KAPS indicate changes in desired practices from pre-training to post-training. Thematic analysis of KIIs highlight essential components for program implementation and effectiveness, including strong leadership, buy-in, secure funding, reliable supply chains, training and adequate staffing. This evaluation of program implementation highlights successful strategies and challenges in implementing CNP to improve the health of children in Mongolia and the Philippines. Lessons learned from the implementation of CNP can inform growth of the program, scaling strategies and provide insights for similar interventions.Nutrition and feeding interventions are important for children’s growth and development. Holt International’s Child Nutrition Program (CNP) is a child nutrition and feeding intervention. This study aims to describe and explore the implementation of CNP in Mongolia and the Philippines using mixed methods including qualitative and quantitative data analysis. The analysis framework was guided by the WHO’s Monitoring the Building Blocks of Health Systems. Key informant interviews (KIIs) were conducted, transcribed, translated and coded. Knowledge, Attitude and Practice Surveys (KAPS) and pre-/post-tests from routine program audit data were analyzed. Analysis of nutrition (Mongolia: 95% CI: 7.5-16.6 ( Millions of children around the world continue to suffer from malnutrition for reasons including inadequate access to nutritious food, feeding practices and poor hygiene and sanitation ,2,3,4. NHolt International is a 67-year-old child welfare non-profit working in 15 countries. In 2012, Holt identified that many of the children participating in its programs globally were at risk for malnutrition or experiencing malnutrition. Motivated to address this issue, Holt developed the Child Nutrition Program (CNP). The CNP works to address the critical nutrition, feeding, health and development needs of vulnerable children who are most at risk of malnutrition by providing training, resources and support for caregivers and sites providing care for children . The proThis study follows two retrospective analyses on the nutritional and feeding status of children who participate in the CNP ,7. This Describe and assess the implementation of the CNP in Mongolia and the Philippines;Identify and describe the barriers, disruptions, enablers and solutions for implementation at a caregiver, site, country, multinational implementers and policy level; Explore key factors important for implementation and growth of the CNP.Ethical approval was obtained from the London School of Hygiene and Tropical Medicine (ref: 22865). The National Center of Public Health of Mongolia approved the research methodology/protocol and ethical approval was obtained from the Medical Ethics Control Committee of the Mongolian Ministry of Health (ref: 230). Ethical approval was obtained from the St. Cabrini Medical Center-Asian Eye Institute Ethics Review Committee (SCMC-AEI) Ethics Review Committee in the Philippines (ref: 2021-002). We have reported according to the TREND statement  16]. A . A 16]. This study uses mixed methods to examine the implementation of a large multi-country nutrition and feeding intervention program. This study was designed by ED, MK, CT and TS and uses primary data collected by the principal investigator (PI), ED, and the CNP champions in Mongolia and the Philippines, in addition to secondary data from routine program audits of which all available data were used. The framework developed for this evaluation of process utilized a health systems approach guided by the WHO’s Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and their Measurement Strategies ,18,19. The CNP currently operates in eight countries at 68 sites serving over 7500 children. Countries include China, India, Mongolia, the Philippines, Ethiopia, Uganda, Vietnam and Haiti. The program operates in community-based settings, foster care systems, health care facilities and IBC. Mongolia began program implementation in 2016 and the Philippines in 2017. In the Philippines, there are seven sites consisting of five IBC and two foster care programs. In Mongolia, there are 13 sites including 4 health centers, 3 IBC, 5 schools/daycare sites and 1 facility with IBC, in-patient and outpatient services. Mongolia and the Philippines were selected for analysis because of logistics and data availability. This study utilized primary and secondary data. Participants in the primary data collection included key informants (KIs) who participated in key informant interviews (KIIs). KIs were selected using purposive sampling of one interviewee per site and per country program. The secondary data were collected during routine program audits. This data consisted of KAPS and nutrition and feeding pre-/post-training tests completed by staff at sites participating in the CNP as part of program implementation. These data components were analyzed using quantitative and qualitative methodologies and the findings were then combined to provide a broader synthesis of the CNP implementation.t-tests were conducted comparing the unmatched pre-training and post-training tests  were collected during routine program audits prior to the site being trained in the CNP and after sites were trained between 2016 and 2020 in Mongolia and the Philippines. The KAPS were completed by staff of all levels at sites participating in the CNP. The surveys provide feedback to the program about participants knowledge, attitudes and practices in key programmatic areas. The surveys are routinely completed as part of program monitoring and evaluation systems and are used to track changes over time and inform trainers of key areas for training, as well as areas to support site implementation. The KAPS included respondent demographics and questions about nutrition, feeding, health, growth monitoring, disability, child development, hygiene and sanitation. There were a total of 25 questions; 11 knowledge-based questions, 5 attitude-based questions and 9 practice-based questions. As some of the questions reflected participants’ views and there were not “correct” answers, we summarized the KAPS using the program’s previously identified “desired” answers out of the total number of responses . Each quThe semi-structured KIIs were designed and pretested by the PI (ED) and the two CNP champions who are lead trained trainers and manage the program in the Philippines and Mongolia . The in-The CNP champions received interview training and practice prior to conducting interviews. All interviewees were provided and signed participant information and consent forms via DocuSign  prior to the interviews. Interviews were conducted via password protected Zoom . Interviews were transcribed, de-identified and then translated and shared with the PI (ED). The PI (ED) interviewed the two CNP champions on country level implementation. ED is the director of CNP, a lead trainer, has trained in all implementing countries and maintains relationships at the country level and site level. t-tests were used to compare the independent nutrition and feeding pre-training and post-training tests  and Microsoft Excel (2013). Independent-samples ng tests . A bar gng tests . Descriptive statistics were produced to summarize the independent KAPS. Respondent demographics and the frequency and percent of desired answers prior to training and after training are presented. A two-sided Fisher’s Exact test was used to assess whether there was any difference in the domains  from pre-training compared to post-training . Demographic information of key informants who participated in the KIIs is presented. The qualitative data from semi-structured interviews were analyzed with descriptive coding for thematic content using NVivo 21 (released March 2020) and following the COREQ checklist . The codFollowing the WHO’s monitoring and evaluation of health systems strengthening inputs, processes, outputs, outcomes and impact were summarized by each of the six building blocks . AdditioIn both Mongolia and the Philippines, the CNP was implemented at sites following standard program implementation starting with a formal assessment followed by a training and evaluation. After the evaluation, country level CNP staff provided ongoing support to sites and caregivers with additional training, resources and monitoring and evaluation systems. There were two main differences in context between Mongolia and the Philippines—the types of sites and who is trained. In Mongolia, many of the sites are health centers and daycares or schools for children with disabilities, which engage children’s caregivers, including mothers and fathers, and teachers or health center staff in training. In the Philippines, there are more IBC and foster care programs than in Mongolia, therefore training participants are primarily foster care parents or IBC staff. p ≤ 0.0001), Philippines: 95% CI: 7.6–15.7 (p ≤ 0.0001)) and feeding (Mongolia: 95% CI: 11.7–23.9 (p ≤ 0.0001), Philippines: 95% CI: 6.6–16.9 (p ≤ 0.0001) tests suggest an improvement in knowledge and practices in both countries between the pre- and post-training (p ≤ 0.0001) and 1.5-year post-training . Differences at other test points may be due to chance, possibly related to changes in sample size or that the tests takers at different time points may not be the same. Analysis of the unmatched nutrition  were women and 65/98 (66%) had attended a university, graduate or professional school . For MonThere was an increase in desired answers from the practice domain and overall from the pre-training to post-training for both countries consistent with a positive change in implementation of practices. . The PhiIn Mongolia, 13 site directors or key staff and one CNP champion were invited to participate in KIIs, of which 10 staff from different sites and one CNP champion were interviewed. In the Philippines, eight individuals were invited to participate of which six agreed to participate. The six KIIs were conducted with individuals from five different sites and one interview was conducted with the CNP champion of the Philippines. All of the KIs were female. Of the types of sites, seven were from IBC facilities, six were community-based programs, such as schools for children with disabilities, one was a health center and a final site was a hospital that offers IBC, day-care/community services and inpatient/out-patient clinical services for children. KIs had participated in the CNP a median time of three years (IQR: 2–5 years) and their sites had participated for a median of four years (IQR: 2–5 years). The CNP champion in Mongolia has led the CNP for six years and the champion in the Philippines for four years. Analysis of the KIIs identified key barriers/ disruptions, facilitators and solutions to implementation . Key barFrequent training and retraining for all staff at the sites were the most frequently mentioned factors for sustained standardized program implementation over time. Training was reported as driving behavior change at a caregiver and site level. “Since they were able to attend training and they know what its benefit is, I feel like the house parents can be encouraged to really do the practice,”—CNP Site Director“Our