Community engagement is important for promoting health equity. However, effective community engagement requires trust, collaboration, and the opportunity for all stakeholders to share in decision-making. Community-based training in public health research can build trust and increase community comfort with shared decision-making in academic and community partnerships. The Community Research Fellows Training (CRFT) Program is a community-based training program that promotes the role of underserved populations in research by enhancing participant knowledge and understanding of public health research and other relevant topics in health. This paper describes the process of modifying the original 15-week in-person training program to a 12-week online, virtual format to assure program continuation. In addition, we provide program evaluation data of the virtual training. Average post-test scores were higher than pre-test scores for every session, establishing the feasibility of virtual course delivery. While the knowledge gains observed were not as strong as those observed for the in-person training program, findings suggest the appropriateness of continuing to adapt CRFT for virtual formats. Our previous research suggests that as science advances and health research and care become more complex, it remains important that patients and other health stakeholders have the ability to participate in decision-making at the level desired ,2. To faCommunity engagement is an important tool for promoting positive social and community health change . HoweverThe Community Research Fellows Training (CRFT) Program is a community-based training program that promotes the role of underserved populations in research by enhancing the capacity for CBPR ,3,6,7. TThe inclusion criteria for the CRFT program required participants to be at least 18 years old and live or work in, or willing to commute to, the St. Louis greater metropolitan area. The program participants do not receive compensation but receive free training and resources. Participants are referred to as “Fellows” to further empower and engage them in the academic process.In April 2020, a sixth CRFT cohort was cancelled due to the COVID-19 shutdown. The cancellation occurred after the application deadline but prior to any formal acceptance of Fellows into the program. This paper describes the process of modifying the original 15-week in-person program to a 12-week online program offered in a virtual format, to assure program continuation. The team decided that the virtual program was the most feasible strategy to continue teaching community members during the COVID-19 pandemic.The Human Research Protection Office at Washington University in St. Louis classified the study of “virtual” CRFT underlying this paper as program evaluation and non-human subject research.A community advisory board (CAB) that consists of 12 members, 8 CRFT graduates and 4 community stakeholders, helps to guide all aspects of the CRFT program, including recruitment, selection, program implementation, and evaluation of the program. The CAB and Project Team collaborated as a revision team to consider how to continue an established and evaluated community-based training program ,6,7 in aDiscussions on transitioning CRFT to a virtual delivery began in September 2020 after several members of the Project Team had adapted other courses to a virtual format for the academic summer and fall semesters. They were able to bring lessons learned from those experiences to the discussions. In addition, the Washington University in St. Louis Center for Teaching and Learning provided many resources ,25,26 toThe program continues to pursue the original goals of the CRFT program. The first goal is to equip community members with sufficient research knowledge to be good consumers of that research. In addition, the program seeks to help community members to understand how to use research to improve the community health status and well-being. The final goal is to increase community readiness for community/academic collaboration and partnership on mutually beneficial projects and programs. Additionally, the same multidisciplinary faculty taught the virtual program who had taught the in-person program. The team also recommended a reduced number of sessions (from 15 to 12), inclusion of an online orientation that provided an overview of Canvas© and Zoom© navigation, and one workshop intended to train community members in qualitative research methods, as well as an online graduation ceremony and optional outdoor, in-person celebration See .The Project Team received permission from the home institution to administer the course using the Canvas© Learning Management System (LMS). The session readings, activities, homework, and supplemental materials were available in Canvas© modules. The Project Team decided that each lecture topic would be 45 to 50 min, with 10 to 15 min reserved for questions. Faculty modified the session objectives and class activities to accommodate the new 2 h course duration See . The ProGiven the online format, the Project Team made the decision to keep the virtual online cohort (Cohort VI for 2021) small to encourage greater interactive participation. The cohort was limited to a maximum of 25 participants, which was similar to Cohorts III–V. Prior CRFT cohorts were recruited through a local newspaper, E-mail, community websites, community newsletters, flyers, personal referrals, and word of mouth. However, the Project Team decided to approach those who applied for the cancelled 2020 cohort (n = 29), individuals who contacted staff to express interest in a future cohort (n = 23), and send emails to the CRFT alumni network and other CRFT affiliated individuals. Applicants had an opportunity to use a previous application, provide an updated application, or submit a new application.The Project Team reviewed the applications and selected a cohort that was diverse in work, education, and life experiences, just as the in-person CRFT cohorts had been. Twenty-three of the thirty-eight individuals who applied to participate in the 2021 cohort had previously applied in 2020. Sixteen of those twenty-three past applicants were selected as Fellows for the 2021 cohort. There were 15 new applicants in 2021, with 9 selected to participate in the 2021 cohort.