With the rapid development of space geodetic information technology, the Global Positioning System (GPS) has been widely used in seismology and space environmental research. Typically, the occurrence of a large earthquake will lead to some changes in the ionosphere, this phenomenon is called coseismic ionospheric disturbances (CIDs). In this contribution, differential slant total electron content (dSTEC) is used to study the anomalous characteristics of the ionosphere. First, based on the ionospheric dSTEC time series and two-dimensional disturbance detection, the temporal and spatial characteristics of ionospheric disturbances can be accurately analysed. Secondly, using wavelet transform spectrum analysis and disturbance propagation velocity, it can be determined that the disturbance sources of this earthquake can be identified as acoustic wave, gravity wave and Rayleigh wave. Finally, in order to further clarify the direction of the earthquake disturbance, this study focuses on proposing an innovative method for the disturbance propagation direction, and determines that there are two directions of the propagation of the CIDs of the Alaski earthquake. Owning to the complexity and difficulty of seismic tectonic mechanisms, the study of seismic phenomena and seismic prediction are hotly debated issues. However, with the continued maturation of coupled Global Navigation Satellite System (GNSS) and seismic technology, it is beneficial to detect the characteristics of temporal and spatial perturbations in the ionosphere caused by earthquakes. Currently, a new technology with wide applications in seismology is the GNSS and seismic coupling technology, due to the occurrence of earthquake-induced seismic waves that change the total electron content (TEC) of the ionosphere3. GNSS technology can be used to invert the TEC before and after the earthquake to improve the accuracy of seismic predictions.Earthquakes are a natural phenomenon caused by the movement of tectonic plates, resulting in rupture and plate deformation5, volcanoes6, and solar flares7, anomalies occur. Earthquakes, in particular, are extremely destructive and cause huge losses to society. An earthquake causes a vertical upward seismic wave at the land or ocean surface. When the seismic wave reaches the ionosphere, it changes the total electron content, eventually causing an anomaly in the ionosphere known as a coseismic ionospheric disturbance (CIDs)14. Currently, scientists have developed a relatively complete theoretical system for studying CIDs. Using GPS technology, Calais and Bernard15 observed that ionospheric disturbances near the epicentre of the Northridge earthquake lasted for several minutes and moved away from the epicentre with increasing time from the GPS observation. Further, Heki et al.16 found that earthquakes commonly occur in different types of seismic waves and classified three different types of ionospheric anomalies : 1. a sound wave travelling vertically directly from the seismic source; 2. gravity waves caused by earthquakes or tsunamis; 3. a secondary acoustic wave of the Rayleigh wave far from the source area. These conclusions have been widely used and verified by subsequent scholars17. For example, Ducic et al.18 detected Rayleigh waves in the 2002 Denali earthquake, Astafyeva and Heki19 detected two types of seismic waves in the 1994 Kurile earthquake , and Chen et al. discovered two types of seismic waves in the 2015 Nepal earthquake and 2013 Lushan earthquake21. Liu et al.22 used ray tracing technology to detect the abnormal propagation velocity of the ionosphere and the location of the focus of the 1999 Taiwan earthquake. In 2015, Cahyadi and Heki23 estimated the velocity of the sound waves from the 2012 Sumatra earthquake to be about 1 km/s. At the same time, other researchers also found that the ionospheric perturbation is asymmetric in the northern and southern hemispheres, i.e. perturbations of northern hemisphere earthquakes occur mainly south of the relative epicentre, and perturbations north of the relative epicentre are not significant24. Additionally, Kong et al.25 used the lithosphere—atmosphere—ionosphere coupling to construct an electric field penetration model to analyse the potential physical mechanism, further confirming the ionospheric anomaly theory. In 2021, Shi et al.26 analysed the 2017 Chiapas earthquake, detected an abnormal source location as well as amplitude changes and determined the variation of ionospheric anomalies. Besides, based on GPS TEC technology, relevant scholars have added the new technology of Moderate Resolution Imaging Spectroradiometer (MODIS) Land Surface Temperature (LST) to further detect the changing characteristics of CIDs, and provide new theoretical guidance for earthquake monitoring27.When the ionosphere is unaffected by the external environment, it is in a relatively stable state, and the TEC does not fluctuate, whereas in the ionosphere affected by the external environment, such as earthquakes, magnetic storms28. Therefore, based on the study of the disturbance sources and the spatio-temporal variation characteristics of the Alaska earthquake, this paper further quantitatively studies the specific direction of the anomaly propagation of the Alaska earthquake, which provides a certain reference value for the later study of the propagation direction and mechanism of the CIDs of the same earthquake in the high-incidence area, and for the earthquake monitoring. This manuscript presents processed GPS data from 98 Continuously Operating Reference Stations (CORS) in the vicinity of the earthquake, comprehensively analyses the azimuth of the station’s maximum anomaly, determines the specific propagation direction of ionospheric anomalies, and summarises the relationship between the propagation direction and the tectonic plate boundary.Although GNSS technology has been used to study the Mw8.2 Alaska earthquake, there have been few previous studies on the azimuth of large anomalies in the earthquake, and no specific research on the propagation direction of CIDsOn July 29, 2021, at 06:15:41 UT , a Mw8.2 earthquake occurred near the Aleutian Islands, Alaska. The focal depth was about 15 km, and the epicentre was located at 55.40°N, 158.00°W, making it a shallow earthquake accompanied by more than 20 aftershocks. This earthquake is the result of a thrust rupture (about 200 km long and 80 km wide) at near the subduction zone between the Pacific and North American plates. The study comprehensively analyses 98 GPS stations with a 30 s sampling interval provided by the UNAVCO , and the TEC in the zenith direction is recorded as the vertical total electron content (VTEC), and the VTEC value in the zenith direction is small, and the ionospheric projection function can realise the mutual conversion between STEC and VTEC20 :dSTECi represents the difference between the STEC at time i + 1 and STEC at time i, and dSTECi+1 represents the difference between the STEC at time i + 2 and STEC at time i + 1.When the ionosphere is not disturbed by the external environment, the STEC is relatively smooth when the ground station tracks the satellite, and fluctuates in a short time when the earthquake occurs. Due to the large rate change of STEC, it is difficult to directly detect the CIDs. Therefore, the Gaussian difference STEC method to obtain the relative change of STEC, i.e. dSTEC, is defined as (2)We have chosen satellite G06 at station AB02 in order to further investigate the variability characteristics of the dSTEC time series. Figure 19.33 . When the dSTEC time series is passed through the wavelet transform band-pass filter, the time series with ionospheric anomalies appear as obvious disturbances. In Fig. To analyse the anomalous small changes in the ionosphere, the trend element must be removed from the dSTEC time series. In this study, a band-pass filter is used to allow waves in certain frequency bands to pass through while shielding waves in other frequency bands34. The Kp index, Dst index, Ap index and F10.7 index are commonly used to study geomagnetic activity and solar activity. The F10.7 index is closely related to solar activity, and the solar activity index F10.7 < 100 SFU in a quiet state. The Dst index reflects the geomagnetic activity in the equatorial region, and the intensity of magnetic storms is divided into strong magnetic storms (Dst < − 100 nT), moderate magnetic storms (− 100 nT < Dst < − 50 nT) and weak magnetic storms (− 50nT < Dst < − 30nT). The Kp index represents the global geomagnetic activity and the Ap index is converted from the Kp index. Figure Before discussing the CIDs of this earthquake, this study considers the influence of factors such as geomagnetic activity and solar activity changes in this areaIt is often the case that only a small number of satellites pass through the epicentre when seismic waves reach the ionosphere; therefore, only a small number of satellites can detect the ionospheric anomaly. In this study, four satellites  recorded significant disturbances and were selected to analyse the time series changes of filtered dSTEC after 06:00–07:00 UT. The aim is to obtain the spatial and temporal changes over the Alaska earthquake by analysing the disturbance amplitude, azimuth, and epicentral distance of the maximum anomaly.To analyse the causes of the CIDs on 29 July, this study constructs time sequence diagrams for different stations from a time perspective. The distance between the station’s maximum anomaly and the epicentral distance is the primary factor, and the epicentral distance of the maximum anomaly for each station from 06:00–07:00 UT is arranged in ascending order. The epicentral distance of each satellite time series gradually increases from bottom to top according to the maximum anomalous value of the station.Figure Figure Figure Figure In summary, significant ionospheric “N” type anomalies appear about 10–13 min after the earthquake and are mainly concentrated less than 300 km northeast and southwest of the epicentre. Furthermore, with increasing distance from the epicentre, the disturbance of the maximum number of stations is not significant or even abnormal. Only a few stations show anomalies, and their time of occurrence is delayed by several minutes compared to the stations close to the epicentre. Therefore, it can be speculated that both the epicentral distance and the azimuth angle have a direct influence on the occurrence of anomalies.In order to detect the spatial variation of the CIDs, the two-dimensional ionospheric disturbance at 06:20–06:41 UT on 29 July 2021 over the region after the earthquake is analysed  and slow propagation 0.52–0.68 km/s)ave Fig. a,b. A prave Fig. c. A prop km/save Then, this study analyses the disturbance spectral relationship from the filtered dSTEC time–frequency diagram to illustrate what type of seismic waves caused the CIDs. Stations with different satellite epicentral distances  are selected for the spectral relationship analysis . Station AV34 is located southwest of the epicentre and station WAAK is located northeast of the