Physician-scientist training programs expect applicants to have had extensive research experience prior to applying. Even at the best of times, this leaves individuals from underserved and underrepresented backgrounds at a competitive disadvantage, especially those remote from major academic centers. The COVID-19 pandemic exacerbated that disadvantage by closing research laboratories and suspending summer research opportunities.The Virtual Summer Research Program (VSRP) was designed to combat this shortfall by helping participating students become better informed and better prepared for applying to MD/DO–PhD programs. 156 participants were recruited from historically black colleges and universities and from national organizations for underrepresented trainees. Participants were paired with medical school faculty members and current MD/DO–PhD students from 35 participating institutions. The program lasted for at least 4 weeks and included a short research project, interactive sessions, journal clubs, social events, and attendance at a regional American Physician Scientists Association conference.In follow-up surveys, participants reported improvements in their science-related skills and in their confidence in becoming a physician-scientist, applying to training programs, and navigating mentorship relationships. A follow-up study completed one year later indicated that participants felt they had benefited from an enhanced skill set, long-term relationships with their mentors, and connections to the physician-scientist community at large.The results suggest that VSRP met its primary goals, which were to provide a diverse group of trainees with mentors, provide skills and resources for MD/DO–PhD application and matriculation and to support the development of longitudinal relationships between VSRP mentees and APSA. VSRP provides an approach that can be applied at an even larger scale when the constraints caused by a global pandemic have lifted. The need for greater diversity among physicians and physician-scientists has received a great deal of attention. Patients are more likely to adhere to medical advice, have better outcomes, and trust their providers when they share cultural, racial, or gender identity with their physicians –3. DiverNevertheless, the NIH 2014 Physician-Scientist Workforce Working Group demonstrated that the pipeline of underrepresented groups into dual degree (MD/DO–PhD) programs is meager and not growing . They rePrior research experience is an important part of successfully applying to physician-scientist training programs . ChallenCoronavirus disease 2019 (COVID-19) transformed the reality of college students in the Spring of 2020, precipitating abrupt transitions to remote learning and financial hardships. A study conducted at Arizona State University found that the pandemic exacerbated socioeconomic inequities. Graduations were delayed, approximately 10% fewer students pursued STEM fields, and 40% of students lost a job offer, internship, or current job . ResearcThe suspension of research programs in the summer of 2020 placed many students at a disadvantage, but especially those from groups underrepresented in medicine and from families that either lacked the experience of navigating the complex medical school admissions process or lacked the resources and social networks required to go where opportunities abound . The AmeThe goal of VSRP was to conduct a summer research program virtually by pairing mentors, such as principal investigators, postdoctoral scholars, and graduate students, with premedical and pre-graduate trainees, most of whom were from groups underrepresented in medicine by one criterion or another. The program hoped to provide mentees with an appropriate mentor, foster the development of skills and resources for MD/DO–PhD program applications and training, and support longitudinal relationships between mentees and APSA. Our hypothesis was that useful research skills, such as literature review, data analysis and interpretation, and academic writing, can be developed in a virtual research environment and that doing so in a research setting, however briefly, would help participants move ahead with their career preparation . Here, wTo recruit students and mentors, the authors reached out to an extensive physician-scientist network: historically black colleges and universities, national organizations of URiM trainees, personal networks, and APSA social media. These networks included physician-scientist trainees of various identities and their respective communities including organizations such as the Medical Student Pride Alliance, The National First Generation and Low-income Medicine Association and Medical Students with Disability and Chronic Illness. A website, flyers, and emails were distributed to these sources which included information about the program and an online application link. 122 faculty mentors were recruited from 35 participating institutions. Half were from the University of Pennsylvania. All mentors who applied were included in the program. Students were enrolled via an online portal, which received 645 applications in the seven days that it was open. Of these 645 applicants, 286 were interested in applying to MD–PhD and DO–PhD programs and had an underrepresented identity. Underrepresented identities include racial/ethnic minorities, first-generation college students, LGBT+, low-income, and disabled. These 286 students then moved on to the second round of the selection program.A matching algorithm was used to identify potential mentor–mentee pairs. Pairwise scores for every possible mentor–mentee pair were generated from common research areas and interests (with a weight of six) as well as skills that a mentor preferred that a mentee had (with a weight of two). Some mentors requested that their mentees have computer programing experience in R or Python, and some requested skills in scientific literature review and writing. The algorithm identified the top three mentors for each mentee and limited each mentor to a maximum of eight matches. Each mentor was sent the applicant resumes identified by the algorithm and asked to rank these mentees. Students closer to graduation and potential application to MD/DO–PhD programs were prioritized for matching. Based on mentor preferences and spots available, 156 mentor–mentee matches were made.In addition to the mentored research experience, VSRP included journal club sessions, a weekly interactive series, and social hours. The program required four full-time weeks of research. Research fields included anthropology, computational biology, engineering, epidemiology, genetics, immunology, molecular biology, neuroscience, pharmacology, and psychology. Twelve journal club sessions were led by current MD–PhD and DO–PhD students to introduce participants to novel and innovative scientific research, enhance critical reading skills, analyze academic writings, and learn about effective scientific communication. Four professional development sessions were hosted by leaders within the physician-scientist community. Topics included imposter syndrome, leveraging mentoring, and navigating the physician-scientist path as an underrepresented minority. These sessions sought to complement foundational scientific skills such as data analysis, experimental design, and literature review by adding power skills critical to success .Two virtual social hours were held in partnership with the Student National Medical Association and the First-Generation and Low-Income in Medicine Association. Part of the goal was to connect participants with other medical societies and provide them the opportunity to engage with a community of future and current trainees in the biomedical sciences with whom they may share identities. At the conclusion of the program, participants were expected to present their work at a regional APSA conference to motivate them and provide an additional experience in networking and scientific communication.1 offers a sample of abstract titles from VSRP research projects that were submitted to APSA’s 2020 Southern Regional conference. A sample schedule is provided in supplemental figure 1.To provide an idea of the scope of participant research projects, supplemental table 2 summarizes the tasks and time commitments associated with running this program for 4 weeks.Physician-scientist trainees ran VSRP, taking care of duties that included publicizing the program, reviewing applications, matching mentees, and mentors, coordinating programing for professional development sessions and journal club sessions, answering queries via email, and holding office hours. Supplementary table Evaluation of VSRP followed an adapted form of Kirkpatrick’s four-level evaluation model: (1) learner satisfaction and reaction; (2) measures of learning attributed to the program; (3) change to learner’s behavior in the evaluated context, while (4) ultimate positive outcomes on admissions were unable to be evaluated in a short-term manner . Pre-, pp-values are Bonferroni-corrected . Plots were generated using ggplot2  would have never had the chance to meet” outside of VSRP. Others indicated that they continue to research with their mentor and will publish their work as a result of VSRP. Another said that their mentor helped them get a full-time technician job and wrote a letter of recommendation for their MD-PhD applications. One stated that something they “have taken away from the experience is that mentorship (short or long term) is really important and the connections [they] made through VSRP continue to be resources even a year later.”Almost 60% (n=36) of respondents indicated that they continued to engage with other APSA programing since the end of VSRP 2020. Programming events include virtual interactive sessions where participants learn about applying to MD/DO–PhD programs and career options. Another popular programing event is the APSA undergraduate mentorship program which pairs current MD/DO–PhD trainees with undergraduates.The goals of the VSRP in 2020 were to replace opportunities that had been curtailed or eliminated by the COVID-19 pandemic; connect participants with enthusiastic mentors, who would help mentees achieve their academic and career goals; provide a research experience which would foster the skills and domain knowledge necessary to obtain future research opportunities; and empower mentees to pursue graduate training - all through serving students who share identities that are underrepresented in science and medicine. The results suggest that VSRP achieved these goals as evaluated by the Kirkpatrick’s four-level evaluation model. Students felt individually supported because of one-on-one relationships with mentors and dedicated program leaders. The majority of survey respondents said that they would recommend the program to others. Even in a four-week program, mentees expressed how the program positively impacted their career trajectory.The first goal of the program was to provide participants an opportunity to connect with a mentor who could advocate for them and write them letters of evaluation based on their individual strengths. The majority of participants maintained long-term contact with their mentors and a quarter are still working with their mentors. This was an important outcome as four-weeks of research experience in a virtual environment is not independently sufficient to prepare participants for MD/DO–PhD training, application, or matriculation. VSRP facilitated these relationships simply through introduction, and yet this could have a tremendous impact on the trajectories of VSRP participants. The majority of survey respondents will or already have asked their mentors for letters of recommendation to graduate school. Respondents strongly felt that mentorship and networking were key drivers in helping them pursue their goals. Many of the survey open-ended sections included stories about how mentors helped mentees achieve their academic and career goals.The next goal of VSRP was to provide participants with some of the tools for successful matriculation into MD–PhD or DO–PhD programs. Participants reported significantly improved confidence in becoming a physician-scientist, applying to physician-scientist training programs, and navigating mentorship relationships. This is incredibly important, as confidence in becoming a physician-scientist is a key barrier to applying and matriculating into MD–PhD and DO–PhD programs ,10. ThesFinally, VSRP was successful in creating longitudinal relationships between APSA and VSRP participants, with over half of respondents reporting continued interaction with APSA post-program. This data suggests that relationships with APSA, or other professional organizations, can provide a vital longitudinal component to summer research experiences.two details the tasks needed for program implementation in order to facilitate the model being adopted in other contexts and with other institutions. The remote model is beneficial because it helps connect students from geographically disadvantaged areas to mentors they might otherwise never have met, extending support networks beyond the local communities of participants and better distributing often-geographically concentrated resources. For such a program to succeed, faculty ambassadors are crucial for recruiting passionate mentors at the institutional level, as evidenced by overwhelming success with recruiting mentors at the University of Pennsylvania.VSRP is unique because it is trainee-run, with mentored faculty support including key members of the MD/DO–PhD community. It also has a holistic mentor–mentee matching process. Additionally, the ease of implementation of VSRP means it can serve as a model for future programs that support students from underrepresented backgrounds to find research opportunities at the undergraduate, medical, or graduate