®. REDCap® is a secure, web-based software platform designed to support data capture for research and evaluation. The orientation session lasted 2 h, with about 30 min set aside for a walkthrough of virtual course materials, including how to use Canvas©. All 25 Fellows were able to attend the orientation session.We offered training on how to use Canvas©, the learning management system during the CRFT program orientation. Canvas© was mainly used as a way to store and organize CRFT program materials, whereas assessments were given outside of Canvas©, using a survey administration platform, REDCapDuring the introduction to Canvas©, CRFT team members demonstrated going to the institution specific Canvas© website, creating an account, logging into the system, and navigating through the course materials, which were set up using the modules feature in Canvas©. In addition to the live walkthrough of Canvas©, the general and institution specific information was sent via email. The process of creating an account was more difficult for Fellows than using Canvas©, as several Fellows reached out to the CRFT team for assistance and questions on account creation. However, once an account was created, Fellows did not voice concerns on accessing course materials. One Fellow, who also did not finish the program, was never able to create a Canvas© account. Fellows also received a one-page guide on how to access Canvas© prepared by the CRFT team.Fellows’ increase in knowledge of public health principles and CBPR was assessed via a questionnaire administered before session 2 (baseline) and after session 12  of the program. Each questionnaire to assess public health knowledge consisted of 20 identical multiple-choice questions created by the CRFT Project Team and faculty to measure the Fellow’s knowledge of the CRFT training topics and learning objectives . The queA baseline and final score were computed for each individual by summing the responses for all questions, where a value of 1 was assigned for a correct response and a value of 0 for an incorrect response (including missing and “I don’t know” responses). A maximum total score of 20 points was possible for each score. We then converted this to a percentage score. To assess the difference between the baseline and final assessment, we performed a non-parametric test, the Wilcoxon signed-rank test, due to violations of normality assumptions.Fellows took pre- and post-tests at each of the 12 sessions. Pre- and post-test measures assessed the content at the beginning of each session and at the end of each session, using identical items. All tests were shortened from the pre- and post-tests administered during the in-person sessions. The tests were shortened from 10 items to 5 items in order to reduce participant burden. Pre- and post-tests were scored similar to the baseline and final assessment, using a sum score of correct responses, where a value of 1 was assigned for a correct response and 0 for incorrect response (including missing or don’t know). A maximum total score of 5 was possible for each pre- and post-test. We then converted this to a percentage score. Due to the violation of normality assumptions, we used a non-parametric test, the Wilcoxon signed-rank test, to evaluate the score differences on pre-test and post-test for each session.At the end of each of the 12 training sessions, Fellows completed session evaluations. Fellows rated their satisfaction level on that week’s topic and content covered as well as evaluation of the faculty member presenting. Evaluations consisted of six statements with Likert-scale response options. The Likert-scale items were about satisfaction with the learning objectives for the topic as well as the perceived quality of the presentation for the session. In addition, there were four free response questions.Analyses were completed using SAS/STAT 9.4 .There were 25 Fellows enrolled in the virtual online CRFT program. Of these 25 Fellows, 23 (92%) completed the 12-week virtual training program. We obtained complete baseline and final assessment data from 21 of the 23 Fellows who completed the program (91%). The three largest groups comprising the cohort were individuals affiliated with community-based organizations (32%), followed by health care workers (28%) and individuals with multiple roles (28%). The remaining Fellows were community members and those affiliated with faith-based organizations (8%) and those in academia (4%). The mean age of Fellows was 45, with an age range from 25 to 65. All Fellows had some college or an associate’s degree or higher, including 48% with graduate education, and 68%of the cohort reported that they had previously completed a course on research. The majority of fellows were African-American/Black (76%).All of the Fellows who completed both the program and final assessments (n = 21) were female and 71% were African-American/Black. The four individuals who did not complete the training and/or the final assessment were African-American/Black, with one male and three females. These individuals were similar to the 21 Fellows who completed the program and final assessment in all respects except age. The mean age was slightly lower, 38 and ranged from 33 to 43, compared to the 21 individuals who completed the program and final assessments .p = 0.0005).The average score increased from 65% correct on the baseline public health and CBPR knowledge assessment to 76% correct on the final assessment (n = 20 (one outlying observation excluded), mean change of 11%, range −10% to 40%). Only two Fellows  decreased their scores from baseline to final assessment. The Wilcoxon signed-rank test for this knowledge change was significant  completed all pre-/post-tests. During the first half of the course, 60–68% of participants completed the pre- and post-tests, and during the second half of the course, 36–54% of participants completed both tests.Due to the online nature of the course, participants found it challenging to complete pre-/post-tests. In addition, due to non-participant technical errors involving REDCapThere is evidence of knowledge gained. However, the in-person program had a greater number of sessions with Fellows showing statistically significant gains compared to the online program ,3. Data The following quotes were offered in the final assessment in response to the prompt to “Please provide us with any additional comments or suggestions”. The Fellows indicated that they appreciated the effort to continue the program despite ongoing pandemic precautions. Representative quotes are provided below.“Thank you for taking the time to re-structure the program and your continued energy, patience and support throughout the program!”“Thank you for the opportunity to participate in this outstanding program. I (sic) is a testament to the dedication of your staff to engage the community in the advancement of public health. Please continue the program!”