Cigarette smoking is a main cause of preventable morbidity and mortality. Many young adults begin smoking in the military, with smoking rates higher among soldiers than in the general population. Among other health effects, smoking impairs performance among soldiers. Smoking cessation programs in the military are challenging due to the unique settings and low access to smoking cessation resources. Studies have shown that text-messaging smoking cessation programs are feasible and effective, but there is a lack of studies on soldiers.To evaluate the feasibility of a text-messaging smoking cessation program tailored for soldiers.We recruited 81 soldiers who smoked, 76.5% of whom were male. Following enrollment, participants filled out a baseline survey and were given a text messaging program for 6 months. Participants could send predetermined keywords and immediately receive a response from a list of messages that were constructed as a response to the specific keyword. Participants filled out a follow-up survey at 1 month. Additionally, we retrieved and analyzed program usage data, including keywords sent and received, for the entire program period. Based on the follow-up survey and the program usage data, we assessed feasibility of the recruitment methods, participants’ engagement and satisfaction and technical usability of the program.At 1 month, 20.6% reported that they had not smoked in the past week. A high percentage of the participants were engaged in the program, with 82.5% sending at least one valid keyword. The lowest self-efficacy group had higher chances of leaving the program (50.0%) while for the highest group there were much lower chances (4.8%). Most of the soldiers (96.8%) found the program easy to use and would recommend it to a friend (84.1%).The study demonstrates that a text-messaging smoking cessation program is feasible in a military setting. Further development and evaluation of digital smoking cessation tools tailored for soldiers are warranted. Tobacco use is the world’s largest preventable cause of death . Epidemi2 = 71%; six studies; 7360 participants) [N = 38), were Israeli smokers who spoke English. Surveys conducted 4 weeks after enrollment in the English language version of IStopSmoke assessed participant smoking status, technical issues and user satisfaction. Using an Intention-To-Treat (ITT) analysis, 23.7% of the participants reported that they had not smoked for 7 days. No participants reported technical issues receiving messages, and 23.3% reported technical issues sending responses or using keywords. Satisfaction rates were high, with 63.6% reporting that the program helped them quit smoking, and 68.2% stating they would recommend the program to a friend [Several studies have shown the benefit of text-messaging based smoking cessation interventions in helping users change their behavior. A randomized trial that included 5800 participants reported a doubling of biochemically verified continuous abstinence at 6 months for the intervention group . The smoking status in this study was biochemically confirmed . A meta-cipants) , 11. Furcipants) . Other scipants)  and pregcipants) , 15, supcipants)  in Israecipants) , a publicipants) . The adacipants) . A full cipants) . In briecipants) , as parta friend . These rFollowing the successful pilot study for iStopSmoke, we adapted a text-messaging smoking cessation program tailored for soldiers serving in the Israeli Defense Forces (IDF). We hypothesized that a program tailored specifically to the needs of this population would be an important addition to promoting smoking cessation among soldiers. The objective of this study was to evaluate whether the adapted program was feasible for soldiers in the IDF, including assessing recruitment methods, participants’ engagement and satisfaction and technical usability of the program.Following the iStopSmoke pilot a Hebrew language program was developed for use in the military. The free-of-charge program was developed by a multi-disciplinary team and based on the experience and evidence supplied by the American SmokeFreeTXT and the Israeli iStopSmoke. Advice and comments were provided by military medical personnel and experts from the Israel Cancer Association, Ministry of Health, and the Israeli Medical Association for Smoking Cessation and Prevention as well as participant of iStopSmoke. The advisors reviewed text messages in the database and suggested revisions. Health professionals provided suggestions based on their clinical experience with smoking cessation, as well as specific experience with military personnel. Comments from the iStopSmoke program users were collected from the 2-week follow-up assessment survey filled out by the participants. Examples of changes to the program, following these suggestions are: 1) expanding the information provided through the program website 2) customization by gender. This was particularly important, because in addition to customizing for expected gender differences and appropriate recommendations, Hebrew has grammatical gender, requiring separate message formulation for men and women. While the general program was retained, several changes were made compared to iStopSmoke in order to tailor these to the unique culture and language in the military, and the aforementioned suggestions from iStopSmoke participants. Participants were offered to choose a quit day up to 14 days after registration instead of seven, and the entire program was extended to 6 months after the quit day instead of 30 days. Messages suggesting adopting a pet or going to the theater were replaced with recommendations relevant to the military setting, such as going for a run or reading a book. Relevant medical recourses within the military and civilian health systems in Israel were provided by text message throughout the program. Evaluation was updated, and used an online survey and phone survey as opposed to personal meetings.Beginning at registration and up to the chosen quit day, the participants received between two and three daily messages. Participants received four daily messages during the first week after quit day, three daily messages for the next 2 weeks, and then two daily messages for the last week of the first month after quit day. During the second month, they received messages every other day, decreasing to weekly messages at day 90, and continuing in this manner until 180 days when the program was concluded. As in iStopSmoke the messages sent were relevant to the stage of the program, i.e. messages promoting cessation up until the quit date and messages encouraging the participants to remain smoke free. Examples for some of the messages can be found in Salesforce.com).Following participant suggestions from our previous study , the proThe study was approved by the Hadassah Medical Center and IDF institutional review board (IRB) committees . All participants provided consent by signing an electronic form and replying “approve” to a text message they received after completing the form.Eligibility criteria for this study included: (1) being aged ≥18 years; (2) smoking at least one cigarette a day; (3) reporting willingness to try to quit smoking within 2 weeks; (4) having a cell phone with ability to send and receive text messages; (5) able to read and write Hebrew; and (6) currently serving in the IDF. Participants were excluded if they were pregnant. Participants were recruited from both “open” and “closed” units. In “open” units, soldiers do not sleep at their base, but rather sleep at home every night, similar to a day job. In “closed” units, they only go home for weekends (or less frequently).Recruitment began on May 31, 2016 and ended August 11, 2016. Recruitment was promoted in several ways. Soldiers were contacted directly by sending e-mail messages out via the IDF internal e-mail system. In addition, doctors and clinic commanders received an e-mail encouraging them to promote the program among their patients. Mainstream media outlets published articles about the program. Public service announcements broadcasted on the IDF radio station encouraged soldiers to participate. Facebook ads were published, without “promotion”, through the public pages of the Israel Cancer Association and the IDF and posts were shown on the organization websites. The ad invited soldiers to join a smoking cessation text-message program tailored for their needs, free of charge as part of a study. Additionally, a short text message was sent to army doctors and soldiers encouraging them to pass it along to their friends and colleagues. Recent research has shown that social media in general and Facebook specifically can be useful methods of recruiting participants to health research studies .n = 29, 35.8%) (e) Upon submitting the form, participants received a text message requiring them to reply “accept” in order to finalize their registration for the study (and the program); (f) A member of the research time reviewed each participant to make sure they met the inclusion criteria. If requested, they called the participant and answered any questions; (g) The researcher approved the participant’s inclusion in the study and activated the program. Participants did not receive any financial compensation for participation and could withdraw from the program and/or the study at any point.The enrollment process had eight steps: (a) Participants completed a registration survey that could be reached through the Israel Cancer Association’s website or a direct link from the various digital advertisements. This