epicentre (Fig. Sequences No. 7 and 8 show the disturbance of stations AB02 and AV38 for satellite G16. Both stations AB02 and AV38 are located north-east of the epicentre. Station AB02 is closer to the epicentre and the maximum anomaly value is larger. The time of occurrence of anomaly is also 1 min earlier Fig. m,n. The The results show that the seismic anomaly is caused by acoustic waves and Rayleigh waves. However, the change in the two-dimensional disturbance can only roughly explain why the large-scale ionospheric anomaly is oriented to the northeast and southwest, and it is difficult to determine the specific propagation direction. The following section focuses on the further determination of the azimuth based on the abnormal azimuth.28. In order to further detect the ionosphere anomaly of Alaska earthquake, the specific propagation direction of the Alaska earthquake, we apply a new method to study the anomalous propagation direction of the Alaska earthquake. According to the azimuth angle perturbation of the sounding point, if the azimuth angle of a sub-ionospheric point at different stations at different times is used to comprehensively analyse the variation trend of abnormal values, the propagation direction of ionospheric anomalies in this earthquake can be determined. The specific method is to first count the filtered dSTEC with significant anomalies and construct the curve of the filtered dSTEC corresponding to the azimuth angle as well as finding the interval where the abnormal azimuth angle is mainly concentrated from the curve. The mean Azi represents the azimuth angle of all points with significant disturbance at the same time, and the filtered dSTECi value is commonly greater than the azimuth angle of 0.05 TECU.Li et al. studied the propagation direction of the Alaska earthquake ionosphere anomaly and found that the Alaska earthquake anomaly was mainly concentrated in the direction of east-northeast of the epicentre, and the vertical crustal displacement caused by the earthquake rupture was not significantFigure In summary, the ionospheric anomalies started about 10 min after the earthquake near the epicentre. At 06:33 UT, the anomalies started to weaken gradually, and the total duration was about 8 min. The anomalies near the epicentre are mainly concentrated to the northeast and southwest of the epicentre and propagate in the directions of 46°-68° and 201°-211°. Since the direction of the anomaly is approximately parallel to the tectonic plate boundary line and the epicentre is close to the Pacific plate boundary line, it is speculated that the direction of the ionospheric anomaly is directly and closely related to the Alaska-Aleutian subduction in the Pacific plate.In terms of temporal variation of dSTEC during the earthquake: significant disturbance appeared 10–13 min after the earthquake near the epicentre, and the duration was 5–8 min. In areas where the epicentre distance is greater than 300 km, a few stations have weak disturbances. Regarding change characteristics of disturbance propagation velocity and wavelet transform spectrum relationship: the seismic propagation velocity after the earthquake reached 0.43–1.67 km/s and was caused by the acoustic wave generated by the earthquake. When the propagation speed is 2.31 km/s, the wave is caused by the mixed superposition of an acoustic wave and Rayleigh wave. For the disturbance propagation direction, the vicinity of the epicentre shows propagation in two directions, namely, to the northeast and southwest of the epicentre after the earthquake. The disturbance azimuth is 46°-68° and 201°-211°, and the azimuth of 46°-68° is approximately parallel to the boundary line of the Pacific plate.This study uses GPS data from 98 CORS continuous tracking stations to analyse ionospheric anomalies related to the Alaskan earthquake on July 29, 2021. The conclusions are summarized as follows:


A 20-valent pneumococcal vaccine (PCV20) was approved in April 2023 by the US FDA for use in children < 18 years of age. Routine use in infants consists of a 3-dose schedule followed by a booster dose between 12 and 15 months of age. In addition, a catch-up program for children previously vaccinated with PCV13 who remain at risk of disease associated with the 7 new covered serotypes in PCV20 can potentially improve direct protection and accelerate the onset of indirect effects in the population. This study evaluated the cost-effectiveness of a PCV20 catch-up program in US children aged 14– 59 months who previously completed the recommended PCV13 series.A population-based, multi-cohort, decision-analytic Markov model was developed to estimate the public health impact and cost-effectiveness of a PCV20 catch-up program from both a societal (base-case) and health-care perspective over a 10-year time horizon. In the model a single supplemental dose was assumed to be given to 63% of children aged 14-59 months who had received a complete schedule of PCV13. Input parameters for costs, disutilities, and epidemiology of pneumonia and otitis media (OM) were extracted from published data sources. Data on invasive pneumococcal disease (IPD) were based on published and unpublished (ABC) data. PCV20 effectiveness estimates were based on PCV7/PCV13 studies.The direct and indirect effects of a PCV20 catch-up program was estimated to prevent an additional 5,500 invasive IPD cases, 270,000 pneumonia cases, 0.6 million OM cases, and 1800 deaths compared to a 3+1 PCV20 program without a PCV20 catch-up program. This corresponds to a net gain of 30,000 life years or 55,600 QALYs. Most health gains were achieved due to the assumed accelerated indirect effects because of the catch-up program. Acquisition costs for the PCV20 catch-up program were offset by monetary savings from averted disease cases resulting in $800 million net saving. The catch-up program was also dominant from the health-care perspective.Implementation of a PCV20 catch-up program is expected to increase direct impact and accelerated indirect effects, more rapidly reducing pneumococcal disease burden and saving substantial health-care costs across the US population.Mark Rozenbaum, Ph.D., M.B.A., Pfizer: Stocks/Bonds Liping Huang, MD, MA, MS, Pfizer Inc.: Stocks/Bonds Johnna Perdrizet, MPH, Pfizer Inc: Stocks/Bonds Alejandro D. Cane, MD, PhD, Pfizer: Stocks/Bonds Adriano Arguedas, Medical director, Pfizer: Emplyee|Pfizer: Stocks/Bonds Kyla hayford, PhD, Pfizer: Employee|Pfizer: Ownership Interest|Pfizer: Stocks/Bonds Maria J Tort, PhD, Pfizer Inc: Stocks/Bonds Ruth Chapman, MSc, PhD, Pfizer: Advisor/Consultant Vincenza Snow, MD, Pfizer Vaccines: employee|Pfizer Vaccines: Stocks/Bonds Erica Chilson, PharmD, Pfizer, Inc: Ownership Interest|Pfizer, Inc: Stocks/Bonds Ray Farkouh, PhD, Pfizer: Stocks/Bonds Desmond Dillon-Murphy, MSc, PhD, Pfizer: Advisor/Consultant


Studying at university involves demanding academic and clinical training requirements for students from Psychology and other health-allied fields, potentially having severe physical and mental health implications. Existing training programs for addressing burnout have focused thus far on specific areas  with promising outcomes. However, no comprehensive programs have been developed to train students and staff in the early identification of burnout signs and characteristics as well as in self-assessing personal needs and habits , or in identifying community resources and evidence-based strategies to overcome burnout . This paper describes the content development, refinement, and piloting process of the BENDiT-EU program as part of a European collaborative to address academic burnout for health-allied students. Piloting results showed that participants viewed the program positively and provided helpful suggestions for content improvement and training delivery. Future research directions should target experimental investigations of the program’s effectiveness and the longitudinal interaction of burnout with other variables . This isSimilar findings have been found with Psychology and Nursing students e.g., . For exa2.2.1.As a distinct “occupational phenomenon” , academiA series of conceptual models were developed regarding burnout syndrome. Initially, the relationship between the three dimensions of burnout was understood as sequential, with exhaustion assumed to develop first (as a direct result of overload), followed by depersonalization , and culminating with feelings of professional inadequacy and inefficacy . Recent In sum, the three conceptual models guide researchers to identify ways  to support students’ socio-emotional needs by providing self-care information and facilitating student involvement in applying work-life balance practices.2.2.If not acknowledged and addressed, student burnout can have significant individual consequences  and highA series of specific factors may contribute to the emergence of burnout in health-allied academic environments. External factors typically include the significant demands of the academic program and clinical training , the lon2.3.Considering the prevalence of burnout among students and its negative consequences, prevention and intervention strategies and programs should be implemented. While many universities ensure students’ well-being and offer psychological services  , these eAccording to Current research suggests developing and implementing comprehensive training programs that could provide holistic and targeted support for burnout . Existin3.This study aimed to develop an innovative training program that provides students and staff with basic information about preventing, self-assessing, and managing burnout symptoms. The BENDiT-EU program envisions improving student well-being by (a) offering a personalized intervention plan based on student self-reflection regarding habits, needs, and responsibilities; (b) exposing participants to evidence-based intervention strategies to practice and then select suitable strategies to include in their individualized plan; (c) facilitating access to community resources, and (d) promoting inclusivity for all. Particularly, university students and staff with an international status may encounter adjustment hardships in addition to academic demands. The training content and activities have been designed to address ethnic diversity.Furthermore, the team’s objective was to make the program sustainable with a low cost-to-benefit ratio. To achieve this, the researchers collaborated with experts and students in Medicine and health-allied fields from different European countries to ensure social and content validity in the design and evaluation of the curriculum. The training program is the result of the European-funded project “Burnout Education, Normatives and Digital Tools for European Universities” (BENDiT-EU), whose task was to construct a comprehensive set of resources for Medicine and health-allied students and professionals to address academic burnout. For more information about the project’s consortium, targets, and outcomes, readers may visit the project’s website.4.4.1.The BENDiT-EU is a comprehensive program