To describe the healthcare provider (HCP) experience of launching a COVID-19 remote patient monitoring (CRPM) program during the global COVID-19 pandemic.We conducted qualitative, semi-structured interviews with eight HCPs involved in deploying the CRPM pilot program in the Military Health System (MHS) from June to December 2020. Interviews were audio recorded, transcribed, and analyzed thematically using an inductive approach. We then deductively mapped themes from interviews to the updated Consolidated Framework for Implementation Research (CFIR).We identified the following main themes mapped to CFIR domains listed in parentheses: external and internal environments (outer and inner settings), processes around implementation (implementation process domain), the right people , and program characteristics (innovation domain). Participants believed that buy-in from leadership and HCPs was critical for successful program implementation. HCP participants showed qualities of clinical champions and believed in the CRPM program.The MHS deployed a successful remote patient monitoring pilot program during the global COVID-19 pandemic. HCPs found the CRPM program and the technology enabling the program to be acceptable, feasible, and usable. HCP participants exhibited characteristics of clinical champions. Leadership engagement was the most often-cited key factor for successful program implementation. LawmakeThe COVID-19 remote patient monitoring (CRPM) pilot program implemented within the Military Health System (MHS) in the United States was an example of a highly successful virtual care program .1.2.The MHS is one the most complex and largest healthcare systems in the United States that is tasked to deliver healthcare services to almost 10 million uniformed service members, military retirees, and families . The DefBefore the COVID-19 pandemic, the MHS had some capabilities for telehealth . These cThe pilot proposal was approved, and the Virtual Medical Center launched a CRPM program in May 2020. Military treatment facilities  were given information about the pilot program and invited to participate if they could show HCP buy-in by providing one lead physician and one lead nurse to run the project at their facility. The pilot phase of CRPM began in August 2020 with 10 participating MTFs from all three military services  across the United States, enrolling patients hospitalized by COVID-19 infection. From March 2021, additional populations, including post-surgical and acute medical patients, were also enrolled in the CRPM program. The data collection period of the CRPM pilot program ran from 7 June 2020 to 7 December 2020.1.3.The MHS chose the Current Health platform for their virtual care program  after undergoing a rigorous market analysis and vetting process. The Current Health platform enables healthcare organizations to deliver healthcare services at home for different clinical conditions  and acuity levels. It includes an FDA-cleared small, round, wearable device worn on the upper arm and integrated peripherals to monitor vital signs  . It incoWe conducted a qualitative study, interviewing personnel involved with developing and implementing the CRPM pilot program to understand the participant experience of deploying the program and what might have made it a success.1.4.DHTs offer substantial opportunities to improve clinical care, research, and public health. They can give HCPs a more holistic and longitudinal view of a patient's health trajectory and patients more control and understanding of their own health . From diDigital health has a broad scope and according to the FDA includes “categories such as mobile health , health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine” . DHTs utWhile HCPs and patients have given high scores for the perceived usefulness and ease of use of wearable sensors that provide continuous monitoring , DHTs br1.5.Implementing change, whether involving DHTs or not, can take considerable resources . Many anKey factors associated with successful program implementation are explored, described, expanded on, and defined in the updated Consolidated Framework for Implementation Research (CFIR)  which pr1.6.1.Understand the processes involved in operationalizing and using the CRPM pilot program.2.Explore feasibility, acceptability, and usability of the CRPM pilot program among HCPs.3.Explore barriers and facilitators of deploying an RPM program during the global COVID-19 pandemic.The overall objective of this qualitative study was to explore the experience of HCPs in launching the CRPM program. Our research objectives were to:2.2.1.Our population of interest included HCPs (inclusive of their administrators) who helped stand-up and deploy the CRPM pilot program rolled out to hospitals within the MHS between June and December 2020. Interviews took place between November 2021 and March 2022. We used information power  to guideParticipants were initially recruited from collaborators within MHS and thereafter from interviewees themselves using a convenience and snowball sampling strategy . Twenty-Participants that agreed to an interview were remotely consented. They could sign the informed consent form ahead of speaking with the researcher or go over it at the start of the call. They could opt out of audio recording the interview, but none chose this option.2.2.Based on previous experience developing interviews for understanding engagement with digital technology and exposure to the CFIR  and the JP had an email communication with two participants who invited her and the Current Health research team to conduct this qualitative study. These communications were for ensuring that correct protocol was followed through study setup. There was no relationship established between the remaining six participants prior to study commencement. All participants knew that JP was a research scientist employed by Current Health. At the time of the study, JP was a Senior Clinical Research Scientist at Current Health. She has over 10 years of experience conducting interviews for mixed-methods and qualitative research, holds a DrPH and MPH in epidemiology, and is a female.2.3.Participant interviews were recorded using a laptop application  and a handheld digital recorder as a backup. Interviews were anonymized and transcribed using a third-party transcription service. This transcription was then checked by the researcher that conducted the interviews (JP) using Trint software  when necessary. If there were any words or phrases that were unintelligible to the researcher (JP), a second researcher (JLT) checked the audio. In this way, the transcribed data were rigorously assessed for accuracy. Familiarization with the data began at this early stage. JLT was an employee of Current Health at the time the study was conducted. No field notes were made, no repeat interviews were conducted, and no transcripts were returned to participants for review or comment. However, participants were available to answer questions about their interview after it took place.2.4.JP coded the data using QSR International NVivo Qualitative Data Analysis Software version 12 . The dat3.We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for reporting results  . “Nurse lead” was defined as a leadership role, either within the CRPM program or in their department.We identified and explored in-depth the following themes: internal and external environments, processes around implementation, the right people, and program characteristics. We mapped these themes to the updated CFIR domains and constructs, and these results are presented in 3.1.This theme relates to the updated CFIR constructs of local conditions and policies and laws, set within the outer setting domain . These tAt the time [preparing for COVID], we didn't have anything. The remote patient monitoring capabilities we had were very rudimentary.Nurse LeadI think remote monitored programs had been tried before, but there just hadn’t been any incentive to do it or the need.PhysicianThe CARES Act allowed us to be able…to do a very rapid funding request and get that approved, literally in a matter of weeks, which is unheard of, to ask for multimillion-dollar contracts and be able to actually keep those within the period of several weeks.PhysicianCOVID-19 was such a significant disruptor; it set in motion the political will  to drive requirements for care (policies and laws). Once the requirements were in place, the processes and solutions developed around them.A requirement makes people have to do it, and then actually it can help drive the resources to support it.PhysicianThere were organizational characteristics identified by participants that affected the implementation of the CRPM pilot program. The lead MTF was one of the largest military medical centers in the Department of Defense, had army leadership, and was a tri-service facility, meaning that they had army, navy, and air force personnel. Participants said that within the MHS, risk was generally not well-tolerated and communication could be a major issue because of the size of the organization.3.2.The CFIR describes the implementation process domain as the “activities and strategies used to implement the innovation” , 42 whic3.2.1.The planning and creation stages involved identifying problems and solutions in the earliest stages of program development and deployment. One participant shared an anecdote about the COVID-19 surges that were headed their way based on what the world had seen in Italy and New York. He had a contact with the Chief of Infectious Disease at a major academic medical center in New York who agreed to talk with him about lessons learned, and it was this conversation that got him thinking about an RPM platform as a possible solution. Another participant recounted a colleague asking whether there were any technological solutions to help with the approach of a COVID-19 surge. Participants also knew that they needed to plan for adequate staffing.I think it was probably around April of 2020 right after COVID-19 started spreading across Europe, the Chief of Pulmonary/Critical Care Medicine…came to me and said, ‘You know, we’ve seen what's happening in Europe and Italy right now, ICUs are becoming overwhelmed with patients. Do we have any type of technology or capability where we can keep patients out of the hospital to thereby prevent the spread of infection internally to the organization and to protect these patients who don’t have it from getting it if they’re immunocompromised?’ Basically, how can we keep patients in their homes, decrease the need for staffing and open up bedspace for those who really need to be in the hospital?Nurse LeadJust having talked to a couple of the military treatment facilities that were interested in participating, we knew that if we asked them to provide organic nursing support to monitor their patients that it was doomed to fail.Nurse Lead3.2.2.Leadership sought buy-in from HCPs within MTFs that could act as clinical champions for the CRPM pilot program as well as from the individuals responsible for integrating the CRPM pilot program into the hospital workflow. Training was also used to ensure competence and engagement in the innovation deliverers. All training was virtually conducted because the pandemic made in-person training untenable. However, there was equipment onsite so staff could see it and handle it in-person, and this was an important part of feeling comfortable and engaged with the technology.Our actual training was fairly fast. When we had meetings, we were in person, and we were able to touch and feel and kind of play with the mechanisms of the Current Health kit.Nurse3.2.3.Besides training, HCPs acknowledged that it took some time to recognize how to efficiently run the CRPM pilot program. Nurses and physicians had to reassess their roles and interactions in the virtual environment. Learnings, problems, and solutions were discussed in regular meetings with CRPM project leads, and issues that arose were shared with leadership.The nurses seemed to be trained well to kind of know when to start reaching out to us [physicians], vs. me just kind of…looking at the data, and saying, ‘okay, what am I seeing?’