks to the ability of music to trigger memories and to strengthen links with one’s identity and biography, taking part in the program represented a valuable opportunity for residents to stimulate and to value their cognitive abilities. Furthermore, the collective dimension of the program facilitated interpersonal relationships. This element seems particularly important considering the feelings of isolation reported by interviewees and often experienced in the context of nursing homes . In thisgroup, music, and making had an important role in the residents’ experiences, and the majority of themes and sub-themes were related to a combination of at least two of them.A deeper analysis suggests that each of the three components of music was crucial: participants were delighted to take part in the musical activities. In some cases, they waited the whole week for the session, and by attending it they strengthened links to their memories and identities. Both listening to and making music improved mood and stimulated attention and imagination, in agreement with other studies .Negative effects occurred only in a few cases. The capacity for ng music , stress Considering this overall picture through the lens of the PERMA model , our finmeaningful role even in the late stages of life, as in its different forms of consumption it can trigger autobiographical memories, reinforce identity, and stimulate the most intimate and spiritual dimensions of individuals. In line with earlier contributions . The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In this study, the measured accelerations of a single smartphone were used to provide an earthquake early warning system. In the presented system, after the smartphone is triggered, the triggering event is then classified as an earthquake event or not. Once an earthquake event is detected, the peak ground acceleration is then predicted every second until 10 s after the trigger. These predictions are made by the neural network classifier and predictor embedded in the smartphone, and an alert can be issued if a large peak ground acceleration is predicted. The proposed system is unique among approaches that use crowdsourcing ideas for earthquake early warning because the proposed system provides on-site earthquake early warning. In general, the accuracy rates of the earthquake classifications and peak ground acceleration predictions of the system were quite high according to the results of large amounts of earthquake and non-earthquake data. More specifically, according to said earthquake data, 96.9% of the issued alerts would be correct and 61.9% of the earthquakes that exceeded the threshold would have resulted in an alert being issued before the arrival of the peak ground acceleration. Among the false negative cases, approximate 97.8% would occur because of negative lead time. Using the shake table tests of worldwide and Meinong earthquake datasets, the proposed approach is confirmed to be quite promising. Earthquake early warning (EEW) aims to deliver alerts to the public and automated systems before destructive waves strike them. Although the idea was first proposed by Cooper in the mid-19th century . The devEEW systems can mainly be divided into two categories, namely regional and on-site ones. A regional EEW system requires a seismic network, while on-site EEW systems only use one seismic station. Recently, the idea of participatory sensing, in which mobile devices are used collectively to gather critical information, was introduced by Burke et al. . With reThe Earthquake Network project ,15 develThe MyShake app ,17 offerIn this study, we propose a system that further leverages smartphone computational resources to run a single-station (on-site) EEW algorithm in each smartphone. For this system, the artificial neural network (ANN) approach was used to construct a classifier for distinguishing earthquakes from human activities, and also to construct a peak ground acceleration (PGA) predictor based on the accelerations measured by smartphones. The flowchart of training the earthquake classifier, training the PGA predictor, and implementation of these two models is summarized in P-wave arrival time. In general, the amplitude during the first several seconds after a trigger is quite small; hence, using smartphones for on-site EEW is valid in most cases. The exceptions in which the amplitude is large during the first several seconds after a trigger occur when smartphones are close to the epicenter of an earthquake. In such cases, however, the smartphones are very possibly within the regions of the blind zone for EEW in which no alerts can be issued before the strong waves arrive.Previous studies have confirmed that smartphones fixed on shake tables can measure ground motion accurately between 0.5 and 10 Hz ,19. WhenIn this study, five mid-priced smartphones of different brands were used, as shown in In order to develop the algorithms used to distinguish whether the movements of smartphones have been caused by earthquakes or human activities, the accelerations measured by smartphones resulting from both human activities and earthquakes are required. In this study, human activity data were collected from the smartphones as the smartphones remained stationary for at least 10 min. Once the ratio of the short-term average and long-term average on any of the three components exceeded a threshold , the smaThe earthquake data used in this study were replicated from existing ground motions recorded by the Taiwan Strong Motion Instrument Program (TSMIP) maintained by the Central Weather Bureau (CWB) in Taiwan. In order to generate acceleration signals similar to what could be measured on steady smartphones during real earthquakes, the ground motions were converted to the resolution of each smartphone, and then the noise signals of each smartphone recorded during the noise floor tests were added to the ground motions. The TSMIP data recorded from 29th July 1992 to 31st December 2006 were used in this study. Because the noise floor and resolution of each smartphone are different, the number of ground motions produced for each smartphone were different, as shown in Kong et al.  developeIn this study, 75%, 12.5%, and 12.5% of both 10,000 pieces of earthquake data and 10,000 pieces of non-earthquake data were used to train, validate, and test the ANN classifier, respectively. The non-earthquake data were randomly selected from the available database. As for the earthquake data, we tried to keep the numbers