student levels. VSRP is flexible to implement because it can operate remotely and with a relatively low cost. Supplementary table The primary limitation of our analysis is that measures of confidence and analytical skills were done based on individual self-reporting. Furthermore, surveys did not receive full participation for all VSRP mentees, and thus response bias is a possible limitation. Only the student perspective was analyzed, and future work will involve analyzing and improving the mentor experience, and, broadly, the program framework. Finally, given the short timeline of this evaluation, the fourth level of the Kirkpatrick model, such as the impact of VSRP on success in application to MD–PhD or DO–PhD programs, could not be applied .Participant and mentor feedback was incorporated into the design of VSRP 2021. Areas of feedback included: facilitating student camaraderie with additional social hours, increasing the breadth of programing events, and optimizing the matching algorithm. In parallel, more journal club topics were included, and organizers were encouraged to use interactive journal club formats. To enhance and elevate mentor–mentee relationship and acquisition of research skills, the minimum experience length was increased to eight weeks. While increasing program length is an improvement, additional integration of reflection exercises and consistent longitudinal follow-up with these trainees would support long-term retention of these participants within the physician-scientist workforce. The major barrier to continued success and implementation of this program is financial resources including for participant stipends. However, the distributed design of the program provides institutional partners with limited administrative financial commitment and allows for participant community development, networking, and trainee interactions at the national level. While in 2020 the focus of this program was to replace disrupted and canceled programing, in the future VSRP will pivot toward providing first research experiences as these initial experiences are pivotal and can be transformational in their impact on future opportunities.In summary, the VSRP filled a gap by supporting individuals early in their pursuit of a physician-scientist career, not only in the context of a global pandemic, but in a generalizable way that can reduce inequities in healthcare by diversifying the matriculant pool of MD-PhD/DO-PhD programs.


The University of Alabama at Birmingham Heersink School of Medicine established the Pittman Scholars Program in 2015 to elevate scientific impact and to support the recruitment and retention of highly competitive junior faculty. The authors examined the impact of this program on research productivity and on faculty retention. The authors evaluated publications and extramural grant awards and available demographic data for the Pittman Scholars compared to all junior faculty in the Heersink School of Medicine. From 2015 to 2021, the program awarded a diverse group of 41 junior faculty members across the institution. For this cohort, ninety-four new extramural grants were awarded and 146 grant applications were submitted since the inception of the scholar award. Pittman Scholars published a total of 411 papers during the term of the award. The faculty retention rate of the scholars was 95%, comparable to that of all Heersink junior faculty, with 2 recipients being recruited to other institutions. The implementation of the Pittman Scholars Program has been an effective strategy to celebrate scientific impact and acknowledge junior faculty members as outstanding scientists at our institution. The Pittman Scholars award allows junior faculty to use funds for their research program, publications, collaborations, and career advancement. The Pittman Scholars are recognized at local, regional, and national levels for the work they are contributing to academic medicine. The program has served as an important pipeline faculty development program and an avenue for individual recognition for research-intensive faculty. Recruiting and retaining talented early-career faculty members is a major emphasis for academic medical centers (AMCs). The challenges of a leaky pipeline in academic medicine, particularly for physician-scientists, continue to be significant and have been highlighted in several publications . Diversist in National Institutes of Health (NIH) funding, its lowest in over a decade [In 2013 the University of Alabama at Birmingham (UAB) Heersink School of Medicine began a significant effort of transformation to address a decline in extramural funding, where it had fallen to 31a decade . This trThe Pittman Scholars Program was established in 2015 to support the recruitment and retention of highly competitive junior faculty members in the UAB Heersink School of Medicine. The Pittman Scholars Program is named after the late James A. Pittman, MD. Dr. Pittman served as dean of the Heersink School of Medicine for 19 years (1973 to 1992) and was recognized for his ability to recruit and retain nationally and internationally known scientists and physicians to UAB. Each year, an application request is released and advertised through the Dean’s newsletter. The scholars are nominated by department chairs and receive funding of the equivalent of spendable income  generated from a $250,000 endowed fund each year for three years and are designated as a Pittman Scholar to support their research or scholarly pursuits in basic or clinical sciences. The nomination package includes a cover letter (limited to one page) from the department chair along with the nominee’s resume and a one-page personal statement. Candidates are recognized as Pittman Scholars for the duration of their award (3 years). As a scholar, their primary responsibility is research, although teaching and some clinical duties are included. A junior faculty member can be nominated if they are a full-time Assistant Professor in the Heersink School of Medicine within the first five years of their initial appointment at this rank. Faculty members with highly competitive research programs judged by extramural funding and publications are eligible .Table 1Once all nominations are received, a panel of reviewers, which include former Pittman Scholars, review the applications to identify Pittman Scholars. Each application is reviewed by at least 6 reviewers and scored on a scale of 1–5 (1 being the best) based on the merits of the nominee particularly focused on high impact publications, extramural funding, and recognition with major awards at the regional/national level. Reviewers do not review applications from their respective departments to avoid any conflicts. Historically, 5 to 10 Pittman Scholars have been recognized each year. Funding may be used to support the research-related activities or scholarly enrichment of the faculty member. Since the Pittman Scholars Program inception in 2015, the program has supported 41 junior faculty at the Assistant Professor rank.Each Pittman Scholar submitted an annual progress report that included a list of publications, extramural support and grant applications. These documents also included a narrative section where the scholar describe how the award had allowed them to gain or maintain NIH or extramural funding, enhance collaborative interactions, produce high-impact publications, and along with a description of any unanticipated challenges. Details on how the funds have been used by category and description of the expenses in each category noting if the nature of expenses was research related or scholarly enrichment. Quantative analysis involved developing a count of totals where appropriate and the narratives were analyzed with attention to those that made an explicit linkage to the funding and subsequent scholarly achievement. To understand the Pittman Scholars Program’s impact on retention, retention rates of scholars were compared to that of all assistant professors in the Heersink School of Medicine.From the inception of this program in 2015, over 100 applications were received and 41Pittman Scholars have been supported , with a From 2015 to 2021, Pittman Scholars had a total of 106 extramural grants active at the time of receipt of the scholar award. Ninety-four new extramural grants were awarded since the inception of the scholar award, and 146 extramural grant applications were submitted since the inception of the scholar award. Overall, a total of 411 papers were published after receiving the Pittman Scholar award .Table 5The Pittman Scholars Program has impacted early-career faculty and has provided a positive return on investment with faculty retention, extramural funding, and publications from the recipients. Recipients have worked on a multitude of collaborative interactions that have enhanced extramural funding and publications. Scholars reported that these collaborations resulted in, but were not limited to, NIH R01 and R21 awards, K awards, and career development awards from the Department of Veterans Affairs and other funding agencies. The award has provided scholars a platform for a support system and recognition at an institutional level to establish interdisciplinary collaborations. As a group of scholars, they have enhanced networking opportunities.“The Pittman scholar award supported research funded by an NIH K23 project, lead to a collaborative R01, a D43 submission, publication of 6 manuscripts per year and attendance to scientific meetings to present study findings.” Another scholar noted, “The award has assisted in maintaining laboratory funding and has been able to contribute to continued training of graduate students and post-doctoral fellows in advancing research projects”. Another recipient stated, “The Pittman Scholar Award has been used to allow their laboratory to harness whole-genome sequencing approaches to generate novel pilot data. The award also contributed to the ability to attend conferences to allow for further networking, chances for funding, recruitment to laboratories, and opportunities for external collaborations.” Yet another scholar mentioned, “The Pittman Scholar award has greatly assisted me in advancing my research on surgical disparities and health literacy. I have been able to fund assistants to help measure health literacy in the clinic and to establish a health literacy database, this work lead to a K12 award, and is now supported by a K23 grant that was funded on its first submission.” “Pittman Scholars award allows for flexibility for new techniques, executing pilot experiments, and ultimately discovering new areas of exploration for future grants and publications.”A few select comments from recipients are listed below:The faculty retention rate was 95%, with only 2 of the 41 scholars being recruited elsewhere since the initiation of this program. This is the same as the faculty retention rate of all Heersink School of Medicine junior faculty for the same time period (95%). Both faculty members who left the institution continue to pursue scholarly research at other academic institutions. Pittman Scholars are invited to participate in the annual research retreat for the Heersink School of Medicine where they present their research work in the form of posters. Although a relatively a new program, several recipients have been recognized by membership and awards in prestigious societies such as the American Society for Clinical Investigation and other specialty-specific organizations.The results of this work highlight the impact and success of the Pittman Scholars Program for early-career faculty at the Heersink School of Medicine over the past several years. The program is intended to provide an opportunity for junior faculty members to advance their careers. At the institutional level, the goals of the program were to elevate scientific impact and recruit and retain talented junior faculty. The Pittman Scholars Program has reached these goals by the reputation of the program and the productivity of the recipients, faculty recognition, and faculty retention.The Pittman Scholars have shown excellent productivity through extramural funding and publications while in the program over the past six years. With over 400 publications, scholars serve in a variety of roles including principal investigators, mentors, co-investigators, collaborators, and more. In addition to the productivity of the Pittman Scholars, this program was able to recognize junior faculty across 15 departments at our institution. This recognition was aided with the recruitment and retention of junior faculty within the institution, for which Dr. James A. Pittman strived.Paller and Cerra described a seed grants program  to investigators to initiate a new area of research or for innovative projects over a 6-year period at the University of Minnesota . This prGiven that the Pittman Scholars Program is a relatively new and single-institution program with a small sample size, the recipients have embraced the opportunity and the award has truly impacted each recipient and the institution. We focused on scholarly research productivity and did not include teaching or clinical service-related accomplishments and hope to add these metrics going forward.In conclusion, the implementation of the Pittman Scholars Program has been an effective strategy to recognize junior faculty members at our institution. The award allows junior faculty members to use flexible funds for research support, publications, collaborations, and career advancement. The Pittman Scholars Program provides multiple opportunities for junior faculty members to be recognized at local, regional, and national levels, which are typically only for senior rank faculty. The success of the Pittman Scholars Program highlights the value of allocating resources to junior faculty for their careers as well as their growth within the institution.