designed to help students and staff: (a) understand the main characteristics of burnout and its progression phases; (b) self-assess any burnout signs by utilizing online psychometric measures accessed via the BENDiT-EU platform; and (c) develop an individualized intervention plan to prevent burnout signs by identifying potential risk and protective factors as well as implementing strategies from the program’s toolbox. Specifically, the BENDiT-EU program includes two training modules and a resource guide for trainers (See section 4.2) . Table 1The first module is designed to provide a theoretical overview of academic burnout (Days 1–3), while the second module gives practical ideas on managing academic burnout and exploring individual and organizational resources to seek support services (Days 4–5). Specifically, Day 1 focuses on introducing the concept of burnout, exploring perceptions of burnout, and discussing its signs and symptoms. Participants engage in interactive activities such as working on case studies to identify burnout symptoms and consequences, pairing up to interview one another, discussing burnout in small groups, and completing a hands-on activity to visualize daily activities and responsibilities. Day 2 delves into academic burnout assessment. Participants learn about self-evaluation and assessment tools for academic burnout, complete assessments using the BENDiT-EU platform, and engage in reflection and discussion activities. Day 3 aims to identify ways to prevent and intervene. Participants discuss risk and protective factors for burnout, learn to identify early signs of academic burnout, and apply this knowledge through case studies. They also engage in activities designed to increase awareness of their daily routines and schedules and how these may contribute to or alleviate burnout. Day 4 centers on developing an academic burnout intervention strategy toolkit. Participants learn and practice various techniques for preventing and intervening, such as planning based on personal values, breathing exercises, relaxation strategies, cognitive behavioral therapy, and mindfulness. They also explore coping skills, social support and create an individualized “toolbox” for improving well-being and reducing academic stress. Day 5 aims to identify and discuss systems of support available to students dealing with academic burnout. Participants share their experiences with intervention strategies, learn about social support, and create a social network map. They also discuss strengthening their support networks, peer mentoring, and Balint groups.The BENDiT-EU program is designed to be inclusive for international participants. For each training day, there are specific prompts for trainers to consider for integrating local and international students in group activities. Specifically, case study scenarios during interactive activities incorporate the experiences of international students, and participants are tasked to analyze the cases based on guided questions. Trainers ensure that international participants are fully included in groups with appropriate accommodations .4.2.The train-the-trainer resource guide aims to equip staff from counseling or other health-related services with the necessary competencies and resources to effectively train students on burnout prevention and intervention strategies. As an additional component to the BENDiT-EU program, the guide offers essential information for preparing, delivering, and following the training sessions and practical teaching tips for adult learners.The first section of the resource guide focuses on preparing for the training, which encompasses two key aspects: (a) an overview of adult learning principles grounded in the theory of andragogy, as proposed by 5.As 5.1.The research team developed the program content based on an extensive literature review on academic burnout prevention and intervention see . The conThe training content was reviewed for coherence, clarity, and logical sequence by 10 research team members at an in-person meeting in Spain in July 2022. During this meeting, members were asked to present their assigned topic while soliciting colleague feedback to enhance the content and optimize the session delivery. The initial review concluded with each research member anonymously, evaluating the five training day presentations via a questionnaire and providing quantitative and qualitative feedback. When analyzing the qualitative comments, there were suggestions for improving the interactiveness and engagement of training activities with the inclusion of case studies representing diverse students, incorporating prompt questions for group discussion, connecting activities with the ideas of gender and culture, including practice activity about planning and organization, and opportunities for reflection on the activities. Suggestions were provided for strengthening the training content concerning gender differences in academic burnout, factors of burnout for international students, a circle of social network support, a list of resources for international students, and summarizing the main ideas after each training day. Managing training time effectively was an additional component that was raised. Content adjustments had to be made to ensure activity transitions were kept to a minimum and time for discussion and reflection during activities was sufficient.Following the internal review and evaluation, a revised draft was prepared and presented to 10 external academic faculty across five academic institutions in Bulgaria, Cyprus, Portugal, Romania, and Spain. The sample was purposive. The research team identified faculty who had not been involved in the project but had academic teaching experience to assess the content clarity and suitability for university students. Specifically, an assigned research member presented the modules to their colleagues at each institution, and then the latter provided qualitative feedback. All 10 participants were positioned favorably about the usefulness and necessity of the topic and its training content. They identified a clear balance between burnout theory and hands-on activities. However, four external reviewers suggested including a warm-up activity for Day 2 and making transitions more transparent at the beginning/end of each day by incorporating short revisions. The research team refined the program and then proceeded with the pilot in Phase II.5.2.In this phase, the research team piloted the program in a five-day training with 20 undergraduate students majoring in Psychology, Medicine, Nursing, and Social Work from five countries. Students participated voluntarily and did not present any severe burnout symptoms. At the end of each day, students were asked to evaluate their satisfaction and share feedback about the program  and its usefulness through an anonymous survey questionnaire using paper and pencil. Project staff members blind to the study’s purpose collected the questionnaires and gave them to the research team.5.3.After receiving student feedback in Phase II, the research team revised further the program content. They then started translating the program into Bulgarian, Greek, Romanian, Portuguese, and Spanish, using the English document as their reference. As a result, the BENDiT-EU program is now accessible in six different languages.6.This paper presented the content, development, and refinement process of the BENDiT-EU program for addressing burnout in students from Psychology, Medicine, and health-allied fields. This program responds to previous research inquiries about establishing comprehensive programs see  by folloThe comprehensive focus of the BENDiT-EU program envisions training students to maintain a healthy work-life balance . DespiteAnother significant aspect of the BENDiT-EU program is its collaborative nature. Partner universities have pooled their knowledge, resources, and expertise to create an inclusive and theoretically-driven program. This mitigates the need for individual institutions to create distinct trainings and cultivates the ground for a future European standard in preventing academic burnout.6.1.As with all studies, this study presents some limitations. First, the study utilized a small sample size to establish the program’s content validity. Future research should include larger samples with diverse student populations . A second limitation is the absence of experimental control to determine the program’s causality in reducing burnout. Future well-designed experimental studies could enable researchers to more accurately assess the impact of the BENDiT-EU program while controlling for potential confounding variables. Third, the program did not explore any cultural variations of burnout within the five participating countries, but it adopted the 6.2.The BENDiT-EU program has significant implications for practice. First, the training content and structure are designed to cater to the needs of different student populations on campus. As stated, each participant is guided carefully to prioritize their needs and life goals and then develop a customized plan using empirically-driven intervention strategies, including some that may be applied early. Second, the program could be offered campus-wide while maintaining flexibility to adapt the program’s interactive activities and examples according to each discipline. Finally, implementing the BENDiT-EU program across campuses and countries could have notable cost-effective advantages. By adopting a universal approach through interdisciplinary collaboration, the program can potentially lessen the financial burden on campuses when dealing with students’ mental health issues .7.The BENDiT-EU program provides a comprehensive approach to addressing student burnout. Unlike traditional methods focusing on isolated strategies, BENDiT-EU provides a holistic, customizable toolkit for burnout prevention and management. Its emphasis on early intervention and individualized planning could better prepare graduates for demanding professional roles while also improving the quality and cost-effectiveness of academic institutions. While more research is warranted, the program is a valuable stepping stone for future mental health interventions in academic environments.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by the University Research Ethics Committee/University of Nicosia. The studies were conducted in accordance with the local legislation and institutional requirements. The Ethics Committee/Institutional Review Board waived the requirement of written informed consent for participation from the participants or the participants’ legal guardians/next of kin because written informed consent had been provided as part of the ERASMUS project requirements.LK prepared the manuscript outline and performed the descriptive analysis and wrote the first draft of the manuscript. EP, LD, and OP-V contributed to the conception of the outline and wrote the sections of the manuscript. All authors contributed to the manuscript’s revision and read and approved the submitted version.