of selected pieces of data with different PGA ranges as even as possible. We selected the LG Stylus smartphone, which had the worst resolution and moderate noise floor among the available smartphones, as a representative benchmark. The results of all the available earthquake and non-earthquake data are shown in the following paragraphs.First, we use the features of the first two seconds after a trigger of both earthquake and non-earthquake data as the inputs of the ANN. The features we used are the IQR and ZC of three components . The CAV was not used because we found that no significantly better results were obtained if it was included. A grid search was conducted to test different numbers of neurons and layers. The best performance was achieved when the ANN had two hidden layers with 15 neurons with sigmoid activation function. The true positive rate  and true negative rate  of the ANN classifier when the data from the first 2 s after a trigger were used were 99.09% and 97.85%, respectively.After the 2 s ANN classifier was obtained, ANN classifiers using the features of N seconds after a trigger were constructed in a similar way, with N starting between one second to ten seconds after the trigger. The features of the first N seconds after a trigger of both earthquake and non-earthquake data were used as the inputs of the ANN. For each length of N, an ANN classifier was trained. Therefore, a total of 10 ANN classifiers were obtained. In order to reduce the possibility of missing an earthquake, the trigger event was classified as an earthquake once it was classified as an earthquake at any second after the trigger using the corresponding ANN classifier. The number of cases missed (earthquakes classified as non-earthquakes) as a result among all 77,994 cases of earthquake data with different PGA ranges after N seconds are listed in The above classifier was developed for the LG Stylus smartphone, i.e., it was the LG classifier model. If this model was applied to the other four smartphone models without any adjustment, the performance would be quite bad, mainly because the resolution of the LG Stylus smartphone was quite large relative to those of the other smartphone models. However, when the accelerations of these four smartphones were converted to the resolution of the LG Stylus smartphone, the performance of the smartphones when using the LG classifier model was quite good. The typical TPR and TNR results of the 2 s ANN classifier of each smartphone are summarized in p-wave arrival, respectively. Moreover, the integral of square velocity was calculated asIn this study, we tried to implement a single-station EEW approach on smartphones. The approach developed by Hsu et al.  using siAgain, 75%, 12.5%, and 12.5% of the same 10,000 pieces of earthquake data were used to train, validate, and test each PGA prediction model, respectively. After the zero-mean normalization of the original strong ground motion records was applied, the records were integrated once and twice to obtain velocity and displacement signals, respectively. The second-order 0.075 Hz high-pass Butterworth filter was applied to remove the low frequency drift after integration. The results of all the available earthquake data are shown in the following paragraphs of this section. The PGA prediction models were only constructed for the LG Stylus smartphone using earthquakes with corresponding resolution and noise floor values. A grid search was conducted to test different numbers of neurons and layers, and the best performance was achieved when the ANN had two hidden layers with 20 neurons with sigmoid activation function. The predicted PGA values of the typical 3 s prediction model are compared with the real PGA values for all the 77,994 pieces of earthquake data in We defined the intensity prediction accuracy ratio (IPAR) as the ratio at which the predicted intensity scale was located within a one-scale difference from the real intensity scale among all the considered earthquake data. Only the earthquake data with a measured intensity scale ≥4 or a predicted intensity scale ≥4 were considered. The IPAR values of the different N seconds of the LG Stylus smartphone are shown in The above LG Stylus prediction models were applied to the other smartphones without any modification. The only difference, therefore, was in the acceleration quality of the smartphones themselves. Comparisons of the predicted and real PGA values of the typical 3 s prediction models of the different smartphones are shown in p-wave features are calculated using larger amplitudes of acceleration, then intuitively the predicted PGA values based on these features tend to be larger.In terms of the RMSLE values, all the smartphones were quite comparable, with the exception of the ASUS ZenFone Selfie, whose RMSLE values were obviously larger than those of the other smartphones. Apparently, the predicted PGAs of ASUS ZenFone Selfie were biased to be larger than the real ones, as can be observed in In terms of the IPAR values, those of the Huawei P3 smartphone indicated similar performance to those of the LG Stylus smartphone. As for the HTC eye and Redmi Note4 smartphones, their IPAR values were lower, approximately 1% lower in general, than those of the LG Stylus smartphone. Meanwhile, the IPAR values of the ASUS ZenFone Selfie were larger than those of the LG Stylus. Again, these results were mainly affected by the noise floor values of the smartphones , false negatives (FN), true positives (TP), and true negatives (TN) is used here to detail the classification performance of the alerts. Note that only when an alert was issued before the threshold was reached was the alert classified as a TP. In addition, a tolerance range with a scale of ± 1 was used for defining whether a classification was acceptable or not (modified from ). Only iAmong all the 77,994 pieces of earthquake data converted to the quality of the LG Stylus smartphone, 13,986, 8420, 446, and 54,955 were classified as TP, FN, FP, and TN, respectively. The distribution of the TP cases at different lead time ranges is summarized in In order to understand the effects of using the differing accelerations resulting from differing quality levels of smartphones on lead time, an on-site EEW approach conducted following the same procedures and using the same earthquakes with the original high quality of accelerations was employed as a reference. Here, without loss of generality, only the results using the typical 3 s prediction model