“This was an awesome opportunity. The information gained will be used to help me to be a better collaborator as I work to improve areas of the community in which I serve”.In addition, Fellows were asked to share opportunities to change or improve the training sessions. There were comments related to virtual versus in person sessions. Some Fellows liked the virtual sessions and some did not.“I think in person would of course be better, but with the pandemic that couldn’t be done”.“I really liked the virtual setting”.“Do not offer online/virtually”.However, the main concerns discussed were the desire for more interaction and group discussions, more time for each session .Finally, data from the final assessment indicated that 81% (n = 17) of Fellows agreed or strongly agreed “the structure of the training was beneficial to the learning process”. In addition, 95% (n = 20) agreed or strongly agreed that they “would recommend the CRFT program to others”.This paper describes the process of modifying the original CRFT 15-week in person training program to a 12-week virtual online format. The virtual format proposed was the most feasible strategy to continue training community members during the COVID-19 pandemic. In addition, it increased the number of communities and participants with access to this community-based public research training program ,6,7 by cThere were both facilitators and barriers to implementation. Throughout the 12-week training, Fellows remained engaged in the training, indicating high potential for a virtual CRFT training environment. In addition, all CRFT faculty continued to be committed to the goals of the training and willing to adapt curricula from for online virtual format. Faculty used several Zoom© features, including breakout rooms, polls, and the chat to facilitate participation. On the other hand, while many Fellows understood and supported a virtual format, feedback also indicates that many value opportunities for face-to-face trainings. In addition, the recommendations offered suggest the need to add additional time to online sessions. Low pre-/post-test completion rates indicate some limitations in administration of online materials asynchronously, as discussed in the next section. One participant who failed to complete the program was never able to establish an LMS account and this likely hampered the quality of the experience and program completion.The cohort of Fellows was comprised of individuals affiliated with community-based organizations and other diverse stakeholders. The cohort had greater age and educational diversity than racial/ethnic and gender diversity. Ninety-two percent of CRFT VI Fellows completed the 12-week training program and ninety-one percent of these Fellows completed both the baseline and final assessments. There was a statistically significant average score increase from the baseline assessment to the final assessment (mean change of 11%).The average post-test scores were higher than the pre-test scores for every session; however, as Given the virtual nature of the course, participant evaluations are important. Ninety-five percent of Fellows indicated that they would recommend the CRFT program to others and a smaller, but large, percentage reported that the structure of the program was beneficial to the learning process. While these findings establish the feasibility of virtual course delivery, the knowledge gains were not as strong as those observed for the in-person training program.® to provide reminders failed. We learned that it is important to test all features of the LMS system and develop alternative strategies for implementation of program components prior to the launch of virtual programming, including those related to evaluation processes.Despite these positive findings, there are limitations to this evaluation and some findings should be interpreted with caution. First, a low percentage of Fellows completed all of the pre/post-tests (16%), and the percentages completing the tests during the first half of the program was significantly higher than the percentage completing the tests in the second half of the program. One issue was the ability to send reminders to Fellows reliably. With implementation of the virtual format, CRFT staff reminded Fellows to complete pre- and post-tests at the beginning and end of each session. The in-person format allowed staff to ensure compliance with the tests, while the effort to use REDCapWhile prior CRFT cohorts have been predominantly female ,3, this CRFT VI demonstrated the feasibility of providing community-based training in public health research using a virtual online format. Despite the existence of other programs designed to provide community training on research ,28, most


The use of musculoskeletal ultrasound (MSKUS) for point-of-care (POC) evaluation of hemophilic arthropathy is growing rapidly. However, the extent to which MSKUS influences clinical treatment decisions is unknown.TissueActivity and Damage Exam (JADE) protocol at baseline and approximately annually for two additional times. Treatment decisions, including physical therapy (PT) and “medical”  were recorded in relation to POC-MSKUS.We conducted a three-year, prospective, multi-center study at three hemophilia treatment centers in the United States to evaluate the utilization of POC-MSKUS for routine clinical decision-making in adult persons with hemophilic arthropathy. Bilateral elbows, knees and ankles were assessed clinically [Hemophilia Joint Health Score (HJHS)] and with POC-MSKUS by the Joint Forty-four persons [median age 37 years ], mostly with severe Hemophilia A on clotting factor prophylaxis, completed 129 visits, yielding 792 joint exams by POC-MSKUS and HJHS [median at baseline 27 ] over a median follow up of 584 days (range: 363 to 1072). Among 157 management decisions, 70% were related to PT plans (n = 110) and 30% were “medical”. Point-of-care MSKUS influenced 47/110 (43%) PT plans, mostly informing treatment of specific arthropathic joints (45/47 plans) in patients with high HJHS. Physical therapy plans influenced by POC-MSKUS directed more manual therapy/therapeutic exercises, while plans based on physical exam were focused more on global exercises and wellness. Treatment decisions were mostly based on the identification of specific musculoskeletal abnormalities visualized by POC-MSKUS. Of note 20/47 (43%) POC-MSKUS plans included de-escalation strategies, thereby reducing exercise intensity, mostly for joint instability and subclinical hemarthroses. Point-of-care MSKUS also informed 68% (32/47) of “medical” decisions, surprisingly mostly for injections/aspirations and referrals to orthopedics, and not for adjustments