. But that just became inefficient, and so I started relying more and more on the nurses, to start highlighting important stuff.PhysicianIn the first month, when only a handful of patients had been enrolled in the CRPM pilot program, the teams involved had an opportunity to see the Current Health technology and implementation teams in action and began gaining confidence that the system was working.We had two or three patients that the nurses were monitoring at home and felt that they were decompensating and got them back to a facility to make sure that they were getting care and what they needed. So, I think that validated that the technology works and that our nurses understood what their role was, to make sure that if the patient was decompensating, we had a good mechanism in place to get them the care that was necessary to prevent further decompensation.Nurse Lead3.3.The CFIR identifies many types of roles within the individuals domain that contribute to successful program implementation. For example, the innovation deliverers deploy the innovation to recipients known as innovation recipients. There are also constructs for leaders with varying levels of authority, decision-making capabilities, and informal influence. Implementation leads are individuals who lead the innovation implementation and can also be thought of as clinical champions. The CFIR goes onto categorize characteristics of roles into (1) need , (2) capability (the knowledge and competence to fulfill the role), (3) opportunity (the power and scope to fulfill the role), and (4) motivation  .Participants talked about HCP and leadership qualities that contributed to successful implementation of the CRPM pilot program. These qualities included enthusiasm for and belief in the program  and an ability to anticipate problems, manage expectations, and persist through them (capability). Finding the right people came up repeatedly in interviews as one of the most important factors associated with implementation. Participants spoke about finding (a) the right HCPs or innovation deliverers to deliver new programs using new technology and the right industry partners to collaborate with, (b) engagement and support from leaders and champions, and (c) the right patients or innovation recipients to be enrolled in the CRPM program. Qualities and characteristics of these “right people” are explored in more detail below and linked to CFIR constructs explained above.3.3.1.Enthusiasm for the CRPM pilot program and innovation was evident in all participant interviews (motivation). They brought into the pilot's proof of concept and believed in the technology as a solution for both current and future patients and healthcare settings (need). They believed that CH helped them “complete the mission” by providing the right “constellation of capability” in caring for patients.I think what has been unique about Current Health is that it's integrated not just real-time by physiologic monitoring—or near real time—but also the ability to pair that with devices which add collateral information…And then at the most acute level, be able to facilitate video communication in real time with the patient. So, that kind of constellation of capability.PhysicianIt was clear that HCP participants deeply cared for their patients and had patient needs in mind while designing this program (motivation). They felt that the Current Health platform allowed them to improve their primary objective of improving the patient experience. The technology allowed them to help a broader range of patients, providing them with a safety net and allowing the patient to feel empowered by being more involved in their own care. This sense of purpose was coupled with an ability to persevere through the growing pains of implementation (capability).I'm able to really help a broader range of people… And overall, our goal is always to help more people. We're able to get them the help that they need and get them back into the hospital faster than they probably ever would have in an emergency, be their safety blanket and help their anxiety. I mean, that peace of mind goes a long way. So we had to go back…there were times that we had to go back to the drawing board and say, ‘okay…you can’t see this, let's try doing it this way.’Nurse3.4.3.4.1.Participants talked about leadership engagement and the implementation climate at MHS. They all agreed that leadership buy-in was critically important. Furthermore, the leadership included HCPs in discussions around the CRPM program development and implementation from the earliest stages. This in turn facilitated acceptance from the HCPs creating a collaborative environment that supported the emergence of clinical champions (implementation leads).What was great about this was our leadership actually asked the nurses what we thought about, what we could do better or how we should do it…So I think we all played a crucial role in giving our two cents as far as the set-up process and the process itself of getting this thing going, because I don't think we had anything really to go off of. We were the first to ever get this done.NurseA key part of successful program implementation was finding clinical champions to lead, build, and communicate. Clinical champions are a known critical component of successful program implementation and can be mapped to implementation leads in the updated CFIR. These implementation leads were baked into the process of implementing the CRPM pilot program.There was an agreement that if an MTF [military treatment facility] was going to participate they had to provide one lead provider and one lead nurse to run the project at their facility, and that was critical because we knew again that if we didn't have physician and nursing buy-in to support this at the functional and leadership level, that it was not going to be successful.Nurse LeadThis participant went on to explain that while they were contracting for the technology  and the nursing staff, they simultaneously formed a clinical working group . He said that one person took the lead on this because of his extensive connections in pulmonary departments across facilities (opportunity). Other participants identified leads that made a tremendous contribution to the CRPM pilot program implementation and saw them as critical to the program's success.He was amazing. He is the biggest cheerleader for Current Health. He thought of everything, and he really pushed it out and really just got providers excited and let them know the potential that remote patient monitoring could bring to better patient outcomes.NurseFor an intervention as complex as the CRPM pilot program, there were a huge number of variables that affected success. When something went wrong, was it the technology, the HCPs using the technology, or the patients using the technology? This puzzle of possibilities necessitated a strong partnership with the company providing the CH platform and technology. Participants talked about the qualities and characteristics of their CH colleagues that factored into program implementation which track with the CFIR characteristics subdomain constructs. Current Health innovation deliverers were seen as being quick to respond to requests , being open and receptive to feedback (motivation), wanting to make improvements (motivation), and always putting the patient first  that were identified as important qualities in CH colleagues.Any time we had a ticket put in for any tech issues, regardless of whether or not our patients had COVID, I mean [CH] staff was pretty much on it. They responded quickly…and we appreciate that. The consistency is very much appreciated, especially in an unknown time, and the COVID itself is stressful on the patient coming home and being at the hospital is stressful enough.NurseI think the best part of it was [CH had] a really good team that wants to make sure that our patients are safe and that we can always keep an eye on the patients.Nurse3.5.At the beginning of the deployment, the type of patient enrolled into CRPM could not require high levels of care and in fact needed to be well enough that they were close to discharge and did not require nurse visits at home. However, they also had to be willing to use the CH kit. While many patients were thrilled to be able to recuperate at home and have the security of an HCP watching over their vital signs, there were some limiting factors. One of the limiting factors around participation was the patient's willingness to engage with technology, and this could vary based on age, clinical condition, or support from more technologically savvy family members. The hurdle of the initial setup could be challenging at a time when a patient was feeling ill and vulnerable. In other words, a patient's capability and motivation were important factors around program adoption .A lot of the older folks would look at that jumble of wires and would immediately just become scared…And you'd tell them, you've got an iPhone in your hand. If you have an iPhone in your hand, and you know how to plug something into a wall, you can do this, I promise you can do it. Some people would refuse to do it after they'd looked at the equipment and say this is going to be too complicated for me.Nurse Lead3.6.The innovation domain in the updated CFIR focuses on factors related to the intervention or thing being implemented, in other words, the innovation. Innovation adaptability reflects the extent to which the innovation was able to be modified or tailored to fit the local context. Innovation relative advantage reflects whether the innovation is better than other alternatives or current practice. Innovation cost and innovation design are about the innovation's affordability and how well it is packaged, assembled, and presented. In line with these CFIR constructs, the CRPM pilot program was adaptable and could be integrated with current workflow (innovation adaptability), had relative advantage over the status quo (innovation relative advantage), showed return on investment (innovation cost), and could be learned quickly and easily (innovation design).The CRPM pilot program implemented by the MHS was viewed by participants as an innovative and cutting-edge approach to handling the increase in patient volume caused by COVID-19. Many spoke about the problems that already existed around access to healthcare and saw that RPM and hospital at-home programs, which have seen enormous growth during the COVID-19 pandemic, become part of the healthcare landscape.We're really pushing the envelope, not just within our own community, but this was the first time that we were doing this within a military facility, but we were doing it really kind of at the leading edge of what was even being done in civilian medicine.PhysicianThe CRPM pilot program showed that it had innovation adaptability, as it was repurposed for new sites, new use cases, and new staffing capabilities. It was successfully incorporated into a facility's existing workflow. Adaptability is one of the reasons the CRPM pilot program was able to be used across different MTFs and branches of the military and later for different use cases like COPD or heart failure.