are discussed for conciseness. The average delay of lead time (AD) using the different smartphones for the earthquakes of different intensity scales is summarized in Two strong motion datasets were employed to verify the performance of the proposed approach using smartphones during the shake table test. The shake table used was Moog’s Electric Motion Base MB-E-6DOF/24/1800KG in the National Center for Research on Earthquake Engineering, Taiwan. The first strong motion dataset was collected from worldwide earthquakes. Among the 50 significant earthquakes provided by the Center for Engineering Strong Motion Data (CESMD), a cooperative center established by the US Geological Survey (USGS) and the California Geological Survey (CGS), 10 strong motions were selected from these significant earthquakes that occurred in different regions. In addition, five more strong motions of the 1999 Chi-Chi earthquake, Taiwan, the 2018 Hualian earthquake, Taiwan, the 2008 Wenchun earthquake, China, the 1997 Northwest earthquake, China, and the 1995 Kobe earthquake, Japan were also included. In total, the worldwide earthquake dataset used consisted of 15 strong motions, as listed in Because the PGAs of most of the strong motions in the first dataset are quite large, the second of the two strong motion datasets was selected from the strong motions of the 2016 Meinong earthquake, Taiwan. The Meinong earthquake had a moment magnitude of 6.53 and a focal depth of 14.6 km and caused 117 deaths and 551 injuries, in addition to causing the collapse of six buildings and serious damage to 247 buildings. In total, 43 strong motions from small to large PGA values of the Meinong earthquake were selected. The distribution of the PGA values and the epicenter distance is shown in P-wave due to the noise signals at rest. A typical case of false classification can be found in P-wave arrived, the program could not detect it and only recognized it as part of the trigger event that previously occurred. As for the second Meinong earthquake dataset, most of the 43 cases were classified correctly for all the smartphones. Only one to four cases with PGA values of only approximately 25 Gals were misclassified. This was mainly because the signal-to-noise ratios of these cases with small amplitudes were not high enough  occurred because of a negative lead time. For the TP cases, less than 10 s of lead time could be provided for most of the cases. Compared to the results using original high-quality accelerations, the average delay of lead time using the smartphones was approximately only 2 s, except for the smartphone with the larger noise floor, i.e., the ASUS ZenFone Selfie, whose average delay was 0.5 s longer.Based on the results of the shake table verification when using the program embedded into the smartphones, the performance of the proposed approach in terms of the earthquake classification and PGA prediction of the strong motions in the worldwide and Meinong datasets was quite promising. Moreover, true positive alerts were provided by all the smartphones for all the considered strong motions classified as earthquake events.p-wave records for earthquake detection and PGA prediction. If the smartphones are located at the upper floors of a building, the measured acceleration signals should also contain the structural response. Fortunately, at the very beginning of the measured acceleration signals, the structural response is usually not excited substantially; hence the ground excitation may not be contaminated by the structural response extensively. There are also other conditions may affect the performance of the proposed approach, e.g., smartphones placed on a soft object. In order to ascertain the effects on the performance of the proposed approach due to smartphone locations, further studies should be conducted in the future.Nevertheless, substantial technological challenges remain for delivering earthquake early warning alerts using the proposed approach. For instance, false positive alerts could be issued because of non-earthquake events. In order to reduce the possibility of false positive alerts being issued due to non-earthquake events, a network detection algorithm is necessary. Therefore, the next step building upon this study will be to develop an app that can be downloaded to a smartphone by members of the public. With this app, only when enough smartphones within a certain area predict large PGA values will an alert be announced from the server to the smartphone users. In addition, the proposed approach uses the first several seconds of the


Sketch, can efficiently solve complex program sketches, but uses an integer encoding that often performs poorly if the sketched program manipulates large integer values. In this paper, we propose a new solving technique that allows Sketch to handle large integer values while retaining its integer encoding. Our technique uses a result from number theory, the Chinese Remainder Theorem, to rewrite program sketches to only track the remainders of certain variable values with respect to several prime numbers. We prove that our transformation is sound and the encoding of the resulting programs are exponentially more succinct than existing Sketch encodings. We evaluate our technique on a variety of benchmarks manipulating large integer values. Our technique provides speedups against both existing Sketch solvers and can solve benchmarks that existing Sketch solvers cannot handle.Program sketching is a program synthesis paradigm in which the programmer provides a partial program with holes and assertions. The goal of the synthesizer is to automatically find integer values for the holes so that the resulting program satisfies the assertions. The most popular sketching tool,