employees’ passion and care for children, especially special needs [children with disabilities], have increased and changed positively. We learned to feed a child with swallowing and chewing difficulties. Children with disabilities, especially CP [Cerebral palsy], were fed with only very thin “liquidish” pureed food by bottles when they lay on their back. Now, we all use proper positioning as possible as their physical condition lets and feed them with proper food texture using cut out cups or maroon spoons adjusted with their abilities. We used to tell our children to sit quietly during meal times, but now we encourage them to communicate and interact with each other and our teachers improved their intention to interact with special needs kids,”—CNP Site DirectorTechnology, such as lack of access to the internet or computers, was identified as a key barrier to implementation. As part of implementing the CNP, sites are supported with supplies and access to the internet when needed and provided an electronic nutrition screening database. Use of the nutrition screening database was reported as an essential piece for implementation for both sites and country level implementers. The database allows sites to track and monitor children’s health and growth through analysis of health records. Participants frequently reported database use as a valuable tool in making other parts of their roles easier. Informants mentioned valuing the database due to its simplicity for monitoring and reporting of nutrition and health data which improves user experience and supports sites’ ability to easily report information to local government systems. “We realize and see many positive changes in children’s health and development since implementing CNP at our site. We never had such [a] monitoring system and methods before. Now we can see the growth and nutrition progresses using CNP database. Children’s nutrition intakes and feeding quality were much improved and so their health condition became better,”—CNP Site DirectorBuy-in was also frequently noted as a key element to implementation. Buy-in and understanding of the program and its value to children is needed at all levels, including for caregivers, site staff, site leadership and other key stakeholders, such as local government. To achieve this, KIs suggested sharing of success from already existing programs, engagement of other stakeholders in training  and ensuring participatory training is part of the onboarding process for all of the new staff.“We try to organize some CNP trainings in extended scope and we intend to introduce the CNP to every one of the whole organization and we try to involve all level staff, including directors and also executive staff, also the children’s parents who have disabled children. We try to involve everyone who participates in taking care of the children. So I think it’s very important to make them understand of CNP,”—CNP Champion“Maybe we can best achieve that [buy-in] by also, although we’ve done that already. We’ve sought help of the center head so it’s the sites’ leadership, so whenever we go to the regional director, we have center head with us, so that it’s not just KBF or Holt going to the regional office but also the center head. The sites and the sites’ center head goes along with us and shows that the site really has the need. So it goes two ways I think—so we connect the higher officials with the senior leadership and then we seek the support of the center head, so that we can have the center head share about the need and then she or he is able to go to the senior leadership and then say that, ‘Yeah this program is needed [at the site], and we really need it and that’s why we’re here to seek your support as well, so that whenever we need something we can ask you and can request anything from the senior leadership [government].’ Yeah, so I think that’s one way,”—CNP ChampionKIs identified that the aims and objectives for nutrition programs or other services for children need to fit within sites and countries goals.“CNP complies with our organization’s medium-term strategic plan and the organization’s child protection policy by identifying barriers to learning, development and quality of life for every child with a disability that will have a positive impact on the child’s development and growth. It is also in line with the Mongolian Government policy for 2020-2024 program, ‘Vision-2050′—Mongolia’s long-term development policy, State Education Policy for 2014-2024 programs, the Convention on the Child Rights, the Child Protection Law and government resolutions,”—CNP ChampionFunding was identified as necessary to implementation with a lack of diverse or secure funding being a key barrier. Often, funding or gifts-in-kind did not match site priorities. For example, sites received cookies instead of needed diapers, fruits or vegetables.“We found that it’s good to have partnership[s] with outside entities. We don’t want to be too dependent on one— because it’s very constricting. We’re boxed into the budget we receive,”—CNP Site Director“When there are donors, it’s like—more on, not really for the kitchen or stocks, especially diapers, things like that. That’s the priority of the institution. Diapers, milk—things like that,”—CNP Site DirectorIn both countries, implementation of this program worked top down from government relationships and bottom up from site level partnerships. KIIs reported a high value in signing agreements with clear expectations of all parties, including government agencies, suppliers and sites. Quality implementation and sustainability of the program correlated with government support, site partnerships and quality relationships with key stakeholders. Some of the sites have received recognition/awards from the government for their overall center quality, which included implementation of the CNP. This was reported to help to reinforce site commitment to the program.“We have reached not only the center head of the site, but also the regional directors so we conducted meetings with them and then we’ve made memorandum of agreement with them, though there’s like it’s not implemented right to the right for every word for word that’s in there but we have to be flexible, with what the site needs, but I think the partnership is there and in trusting each other to conduct this together and troubleshoot or whenever there’s like this needed help/there’s needed assistance, we can support each other in a way on how to make CNP doable for everyone,”—CNP ChampionDissemination and raising awareness about the program and its benefits was identified as essential for program growth. Sites that requested the program were noted to have high levels of implementation. These sites often referred new sites to the country level CNP staff to utilize the program based on the impact it has on children’s development at their site. KIs suggested engaging site directors from currently implementing sites into meetings with government officials, new potential sites and other stakeholders to share about program operation and impact. Additionally, the need for advocacy and awareness of the program was identified with suggestions to develop a focused media strategy and better share about research on the program with wider audiences. “And I think one step for that, aside from the ongoing attempt to expand this to [new CNP sites], we plan also for gathering existing current champions and creating a best practices manual or anything that can be shared to anyone to see how CNP has been successful here. So I think my vision is something like that, so we can easily inform other people and other sites about CNP so that acceptance of the program can be easier,”—CNP Champion“I think it will be very helpful to involving some of those Public Health National Center and also Health Ministry and Educational Ministry and Social Welfare Ministry people for their attention because you know, Mongolia has like straight line managing system, so those ministries are the most upper level supervising and managing and also developing strategy and policies for those sites, so I think their involvement would be helpful to scaling our program because CNP has lots of benefits for those vulnerable population,”—CNP Champion“Maybe we can find someone who can somehow make nice about the CNP and really put CNP out there. Really make it popular somehow or make it really known to most people because, like when we think of businesses, when we think of important information we’ve been to like make it like trending or sensationalize… to put it out there, to really make it known in a way. Like maybe have someone who’s good at communication [or] publishing. And maybe for this research as well. If this research goes well and it finishes, then we can publish it further and then share with the scientific bodies, the experts and then show them [the value of the CNP],”—CNP ChampionExploration of the implementation of the CNP in Mongolia and the Philippines provides key insights that have the potential to increase the sustainability of the CNP interventions and improve implementation. The goal of this research was to be relevant and practical for implementers of CNP and potentially inform wider nutrition and feeding interventions. This research informs CNP staff, partners and similar programs on implementation strategies, as well as areas for future research.Interviews with CNP champions and lead site staff provided key insights for implementation in the different contexts in which the CNP operates . They idOur findings show that successful sustained implementation of the CNP requires behavior change at both a caregiver level and a site-wide level. At both levels, behavior change was strongly linked to frequent training, hands-on practicums, clear roles and responsibilities, support, access to resources and adequate staffing. Similar to other programs, such as Ubuntu, Baby Ubuntu and Juntos, the CNP is structured to provide participatory training, resources and support to caregivers ,26,27. TTaking into consideration the results from the KIIs, KAPS, and nutrition and feeding pre-/post-training tests, behavior change and maintaining high quality implementation and integration takes ongoing support, frequent training and reinforcement  8]. Usi. Usi8]. Next steps will be to use this information to explore different contexts and to investigate how best to scale up the CNP in countries where it currently operates, as well as future countries . InvolviThis study adds to limited evidence on implementation of nutrition and feeding intervention programs. We used a mixed-methods health systems approach to provide a more comprehensive evaluation of the process of implementing the CNP. The research practices were built upon strong existing relationships and took cultural protocols into consideration. Using mixed methods and analysis of different aspects of implementation enabled the research methods to complement each other to understand a complex implementation process more fully. This study included data and interviews from KIs in two countries of the eight where the CNP is implemented. These countries were selected because of data availability and logistics, but future research could