Childhood cancer survivors face education and employment challenges due to physical, cognitive, and psychosocial effects of the disease and treatments, with few established programs to assist them. The objectives of this study were to describe the implementation of Goal Attainment Scaling (GAS) to evaluate an educational and vocational counseling program established for survivors of childhood cancer, and analyze patterns of program engagement and client outcomes, stratified by demographic and diagnostic characteristics.A population‐based retrospective cohort study of childhood cancer survivors who were engaged with the Pediatric Oncology Group of Ontario's School and Work Transitions Program (SWTP) between January 2015 and December 2018 was utilized. Survivors were followed from SWTP engagement until May 30, 2019 to capture goal attainment. Individual goals were summarized across various demographic, disease, and treatment strata.In total, 470 childhood cancer survivors  set 4,208 goals in the SWTP during the study period. The mean length of observation was 130.8 weeks (SD = 56.9). Overall, 68% of the goals were achieved. Eighty‐three percent of the goals related to further education. Clients diagnosed with a solid tumor set the most goals on average, followed by those with central nervous system tumors and leukemia/lymphoma.The SWTP assists childhood cancer survivors in realizing their academic and vocational goals. Application of GAS in this setting is a feasible way to evaluate program outcomes. From the volume and breadth of the GAS goals set and achieved, the overall success of the SWTP appears strong. Childhood cancer survivors face education and employment challenges due to physical, cognitive, and psychosocial effects of the disease and treatments, with few established programs to assist them. The School and Work Transitions Program assists childhood cancer survivors in realizing their academic and vocational goals. Application of Goal Attainment Scaling in this setting is a feasible way to evaluate program outcomes.  Although the SWTP demonstrated qualitative evidence of success in a small group of clients,In an effort to better track individualized goals and related outcomes of each client, identify similarities and differences across clients, and to act as markers of success, the SWTP implemented Goal Attainment Scaling GAS17 in 20The objectives of this study were to describe the implementation of GAS in the SWTP, analyze patterns of program engagement, and use GAS to measure outcomes among SWTP clients, stratified by demographic and diagnostic characteristics.2In this population‐based retrospective cohort study, participants were childhood cancer survivors who were referred to and initially engaged  with the SWTP between January 1, 2015 and December 31, 2018. Participants were followed from date of initial engagement until May 30, 2019. This project was approved by the Research Ethics committee at the University of Toronto (Protocol No. 37234). This study is a secondary analysis of routinely collected data and was completed under a waiver of consent.Referrals to the SWTP come through Pediatric AfterCare Clinics at tertiary hospitals throughout Ontario , other health care providers, and self‐referral. SWTP counselors regularly attend AfterCare Clinics to ensure clinic staff and potential clients have an understanding of the program and services offered to encourage and facilitate client referrals. The referral process requests that one or more referral reasons, selected from five broad areas  be identified which are then prioritized by the counselor and client. Following referral, potential clients are contacted by one of the SWTP counselors in the province and enrolled in the program if they are interested. Counselors work with clients to define and support their academic, vocational, or community services support goal(s) via in‐person meetings, telephone calls, or through electronic correspondence. Clients with SWTP experience prior to 2015 were excluded from analyses as the GAS system was not fully implemented. Referred clients who chose not to engage with the program after initial contact were also excluded since no goals were set. The timing and amount of support provided to clients varies as client needs change.GAS was used to quantify clients' progress in achieving goals. SWTP counselors worked with clients to set feasible goals that were client actions and were agreed upon by both client and counselor. Generally, the goals were personally meaningful and followed the SMART framework, that is, specific, measurable, attainable, relevant, and time‐bound.Members of the implementation team and all counselors underwent a one‐day training session on the development and implementation of GAS goals. During this face‐to‐face, hands‐on training counselors were able to develop goals using client scenarios, followed by group discussion on how the goals could be improved. As part of the SWTP, counselors meet regularly to discuss program issues and during the preliminary implementation phase, time during these meetings was devoted to collectively discussing GAS goals. Any questions that were not able to be addressed among their own community of practice were discussed with the implementation team. As new counselors joined the program, the SWTP Manager provided in‐depth orientation and training to GAS goal setting to ensure consistency across the program.To begin using GAS to measure SWTP outcomes, all client goals set in a preliminary period of 6–8 months were examined by two members of the implementation team (JDP and BW) to identify common domains of practice and goals set with clients across sites. The creation of standard goals was necessitated by counselor time constraints and the associated additional time needed to create each GAS goal de novo. After reviewing several hundred GAS goals set by five counselors, repetition in goals was evident. From this effort, 15 standard goals were established .2.2Overall, the analysis as planned was descriptive in nature with the number, type, and outcome of the GAS goals examined and stratified by demographic and disease factors. The analysis stratified participants into three broad diagnostic groups according to the first primary cancer  tumors, and other extracranial solid tumors). These groups were selected due to general physical and cognitive deficits experienced as resulting from diagnosis and treatment. Length of engagement with SWTP was examined by categorizing the duration into five periods: 0–<1, 1–<2, 2–<3, 3–<4, and 4+ years. Given that the length of engagement with SWTP was thought to impact the number and type of goals set, a stratified analysis was undertaken that examined the outcomes in the first and second half of the total length of SWTP engagement. Only clients that had GAS goals set within both first‐half and second‐half of their engagement period were considered for the stratified split‐half analysis. Raw GAS scores were converted to T‐scores following the Keresuk and Sherman method before all analyses.3There were 470 study participants (clients) who had their first referral and engaged with SWTP between January 1, 2015 and December 31, 2018. Of these, 259 participants had multiple engagements (re‐engagement) with SWTP over the period of observation.Table When considering differences in demographic and disease characteristics by length of engagement with SWTP (data not shown), those participants with engagements of 4+ compared to 1–2 years had a higher proportion of males (63.8% vs. 53.7%) and a diagnosis of leukemia/lymphoma (61.7% vs. 50.4%). There was a lower proportion of solid tumors (19.2% vs. 25.6%) and the median age at diagnosis was also lower (5.5 years vs. 9.8 years) in the 4+ versus 1–2 years engagement groups.Table The solid tumor group set the highest average number of goals  followed by the CNS group (9.4) then the leukemia/lymphoma group (7.8). Goal achievement was similar among the diagnostic groups ranging from 67–70% achievement. The CNS group set the highest proportion of community resources goals (16%) followed by solid tumors (9%), and leukemia/lymphoma (5%), with each group having similar levels of goal achievement. Similarly, the CNS group set the highest proportion of education goals (87%) followed by leukemia/lymphoma (82%) and solid tumors (80%), although the CNS group achieved less of their educational goals  compared to the other groups (each with 70%). The solid tumor group set the highest proportion of employment/volunteer goals (35%), followed by leukemia/lymphoma (29%) and solid tumors (24%) with the leukemia/lymphoma group having lowest proportion of goal achievement (62%) followed by solid tumors (68%) and CNS (72%).When examining GAS outcomes stratified by age at initial engagement with SWTP (data not shown), there was little difference in achievement by age . The 19–22 years old set the highest proportion of community resources goals (3.3%) followed by those aged 23+ (3.1%) and then the <19 (1.6%). Those aged <19 year set the highest proportion of education goals (74.5%) followed by 19–22 (59.7%) and then the 23+ years old (39.5%). Those 23+ years old set the highest proportion of employment/volunteer goals (45.3%) followed by those aged 19–22 years (21.6%) and then the <19 years old (9.4%).The split‐half analysis assessing if the length of engagement with SWTP impacted on the number and type of goals set, utilized only 394 participants . Overall, participants were setting 1.3 times more goals in the earlier period compared to the later with the greatest difference in the solid tumor group (1.7 times), followed by the CNS group (1.3 times), and the leukemia/lymphoma group (1.2 times). The proportion of achieved goals is similar comparing the early to later period in the leukemia/lymphoma group (69% vs. 66%), with small differences in the CNS group (69% vs. 64%), and the largest difference in the solid tumor group (74% vs. 65%).Table 4The POGO's SWTP is a unique counseling support program for survivors of childhood cancer. Given that the structure of the program is fundamentally an individual one‐to‐one counseling experience, assessing global program outcomes is difficult. GAS was successfully introduced to the counseling service. SWTP created a standardized set of goals and integrated this into the electronic charting system, allowing us to characterize the academic and vocational goals of childhood cancer survivors, understand SWTP counselors' impact in helping survivors achieve their goals, and identify gaps in service provision. Application of GAS in this setting is feasible as evidenced by the high average number of goals set for each client.The characteristics of the clients who engage with SWTP are reasonably representative of the childhood cancer survivor population in Ontario with the notable difference being the higher proportion of male clients. Whether this is due to referral bias, or that males seek the support offered by the SWTP more often than females is unclear and requires further research. Female participation has been more common in late‐effects research and counseling intervention programs for childhood cancer survivors.When