Due to multimorbidity and geriatric problems, older people often require both psychosocial and medical care. Collaboration between medical and social professionals is a prerequisite to deliver high-quality care for community-living older people. Effective, safe, and person-centered care relies on skilled interprofessional collaboration and practice. Little is known about interprofessional education to increase interprofessional collaboration in practice (IPCP) in the context of community care for older people. This study examines the feasibility of the implementation of an IPCP program in three community districts and determines its potential to increase interprofessional collaboration between primary healthcare professionals caring for older people.A feasibility study was conducted to determine the acceptability and feasibility of data collection and analysis regarding interprofessional collaboration in network development. A questionnaire was used to measure the learning experience and the acquisition of knowledge and skills regarding the program. Network development was assessed by distributing a social network survey among professionals attending the program as well as professionals not attending the program at baseline and 5.5 months after. Network development was determined by calculating the number, reciprocity, value, and diversity of contacts between professionals using social network analysis.The IPCP program was found to be instructive and the knowledge and skills gained were applicable in practice. Social network analysis was feasible to conduct and revealed a spill-over effect regarding network development. Program participants, as well as non-program participants, had larger, more reciprocal, and more diverse interprofessional networks than they did before the program.This study showed the feasibility of implementing an IPCP program in terms of acceptability, feasibility of data collection, and social network analysis to measure network development, and indicated potential to increase interprofessional collaboration between primary healthcare professionals. Both program participants and non-program participants developed a larger, more collaborative, and diverse interprofessional network.The online version contains supplementary material available at 10.1186/s40814-020-00746-3. With rapid population aging, the provision of care to older people with complex health issues resulting from multimorbidity and geriatric problems is a major challenge . In the Interprofessional collaboration has been defined as follows: an evolving interpersonal process, involving a diverse team of healthcare and other community providers who interdependently engage in frequent communication and shared decision-making, for the purposes of providing optimal health and social care services to community-living older adults and their families . IPCP inWe performed a pre-post study to examine the feasibility of implementing a previously developed IPCP program in three community districts. Figure Participants who were attending the IPCP program (“programme participants”) were primary healthcare professionals delivering care to community-living older people in three community districts in the city of Utrecht , the Netherlands. Participants included GPs, practice nurses, district nurses, social workers, physiotherapists, and pharmacists. In addition, “non-programme participants” were included. Non-program participants were professionals who did not participate in the IPCP program but only participated with consent in the social network data collection.The IPCP program was developed to enhance interprofessional collaboration among primary healthcare providers and was co-created by professionals from clinical practice, education, and research. The developmental process of the IPCP program has been described elsewhere . A develThe acceptability of the IPCP program was defined as (1) the views on the learning experience and its interprofessional nature, and (2) the acquisition of knowledge and skills linked to interprofessional collaboration indicated by the program participants .The feasibility of data collection and analysis was determined by collecting and measuring network development regarding the interprofessional collaboration between professionals working in the same district. To compare the community’s collaboration networks, we assessed network development by the number of contacts with other professionals, the extent to which contacts are reciprocal, the diversity of contacts, and the perceived value of contacts.The acceptability of the IPCP program was, after delivery, evaluated among 22 program participants using a self-reported questionnaire. The questionnaire, originally developed by the Expertise Center for Education and Training located at the Utrecht Medical Center (The Netherlands), was adapted to the context of IPCP and included two concepts based on the adapted framework of Kirkpatrick for interprofessional education . First, N = 22) and non-program participants  using a social network survey. The IPCP program was delivered to a maximum of ten professionals in each district. The nature of the IPCP program was to enhance interprofessional collaboration in which we expect a spill-over effect of the IPCP program. To capture this spill-over effect, non-program participants were also included. A social network survey was administered at two-time points  were asked to provide a list of all primary healthcare professionals with whom they collaborate with about care for community-living older people . In addiUsing the data collected in the first round, a list of names including all program participants (egos) and their nominations  was created, resulting in a single, comprehensive list of potential healthcare professionals who may collaborate with each other in each community district. Subsequently, all professionals from this list were invited to complete, and thereby gave their consent for, the survey see Fig. . We askeAt the second time point, we again used this comprehensive list of names to delineate the community’s collaboration networks.In each community district, between 27% and 40% of all nominated healthcare professionals responded and consented to the social network survey during round 2 of the data collection. The response rate also indicates the unit non-response, which is defined as completely missing for healthcare professionals for whom all outgoing contacts of the professional are missing but not the incoming contacts. This is because professionals who did respond also nominated the non-responding professionals as professionals with whom they work . The colThe number of contacts was calculated for each professional as the number of professionals with whom the participant indicated as collaborating with regarding care for older people (out-degree) . A sociaReciprocity of contacts was calculated as the ratio of the number of pairs who shared a reciprocal network connection,  relative to the number of pairs within any given contact. A high level of reciprocity reflects a high level of reciprocal collaboration between professionals in a district . ReciproDiversity of contacts was calculated as the extent to which contacts in the community district transcend the