of hemostatic treatment. Although not formally studied, ultrasound images were used frequently for patient education.Routine joint evaluations with POC-MSKUS resulted in few changes regarding medical management decisions but had a profound effect on the formulation of PT plans. Based on these findings, new studies are essential to determine the benefit of MSKUS-informed management plans on joint health outcomes. Hemophilic arthropathy (HA) is the consequence of joint remodeling resulting from recurrent hemarthroses in persons with hemophilia (PwH), a rare congenital X-linked bleeding disorder characterized by the lack of coagulation factors VIII or IX . HemophiHemophilic arthropathy affects the quality of life of PwH , 6. CurrFor timely and meaningful management of HA, it is critical to assess the extent and progression of HA regularly. Scores based on clinical joint examination, such as the Hemophilia Joint Health Score (HJHS) , 18, aretissue Activity and Damage Exam (JADE) is a musculoskeletal ultrasound protocol that incorporates direct measurements of tissue abnormalities, such as soft tissue thickness, osteochondral alterations, and cartilage thickness, using specific views  and 2 [range 1 to 2] per visit). Most procedures were recommended for ankles (54%), followed by elbows (23%), knees (18%), and shoulders (5%). The procedural indications were made on clinical grounds only (not based on POC-MSKUS findings). Based on patient preference, only 55% (12/22) of the recommended injections/aspirations were performed; all under ultrasound guidance, informing the procedural approach. In addition, the use of POC-MSKUS identified one additional effusion, which was suspicious for subacute bleeding (complex appearance), confirmed by aspiration.To evaluate the extent of clinical arthropathy of the joints proposed for injection/aspiration, the joints were ranked by HJHS percentile. It appeared that many joints were above the 80th percentile, indicating relatively far advanced arthropathy. In more detail, the HJHSs of elbows, knees and ankles fell on the 86th, 94th, 77th percentile at baseline; (no events), 83th, 68th at the first, and 61th, 86th, 87th at the second follow-up visit, respectively.Only 11 hemostatic treatment plans were adjusted or changed in 9 PwH during the study period. Decisions were based predominantly on clinical assessment (e.g. number of patient-perceived bleeding events) rather than findings with POC-MSKUS. The most common reason for the adjustments during visits was a switch from conventional half-life to extended half-life clotting factor formulations [45% (5/11)], followed by the transition to emicizumab  [27% (3/11)], and changes in dose [18% (2/11)] and/or frequency [11% (1/11)] of conventional half-life formulations. There was only one case where an increase in clotting factor dosing was proposed based on POC-MSKUS findings, describing “rapid joint deterioration.”Only 3 new prescriptions for oral anti-inflammatory medications were provided, whereby POC-MSKUS guided only one decision .Seven PwH were referred to Orthopedic Surgery during the study period for evaluation of 11 painful joints . Point-of-care MSKUS triggered the referral for 8/11 joint evaluations (73%), documenting pronounced soft tissue proliferation in 6/8 joints , and severe osteochondral alterations in the remaining 2 joints. Of note, more than half of the joints (5/8) evaluated by orthopedics based on a referral triggered by POC-MSKUS examination proceeded to surgical interventions.A total of 110 PT plans (either new or adjusted from previous) were proposed for 84% (37/44) PwH, occurring during 57% of visits (73/129). The median number of new or adjusted PT plans per patient was 3 (range: 1 to 7) during the study period, with a median of 1 plan per patient for each visit (range: 1 to 3). Overall, POC-MSKUS informed the design of 43% (47/110) PT plans, affecting 60% (22/37) of the PwH at least once .Most PT prescriptions  were directed to a specific joint, while 17% prescriptions (19/110) encompassed a global wellness/strengthening PT program. When prescriptions were divided into those informed by POC-MSKUS (43%) and those not (57%), targeted joint-specific plans were almost all informed by POC-MSKUS, whereas global PT programs were to a much less extent (96% vs. 4%) Fig. . NotablyAlso of note, most joint-specific plans [86% (78/91)] were directed to one of the self-reported arthropathic joints, whether or not POC-MSKUS was used to inform plans (POC-MSKUS 80% vs. non POC-MSKUS 95%).The median total HJHS for the PwH was 34  and 30  during visits triggering PT plans informed and uninformed by POC-MSKUS. In contrast, the median HJHS was 20.5  in the group that did not receive a PT plan. These findings suggest that joint health status was similarly poor between the groups receiving PT plans whether informed or uninformed by POC-MSKUS, and worse compared to those PwH who did not undergo PT.Hemophilia joint health scores differed between the groups receiving PT informed or uninformed by POC-MSKUS when the gait component was omitted . Since the gait score was similar in both groups , this finding suggests that PwH receiving POC-MSKUS informed-PT plans had more pronounced arthropathy compared to those receiving PT plans uninformed by POC-MSKUS.Overall, the HJHS for PwH who underwent global wellness/strengthening programs (not discriminating between POC-MSKUS informed or not) was higher compared to the group with joint-specific PT plans , suggesting advanced arthropathy status requiring a more functional rehabilitation program.n = 47) and -uninformed plans (n = 63) were formulated with exercises and PT measures (named “items”) fitting into the following 7 domains: manual therapy, therapeutic exercises, wellness/pain management, balance/gait training, bracing/assistive devices, activities of daily living training and others. Final plans included a single item or a combination of items. The median number of items in POC-MSKUS-informed and uninformed plans were similar [2 ], with a total number of 102 and 123 items, respectively.It appeared that PT plan compositions were influenced by information derived from POC-MSKUS examinations. Both POC-MSKUS informed  resulted in considerable de-escalation of therapy plans . The most common reason for de-escalation of therapy were findings of severe osteochondral alterations (8/21), followed by “unstable joint” by dynamic arthrokinematics visualized during evaluation (4/21), subclinical hemarthroses (5/21), severe soft tissue inflammation by PD evaluation (1/21) and ‘not specified’ (3/21). In general, specific POC-MSKUS findings described by the