Big and Mini” was created in April 2020 to link young and older adults together. As part of an evaluation of Big and Mini, a survey with both close and open-ended questions was sent to participants. Methods: A total of 63 Bigs and 53 Minis completed the survey. Their stress compared to before COVID-19, loneliness, life satisfaction, intergenerational closeness, and satisfaction with the program were measured for participants. Descriptive, bivariate correlation and conventional content analyses were conducted. Results: On average, Bigs and Minis had participated in the program for 3.73 and 3.49 months, respectively. Approximately half of the Bigs (47.6%) and Minis (52.8%) felt the same stress level compared to before COVID-19. A few participants felt “less stressed” compared to before COVID -9 . All participants reported medium levels of loneliness, high levels of satisfaction with life, satisfaction with the program, and intergenerational closeness. Content analysis suggested that the reasons to join or expectations of the program were friendship, mutually beneficial intergenerational connections, and coping with loneliness. Conclusions: The Big and Mini program offers a promising approach with mutual benefits for participants. Strategies to improve the program and implications for intergenerational programs are presented.Introduction: To help older adults cope with loneliness during COVID-19, a weekly, telephone-based intergenerational program called “ Physical or mental health impairment(s) in later life may increase an individual’s risk of isolation and limit their support networks. According to the National Council on Aging, more than 6.7 million adults are aged 65 and older, and about 17 percent of this older generation live in social or geographical isolation, or both . OverallSocial isolation and loneliness are a serious social and public health problem affecting significant numbers of older adults aged 65 and older and their health . IndividIncreased risk of loneliness among persons aged 50 and older is often related to factors such as living alone, the loss of family or friends, chronic illness, and sensory impairments ; howeverOne possible avenue for building and sustaining social connections in the community for older and younger generations is through befriending. Befriending is commonly defined as “a relationship between two or more individuals which is initiated, supported and monitored by an agency that has defined one or more parties as likely to benefit. Ideally the relationship is non-judgmental, mutual, purposeful, and there is a commitment over time” . While tBig and Mini, was created in April 2020 to link young (ages 18+) and older adults (ages 50+) together (matched through a custom website developed for this program) in an effort to help increase social connectivity through weekly phone calls. The program designers wanted to be inclusive of age 50+ because the statistics from CDC [Big and Mini program  was created and developed by three young adults. Since its launch, Big and Mini has successfully recruited over 6000 dyads of older and young adult participants. It also attracted attention from several media outlets [To help older adults cope with social isolation or loneliness during COVID-19, a new intergenerational program, from CDC  and the from CDC  showed tung ages + and oldBig and Mini proceeds as follows: Once a young or older adult is interested in participating, she/he/they can go to the Big and Mini website and fill out the required details on the signup page. Next, after submission, participants receive a verification email. By clicking the verification link in the email and logging onto Big and Mini, participants fill out their profile details so that the program can find them a match with similar interests, availability, and goals. Both Big and Mini participants receive online training details and complete a quiz at the end of the training, most of which are about the “do and do nots” during the program. Once a participant completes the training, she/he is qualified and approved to be matched. In the upcoming weeks, the program sends them an email with the details of their match. The participants then log onto the Big and Mini dashboard and schedule subsequent meetings based on an agreed date/time. When the time of their match arrives, they need to log in to their dashboard and click the meeting link to be redirected to the video call platform. Enrolling in The quality of interaction and sense of motivation between Bigs and Minis is of utmost importance to the program. One way to promote dyad activity is through the use of built-in conversation starters as well as guides explaining how the process works . Inherently, the serendipitous nature of matches  also contributes to the motivation to continue making a meaningful effort to maintain the connection. Ultimately, if a decline in dyad activity continues, it may just be a sign that the match was not entirely compatible from the offset or that participants’ lives and schedules are changing. The program staff then look at the factors in the match, such as how the frequency of meetings changes over time and the individual’s backgrounds, to improve future matches. If a user requests another match, that will be accommodated accordingly.Big and Mini program solicited feedback from participants to evaluate the usefulness of the program. Given that social isolation disproportionately affected older adults prior to the COVID-19 pandemic [Big and Mini developers wanted to specifically evaluate whether and how this new program helped with participants’ psychological well-being . In addition, there were growing concerns of ageism among young adults during COVID-19 and the team felt that it was important to know whether increasing social connectivity and connecting older and younger generations could combat ageism. A few months after the program launched, the pandemic  as well pandemic , the BigBig and Mini founders collaborated with a university research team for this study. Using a survey with close and open-ended questions, this team quantitatively evaluated dyad participants’ feedback on loneliness, satisfaction with life, as well as the young adult participants’ attitudes towards aging. The open-ended questions at the end of survey collected more detailed experiences from participants as well as participants’ feedback for the overall program. The overarching research questions for this study included:The What were the general psychological well-being conditions  and intergenerational closeness for Bigs and Minis, respectively?Whether there were group differences of psychological well-being and intergenerational closeness between the Bigs and Minis?Big and Mini?What were the reasons and/or expectations of joining What did Bigs and Minis most like about or benefit from the program?What did Bigs and Minis most dislike about the program?Big and Mini program were invited to complete the study survey. The study was approved by the Institutional Review Board (IRB) (#2021-0001) of University of Texas at Arlington. The informed consent form and survey questions were created through QuestionPro and the link was sent to participants’ email and advertised in the Big and Mini monthly news. The informed consent form was presented first in the QuestionPro survey. Participants were clearly informed of the purpose, study procedures, risks and benefits of participation, how deidentified data would be used for research, and that they could withdraw from participation at any stage of the study without any penalty. Contact information of the principal investigator and IRB was included in the consent form. Only after the participants signed the consent form by clicking the “accept” button could they move on to the survey. The survey consisted of several multiple-choice quantitative survey questions as well as three open questions at the end. To encourage a high response rate, participants were given the opportunity to enter a raffle for an Amazon e-gift card . As per instructions from the IRB, interested participants for the raffle were asked to provide their email address in a separate QuestionPro survey. Among the active 120 dyads at the time of the study, 85 Bigs and 82 Minis started the survey. However, only 63 Bigs (age 50+) and 53 Minis (age 18+) completed the survey, yielding a 52.5% and 44.2% response rates for Bigs and Minis, respectively. At the time of the survey in September 2020, all current participants of the Loneliness. This 6-item scale of the De Jong Gierveld [none of the time” to “5 = all of the time”. Item numbers 2, 3, and 5 were positive statements and thus the scores needed to be reversed. The sum of the six items ranged from 6 to 30, and the higher score meant a higher level of loneliness. The reliability of this scale was 0.81 for Bigs and 0.77 for Minis.Gierveld  lonelineGierveld . The iteSatisfaction with Life. A 5-item satisfaction with life scale [strongly disagree” to “7 = strongly agree”. The sum of the five items contributed to the total score, ranging from 5 to 35. The higher the total score, the higher the life satisfaction. The value of Cronbach’s alpha was 0.93 for Bigs.fe scale  was usedfe scale ,22. EachAttitude towards Aging. The Fraboni scale of ageism (FSA) [strongly disagree” to “4 = strongly agree”. Items with positive statements were reversed. An additive score was calculated, ranging from 29 to 116. A higher score indicated a greater level of ageism. The Cronbach’s alpha was 0.85 for the Mini sample.sm (FSA)  was usedsm (FSA) ,25. ThisStress. The stress compared to before COVID-19 was measured for both Bigs and Minis by a single question, “Compared to before the pandemic, how stressful is your life now?”, which was answered with either “1 = higher than usual”, “2 = about the same”, or “3 = lower than usual”. We dummy recoded the answers into “0 = the same/lower than usual” and “1 = higher than usual” for analyses.Other Key Variables. Length in the Big and Mini program was a continuous variable assessing how many months the respondents had been in the program. Satisfaction with the program was measured based on a 5-point Likert scale from “1 = very unsatisfied” to “5 = very satisfied”. Intergenerational closeness was assessed by three questions adapted from the Intergenerational Solidarity Inventory [not at all”, “2 = to some degree”, to “3 = very”. An additive score was calculated for each respondent, ranging from 3 to 9, with a higher score indicating better intergenerational closeness. The reliability of this scale was 0.88 for Bigs and 0.90 for Minis.nventory : namely,(1)Big and Mini program? Or what are your expectations about this program?Please explain why you chose to participate in the (2)What aspect of the program that you like/benefit the best?