survey was later served as their baseline survey if they were found eligible; (b) After completing the survey participants were immediately asked to choose a quit-date 2–14 days forward (c) Participants completed and electronically signed the consent form which appeared after completing the previous steps; (d) Participants were given the option to request that a member of the research team contact them before beginning the program , smoking characteristics  and mobile phone usage. The full survey is included in Similar to previous research , usage dParticipants received an online follow-up survey via email and text message 1 month after their chosen quit date. The question asked in the online survey regarding smoking status was: “Have you relapsed, and returned to smoking after quitting?” Those who answered yes to this question, were considered to still be smoking. In addition, a single question survey sent by text message asked: “Have you quit smoking since the beginning of the program?” This question was sent on days 7, 30, and 90, with low response rates of 36 (44.4%), 30 (37.0%), and 27 (33.3%) respectively. Due to low response rates and the question being unclear, we did not analyze the cessation rates. We analyzed the smoking cessation rates both as a percentage of the survey responders, and with a conservative estimate, assuming that all non-responders were still smoking .Participants who did not complete the online follow-up surveys were reminded once more by text message and then subsequently by phone where they were offered the option of completing the survey during the call. Up to five phone calls were made to each participant in order to receive as many surveys as possible. The participants completed the survey within 5 weeks. Participants who reported leaving the program were compared to those who remained among several variables, including sex and self-efficacy. Self-efficacy was defined on a five point Likert Scale , as the participant’s self-stated ability to quit smoking based on the answer to the question: “To what degree to do you rate your ability to quit smoking”, on the baseline survey. Technical usability was assessed by a user’s self-report of technical issues with the program during the study period.Baseline characteristics are presented as frequencies and percentages for the qualitative variables and means ± Standard deviation (SD) for the quantitative variables. Engagement was assessed by analyzing the use of keywords by the participants, number of participants that sent each of the keywords, proportion of participants who sent more than one keywords, and average number of keywords each participant sent. Additionally, the use of keywords was used as an indication of the program’s technical usability. The total number of keywords sent by the participants was also assessed from participant self-report, enabling assessment of both the subjective feeling of the participants in comparison to objective usage data.Participant satisfaction and technical usability as reported in the survey are presented as number and proportion of participants who responded positively to the question. Variables were assessed for association with leaving the program using Chi-squared and Fisher’s exact test. Smoking status is presented as number of participants not smoking at follow-up and their proportion.Feasibility was defined as a composite of previously described measures , 23. It n = 63/81). All participants texted in the keyword APPROVE, to complete their enrollment in the program. The 81 participants reported that they heard about the program through: E-mail (49.4%), Friends/family (22.2%), Clinic (9.9%), Facebook (9.9%), WhatsApp/SMS (3.7%), Commander (2.5%), Newspaper (1.2%), Website (1.2%).Eighty-five potential participants expressed interest in the program. Two of them were excluded for not being soldiers, and two more for not providing proper consent. Thus, 81 soldiers were enrolled in the study. The response rate for the online survey at 1 month follow up was 77.8%  and male . They reported smoking 13.0 ± 6.0 cigarettes daily, an average smoking initiation age of 16.7 ± 2.4 years, and several previous quit attempts (5.3 ± 8.1). Six (7.4%) reported smoking within 5 min of waking up in the morning. About half of the participants reported living with a smoker. They all owned a smartphone, and they reported sending 99.8 ± 209.0 text messages per week on average. 36 (44.4%) of the soldiers served in an “open” base, and the other 56.6% served in “closed” bases. (Table The participants were mostly young (24.4 ± 8.2), single n = 66, 8.5% and mn = 69, 82.5%) sent at least one valid keyword, besides APPROVE, which was required in order to enroll. On average, each participant sent 7.6 ± 6.6 keywords based to usage data, similar to 6.6 ± 10.9 based on self-report. . Previous methods included several options with the most prevalent being: e-cigarettes (22%), self-help literature (16%), nicotine replacements (12%) and willpower (59%). Most participants reported reading “more than half of the messages”. Most participants stated “making an attempt” to quit (88.9%).n = 5, 7.9%). Three participants reported having trouble choosing a new quit date. One participant, tried to send an open question to the system (despite this not being possible), and another did not understand how to send keywords. Most of the participants found the program easy to use . The vast majority (84.1%), including many that had not quit smoking, stated that they would recommend the program to a friend. Only 66.7% agreed that the messages helped them quit. . For the lowest self-efficacy group the chances of leaving the program were 50.0%, while for the highest they were 4.8%  reported leaving the program before completion. The only variable that was associated with chances of leaving the program was self-efficacy at baseline  participants reported not smoking. Assuming all those lost to follow-up had returned to smoking, 16.0% were not smoking.We evaluated for the first time the feasibility of a text-messaging smoking cessation program for soldiers in Israel. Recruitment of 81 participants was fast and efficient. The response rate for the online survey at 1 month was suboptimal (78%). Technical problems were rarely reported (7.9%). Participants’ engagement was high, as 82.5% sent a least one valid keyword and most participants reported reading more than half of the messages. Satisfaction was high as 96.8% found the program easy to use and 84.1% would recommend it to a friend. Low self-efficacy at baseline was associated with higher chances of leaving the program. At 1 month, 20.6% reported that they had not smoked in the past week. Overall, the study demonstrates that a text-messaging smoking cessation program is feasible in a military setting.Engagement with the program was high, similar to the results seen in other studies , 16, agaThe higher response rate to the online survey compared to the text-message survey raises questions about the best method of assessing such a program. Although a one-word answer could be thought to be easier for participants to respond to, this was not the case. One explanation may be the reminders that participants received for the online survey.Participants that reported leaving the program had a significantly lower self-efficacy rate than those that remained in the program. Previous studies have shown that self-efficacy may predict smoking cessation –27, and Limitations of the study include a small sample size, and it not being a randomized control trial, meaning it was not designed to enable assessment of program effectiveness. We could not assess representativeness of study participants in comparison to the target population. We cannot rule out the possibility of self-selection into the study, as participants may be those that are more inclined to quit or are more technologically savvy than others. While the response to the survey was relatively high, it was not 100%, and it required a relatively large amount of effort from the research team, which would be problematic in a larger study.Advantages of the study include it being based on previous successful programs  as well Smoking cessation programs in the military setting could be further supported smoke-free settings and policy. Commanders and peers can take advantage of the military authority and motivate soldiers to quit smoking. This is beginning to happen in the Israeli army, with new smoking restrictions being put into effect . LessonsThis study demonstrated advantages to adapting such a program to a specific group, and suggests that it may be worth designing a program to meet the needs of other specialized groups as well. Further thought should also be given to expanding this program to offer additional support during the program, while considering the challenges of a military setting. Text-messaging programs can be used as a stand-alone service or be used to supplement other services like group and phone consultation. Another feature to consider is the possibility of interaction between the participants themselves. Although this study provides evidence of feasibility, future large-scale studies will be needed in order to properly assess effectiveness of such programs, and integration with other smoking cessation programs.In conclusion, the study demonstrates that a text-messaging smoking cessation program is feasible in a military setting. Further development and evaluation of digital smoking cessation tools provided to soldiers are warranted.