physical therapist informed the formulation of 34% (16/47) PT plans. Those findings were listed as severe hemarthritic changes 7/16), the presence of osteophytes (5/16), soft tissue impingements (2/16), tendinopathy (1/16), and ‘unspecified’ (1/16).Of interest, the use of POC-MSKUS to devise PT plans (n = 9), lifestyle modifications (n = 10), factor plan treatment adherence (n = 9), and rationale for a specific exercise plan (n = 8).Evaluation of written provider comments during the course of the study indicated that POC-MSKUS findings prompted educational discussions during 19% (24/129) of all visits, mainly during the 1st and 2nd follow-up visits. Point-of-care MSKUS informed 36 discussions with 18/44 (41%) PwH at least once . Point-of-care MSKUS informed discussions included education about joint health  were involved in PT throughout the study period and MSKUS was utilized actively by the physical therapists to devise or adjust plans in a ‘real time’ fashion. Nearly half of the plans were informed by POC-MSKUS, based on direct visualization of joint tissue abnormalities and their integration with clinical findings.Musculoskeletal ultrasound examinations were performed with the JADE protocol , which uTissue measurements may be more helpful to quantify the effects of treatment interventions over time. The identification of musculoskeletal abnormalities is thought to contribute to discomfort, or musculoskeletal ailments and should drive the formulation of timely PT decisions. Musculoskeletal ultrasound appeared most useful in informing joint-specific rehabilitation plans for joints with high HJHSs  rather than to devise general wellness measures. Musculoskeletal ultrasound allowed shaping the design of PT plans in targeted fashion with manual therapies, fitting bracing/assisting devices, and gait/balance training.It is noteworthy that approximately half of the PT plans informed by MSKUS included a de-escalation of the therapeutic intensity previously felt to be safe and appropriate. In this context, subclinical hemarthroses were one of several prominent findings leading to less aggressive joint rehabilitation. Also, plans informed by POC-MSKUS were more specific addressing particular findings, prescribing directed therapies such as manual therapy, bracing/assistive devices, and gait/balance training exercises. On the other hand, PT plans uninformed by POC-MSKUS provided a more general approach to exercise, wellness and pain mitigation. In this context it is important to state that PT interventions in hemophilia are highly effective  and thatThere is mounting evidence that ankles are now superseding the knee as the arthropathic joint indicator for PwH , and ourThe lack of influence of POC-MSKUS on medical decision-making, especially regarding clotting factor adjustments, was notable and may be because the study cohort only included adult subjects, many with established arthropathy. It is conceivable that the benefit of adjusting hemostatic management, especially in subjects with advanced arthropathy, was perceived as less impactful than PT offerings to strengthen musculoskeletal fitness and overall physical well-being. The use of MSKUS in children or adolescents with relatively preserved joints may influence management decisions differently where early findings of osteochondral damage or synovial swelling may trigger the more aggressive use of clotting factor replacement, rather than PT alone. However, it must be emphasized that there are no studies to date showing that MSKUS-guided management improves joint outcomes. The indication for corticosteroid joint injections was almost always clinical, although POC-MSKUS was adopted for needle guidance in all instances, probably based on the growing knowledge that accuracy of needle placement results in improved pain relief, with very good success in hemophilic joints .This study revealed several important aspects related to the potential of MSKUS in routine hemophilia care. First, physical therapists were the predominant specialty to embrace decision-making based on POC imaging findings, using it to inform management plans. These findings align with results from an international survey of HTCs by the International Prophylaxis Study group, identifying physical therapists as the clinical staff performing MSKUS > 50% of the time in routine practice . Second,This study has several limitations. First, the results only apply to adult PwH with more advanced hemophilic arthropathy and not to children or younger populations with hemophilia and lesser arthropathy. Second, the evaluation of study results is often more descriptive than quantitative, based on the unanticipated finding that MSKUS was used disproportionally for the formulation of PT plans involving the dissection of written notes. Third, MSKUS and joint examinations were both performed by the physical therapists in all centers, and not always in the same sequence, in alignment with unpredictable flow during comprehensive care clinic visits. Therefore, one cannot exclude that management approaches were biased by knowledge derived from both exam modalities.This study found that MSKUS, when incorporated into comprehensive hemophilia care during routine follow-up visits, was utilized most frequently to inform joint-specific PT plans, rather than leading to adjustments in hemostatic support. We expect that the continued amalgamation of imaging findings using POC-MSKUS and clinical findings (such as HJHS) will lead to improvements in hemophilia management, especially in the area of PT. These findings should stimulate future studies designed to identify the benefit of MSKUS-informed management plans on joint health outcomes.


Informed by the Ecological and Health Belief models, the manualized Stroll Safe program addresses the unmet need of a targeted outdoors falls prevention program. We examined the efficacy of the program in partnership with eight Naturally Occurring Retirement Community program sites in one U.S city (N=86). Participants age 60 and older with a history of falls or a fear of falling were recruited. Community sites were randomly assigned to the treatment or wait list control group. Results of independent samples t-tests reveal a statistically significant improvement in knowledge of outdoor fall risks and safe community mobility strategy use for the treatment group as compared to the wait list control group on the Outdoor Falls Questionnaire (OFQ) and Falls Behavioral Scale for the Older Person (FaB) . Improvements were retained at 6-week follow up. Implementation strategies are being developed to facilitate program adoption by other occupational therapists.