look at implementation in all the countries were CNP is implemented. Conducting remote KIIs enabled this research to be efficient and less time consuming for our research team and interviewers although there is potential sampling and recruitment bias, as not all KIs were able to participate. Responder bias could also be present, as these KIs work at sites that benefit from support from Holt. Additionally, the principal investigator and some of the co-authors on this research are trainers or CNP champions who lead this program and whilst this can potentially introduce some influence, it also allows for enhanced analysis of the data because of a deep understanding of program operations and relationships with sites. Future research could consider using other methods such as use of control groups or independent evaluators to address the potential bias in this paper. As KAPS and nutrition and feeding pre-/post-training test samples were independent and there were smaller sample sizes at different time points, this could impact analysis of the results. These tests were conducted as part of routine program operations with unknown validity. Future research could further examine these tools. This research was also impacted by the COVID-19 pandemic because implementation of the CNP adapted as sites navigated through changes in public health restrictions. Other limitations included the fact that KIIs did not include other important stakeholders including children, caregivers, community members, families or government partners. The implementation of the CNP in Mongolia and the Philippines provides insights for implementation in other countries and for other similar nutrition and feeding interventions, in addition to areas for future research. With appropriate inputs, processes and implementation methods to address barriers and facilitators, programs such as the CNP could have the potential for substantial impact and growth. Strong partnerships and relationships with local government, secure funding, buy-in at all levels, adequate staffing, frequent training, support systems and adequate supply chains were identified as essential to implementation. As malnutrition continues to impact millions of children, programs that address the needs of caregivers and children, such as the CNP, should be prioritized. Applying scaling frameworks to future research on the CNP could provide additional information on how to scale-up programs to reach more children globally.


This paper presents a qualitative analysis of COVID-19′s impact on the development, delivery, and uptake of “Favoring Myself”, a school-based interactive wellness program conducted via Zoom during 2020–2021. “Favoring Myself” targets resilience, self-esteem, body-esteem, self-care behaviors, and media literacy among 5th-grade preadolescents. Data were obtained from meetings, 23 semi-structured interviews with parents, teachers, and principals, and other modes of correspondence. All data were transcribed and thematically analyzed. The analysis highlighted the barriers faced when delivering external programs during COVID-19. Parents’ difficulties in cooperating with the program, distrustful relationships between parents and the education system, as well as teachers’ overload and stress, were identified as barriers to the external program’s sustainability. These challenges are discussed in light of previous studies of school-based programs, the psychological and social contexts of an ongoing crisis and the impact of neoliberalism on education. This study concludes that school-based prevention programs and accompanying research should be more flexible and focus on understanding and relating to parents’ and schools’ fears, uncertainties, and resistance. It is the hope of the authors that knowledge created through this exploration will be helpful in future coping vis-à-vis prevention program teams and recipients in times of unpredictable, unmanageable, and overpowering crises. This article explores parents’ and teachers’ engagement and difficulties in co-operating with the wellness program “Favoring Myself” and its accompanying research during the COVID-19 pandemic. “Favoring Myself”—a school-based resilience program—was integrated into the school curriculum in Israel four years ago. The program’s contents and face-to-face delivery effectiveness have been studied extensively see, for example, . When thThe following literature review explores the importance of cooperation between prevention program teams, teachers, and parents. Then, the literature on the influence of the COVID-19 pandemic on educational systems in general and mainly on remote learning is reviewed. Finally, a description of “Favoring Myself” follows, with its accompanying research, and the modifications this program has undergone to make it relevant to current conditions.The socio-ecological scientific prevention method, as well as other universal, and multimethod programs advocate approaching multiple levels, with the understanding that promoting the strengths of children, parents, and schools may lead to multiple positive outcomes ,4,5. In The recent COVID-19 outbreak has challenged youth’s ability to continue to perform tasks, develop, and achieve goals under conditions of vulnerability, helplessness, uncertainty, and a relative lack of control over outcomes . During In terms of COVID-19′s influence on relationships, it has been found that students and their parents who are confined to their homes feel stressed and anxious and that relationships between the parents and schoolteachers become strained . Consequ“Favoring Myself” is an interactive, school-based, wellness program that has been integrated into the school curriculum in Israel as part of a module on life skills initiated by the National Ministry of Education in primary schools. The program highlights key protective factors to increase resilience and well-being, reduce risk behaviors and prevent internalizing unrealistic sociocultural norms. The program consists of ten 90-min weekly sessions ,2 with eA.A unique community coordinator assisted with recruiting and addressing the difficulties caused by COVID-19.B.Duration of sessions was reduced from 90 to 60 min. Lengthy discussions were replaced by interactive activities.C.Each class was divided into two sub-groups that attended the program during different hours to enable their class teacher to participate in both.D.School-team collaboration: (1) An introductory Zoom conversation was conducted with each school team. (2) To facilitate supervision of instructors by teachers, as well as communication among all members of the program team, a computerized form was implemented. (3) Each school principal was advised to request that the head of the parents’ committee support the program.E.Engagement strategies for the 5th-grade participants included the following: (1) Two pupils were chosen in each class to assist the facilitators, motivating the group to attend and complete assignments. (2) A competition was planned between classes, measuring attendance, cooperation rate, and task submission. (3) Facilitators reached out to the fifth-grade participants before and after the program sessions, sending humorous messages as reminders to practice the skills taught in class.F.Parental component: (1) Parents received information about the program content, structure, and previous outcomes, along with a link to a short video describing the program. (2) Consenting parents received weekly updates about the topic discussed and its importance, and one or two shared assignments to be practiced with their children. (3) Two reminders were sent to participants who did not complete the weekly assignment. (4) An assignment delivered by both the child and a parent received two stars, while those produced only by the child received one star.G.Evaluative research modification: (1) A Kahoot simulation questionnaire was created to prepare pupils to answer the research questionnaire. (2) The program facilitators discussed the various feelings participants might experience when they faced questions, they were not sure of how to answer or felt embarrassed about. (3) Each subgroup of 12 to 14 participants was divided into two Zoom breakout rooms, and additional research assistants were present in each room to assist pupils who had difficulties in understanding the questionnaire.With the outbreak of COVID-19, it was clear that some modifications would have to be made in order to implement preventive strategies , includiThe current article is based on a qualitative study, aimed to understand the perceptions and opinions of parents and school teams to the implementation of “Favoring Myself” and its accompanying effectiveness research during the COVID-19 pandemic.Choosing a qualitative approach stemmed from the search for an interpretive, subjective manner of studying people’s own perceptions of events to understand and interpret reality from their points of view, highlight and explain life experiences, and give them meaning. Qualitative research allows us to deeply explore different perspectives and to discover the complexities of situations through a holistic framework ,25,26. QThe four educational institutions in which the program was conducted are in the north of Israel, serving a financially comfortable population. Since data included protocols of meetings, phone calls, and WhatsApp contacts, all the people involved in the program from 2020 to 2021 are considered as participants in this study. In addition, twenty-three people agreed to be interviewed at the program’s completion. The school principals were asked to invite all the teachers and parents who were involved in the project to contact the researchers if they were willing to be interviewed regarding their experiences with “Favoring Myself”. Initially, only two school principals, three teachers, and six parents contacted the researchers. Using a snowball method, additional interviewees were recruited. Finally, two school principals, five 5th grade teachers, and sixteen parents were interviewed. The interviewed parents represented various attitudes and behavioral responses to the program that year: Six were highly engaged with the parental component of the intervention, four refused to consent to their child’s participation in the study, and six withdrew their consent for their child’s participation and involvement in the parental component.This study received approval from the College Institutional Review Board . Parents and school teams received information about the program and the qualitative study and provided their informed consent via computerized links. All the procedures involved in this study comply with the ethical standards of the 1975 Helsinki Declaration and Consort 2010 guidelines and regulations.1.Data from meetings of the research team with the schools to set shared objectives, build trust, and discuss ways to address participants’ engagement.2.WhatsApp messages and telephone calls: Some parents who had concerns regarding the program sent messages to the teachers and researchers. These messages were saved. Phone calls from parents were documented by teachers, facilitators, and researchers as soon as possible after their