considering the pattern of goals set and the success of achieving them, it was surprising that the CNS group did not have the highest number of goals set or the lowest success. Given the often complex physical, cognitive, and social deficits that are associated with surviving a CNS tumor,As expected, the number of goals set in the first half of the client engagement period was higher than the second half possibly owing to counselors making the initial goals smaller and less complex until they learn more about the individual client and the client's personal commitment to achieving the goals.Previous work has identified that childhood cancers survivors utilize special education services nearly three times more frequently than sibling controls and overall educational attainment is reduced and related to specific diagnostic and treatment sub‐groups.The small number of goals set in the community resources domain should not be interpreted as a lack of interest by the clients for assistance in these areas. Although only a small number of clients set goals in this area, access to these community services is vital and can be complex. Clients may not be aware of available services and resources in the community and the SWTP program serves a special niche in providing clients with assistance in identifying and engaging with these difficult to access resources.A 2015 review highlighted the special psychosocial, health‐promotion, and neurocognitive needs of adult survivors of childhood cancer.The SWTP offered to survivors of childhood cancer in Ontario, Canada appears to be unique. The program has good engagement with clients, who come to the program with multiple goals. The overall outcome of the program appears positive, is valid across diagnoses and for several groups of issues. The success is likely a result of the one‐to‐one counseling model where client‐counselor relationships can drive individual progress toward education and employment goals to bolster and support survivors toward a productive and rewarding future. Similar programs to the SWTP delivering direct‐to‐client services to survivors of childhood cancer should be considered as part of routine long‐term follow‐up care.


The global extant literature acknowledge that housing serves as a key social determinant of health. Housing interventions that involve group homes have been found to support the recovery of persons with mental illness and those with addiction issues. The current study explored the views of homeowners in relation to a supportive housing program called Community Homes for Opportunity (CHO) that modernised a provincial group home program  and provided recommendations for improving the program implementation in other geographical areas of Ontario.We applied ethnographic qualitative techniques to purposefully recruit 36 homeowner participants from 28 group homes in Southwest Ontario, Ontario Canada. Focus group discussions were conducted at two time points, during CHO program implementation  respectively.Data analysis yielded 5 major themes. These include: (1) general impressions about the modernization process, (2) perceived social, economic and health outcomes, (3) enablers of the modernization program, (4) challenges to implementation of the modernization program, and (5) suggestions for implementation of the CHO in future.A more effective and expanded CHO program will need the effective collaboration of all stakeholders including homeowners for successful implementation. The global extant literature acknowledge that housing serves as a critical social determinant of health –5. Yet, Supportive housing is a program where staff provide various support services within the tenants’ residences. Supportive housing is provided in multiple housing types, including group homes, clustered apartments, and halfway homes , 16. OveSupportive housing models are guided by housing first principles to aid recovery with less emphasis on pathology while emphasizing rehabilitation. Supportive housing frameworks also foster individual strength-building where the consumer is seen as an expert and part of the shared decision-making process that promotes autonomy in the end . OverallThe current study (Community Homes for Opportunity [CHO]) falls within the confines of supportive housing and applies Housing First principles to provide housing stability and enhanced community integration for tenants. The overall goal of the CHO is to assist tenants in integrating into the community. The CHO is a person-centered community-based housing model that offers institutional care through meals and 24-h staff support. The CHO program promotes tenants’ recovery, autonomy, and community integration while encouraging them to participate actively in their care regarding goal setting, planning, and individual choices.Supportive housing programs such as the CHO that provide combined formal  and informal on-site supports that include homeowners, and their staff, are effective in reducing homelessness , 23–25. The public health impact of unstable housing on persons with mental illness, including addiction problems, is well documented in the extant literature , 6–9. WhThis study was part of a larger mixed-methods research project that was conducted to evaluate the ‘Phase One Homes for Special Care (HSC) modernization program’ within 28 homes operating through St. Joseph’s Health Care London within a geographic area encompassing the former catchment areas of London and St. Thomas provincial psychiatric hospitals in Ontario, Canada. This evaluation examined the nature and experiences of homeowners (Private operators of the homes that adopted the CHO program) in response to the changes being made.The CHO is a modified version of the Homes for Special Care (HSC) program . The HSC was administered through the hospitals’ former psychiatric system with 24-h availability of staff, meals, supervision, and assistance of tenants with activities of daily living. Although the HSC provided some form of supportive housing, it was more custodial and did not offer tenants autonomy and choice  . TherefoSince 2018, the CHO has provided individuals access to subsidized group housing with support where staff with expertise offer care and ongoing assistance to promote growth and independence. To enable tenants to achieve this integration, they receive increased financial support and assistance with life skills through a variety of activities and programs, including furthering education, financial literacy, and personal hygiene, managing their resources, and taking part in leisure activities of their choice within the home and the community. Tenants are also paired with a community social worker for extra support in the home and the community for improved physical and mental health.The research explored the views of homeowners concerning the process and outcomes of the CHO implementation program in South-West Ontario using focused ethnographic techniques. The focused ethnography design was deemed fit for examining the nature and experience of the homeowners because it facilitates a timely investigation of health problems within a relatively short period compared to classical ethnography, which requires engagement over a prolonged period –29. The Twenty-eight homes serving 368 tenants were included in the evaluation of the CHO program implementation. After explaining the purpose of the study and gaining consent, the homeowners whose homes were already part of the CHO implementation program were enrolled in the study. In all, 36 homeowners were enrolled in the study.n = 10) and 12 focus groups (n = 26) participants during CHO program implementation  and post-implementation phases (Winter 2019), respectively. Over the period, focus groups were conducted with different homeowner groups. The participants did not necessarily have to join the same group at the two data collection points. This variety among participants improved the group dynamics while enhancing diverse opinions from the homeowners.The current study was approved by the Western University Health Sciences Research Ethics Board (HSREB). Posters announcing the research were distributed in the CHO homes for participant recruitment. Focus groups were conducted with the homeowners to identify issues, solutions, and recommendations for improving the CHO. We used focus group discussions to gain an in‐depth understanding of the homeowners’ perspectives concerning social change among their tenants and the homes. Before the commencement of data collection, the researchers reiterated the study’s objectives, after which they obtained written informed consent from each participant before starting the focus groups. Focus group discussions took an average of 50 to 90 min each. The focus group discussions dwelled on the following questions: (1) What is the context/circumstance of the home? (2) What are the factors/issues that you perceive as barriers and facilitators while implementing the modernized program? (3) What are the perceived benefits and challenges of implementing the modernized program? (4) What are the modernized program's health, social, and economic outcomes ? (5) What do you recommend to improve the service? Data were audio-recorded and then transcribed verbatim by two research team members. Note-takers gathered information about group dynamics, context, and non-verbal communication, which were later integrated into the transcribed data to augment research findings. The homeowner focus groups were conducted at two-time points. The 36 homeowners who took part in the study participated in 19 discussions, i.e., seven (7) focus groups . The majority 61%) of these participants were female. About 70% of the homeowner participants were aged 40–59 years. See Table % of thesData analysis yielded five (5) major themes with several subthemes. The major themes identified included: general impression about the CHO program, perceived social, economic, and health outcomes, enablers of the program implementation, challenges to effective program implementation, and suggestions for the effectiveness of the CHO intervention. See Table The homeowners revealed how they perceived the CHO program. Their views pertained to opinions they had formed during the CHO implementation period in relation to the impact of the program. Some of their impressions include positive perceptions about CHO and cordial interpersonal relationships among tenants, staff, and homeowners.Some homeowners expressed positive feelings about how the CHO program was being implemented. They felt they were getting extra coverage under the new housing intervention compared to the old program (the HSC). For instance, under the new housing intervention, homeowners get paid some money when a tenant moves in and when they incur an empty bed due to someone moving out of the house.With the HSC [previous program], it was very centralized. We had restrictive legislation for HSC. With this new program, two things are accomplished. Tenants not only have the backing through the Community Agency, they have the encouragement of the CHO program.This participant expressed;The 60 days payable empty bed is a plus, the transition pay for 90 days is $5/day. When somebody