different backgrounds in disciplines  and a fixed-list selection of names, we obtained access to each whole community of healthcare professionals of which 33 non-program participants consented to participate in our study .T test was performed using the SPSS software version 24 for Windows .All social network measures were calculated and analyzed using UCINET 6.6, a network analysis program used for descriptive and inferential network statistics . To deteTwenty-two participants participated in the IPCP program, and a total of 55 program and non-program participants were included in the data analysis . Approximately 86% of the program participants indicated to act differently toward fellow professionals after attending the program, and 95% of the program participants indicated that they were able to apply the knowledge and skills of the program in practice. The participants valued the IPCP program with an average of 7.6 out of 10 (sd 1.0). For detailed information regarding the results of the questionnaire see Additional file The community’s collaboration networks before and after the IPCP program suggested that collaboration networks developed in each community district . An examination of the change in network density before and after the IPCP program suggests that in all three districts, the network density increased after the IPCP program. For example, for district 1, density increased from 34 to 51%. Before the program, roughly a third of all potential connections among the healthcare professionals were actually present within a district, which increased to about half of all connections after the program. In other words, after the program, the professionals in the district tended to collaborate with more and other professionals across the district. This increase in collaboration not only held for participants in the IPCP program but also extended to non-program participants, as expressed by an increased E-I index for all districts.Program participants and non-program participants had more reciprocal contacts after the IPCP program than before, which is shown in Fig. p value < 0.001) in district 1 and 6% in district 2  and district 3 . For example, district 1 showed that of all possible diverse contacts, 32% of these were used before the IPCP program. The diversity of contacts, thus, the interprofessional collaboration between professionals, increased to 42% after the IPCP program. This finding suggests that the IPCP program contributed to a more diverse network of healthcare professionals, for both program participants as well as non-program participants.The diversity of contacts increased over time, with almost 10% . However, this significant increase could not be confirmed for districts 1  and 3 .Participants from district 2 valued their collaboration with other professionals significantly more after the IPCP program (This study examined the feasibility of implementation of the IPCP program in three districts and evaluated its potential to increase interprofessional collaboration in caring for older people. First, our results indicate a high acceptability of the IPCP program as determined by the program participants. Second, the data collection as described in the “Our study showed that the IPCP program was found to be acceptable by the program participants. A more in depth understanding could be obtained when using validated questionnaires measuring levels 1, 2, and 3 of the adapted framework of Kirkpatrick for interprofessional education . HoweverThis study showed that it was feasible to collect social network data despite the lack of a clear network boundary. Because of scattered healthcare organizations in the districts, it was very difficult to generate a name roster of all professionals per district. These so-called “hidden,” fluid networks are difficult to reach , and it This study showed that the interprofessional network of the participants of the IPCP program increased in size after the program. A larger network increases the likelihood of encountering actionable knowledge . MoreoveThe reciprocity in the district collaboration networks increased after the IPCP program. In other words, health and social care professionals tended to engage in more reciprocal connections after the IPCP program than before. Districts 1 and 3 showed a high increase in the reciprocity of contacts, and district 2 showed a low increase. District 2 also differed from the other districts with a lower reciprocity before the IPCP program. This study did not examine the underlying aspects for these changes. However, collaboration is a process that takes time and energy , 29. FurIn this study, the terms “collaboration” and “value” were not explicitly defined. The researchers have consciously made this choice because how professionals perceive and define collaboration can differ. For example, some professionals can value another professional because of their accessibility while for others, the fruitfulness of their contacts, regarding care for older people, is more important. This is in line with a concept analysis of interprofessional collaboration that demonstrates that IPC is a complex concept, which continues to evolve . IPC hasThis study is among the first that uses SNA to enrich common research methods to examine the feasibility of implementing an IPCP program. While SNA is an underused method within healthcare education and intervention design, it is a useful technique for examining how social relationships among professionals are established and evolved –41. AnotThis study also has some limitations. First, the presence of a Hawthorne effect, the effect of an intervention that is solely due to intervention participation, cannot completely be excluded . HoweverThis study showed that it was feasible to implement an IPCP program in terms of acceptability, feasibility of data collection and social network analysis, and to measure network development in order to see the potential of the IPCP program to increase interprofessional collaboration between primary healthcare professionals in caring for the older population. After the IPCP program, the program participants as well as non-program participants gained a larger more collaborative, and diverse interprofessional network in primary care, suggesting a spill-over effect of networked interventions. Future studies are needed to determine the effects of interprofessional collaboration on continuity of care as well as its cost-savings.Additional file 1. Evaluation questions IPCP program.