completion.3.Zoom meeting: To avoid the escalation of parents’ agitation in one of the schools, the first author suggested that the school principal host a Zoom meeting with interested parents and school team members. A 1.5-h discussion with 30 volunteering parents and the school’s fifth-grade teachers was conducted via Zoom by the first author and the school principal, during the second week of the program. This meeting, in which parents expressed a great deal of anger and frustration, was recorded, with the consent of all participants, and then transcribed.4.Interviews: At the program conclusion, twenty-three in-depth, semi-structured personal interviews (see Data were obtained from the program’s participants and collaborators: school principals, teachers, and parents using the following methods:Data from all resources were analyzed using the thematic analysis approach. Reading and re-reading the texts was initially performed, and side notes were taken. Then, the researchers identified recurring key themes that shed light on interviewees’ experiences and attitudes. Stories of different participants which seemed to have common motives were connected, in order to represent processes  and undeThis analysis gave us profound insight into school principals’, teachers’, and parents’ reactions toward the program as well as a deeper understanding of the relationship between the parents and the education system in times of persistent crisis.A thematic analysis of data obtained from preparatory meetings, emails, WhatsApp messages, interviews, and the Zoom meeting, identified themes, which are presented hereby divided into school reactions, parent reactions, and parent–school relationships.The reactions in the educational systems can be divided into school’s ambivalence, teachers’ difficulties in co-operating with facilitators, and principals’ reactions.due to the uncertainty regarding the reopening of the schools, the teaching methods, and handling of the schools’ competing needs”. They said, “It is not the right time for these decisions.” Finally, four schools chose to enroll, providing their consent only in October 2020, but only three of them adhered to the program’s agreed schedule. The fourth school slated the program time to the afternoons, which resulted in the absence of pupils who had joined a basketball class. The school’s coordinating teacher was quite upset: “I failed to convince the principal that changing the program’s schedule would decrease participants’ motivation”, and also noted that no one considered that changing the time of the program imposed personal challenges: “I had to be present during these sessions after my teaching day had ended.”Unlike in previous years, schools were reluctant to commit to the program, which manifested itself from the onset in principals’ inconsistent responsiveness to the program’s community coordinator’s calls. After receiving information letters with a link to a three-minute video highlighting the program’s importance, objectives, and novelty, only seven out of the seventeen approached schools expressed their interest. During the initial months of recruitment, principals were not ready to commit ““a lack of gratitude from the participants’ parents, which made it hard to remain involved and motivated”. One of them said: “I understand that it is an important program, and I see the facilitators’ efforts, but I cannot supervise them thoroughly. I am always in a rush to my next class.”Although introductory Zoom meetings were attended by the vast majority of teachers of eligible classes, and most of them expressed enthusiasm towards the program and agreed to the research demands, eventually many of them had a hard time maintaining their ongoing collaboration with the program’s facilitators. While some teachers provided helpful feedback to the group facilitators after sessions, many failed to do so consistently. In the interviews, these teachers self-confessed that they were exhausted after having experienced “didn’t want to fuel the fire” and that the parents were too upset for them to “confront them over an external program” or that “the parents overreacted, even violently, to the program, and to protect myself, I took a step back and maintained a cordial relationship with them.”In addition, only one teacher out of the four classes in which parents mounted resistance to the program, attempted to mediate and negotiate with these parents. The other teachers confessed that they The following quote from one of the teachers seems to express the complexity of their experience: “I have gone above and beyond to recruit participants to attend these lessons, stayed after my working hours. And combined with the emotional burden of my students and the lack of privacy, ‘Favoring Myself’ was not prioritized”. This teacher’s experience demonstrates how, despite good intentions, cooperation became almost impossible.School principals varied in the way they coped with the challenges surrounding the program’s delivery during the COVID-19 pandemic.“The questionnaire and the program relate to complex and latent topics that are not discussed in most households… the child’s teacher and school counselor attend the sessions and explain the research topics to participants. Our objective is to educate a mature, aware, and resilient generation”.One of the principals sent out a clarification letter to the parents, in which she explained the importance of the program as part of a mandatory lesson, and the choice of “Favoring Myself” due to its excellent reputation. Relating to parents’ concerns regarding sensitive issues she explained: In his interview, another principal explained, “Dealing with our parents is complicated, which we know from experience. Now they are more antagonistic than ever before”. A third school principal asserted, “Despite the good intentions of the program’s facilitators and the class teacher, this year, introducing the program was an incorrect decision. It is a wonderful program with great objectives. Still, such sessions lose their effectiveness over a Zoom platform where participants’ privacy is compromised, and implementation is problematic due to the exhaustion of the system and the teachers, and the sacrifices that have been made this year.”Parents’ reactions are divided into their reactions to the program itself and their experiences with the accompanying study.“the program includes intimidating topics that should be discussed delicately and not by young students as facilitators.” Thus, for example, a mother praised one of the assignments but objected to uploading a picture of her and her son exercising on the class WhatsApp group: “I do not understand why I should share our activities with others. It bothered me.”Parents’ views of the sessions varied. Some appreciated the opportunity, while others felt that “if I do not like to perform the shared assignments, I am the ‘bad guy’ who causes my child’s class to receive fewer stars.” One of the mothers stated, “It bothered me when I heard my daughter tell her friend that if they do not complete the assignments, their group will not get the stars. This is social pressure,” or: “If this is a positive challenge, why bribe them?”As mentioned earlier, one of the modifications to the program due to the pandemic was adding a competition game component in order to encourage attendance and performance of assignments by the child or the family. Competition between classes was perceived by some parents as harmful because Our children sit in front of the screen for so many hours a day as it is. We may say we are in control, but the truth is we are not.” On the other hand, and potentially as a reaction, the Zoom classes were perceived and presented by parents as an opportunity to observe teachers’ and facilitators’ conduct. One of the mothers said, “I sat and watched many of these lessons. Some are nice, but sometimes you hear the facilitator pushing the children into a corner.” One of the mothers stated, “You are using our children for a damaging experiment, and I say so because this program has never been delivered on Zoom.”Interestingly the delivery of the program over the Zoom was experienced as two-folded. On the one hand, it was perceived as problematic, as one mother stated: ““existing load of assignments”, or feeling that “such a study should not be conducted during the COVID crisis”, and ending with extreme reactions, such as saying that they did not want their child to be “treated as a guineapig” or to be “forced to participate in the study”. “It is not acceptable that our children are obligated to answer personal questions,” said one of the fathers.Parents’ reactions to the research were overall quite negative, varying from passive non-cooperation, such as forgetting to turn in forms they agreed to sign, to moderate complaints focusing on the burden of filling out questionnaires by their child, who already had difficulties with his/her “wake up sleeping dogs.” For example, a mother who felt that her daughter “never worried about her body, and as a person who suffered from eating disorders in the past, I do not want her to answer these questions.” A somewhat more practical and moderate approach was expressed by parents who suggested that “if the whole questionnaire and the program protocols had been sent to parents earlier, we might have felt differently.”.Some parents were worried that specific themes appearing in the questionnaires would from my point of view, clear boundaries were crossed here and under the roof of our local school.” In relation to the study, one of the parents wondered, “Who in our school permitted the research process?” Other parents were more concerned with their child’s confidentiality and addressed their school’s management with questions such as “How do you secure our children’s privacy?” Teachers also had their own reactions to being distrusted and criticized by parents. One of the teachers commented on the parents’ protest, saying, “The class teachers accompanied this process. You talk as if we were not there. We were there to mediate.” A school principal described the parents as “opinionated and suspicious”.Some parents expressed anger towards the school or the school’s management. A parent wrote, “The current research addresses some of the barriers faced when attempting to establish academic–school–parent collaboration for the application of a wellness program during the COVID-19 pandemic.According to the results, parents expressed ambivalence toward the program. Initially, they agreed to their children’s participation, and some of them were pleased with certain activities or sessions. But when they were expected to perform assignments with their children and consequently were exposed to the program’s more personal and sensitive themes, various parents reacted with anger and criticism. In response to parents’ concerns that research on body image might precipitate body or eating problems in their child, it was explained that previous research has shown a very low prevalence of distress due to children’s participation in body image research . NeverthMany parents were also opposed to the use of incentives to encourage attendance and performance of assignments. They talked