(3)What aspect of the program that you like the least?At the end of the survey, both Bigs and Minis were asked three open-ended questions:For the close-ended questions in the survey, quantitative data analyses were conducted. First, descriptives of the sample characteristics were conducted to have a brief understanding of the participants. Second, bivariate correlation analyses were performed, including all the key variables separately for Bigs and Minis. Subsequently, independent-sample t-tests were used to examine the differences of loneliness and intergenerational closeness between Bigs and Minis, and chi-squared test was conducted to compare the stress compared to before COVID-19 between Bigs and Minis. These analyses were performed using the Statistical Package for Social Sciences (SPSS) 25.0.For the open-ended questions in the survey, content analysis was used to analyze the data by three members of the research team. The researchers, first, independently read the transcripts and developed codes and working definitions for each code . Then, tSD = 7.30). Around half of them had a graduate or professional degree and the other half had some college or bachelor’s degrees. Most of the Bigs were women (73.0%) and White (87.3%). A total of 39.7% of the Bigs were married/cohabiting, followed by being divorced (25.4%), never married (15.9%), widowed (15.9%), and separated/others (3.2%). Nearly half of the Bigs lived alone, and another half lived with their spouse or others. The average score of the self-rated health for the Bigs was 3.65 out of 5 (SD = 0.96), reflecting a moderate level of health condition. The mean score of financial hardship was 1.40 out of 5, which indicated a low level of financial stress. Few of the Bigs had ADL  or IADL  assistance needs. The average length of the Bigs’s participation in the program was 3.44 months (SD = 2.09). Bigs reported a high level of satisfaction with the program . Bigs had a moderate level of stress at the beginning of COVID-19 . A total of 38.1% of the Bigs reported that their current stress level was higher than the stress before COVID-19. More than half of the Bigs did not receive any support to help them cope with stress during the pandemic, and 38.1% of the Bigs had received support a few times or once a week. The average score of social isolation for Bigs was 15.57 out of 30 (SD = 4.18), indicating a moderate level of social and emotional loneliness. The mean score of their life satisfaction was 23.79 out of 35 (SD = 7.92), reflecting a high level of satisfaction with life. Bigs reported close intergenerational relationships with Minis .SD = 7.79). A total of 84.9% of them had some college or higher-level degrees. Most of them were women (79.2%). A total of 45.3% of the Minis were White, followed by Asian (37.7%), and African American/Hispanic/others (15.1%). Most of them were never married (83.0%). A total of 20.8% of the Minis lived alone, and the remainder of the Minis lived with a roommate (30.2%), parent(s) (24.5%), or spouse/sibling/others (22.6%). Nearly half of them were full-time college students. The Minis reported a moderate level of health conditions  and a low level of financial hardship . Their average length in the program was 3.49 months (SD = 1.99). Minis reported a high level of satisfaction with the program . They had a moderate level of stress at the beginning of COVID-19 . A total of 37.7% of the Minis perceived higher stress than before COVID-19. A total of 34.0% of the Minis reported not receiving any support to cope with stress and 60.4% of the Minis reported receiving support a few times or once a week during the pandemic. The average score of social isolation for the Minis was 15.24 out of 30 (SD = 4.27), indicating a moderate level of social and emotional loneliness. Their mean score of ageism was 46.76 out of 116 (SD = 8.16), reflecting a good attitude towards aging. The Minis reported good intergenerational relationships with the Bigs .The characteristics of the Minis are illustrated in r = −0.55, p < 0.001). Compared to experiencing ‘the same or lower stress than before COVID-19’, the perception of ‘higher stress compared to before COVID-19’ was correlated with a higher level of loneliness . Higher stress compared to before COVID-19 was related to lower life satisfaction . Intergenerational closeness was positively correlated with the Bigs’ satisfaction with the program .r = −0.44, p < 0.01) and satisfaction with the program  were negatively correlated with the Minis’ ageism scores. Moreover, better intergenerational closeness was related to a lower level of ageism . Intergenerational closeness was positively correlated with the Minis’ satisfaction with the program .The results of correlation analyses of the Minis are presented in M = 15.57, SD = 4.18) was slightly higher than that of the Minis , but this difference did not reach statistical significance . A total of 38.1% of the Bigs reported higher stress compared to before COVID-19 and 38.5% of the Minis perceived a higher stress level than usual, which did not yield a significant result . The average intergenerational closeness of the Bigs  was higher than that of the Minis , but such difference was statistically nonsignificant . Because no significant group differences were found for the key variables, a table was not created.In terms of the comparisons between Bigs and Minis, the average loneliness of the Bigs  mutually beneficial intergenerational connections; (2) making a difference during the Pandemic; (3) coping with loneliness; (4) friendship; and (5) curiosity. Mutually Beneficial Intergenerational Connections. The most common theme related to joining Big and Mini was mutually beneficial intergenerational connections. For example, one Big mentioned, “I love, am interested in, connecting with young people” (B39) while another stated “it would be fun to get to know how a younger person feels about life… to have my perspective broadened” (B45). Similarly, another Big shared, “I wanted to connect with a young person, college student or young adult under 30, to discuss generation divide and how to improve that” (B28), while another Big reported, “I was curious and anxious to meet younger people to learn from them esp. their views on politics, learn how they are using technology, etc.” (B55). One Big shared:Big and Mini, I knew this not only could be a great way to stay connected to people in general because of COVID, but it could also fulfill my desire to be interacting with someone a lot younger than I and keep in the youth loop.”“As an elder, I have always wanted to have a diverse life, including intergenerational connections. When I saw (B4)Similarly, Minis reported joining the program because of expectations of intergenerational connections. Two Minis said, “interested in intergenerational activities and learning (M9), “I wanted to get to know older members of the community, I don’t see my grandparents as often while in college and miss them” (M28). Another Mini shared: “I typically enjoy older people and feel that intergenerational exchange is healthy for everyone involved. I wanted to be there for an older person who may need some company right now, and also experience the benefit of listening to and learning from them.”(M45)Making A Difference During the Pandemic. A second theme related to reasons for joining the Big and Mini program was to make a contribution to the program or other persons, especially during the COVID-19 pandemic. For Bigs, they wanted to share their life experience with Minis and hoped to mentor younger generations or support younger people. For example, two Bigs shared that “I had time and energy available and thought I might be able to help a young person”(B14) and “I like volunteering and was hoping to help someone” (B25). Others stated, “I love the idea of mentoring a young person” (B35), “Pass on hard learned experiences” (B40), and “I was looking to help a mini as far as business and life advice” (B42). Other Bigs similarly mentioned:“I wanted to support young people who were experiencing social isolation and I also wanted to support the young people who took the initiative and created the program.”(B17)“I felt that I could share my experience in life—have lived and worked in 5 countries, have traveled to almost 50 countries, have been involved in charity projects and have been working for almost 50 years.”(B12)Minis also shared that they wanted to provide support to Bigs. Some Minis indicated that they wanted to positively impact others through this program, such as “I decided to sign up because I loved the idea of the one-on-one connection and because I knew that the platform was such a good opportunity to impact someone in a positive way” (M14). Some Minis specifically wanted to help older adults cope with loneliness by making connections with weekly calls. For example, one Mini said, “I wanted to help an elder feel like they have someone they can talk to and don’t have to feel lonely” (M20). While Minis wanted to make contributions to the society, the program, and specifically the older adults, they also expressed expectations of benefiting from connecting with the older generation, such as “To help me mature” (M31), “I like to be around people and learn” (M25), or “I thought it would be a great opportunity to learn from and interact with a person who has already experienced most of their life. I also was very interested in receiving advice from such a person” (M32). Big and Mini would be enjoyable for both me and my Big” (M24) or “I also needed support during the pandemic, and I usually help myself by helping others” (M36). Other Minis also mentioned:Some Minis hoped to make a difference in the Bigs’ lives while also benefiting from the intergenerational connections, as Minis said, “joining “I joined because I thought it would be a great way to not only gain wisdom about what would be a good career path for me (as a fresh graduate with lots of decisions to make), but also because it’s incredibly important right now that the high-risk community does not feel lonely.”(M13)“I wanted to give back in some way during the pandemic, and this provided an easy option that was also beneficial for me. I’ve lost all of my grandparents, so having a connection with an older person was something that I was missing. I also strongly care about combatting loneliness in our society.”(M16)Another Mini shared:“I’d like to do some volunteering over the summer, talk to someone who might experience loneliness because of their old age, tech unsavviness, or physical isolation. I’d like to learn something from a total stranger, too.”