Despite the integration of peer workers into harm reduction services, there is little documentation regarding the experience of this integration or of models in which peers are fully integrated as members of health care teams. The purpose of this study was to gain an in-depth understanding of the transition from client to support worker from the perspective of two individuals who received treatment for hepatitis C at a multi-disciplinary, community-based program, grounded in a harm reduction approach to substance use.A participatory case study design was selected. Interviews were conducted with two current peer workers who were also involved in the study design, analysis and writing. Data was coded and analyzed using an inductive approach to identify emergent themes.Five primary themes emerged during our analysis of the facilitators and challenges of the transition from client to support worker: (1) the role of prior experience, (2) changes in substance use practices, (3) shifts in relationships with community members and friends, (4) supportive organizational and structural factors, and (5) role transition as a journey. In some cases, themes overlapped and contained elements that were both facilitating and challenging.The transition from client to co-worker is a gradual process and one that is supported by, and in turn helps to support, a number of other personal transitions. The cases examined here suggest that a model of peer employment with broad qualification criteria, sufficient transition timelines, flexible job responsibilities, a solid investment in the inclusion of people with lived experience, and a harm reduction framework will support successful integration of current and/or former clients into health care teams. The involvement of people who use drugs in the development and provision of harm reduction services is increasingly common and widely recognized as best practice . People HCV is one of the most common viral illnesses worldwide, with recent estimates suggesting over 71 million people are living with the infection . It has Low-barrier, multi-disciplinary, harm reduction based models of HCV treatment, which emerged in the last decade in response to the gaps in treatment access, have demonstrated success in engaging people who use drugs in HCV care with outcomes that are comparable to clinical trials –29. ManyThe Toronto Community Hep C Program (TCHCP) began in 2007 in response to many of the gaps and barriers to health care for marginalized people living with HCV noted above. The program is a partnership between three community-based health centers with integrated on-site specialist support from a nearby hospital. HCV treatment is delivered alongside a weekly education and support group held at each of the three partner sites. Primary care clinicians  are available during the weekly group sessions with monthly on-site support from the HCV treatment specialist. Clients receive both HCV-specific and more general primary care. They may also access case management, counseling, or other one-on-one supports and referrals through the group facilitators or other program staff. In addition to the treatment group, the program also offers a drop-in group for clients who have completed treatment or who are not eligible for or currently able to do treatment, as a way of maintaining their engagement in care. The program has demonstrated positive treatment outcomes that are comparable to clinical trials in hospital-based settings , 28.The TCHCP is based on the theories and practices of harm reduction and community development, both of which value the involvement of people with lived experience in decision making and service delivery. These program model theories have been previously described . The TCH. The program encourages collective action and organizing and aims to equip clients with the necessary skills for self-advocacy, as well as critical awareness at a personal, program, and community level.Each type of TCHCP group offered by the program is established as a welcoming space where a sense of community and mutual support are nurtured. The group is an important place of belonging and peer-to-peer support and knowledge sharing. Clients who are further along in their treatment process act as resources and mentors for newer members. Those who have recently finished treatment are able to offer encouragement and reassurance to individuals who are experiencing side-effects or other life challenges while on treatment. Through the program’s groups, participants learn about and get connected to other community resourcesThe program’s Patient Advisory Board (PAB) was established in the fall of 2010 to enable the meaningful participation of people living with HCV in the development, implementation, and evaluation of the program. PAB members participate in partnership meetings, presentations, workshops, training, and strategic planning. The PAB is made up of two group members from each site who are elected by other group members and aims to be representative of the diversity of program clients. The PAB meets monthly or more, when needed, and members are paid an honorarium for their time at meetings and other events. The PAB has three main roles: (1) to provide feedback on existing program components, practices, and issues; (2) to provide guidance and input into program development, research, evaluation, and training; (3) to conduct public education and awareness regarding HCV through presentations and other public speaking engagements.Since August 2011, the program has annually offered a Community Support Worker (CSW) training program for up to 12 current or former TCHCP clients. The purpose of this training is to further increase the capacity of program clients to act as support workers for their peers within the program or at other agencies elsewhere in the community. The training program consists of approximately 16 weekly, 2-hour sessions focused on skills-building and topics such as communication, self-care, boundaries, and advocacy. The HCV Case Manager  provides overall development and coordination for the training program including facilitating several of the training sessions and providing one-on-one support for participants. The training program was advertised by flyers that were circulated at the TCHCP groups and posted throughout the health centers. Past clients who had previously expressed interest in employment opportunities were contacted by phone and told about the training. Interested clients applied in writing by submitting a brief and informal (could be hand written) letter of interest to the training coordinator. The number of training spots was capped at 12 based on the coordinator’s past experience of running a variety of psycho-educational and training programs; to allow for adequate group discussion and cohesion and to ensure sufficient staff capacity to identify and support individual learning and training needs. To date, the program has received approximately 12 applications per training cycle and as such has been able to accommodate all clients who applied.In June 2012, six peer training program graduates were hired for two HCV CSW positions at each of the three program sites. The goal of these positions is multi-fold: to provide a meaningful employment/skill building opportunity for clients, to keep the program grounded in and responsive to the needs of the community, and to fill a program need for additional client support/education. The work of these positions varies from worker to worker and has evolved for each individual over time. Responsibilities and tasks remain flexible to allow for varying stages of job readiness and worker interest. CSW responsibilities currently include group facilitation, public speaking, training of other peer workers, client accompaniment to appointments, administrative program support, and informal one-on-one client support. CSWs are employees of South Riverdale Community Health Centre which is not a unionized organization and are paid an hourly wage, vacation pay and sick time. They work a minimum of 6 hour per week. As much as possible (limited primarily by hours of work), CSWs are fully integrated members of the multi-disciplinary HCV program/team: attending meetings, participating in case conferencing, independently representing the program externally, attending conferences and professional development workshops, and contributing to program planning and research. CSWs receive practical support, supervision and mentorship from the HCV case manager who works closely with the CSWs on most activities. Support is integrated during service delivery or program activities, as well as in pre- and post-shift discussions. While client care provision through the TCHCP is time limited (clients leave the program 12-weeks post end of treatment), CSWs may continue to be primary care and/or harm reduction clients at one of the three health centers where the TCHCP is offered. Wherever possible, the program attempts to separate where CSWs work from where they receive care. With three locations, the program has some ability to ensure CSWs do not work (or work very little) in the health center where they continue to receive health care or will help them to find primary care elsewhere if desired. Authors Jennifer Broad and Marty Behm have both been in the CSW role since it began and are the only workers from the original group of six who were still in the role. Two from this original group had gone on to full-time employment in other sectors. Pre-existing alcohol use or mental health issues became problematic for the two remaining workers who had to leave the role to prioritize this aspect of their health.A participatory approach was chosen for this study. The study idea was generated by the program’s patient advisory board and CSWs who were interested in using research as a tool for exploring and detailing the experiences of peer workers. Everyone on the study team, including the CSWs who ultimately became participants of the study, as well as co-researchers, had an equitable contribution and were involved in all stages of the design and analysis . This apA case study design was selected as the best method for undertaking a more holistic investigation into how and why some individuals successfully make the transition from client to peer worker. It was the study team’s hypothesis that factors would be complex, and the selected methodology allowed for in-depth exploration, as well as diverse and contextual perspectives . The casTwo participants were purposefully drawn from the group of five community support workers who were employed by the TCHCP at the time of data collection. Authors Jennifer Broad and Marty Behm self-selected for the project out of an interest both in taking a more active research role within the program and in examining their own personal experiences. Jennifer was still a TCHCP client (for her second round of treatment) when she began her employment as a CSW and both continue to be primary care clients at one of the health centers where the TCHCP takes place. Jennifer and Marty had been patient advisory board members and were two of the original six peer workers hired with the program. As such, it was felt that they had sufficient program exposure and work experience to adequately comment on the study questions. The study team (including Jennifer and Marty) also felt that they best represented the program’s client diversity in terms of personal characteristics, background, and trajectories. Multiple conversations took place with Marty, Jennifer, and the rest of the study team prior to initiation and throughout the analysis and writing regarding the potential ramifications of their open participation. Both Jennifer and Marty already had considerable experience as public speakers where they have shared similar life details. They also felt strongly that any negative personal impact would be outweighed by the potential community benefit of reducing stigma and contributing to an understanding that people who use drugs are equal and valuable contributors to their communities. Jennifer and Marty viewed their participation in this paper as a form of activism, and felt that being open and vulnerable is the right thing to do even at some possible risk to them. Both also feel protected somewhat by their age and certain knowledge of their future goals, which do not include working in places where their current or past substance use would be judged negatively. The study team also undertook a lengthy process of reflection on the transcripts and revision of the manuscript. Decisions on what to include were ultimately made by Jennifer and/or Marty.A formal informed consent process took place prior to the interviews and any audio recording. Written consent was obtained, and interviews were conducted by a health care provider (Lise Bondy) not otherwise affiliated with the program in the fall of 2015. This decision was made