As the roles of a pharmacist continue to evolve, leadership is an imperative skill for pharmacists to advance in their profession. To advance leadership behaviors, a number of tools, programs, and services have been developed worldwide to encourage the use of these behaviors in practice. A brief summary of different leadership opportunities around the globe are provided. A continuing professional development process and tool for developing and mentoring leaders that are ready to take the next step in their growth journey is introduced. This tool can be used in a live or online setting and is amenable to a longitudinal environment for leadership development and mentoring. A detailed process for implementing an online leadership development program and opportunities for future development are also described. While leadership skills can be developed in many ways, it is still unclear which methods and tools are the most effective in training pharmacists to maximize their leadership abilities. Additional research on effectiveness and impact of tools and processes for development are needed. Individuals and organizations are encouraged to consider implementing easily accessible leadership development and mentoring programs to advance the leadership skills of interested individuals. As the roles of a pharmacist continue to evolve, leadership is an imperative skill for pharmacists to advance in their profession. Whether the individual holds a management position or not, pharmacists must portray leadership responsibilities such as overseeing and supervising technicians or other employees, problem solving, managing change, managing finances or budgets, and making decisions regarding patient safety . The maiStandards for pharmacy professionals, as the need for pharmacists to demonstrate leadership [Standards for pharmacy professionals further states that pharmacists “must provide leadership to the people they work with and to others” [The definition of leadership is thought to be heavily theorized and debated. However, the traditional definition of leadership is “the action of leading a group of people or an organization” . Leadersadership . The Sta others” . Additio others” . Althoug others” . While t others” . Another others” .Opportunities for pharmacists to advance their leadership abilities are available; however, these programs seem to be few and far between. In some regions of the world, e.g., South America, there seems to be a lack of leadership development programs and tools available for pharmacists. Many of the programs or courses are not funded by a governing body, therefore, pharmacists need to pay for the program or course themselves. This may be a deterrent for pharmacists to join and be a part of a course which can develop their leadership skills. This is especially true for those who do not see the significance of leadership in personal development and the pharmacy profession. An example of this is the Top Pharmacy Leadership program which was withdrawn as an available course due to the lack of funding by the National Health Service (NHS) . This emDespite the availability of all these programs, at global conferences, there are still requests from conference participants, to engage in easily accessible programs that could be done in a virtual environment. The aim is to allow for ongoing professional development and mentorship, over a long period of time for about a year or two. We describe here a program that was developed and refined to address these requests.In 2019, an international team of pharmacy professionals and leaders embarked upon a process to develop and mentor interested young pharmacy professionals from around the world. The goal was to build upon the key foundational leadership principles of teamwork, project management, communication, and service using a continuing professional development framework ,29. A leParticipants were given the CPD for Leaders tool  and askeAfter the Leadership Forum concluded, there were no suggestions for improvement received from AACP. The CPD for Leaders Tool was, however, updated to include two additional sections to benefit a longitudinal leadership development framework and online/virtual experience. The first section added allowed participants in a leadership development program to provide weekly or monthly reflection and journaling around leadership matters, challenges or learning encounters. Questions for the participant to consider include: What would you say you learned from the Leadership program this (Week/Month)? What did you start doing that is leadership related? What did you stop doing that is leadership related? What process or habit have you questioned that is leadership related? What are you proud of?The second section added to the tool, provides the opportunity for feedback to the mentor or program organizer and can assist in program revision or refinement. Questions posed include: Overall, what would you say you have learned from the Leadership program this year? What went well with the program? What could we have done differently? What advice do you have for the next cohort of learners?The updated CPD for Leaders Tool is ideal for leaders that might be interested in undergoing a longitudinal leadership development or mentoring program that builds upon some foundational leadership training or certificate course or workshop. The Tool was reintroduced to a group of approximately 30 young pharmacists who completed the Leadership Development Workshop at the 2019 International Pharmaceutical Federation (FIP) congress held in Abu Dhabi and its implementation is further described below . The CPDThe global leadership program was introduced in 2019 as a way to provide ongoing mentorship and further leadership development as young pharmacy leaders engaged with routine work activities at their home countries. Select leaders from the international pharmaceutical student’s federation (IPSF), Howard University College of Pharmacy and the FIP young pharmacists group (YPG) were a part of the team consulted to ensure that the program would be desirable to their colleagues. The main overarching goal in developing the program was to design a learning opportunity that could be replicated easily and would allow participants to deepen their learning obtained from a previously attended onsite leadership workshop. Another goal was to keep participants engaged throughout the year in a virtual environment while maximizing experiential opportunities in their home countries. Learning objectives for participants included helping them identify leadership development goals for the year, applying leadership concepts to accomplish established goals, implementing a leadership project using learned leadership concepts, and critiquing their personal progress in achieving their leadership goals. Young pharmacists concluding the Leadership Development Workshop at the FIP congress in Abu Dhabi were verbally introduced to the inaugural program. Interested participants signed up by sharing their name and email address with the facilitator after the workshop. The leadership content was proposed by one of the authors who is also a Global Lead for the Workforce Development Hub focusing on Leadership development . The content and book chosen, had been used in prior leadership training sessions by this leader over the past decades. It was agreed to by the key stakeholders . Logistically, it was decided to hold one online meeting, via Zoom©, each month at a standardized time of GMT + 0 noon, to account for the varied time zones of all the participants. Meetings were 1.5 h and participants were required to have the ability to call in virtually to attend at least 80% of the sessions for a completion certificate at the end of the program. The program is designed for a virtual environment with an opportunity for completion in 10–12 months and allows for participation from around the world.To begin the program, all participants used the CPD for Leaders Tool to identify gaps and areas of growth as well as the StrengthsFinder 2.0 online