Yushu, Qinghai Province, which is located in the remote Tibetan Plateau in western China, was struck by a disastrous earthquake in 2010.t-tests, Wilcoxon rank-sum tests, Kruskal-Wallis H tests, and stepwise linear regression were used to analyze data.This study aimed to compare the health status of adolescents who had (Exp-Group) and had not (Non-Group) experienced the Yushu earthquake, 7 years after it occurred; additionally, group-specific predictors of health status were identified. A cross-sectional study was adopted among students from two junior schools in Yushu, whereby two groups were compared. Descriptive statistics, Exp-Group scored higher than Non-Group on Physiological Component Summary (PCS) but not on Mental Component Summary (MCS). Among Exp-Group participants, lower PCS scores were predicted for “house damaged,” “injured,” “family member injured,” and “family member or friend dead.” Lower MCS scores were predicted by “family member or friend dead.” Among Non-Group participants, PCS scores were predicted by “residence” and “family member or friend dead.” Lower MCS scores were predicted by “not living with parents.”Lower PCS and MCS scores of Exp-Group adolescents mainly contributed to earthquake-related injuries, while lower PCS and MCS scores of Non-Group are related to poor living conditions and the fact of the left-behind child. On 14 April 2010, the city of Yushu, in Qinghai Province, which is a remote plateau in western China, was struck by an earthquake measuring 7.1 on the Richter scale (maximum intensity: 8), which resulted in 2,698 deaths, 12,135 injuries, and an average elevation of 4,493 m. It has been evaluated that experiencing an earthquake has an impact on both the physical and mental health of survivors –13. To tGeographically, the city of Yushu in Qinghai Province is a remote plateau in western China, and high morbidity and mortality and poor health status among nomadic herdsmen who live in pastures are global public health problems , 14–17. Additionally, cultural difference is another important dimension that is worthy of consideration because it has significant implications for health . FurtherThe aim of this study was to examine the long-term effects of the Yushu earthquake on the physical and mental health of children and adolescents residing in remote Tibetan plateaus in western China. This was to be achieved by comparing the physical and mental health status of children and adolescents who had and had not experienced the Yushu earthquake. The resultant findings were to be used as an empirical base on which recommendations for long-term health interventions for children and adolescents who have experienced earthquakes can be found. The Chinese version of the Short Form-12 (SF-12), a simplified version of the 36 Schedule Health Surveys (SF-36), was used, which has been used in numerous studies worldwide, including items that have been drawn from scales measuring bodily pain, general health, vitality, and social functioning; additionally, it contains two items from each of the scales measuring physical functioning, role-physical, role-emotional, and mental health .A cross-sectional survey was conducted in August 2017, at which time 7 years had passed since the Yushu earthquake , 24. In To examine the impact of the Yushu earthquake on adolescent health, we divided the research participants into two groups, namely, those who had experienced the earthquake (Exp-Group) and those who had not experienced the earthquake (Non-Group). Group-specific multiple linear regressions were conducted to identify the factors that influence adolescent health in each group.The number of students in Qironglian College Primary School is 433, and the number of students in the Second Boarding Primary School is 245. Owing to missing responses, four questionnaires were excluded (3 lacked the data on ‘experienced Yushu earthquake or not' and 1 refused to participate in the questionnaire). Therefore, the total number of participants in this study was 674.The survey was conducted by eight undergraduates from the Navy Military Medical University. The project leader conducted a centralized training in Shanghai for the eight investigators before the initiation of the research, whereby he briefed them about the details of the study and answered their questions about the study. The investigation was conducted between 10 and 24 August 2017. The survey was conducted within the confines of school classrooms. The researchers briefed the respondents about the details of the questionnaire and answered relevant questions that helped them complete the questionnaire.The social and demographic information that was collected in this study pertained to the following: “age,” “family living area,” and “living with parents.” Students who did not live with their parents were referred to as left-behind children, which is defined as those who live with their parents for <30 days in 1 year.Information related to students' experiences of an earthquake was elicited using questions adapted from an earthquake exposure scale. The items included “residence,” “living with parents,” “experienced Yushu earthquake,” “house damaged in earthquake,” “injured in earthquake,” “family member injured in earthquake,” and “family member or friend dead in earthquake” . The resStudent health status was assessed using the Chinese version of the Short Form-12 (SF-12), which is a simplified version of the 36 Schedule Health Surveys (SF-36). The Chinese version of the SF-12 has been validated using samples of Chinese youth . Specifit-test . Descriptive statistics  were calculated. Subsequently, nonparametric analyses were used . Multiple linear regression analysis was used to identify the group-specific factors that predict PCS and MCS scores . Meanwhit-test . AdditioParticipants' ages at the time of the survey ranged from 8 to 15 years. Of the 674 participants, 590 (87.5%) lived on pasture lands and 624 (92.4%) lived with their parents. Over half of the sample  had experienced the Yushu earthquake in 2010. Furthermore, with regard to the consequences of the earthquake, 41 (6.1%) participants reported that their family members had been injured; 120 (17.8%) reported that family members or friends had died; 53 (15.4%) reported that their houses had been damaged; and 13 (3.8%) reported that they had sustained injuries .p < 0.05). However, the mean MCS score of the Exp-Group (40.56 ± 8.56) is not statistically different from that of the Non-Group (41.42 ± 7.91) (p = 0.18)  is significantly lower than that of the Non-Group (50.64 ± 7.89) ( = 0.18) .p = 0.02). The mean MCS score of the