(M33)Coping with Loneliness. A third theme related to reasons to/expectations of joining the Big and Mini program was because of loneliness and wanting to cope with loneliness through this program. Bigs mentioned “boredom” (B18), “I am lonely” (B31), “Isolation and COVID now” (B47), “I have experienced loneliness and isolation. I have no family ties” (B34), and “My life came to a standstill once the pandemic arrived. I live alone, have no family in this state and no pets” (B16). Similarly, Mini participants shared, “I was looking for something to do at the start of the pandemic because everything just stopped. And I thought it would be nice to talk to someone since I was lonely.” (M4) and “I was feeling really lonely and sad and I wanted someone to talk to or to connect with” (M7). Friendship. A fourth theme was centered on friendship. Both Bigs and Minis mentioned expectations to meet new friends or to meet someone with a different life experience than them. For example, some Bigs shared “Make a new friend” (B41), “Wanted to meet someone ‘new’ to me & with different life experiences/opinions/perspective.” (B11), or “To meet someone new who I could connect with and keep me company”. One Big shared similarly, “I love meeting new people. New experience. New adventure. I always look for the adventures in life. No matter the age we all can learn from one another” (B13).Minis also reported a desire for friendships and connection. For example, Minis said: “I wanted the chance to connect with someone who I wouldn’t have otherwise met. And to offer companionship during a hard time” (M3), “I wanted to meet someone new and keep people company” (M5), “To connect with others” (M17), “To meet others and connect with someone new during an isolating time” (M18), “Wanted to make a unique connection and meet someone I wouldn’t meet otherwise”, and “Make a new connection with someone who is older and has more life perspective than me” (M41). Curiosity/Exploration. A fifth theme was related to being curious about and wanting to explore the Big and Mini program. For example, some Bigs mentioned “out of curiosity” (B44), “To see how this nifty program works” (B2), and “I was curious about how it worked and wanted to share information with other older adults” (B56). Several Minis also shared that they simply wanted to explore the experience. For example, Minis stated “My mom thought it would be good for me” (M2), “Not exactly sure why, just kind of a spur of the moment choice” (M40), and “easy to register and connect. So just joined it” (M42).Big and Mini program that they liked best at the time of the survey. Themes included: intergenerational relationship and connections, learning and sharing, friendship, and the flexibility of the program. Participants reported what aspects of the Intergenerational Relationship and Connections. Participants reported an appreciation for the intergenerational relationship and connections that the Big and Mini program offered. For example, one Big shared, “Just meeting and sharing with a delightful young lady the age of my grandchildren.” (B15) Another Big reported, “The conversations my Mini and I have. She reminds me of my granddaughter, and I really enjoy chatting with her.” (B59) Minis similarly shared:“Connection of a young adult to an older adult and speaking and sharing your thoughts, knowledge, perspectives and mainly culture. And of course, meeting my BIG, was just the best thing ever.”(M8)“I love how open it is with my Big they did a wonderful job matching us. The chat function is also very nice so we can still talk during the week if we think of each other.”(M4)Learning and Sharing. Participants shared that they appreciated the learning and sharing opportunity that the Big and Mini program offered. First, both Bigs and Minis learned new things from their partners. For example, Minis shared, “I like learning about Jude’s (M3′s Big) life.” (M3) and “All the learning. You learn in a lot of ways and feel closer to someone that in any other way you wouldn’t have met” (M7). Similarly, learning new things from the younger generation was one of the benefits that Bigs perceived. As one Big shared below:“Learning new things from my Mini, such as about the summers he spends in Peru with his cousins, Peruvians recipes (which I have cooked and enjoyed), information about ancient Roman history (his big interest), because he is bilingual, that has incentivized me to get serious about improving the limited Spanish I know , etc. My Mini has enriched my life in many ways. On our call this morning, we both lamented having to learn ‘Statistics’ in college.”(B5)Big and Mini program. For example, “I enjoy talking with my Big and we learn a lot from each other.” (M19), “Mentorship opportunities in both directions and simultaneously” (M13). Some Bigs even mentioned they liked the opportunity to provide help and give back to society. For example, one Big mentioned that she liked the “Opportunity to give back to an individual mini or a group—what I have learned from my experience in life in different continents.” (B12) Another Big had similar thoughts that she enjoyed offering help to her partner:Participants also mentioned that mutual learning from each other was an important component that they enjoyed about the “My ‘mini’ is faithful in keeping our conversations going, and seems to be glad to talk with me. That means a lot. And I love getting to know her and being a listening, understanding—and maybe even helpful—ear.”(B31)Friendship. Friendship between two different generations was another component of the program that some participants liked best. Some Minis mentioned “I like that I have made a new friend and we continue to get closer each week.” (M24), “Meeting someone new who you wouldn’t have otherwise met” (M41), and “I feel like my and my Big have a lot in common and are a great match. He’s super easy to talk to!” (M16). Bigs had similar thoughts about friendship. “I so enjoy my weekly meetings with my mini and that she e-mails me when she has some news. I actually feel that I am a part of her life now as she is a part of mine.”(B7)Flexibility. Some participants mentioned that they liked the flexibility and the virtual chat platform. For example, Minis talked about the flexible schedule: “Flexibility to log on to the meeting whenever is best for the Bigs and Minis. Also, the chat and nudge functions are useful.” (M26), “Ability to be flexible with my schedule” (M34), and “Being able to do good in a virtual format” (M47). Some participants also liked the Big and Mini program platform. For example, M17 and M43 as well as B44 and B60 commented they best liked the “Video chats” component of the Big and Mini program.When asking what aspects of the program that participants liked least, most of the participants did not provide a comment or shared positive comments instead. For example, several Bigs shared, “All is good.”  “So far everything has been beyond my expectations.” (B9)” I think it’s terrific, and I thank you for dreaming it up, implementing it, and continuing it” (B48). Some Bigs also gave positive feedback about the program: “…I think it’s wonderful and I’m so impressed that it was young people who conceived of it and created it. It was a brilliant idea. It was fun to be in two videos about it, too! “(B31) and “I’ve built a better sense of confidence about our youths by knowing her and seeing that she’s genuinely interested in engaging with me. Thank you.” (B32) Similarly, most Minis did not provide comments about what aspects of the program they disliked most. For example, Minis shared, “I don’t have anything to really complain about” (M4) or “Nothing” . However, two aspects were mentioned by some participants that they disliked most: technology and administration. Technology (Internet connection). The aspects that participants disliked most was the technology, especially for Bigs. For example, Bigs shared: “Problems with the internet program. We now use zoom which seems to work better for us.” (B15), “Technology not always working when you need it.” (B17), “Technology not working. Poor connections on video chats.” (B57), “Technology at first was confusing” (B58), and “Video call sometimes glitches” (B59). Similarly, Minis reported technology issues such as “The video chat software doesn’t work too well but it’s okay my big and I FaceTime instead! ” (M23). Another Mini shared their experience:“I think the online dashboard could be easier to use both for me and my Big. My Big wasn’t clear on exactly how to connect to our meeting, and we had trouble communicating on the dashboard because we never checked it. After my Big was a no-show the first time, I sent an email as instructed and never received a response. Thankfully my Big and I exchanged emails and were able to find a time to meet.”(M16)Administration. A few participants mentioned the administrative functions of the program that challenged them. For example, some participants thought that the matching process took longer than expected: “The long matching process. Still waiting to be matched with a new buddy because my old one didn’t show!” (M13). Some Bigs also disliked the matching process . Another administration issue was the timing of each call, which was mentioned by the Bigs rather than the Minis. For example, one Big mentioned “Not knowing when to end the call” (B10), “no structure for ending the relationship” (B38). Lack of follow-up from staff or no communication with leaders was another challenge mentioned by some Bigs . Big and Mini program a few months after the program was launched. Both Bigs and Minis reported some level of social and emotional loneliness at the time of the survey when COVID-19 cases were rampant and there were no vaccines available yet to the public. However, they also reported high levels of satisfaction with life, satisfaction with the program, and intergenerational closeness. Content analysis of the open-ended questions showed that the reasons to join or expectations of the program were mainly friendship, mutually beneficial intergenerational connections, and coping with loneliness. Both Bigs and Minis also shared aspects of the program they liked best and least. In general, the results from both the closed and open-ended questions indicated that the Big and Mini program offers a promising approach with mutual benefits for both young and older generations. This confirmed previous research finding that intergenerational programs, as a nonpharmacological intervention, have been utilized with promising results for both young and older adults [Using a survey with both closed and open-ended questions, this study evaluated dyad participants’ feedback of the r adults , especiar adults ,16.First, consistent with previous research, the survey data showed that both the young and older generations experienced a certain level of stress and loneliness during COVID-19 when they joined the program and more than one-third of them even reported higher stress compared to before COVID-19. A national survey from Cigna reported that all ages may experience social isolation and loneliness . The finBig and Mini, may provide a promising strategy to help young adults improve their views about aging. Second, Bigs and Minis quantitatively reported high levels of satisfaction with life, satisfaction with the program, and intergenerational closeness. Specifically, intergenerational closeness with partners reported by both Bigs and Minis was highly corelated to their satisfaction with the program as well as lower levels of loneliness. These study findings echoed the prior literature that more intergenerational intimacy was associated with less COVID-19 pandemic-related stress and with more happiness and life satisfaction . In addiThird, the open-ended questions showed that the reasons to join/expectations of the program were friendship, mutually beneficial intergenerational connections, coping with loneliness, and curiosity. The most enjoyable parts of the program that participants reported corresponded to the expectations. These study findings are consistent with the previous systematic review that concluded that both the older adults and the youth gained a mutual benefit in the physical, social, and physiological domains through the intergenerational program . SpecifiBig and Mini program offers a platform for them as a way to cope with the loss of not seeing their grandkids or grandparents during COVID-19 and to expand their social network. Furthermore, the Big and Mini program has the potential to serve as a health promoter for participants to cope with loneliness. This is also consistent with the literature that showed that intergenerational programs decrease the risk of social isolation and give older adults a sense of meaning [The COVID-19 pandemic has caused some grandchildren or grandparents to lose their physical, face-to-face connections. The  meaning , especia meaning . Besides meaning . Big and Mini program was launched. Therefore, only cross-sectional data at one time point were collected and it is difficult to