…it [CH platform] incorporates with the current platforms that we have… new technology can be incorporated into the current workflow.HCP AdministratorNo one in the DOD [Department of Defense] was set up to use this [Current Health platform] and I think that multiple people in military treatment facilities came up with their own way of, ‘this is how we’re going to deliver the devices, these are the types of population of patients we’re going to use it on.’Nurse LeadThe adaptability of alarm thresholds proved critical to the program's success. HCPs were alerted if a patient's vital signs went out of pre-set parameters, setting in motion a chain of events ranging from calling the patient to asking the patient to go into a hospital or clinic or initiating emergency responses. Those alarming thresholds were initially set more conservatively than was recommended by medical personnel from Current Health. One participant talked about the consequences of this decision, why they took the course of action they did, and the subsequent decision to return to recommended thresholds.I think we've all become very used to and very good at looking at the alarm system…I do think we were very conservative, meaning that we were very generous and had wide alarm rates… But we felt at least at first, that was the right way to go and to over-activate and we certainly did over-activate. And we've seen that that went down pretty quickly from our nurses [laughs], that they were being…basically burdened with alarm fatigue as a result of the distinction.Nurseoutside the hospital which was better than current practice (innovation relative advantage). There is a real advantage to seeing trends in patient data vs. spot checks that makes RPM a part of healthcare that gives a more holistic view of a patient's health.One of the strongest reasons for implementing the CRPM pilot program was that it offered a substantial and essential relative advantage over keeping patients in the hospital (unfeasible during the pandemic) or only having intermittent vital signs data if patients were sent home (dangerous if a patient quickly decompensated). It did this by providing continuous monitoring I think the biggest thing is, I've learned a snapshot of vital signs is not necessarily a good indicator of how the patient is truly doing or even just what the patient is reporting is not always the best indicator of what is actually happening.Nurse…we needed to be able to provide a safety net for patients that were being discharged from the medical, surgical environment during…COVID. We needed a way to monitor those patients to make sure that they were okay, and that they didn't have a recurrence of symptoms or worsening of symptoms. And we needed to be able to move them out quicker. And this [CH platform] allowed us to do that.Physiciandespite providing remote care but because of providing remote care.One unanticipated finding of this study found that nurses reported an improved sense of connection with their patients (innovation relative advantage), not Honestly, I would tell them this is by far the most engagement that I feel like I've had with patients…and so for a lot of us, we went into nursing because of education, and this gives us that opportunity to do that, and then some.NurseA major factor in any intervention will be its cost and return on investment (innovation cost). The MHS was collecting data to understand return on investment and cost savings of the CRPM pilot program and CH platform.…we were still able to show a significant return on investment within the first month of it going live. I mean, we were decreasing in-patient bed days, we were keeping patients out of the ER, we were reducing readmissions, we were decreasing average length of stay, you know?Nurse LeadAnother key characteristic that was vital to success was the ability for HCP users to quickly learn the technology and continue to use it with ease. Learning new DHT can be time-consuming for HCPs, but these participants reported that the Current Health platform was easy to learn and use (innovation design). This required the CH platform and kit to be well designed and easy to assemble and present.It was pretty intuitive for the information that was being provided, it was just a matter of figuring out how it was organized, and what the interface could do.Physician4.We explored HCP experiences in launching a COVID-19 remote patient monitoring pilot program during a global pandemic. Guided by our research objectives and the CFIR framework, we asked about processes, feasibility, acceptability, usability, barriers, and facilitators in implementing virtual healthcare with new technology during a stressful time. While understanding how HCPs dealt with these changes, we also wanted to understand what made this program successful .4.1.The creators of the CRPM pilot program took a multilevel approach and considered the individual-, departmental-, institutional-, and national-level factors at play which is supported in the literature as being essential for program success . While pNot only did the CRPM program developers seek buy-in from their stakeholders and HCP users but made sure that they did this at the earliest stages of development . Sharma As the program was implemented, all eight participants talked about the various ways that outcomes, success, and patient satisfaction were monitored. They spent a good amount of time planning the implementation and engaging stakeholders and were in a regular state of reflecting and evaluating implementation and program success, all CFIR constructs shown to be associated with high success implementations . They weAnother key aspect of successful implementation processes is the close and early collaboration between the technology developers and clinicians . Partici4.2.The CRPM pilot program and CH platform were adaptable, relatively advantageous to the status quo, and able to integrate with current workflow and hospital technology, were quickly learned and easily used, and showed return on investment as early as the first month of deployment. Relative advantage is a construct shown to be associated with a high level of success implementations . OverallParticipants also believed that the CH kit was feasible, acceptable, and usable for most of their patients, the innovation recipients. Patients were overall pleased to be able to recover from home while being monitored and having the security of HCP eyes on their health status. However, there were some patients that were daunted by the technology, and there were times HCPs had to troubleshoot and identify family members or friends of the patient that could offer support for CH kit utilization once the patient was discharged.The most surprising aspect of this research was that HCPs reported an enhanced sense of connection because of the CH platform and not simply despite it. From the nurses' points of view, this made them more interested in CRPM program involvement. There is some evidence that mHealth apps can have a positive effect on the patient–provider relationship , 58, and4.3.Interestingly, while the COVID-19 pandemic made many things so much harder, it was frequently cited as the main catalyst for creating and sustaining the CRPM pilot program. Many participants believed that had COVID-19 not happened, they would not have had the funding, opportunity, or leadership drive to make it happen. COVID-19 meant that traditional methods for patient care were not up to the task of caring for the surge in patient volume. Finding solutions became a worldwide necessity as evidenced by the removal of regulatory barriers around virtual care and telehealth .The MHS is large, mature, and composed of semi-autonomous departments and, as a result, would be predicted to assimilate innovations more readily , 62. BecIt was clear that study participants felt valued within this organization and supported through the work of creating and implementing the CRPM pilot program. Feedback loops between leadership, physicians, and nurses were reported by everyone, and HCP users most “on the ground” had feelings of ownership and pride for the work they were doing. Every participant strongly believed that leadership buy-in and top–down support was one of the key factors that was critical to successful program implementation. Indeed, leadership engagement, cross-boundary working relationships, and innovation-related communications have been shown to be associated with high implementation innovations .While we did not set out to explore anything specifically around the concept of clinical champions, it was clear from the beginning of the interview process that we were in fact dealing with clinicians that fit the definition of implementation leaders or “clinical champions.” Identifying whether a program has a clear clinical champion or not is a key activity of assessing the implementation process . ParticiBeyond acknowledging that champions were important for implementation, participants spoke about the qualities of these “right people,” e.g., champions as well as HCPs. Broadly speaking, the characteristics and behaviors of clinical champions can be condensed into three main factors: expressing enthusiasm and confidence about the success of the innovation or program, persisting under adversity, and getting the right people involved , 67. TheParticipants were clear about the program goals and managed expectations around the inevitable wrinkles that were part of deployment.Barriers to adoption of DHTs by HCPs can mainly be categorized into technical factors around security, individual factors around technology literacy, and health systems factors such as economics and policies . In line4.4.While this research involved a military population in the United States, the main recommendations and learnings  are not 5.6.Like many studies involving in-depth interviews, the sample was restricted to participants that were willing and able to grant an interview. A military setting can make it difficult to secure interviews as active-duty military have duty assignments away from home or move jobs more frequently than a civilian population. The nurses involved in the CRPM pilot program were not active duty, however, but contracted out and that also could make it difficult to connect with possible interviewees. This was likely one reason that we had eight participants out of the 24 invitations we sent to individuals. Four of those invitations were for an MTF that did not allow HCPs to participate in this research. This could mean that the participants willing to respond to our requests for interview had more positive feelings about the CRPM program than individuals that did not respond, and indeed, our participants were all directly involved with implementing the CRPM pilot program. However, we had access to two participants that helped develop this study and assisted with finding interviewees. Because of this, we know that even though we could not secure interviews with some individuals invited for interview, they nonetheless were champions of the CRPM program.Our methodology could have been strengthened by designing follow-up with our participants to validate our interview schedule. However, recruiting HCPs or other busy professionals is very challenging , 70. We The study had a good balance of nurses and physicians and one HCP administrator, and we believe that we had reasonable information power  though o7.Finding a way to make the technology unintimidating to patients that may otherwise struggle with technology will further reduce health disparities associated with access to this type of care. One of our most interesting and unanticipated findings was that in this pilot program DHT enhanced a sense of connection with patients as reported by HCPs. We believe that future research could focus on what aspects of the CH platform contributed to this enhanced connection and whether patients experience this as well. Intuitively, the research team believed that technology could feel cold and that being remotely monitored might reduce a sense of connection as it surely reduced face-to-face contact in this intervention. There may be more to learn about the kind of care an HCP delivers via DHTs and what kind of “website manner” leads to better connection .8.We sought to understand the HCP experience of launching a successful continuous RPM program during the global COVID-19 pandemic. The CRPM pilot program and CH platform were found to be acceptable, feasible, and usable. HCP participants showed the qualities of enthusiasm, persistence with problem-solving and expectation management, ability to involve the right people in the CRPM pilot, and a belief in the CRPM program. Leadership buy-in was the most often-cited key factor for successful program implementation.