to allow for peer workers to be critical about the transition in ways that they might not have felt comfortable to do with their colleagues. The involvement of an external co-investigator also provided an objective perspective that helped validate and foster the reflexivity of the rest of the research team. Although participants were also co-researchers, the consent process was structured as it is for other potential research participants to ensure that the same rights and concerns were addressed. As part of the consent process, the participants/co-researchers were reminded that they should be careful with the information that they shared and assured that they would be able to remove any sensitivities from transcripts and/or this manuscript. Consent to be audio recorded was optional and was a separate part of the consent form. Participant/co-researchers understood that the study findings would be reported internally and would be submitted for publication in a peer-reviewed journal. Participants/co-researchers were also informed that they could withdraw from the study at any time and that nothing would be included in any reports or presentations without their permission. Interviews were guided by a set of semi-structured, open-ended questions and took approximately 55 min each. Questions covered each participant’s personal background, TCHCP client experience, and CSW experience. The interview questions and schedule were collectively designed and agreed upon by the study team.Audio recordings of the interviews were transcribed verbatim. Only investigators participating in the analysis had access to the transcripts and recordings. Data collected from the interviews was coded and analyzed using an inductive approach to identify emergent themes. We employed a cross-case analysis to identify common and unique themes. A collective process of organizing and sorting the data was undertaken. One of the authors with experience in qualitative analysis provided a training session and guidance throughout the process. Authors PT, KM, JB, and MB initially reviewed the transcripts on their own for first impressions and then re-read for patterns. At this point, the authors began a series of group discussions interspersed with individual re-readings of the transcripts to compare notes, revise, and finally refine the emerging themes and concepts. These authors met six times over a period of 6 months to compare, review, and discuss findings. The focus of analysis was on uncovering both unique and common features of each transition from client to coworker and on the factors that were challenges or facilitators in this transition. From these discussions, the study team extrapolated and identified those factors that seemed to support the successful transition in these cases. The case presentations were initially pieced together from the formal interviews and were revised in subsequent discussions during data analysis. Sections were included to give the reader a sense of each person’s background and to provide relevant context to help frame and support our qualitative analysis. The HCV treatment experience itself was a significant life turning point for both participants and as such is a large part of each story. Each participant re-worked and finalized their own story. Writing of the manuscript was coordinated by a single author, but writing was often collaborative with sections revised and edited in group meetings. This process was time consuming, but ultimately produced what the study authors hope is a manuscript that is useful and accessible to academics and non-academics alike.I am 48 years old and was diagnosed with hep C in 2003 or 2004. I fought so hard to be able to do hep C treatment. I had to travel all across Canada. I was denied treatment about four times because I was an active drug user and they all wanted me to be abstinent for like six months. I tried different treatment programs but never lasted. It took four years until I finally made it to Toronto and to a nurse who led me to the [Toronto Community Hep C] Program. I had been shot down so much by then I was basically scared of health care. I did not want go in and get rejected again just because I smoke a joint or do a smash or drink a beer. Once I found the program it was still about two and a half years before I could start treatment because they found out that I also have HIV. So I had to build myself up, my immune system, because it was the old system of interferon back then, so that made it a lot rougher. The treatment really sucked – I had a lot of puking, I lost hair, I was nauseous a lot. You were emotionally and physically all over the place on that stuff [interferon]. I could not give up on it though. I’d given up on too many things. Giving up on treatment would have meant giving up on myself.When I came to the program I was homeless, transient, all over the place. I was using drugs every day, all day. The program helped me find respite housing for a few months while I was on treatment and that really helped – so did the group, the camaraderie … and the meal! I got involved in the first Patient Advisory Board to help other people who were co-infected to access treatment, to stand up for other people in the community and to try to give everyone a voice in how they are treated – especially people who are marginalized. I was unsure at first about the peer training. I did not think I would ever get a job or even accepted into the training. But I wanted to try — to give back to the community and to myself.Right now one of the biggest parts of my job is running the weekly Continuing Care Group, for clients who have gone through the treatment or who are not eligible for treatment right now. It’s a place for people to come and socialize and get support – so they can stay engaged with health care and harm reduction education. For many people it’s the highlight of their day. I like giving back to the community – not being looked at as a burden. I love the challenge of this job. It’s constantly changing, the people are constantly changing. I do not get bored. Having the community look up to me … I have improved my own lifestyle, people take note of that. It does not come right away but it does happen.I am 50 years old — born and raised for the most part in Toronto. I was adopted as a newborn but the adoption broke down when I was six years old. Consequently, I grew up in child services, living in many different group homes located throughout Southern Ontario. I started using drugs at a very early age. I can't even remember exactly when. There was a period in my life where I was drug-free during which I went to school, became a nurse and moved to Arizona to practice. While in the States I began using drugs again, lost my license to practice, contracted hepatitis C, went to prison and was eventually deported back to Canada. Upon arriving back in Toronto I had no supports or people I could turn to so I found myself either living in shelters or on the street.I heard about the Toronto Community Hep C Program from my now husband as he knew someone who had been through it and who had received help applying for and obtaining disability benefits. This interested me since the more money I could get the more I would have for drugs. The TCHCP, of course, wanted to treat my hep C if I was eligible for treatment. Although treatment was not a priority for me, I decided to stay with the program and just kind of ‘went with the flow’ — partially because of the honorarium and the food provided at the weekly group but also because it was the one single thing that I did every week that was good. Everything else I was doing was not so good but this was something positive that I was doing for myself. As it turned out my fibrosis score was high enough (2-3) that I was eligible for treatment. This came as a bit of a shock since I really hadn't had hep C all that long, less than five years, and I wasn't a drinker. I was offered treatment and I thought: “Okay if you want to treat me, what the heck? Let’s do this.” I started treatment for the first time in the spring of 2011 (interferon and ribavarin) but was only a partial responder. The second go-round I was treated with interferon, ribavarin and telaprevir which had to be taken every eight hours and with 30 grams of fat. I just knew that there was no way I could do this particular treatment and still be using drugs. So I quit doing drugs. Thankfully my husband was very supportive and quit with me which made things easier. This time it took — it worked. I am now hep C free. I am blessed. I never felt stigmatized around hep C. Maybe because I didn't have it long enough. I felt stigmatized, more so, for being an injection drug user — specifically. Not just as a drug user, but an injection drug user. That is what I attempted to hide from others and made me feel shame ... not the drugs but the needles.I was encouraged to join the Patient Advisory Board, the PAB, and did so because I wanted to be more involved and give back to the program that played such a positive role in my life. There was also an honorarium for being on the PAB and every little bit helped in improving my quality of life so I thought, why not? I wanted to apply for the Community Support Worker training but I had lost a lot of confidence in myself. I made the application process into some huge, insurmountable barrier. In the end I applied but missed the deadline and was therefore not given one of the spots. Thankfully a spot opened up a couple of weeks into the training and I got in, completed and graduated. I wasn't sure I wanted the job as a Community Support Worker and was feeling a lot of ambivalence but applied because I felt it was expected of me. Left to my own devices I probably wouldn't have applied but I am so grateful that I was able to get out of my own way and that I did.My job as a Community Support Worker has changed a lot since I started. I used to help facilitate one of the treatment groups but now I mostly do hepatitis C education for new clients and training for other peer workers. I am driven by wanting to help people access treatment — to get as many people on treatment as possible. It's also a way for me to give back and stay humble. I'm not where I was when I started this journey and I need to remember this and stay grounded. This job, helping others, allows me to do that.Five primary themes emerged during our analysis of the facilitators and challenges in the transition from client to support worker: (1) the role of prior experiences, (2) changes in substance use practices, (3) shifts in relationships with community members and friends, (4) supportive organizational and structural factors, and (5) role transition as a journey. In some cases, key factors contained elements that were both facilitating and challenging.“I realized something the other day … I was a really good nurse because it’s very cut and dry and it has a start and it has an end and this work doesn’t have an end and it doesn’t really have a clear start either, you know what I mean? It’s fluid. Not that nursing cannot be fluid at times … here it’s never ending. It just doesn’t stop … I don’t think I am as good … yeah, I’m not a good social worker [laughs].” JenniferJennifer and Marty brought very different work histories to their role as CSW. Marty had worked primarily in a variety of non-office based labor jobs, and Jennifer had worked as a hospital-based nurse. While Jennifer felt that her past employment experience in a health care setting helped to prepare her for a successful transition to CSW, she also acknowledged that this work history may have also initially been a challenge as she had to unlearn some of the discipline she had been taught as a nurse before she could become comfortable in her new role.Both agreed that Marty’s varied and adaptive work history might have initially been more helpful for the ever-changing and intuitive work of a CSW.“ … I really realized that, yeah, I know a lot of the people coming into the program and a lot of people were looking up to me at the time because I had helped implement all these different programs [as part of the patient advisory board] and stuff so I figured, well hey, I might as well just keep going with it and see what happens.” MartyThroughout the interviews and when directly asked to identify what helps someone to successfully make the transition from client to worker, both also identified several personal qualities that they felt were key. Marty identified being non-judgmental, easygoing, and conflict avoidant as qualities he felt were important in his successful transition to peer work, while Jennifer identified her serious predisposition as contributing to her success. Both Marty and Jennifer identified as being “natural helpers” or leaders, partly because of some of these individual qualities but also because of their past experience as founding members of the program’s patient advisory board.