about “bribing” and “social pressure”. General resistance was elicited, mainly when a few parents, quarantined at home, saw their children struggling to complete the research questionnaire. They saw the questionnaire as a sign of exploitation of their children by the program, the facilitators, and the researcher. Consequently, they condemned the school and program staff for damaging their children’s well-being. They were not appeased by the calming statements from the class teachers, school counselor, principal, and the first author.Some parents were annoyed by the facilitators’ and researchers’ expectations that they would join their children’s assignments. COVID-19 has changed teaching and learning processes , puttingParents’ rageful comparisons of their children to laboratory animals, may be a reflection of worldwide disputes around the COVID-19 vaccine. Skepticism about vaccine development , fear ofTheir resentment and worries resemble the findings of other studies regarding the general mood during the pandemic. Current research shows that many people experienced distress, including anxiety, depression, and over-excitement ,23. It s“over an external program”.Teachers’ reactions to the program were characterized by frustration and even a sense of helplessness. This finding is consistent with Carlson’s  study shRegarding parent–school relationships, the results resemble previous studies, which have demonstrated strained relations between parents and schoolteachers during the pandemic ,20. An iThis parental response also resonates with neo-liberal education policies which promote parental educational rights, responsibilities, and involvement, while encouraging them to express their choices, and legitimizing their refusal to obey school instructions. Hornby et al.  have she“this year the initiation of the program was an incorrect decision” may have articulated the experiences of the program’s team as well. Indeed, many school-based wellness interventions have been suspended during the pandemic [Finally, building on studies and theories supporting the effectiveness of socio-ecological prevention methods , “Favoripandemic .It, therefore, seems important to suggest ways in which prevention program teams and developers may cope with future unpredictable crises. Fornaro, Struloeff, and Flowers  who studFornaro, Struloeff, and Flowers  also sugThis research provides essential information about the barriers faced in prevention programs during times of crisis. Twenty-three interviews, a group meeting, WhatsApp messages, and emails are regarded as a small sample, to draw general conclusions. Qualitative research, however, does not demand bigger samples since its reliability and validity are achieved through a deeper analysis of an existing sample with its multiplicity of voices ,48. In a“Favoring Myself” is rooted in the socio-ecological scientific prevention approach  and is d


Metro systems extended rapidly in China, especially in the last decade, developing over a half-century. This work explores the dynamical evolution of the structural efficiency of metro systems interpreted as complex networks for 14 large cities in mainland China. Based on the empirical observations, we find that the global efficiencies scale with the number of stations and counter-intuitively decreases as the metro networks expand, which shows a long-tail characteristic. The evolution of metro networks is, in essence, the improvement of the relative ratio of average nodal efficiency in the core compared to global efficiency. These relationships are in good agreement with the temporal structure of metro networks. Besides, we find that the metro stations with the higher efficiencies are those surrounding the urban center, and most of them dwell within the core and gradually expand the branches in space. Our findings suggest that the evolution properties of metro systems influenced by numerous geographical, historical, and social activities suggest that underlying, universal mechanisms are at play during their evolution in the spatial–temporal dimension. Compared with other transportation modes, metro systems offer an effective solution for addressing the urban issues of being safer, punctual, quicker, cleaner, land-saving, and high capacity. The dependence on metro systems keeps growing in cities worldwide as societies become ever more urbanized, which leads to a rapid increase in metro scale. This massive growth is credited to development in a few countries, especially China2.Metro systems are integral parts of transit systems in large cities, acting as a critical solution in supporting commuter traffic demand within the metropolis area3. As one type of transportation mode, the evolution of metro networks reflects the evolution of the population and activity densities. Indeed top-down planning controlled by a central authority plays a vital role in the construction of metro networks which are always intentionally structured in a core-periphery shape. This would be true if these metro networks were planned from the beginning to their current shape, but this is not the case for most networks. The metro network results from a superimposition of multi-type actions such as urban planning, the reorganization and regeneration of economic activities, and the growth of residential populations4. Although central intervention is severe limitations to the possibility of modeling the dynamic metro network, top-down planning, as one of the influencing factors, could be thought of as an external perturbation5 when modeling a city and its expansion as a self-organized phenomenon. Understanding how metro networks evolve under different geographical, historical, and social-economic circumstances and what are the dominant mechanisms in a long time. If any, the universal features of such a large-scale self-organized process, are more critical than ever as policymakers, professionals, and the scientific communities are actively looking for new paradigms in urban planning and land management7.As continually adding new lines and stations, the metro system, developed to improve mobility and reduce congestion in urban areas, has become an increasingly large and complex network with the city's development8 adapted graph theory to describe the metro network characteristics of the state, from, and structure. They concluded that the network topology plays a crucial role in attracting travelers to public transit. Despite their geographical and economic differences, Roth et al.9 found that metro networks worldwide share a common generic feature . However, the analysis was restricted to configurational metrics and ignored other attributes such the travel time and distances. Cats10 conducted longitudinal research on the topological evolution by investigating the Stockholm rail network from 1950 to 2025, which exhibited smooth long-term technological and spatial trends. Even though the growth of transportation networks is complicated and multidimensional, and the duration is usually measured in decades, it may still be tractable and predictable with a further understanding of the underlying mechanisms11. However, literature related to the evolution of metro networks has rarely been studied. Leng et al.12 proposed a new growth model composed of expanding and intensifying modes to measure the development of the transfer network of the Beijing metro. Motivated by the shape of metro networks, Aldous et al.13 calculated the optimal structure of metro networks as a function of the total length. They found that in the medium-length regime, resources go preferentially to radial branches as the total length increases, and this is a sharp transition when a loop appears.The detection and characterization of these universal features require us to understand the evolution of these spatial structures. The metro network embedded in space forms a graph where stations are nodes and links represent rail connections. The evolution of the metro network is a critical aspect of the time-dependent spatial topology, which has been studied in recent years for the availability of longitudinal infrastructure data. Derrible et al.accessibility in transport geography) measures how people interact with other people, and places were first used in transportation planning since Hansen proposed14. Transport operators and planners have increasingly adopted efficiency as a desirable planning goal and a key performance metric15. Efficiency has always been evaluated in single-mode, such as car and public transport17. A recent study proposed a new measurement approach, called Urban Accessibility Relative Index, for understanding the spatiotemporal patterns of efficiency in urban areas. Results demonstrated that the metro has a higher impact on public transit efficiency than bus18. The evolution of the metro network is essential to the progress of changing the opportunities of locations by metro systems, along with the developing spatial pattern, although this type of infrastructure network also lacks a high redundancy because of the high cost of adding new lines or stations. We now understand pretty well how to characterize the structure of their temporal evolution19, while transportation networks are the underlying critical infrastructures for improving the movement of people and reducing congestion in urban areas21. Unfortunately, the efficiencies changing with the structures and their evolution characteristics are generally ignored in previous studies, although the calculation and comparison of static efficiencies among metro networks appeared in several studies24.The metro network plays a vital role in improving commuting efficiency and promoting economic development. The efficiency . An intuitive idea would be that the number of branches . For each metro network, a specific page per metro line includes various information such as the station names, the first date of operation for each station, the distance between neighbor stations, and the total length of each line. This information allows for a complete reconstruction of the metro lines and corresponding operating stations at any time.The first step toward analyzing the evolution of metro systems is to collect data on their structures. We gathered and analyzed data related to the metro networks from 1969 to 2019. The primary topological data were obtained from Wikipedia (https://map.baidu.com/) to double-check the structure. It is worth mentioning that the metro maps in 2019 cannot process all the stations for each year of their existence. For example, a station that closed before 2019 and remained closed  will be handled separately. Eventually, the topological structure of metro networks is modeled in L-space as an undirected and weighted graph For a given year 9 found that the topological structures of large metro networks in the world gradually developed into the shape with a denser core  and branches reaching out to the suburbs or areas further from the core.Metro network in the early stage always begins with linear, circular, or star form, then becomes increasingly large and complex. Although it is challenging to classify the form of the metro network into a single topology category, it is evident that its form has changed