assessment to provide baseline self-awareness information . All proDeveloping the Leader Within You 2.0 by John Maxwell [Each monthly virtual meeting incorporated one chapter of the book,  Maxwell . BetweenThe submission of participant reflections on a periodic basis allowed program leads to evaluate the growth of the participants and the impact of the program. Thus far, two submissions, using the CPD for leaders Tool, have occurred. The first submission was in November 2019 and the second in January 2020. Participants answered questions about what they learned in the leadership program during the month, what they started doing that was leadership related, what they stopped doing that is leadership related, what leadership processes they had questions about, and what they are proud of achieving for themselves while in the program. In general, participants noted in their reflections that the program has helped them to increase awareness of their personal leadership strengths, has improved their leadership abilities by teaching them to provide validation to those they lead, improve time management and prioritization of tasks, improve people skills and understand the value of each member of the team, and as a leader know that it is okay to ask for help . Not onlFrom the facilitator’s standpoint, the sessions have gone well and were well received. We observed that the monthly sessions have helped the ongoing discussions on leadership topics and allowed participants to pose questions of interest to the facilitators, thereby opening up an informal mentoring opportunity for all participants. The authors plan to conduct a formal evaluation of the value of using the CPD for Leaders tool in addition to assessing the impact of the longitudinal program soon. Facilitators are making sure to be patient with participants who may have intermittent internet connectivity issues during a session.There is much room for growth and development of leadership training programs for pharmacists. Currently, available programs often cater locally to participants of that country, and there are a limited number of programs that are available to an international audience. Leadership training programs also require out of pocket expenses from participants, many of which may choose not to participate due to financial reasons. Opportunities for sponsorship of such programs through grants could help facilitate participation from those who are unable to meet the financial obligations.As leadership development programs are implemented, it is also vital to ensure that research surrounding their impact is pursued. Leadership skills can be developed in many ways and it is still unclear which methods and tools are the most effective in training pharmacists to maximize their leadership abilities. Additionally, research looking into how individuals who participate in leadership training programs compare to those individuals who do not, can shed further light on the value of such programs to the individual and their true value added, to the work of the pharmacy profession.The importance of leadership development for pharmacists cannot be underestimated or overemphasized as an essential component to continuing professional development. As the roles of pharmacists continue to grow and young pharmacists explore opportunities in non-traditional pharmacy settings, leadership abilities are crucial to the success of not only the individual but also the profession. Programs and opportunities for pharmacists to advance their leadership skills should be available to all those who are interested. Examples of current programs that are available, as well as tools and implementation methods to develop novel, easily accessible, leadership development programs, are provided.


ObjectiveThe American Board of Pediatrics Certifying Exam (ABP CE) is a high stakes exam and is important for employment and fellowship opportunities in pediatrics. Although research has suggested interventions which may improve scores, little research has focused on resident perception of preparation for the ABP CE. In this study, we aimed to better define pediatric residents’ attitudes and preferences regarding preparation for the ABP CE.MethodsPediatric residents from one residency program were invited to participate in focus groups to discuss their attitudes and preferences on board exam preparation for the ABP CE. Focus groups were audio recorded and transcribed. Conventional content analysis was used to analyze qualitative data. From the transcripts, authors developed codes through an iterative process, which were then organized into categories. These categories were then grouped into themes.ResultsNineteen residents participated in three focus groups. Focus group transcription analysis resulted in 49 codes, which were sorted into 26 categories. The categories were then grouped into four key themes: 1) the ABP CE is not immediately important early in residency; 2) more personalized guidance is preferred; 3) consistent board preparation focus from the residency program is valued; 4) learning format is important.ConclusionsResidents believe preparation for the ABP CE increases in importance as they progress through residency, and they desire more personalized, consistent, and structured focus from their training program related to ABP CE preparation. Attention to these perceptions can help guide pediatric residency program leadership in developing effective board exam preparation strategies and curricula for their residents. The American Board of Pediatrics Certifying Exam (ABP CE) is required for pediatricians to become board certified . AlthougTo improve performance on the ABP CE, pediatric residency programs typically implement a variety of educational interventions to prepare trainees for this exam. Research on the efficacy of various board review methods has been conducted in different specialties -6. HowevUnderstanding learning styles and preferences is an important part of curriculum design and development. In the commonly utilized Kern’s approach to curriculum development, understanding learner preferences is a key component of a targeted needs assessment and informs the development of appropriate educational strategies . AdditioResearch designFor this exploratory study, we used focus group-based qualitative research methodology to characterize pediatric resident attitudes and preferences for ABP exam preparation in a single institution in June 2018 . Our proStudy setting and populationSubjects included in this study were categorical pediatric residents at Nationwide Children’s Hospital. We invited individuals from all training years (PL1 - PL3) to participate in three separate focus groups with the goal of 6-8 participants per group.Focus group development and administrationFocus groups were designed according to best practices, with the goal of eliciting discussion and feedback about the pediatric board exam and board preparation in general . Focus gData analysisWe analyzed qualitative data from focus groups transcripts using conventional content analysis . InvestiA total of three focus groups were conducted, one for each training year: Eight PL-1 residents, six PL-2 residents, and five PL-3 residents. Demographics of participating residents are found in Table Focus group duration ranged from 45 to 60 minutes. Within the focus groups, several specific codes emerged across groups. The focus groups yielded 49 codes which were sorted into 26 categories. The categories yielded four themes regarding ABP CE preparation: 1) preparation for the ABP CE is not of immediate importance, particularly early in training; 2) more personalized guidance for board preparation is preferred; 3) increased board preparation emphasis from the residency program is valued; and 4) varied learning formats are key to individualized board preparation. Categories and themes are shown in Figure Theme 1: Boards are not of immediate importanceResidents emphasized that they found the ABP CE, and preparation for the ABP CE important, with some individuals expressing