“I didn't even really want the job. I didn't think it would last very long. I thought it would bring more turmoil in my life … Out of the six workers they hired I figured I would have been the first one gone … and I'm still here so I must be doing something right.” MartyDespite this natural tendency towards and experience with community leadership, both were initially reluctant to apply for the CSW role. Marty was hesitant because he felt it would further complicate his life.Jennifer had initial ambivalence about taking the job and felt motivated to pursue the position primarily out of feeling like program staff expected her to and had encouraged her to do so and because it was the “next step” in her engagement with the program.“There’s much better ways of doing … using drugs, so that’s how I practice. Drug, set, setting.”A change in illicit drug use was identified in both cases as facilitating success in the CSW role. For Jennifer, the transition to becoming a CSW was supported by a transition to abstinence from drugs, which was then reinforcing: “I think being a community support worker has; well it’s probably helped me to stay clean too.” Marty continues to use illicit drugs on a daily basis but notes that he uses differently now and that this has been important to his work as a CSW:“I just feel like, when are you going to get it? And I want them to get it and I get frustrated that they don't get it and there's nothing I can do about that; you know everybody comes to it in their own time.” JenniferThe lack of change in substance use practices of other clients was cited as a challenge. In both cases, concern was expressed regarding having to witness the potentially unhealthy substance use patterns (such as not having enough money left over for groceries after a period of binge use) of program clients, which produced feelings of frustration and anxiety.“I live in the neighbourhood where most of the people are and I still associate with a lot of them. That's been one of the trials and tribulations of this job — is knowing your boundaries, because even when I'm done work, you know, and I'm used to going out partying with these guys. I can't do that as much anymore cause they kind of look up at me as a role model up here or whatever. You want to call it right so I can't be going out there and getting in fights and stuff. I have to be able to walk away from things and even though it's not, I'm not at work I still have to practice that.” MartyBoth Jennifer and Marty felt that being able to identify, shift, and maintain new personal or community boundaries was critical to their success as peer workers. In both cases, establishing boundaries also meant making personal changes outside of work. For Marty, this centered mainly on his approach to drug use and conflict resolution:“I feel like the more clean time I have and the more my life has changed and progressed on from that [client stage of life], I feel like my buy-in is becoming … less.” JenniferFor Jennifer, the job was facilitated by establishing a physical boundary with a move to a new neighborhood. This move, which supported Jennifer’s decision to stop using drugs, was cited as reason for success in the role but was also identified as a challenge in terms of staying connected to the community and feeling “authentic” as a peer.Jennifer and Marty also cited that identifying and maintaining professional boundaries with clients is an ongoing challenge and area of potential risk. They discussed instances early in their employment where they had crossed a particular boundary without, but with the potential for, negative consequences. Both felt that their ability to critically self-reflect, take ownership of, and learn from these transgressions was key to their long-term success in the role.“… I love to teach, I really like teaching so [the job] changed in that way where they saw that I’m good at it, so I started doing more, like in the groups, like I would teach the Hep C 101.” JenniferSeveral organizational and structural factors were also identified throughout both interviews as key to the transition from client to peer worker. At an organizational level, the flexible parameters of the job responsibilities were cited by both Jennifer and Marty as important in their transition, allowing them to each find a niche that felt meaningful because it suited their strengths and interests. Having additional hours to attend team meetings and do administrative or program planning activities was also identified by both as a facilitator.“Having good bosses [helped with the transition], yeah and plus they were pretty lenient when I first started the job.” Marty“… I think it was kind of important, like finding that balance between being supportive … and the work expectations. So, you know, I think that’s for me the biggest thing and then just like stick with it because I think it takes time for people to start to feel comfortable in their roles and for people to take it on.” JenniferThe support and expectations of other program staff, specifically supervisors/managers and co-workers, was also identified. While the patience and lenience of these staff was noted as a facilitator, Jennifer and Marty also expressed the need for this to be balanced with some firm and high expectations. Both also strongly identified the need for sufficient time in the role as key to their transition.At a structural level, stable housing and the additional income provided by the position were also identified by both as important factors that contributed to their successful transition.“There’s no road map for it.” Jennifer“It was all just kind of gradual but everything has changed.” Marty“There was no big change besides getting treated … it was a big build-up to get on treatment and there was a big build-up afterwards to get my health back — energy levels and thinking.” Marty“There’s been lots of turning points. So, the first would be the fact that I came every week [to group] … getting onto [disability support] was a huge turning point … it allowed me to move, you know, to a better place. Coming to meetings regularly. Yeah that was probably the biggest and then, like, actually doing the Patient Advisory Board. That was probably a bit of a turning point too and then getting married of course was a huge turning point. Yeah, everything like progressively got better.” JenniferThroughout both interviews, numerous literal or symbolic journeys were identified. For Marty, attempting to access HCV treatment and arriving at the program itself was a literal journey that took him across Canada. For Jennifer, arriving at the program had also been the result of a literal journey, one of deportation from the United States. The job itself has been a metaphorical journey with its evolving tasks and responsibilities as both attempted to find a niche that felt meaningful within the role’s scope of practice. Both Jennifer and Marty have also undergone substantial transformational life journeys since becoming involved with the program—from unstable to stable living situations, from unstable to healthier relationships, and from unstable to stable patterns of drug use. Both Marty and Jennifer were homeless when they began with the program and each now lives in their own apartment. Jennifer is now married and Marty ended a difficult relationship. However, for both Jennifer and Marty, a more notable transition than that from client to worker was the personal transformation that each attributed to their experience of doing HCV treatment, from not being engaged in the program to being deeply engaged. Both experienced difficult treatment experiences and lengthy program engagement periods as clients during which they each made significant life changes. The client experience was itself a journey and was identified as a period of significant personal transition in each case.A goal of this study was to provide a better understanding of the factors that appear to be key in the successful transition from client to peer support worker. The role of past experiences, the ability to shift relationships and manage boundaries, a change in substance use, and organizational and structural supports were themes that were identified. In both cases, the transition from peer to worker was marked by a series of literal or metaphorical journeys. There was considerable overlap and interplay between these themes. For example, the flexibility of the CSW positions  allowed each worker to find a niche that suited their skills (past experiences). An understanding of the fluidity and complexity of these areas of facilitation and challenge is critical to improving the selection, training, and support of potential peer workers.Although both of the peer workers who were interviewed in this study identified being “natural leaders” as helping in their transition to peer work, there was little else in terms of past experiences or personal qualities that they identified in common other than an initial hesitation to pursue the job. Both had very different employment histories, from stable employment in a medical role to a varied job history of only non-office-based jobs. In terms of their substance use, they reflect different ends of the harm reduction continuum with one worker still using drugs and one who no longer does. This finding suggests that a supportive harm reduction philosophy that extends to employment expectations can be applied; that abstinence from drugs does not need to be a requirement for employment, and that substance use can be addressed, if and when it impacts on employment. The overall diversity of Jennifer and Marty’s past experiences and qualifications suggests that having broad eligibility criteria for peer positions is possible and that even seemingly unlikely and reluctant candidates should be encouraged, supported, and given opportunities to succeed.Examination of these peer workers’ experiences supports other studies which have discussed how peer work is supported or limited by organizational structures and suggests a need for flexible role parameters and/or programming , 45–47. Undergoing treatment and being cured of HCV was noted in both cases as a more significant transformative experience than the transformation from client to co-worker. Both workers described a lengthy role transition period. The lengthy program engagement that the old interferon-based HCV treatment required was likely a major factor impacting the transition from client to worker. In addition, both had been founding members of the program’s patient advisory board and were graduates of its peer training course. By the time both Jennifer and Marty began working as CSWs, they had already established a lengthy and deep commitment to the program and to their own personal well-being and self-development. This suggests that an organizational commitment to community development, capacity building for clients and their involvement in program development might support peer worker integration efforts; a finding that is supported by other studies of peer work models , 37, 48.Our findings represent only two individuals’ experiences with the transition from client to worker within a hepatitis C treatment program and may not be generalizable to other peer workers or contexts. This study may be limited by selection bias since only peer workers who were still employed by the program were selected and would be complemented by further research which explores why some individuals are not successful as peer workers; however, this was beyond our current scope. The fact that co-authors were in some cases co-workers might have limited what the author-participants felt comfortable saying. This may be particularly true regarding the co-worker dynamic that was not explored here, and yet is an important component of the peer work experience, which warrants further study. Validity was enhanced by involving the research participants themselves in the analysis and writing. The case study participatory design is meant to provide an in-depth evaluation to identify themes for hypothesis generation or further study. The richness of the case studies in our paper provides information and personal insights that would likely have been lost with other more traditional qualitative study designs.This study provides insight into the transition from client to support worker and offers some suggestions for how peer workers may be supported in similar programs. The transition was a gradual and non-linear process and one that was supported by and in turn helped to support a number of other personal transitions. The cases examined here suggest that a model of peer employment with broad qualification criteria, sufficient transition timelines, flexible job responsibilities, a solid investment in the inclusion of people with lived experience, and a harm reduction framework supported the successful integration of current and/or former clients into health care teams.