determine whether this intergenerational program is effective in coping with loneliness during COVID-19. Future studies should consider longitudinal surveys to track the psychological well-being of participants and investigate whether improvements on psychological wellbeing were achieved after participating in this program. Second, the survey questions, in general, were not in depth. For example, stress and satisfaction with life was asked by a single question, rather than a standardized scale. Third, though we tried to utilize a mixed methods approach by using both closed and open-ended questions, the answers to the open-ended questions were limited to their length and depth as well as a few without responses. Future studies should include conducting in-depth interviews with a random selection of participants in order to better understand their experiences with the Big and Mini program. Fourth, the small number of participants , the relatively low response rate, and, therefore, the potential sample selection bias are also limitations of the present study. These limitations might influence the interpretation of the present study as people who take part in questionnaires are usually those who are more interested in the topic. Future studies need to examine why some Bigs and Minis started but did not complete the survey. Lastly, the sample of Bigs and Minis were generally healthy with high levels of education and with few concerns about financial needs. In addition, Bigs were those aged 50+, rather than 60+ or 65+ as suggested by the literature, though CDC suggests that those aged 50 are lonely. Therefore, the results from the present study as well as comparison with the previous literature should be interpreted with caution. Community outreach from the Big and Mini program should also include specific strategies for enrolling more diverse participants in terms of racial and ethnic background, socioeconomic status, and self-reported health.There were some limitations in this study. First, the survey was distributed to participants three months after the Big and Mini program is a promising approach for connecting young and older adults. In general, feedback from the Bigs and Minis showed that this program provides benefits of intergenerational learning and connection, friendship, coping with loneliness, and opportunities to contribute to and help others. These findings confirmed the overall benefits of intergenerational programs that link young and older generations together [Despite these limitations, the study suggested that the together . It woulIn addition, positive interaction and intergenerational relational qualities between young and older generations greatly matter. Some research suggests that simply increasing the frequency of contact between individuals is unlikely to reduce loneliness, unless these are positive, substantial connections, such as those among members of a “social support network” . TherefoBig and Mini program as well as in the literature [Lastly, while virtual connections show promise in benefiting both young and older generations as shown in the terature , technolterature . BridginBig and Mini program offers a promising platform for promoting social connections, intergenerational closeness, and creating new friendships. Study findings bolster support for future research about the Big and Mini program and highlight the value of intergenerational relationships for other programs designed to combat social isolation and loneliness.The long-term social impact of social isolation and loneliness during COVID-19 remains largely unknown. As new variants emerge and vaccination rates stall or decline worldwide, we may continue to see increased rates of social isolation and loneliness across populations. It is imperative that interventions and programs seeking to promote meaningful social connectivity consider the continued need for virtual engagement due to safety and health concerns. The


Objectives: To evaluate, in a Compassionate City pilot experience (Sevilla), the impact results on health in a population of people with advanced illness and at the end of life. Methods: The project was undertaken in Sevilla, Spain, between January 2019 and June 2020. A longitudinal, descriptive study was conducted using a longitudinal cohort design with two cross-sectional measurements, pre and post intervention. All patients who entered the program on the start date were included. The networks of care around people with advanced illness and at the end of life, palliative care needs, quality of life, loneliness, anxiety, depression, caregivers’ burden and family satisfaction were evaluated. The interventions were conducted by community promoters assigned to the “Sevilla Contigo, Compassionate City” program. Results: A total of 83 people were included in the program. The average number of people involved in care at the beginning of the evaluations was 3.6, increasing to 6.1 at the end of the interventions. The average number of needs detected at the beginning was 15.58, and at the end of interventions, it was 16.56 out of 25. The unmet needs were those related to last wishes (40.7%), emotional relief (18.5%), entertainment (16%), help to walk up and down stairs (8.6%) and help to walk (6.2%). A total of 54.2% showed improved loneliness in the final evaluation. Out of 26 people evaluated for pre and post quality of life, 7 (26.9%) improved their quality of life in the general evaluation and 5 (19.2%) displayed improved anxiety/depression. A total of 6 people (28.6%) improved their quality-of-life thermometer scores. A total of 57.7% of caregivers improved their burden with a mean score of 17.8. Compassionate Communities at the end of life have been conceived as a model of social innovation that complements palliative care towards integrated health, social and community care ,2,3,4. IIn recent decades, there has been an emerging development of Compassionate Communities and Cities designed with the aim of involving society in the care and support of people who are in a process of advanced illness and/or at the end of life, being diagnosed with cancer or other pathologies ,7. TheseMost of the initiatives launched have been aimed at raising awareness and educating society about the importance of caring for and accompanying these people ,7,11 andAs Abel et al.  and LibrCommunity intervention experiences are unusual and differ from one another in terms of impact results. Studies have been conducted measuring the economic impact of the development of public health and palliative care initiatives, such as the experience of the Frome, a Compassionate City , which hOther initiatives have been shown to improve quality of life in people at the end of life with volunteering experiences, improve loneliness and increase community involvement , and redIn the processes of community intervention, the first goal is generating care networks that allow the meeting of the needs of people with advanced illness and at the end of life thanks to the involvement of the community ,19. For The “Sevilla Contigo, Compassionate City” program of the New Health Foundation is the first pioneering program in the world to implement the “Todos Contigo” method  and to uThe objective of this study was to evaluate, based on this pilot experience, the impact results on health in a population of people with advanced illness and at the end of life, diagnosed with cancer and other non-oncological diseases, in terms of quality of life and well-being, anxiety/depression and loneliness. As well as evaluating the care and support networks around these people, the emotional/physical caregiver burden and the satisfaction of caregivers and family members were evaluated.A longitudinal, descriptive study on a population of people with advanced oncological or non-oncological illness and/or at the end of life referred to a community intervention program “Sevilla Contigo, Compassionate City” between 1 January 2019, and 30 June 2020.Inclusion criteria: People living in several districts of the city of Sevilla  with oncological or non-oncological illness, advanced and/or at the end of life who had palliative care needs that could be covered by the community, by a palliative care team and by a community promoter.Exclusion criteria: People in a very advanced state of their disease with a life expectancy of less than one week. A patient was considered to be discharged from the program when they had died or voluntarily resigned from the program, or moved to an area where there was not a program intervention.The value of data loss was estimated to be 20% from the inclusion criteria and 15% from the possible disclaimers, loss of information or non-response of the population during the intervention process.The intervention process of people referred and beneficiaries of “Sevilla Contigo, Compassionate City” program was followed in accordance with the RedCuida protocol  using thSociodemographic characterization of people referred and beneficiaries of the program.Sex (Man/Woman).Average Age.Diagnosis .Referral to the program.Number of people referred to the program.Origin of referral .People in a situation of last days to the date of referral to the program.The variables used for the study were the following:Inclusion in the program, scope of care and state of the population.Number of people included in the program.Care setting .○Active: patient who meets criteria and has active follow-up by the promoter throughout the entire intervention process.○Passive: patient who, being within the program, sees their needs satisfied thanks to the intervention of the promoter and the network and who passes to this passive state where less follow-up is conducted (biweekly by phone) to verify that the needs have not changed and continue to be covered, and to whom at least one face-to-face visit is made per month.○Resignation: person who decides not to continue in the program.○Transfer: person who leaves the program due to transfer to another area where the program is not offered.○Deceased: person who dies while in the program.State of the population:Place of death.Median survival of patients included in the program.Social assessment of beneficiaries of the program.People included in the program with social support networks .Sociodemographic characterization of main caregiver.Number of people with main caregiver.Sex (Man/Woman).Average age of main caregiver.Relationship: Father/Mother, Spouse, Son/daughter, Brother/sister, Cousin, Nephew/niece, Grandson/daughter, Son-in-law/Daughter-in-law, Friend, Professional Caregiver, Domestic Employee, Other.Characterization of initial network and final support network .Number and average number of people in the initial network.Number and average of people involved in the initial network.Number and average number of people in the final network.Number and average number of people involved in the final network.Average increase in the networks involved from start to finish.Quality of Life and Well-being Impact.Number and average needs of patients in the initial and final assessment.Number and average of satisfied needs of patients.For the application of the RedCuida protocol, the Barthel scale [You do not need (you do not require) help from the community to conduct the activity.