Exp-Group (40.56 ± 8.56) is also lower than that of the general adolescent population in China (45.4 ± 9.7) (p < 0.05) (The mean PCS score of the Exp-Group (48.76 ± 7.84) is significantly lower than that of the general adolescent population in China (49.8 ± 6.6)  (p = 0.04 ± 9.7)  (p < 0.0 < 0.05) .p = 0.05). In contrast, the mean MCS score of the Non-Group (41.42 ± SD 7.91) is significantly lower than that of the general adolescent population in China (45.4 ± 9.7) (p < 0.05) (The mean PCS score of the Non-Group (50.65 ± 7.89) is not significantly different from that of the general adolescent population in China (49.8 ± 6.6)  (p = 0.04 ± 9.7)  (p < 0.0 < 0.05) .The results presented in The results of the multiple stepwise regression analyses  revealedAs presented in Multiple stepwise regression analysis  revealedExperiencing an earthquake can have long-term physiological and psychological effects on adolescents , 12, 30.Among participants who belonged to the Exp-Group, PCS scores were found to vary according to houses damaged as a result of the earthquake or not and sustain injuries or not. These results are inconsistent with past findings that these variables have no significant effect on the PCS scores of survivors of natural disasters . HoweverAmong participants of the Exp-Group, the death of a family member or friend in the earthquake was found to be negatively related to physical and mental health. This finding, which concurs with those of past studies, has been found to be more likely to occur among people who have poor mental health at the time of occurrence of a natural disaster , 12, 34.Among participants of the Non-Group, the place of residence was found to have significant implications for physical health. Many studies have found that rural and urban living places differentially influence children's nutritional intake and eating habits, which in turn have an impact on their PCS scores , 38–40. Among participants of the Non-Group, those who reported living with their parents obtained higher MCS scores than those who did not. This might be the case because China has been rapidly urbanizing in the past few decades. In fact, one out of ten individuals are immigrants who are seeking employment opportunities in both rural and urban areas. Accordingly, quite a few participants reported that they did not live with their parents.Evidence from national studies suggests that a stable family environment contributes to the healthy development of children , 41, 42.This study has a few limitations that merit further discussion. First, this study adopted a cross-sectional research design, whereby those who had and had not experienced an earthquake were compared. Second, although this study was conducted by well-trained researchers, data collection relied on self-reports of child survivors 7 years after the Yushu earthquake; these self-reports might have been adversely affected by recall bias. Despite these limitations, this study is the first to analyze the health status of children and adolescents who had experienced the Yushu earthquake. It is also one of the few cross-sectional studies that have focused on long-term health status and associated risk factors among children and adolescents who had experienced earthquakes in the remote Tibetan plateau of western China. Further study will focus on the effect of psychological interventions on the long-term health status of children and adolescents who had experienced earthquakes.This study found that the lower PCS and MCS scores of children and adolescents who had experienced the Yushu earthquake are mainly contributed to earthquake-related injuries, while the lower PCS and MCS scores of those who had not experienced the Yushu earthquake are related to poor living conditions and the fact of being a left-behind child. In conclusion, these children and adolescents who have experienced the Yushu earthquake must be provided with specialized care and long-term psychological interventions; such services must also be rendered to those who were injured in the earthquake and those who have lost family members or friends as a result of the earthquake. In contrast, children and adolescents who have not experienced the Yushu earthquake, especially left-behind children, can be helped by improving their school atmosphere and living conditions.The original contributions presented in the study are included in the article/XL, BT, and FZ discussed and developed the question for this study. XL and HY abstracted data from medical records. QC and JW carried out all analysis. BT and FZ wrote the first draft of this paper, which was reviewed LZ and XL. XL is the guarantor. All authors have read and approved the manuscript, involved in the interpretation and discussion of results, and agreed on the final draft of this study.Work on this manuscript was sponsored by the National Natural Science Foundation of China XL, Grant Number [71774166]; BT, Grant Number [71804186]; LZ, Grant Number ; JW, Grant Number [71904200], Chinese National Defence Research Program of Science and Technology XL, Grant Number [2019-JCJQ-JJ-065], San Hang Program of Naval Medical University XL and BT, and Shanghai Pujiang Program BT, Grant Number [18PJC116], Military Key Disciplines Construction Project . The design and data collection of the study were funded by the funding granted 71774166, 71804186, 71904200, and 72174204. The analysis, and interpretation of data were funded by the funding granted 91224005, 2019-JCJQ-JJ-065, and 18PJC116. The writing of the manuscript was funded by the funding granted 03 and San Hang Program of Naval Medical University XL and BT.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Recently, the use of digital skills as a tool to alleviate unemployment concerns of university graduates has gained considerable attention among governments in developing economies. The present study examines the impact of the E-education program  on the unemployment reduction of young graduates of higher educational institutes (HEIs). We also explore the mediating influence of innovation in the association between E-education and unemployment reduction. The target population of the study was students who have successfully completed the E-education program. The convenient sampling technique was used for data collection from 416 respondents through a structured questionnaire. Collected data were analyzed using different statistical techniques, such as descriptive statistics  and structural equation modeling for measurement of the structural model. The study findings assert that the E-education program has significant effects on the unemployment