from a simple to a more complicated form. In 2012, Roth et al.k-core decomposition25, where k-core subgraph considered the metro network's core, which seems to be located in the center of the spatial topology in Fig. 9.Metro networks investigated here display a core-branches structure through spatial representations plotted by the relative location of stations in Fig. mentclass2pt{minim30. However, this definition of barycenter has several restrictions on the application of the metro network: First, the metro network is always considered a planar spatial graph formed with an anisotropic shape for the most extensive networks . While several metro networks may not have this characteristic due to geographical constraints such as the sea in the south of Shenzhen, this may cause the movement of barycenter with the evolution of the network and generate deviations for measuring the spatial organization of the network9. Besides the developing metro networks , the barycenter is not surrounded by the core nodes, as shown in Fig. The geographical barycenter is always considered as the center defined as the average location of all the stations. The geographical barycenter (marked in black nodes in Fig. The network efficiency is an indicator of exchange information based on the shortest path calculated as path distances or the opportunity costs at a station to other stations in a metro network. The average efficiency of node 32.The global efficiency 38 rescaled the value of global efficiency in The value of For all 36.For metro networks, the physical distances are well-defined by the underlying geometry and computed as corresponding great-circle distance about spatial coordinates of stations


Scientific identification of the factors that underpin the success of construction program can effectively promote the success of construction program. Based on literature statistics, this paper developed the measurement items of key success factors of construction program in Chinese context. Based on exploratory factor analysis, seven key success factors of construction program were extracted. Then, the excellence model of construction program was constructed by referring to the ideas, concepts, and theoretical mechanisms of EFQM model. The research conclusions of this paper provide a systematic and holistic guidance for the successful implementation of the program by the construction program organization and promote the success of the program. With the economic development having been switched from high-speed development to high-quality development, China is now facing a critical period of development mode transformation, economic structure optimization, and growth momentum conversion. Against this background, the construction industry needs to achieve high-quality development through transformation and upgrading. With the continuous expansion of the scale of the construction industry and the implementation of national strategies such as “Belt and Road Initiative” and “New Urbanization,” the number and scale of construction programs are increasing day by day, and the construction program aims to pursue higher values and benefits and achieve the expected goals through unified coordination and management of multiple projects so as to promote the high-quality development of the construction industry. Compared with an individual project, the construction program is not only larger in scale, but also characterized with higher complexity, longer duration, higher cost, and greater risk, and it also has more significant social and economic impact . TherefoAt present, the academic circles in foreign countries have conducted a large number of theoretical and empirical studies on the key success factors of the program, and the scholars have set forth different views on this matter ,4. With The research results mentioned above have enriched the theoretical system of the key success factors of the construction program and formed a general key success factor model of the construction program. However, the researchers have not reached a unified conclusion as to the key factors that influence the construction program. At the same time, cultural and industrial discrepancy may affect the applicability of the key success factor frameworks of construction program proposed by different scholars , and PeThere is a causal relationship between the success criteria of the construction program and the key success factors, and different key success factors will be identified for different success criteria. Therefore, defining the meaning and the success criteria of the construction program is the basis for scientifically identifying the key success factors of the program. Based on the previous research, this paper develops the standard measurement items for the success of construction programs in the Chinese context based on literature statistics and China's construction program management practices. On the basis of the data collected by the questionnaire survey, the SPSS22.0 statistical analysis software is adopted as an auxiliary tool to carry out exploratory factor analysis for the success criteria of the construction program, and the success criteria of the construction program are extracted: the success of the construction program management, the success of the construction program organization strategy, and the harmony of the stakeholders of the construction program.At present, the research on the key success factors of construction program is still in its infancy worldwide, and there are few related documents. Seven papers on the key success factors of construction program published in international authoritative journals were selected. By comparing and analyzing the key success factors between construction projects and construction programs, the results indicate that more emphasis is put on the key influence of “executive support,” “clear goals,” and other factors on the success of the construction program, while more emphasis is put on the key influence of factors such as “team member ability” and “team communication” and other factors on the success of the construction project.Literature analysis lays the foundation for identifying the key success factors of construction program. Due to the differences in the construction environment of the programs in various countries, this paper draws on the statistical conclusions of literature, the 66 key success factors of construction program proposed by scholars such as Sarmad Kiania , and theThis paper adopts questionnaire survey to carry out empirical research on the key success factors of construction program, and a total of 32 valid questionnaires were collected. The subjects of the survey are company executives, program managers, program management support personnel/auxiliary personnel, etc. Most of the subjects are highly educated and have relatively rich work experience, so the questionnaire results are representative, reliable, and authentic.In order to analyze the quality of the questionnaires, this paper needs to test the reliability and validity of the scale data. The output results suggest that the correlation coefficient matrix is “nonpositive definite matrix.” Neither KMO nor Bartlett's test shows the results. The main reasons mainly come from two aspects: (1) The sample size is too small while there are too many indicators. (2) The correlation between certain variables is too strong. There are 40 measurement items for the key success factors of the construction program, but only 32 questionnaires were effectively collected. The main reason is that the management idea of the construction program has not been effectively promoted in China's program practice. Therefore, there is a need to process the data in order to analyze the key success factors of construction program. The main measure taken is to reduce the number of measurement items. Through the analysis of the correlation of indicators, eleven items were deleted from the key success factor measurement items of the construction program, so as to meet the requirements of the quality inspection of the factor analysis, as shown in SPSS 22.0 tool was used to perform exploratory factor analysis on the scale data, and the common factor is extracted based on the standard where the feature value is greater than 1 and the cumulative contribution rate is greater than 80%, and the factor analysis results are shown in From the results in In order to further explain the 6 common factors that have been extracted, the maximum variance orthogonal rotation method is used to perform factor rotation on the extracted factors. The rotated factor loading matrix is shown in Factor 1 explains the measurement items of SF11, SF36, SF6, SF4, and SF5 and reflects that the completeness of the construction program organization and management system directly affects the success or failure of the construction program, so it is named the organization/management standard system completeness factor.Factor 2 explains the measurement items of SF27, SF13, SF26, SF29, SF25, and SF37, reflects the connotation of the whole process management of the construction program, and shows that the effective management of the whole process of the construction program is the key factor to promote the success of the program, so it is named excellent program management factor.Factor 3 explains the measurement items of SF34, SF20, SF19, SF33, SF38, and SF14 and reflects that high competency of the construction program management team can effectively promote the success of the program. Therefore, it is named the excellent program management team factor.Factor 4 explains the measurement items of SF18, SF40, SF12, SF3, SF39, and SF1. It is divided into two factors since it cannot effectively explain the key success factors of specific construction programs. SF18, SF12, and SF1 explain the organization strategy and goal of construction programs, indicating that organizational strategy has a guiding role in the implementation of the program. Organizational strategy is the basis for the success of the program, so it is named the organizational strategy/clear target factor; SF40 and SF39 explain the role of government support in promoting the success of the construction program, and it is named the government support factor.Factor 5 explains the measurement items of SF16, SF31, and SF30 and reflects the interest demands and cooperation of the stakeholders of the construction program, so it is named the stakeholder cooperation factor.Factor 6 explains the measurement items of SF7 and SF8, indicating that the support of senior executives is inseparable from the success of the program, and it is named the senior executive support factor.Organizational strategy and goals are the blueprint and outlook for the strategic goals and mission scope of the construction program. The implementation of any project/program is inseparable from a clear organizational strategy and target.The achievability of the project objectives is the prerequisite for the smooth implementation of a construction project. Researches have shown that the formulation of an implementable plan can substantively improve the possibility of achieving overall success and project progress, thereby improving