○YES: When a member of the community helps you in the development of the activity and the profile of the person who meets the need is identified. To score this field, the need must be 100% satisfied by the community member(s). To evaluate this field, the promoter makes the assessment, whenever possible, with the main caregiver, taking into account, in case of overload, what kind of help is needed, and recording said needs as “unsatisfied” when it is necessary to incorporate people from the network for your complete satisfaction.○NO: When you need help, you do not have any member of the community, or those you have do not reach 100% of the help required in the development of such an activity, either because your needs are greater or because the person covering them is overloaded and needs help. In this case, unsatisfied must always be marked and it will be part of the intervention process to identify another member of the network who satisfies it.Satisfied:el scale  and Lawtel scale  were useel scale  to learnAssessment of Loneliness  .Percentage of patients who improve loneliness. The total score of the scale ranges between 0 and 30 and is obtained by adding the score of each of the items on the scale. There are 3 levels of Social Loneliness depending on the score obtained: Low → 0 to 10 points; Medium → 11 to 20 points; High → 21 to 30 points.Quality-of-Life Assessment (EUROQOL-5D) .Percentage of patients with improved quality of life.Percentage of patients with improved anxiety/depression.In each dimension of the EUROQOL-5D scale, the severity levels are coded 1 if the response option is “(I have) no problems”; with a 2 if the answer option is «some or moderate problems»; and with a 3 if the answer option is «many problems». The second part of the EUROQOL-5D provides a complementary score to the descriptive system of the self-assessment of the individual’s state of health, using a vertical VAS scale of 20 cm and millimeters, ranging from 0  to 100 . The combination of the values of all the dimensions generates a 5-digit number, with 243 possible combinations of health states, which can be used as profiles. The average quality of life is obtained, among all these combinations.Main Caregiver Burden  .Number of main caregivers with burden/not burdened in the initial and final evaluation.Number of main caregivers who improve their burden in the final assessment.The maximum possible score is 35 points. An equal result, or less than 17 points, would indicate that there is no burden, and a value bigger than 17 is the opposite.Family satisfaction.Satisfaction with the community intervention process.The satisfaction scale is conducted by a person other than the one who conducted the intervention process. It is conducted via a telephone survey of 8 items to the caregivers of deceased patients in which the caregiver responds to the survey by answering each of the questions with the scores:No, never (1), A few times (2), Sometimes (3), Quite a few times (4), Yes, always (5).The variables of the study were compiled in a data collection notebook by the community promoter in each of the interviews and scales were applied to the beneficiaries of the program and their families. A database was designed in Microsoft Access for the recording of the variables under study and their subsequent data processing.A descriptive analysis of all the variables related to the needs of the patients and the profiles of the people involved in the network was conducted. The data before and after the detection of needs, generation of care networks and start and end assessments were analyzed and described. This analysis included measures of central tendency , 95% confidence intervals for the mean, contingency tables, and frequency analysis.The study was approved by the Ethics and Research Committee of the Virgen del Rocío University Hospital and the Virgen Macarena Hospital of the Andalusian Health Service of the Junta de Andalucía, Spain (CI 1020-N-17), in June 2018. The study used an informed consent approved by the mentioned Committee.All beneficiaries of the program, and their main caregivers, were informed verbally and in writing of the intervention process, signing an informed consent for participation in the program and for the provision of their data for analytical and research purposes. To guarantee the confidentiality of the data, they were codified and encrypted so that they could not be identified. The questionnaires were coded with an alphanumerical identifier in a separate database independent of the one containing the patient identification data.From 1 January 2019 to 30 June 2020, 104 people were referred to the program . A total of 49 had an oncological disease (47.1%), 47 non-oncological (45.2%) and 8 without a specification of the diagnosis (7.7%). The average age of the people was 74.3 years (svtp 14.2).Of this population, 16 people (15.4%) refused to enter the program because their needs were covered by their family network or because they needed another type of help other than that of the program. A total of 5 people (4.8%) were in a last-day situation when they were referred to the program.The origin of the referral to the program is represented in Finally, 83 people (79.8%) were included in the program. There were 45 men (54.2%) and 38 women (45.8%), with an average age of 74.5 years (svtp 14.4). There were 41 cancer patients (49.4%) and 40 non-cancer patients (48.2%). No diagnostic data was obtained for 2 of the people included in the study (2.4%). A total of 78.3% of the patients included in the program belonged to the San Pablo-Santa Justa district, 20.5% to the Macarena district, and 1.2% to the Nervión district.The care environment of the people included in the program was 80.7% home care, 13.3% hospital care and 6% in residential centers. The average number of days spent in the program was 133 days . The average length of stay for cancer patients was 170 versus 104 days for non-cancer patients.During the study period, 36 people (43.4%) died, 12 abandoned the program (14.4%) and 3 were transferred to other services or locations (3.6%). From the remaining 32 people, 17 remained active in the program (20.5%) and 15 passives (18.1%).n = 36), 11 died at home (30.6%), 24 in hospital (66.7%) and 1 in a residential center (2.8%). The average survival of patients who died in the program was 21.5 days. The inclusion process is represented in the following From those who died in the program (n = 78) of the patients had a social support network. A total of 6% (n = 5) did not have a social support network.At the time of inclusion in the program, 94% (n = 71). Of these, 94.4% were direct relatives and 5.65% non-relatives. The sociodemographic profile of the main caregivers was 66.2% women (n = 47) and 33.8% men (n = 24) with a mean age of 57 years (svtp 15.24). The kinship of the caregivers corresponded to 42.3% being a son/daughter, 36.6% spouse, 5.6% brother/sister, 4.2% niece/nephew, 2.8% professional caregiver, 2.8% son-in-law/daughter-in-law, 1.4% mother, 1.4 cousin, 1.4% friend and 1.4% domestic employer.A total of 85.5% of the patients had a primary caregiver . The average number of people in the initial network was 5.4 people. Of these 420 people, 285 (67.9%) were directly involved in care and support, resulting in an average of 3.6 people involved in the initial network.The total number of people included in the final network was 487, with 60.6% being family members and 39.4% non-family members . The average number of people involved in the final network was 6.1, assuming an increase in the networks involved from the beginning to the end of 2.5 people . An analThe initial and final needs of the beneficiaries .The community promoters evaluated a total of 25 needs .Upon entry into the program, a needs assessment was made for a total of 81 people . The average number of needs per person, among the 25 needs assessed, was 15.58 (representing 62.3% of the needs assessed). These detected needs were covered by members of the network in 91.5% of the cases. On the other hand, 8.5% of the needs identified in these people were not covered by members of the network in this initial assessment.The needs not covered in the initial assessment were those related to the preparation of last wishes (40.7%), followed by emotional release (18.5%), entertainment (16%), help to go up and down stairs (8.6%) and help in ambulation (6.2%) .The assessment of needs in the final network was made for a total of 62 people . The average of needs per person was 16.56. A total of 6.9% of the needs of these people were left uncovered in the final network .Loneliness was assessed in 57 patients at the initial assessment.At the beginning of the intervention, 68.4% of the people had some type of loneliness  .Evaluations of loneliness at the beginning and end of the interventions were completed in a total of 24 people. For these 24 people, the mean loneliness score in the initial evaluation was 12.75, and in the final evaluation, there was an average of 12.12. (Mean difference −0.62500). A total of 54.2%  reported that their perception of loneliness improved in the final evaluation. A total of 100% stated that they felt more accompanied after the work of the community promoter.The quality of life was evaluated in 73 people in the initial evaluations and in 26 in the final evaluations. The average quality of life in the patients who were evaluated at the beginning of the intervention was 0.34 . The average quality of life in the final assessments was 0.36 .Out of the 26 people evaluated in the initial and final assessments, 7 (26.9%) improved their scores on the general scale and 5 (19.2%) improved their anxiety/depression scores. A total of 6 people (28.6%) improved their quality-of-life thermometer scores.n = 17) of the caregivers presented overload with a mean score of 20.8 on the reduced Zarit scale. In the final evaluation, 34.6% of the caregivers (n = 9) presented burden, and 57.7% improved their burden with a mean score of 17.8.The evolution of caregiver burden using the reduced Zarit scale was measured, in the initial and final assessments, for a total of 26 main caregivers. Of these, at the beginning, 64.4%  . AccordiBeing a longitudinal study, and due to the characteristics of the population, the probabilities of non-inclusion were estimated at 20% and those of abandonment during the study period were estimated at 15%. Therefore, the percentage of rejections or non-inclusion is considered appropriate to the forecasts that were made according to the type of study .The population referred to a palliative care program is usually oncological, even though the prevalence of diseases is 70% non-oncological and 30% oncological [One of the objectives of palliative care is to provide care in the place of preference of patients and their families . The homIncreasingly, the chances of dying at home decrease with age; the older the person, the greater the chance of dying in hospital. This relationship is in turn related to the scarcity of networks, with not wanting to be considered a burden to others , with feThe median survival of patients treated in the “Sevilla Contigo” program was 21.5 days, slightly higher than the median number of days of people who died in palliative care programs, which was 19 days .In the absence of other studies that have measured the relationship between community intervention processes and survival in a palliative care program, it has not been possible to show whether this effect could be improving thanks to the creation of intervention structures such as integrated commissions or to the actions of social awareness and training that cause greater knowledge about the referral pathways to