moves in, we get an extra $5/day to compensate for the increase in workload. I feel I have more support to take care of tenants. If [I] have an emergency I know they will support me.Another participant revealed;In addition to the Positive Perceptions about the modernized program, homeowners mentioned the development of healthy interaction between stakeholders such as the CHO workers and the tenants. The CHO staff built good relationships with tenants to the extent that some have been helping tenants in managing their money. Such working relationships and support for tenants contribute immensely to their autonomy vis-à-vis day-to-day life. Healthy relationships between the workers and tenants were vital to homeowners because positive relationships enhance therapeutic relations and tenant experiences of satisfaction, adherence to treatment modalities, and improved quality of life , 32. A pThe modernized program offers the tenants more opportunities to be involved in the community. Even individuals who previously had no interest in taking the bus had started going out on their own more than they did with the previous program (HSC). The enhanced funding enabled the tenants to embark on various social activities that improved their social acceptance and inclusion. This participant revealed; “CHO has rewarded them [Tenants] more opportunity to get into a community and back with transportation. The funding change has a greater effect on this home. So there’s more opportunity”. Another participant said; “There are things that they want to do, and it’s coming out. And even individuals who don’t take the bus are now thinking about taking it”.Some homeowners observed that tenants were now getting a lot of financial assistance from the increase in the amount of money. Their tenants had money to do the things they needed to do. For instance, homeowners mentioned that tenants were more receptive to getting engaged in a lot more activities outside the home. Despite this positive observation, some homeowners disagreed with the financial choices of some tenants and commented that tenants were misusing the monies they were receiving (not using the money for the intended purpose). Despite the glitches, the homeowners described the CHO as an incentive for improved engagement in leisure activities for tenants. A participant expressed; “Some clients are enjoying [because of] the increased amount of personal needs allowance. For others, it’s been a wonderful bonus. [They] can manage things well”.We had some problems, the increase in personal needs allowance for the residents has created in a positive way a lot of cases, but it also created some mini monsters around too; people refusing to look after what the money was intended for, example, haircuts. Now they’re saying, ‘I don’t have to’.This participant revealed;Despite initial fears among some homeowners about introducing the CHO intervention, focused group discussions with these landlords revealed improvement in the standard of health, comfort, and happiness among tenants. The positive progress with the CHO gave hope to the homeowners about the prospects of the program.In terms of modernization, I think it’s critical that it [CHO] continues, not only because of all the work that’s gone into the first portion of it but just from a basic understanding that, from a quality of life perspective there’s been great gains. The positive impacts certainly have outnumbered [the negatives] 2-foldA participant stated;We’ve seen a presence [referring to CHO] for a year now and there’s been a huge change in their [tenants] behaviors. Very receptive and opening up. That’s the biggest plus. For sure there’s way more positives than negatives. I’d say, excellent!Another participant said;Homeowners compared the CHO with the HSC. They concluded that the modernized program was more adaptable to the current needs of the tenants in fostering individuality, independence, human rights, and autonomy toward recovery and community integration. Improving tenant autonomy and independence was one of the key underlying principles of the supportive housing project, CHO. According to most homeowners, many tenants began making decisions on their own, and doing things they felt could benefit them. Only a few needed some form of guidance from time to time. Sometimes the landlords needed to consult with the tenants before certain activities were undertaken including food choices, and groceries among others. Such interactions proved healthy for both parties  in navigating the therapeutic trajectory.So, we’ll say do you have a grocery list that you take? It’s not like ok you’re getting this food, it’s like ‘what would you like, what do you want to eat?’ Yea, like we follow the Canada food guide. So, there’s meat, there’s vegetables and we make sure the meals are balancedA homeowner said;We’ve provided locked space for each of the tenants here. We did some closet adjustments and put some walls between closets that used to be shared so that everybody can have their own secured locked space. So, we did that, and it’s worked out very well…Yea more independence, more decisions for themselvesAnother participant added;The effective communication processes occurring between stakeholders  build strong bridges that are good for strengthening service delivery to the clients through easy access and less cumbersome referral procedures to the homes. The community agency acts as a centralized agency, liaising with homeowners and aiding people with mental illness with appropriate support. A homeowner disclosed; “…numbers have been up because there’s more access to more referrals… our homes are filled now with tenants. The fact that there’s cooperation in everybody targeting this new CHO is probably the best thing about it right now”. Another participant intimated; “The Community Agency is taking the referrals in for CHO. So, when they get a referral in, they’re able to now streamline it to the most appropriate housing for that individual. I think it’s beneficial for the clients.”Focused groups with homeowners revealed that some of them were satisfied with the payment mode of their monies even though there was room for improvement. They believed the decentralized system with Community Agencies in the modernized program was more effective in addressing pay issues more quickly than the centralized system at the hospital which previously existed. They were confident prompt payments would go a long way to strengthen their service delivery towards an effective and sustained CHO program. This participant said: “I mean a big challenge for homeowners is pay but that’s been going alright. The funding is fine. I mean they were late a few times in the beginning, but they’ve rectified that”. Another participant added: “We’re not getting paid statements, but money is flowing into our accounts…money is flowing which was a worry in the beginning…we got paid by the ministry as well so this should really be a good thing”.Focus group discussions with homeowners yielded a variety of opinions. For instance, the participants identified the absence of clear guidelines and tools, including job descriptions and responsibilities for workers in the homes, leading to role confusion and, in some instances, strained relationships between some stakeholders. Some participants believed the absence of a uniform structure provincially was hampering the effectiveness of the CHO program.We argued from the very beginning [that] if you want this to have a provincial feel to it you’ve gotta give provincial structure and you’re gonna build this in collaboration with the agencies. For the basics of how the money is gonna flow and what the forms are gonna look like, and what is and is not okay for an agency to do, there are no framework so we’re seeing such inconsistencies across agenciesA participant disclosed;Planning from the beginning was huge and they [Community Agency] made it very clear that CHO would be implemented, and we’d still be building it, you know so, that was made clear to us but even with that statement I think it’s falling short of what everybody should be doingAnother participant added;Some homeowners complained that rooms in the home were small and therefore could not fit lockers as was directed by the community agencies. The lack of space in the homes was one of the major challenges affecting tenants’ comfort and privacy. A homeowner disclosed; “You know like I said it depends on the home like my home doesn’t have room for lockers, like you can go and see the rooms how small”.The space in the home is maximized with what we have. We have a kitchen, she [Community Agency staff] can sit in the kitchen with people, she can sit in the dining room with people. That’s generally what she does; she’ll sit at the dining room table and take up the whole table with her papersThis homeowner expressed some concerns;Some homeowners who participated in the study complained about the seeming lack of funds and relevant resources for running the home activities. Whiles some bemoaned the lack of incentives, others criticized the funding model due to some inconsistencies in reimbursement. Funding had not increased to match the current cost of living. Homeowners, therefore, had to make an additional budget and pay out of their pocket for repairs and maintenance and additional food due to limited funds.You pull your hair out…we don’t work on volume and we can’t afford it, we can’t afford to pay our staff, and that’s why we can’t keep staff either, it’s a big turnover. The funding is shrinking dramatically with the amount of work we’re having to pick up and doA homeowner disclosed;… You know we have a budget here because we’re very limited with money and that’s another thing too. We’re going to do like a cooking class; to bake cookies or bake whatever and the thing is it’s stuff we don’t use on a regular basis. We don’t have the money for thatAnother homeowner said;Focused group discussions revealed the need to offer continuous help to tenants in relation to how they spend their money and their choices. The homeowners also identified a lack of financial literacy. By this, some tenants were found to have difficulty managing their finances. They engaged in wasteful spending  major themes. These include general impressions about the CHO intervention, perceived social, economic, and health outcomes, enablers of the modernization program, challenges to the CHO implementation program, and suggestions for future implementation.Supportive housing is generally reported to be effective among vulnerable populations faced with complex life challenges such as individuals with persistent mental illness or families experiencing homelessness , 33–35. Homeowner participants of the current study expressed positive opinions about the modernization process of the HSC to CHO. The homeowners held positive perceptions of CHO. They also expressed a high level of optimism about the success of the housing program due to the cordial interpersonal relationships among tenants, staff, and homeowners. Such strong relationships among all stakeholders including landlords and the network of tenants (consumers), clinicians (staff), and managers are