project performance . TherefoSenior executive support refers to the phenomenon that the senior executives provide various resources as well as written and verbal support to the program team during the whole process of building the construction program. Existing studies believe that senior executive support is one of the necessary conditions for project success . Senior executive support promotes the success of the construction program mainly through the following aspects: The senior executives promise to complete the program; pay attention to the progress of the construction program; actively participate in the program and provide necessary support; ensure that the project/program has an appropriate priority.Standardization of the organization and management system is the basic element for the success of construction projects/programs. By constructing a positive organization culture and establishing a reasonable organization structure for the construction program, the ability of the organization and individuals can be effectively boosted and the effectiveness of the policy and strategic goals can be improved, so that the management efficiency of construction project/program can be raised to promote the success of the program .The organization of the construction program is determined by the strategic goal of the program, and the organization is an important foundation and support for the realization of the strategic target. Construction program management is a highly integrated management, and the program organization should also achieve the unity of powers, responsibilities, and benefits to ensure that the organization can effectively perform its functions. The larger the construction program and the more complex the task, the more it is necessary to build an effective organization and adopt the correct work process to comprehensively consider the program's targets and resources, so that the program management can be well-organized and the program's strategic targets can be achieved. The positive culture of the construction program has an important impact on the employees participating in the construction program and the program itself . The construction program management team includes the team members with the construction program managers as the core, the management technology used by the managers/team, the application of capabilities, and the needs of the managers/team. Scholars such as Belassi et al. 1996)  believe 96  belieAs the core team of the whole process management, the construction program management team plays an important role in dealing with some complex situations and systems and ensuring the implementation of the construction program and the successful delivery of the program. The construction program management office is a project management organization specially set up for project management, which influences the success of the program by providing practical methods for construction program management. The ability of the members of the construction program management team is matched with the application of technology; that is, the stronger the ability of the program team members, the higher the technical requirements, which is conducive to the success of the project. The manager of the construction program can also resolve the errors and conflicts of a certain subproject or unit by allocating resources to ensure the realization of the goal of the construction program.According to project management theory, project management ability is the key to ensuring project value addition. Construction program management is the key stage for the completion of the construction program products, which must rely on scientific and effective management methods to grasp the critical points of implementation so as to promote the success of the program. Research results show that 62.4% of experienced project/program managers believe that when the project/program management is successful, the project/program will generally succeed . In thisThe implementation of the construction program involves the scope, time, cost, quality, human resources, communication, resources, information and risk, and other management fields of the program. In light of the traditional “iron triangle-time management, cost management, quality management”, etc., it is necessary to take effective control measures under target constraints. At the same time, control measures shall also be strengthened in management areas such as resource management, information management, and risk management.The needs, expectations, requirements, and behaviors of the stakeholders of the construction program can impose influence on or are affected by the program to varying degrees. Their duty-performing ability and level of performance are directly related to the success or failure of the program. The satisfaction of the different interest needs of the stakeholders of the construction project/program and the harmonious relationship between the stakeholders, which benefit all participants, are important factors for the success of the project group; and the inability to achieve effective cooperation among the stakeholders of the project/program will cause organizational chaos  and may Strengthening the communication, coordination, and cooperation among the stakeholders of the construction program\project is essential to the stakeholder relationship management of the construction program. It can promote timely communication, reduce adverse effects, avoid conflicts between departments, and resolve incidents that hinder progress and can help to create a coordinated and harmonious environment and improve the management level and operational efficiency of the entire program, thereby promoting the success of the program.In the decision-making and construction of major construction projects/program, the role of the government is irreplaceable, and the relationship between the government and the construction program is inseparable.Program construction is a large-scale project which entails a lot of attention from the government, and governmental approval is required for various processes involved during the construction process of the program. At the same time, the government also plays a role in the supervision and management of the program construction. Studies have found that the government, which supervises and regulates the implementation process of the construction program through supervisory and regulatory institutions, can achieve the purpose of preventing corruption and promoting the program performance. Efficient public institutions have a great impact on the success of the project , and theThe EFQM model is the first excellence model selected by the European Foundation for Quality Management through evaluation. The EFQM model measures project performance and shows the ideal strategy and targets of the project to elevate its performance to the highest level . This paper refers to the thought of Westerveld  (2003) tIn the facilitation field of the excellence model of the construction program, leadership is a behavior in which managers in an organization use their power to exert influence on their subordinates in order to achieve the goals of the organization. Senior executive support refers to the support of senior executives to their subordinates, and leadership can be interpreted as senior executive support; the personnel, policies and strategies, partners, and resources covered by the facilitation field can be, respectively, interpreted as excellent program management team, clear strategies/targets, complete organization/management, and stakeholder cooperation and government support; the process reflects the whole process of constructing the program, and therefore the process can be deemed as excellent program management. In the result field of the construction program excellence model, the dimensions of personnel results and customer satisfaction correspond to the harmony (satisfaction) of stakeholders; social influence reflects the long-term performance of the organization, that is, the success of the organization's strategy; corporate performance is interpreted by the success of project management.Based on the above analysis, this paper constructs an excellence model of the construction program, which reveals the relationship between the success of the program and the key success factors as well as the enabling paths, as shown in The excellence model of the construction program based on the EFQM model organically combines the “success criteria of construction program” in the success result field and “key success factors of construction program” in the facilitation field. The two constitute a facilitation-feedback relationship; that is, the key success factors of the construction program facilitate the success of the program while the success of the program reacts upon the whole process management of the program. The scientific definition of the success criteria of the construction program plays a guiding role in defining the key success factors of the construction program managers in the whole process management of the program and helps the managers to judge and effectively control the key success factors.Key success factors of the program play a decisive role in determining the success of the construction program. Therefore, in-depth and systematic research on the key success factors of the program will help the construction program organization to focus on the investment in key factors and increase the likelihood of program success.Based on literature statistics, this paper explores the key factors affecting the success of construction programs in China, supplements and excavates the hidden factors of the construction program, and develops the measurement items for the key success factors of the construction program in the Chinese context. Using the data collected by the questionnaire survey, SPSS22.0 statistical analysis software is used as an auxiliary tool for exploratory factor analysis of the key success factors of the construction program, and the key success factors of the construction program are refined: Key success factors in seven dimensions, including clear organizational strategy/targets, senior executive support, government support, organization/management and other standard systems, excellent program management team, stakeholder cooperation, and excellent program management. The ideas, concepts, and theoretical mechanisms of the EFQM model construction program are drawn on to organically integrate the “success criteria of construction program” in the result field and “key success factors of the construction program” in the facilitation field to construct an excellence model of the construction program.The key success factors of the construction program and the excellence model of the construction program established in this paper provide a directional guide for the systematic and holistic success of the implementation of the program by the construction program organization. Real-time monitoring and process control are carried out during the implementation of the program to make the implementation of the program more flexible, reduce the risk of the program, and promote the success of the program.