Healthy cities continuously attempt to improve residents’ health. Health is affected by psychological factors, such as happiness and emotions. Therefore, this study investigates the effects of healthy city program performance on individuals’ emotions, as well as the correlation between healthy city program performance and emotions using personal happiness index as a parameter. We conducted a questionnaire survey of residents in areas implementing healthy city projects. A total of 596 responses were obtained. We used structural equations to analyze the relationship of structural influences. Results showed that healthy city program performance had significant static effects on emotion. This observation shows that healthy city programs decrease local residents’ negative emotions, such as stress and depression. Therefore, healthy city programs stabilize residents’ emotions by increasing health friendliness. To improve the performance of healthy city programs, it is necessary to mitigate health risk factors and positively affect individuals’ emotions. The healthy city paradigm was introduced in the 21st century to improve mortality and quality of life based on New Public Health. The idea of healthy cities was introduced by the World Health Organization (WHO) in 1984 to promote healthy cities and communities; Ottawa was selected as the target of the first healthy cities project .A healthy city program links a city’s living conditions with the citizens’ health and considers health promotion as a basic unit of the community. Healthy cities should lead local communities to participate in local governments and strive to improve the cities’ health and structure. A healthy city program is conducted by a local government based on the assumption that the local government’s interest in the health of the local residents actually improves the health status of the residents.Healthy city programs include healthy urban environment projects, healthy living space projects, healthy living practices, and health services. Healthy urban environment projects include ecological river restoration, fine dust concentration improvement, active bicycle use, water quality inspection visit services, and healthy town developments. Healthy living space projects include maternal and child health programs, youth health promotion programs, elderly welfare projects, healthy home-building projects, multicultural family visiting education, school meal services, child food safety management, healthy and safe school management, and disease-free longevity classes. There are alcohol prevention education programs, smoking cessation clinics, revitalization of life sports, and child health experience classrooms as healthy life practices. The programs that strengthen health services include Cardiopulmonary Resuscitation (CPR) training, prevention and management of atopic diseases, internal correction projects, mental health programs, vaccination businesses, and suicide prevention projects.A healthy city program is a project operated by individual local governments. Therefore, it is mainly operated by the health promotion departments in welfare centers and healthy city teams within the local governments. As part of their initiatives, these programs encourage the participation of all residents of an area in conducting projects to build healthy cities. As a result, healthy city programs can be found in living environments in the community, such as in medical and sports facilities.Evaluation of healthy cities is necessary to determine whether the activities of local governments have achieved significant improvements in city health. The optimal state of a healthy city includes public policy-making with the participation of local society members. To induce long-term changes in local society, a healthy environment must be established and society’s ability to solve health-related problems should be continuously improved. The process of development into a healthy city is determined crucially by the local government’s leadership and will to change. New policies, programs, services, or resources under local leadership change the city’s environment and can improve the level of health in local society. Evaluation is also necessary to promote participation and cooperation of society members and to establish a rationale for promoting the healthy city program ,5.Happiness is a variable that expresses a positive mindset and includes both physical and psychological health. Therefore, health and happiness are correlated. The human body perceives happiness as good health, which further reduces pathological symptoms and risk of disease. Psychological variables play a more important role than external variables on health, with internal variables greatly affecting subjective health levels. Subjective welfare, which refers to self-evaluation of one’s satisfaction with life and emotional state, has a strong causal correlation with health and mortality. When individuals experience depressed or joyful moods, they perceive a decrease or increase, respectively, in their quality of life ,7,8. BecIndividual emotional state and physical health in daily activities are known to be closely correlated. Individuals with high emotional perception are less affected by stress than individuals with lower emotional perception. Furthermore, they are protected from negative emotions that can lead to depression and suicidal ideation . DepressHealth is directly affected by psychological factors, such as happiness and emotions. As healthy city program performance improves, the emotional stability of local residents is expected to increase. The present study investigated the effects of healthy city program performance on individuals’ emotions and the correlation between healthy city program performance and emotions using personal happiness index as a parameter. The results could indicate the ideal direction for healthy city programs to follow and important variables for further improving program performance.This study’s objective was to qualitatively define the correlation between a healthy city program’s performance and the local residents’ emotions using personal happiness index as a parameter. The healthy city program performance was used as an independent variable and emotional effects were used as dependent variables. Personal happiness index was defined as a parameter between healthy city program performance and emotions. As previously discussed, psychological variables are closely correlated to health, and the happiness index, which reflects individual psychological state, ultimately affects the emotions. Therefore, the study design assumed that the healthy city program’s ultimate goal was improvement in local residents’ psychological health. The research model is illustrated in Healthy city programs seek to enhance individual health through social, cultural, and economic development. The concept of the healthy city program is based on health benefits obtained from one’s environment. Because healthy city programs require the participation of personnel from different areas, the evaluation process is complex. Duhl (1992)  suggesteHealth promotion refers to active, positive participation of individuals in disease treatment and management to improve or maintain their health. Not only does this improve physical health, it also has positive effects on psychological health, such as decreased depression . EmotionHealth promotion that protects the health status and prevents the occurrence of health problems in an individual’s daily life can contribute to the emotional stability of human beings. The practice of health promotion positively affects emotional influences such as quality of life, psychological well-being, as well as physical health. Performing certain activities for improvement of health can provide a sense of security to local residents’ emotions. Some of the health promotion programs in the healthy city programs include drug addiction treatment, drinking and smoking cessation, and urban development for citizens’ emotional stability. In this way, a healthy city program has a positive effect on the emotions of the local residents because it eliminates negative physical and mental factors.Happiness is known to be correlated with quality of life, life satisfaction, and subjective stability. An individual who subjectively feels positive emotions due to appropriate experiences is defined as happy . HappineEdmundo et al. 1995) emphasized the importance of healthy city programs’ institutional indicators as an evaluative tool . Kegler  emphasizThe personal happiness index parameter was developed using both psychological and socioeconomic variables. To subjectively measure happiness and diagnose psychiatric diseases such as depression or mania, the classification used in study by Lyubomirsky et al. (1999) was modified and Oxford Happiness Questionnaire (OHQ) was developed. Of the psychological variables, stability, health status, interpersonal relations, and residence with family were adopted. These tools were modified to fit the local society’s healthy cities ,26. The The dependent variable of emotion was evaluated using a depression evaluation survey developed by William et al. (1965). This self-evaluation survey for depression comprises items based on patients diagnosed with depression . DepressThe criteria for selection of survey sites were as follows: First, the selection was based on cities that were affiliated with the Korea Healthy Cities Partnership (KHCP) among the local governments promoting healthy city programs. Second, we conducted a survey on the local governments whose healthy city programs were associated with the KHCP. Healthy city programs in Korea are focused on health promotion programs and healthy living environments. Therefore, based on these criteria, we selected the local governments that were actively conducting healthy city programs. Third, in order to compare the results of regional healthy city programs, we divided the cities into metropolitan, independent, and countryside cities. A metropolitan city is a city that is the center of politics, economy, and culture. It is considered to have a population of over 500,000 people. An independent city is a city that integrates cities and counties and refers to cities with a population of over 50,000 people. Countryside cities refer to the eup and myeon areas. The specific analysis targets for metropolitan cities was Seoul; for independent cities, Yongin City, Gyeonggi-do, Changwon, Gyeongsangnam-do; for countryside cities were Yangpyeong County, Gyeonggi-do, Jincheon County, Chungcheongbuk-do, and Buyeo County, Chungcheongnam-do. In Seoul, 22 out of 25 boroughs have healthy city programs. In addition, they are centered on businesses such as healthy town and school developments. Therefore, we selected Seoul, which as compared to other metropolitan cities has the most active healthy city programs. In Yongin City, Gyeonggi-do, there are active discussions with citizens on the development of policies related to healthy cities that citizens can positively participate in. Changwon, Gyeongsangnam-do, was selected as an example of favorable health policies in 2016. In Changwon City, a healthy city program is being implemented through citizen-centered living environment creation. The representative healthy city program in Yangpyeong County, Gyeonggi-do is a physical fitness promotion campaign. To this end, the physical education facilities have been expanded to provide a place for citizens to enjoy sports. The improvement of living conditions and the provision of services for the community will address urban inequality. In addition, social infrastructure will facilitate the provision of health services. In fact, Yangpyeong County increased its population by 30.99% through the revitalization of health businesses including the establishment of healing health support centers . In the On- and off-line surveys were conducted for local