In 2016, two consecutive moderate magnitude earthquakes occurred in Ulsan, South Korea. Therefore, we aimed to investigate the impact of earthquakes on the mental health of residents in Ulsan.We used data from the 2015–2017 Korean Health Insurance Review & Assessment Service National Patient Sample. We conducted an interrupted time series analysis using location-based controls. Changes in the number of antidepressants, benzodiazepines, and zolpidem prescriptions in Ulsan were compared to controls. Overall changes in weekly prescriptions 1 year after the first earthquake, compared to a non-earthquake scenario, were estimated.In antidepressant prescriptions, the increase in trend after an earthquake was significantly higher than controls. However, the changes in benzodiazepines and zolpidem prescribing were not significant. Overall, the impact of the earthquake on weekly antidepressant prescriptions at 1 year was estimated as a 1.32  rate ratio compared to the non-earthquake scenario. This corresponded to an increase of 1,989.7  in the number of prescriptions. Among subgroups, the increase was highest among males aged 20–39 years.The moderate earthquake in Ulsan was associated with an increase in antidepressant prescriptions. The increase in the male group aged 20–39 was the highest. The impact may vary according to the context of the population. On July 5, 2016, a 5.0-magnitude earthquake occurred 52 km east of Ulsan. In Ulsan, this earthquake had an intensity of IV on the Modified Mercalli Intensity scale (MMI). After 2 months, a 5.8-magnitude earthquake, with an MMI scale of V, occurred approximately 25 km northwest of Ulsan. To date, these remain the most powerful earthquakes in Korean history. A total of 23 residents from Ulsan and nearby regions were hospitalized, and four of them were Ulsan residents. No fatalities were reported. The earthquakes mainly caused property damage, resulting in 5,664 houses and about 10 million dollars’ worth of properties being affected. Some regions suffered from the aftermath of the earthquakes, such as plummeting tourism based on the fear of earthquakes. Moreover, misleading information was spread through social media, and there was fear that more severe earthquakes would strike shortly thereafter.2–4 Moreover, several risk factors for mental health problems (including gender and age) have been studied.2,5,6 Although previous studies have focused on major earthquakes (those with a magnitude ≥6)2–6 and the number of victims is incomparable even with moderate magnitude,7 they have suggested that loss of properties, house damage, and low economic status are associated with mental health problems.2,5 This suggests that even non-fatal moderate earthquakes can negatively affect mental health. Thus, we conducted research to investigate the impact of moderate magnitude earthquakes on residents’ mental health in Ulsan.The impact of earthquakes on mental health is widely known. Earthquake victims are vulnerable to several mental health problems, such as posttraumatic stress disorder (PTSD) and depression.Due to the nature of natural disasters, it is difficult to precisely estimate their impact on mental health. Earthquakes have an impact on the residents in the regions extensively; thus, it is difficult to recruit representative samples for entire regions. Similarly, it is difficult to recruit control groups, which are essential for causal estimates. To deal with these challenges, we used nationally representative healthcare data with a controlled interrupted time series (CITS) model.8 In an interrupted time series model, the difference in observed and expected values is estimated. Expected values are estimated based on the pre-existing trend and represent the ‘counterfactual’ values that could have been observed if the events did not happen. Thus, the difference in observed and expected values after an event translates to the effects of the event. The differences can be modeled with various measures, such as level and trend changes. ITS analysis is used in wide ranges of studies, such as in public health interventions at the national level9,10 or for research on natural disasters.11,12 However, the ITS can be biased with time-varying confounders, which occur concurrently with interventions. By comparing the changes with relevant controls, CITS can estimates unbiased effects of event.13 In this way, we aimed to investigate the impact of earthquakes on the mental health of people in Ulsan.The interrupted time series (ITS) model has been used for studies wherein randomization is not feasible.14 The HIRA-NPS was constructed via the stratified sampling of 3% of all patients using national health insurance-covered medical services over 1 year (approximately 1.4 million patients). We applied the weights in the analysis according to this sampling strategy.We used data from the 2015–2017 Korean Health Insurance Review & Assessment Service - National Patient Sample (HIRA-NPS). The validity and reliability of this sample have been previously established.The Korean National Health Insurance is a single-payer system, so the HIRA-NPS represents the whole population in Korea. The HIRA-NPS contains the basic demographic information of the patients, such as gender and age, as well as information on the medical services provided, including drug prescriptions. Furthermore, the HIRA-NPS provided information on the location of medical institutions where patients were prescribed medications. Using this information, we identified the study population.The regional distribution and magnitude of the analyzed earthquakes are represented in Figure r = 0.99; P < 0.001). Therefore, it was almost impossible to analyze the effects of the earthquakes separately. Moreover, although the second earthquake’s MMI scale was higher, the fitness of the model was better when it was modeled based on that Ulsan residents were affected by the first earthquake. The consistency of our results was tested via sensitivity analysis by defining the event differently.We assumed that Ulsan residents were affected, as the first earthquake struck the region on July 5, 2016. Both earthquakes occurred within a short period (2 months); the correlation of time from events was 0.99  struck near Ulsan. The pre-earthquake period was defined as long as the post-earthquake period (497 days). Hence, the starting date for the pre-earthquake period was set to February 24, 2015.13 According to the administrative divisions in Korea, Ulsan is classified as a metropolitan city (Gwangyeoksi). A metropolitan city constitutes the upper level of local autonomy in Korea. The population of a metropolitan city, which is highly developed city, is at least one million. Therefore, the controls were selected from other metropolitan cities.We used location-based controls.There are five other metropolitan cities in Korea. Of these, Daejeon, Gwangju, and Incheon were outside the impact radius of the two earthquakes. The earthquakes did not have sufficient magnitude to affect these cities during the follow-up period either Figure . Gwangju11,15,16 Benzodiazepines and zolpidem cover most of the anxiolytics and hypnotic/sedative medications prescribed in Korea.17 The prescription of each medication was identified according to the Anatomical Therapeutic Chemical code .Sensitivity analyses were performed. First, other metropolitan cities  were used as controls. Second, to verify that prescriptions in control regions were not affected by the earthquake, we performed single ITS with control regions. Third, we assumed that Ulsan residents were affected since the second earthquake, on September 12, 2016. Fourth, since January 1, 2017, permission for antidepressant prescriptions was partially extended. Before 2017, non-psychiatrist physicians were prohibited from prescribing antidepressants for more than 2 months.The study protocol was approved by the institutional review board of the Jaseng Hospital of Korean Medicine (JASENG 2021-06-003) and followed relevant guidelines. The requirement to obtain participants’ informed consent was waived by the institutional review board.The number of psychotropic medication prescriptions during study periods is presented in Table P-value of interaction <0.001). Considering both genders and all age groups, the RR was highest among men aged 20–39 years , followed by men aged 40–59 years  and results were generally consistent in subgroups see . The oveWe found that the earthquakes in Ulsan were associated with an increase in antidepressant prescriptions. After the first earthquake, an increased trend in weekly antidepressant prescriptions was observed in both CITS and ITS. Overall, the impact of the earthquakes on weekly antidepressant prescription rates 1 year later was estimated as RR 1.32. The impact of the earthquakes varied