Scaling evidence-based interventions are key to impacting population health. The National DPP lifestyle change program is one such intervention that has been scaled across the USA over the past 20 years; however, enrollment is an ongoing challenge. Furthermore, little is known about which organizations are most successful with program delivery, enrollment, and scaling. This study aims to understand more about the internal and external organization factors that impact program implementation and reach.inner and outer setting constructs contributed  to the organization’s current level of implementation reach (measured by average participant enrollment per year). A construct by case matrix was created with ratings for each CFIR construct by interviewee and grouped by implementation reach level.Between August 2020 and January 2021, data were collected through semi-structured key informant interviews with 30 National DPP delivery organization implementers. This study uses a qualitative cross-case construct rating methodology to assess which Consolidated Framework for Implementation Research (CFIR) Across the 16 inner and outer setting constructs and subconstructs, the interviewees with greater enrollment per year provided stronger and more positive examples related to implementation and enrollment of the program, while the lower reach groups reported stronger and more negative examples across rated constructs. Four inner setting constructs/subconstructs  were identified as “distinguishing” between enrollment reach levels based on the difference between groups by average rating, the examination of the number of extreme ratings within levels, and the thematic analysis of the content discussed. Within these constructs, factors such as organization size and administrative processes; program fit with existing organization services and programs; the presence of enrollment goals; and active leadership involvement in implementation were identified as influencing program reach.Our study identified a number of influential CFIR constructs and their impact on National DPP implementation reach. These findings can be leveraged to improve efforts in recruiting and assisting delivery organizations to increase the reach and scale of the National DPP as well as other evidence-based interventions.The online version contains supplementary material available at 10.1186/s43058-022-00350-x. Contributions to the literatureA large amount of resources have been dedicated to scaling up the CDC’s National DPP lifestyle change program; however, enrollment (reach) is an ongoing challenge.This is one of only a few implementation research studies of the National DPP focused on the organization level that use the CFIR construct rating qualitative methodology to explore the national implementation of this program.These results have broad application to understand how best to assist organizations to adopt, deliver, and scale evidence-based programs like the National DPP.This study builds upon CFIR research using this analysis approach and could facilitate comparisons across studies.According to 2020 data, the Centers for Disease Control and Prevention (CDC) has reported that 96 million adults (38% of the adult population) in the USA have prediabetes, a condition that indicates a high risk, and progression to, type 2 diabetes . The NatUnderstanding factors related to adoption, implementation, and reach of the National DPP at the organizational level is critical to scaling the program. To date, research and evaluation of the National DPP has largely focused on participant-level outcomes , 8, 17. In addition to intervention characteristics and program participants, other critical contextual factors internal and external to organizations may impact implementation outcomes. Chaudoir, Dugan, and Barr refer to these as organization  and structural  level causal factors in their “Multi-Level Framework Predicting Implementation Outcomes” . FurtherThis study aims to fill this gap by applying the Consolidated Framework for Implementation Research (CFIR), a metatheory comprised of constructs associated with implementation, that has been increasingly utilized in public health research to understand diverse aspects of implementation processes and outcomes –24. Withinner setting and outer setting, focus on internal and external organization factors  it’s nice to have the number, I like numbers. Tell me what you want, I’ll go for that number.” For organizations that did not have formal enrollment goals, interviewees mentioned other goals such as achieving CDC DPRP recognition status, billing Centers for Medicare & Medicaid Services (CMS)/becoming a Medicare DPP supplier, training their staff to implement the program, general diabetes prevention in their communities, or focusing on the retention of their current cohorts first before attempting to enroll more participants. One interviewee from a medium reach organization said because their focus is on establishing a process for billing CMS, they are not concerned about enrollment and prefer a small cohort at the moment. Multiple interviewees that currently did not have enrollment goals said they were interested in setting formal enrollment goals. While the interviews focused on pre-COVID-19 implementation, a few interviewees mentioned how COVID-19 had disrupted their implementation and therefore currently enrollment goals were not a priority.a subconstruct of Readiness for Implementation and refers to the commitment, involvement, and accountability of leaders and managers with the implementation of the program. This construct appeared numerous times throughout most interviews. While the majority of interviewees simply said they have “support” from their leadership, when asked to describe this support in terms of leadership engagement their examples varied greatly. Examples included: leadership being aware of all program activities and events, making presentations to promote the program, connecting with other organization leaders/partners for the program, facilitating internal organization processes  for the program, obtaining resources including adequate staffing for the program, and providing the program for free to organization employees.Leadership engagement is Leadership engagement was a distinguishing construct as high and medium reach cases had more strong positive examples of leadership engagement compared to the low reach cases. High and medium reach interviewees also more often connected leadership engagement with positive examples of successful enrollment efforts and growing the infrastructure for the program. The lower reach group had more mixed experiences with this construct. Leadership was described as not being engaged enough; not doing enough to understand the program, and taking a “hands off” approach. The key message from all interviewees across reach levels was that leadership engagement is highly desired and appreciated when available. Leadership support and knowledge of the program was discussed as a strong facilitator in implementing and scaling the program.This study applied CFIR to examine the internal and external organization factors influencing National DPP implementation. The four distinguishing constructs from the inner setting  indicate that there are multiple factors internal to the organization that can impact implementation and enrollment success. Our findings are consistent with other studies that have found that some of these same constructs influence successful implementation—particularly within the inner setting domains such as leadership engagement and the implementation climate subconstructs , 34, 35.leadership engagement on implementation involved going beyond surface-level support of the program and was highlighted by taking an active role in understanding the program, attending program events, promoting the program, and providing resources [compatibility, relative priority, and goals and feedback indicated that for organizations at higher reach levels, the National DPP fit better with existing services, health promotion programs, and systems, was prioritized by the organization leadership, and had formal enrollment goals outlined.Similar to previous research, positive esources , 30, 34.To date, there is a lack of evaluation of the National DPP using CFIR constructs; however, other lifestyle change programs also focused on physical activity and nourishment behaviors to achieve weight loss have been studied using CFIR , 36–38. structural characteristics) and the importance of partnerships (cosmopolitanism), previously there has been less of a conversation about organization compatibility, priorities, goal setting and feedback, and active leadership engagement which we identified as important in this study [The findings of this study have the potential to facilitate implementation of the National DPP. While the National DPP provides guidance on the standard infrastructure needed for organizations to deliver the program . Lastly, in early 2020 the COVID-19 pandemic disrupted the National DPP, a largely in-person program, greatly. We did try to limit our interview discussions to pre-COVID implementation and saved COVID-19 related conversations to the end of the interview. As the pandemic has been an unignorable outer setting/external factor it is hard to say how much of the discussion of these topics was impacted by implementers who found themselves in a “survival/adaptation mode” at the time of the interview. The recently released CFIR 2.0 update now includes a new as these .This study found that there are a number of CFIR inner setting constructs that impact implementation reach of the National DPP. This understanding can be leveraged to improve efforts in recruiting and assisting delivery organizations to increase the reach and scale of the program. This is one of only a few studies of the National DPP at the organization level and to use the CFIR construct rating qualitative methodology to explore the national implementation of this program. More focused attention to program compatibility, prioritization, setting program goals, and leadership engagement has the potential to improve program implementation. Furthermore, these results have broader application to understand how best to assist organizations to adopt, deliver, and scale evidence-based programs.Additional file 1: Table 1. Interview Guide Questions.