vital. Effective relationships in group homes have been found to encourage landlords to readily consult with the rest of the service team members when problems arise in the homes . Again, The ‘good feelings’ about how the CHO program was implemented transcended most homes due to the extra coverage (support) the homeowners were getting under the new housing intervention compared to the old program (the HSC). For instance, under the new housing intervention, homeowners get paid some money when a tenant moves in and when they incur an empty bed due to someone moving out of the house. This gesture by the stakeholders aligns with positive reinforcement theories of motivation as espoused by Thorndike  where hoFindings from the study established that even though the homeowners had positive impressions about the CHO program in relation to the benefits that accrued to them, some still encountered problems and provided suggestions to further improve the existing program. During the implementation of the CHO, the participants encountered problems that have implications for the quality of life and well-being of their tenants , as poorSupportive housing is a combination of housing and services intended as a cost-effective way to help people live more stable and productive lives . SupportOverall, this CHO study expands on the Housing First literature in terms of (1) tenants receiving needs-driven supports, (2) tenants receiving improved financial support to cater for their needs (3) teamwork/collaboration between stakeholders i.e., homeowners, social workers, and the in-house support staff and (4) structured tenant community involvement and socialization activities for improved empowerment and integration. In all, the study underscores a need for good communication, enhanced resource allocation, and the involvement of homeowners during the planning and execution of all program activities in the participating homes for improved outcomes.Despite the challenges that homeowners experienced, study findings revealed that the participants perceived the CHO program as beneficial for the growth and development of their tenants toward social integration. The successful implementation of the CHO in the London-Middlesex area, emphasizes the need for future implementation of the CHO provincially.Homeowners’ perspectives on the CHO program provide key insights for wide stakeholder involvement and consultation that includes homeowners’ views regarding their input for the successful implementation of the CHO in other jurisdictions. The study also provides tips for policymakers and Community Mental Health Agencies towards strategic planning along with needed investment that is more tailored to the needs assessment of each home for optimum services and outcomes. Overall, the CHO emphasizes housing as a key step towards recovery for persons with mental illness and addiction.One of the strengths of this study is the fact that it highlights the active involvement of homeowners in all stages of the CHO implementation. Not only was the study undertaken in the participants’ settings, but it also provided the homeowner participants an opportunity to express their views (in terms of their experience) with the previous model (HSC) and the modernized program (CHO) respectively. The ethnographic approach facilitated homeowners’ participation that generated relevant findings that helped to uncover the actual nature of the program as well as enablers and barriers to the effective implementation of the modernized program.However, we acknowledge that the findings of this study are based on the experiences of a group of homeowners in relation to the implementation of a particular housing program in response to a peculiar situation. Therefore, these findings may only transfer to contexts and settings like this study’s milieu. We also believe that personal experiences are time and context-dependent. Therefore, the homeowner’s views about the CHO program may change with time. As such, there is a need for continuous evaluation to ascertain other realities that may not have been captured by the current study for update or redress.Supportive housing models such as the CHO constitute an effective pathway to ending chronic homelessness for people with mental illness or addictions. Homeowners play significant roles in making houses to become comfortable and secure homes for tenants.A more efficient and expanded CHO program will need the effective collaboration of all stakeholders including homeowners for successful empowerment and integration of persons with mental illness and addiction. It is hoped that standardizing such organizational functioning of the CHO will improve transparency and collaboration between stakeholders while addressing power relations and philosophical differences that homeowners perceive to exist.


This article was migrated. The article was marked as recommended.Objective: The PreDoc program is a longitudinal apprenticeship aimed at increasing college student interest in pursuing a healthcare career. This program offers the continuity of clinical, research, and educational exposure in academic medicine utilizing a career immersion approach that allows a graduated level of responsibility, experience, and leadership opportunities.Methods: Students get an asynchronous/synchronous curriculum under the direction of academic physicians committed to boosting the pipeline. Training in critical career development skills including “goal setting,” professionalism, communication, and time management are provided to Pre-Docs by their senior peers and program leaders.Results: Since the implementation of the PreDoc program in 2013, 28 students have enrolled in the program. Twenty-three students completed the survey; 100% ranked the program quality as good/excellent. Students reported more interest in academic medicine , neurology , and sleep medicine . A majority of the students reported that they were extremely likely to pursue a medical career . All students have completed or are in the process of completing at least one scholarly product.Conclusions: The PreDoc program has been successful in promoting college student scholarly productivity in healthcare and in garnering student interest in academic medicine, particularly in neurology. Of the 50,000+ self-identified “premed” students applying to medical school, 90% of those who eventually earn an acceptance report “working” with a physician or other healthcare professional before medical school matriculation AAMC-2017. HoApprenticeships allow individuals to develop a professional identity through socialization, mentorship, and experiential learning opportunities. Although healthcare has long embraced the apprenticeship paradigm, the true impact of these apprenticeships is unclear due to limitations in program uniformity or formal assessment of the short or long-term professional development outcomes for the learner. Early career exposure and interactions with positive role models within the profession, is pivotal in increasing the pool of pipeline talent into a particular field (There were three primary objectives of this pilot study: (1) to characterize the goals and objectives of the Pre-Doc program, (2) to define the steps and methods for implementing the Pre-Doc program, and (3) to define and measure the Pre-Doc program efficacy outcomes. Program efficacy was assessed based on the following three outcomes: (1) students’ satisfaction with the PreDoc program, (2) students’ interest and likelihood of pursuing career in heathcare, and (3) students’ scholarly productivity and overall program academic engagement.This study incorporated neurology preceptors and college students enrolled at Johns Hopkins University (JHU) from 2013-2017. The institutional review board approved this study and students signed a consent form.The mission of the PreDoc program is to provide a modern apprenticeship that allows the apprentice  to engage in the development of critical skills necessary to be successful in healthcare. The apprenticeship incorporates an organizational structure of a traditional medical residency program  to provide college students with an accelerated exposure into the medical training paradigm, and to gain some familiarity with the growing focus on team-based delivery of healthcare that involves various stakeholders . As they progress in the program, the PreDocs receive critical professional development skills training  inarguably viewed as essential in demonstrating leadership potential. Although the program has five formal and established goals, it also offers versatility in both the educational exposure and project opportunities. These five goals of the PreDoc program are: (1) To execute an effective program using a novel, efficient curriculum that fosters development of the professional skills necessary for being a successful in healthcare; (2) To execute an effective program that cultivates an educational environment that facilitates excitement and innovation about healthcare; (3) To execute an effective program that cultivates an educational environment that promotes successful scholarly activity; (4) To execute an effective program that fosters an inclusive environment that promotes diversity; (5) To expose premedical students to interprofessional collaborative practice in healthcare.The PreDoc program is a credited course, thereby ensuring students are accountable. Each year, the program takes two to five students  into the Academic Medicine Preview (AMP) as the initial step : “Figure 1 PreDoc Overview”, Part A). Prospective students first apply for a position by completing an application and interview. Chiefs (senior PreDoc students), under the guidance of the director(s), review the applications, complete the interviews, and offer the positions to selected students. Once selected, students set learner goals  for the It is the intention that most of the interns participating in the Academic Medicine Preview class will be selected to participate in the PreDoc program (similar to interns advancing to residents). However, this is not a guarantee. Interns must be engaged and invested in the program to be selected as PreDocs, be reliable and demonstrate an “in it to win it” attitude to be part of the team. In this way, students are more accountable and committed to the program. To personalize the opportunities to the learner interests, students meet with the director to determine interests and focus areas . For example, the director may ask the PreDoc to reflect on their time in the AMP and recall the “mini-projects” engaged in over the last semester to identify particular interests (SF: “Table 2 Student Activity Tracker Examples and Narratives”). There are also opportunities to recognize interests not previously exposed. The director then identifies a main project to match the PreDoc’s interest with the scholarly opportunities that are available.p-value of < 0.05 was considered statistically significant. All students enrolled into the AMP and PreDoc Program were eligible for inclusion in the study.Program effectiveness was assessed by number of scholarship products , activity tracking, reflections, and satisfaction. An anonymous, online internally