according to sex and age, being worst among men aged 20–39 years.2–4,7,19 In Korea, two surveys were conducted for residents who experienced similar-scale earthquakes in other regions20,21; however, due to their design, the representativeness of their sample was restricted and no controls were recruited. In this study, we used a nationally representative Korean sample. Further, we conducted a controlled interrupted time series analysis for causal estimates.To the best of our knowledge, this study is the most robust evidence of the impact of moderate magnitude earthquakes on mental health. The magnitudes and numbers of victims analyzed in previous studies are not comparable to those of the Ulsan earthquake.15 studied the impact of the Sewol ferry disaster, in which 304 of 476 passengers were reported missing or deceased and measured the changes in psychotropic medication prescriptions in Ansan, Korea, where many of the victims lived. The antidepressant prescription rates increased after the disaster; however, rates of prescription for anxiolytics and hypnotic/sedatives did not. The authors claimed that this result might be related to benzodiazepine-related public policies in Korea. The inappropriate usage of benzodiazepine has been an issue in Korea. The most frequent inappropriate prescription among older adults in Korea was benzodiazepine.22 Also, there have been numerous studies investigating possible adverse events associated with benzodiazepine use in Korea.23,24 Due to this problem, the Korean government introduced several measures to reduce benzodiazepine prescriptions; for example, prescribing periods of benzodiazepines are restricted (<30 days per 1 prescription). There has been a slight decrease from 2009 to 2013.25 Also, since October 1, 2015, the drug utilization review (DUR) was implemented. The Ministry of Food and Drug Safety in South Korea introduced DUR to suppress the prescription of tricyclic antidepressants and long-acting benzodiazepine use in older adults aged 65 years or more. Under the DUR system, prescribers receive real-time caution messages on their computer if they prescribe inappropriate medications to outpatients aged 65 years or more. The message warns about possible adverse events and suggests that these medications should be administered in low doses.26 These policies might have prevented the increase in benzodiazepines. However, we have no clear explanation for these results yet.However, the increase in benzodiazepines was not significant and level change in zolpidem lacked robustness. In a previous study investigating the impact of disasters on mental health in Korea, the results were similar. Han, Kim, Lee, Lee, Ko and Paik2,4 this does not reduce our findings’ generalizability.We were unable to analyze the additional effects of the second earthquake on September 12, 2016, because both earthquakes occurred so closely in time. Although the results became clearer when our model was based on that the residents were affected since the second earthquake, this does not mean that we analyzed the impact of the second earthquake separately. Considering that the damage of the second earthquake was more severe than that of the first, it would seem likely that the second earthquake aggravated the impact of the first. However, we do not think this possibility is a limitation. Since both earthquakes occurred consecutively, they can be considered as one event. Moreover, given that previous disasters have also occurred in quick succession,2,5,6 In contrast, some of our findings were consistent with previous studies, where younger and middle-aged people were more vulnerable than older individuals.6,27,28 This may be attributable to the economic burdens on the working-age population.6 Also, in the case of other disasters, economic crises, such as recessions, have been known to negatively affect the male population’s mental health.29–31 Accordingly, this may explain why the earthquakes had a greater impact on males. Ulsan is a manufacturing-oriented society. The proportion of males among the economically active population in Ulsan is the highest among the metropolitan areas in Korea.32 As mentioned, the earthquakes mainly affected the economy; houses and properties were damaged and tourism in nearby regions suffered due to the fear of earthquakes .1 Consequently, the economy in Ulsan and the adjacent areas was also negatively affected. Thus, it can be assumed that the ensuing economic burden might be stressful to the working population, which is mainly composed of males. However, the data used in this study did not include the economic status of the patients, so this aspect should be explored in future studies.The results of the subgroup analysis contrasted with those of previous studies. The antidepressant prescription rates increased most among men aged 20–39 years. In previous studies, women have been reported to be more vulnerable to earthquakes’ effects on mental health.1 and this media exposure may have negatively affected mental health.33 For example, in the case of the Sichuan earthquake in 2008, frequent exposure to images of the disaster was associated with a higher likelihood of PTSD.34 Similar cases have been reported for terrorism35 and pandemics.36 Moreover, rumors on social media can exaggerate the threat and increase mental stress.37 Our results indicated that the prescription rate increased significantly in the 20–39 age group, who are frequently exposed to social media. Thus, media coverage of the earthquakes might have attributed to the results; however, further studies are needed.Media influence might have aggravated the effects of the earthquakes on mental health. After the events, there were rumors and speculation that more severe earthquakes that would quickly follow. Images of the disaster and unverified theories were spread through social media,38–40 Moreover, it takes only an hour by car to reach Ulsan from Gyeongju city, where the residents also suffered from earthquake damage. Thus, Ulsan represents damage to both Ulsan and the nearby regions.As to the generalizability of our findings, the following characteristics of Ulsan should be considered. Ulsan is a highly developed industrial city. Further, its prescription rates for psychotropic medications were relatively lower than those of other metropolitan cities. These characteristics could affect attempts to generalize our findings. For example, if earthquakes of equivalent magnitude occur in different regions with a greater number of economically underdeveloped residents and patients with mental diseases, the impact might be more severe. On the other hand, considering the more prominent medical infrastructure in Ulsan compared to neighboring regions, it can be assumed that patients from nearby regions traveled to Ulsan for medical purposes. Visiting bigger cities for healthcare utilization happens frequently in Korea.41,42 Moreover, psychotropic medications, such as antidepressants, are prescribed for a variety of conditions, not only for depression and PTSD but also for pain management.43,44 Thus, even if the patients exhibited mental health issues, it is likely that some of them were prescribed psychotropic medications under different diagnosis. Therefore, we concluded that investigating overall prescription rates would be appropriate in the present design. These limitations should be investigated in further studies.The major limitation of this study is that we did not analyze the incidence of mental diseases, which is the primary indicator of mental health. Moreover, we did not analyze the diseases for which the psychotropic medications were prescribed. In Korea, there is a significant social stigma attached to mental disease, a tendency that varies according to sex and age.26 However, DUR was implemented in both Ulsan and controls and total antidepressant prescription was on the rise despite the DUR implementation. Thus, it seems that DUR had little effect on our results. Second, since January 1, 2017, restriction on antidepressant prescriptions was eased for patients with cerebrovascular disease, epilepsy, dementia, or Parkinson’s disease. Our sensitivity analysis indicates that the results are robust regardless of the policy change.We believe that our results are robust despite some major events regarding antidepressant prescriptions in South Korea. First, as explained above, the DUR was implemented on October 1, 2015. DUR aimed to suppress the prescription of tricyclic antidepressants in older adults aged 65 years or more.In conclusion, the moderate magnitude earthquakes that occurred in Ulsan, South Korea in 2016 were associated with an increase in antidepressant prescriptions, especially among men aged 20–39. The impact of the earthquake may vary according to the context of the population.