residents in selected areas. The selected subjects were public officials in charge of healthy city programs, related organizations, medical facility workers, and local residents. For diversity of the sample, the experts of the healthy cities were included and the selection criteria included those living in the healthy city program areas. The survey targets were appropriately selected according to age, sex, and residential areas. There are many healthy city programs in Korea. Among them, a survey was conducted on local residents who were part of health promotion programs dealing with issues such as obesity, smoking, and improving living habits, and projects such as creation of villages and parks as part of healthy living areas. Offline surveys were conducted in metropolitan cities from 25 September to 10 October 2017. A total of 200 questionnaires were distributed and 196 (98.0%) questionnaires were collected. In the independent and countryside cities, online surveys were conducted from 14 to 17 August, 2018. Each of the 250 questionnaires were distributed, and 200 questionnaires were retrieved (80%) from the independent cities and 200 (80%) from the countryside. The survey was conducted focusing on the subjects involved in healthy city programs and a total of 596 questionnaires were collected and used for analysis.In a previous research design, only Seoul, which has the largest number of local governments participating in the healthy city programs, was selected as the research target. However, the results of the healthy city programs varied depending on the policies of the different local governments of the healthy cities. Therefore, healthy city program performance was compared by region and further analyzed by adding independent and countryside cities to the research targets.(1)The general characteristics of the survey subjects were calculated as frequency and percentage.(2)Factor analysis was conducted to verify the validity of healthy city program performance, personal happiness index, and emotional influences, and its reliability was verified.(3)t-test was conducted to compare the difference in regional healthy city program performance, individual happiness index, and emotional effects.An independent sample (4)A structural model was used to analyze the structural impact of the performance of the healthy city program on emotions through the Amos Program.The collected data were analyzed using SPSS 25.0  and Amos 18.0 programs . The analysis method was as follows:The participants’ demographics are shown in α was used to confirm the reliability and validity of each variable. A value of 0.6 or higher is regarded as reliable. α values were satisfactory, at 0.6 or higher.Cronbach’s Confirmative factor analysis was used to confirm the study’s validity. One of the six items from healthy city program performance, two of the nine items from personal happiness index, and two of the nine items from emotional effects had mean factor loading values below the cutoff of 0.5. Therefore, these items were excluded, and only the satisfactory items were included in the analysis. Discriminant validity was evaluated by comparing the average variance extracted value and the squared correlation values. Because the squared value of the latent variables’ correlation values was less than the average variance extracted value, discriminant validity was confirmed.t-test was performed to analyze the differences between metropolitan cities, independent cities, and the countryside.In Korea, there is a discrepancy in health levels between different regions. The effect of the city environment on individuals’ health has been discussed as a cause for this. A city’s shape, landscape use, public transportation, and proximity to major facilities significantly affect local residents’ obesity; stress; and walking, cycling, and physical activity habits. It is highly probable that healthy city program performance, personal happiness index, and emotional effects differ according to city type. Therefore, a First, the mean difference between metropolitan cities and the countryside was analyzed. The results showed significant differences between metropolitan cities and the countryside . CountryThe mean difference between metropolitan and independent cities was then analyzed. The results showed significant differences between metropolitan and independent cities . SimilarResults of analysis of the model in this study are shown in β = 0.298, C.R. = 6.966, p < 0.001). In contrast, personal happiness index showed significant negative effects on emotions . The path coefficients of each study model showed that emotions have significant static effects on healthy city program performance . Therefore, personal happiness index acts as partial mediator between healthy city program performance and emotions.To determine the significance of indirect effects, the bootstrapping method was used. Healthy city program performance was observed to have significant indirect effects on emotions using personal happiness index as a parameter (This study investigated the structural effects of healthy city program performance on local residents’ emotions and the personal happiness index parameter. The subjects of the study were residents of metropolitan cities, independent cities, and countryside regions participating in healthy city programs. Metropolitan city residents were selected from Seoul, as local autonomous districts in Seoul are actively conducting healthy city programs.First, we compared the mean static effects of healthy city program performance, personal happiness index, and emotional effects in different regions. The results showed that healthy city program performance, personal happiness index, and emotional effects were all higher in countryside regions and independent cities than in metropolitan cities. In metropolitan cities, highly developed transportation results in limited walking in daily life. Additionally, a crowded environment results in increased stress and irregular eating habits, leading to decreased physical activity and unhealthy diet. Metropolitan cities thus demonstrated relatively lower healthy city program performance ,35. In tStructural equations were used to analyze the structural effects and correlation between healthy city program performance, personal happiness index, and emotions. The results showed that healthy city program performance and emotions were significant when personal happiness index was used as a parameter. Specifically, healthy city program performance had significant static effects on emotion. In other words, the results of the healthy city programs seem to have positively influenced the emotions of local residents. Healthy cities want to alleviate their physical, social, and emotional problems through health promotion activities rather than treating them. Therefore, the results of the performance of healthy city programs seem to have stabilized the emotions of local residents. This shows that healthy city programs decrease local residents’ negative emotions, such as stress and depression . ApproprIn addition, as healthy city program performance improve, personal happiness index increases. This result coincides with a previous study’s results reporting that subjective welfare affects life satisfaction and improves personal happiness index . HappineFinally, the parameter effects of personal happiness index on healthy city program performance and emotions were investigated. Healthy city program performance had negative effects on emotion using personal happiness index as a parameter. The sources and definition of happiness and motivation differ based on individuals’ daily life experiences. Financial security, good family relationships, and social relationships are thought to bring happiness to an individual. However, this is not the case for all. Some individuals feel happiness in response to a comfortable life, whereas others do not. Furthermore, individuals can feel happiness and pride in one month and despair in the next. These observations are due to the fact that subjective happiness differs greatly based on setting and time . HappineThis study confirmed the structural correlation between healthy city program performance, personal happiness index, and emotions. The following efforts are necessary to improve healthy city program performance. First, healthy city programs should be designed according to the region’s size and environment. Emphasis should be placed on healthy city activities centered in residence areas and welfare facilities and services based on the city’s size. The goal of a healthy city program is to allow residents to carry out every aspect of their lives. Health promotion also improves physical, psychological, and social health by preventing, treating, and rehabilitating disease . Health-Second, healthy city programs should be continuously managed through policy amplification. Currently, many local governments conduct healthy city programs. However, passive operation is observed in many cases. A healthy city program is a realization of political will, a long-term project that coexists with the city. Short-term healthy city program planning should be avoided . In KoreThird, continuous and systematic monitoring of healthy city programs is necessary. Currently, most local governments lack effective program development and management. Haphazard program development results in unnecessary programs or discontinuation of activities. Additionally, because healthy cities require cooperation between city components, different departments are connected by a network. Healthy city teams have been formed, but these participate only in health promotion departments in welfare centers. Based on the healthy city program’s characteristics, the welfare center should act as the center of the program. However, welfare centers lack authority in Korea, and cannot effectively lead healthy city programs. The promotion of health programs in Korea started in 1999 as a demonstration of health-promotion-based welfare centers in 12 places. Subsequently, in 2002, this was expanded into 100 welfare centers covering 4 areas which include smoking and drinking cessation, exercise, nutrition, and health practices, and now health promotion programs are being carried out in public welfare centers across the country. Healthy cities consist of area-based health promotion programs that are part of the general health care policy. The implementation of healthy city programs may overlap with the policies implemented by public welfare centers. If a healthy city program is conducted centering on public welfare centers, ongoing monitoring can be achieved. Welfare center-based healthy city programs should be developed and monitored using a network of different departments. This would be helpful in determining health-promoting variables in local residents and would allow for effective management of healthy city programs. The limitations of this study are as follows. First, we failed to analyze the healthy city programs’ performance over time. Healthy city programs are divided into short, medium, and long term depending on the time limits of the program. Therefore, in future research, it is necessary to analyze the effects of the results of the healthy city programs on the local residents by dividing the results into short, medium, and long term. Second, there is no comparative analysis between the regions where healthy city programs are implemented and those where they are not. If a healthy city program has a positive effect on the local residents’ emotions, there will be a difference in the emotions of the residents in the areas where healthy city programs are not implemented. Therefore, it is necessary to analyze the influence of the healthy city programs through analyzing the emotional effects and individual happiness index of the residents in the areas where healthy city programs are enforced and areas where such programs are not implemented.