developed survey was also administered via Qualtrics at the conclusion of the program to assess student demographics, students’ satisfaction with PreDoc Program, and PreDoc program influencing students’ interest and likelihood of pursuing a career in healthcare. Data analysis was blinded and not performed by the directors. The number and percentage of the potential responses to each of the survey items were calculated. To examine demographic differences  across the survey items, Fisher’s exact tests were run due to the small sample size. ATwenty-eight students participated in the PreDoc program since 2013 (SF: “Table 3 Participant Characteristics”). Most students were program alumni (PreDoc post-graduates), but the student population also included current PreDocs and interns (AMP Students). At the conclusion of the program, most students completed at least one “mini-project”, with the rest completing their project in the upcoming year. Moreover, 30% of alumni completed  three or more products .). Following the PreDoc program, most of the alumni were already in medical school or have been accepted into medical school. The rest of the alumni pursued a master’s degree or a science profession  and were in a gap year with plans to enter a health related field . Five  of 28 students did not complete the surveys regarding the satisfaction with the PreDoc program.p<.01), feeling the director’s feedback was extremely useful (p<.01), and feeling the program was useful in deciding on a medical career (p<.05). No gender and race/ethnic group differences were observed. Narrative comments were also collected (SF: “Table 3 Participant Characteristics”).All of the students reported the overall quality was good/excellent (SF: “Table 4 Program Influence”). Most of the students reported that they (a) learned a great deal (65%); (b) the expectations for the program were the right amount (70%); (c) the program’s assignments were very/extremely useful (57%); (d) the director’s feedback was very/extremely useful (64%); (e) the director exhibited concern about them (100%); (f) the program was very good/excellent in assisting them in deciding on a medical career (78%); (g) would recommend the program to a friend (87%). Compared to current and intern students, the alumni students were more likely to report learning a great deal from the program (p<.01), a larger proportion of the interns reported an extremely likely plan to pursue an academic medical career (p<.05). Latino/Hispanic and Black students were more likely than East/Southeast Asian and Non-Hispanic White students to report uncertainty or not having an interest in pursuing a career in medicine (p<.01). No gender differences were observed.As a result of the program, most of the students reported that they were more interested in academic medicine (83%), neurology (78%), and sleep medicine (78%) (SF: “Table 5 Student Satisfaction”). Although most of the students reported that they were extremely likely to pursue a medical career (87%), a high frequency of students reported that they were somewhat likely to pursue an academic medical career (48%). Although a larger proportion of alumni students reported much more interest in academic medicine as a result of the program  using neurology as the learning environment is both feasible and effective. Here, students are introduced to various aspects of healthcare without promoting neurology explicitly but instead offering neurology as the specialty avenue to gain exposure to healthcare.The design of the program is geared towards today’s learners. The current generation values opportunities for personal development to help understand and maximize their individual strengths . StudentThe directors of the PreDoc program were initially junior faculty members when this program was created and were also the clerkship co-directors in neurology. This connection was important to provide opportunities for the PreDocs to engage with medical students and house staff. While there is no full-time equivalent (FTE) support for the directors through the PreDoc program, productivity benefits were considered of value to sustain involvement. The program is currently composed of four key faculty members . Further, the co-directors now have other leadership roles  which provides more opportunities for PreDocs. While PreDocs are exposed to other faculty and healthcare members, the core is kept small intentionally to promote a tight leadership unit.Exposing PreDocs to a diverse group of faculty and healthcare leaders has been a strategic goal for this program, especially since medicine continues to address a widening gap in the number of under-represented in medicine (UIM) physicians. The two PreDoc co-directors are UIM female faculty. Allowing students to work closely with faculty who represent diverse backgrounds affords the opportunity for students to implicitly and explicitly envision themselves or others (regardless of background) in healthcare roles and even rising into leadership roles. While 83% of students were more interested in academic medicine and 78% were more interested in a career in neurology, Latino/Hispanic and Black students were more likely to report uncertainty or not having an interest in pursuing a career in medicine. This may be skewed as many of these students are either interns or current PreDocs and are still figuring out their interest. Future investigation regarding the unique role that apprentice and preceptor demographics plays in the program outcome metrics are critical for understanding optimal models that maybe unique for enhancing the pipeline for UIM talent. While this is only pilot data and the program is still in the early stages, one cannot argue the premise of introducing healthcare to college students in this thoughtfully created environment may be a novel way to strengthen the healthcare pipeline.The PreDoc Program offers an effective, structured academic medicine apprenticeship that prepares students for a career in healthcare with increased interest in academic medicine. The program incorporates new approaches proven to be effective in the business arena for career development that integrates a diverse perspective and engages a vertical horizontal team-based approach modeled after a medical residency. The PreDoc program also provides an earlier opportunity and platform for students to develop an appreciation for scholarly productivity, career coaching and professional development.•The PreDoc program is a longitudinal apprenticeship aimed at increasing college student interest in pursuing a healthcare career.•Training in critical career development skills including goal setting, professionalism, communication, and time management are provided to Pre-Docs by their senior peers and program leaders.•Students reported more interest in academic medicine, neurology, and sleep medicine.•All students have completed or are in the process of completing at least one scholarly product.•The PreDoc program has been successful in promoting college student scholarly productivity in healthcare.https://orcid.org/0000-0002-3945-3336Rachel Marie E. Salas, MD, MEdHP, FAAN is an Associate Professor, Neurology and Nursing at Johns Hopkins Medicine Director of Interprofessional Education and Interprofessional Collaborative Practice for the School of Medicine; Director, Neurology Clerkship Director for the School of Medicine, PreDoc Program for the Johns Hopkins University. ORCHID:https://orcid.org/0000-0003-0072-5151Alyssa A. Gamaldo, PhD is an Assistant Professor, Human Development and Family Studies at the Pennsylvania State University. ORCHID:https://orcid.org/0000-0001-6651-5267Roy E. Strowd, MD, MEdHP is an Assistant Professor, Neurology, Internal Medicine, Section on Hematology and Oncology at Wake Forest School of Medicine in Winston-Salem, North Carolina. He is Director of the Health Professions Education Institute at Wake Forest and focuses on leadership development and mentoring in pre-medical, medical, and post-graduate health professions education. ORCHID:Seulah Choi, BA is a medical student at Icahn School of Medicine at Mount Sinai, New York (MSSM).https://orcid.org/0000-0001-7066-7378Laurence T. Hou, BA is an M. D. Candidate - The Johns Hopkins School of Medicine. ORCHID:https://orcid.org/0000-0003-4098-9143John Shatzer, PhD Associate Professor at Johns Hopkins School of Education. ORCHID:Keri Bischoff, MAED. As a licensed teacher, educational leader, and business owner, Keri uses her knowledge of training, development, and organizational strategy to contribute to the growth of powerful teams. She holds an undergraduate degree in Business Management and Organizational Behavior, and a Master of Arts degree in Education. She is certified as a Bridgeworks Generational trainer.Charlene E. Gamaldo, MD, FAAN, FAASM is an Associate Professor, Neurology, Psychiatry, Anesthesia/Critical Care, Nursing and Public Health Vice Chair, Faculty Development - Neurology Department and Medical Directorhttps://orcid.org/0000-0002-9386-9666JH Center for Sleep. ORCHID:The author has declared that there are no conflicts of interest.This study was approved by Johns Hopkins IRB #HIRB05023.This article has not had any External Funding This review has been migrated. The reviewer awarded 4 stars out of 5 An interesting paper describing a “PreDoc” program which is a longitudinal apprenticeship aimed at increasing college student interest in pursuing a healthcare career. The authors lay out the central problem of inconsistent and unverified apprenticeships and other pre-exposures of medical students to the medical world prior to training. The PreDoc program aims at addressing this problem.The program is well described, and the authors have used the supplementary files to give a large amount of useful detail regarding the course, to the point that others could relatively easily take the program and adapt it to their own needs and circumstances. The evaluation allows for a coherent assessment of the impact of the program.There does, however, need to be some clarity on the enrolment method. The project is described as a Pilot, so this may not yet have been resolved. In addition, one would wish to measure these results against some sort of control group.Still, an interesting and useful program. At the very least, it gives a clear indication to those who realise that they are not suited to medicine, and allows them to change course at an early stage of their academic career.Reviewer Expertise:NANo decision status is available This review has been migrated. The reviewer awarded 4 stars out of 5 Thank you, I enjoyed reading this. Most medical schools look for some evidence of engagement with health care in the applications they receive. However the response from students can be quite variable and it has been noted that students from more affluent backgrounds are more likely to be able to organise such attachments. It is therefore helpful to see a programme that has been formally organised. Two questions however, I was not sure how students were selected and whether WP played any part. Also, who pays? The costs may be hidden but hey are still there.Reviewer Expertise:NANo decision status is available