Our results show that participating in the peer worker training program significantly decreased depression and internalized HIV stigma, and significantly increased self-esteem, medication adherence, and patient self-advocacy. The study underscores that peer worker training programs are important tools to improve not only the work readiness of PLHIV, but also psychosocial and health outcomes. Implications for HIV service providers and stakeholders are discussed.Targeted work readiness training is an important approach to help people living with HIV (PLHIV) to overcome their unique barriers to work, while addressing social determinants of health needs. This study assesses the psychosocial impacts of a work readiness training and internship program among HIV peer workers in New York City. From 2014 through 2018, 137 PLHIV completed the training program, and 55 individuals completed both the training and the six-month peer internship. Depression, HIV internalized stigma, self-esteem, HIV medication adherence, patient self-advocacy, and safer sex communication apprehension were used as outcome measures. Paired  Due to medical advancements, an HIV diagnosis has changed from a terminal illness to a chronic illness and emergent disability ,2. DespiPeer workers  are those who have lived experiences and who work in the healthcare or social service industries ,10. PeerOver the past two decades, peer interventions have become more structured and the roles of peer workers have become more formalized. State and national certifications have been created. Starting in 2007, states with peer certification processes could bill Medicaid for peer delivered behavioral health services and, in 2014, states could bill for health and wellness services . As a reEmployment has been recognized as an important social determinant of health, which has significant associations on the health and wellness of PLHIV. Employment impacts a variety of factors related to financial and life stability, including earned income, access to healthcare, access to housing, and social connectedness; these factors directly or indirectly influence individuals’ health, wellbeing, and quality of life. Maulsby et al. conducted a scoping review study on employment and HIV and found that employment status is associated with HIV continuum of care outcomes, including HIV testing, linkage-to-care, retention-in-care, and medication adherence . StudiesMeanwhile, individuals who have undesirable employment outcomes (job loss and underemployment) often experience negative prevention and health outcomes, such as an increased risk for drug and alcohol use, and developing psychological problems. The quality of employment  also has an impact on the physical and mental well-being of PLHIV . For exaGoldblum and Kohlenberg developed the client-focused considering work model, which is the first model to conceptualize factors and processes associated with considering the work of PLHIV . ConyersVocational development and intervention programs are aimed at helping people re-enter or enter the workforce through structurally based techniques. Conyers and Boomer examined the relationship between the receipt of vocational rehabilitation services and health and prevention outcomes for PLHIV . The stuSince the introduction of highly active antiretroviral therapy (HAART), a variety of evaluation articles on US-based vocational development programs for PLHIV have been published ,49,50,51In program development and evaluation, mediators are the variables a program aims to directly impact, which in turn influence the program’s overall projected outcomes ,58,59. ITo this end, our research question was: were there any significant changes in participants’ psychosocial outcomes  and health-related behavioral outcomes  between baseline, targeted work readiness peer worker training program completion, and peer internship completion. The authors aimed to understand not only the impact of the peer worker training program, but also the additive effects of participating in both the peer worker training program and the peer internship.This study involved a retrospective secondary data analysis of an evaluation conducted between 2014 and 2018 of a work readiness HIV peer worker training and peer internship program. The purpose of the study was to examine the psychosocial and health related behavioral outcomes among 259 individuals living with HIV that participated in the peer worker training program. This was the first longitudinal evaluation efforts of this peer worker training program.This New York City-based peer worker was a comprehensive eight-week training that took place three days a week from 10 am to 4 pm. Training. The training evaluated in this paper was developed by Alliance for Positive Change in the mid-1990s as a foundational peer worker training and later used to help prepare individuals to take state recognized certificate peer trainings, such as NYS HIV peer certification training. The training was called: Peer Recovery Education Program, PREP, and will be entering its 60th cycle of training in 2023. To qualify for the training, individuals must have been diagnosed with HIV, at-risk for HIV, or had close relationships with PLHIV. HIV-positive participants were required to adhere to their HIV medications, compliant with primary care physician appointments, stably housed, and in recovery from drugs and alcohol for at least nine months. The training program focused on work readiness skills necessary to become health educators and patient navigators. Participants learned HIV service skills such as prevention education, presentation skills, treatment techniques, medical advocacy, and outreach and counseling techniques. Participants received training in HIV-related knowledge and its common co-infections, Hepatitis C, STIs, safer sex, substance use, and harm reduction. Participants also learned self-management skills related to, and unrelated to their HIV, such as medication adherence, safer sex skills, medical advocacy, communication skills, and stress management. The following soft skills were learned and applied: getting to work on time, following a set schedule, speaking in a group, getting along with others, and dressing appropriately. Each training cohort involved 25–40 trainees. Lastly, individuals were mandated to participate in weekly support groups.After completing the peer worker training, participants were eligible to apply to enter the peer internship program. The peer internship program functioned in six-month cycles, starting each January and July, and employed approximately 125–150 peer interns at any given time. Interns received an internship placement within the agency and participated in mentor guidance and weekly peer support groups. Participants gained work experience and applied skills learned in their foundational training course. Peers were involved in various direct and indirect HIV service positions, such as medical navigation, food and nutrition services, counseling and testing services, and education and support group facilitation. Depending on the peer placement and the type of public benefits received, a peer worked 10–20 hours a week and earned $15 per hour, up to $1300 each month. Approximately ten agency-trained participants and five other agency-trained participants were hired each cycle. New hires were based on current program needs and available positions. This work met the internship requirements for the New York State HIV peer worker certification.The training curriculum provided participants with self-management skills and experiences aimed at impacting specific types of self-esteem. Morris Rosenberg, the author of the most widely used scale to assess self-esteem  believes that there are two types of self-esteem: global self-esteem or how a person feels about themselves overall, and specific self-esteem, how someone appraises a specific part of themselves . The proFrom September 2014 through December 2018, nine cohorts of training participants were followed through the end of their six-month internship. This study evaluated survey results from participants living with HIV. To meet the eligibility criteria, individuals had to be medically adherent, stably housed, and in recovery for at least nine months for the peer worker training program and twelve months for internship. Through an application and interview process, staff at the agency decided who would become part of the peer worker training program and who would continue as a paid peer intern. People who did not reach program milestones (completion of the training program and 6 months of internship) were not followed. The study was part of an ongoing program evaluation of an agency’s peer worker training and peer internship program. A secondary dataset was used. The inventories selected for the agency’s peer psychosocial and health survey were grounded in the program’s logic model. A description of the survey inventories is provided below. Study participants took part in the peer psychosocial and health survey at three different time points: Time 1) baseline (first day of peer worker training); Time 2) training completion ; and Time 3) peer internship (sixth month of their peer internship). Informed consent was provided with each survey. Participants were informed that the survey would be utilized to evaluate the training and peer program. Participants entered and completed the peer worker training program and internship at different time points. Specific numbers for each cohort is listed in A total of 259 individuals completed a baseline survey. A total of 67 individuals completed a baseline survey only (baseline only group), 137 completed a baseline and training follow-up survey (training group), and 55 individuals completed a baseline, training follow-up, and internship follow-up survey (internship group). The following domains were measured in this study: (1) sociodemographic characteristics ; (2) time since any form of employment; (3) HIV/AIDS status and health indicators ; (4) public benefits received ; (5) psychosocial outcomes ; and (6) health-related behavioral outcomes . The psychosocial outcomes measured were informed by the program’s logic model and specific inventories were identified from the literature; inventory descriptions are found below.Depression. Two inventories were utilized to measure depression during the data collection period, the Beck’s Depression Inventory was utilized from September 2014 through May 2015 (cohorts 1 and 2) and the Patient Health Questionnaire (PHQ-9) from July 2015 through December 2018 (cohorts 3 through 9) [rough 9) . The resrough 9) ,61. The The Beck’s Depression Inventory (BDI) was used with cohorts one and two; it is a 21-item inventory that measures symptoms and attitudes of depression . IndividInternalized HIV Stigma. Internalized HIV stigma refers to negative self-perception of self-image because of one’s HIV status . The IntSelf-esteem. Rosenberg’s Self-Esteem Scale is a 10-question measure used widely for people living with HIV . The invHIV Medication Adherence. The AIDS Clinical Trials Group (ACTG) adherence questionnaire is widely used inventory for measuring the adherence of HIV medications . It is aSafer sex communication apprehension. Safer sex communication apprehension was measured by the safer sex communication apprehension subscale in Elizabeth Babin’s General Sexual Communication Apprehension scale . The subPatient Self-Advocacy. The