a palliative care program.n = 5). These initial assessments conducted by the community promoter were key to identifying the existing people involved in the care, programming the intervention plans for the generation of community networks and being able to compare the networks at the end of the intervention process.Regarding the social assessment and characterization of the networks of the people included in the study, the majority (94%) had a social support network at the beginning of the program, with a greater proportion of people who had only an internal network formed by close relatives (67.9%), since in most cases these people had a primary caregiver (85.5% of cases). These data coincide with the study by Díaz, Redondo and Librada, 2016 , where tThe profile of the main caregivers of the people in the “Sevilla Contigo” program also coincided with those of other studies. This profile is related to family structures, which continue to be the main sources of care in most developed countries ,40,41.The program in Sevilla made it possible to double the care network. This increase highlights the importance of these intervention processes with the community and the way in which the figure of the community promoter allows the involvement of new profiles. These results have made it possible to corroborate the hypotheses of Abel and Horsfall ,19, abouThe needs, as classified by Ferris and Librach , are mulIt should be noted that, for this study, the assessment of needs was limited to those related to the basic and instrumental activities of daily life and to a series of emotional and support needs that were adapted in the RedCuida protocol. This selection is due to the fact that the intervention processes with the community aimed at addressing this type of needs thanks to the community and complement this action with those of professionals who address other types of physical, psychological, emotional or spiritual needs in a multidisciplinary manner. .Regarding loneliness, even though its measurement is complex due to the objective and subjective components that define it, we wanted to measure and address the way in which loneliness is perceived as lower thanks to the community. Loneliness causes inactivity, depression, anxiety, and older people who are less lonely make greater use of health services such as consultation or emergency care. This frequency can be up to 50% higher than in the rest of accompanied people . The perThe quality of life and well-being in people with advanced disease and at the end of life is a situation that is continuously pursued and that is difficult to measure when trying to gather those factors that may be causing a state of discomfort in a person. The selection of a tool to measure quality of life can also be conditioned by the interventions that are going to be conducted on the patient. Thus, being able to put together a scale that brings together all the dimensions of well-being is complicated as well as inappropriate when the patient is in a highly complex situation .The quality-of-life scales in palliative care have been designed to be simple, brief and help quickly identify those situations that are causing this problem. The choice of the EUROQOL 5D scale was determined by the fact that it is a tool that meets these characteristics of simplicity in the application of the scale and measures situations that could be improved thanks to the involvement of the community, such as support in daily activities or anxiety/depression improvement thanks to accompanying actions .As occurs with the needs of patients at the end of life, which vary and increase due to the evolution and complexity of symptoms and the approach of death itself, quality of life, in this profile of patients, also tends to become worse . Even soMobility, self-care, activity, pain/discomfort, and anxiety/depression states were improved for nearly all endpoints. It is true that the networks and accompanying actions cannot reduce a person’s pain from the physical point of view, but it has been proven that the perception of pain decreases as well as the values of anxiety/depression, which improved in all the final evaluations. A total of 54.8% of the patients initially presented anxiety and/or depression, and of these, 11.5% manifested it in a very severe way. At the end of the intervention, 42.3% presented anxiety and/or depression, seeing this improvement in 19.2% of the cases. According to Yanguas et al. , lonelinA total of 57.7% of caregivers improved their burden on the Zarit scale, going from a value of 20.8 to 17.8. This indicator is also related to the progressive increase in needs since, sometimes, although the network increases, as the number of needs to be satisfied and their intensity increase in parallel, it is more complex to lower the overload levels of the main caregivers, and a positive result is a slight improvement or even having maintained these levels at the end of the intervention.Satisfaction is a quality indicator widely used at the end of life that expresses in a very close and sincere way the way in which a certain service has been provided, even more so when in the most difficult moments of a person and their family’s life, and we may feel this sense of being satisfied and grateful with the process . The assThis study has been the first to analyze the health impact of a Compassionate Cities program in advanced illness and at the end of life in terms of improved quality of life and well-being, needs being met, decreased loneliness, decreased anxiety and depression, increased care networks, decreased caregiver burden and family satisfaction. To this date, there are no other similar studies to compare these results within populations with advanced disease and at the end of life.It has been found that some of the intervention processes such as the circle of care tool have also shown good results in people with dementia or disability in improving quality of life and well-being, reduction in the overload of caregivers and reduction in the consumption of health resources for people with high support needs . HoweverFull evaluations of the development of Compassionate Cities have not been found to this date. For this reason, the possibility of evaluating a pilot project such as “Sevilla Contigo” was necessary to be able to measure the behavior of the structure, process and result indicators that allow for the measuring the impact on health and the improvement in the quality of life and well-being. On the other hand, there was a limitation in the selection of coverage areas, and having more professional figures such as community promoters, would have made it possible to increase the scope of the program in the city, reaching a greater part of the population, and consequently, obtaining a larger study sample.One of the most important limitations of the study has been the inability to identify and manage referrals of the population to the program. The study population has been limited by referrals from professionals, and although coordination and referral structures have been developed that could be integrated into existing services in the city, the desired sample size has not been achieved. For this reason, more research would be needed to identify the beneficiaries of this program that would allow, on the one hand, covering a greater part of the population of Sevilla and, on the other, comparing the populations for each of the districts in which the investigation will be repeated.The RedCuida protocol was designed to detect needs and to generate networks, but it does not describe a specific process of community intervention, so there could be a bias in the interventions of each of the promoters who conduct these processes with the family. The activity of the community intervention processes has not been analyzed since it has not been possible to compare them as there is no similar community intervention process in other populations. Even so, the activity of the community promoter was recorded for the internal evaluation of the resource and of the activity within the “Sevilla Contigo” program.The analysis conducted in the initial and final evaluations were of a quantitative nature, although they have a qualitative interpretation that need to be studied in greater depth. The needs of people cannot be interpreted at the same level, nor considering that a need can be covered by a single person. The assessment of the needs that were covered by the network were considered by the promoter from the perception of the people who were being interviewed and their families.The values of quality of life, satisfaction, decrease in the overload of caregivers and family satisfaction also accompany these results, but it cannot be interpreted that they improve only due to the intervention of the community promoter, since the care provided by the palliative care professionals, from health centers, social services or other key agents, also condition these results.The investigations conducted with people who are at the end of life also suppose a limitation due to the very fact of the situation, since on some occasions, assessments cannot be conducted due to the conditions of the patients. Additionally, and more importantly, the initial assessments that start with a larger number of people end up with much smaller samples since they can only be compared with people who have died at the end of the study. For this reason, the populations were been comparable, and the study was limited to a descriptive analysis.The results have allowed us to corroborate the starting hypothesis where community intervention processes improve the quality of life and well-being of people at the end of life, while allowing an increase in the care network and a decrease in the burden of caregivers, but these data, as a whole, were not been able to be compared with each other through variable correlation tests, because the sample, due to its own condition of being in an end-of-life situation, sometimes led to the evaluations not being completed, either due to the complexity of the patients when applying the scales, or due to the deaths of the population, which occur in different periods, causing the start and end evaluations not to be completed due to same reason.Finally, one of the limitations of the study was not being able to obtain a control group that would allow the comparison of health consumption, and its associated costs, of community intervention processes vs. traditional care. This comparative study supposes the next line of investigation of the impact of Compassionate Communities and Cities. With these results, it is expected to be able to complete the evaluation of the impact on health and cost efficiency of the development of Compassionate Communities and Cities from the models of integrated care and from community-based palliative Care.The “Todos Contigo” method and the systematic evaluation of the interventions for the development of Compassionate Communities and Cities allow for the verification of the improvement in the quality of life and well-being of the patients, a greater satisfaction of the family and their care networks, an improvement in loneliness, an increase in the care network and a greater number of needs satisfied by the network.More research is required on community intervention processes and on mixed evaluation models that allow for a more detailed evaluation of the results of these interventions adapted to the preferences of these people and their families.