anxiety about the exam. However, residents found the exam was difficult to study for, citing that the exam was too far in the future and for many residents, motivation to study was hard to find until closer to the exam. Residents reported that the demands of residency also made it difficult to immediately prioritize the exam versus immediate obligations to the residency program. There was also a sense that without the program making it a priority, it was easy for the residents to view preparation as not important enough to invest time and energy at this stage.Theme 2: Personalized guidance for board preparation is desiredParticipants reported a lack of clear direction on how to best prepare for the ABP CE and that this was a barrier to engaging in preparation. They reported uncertainty in how to best approach board preparation and were unsure when it was necessary to start. Residents also reported uncertainty about the types and quality of board preparation resources. Participants desired identification and endorsement of reliable and vetted resources from the residency program, with third year residents stating there was often conflicting advice from others on how best to prepare. First year residents reported they would prefer more structure, such as having a centralized list of resources or a menu of recommended approaches. Participants also stressed that board preparation was very personal, with learners likely to have very different ideas on board preparation schedules, methods and motivation, arguing that individualized guidance would be most preferred and effective.Theme 3: Increased focus on board preparation from the program is valuedResidents wanted the residency program to spend more time and resources on board preparation, and felt that this would spur resident motivation and engagement. In addition, residents reported that their work schedules often left them feeling as if they lacked enough time or were too tired to study for the ABP CE during training. They favored the residency program promoting a more active and apparent board preparation culture. Integration of board exam preparation into the workday was very important to them, with suggestions including working board practice questions into regular journal clubs and lectures, as well as stand-alone board preparation sessions. Some residents suggested that the residency program provide articles and reading materials. All groups stated that the residency program should hold the residents more accountable, with suggestions like individual board exam preparation tracking throughout training.Theme 4: Varied learning formats for board preparation are importantParticipants agreed that they had varied preferences regarding board preparation, and as such, having varied learning formats would be important for any group of residents. They strongly endorsed having a number of effective sources of board preparation information, and they emphasized the personalized nature of board preparation for individuals and how that aligned with serving different individual learning styles and methods. Different residents preferred using questions, videos, podcasts, and/or reading as effective methods to prepare for board exams. The timing and frequency of preparation were important factors to residents, with participants suggesting board preparation should be a consistent process and ideally started early in training. Residents preferred that material should be organized in blocks, with clear delineations between topics. In addition, residents also desired interactive learning, with residents suggesting the value of collaborative and competitive initiatives such as preparation in groups and competitions between various resident clinics. Participants commented that they viewed experiential learning during residency as important to their training but likely insufficient for board preparation. Participants felt that preparing for boards required efforts at both understanding and memorization.In our study, we found four key themes related to pediatric resident attitudes towards ABP CE preparation: 1) preparation for the ABP CE is not of immediate importance early in residency; 2) more personalized guidance for board preparation is preferred; 3) increased board preparation emphasis from the residency program is valued; and 4) the learning format should be individualized for trainees.We found that although residents considered the ABP CE an important exam, it was difficult for them to find motivation to study for the exam during residency, particularly in the midst of the demands of clinical training. This finding has not been emphasized in other literature but it does indicate a key perspective and role for program leadership in this regard. Although residents in other fields have expressed that their certification exams were important to them, difficulty in motivation to study during residency has not been reported . Our resFocus group participants also reported a desire for more personalized guidance regarding the ABP CE. Residents described considerable uncertainty on how to approach preparing for the exam and that quality advice was important to them. This mirrors the results of a study on emergency medicine residents and their preferences for studying for their in-training exams. In this study, emergency medicine residents reported that they particularly valued peer or fellow resident recommendations for preparation . LikewisResidents also reported favoring more organized and integrated focus on board preparation from the residency program, and they desired greater accountability from the program for their study efforts. Accountability, with consequences and incentives, was shown to be moderately effective in increasing psychiatry resident in-training scores . In thisParticipants across all training years reported that preferred board preparation methods were likely to vary among residents, relating a variety of preferences themselves and indicating that this was representative of the larger group of trainees. While participants particularly focused on studying board style questions as a preferred method to prepare for boards, which matches the predominant preference found in other studies, there were a variety of additional preferred learning methods identified by other individuals in the groups . ResidenOur residents also expressed interest in interactive learning formats and competitive learning methods. Research in gamification within medical education aligns with this point. Recently, a report of internal medicine residents, who were surveyed after using a team or individual competition based on answering questions correctly, noted the most important motivator for their participation was the use of a low stakes leaderboard . In one While these results can help inform pediatric residency programs on resident preferences for board preparation there are limitations to our study. Focus groups were conducted at a single center with a limited sample size and may not be reflective of all perspectives. Each focus group represented only a fraction of the pediatric residents in our institution. The focus group coding methodology may have introduced bias as the authors of the study coded and performed the thematic analysis of the study. There was, however, good consensus between the four coders who evaluated the transcripts.We found that residents 1) struggle to prepare since they find the certification exam, given after graduation from residency, not of immediate importance; 2) would like more guidance from the program regarding board preparation materials and methods; 3) welcome more emphasis and accountability placed on them regarding board preparation; and 4) desire a variety of learning formats to meet the different preferences of different residents. Further work in this area could include a multi-center exploration of the validity of these themes and more efforts to match certifying examination preparation methods to resident preferences to determine if these efforts augment resident performance on this examination.