Patient Self-advocacy Scale is a 12-item inventory that measures the involvement of people in their healthcare decision making . The invCronbach’s alpha is used to assess internal consistency for each group at Time 1, Time 2, and Time 3 .p < 0.05) and ANOVA tests (p < 0.05) were used to determine group differences at baseline between those who completed: (1) the baseline only survey, (2) the baseline and training completion survey, and (3) the baseline, training completion, and internship follow-up surveys. Paired t-tests were performed to determine if significant score changes occurred at the individual level between surveys. Independent t-tests were used to assess individual inventory changes at training completion among those who participated in six-months of peer internship and those who did not. Without a control comparison group, paired t-tests were chosen as the most appropriate statistical methodology to help to evaluate results at the individual level before and after each measured programmatic time point.Chi-square  and they were without an AIDS diagnosis (64.57%). Over half were living with HIV for over 15 years (50.6%) and 19.68% for 5 or less years. Most rated their health as good or better (90.22%) and 37.74% were living with two or more other chronic conditions. Many had a mental health diagnosis (46.12%) and/or a substance abuse history (54.86%). According to the participants, 59.8% had last had a job in the past 5 years. Most were receiving medical benefits (85.27%), housing benefits (71.32%), and cash assistance (78.76%). Chi-squared tests of independence were calculated to compare health characteristics and job histories by level of program completion. Overall, participants in each group were similar demographically, similar in their physical and mental health, and had similar work experiences. A significant association was found for a number of chronic conditions. No other significant differences were observed.p < 0.05 level.A one-way between subject ANOVA was conducted to assess if at Time 1 (baseline) there was a statistical difference in psychosocial inventory means between individuals who completed the baseline only survey, the baseline and training completion survey, and those who completed all three. As displayed in t-test was conducted to compare each psychosocial inventory by individual at Time 1 (baseline) and at Time 2 (training completion). t-test results for the full group. At the p < 0.05 level, there was a significant score decrease in depression (PHQ-9) and HIV internalized stigma and a significant score increase in self-esteem, patient advocacy, and medication adherence between Time 1 and Time 2. There was no significant difference for the Beck’s Depression Inventory. Safer sex communication apprehension had no significant score changes.A paired-samples p-value for the paired t-test sorted by level of program participation. Change in the health-related behavioral outcome inventories at the p < 0.05 level differed by those who completed six months of peer internship and those who did not. There was no significant score change in the health-related behavioral outcome inventories for the non-internship participants, but there was a significant score increase at the p < 0.05 level for patient advocacy and HIV medication adherence and a significant score decrease on the safer sex communication apprehension inventory for those who completed six months of a peer internship. Independent t-tests comparing the mean score changes for the training-only participants and the internship and training participants was also conducted. The mean difference for the health-related behavioral outcome inventories differed significantly at the p < 0.05 level for those who completed six months of peer internship and those who did not.Internship participants completed surveys at all three time points, Time 1 (baseline), Time 2 (training completion), and Time 3 (6-months of peer internship). The current study evaluated outcomes among participants in an HIV peer worker training and paid internship program. Results demonstrated positive psychosocial and health-related behavioral outcomes after completing the peer worker training program; these changes were maintained throughout the six-month internship program. We discuss each program outcome, its association with employment, and relevant implications for practitioners and researchers.At the beginning of the study, over 40% of the participants reported at least five years of unemployment and many entered the program struggling with their mental health, trauma, and internalized HIV stigma. This is consistent with past studies indicating that depression and HIV stigma are associated with unemployment among PLHIV ,68,69,70Depression was significantly decreased in PHQ-9 scores after completing the training program and the internship program. However, there was no significant difference in the BDI scores. Titov et al. compared the psychometrics properties of PHQ-9 and BDI and concluded that BDI captured a greater proportion of individuals with severe depression, compared to PHQ-9 [to PHQ-9 . Therefoto PHQ-9 . Social to PHQ-9 . One stuto PHQ-9 . Practitto PHQ-9 . More reInternalized HIV stigma, HIV stigma and discrimination are prevalent among PLHIV [ng PLHIV . Lightneng PLHIV . Internang PLHIV . Our stung PLHIV .Conyers and Boomer examined the role of vocational rehabilitation (VR) access on the goals and objectives of the National HIV/AIDS Strategy and identified that reduced HIV stigma is a key mediator to accessing VR services . SpecifiSelf-esteem was significantly increased in the training-only group. While the peer internship group did not have a significant increase in self-esteem between baseline and training completion, this group did have a significant increase between baseline and internship completion. Escovitz and Donegan evaluated a vocational development program for PLHIV and found that program participation boosted participant’s satisfaction with life [ith life . Hergenrith life . Rosenbeith life ,77. The ith life . FurtherMedication adherence was significantly improved during the training program and maintained after six months of a peer internship. Criteria for entering the program include having an undetectable viral load, so the baseline medication adherence score among participants was already high (with an average of 88.9%). Therefore, most of the participants demonstrated a stable health status upon entering the program and, thus, it was anticipated that change would not be significant after the internship.Previous research also demonstrated a positive impact of employment on medication adherence. In a meta-analysis of medication adherence and employment, Nachega et al. found that employed PLHIV had 27% higher odds of achieving medication adherence, compared to the unemployed PLHIV . MeanwhiSelf-advocacy was defined in this study as the involvement of people in their healthcare decision making. Self-advocacy skills are important for PLHIV to gain autonomy and self-control in their treatment plan and health outcomes. Our results showed a significant increase in self-advocacy during the training program and are maintained after six months of a peer internship.Group interventions have been widely used in facilitating self-advocacy skills. Daniels et al. found that role-play is an effective tool to build self-advocacy skills for PLHIV during their HIV treatment because it provides an opportunity for individuals to share their stories and healthcare experiences . EducatiSafer sex communication apprehension was significantly increased during the training program and maintained after six months of a peer internship. Safer sex communication related to use of condom, HIV status, sex partner’s HIV risk, and a partner’s reaction to proposing or using condoms. Bond et al. suggested that service providers can facilitate communication strategies that address the cultural norms that influence safer sex practices [ractices . In a prractices . At baseOverall, psychosocial changes were mostly associated with participants who continued onto the internship program. There are several possible explanations for this difference. A main purpose of the training was to prepare individuals for a peer internship. HIV service organizations have a long history of utilizing HIV peer workers. Their lived experiences can be advantageous in helping to create behavior change and social support for the individuals they reach through their peer-delivered work ,12. PeerOn the other hand, behavior change related to HIV self-management was rarely assessed in work readiness literature. A group readiness intervention by Beddell and another by Hergenrather et al. measured the impact of program participation on medication adherence and both found no association ,51. BeddData collection for this study was part of a program evaluation and was not designed to be a quasi-experimental study. Selection bias is a major threat to the internal validity of the study. The studied agency chose who would become part of the training program and become a paid peer intern. There might be staff bias during the application and interview process. Another potential source of selection bias is the participants themselves. Those who derived the most benefit from the program might have been more likely to complete the training program and to continue on to completing the internship. In addition, people who did not complete program milestones (completion of training program and six months of peer internship) were not part of the program evaluation. Although statistically, all three baseline groups  were similar demographically and had similar baseline psychosocial inventory scores. This study design limitation made it difficult to decipher if participating in the internship program truly provided additional benefits due to lack of appropriate control groups. Without being able to control for why individual participants were chosen to be part of the two programs, it is hard to decipher true program impact. In addition, the sample size was rather small, and participants were only those residing in New York City. Therefore, it might not be necessarily generalizable to other groups of PLHIV. Data collection took place over many years; programmatic changes occurred cycle to cycle, partly contributing to the fluctuating number of valid observations.Changes included peer pay and changes in requirements of skill sets needed for positions. Furthermore, data collection was self-report. Most participants applied to the training program in the hope of finding employment, and most peer interns hope to retain their peer employment for more than one cycle; it is possible that survey responses were biased due to their employment desires at the agency.People living with HIV are disproportionately impacted by structural social determinants of health, such as racial and ethnic identities, gender and sexual identities, HIV stigma, poverty, substance use, domestic violence, homelessness, incarceration, and unemployment, each contributing to adverse impacts on their physical and psychosocial well-being ,86,87. TThis study assesses the impact of the foundational peer worker training course and paid internship requirements of the state certification on an individual’s psychosocial outcomes. Due to the possible effects on public benefits and an ability to maintain medical care, returning to work full-time might not be the recommended course of action for everyone living with HIV, and therefore was not the goal for program participants. Individuals’ perception about themselves might have an impact on their HIV treatment adherence and overall quality of life; therefore, the psychosocial impacts of the peer worker training and internship programs would be important indicators to evaluating a work readiness peer program. Topping conducted a meta-analysis of peer intervention and education programs and suggested that program structure, funding, management, supervision, and retention are all related to program outcomes . Future Investing in work readiness could save the government millions of dollars through helping PLHIV to become independent from benefits. There has been a dearth of the literature measuring the impact of work readiness programs for PLHIV in the US; fewer than a dozen evaluated programs have been published since the introduction of highly active antiretroviral therapy (HAART) ,54,55,56