Interprofessional education (IPE) is a critical component of medical education and is affected by the characteristics of the clinical teams in which students and residents train. However, clinical teams are often shaped by professional silos and hierarchies which may hinder interprofessional collaborative practice (IPCP). Narrative medicine, a branch of health humanities that focuses on close reading, reflective writing, and sharing in groups, could be an innovative approach for improving IPE and IPCP. In this report, we describe the structure, feasibility, and a process-oriented program evaluation of a narrative medicine program implemented in interprofessional team meetings in three academic primary care clinics. Program evaluation revealed that a year-long narrative medicine program with modest monthly exposure was feasible in academic clinical settings. Staff members expressed engagement and acceptability as well as support for ongoing implementation. Program success required administrative buy-in and sustainability may require staff training in narrative medicine.The online version of this article (10.1007/s40037-019-0497-2) contains supplementary material, which is available to authorized users. Interprofessional education (IPE) is a critical component of medical education that prepares trainees to work effectively in healthcare teams. Academic primary care clinics are sites where robust interprofessional coordination is needed to deliver high quality care; they are also settings where much fundamental medical student and resident education takes place . HoweverNarrative approaches to clinical care, with their focus on allowing space for the diverse voices on interprofessional teams, have the potential to improve interprofessional education and collaborative practice (IPECP) . NarratiWe implemented a narrative medicine program in academic primary care clinics with the long-term goals of improving interprofessional communication and relationships. In this report, we focus on: 1) description of the program structure, 2) barriers and catalysts to program implementation, and 3) process-oriented program evaluation.We implemented a 1-year (April 2016 to March 2017) narrative medicine program in three New York Presbyterian Hospital academic primary care clinics that serve as training sites for medical students and resident physicians in family medicine, internal medicine and paediatrics.We met with clinic leaders before implementation to discuss how narrative medicine might improve teamwork; given shared interest in team development, leaders allotted 30 minutes during monthly required interprofessional team meetings for narrative medicine sessions. In this paper, ‘staff’ refers to attending physicians, resident physicians, nurses, medical assistants, social workers, administrators, and many other clinic personnel. Staff were required to attend the narrative medicine sessions but could opt out of program evaluation. The program evaluation was approved by the Institutional Review Board at the Columbia University Irving Medical Center (protocol # AAAP1351). The work was carried out in accordance with the Declaration of Helsinki including, but not limited to, there being no potential harm to participants, that the anonymity of participants was guaranteed, and that informed consent of participants was obtained.Each 30-minute session consisted of four stages: engaging with a creative work, writing to a prompt, sharing writing in pairs, and sharing writing in a large group . Table 1Evaluation data were derived from: 1) observation notes from narrative medicine sessions by either TC, FJ, or AK; 2) longitudinal semi-structured individual interviews with interprofessional staff from each clinical site at program start, midpoint, and end conducted by either DB, UD or MM ; and 3) 12-question questionnaire exploring barriers and catalysts to participation, and staff’s overall reactions to the program.We used a general inductive approach for qualitative analysis, which asks, ‘What are the core meanings evident in the text, relevant to evaluation objectives?’ –15. DG aOver a 1-year period, 36 narrative medicine sessions took place at three clinics. We analyzed 32 observation notes and 33 interview transcripts. Fifty out of the 104 unique staff members who attended the sessions during the year completed an end-of-program questionnaire. The questionnaire respondents across sites included 14% attending physicians, 16% resident physicians , 26% nurses and nurse practitioners, 16% medical assistants, and 28% other staff. Medical students were not involved in program evaluation. Age was reported by 45 respondents; 47% of respondents were less than 40-years-old and 53% were 40-years-old and over. Average duration of employment was 7.3 years (median 6 years and range 4 months to 23 years).Observation notes and attendance sheets indicated that sessions were attended by an average of 11 staff (82% women and 18% men). Session composition was 21% attending physicians, 9% resident physicians , 11% nurses and nurse practitioners, 12% medical assistants, and 47% other staff. One or two medical students on their primary care clerkship participated at some sessions at the family medicine site. Fifty-six percent (28/50) of staff surveyed at program conclusion reported they had attended over half the offered sessions.We observed that staff participated actively during each of the four stages of the narrative medicine sessions. While exploring creative works (Stage 1), staff actively commented on works and listened and responded to others’ observations. Staff remained open to differing viewpoints on creative works. When asked to write to a prompt (Stage 2), staff wrote attentively and without hesitation. Many continued writing, even after a call was made to stop and reconstitute the larger group. When sharing writing in pairs (Stage 3), staff members sat closely and leaned in to listen to one another. We commonly observed laughter and sometimes witnessed expressions of sadness during sharing of writing. During Stage 4, staff routinely volunteered to read their writing to the group, and other staff listened closely and responded to the reading. Staff sometimes stayed after the conclusion of the session to continue conversations.Based on questionnaires, 94% of staff (47/50) indicated that they would recommend the narrative medicine program to other clinics and 74% (37/50) of staff reported they would continue participating in the program even if it were optional and offered during their free time (before/after clinic or during lunch).One program participant recalled that at program start, some were hesitant to ‘share personal information,’ particularly with staff from different professions. Despite this initial hesitation, staff actively engaged in the sessions and explored personal stories that often invoked strong emotional responses from both reader and listener . This occurred during both pair-sharing and group-sharing; as the year-long program progressed, sharing of personal stories sometimes occurred even earlier in the session during discussion of the creative work.We observed that the participation in discussion and sharing during sessions was distributed evenly across professions and hierarchy. Several staff members stated that one of the most striking aspects of the program was the communication that opened up across professions and levels of hierarchy that had not occurred with other prior team-building activities at the clinic. Indeed, 40% (20/50) of respondents rated the program’s ability to facilitate interprofessional dialogue as excellent, 26% (13/50) rated it as very good, and 24% (12/50) rated it as good. One staff member said, ‘The best thing I think about narrative medicine … is that it really involved everyone.’ In an interview, a staff member noted that the conversations that occurred at the sessions allowed staff to ‘take our hats off’ and ‘really get to know one another on a different level’.Staff most frequently expressed time constraints and the pull of clinical duties as barriers to program success. A staff member said, ‘I think the activity is great. It’s just, where do we carve out the time that doesn’t affect access for patients?’ Thus, buy-in and support from clinic leaders appeared crucial to program success. Support took the form of protecting time for the meetings, arranging coverage for clinical duties, and clinical leaders’ attendance at sessions. At one clinic, leaders even delayed clinic start time by 30 min with a corresponding reduction in patient load to accommodate the sessions.This process-oriented program evaluation revealed that a year-long narrative medicine program with modest monthly exposure was successfully implemented in academic clinical settings, as evidenced by staff member engagement and acceptability. Staff members expressed positive regard for the program and supported its ongoing implementation.Although attendance was required, staff were engaged during sessions and quickly took part in activities. Narrative medicine methods are designed to encourage exploration of one’s personal and professional life. Thus, emotions such as joy and sadness were explored and openly expressed during sessions, in keeping with a recognition that the expression of emotions may be important for clinical care and IPCP , 17. SucIn interviews, staff felt that personal connections made across professions and levels of hierarchy were particularly striking. One staff member said that the sessions allowed ‘the whole care team’ to ‘just talk to each other like human beings.’ This points to the potential of art and literature to serve as a democratizing space where persons can gather to explore life experiences as relative equals . Indeed,We report a narrative medicine program that serves as a feasible model for implementing health humanities in clinical settings. The program’s feasibility was reliant on support from clinic leaders and the availability of a facilitator trained in narrative medicine. Sustainability was not an objective of the project, but it is notable that only the paediatrics clinic, led by a physician with narrative medicine experience, continued monthly narrative medicine activities for an additional year. Staff in that clinic expressed interest in further narrative medicine training. Future narrative medicine interventions will attend to staff training to achieve sustainability. Short, intensive facilitator training programs are under development by the program team to maintain quality while allowing wider dissemination.Narrative medicine has the potential to improve IPCP by strengthening interprofessional communication and relationships while softening clinical hierarchies; this, in turn, could enhance IPE through positive modelling of interprofessional teamwork. With feasibility and acceptability established in this report, the team’s next steps will focus on more rigorous evaluation of narrative medicine’s impact on outcomes relevant to IPCP such as communication, hierarchy, cohesion, and clinically situated behaviours, in addition to the impact on trainees’ behaviours and attitudes. A limitation of this report is that the number and duration of sessions needed to achieve and sustain benefits of narrative medicine programs remains unknown; this will also be investigated in future work. Finally, research in narrative medicine will increasingly strive to measure patient-oriented outcomes such as patient satisfaction, clinical processes, and clinical outcomes.12 Session Narrative Medicine Program: Texts, Writing Prompts and Resources