With the prevalence of obesity increasing, many weight-loss programs were created to aid in combating the trend. The Weight Loss Clinic (WLC) was created to provide personalized support for lifestyle changes using a multidisciplinary team with medical oversight. This study evaluated the clinically-managed weight loss program at the Wellness Institute.This was a prospective evaluation of a newly established program between January 2019–August 2020. Participants who entered the weight loss program were approached to learn about the evaluation. A total of 41 participants were included. The primary outcomes included changes in body weight and achievement of more than 5% initial body weight loss. Outcome measures were collected pre-and post-program and the data was analyzed through paired t-tests on R studio.n = 13 p < 0.001 vs. 1.75 ± 4.43 kg n = 9, p = 0.02). Completers pre-COVID-19 demonstrated improvements in waist circumference, Framingham risk score, blood pressure, hemoglobin A1C, and body fat percentage.Greater body weight-loss was seen in completers pre-COVID-19 compared to those who completed during the pandemic (Mean, ±SD; 7.51 ± 6.24 kg Though the sample size was small to show definitve evidence, the results may suggest the program worked well prior to the pandemic but the pandemic created barriers to weight-loss for participants. Almost two-thirds of Canadian adults are living with overweight or obesity , which cWhile the market is overwhelmed by weight loss products and services that are often non-evidence based, there is a gap in evidence-based, professionally delivered clinical weight loss services in Canada. The 2020 Canadian Clinical Practice Guidelines (CCPG) for obesity management recommends that interventions for adults living with obesity should follow individualized care plans that address the root causes of obesity and provide support for behavioral change such as diet and lifestyle intervention, psychological intervention, pharmacotherapy, or bariatric surgery . As summIn March 2020, Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a global pandemic, changing the lives of everyone around the globe. A number of public health measures were implemented to combat the spread of COVID-19 with varying success . These i2), who had been told by a physician or primary care provider to lose weight, and had tried to lose weight in the past but had been unsuccessful at maintaining weight loss. Women who were pregnant or lactating were not eligible for the program. All potential participants who entered the program were approached and asked if they would like to participate in a program evaluation. Participants gave informed consent before participating in the evaluation. The WLC is located in the WI at SOGH in Winnipeg, Manitoba, Canada. The data was collected at the Chronic Disease Innovation Centre (CDIC), a non-profit health research institute located at SOGH that provides independent research services for academic, industry, and non-profit partners including WI.This study was a prospective evaluation of a newly established weight loss program between January 2019 and August 2020. The inclusion criteria of the program were individuals over the age of 18 years old and living with overweight or obesity  retrospectively as it was a program evaluation and not a clinical trial. Informed consent was obtained from all participants involved in the study.This study was conducted in accordance with the Declaration of Helsinki, and received approval from the Manitoba Research Ethics Board [Ethics # HS22267 (H2018:401)]. It was registered on The WLC was delivered in-person by a team, including a program manager, physician, RD, CCPT and CPA/CBT. The team collaborated to prescribe a plan best suited for the participants’ needs. Appointments with the RD and CCPT consisted of seven 1-h appointments and seven 30-min appointments each  . The effn = 4), medical reasons unlinked to the program (n = 3), family reason (n = 1), program hold (n = 1), decided not to continue (n = 1), not a good fit right now (n = 1), and moved out of the country (n = 1), whereas, for those that completed during COVID-19, reasons for incompletion included loss to follow up (n = 2), decided not to continue (n = 1) and encountered medical reasons requiring stoppage unlinked to the program (n = 1).A total of 43 participants were enrolled in the evaluation; 2 decided not to continue, 16 did not complete, 25 completed and 22 were included at the time of analysis . For those that did not complete the program, reasons for incompletion pre-COVID-19 included loss to follow up , this is an average of 6.34% (p < 0.001) initial body weight loss. There were improvements in waist circumference , Framingham risk score , systolic blood pressure , diastolic blood pressure , hemoglobin A1C , and body fat mass  in completers pre-COVID-19 , decline in uncontrollable eating  and emotional eating , and improvement in general health  based on the questionnaires  but are considered statistically insignificant.Participants who completed pre-COVID 19 lost 7.51 kg ± 6.24 kg, COVID-19  comparedonnaires . There wp = 0.19, n = 9), this is an average of 1.5% (p = 0.07) initial body weight loss. The remaining outcomes  remained unchanged compared to baseline. For participants who completed during COVID-19, quality of life, sleep and nutrition outcomes remained unchanged compared to baseline.Participants who completed during COVID-19 lost  of participants used the Wellness App, 86% (19 out of 22) of participants used the EatLove software for meal planning and preparation, 72% (17 out of 22) of participants gained knowledge, skills, and confidence as the program went on, and 82% (18 out of 22) of participants reported making valuable lifestyle changes. In terms of the satisfaction of the different components of the program, 85% (17 out of 20) reported satisfaction with the nutrition portion, 100% (21 out of 21) reported satisfaction with the exercise portion, and 50% (10 out of 20) reported satisfaction with the psychology portion. As well, 100% (22 out of 22) of participants reported they would recommend the weight loss program to a friend or family member.The evaluation results suggest that participating in the program in-person resulted in health benefits, reduced adiposity and improved cardiometabolic health, however, some outcomes were not seen in some participants due to barriers created by the COVID-19 pandemic. When COVID-19 was declared a pandemic in March 2020, life around the world changed. In Manitoba, the pandemic lockdowns and restrictions made in-person delivery of the weight loss program more difficult or even impossible in some cases. Thus the delivery of the program was done virtually or through telephone with the same number of hours pre-COVID-19 allocated per WLC team member. The program was designed to be delivered in-person, not virtually, and for a virtual program to be successful there may be a need for additional support including online digital platforms.For a four-month weight loss program, the ideal weight lost is between 7.3 to 14.5 kg (one to two pounds per week) , 4. The There were also improvements in the secondary outcomes for those that completed the program pre-COVID-19, including waist circumference, systolic blood pressure, diastolic blood pressure, and body fat percentage. These improvements would suggest a decreased risk of obesity-related morbidities, such as type 2 diabetes , and hypA major issue that weight loss programs may face is an increased risk of drop-outs. A study done by Bauer et al.  found a The WLC is a fee for service program. A base fee was charged monthly for participants. Some services offered, including appointments with the RD or psychologist may be covered through individual participants health insurance plans.A strength of this study is it involves collection of data from an ongoing and existing program, not a program designed to answer a research question. Another strength is the data collection was ongoing prior to the COVID-19 pandemic, creating a unique natural experiment in which looks at the impact of the pandemic. Limitations include the pre-post design, with no control group, and that the impact of COVID-19 included both stoppages in in-person program services due to lockdowns, as well as the heightened stress of living and trying to lose weight during a pandemic. These two factors both could have impaired the WLC program participants success and could not be separated in this study. As well, no exit surveys were collected from participants who dropped out of the evaluation—collecting this data would have provided critical feedback for the program. Finally, the sample size was not based on a power calculation, it was simply dictated by the program capacity, the length of the evaluation period, and the number or program participants who chose to enroll in the evaluation, thus some of the outcomes may have been underpowered.Participating in the WLC program prior to the COVID-19 pandemic resulted in weight loss and improvements in waist circumference, systolic blood pressure, diastolic blood pressure, and body fat percentage. This suggests that the program works for many when it can be conducted as originally designed. The COVID-19 pandemic has created additional barriers to weight loss, including but not limited to, inconsistent in-person delivery and its negative impact on participants’ mental health. Long term effects of this pandemic on weight management in adults could exacerbate the problem of obesity in adults, further increasing the prevalence of adults living with obesity . The demThe original contributions presented in the study are included in the article/KC collected and analyzed the data. KC wrote the first draft of the paper which was edited by RM, SM, and DM. All authors contributed to the article and approved the submitted version.This evaluation study was funded by the Mitacs Accelerate Fellowship partnered with the Chronic Disease Innovation Centre, which is the research arm of the Wellness Institute and Seven Oaks General Hospital. KC was funded by a Mitacs Accelerate fellowship. Mitacs is a Canadian not-for-profit research and training organization. The funders had a role in the design of the program and in the decision to publish the results. The funders had no role in the collection, analyses or interpretation of the data and in the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.