reduction of graduates. Furthermore, innovation also significantly mediates the association between E-education and reduce unemployment among students. It implies that the HEIs should also roll out E-education programs, which would eventually help reduce unemployment and promote the growth of the E-education industry in the country. Finally, policy prescriptions are discussed on the role of an E-education-driven innovation to curtail unemployment in developing countries. Cross-border e-commerce trade activities have witnessed a remarkable surge around the globe in recent years . The intAgainst the backdrop of sluggish economic growth, youth unemployment is one of the critical concerns for governments. While a disproportionate share of youth in unemployment and a considerably higher ratio of young people in emerging countries provide an opportunity as well as pose a challenge to the country’s future. The opportunity emerges from the fact that youth can serve as an engine of development as they have the energy and will to transform a country’s future . ContrarIn the past two decades, information technology (IT) has assumed a central role in the emergence of the knowledge-based economy and has emerged as a key indicator of economic growth for many leading economies of the world. It also creates highly skilled jobs , while cGiven the massive share of youth in Pakistan and their keen interest in the IT field, since 2012, the country’s entrepreneurship and digital innovation landscape have grown exponentially. Thus, considering the 2-fold challenge of creating new jobs and, at the same time, bridging the IT skills gap among youth, on 19 May 2017, the government launched the E-Rozgar training program . This program aims to provide internet-based freelancing training opportunities to youth to curtail unemployment and steer the country’s economic growth. E-education is not an entitlement program, but rather a minimum eligibility criterion that must be fulfilled by the potential candidates. The students must have completed 16 years of education and should be in the age group of 22–35 years to be enrolled in this program. The vision of the program is to “reduce unemployment and drive economic growth in the country by boosting inflows of foreign currency.”The skill development program is an essential step in providing training along with employment opportunities. It provides human capital to society and increases the income levels of individuals. Keeping this in view, several skills development programs have been initiated by the government. However, despite the fact that the government is spending a large amount of funds on such schemes, systematic evaluations of their effects on unemployment reduction and the personal financial management of trainee students are very limited. This article is an attempt to fill this void by exploring the quantitative data, which are collected through a structured questionnaire from the students who have successfully completed the government’s E-education program.Apart from this, it is observed that fundamental skills development and vocational knowledge are imperative for innovation as they promote new abilities to learn, change, and be creative at work . IncessaNotwithstanding the fact that current research focuses on one program  offered by the government of Punjab, Pakistan. It has wider implications for similar programs offered in various parts of the country by educational institutions and the government to curtail unemployment in the youth.The rest of the article is arranged as follows: Section “Literature review and hypotheses development” presents the relevant literature and develops hypotheses, Section “Materials and methods” presents data and methods, Section “Empirical findings” presents the results and discussions, and the final section “Discussion” concludes the study.Unemployment is a situation when people are skilled and willing to do work but are unable to get a suitable job . The menMoreover, e-business skills have the potential to generate incredible new capital, generally through entrepreneurial start-ups and commercial ventures. It is also transforming the rules of competition for established businesses in an extraordinary way. Therefore, in the past few decades, several scholars have shifted their focus toward e-business, innovation, and creativity . SimilarKeeping in view the importance of e-skills, many independent organizations and governments have launched training programs to equip youth with new skills. These programs provide cutting-edge E-education to people and create employment opportunities and are thus considered one of the major factors to reduce unemployment .In a similar vein, H1: E-education program has a positive association with unemployment reduction among students.Innovation is a process of transforming thoughts into opportunities and putting these opportunities into reality. Innovation is concerned with improving how institutions deliver products or services . MoreoveSimilarly, On the contrary, The aforementioned evidence infers a mediating role of innovation between the E-education program and growth in employment opportunities for students see . TherefoH2: Innovation mediates the relationship between the E-education program and the unemployment reduction of students.N = 233) were men; 53.8% of the respondents (N = 224) were 21–25 years old, 31.7% were 26–30 years old, and 14.4% were 31–35 years old. The majority of the respondents received their education in technical (40.6%) and non-technical (34.1%) course tracks, while 25.2% were trained in creative designing.The present study follows a quantitative approach to examine the proposed hypotheses. The primary data were collected by using a survey technique. The population of this study is the students of the E-education program who have successfully completed the program. To obtain an adequate number of responses, we distributed 500 questionnaires using the convenience sampling technique to get maximum responses. A total of 416 students filled the complete survey questionnaires. The response rate was quite high (83%). Demographically, 56% of the respondents . The model was evaluated with a composite index of overall fitness. The results showed that CFI = 0.94, TLI = 0.93, and RMSEA = 0.06, indicating a good fit.The results of CFA are presented in r = 0.44, p < 0.01) and unemployment reduction . Innovation was positively correlated with unemployment reduction . The results of Cronbach’s alpha were also reported, and measurement scales of all the variables were reliable, having a value of above 0.70, as recommended , CFI = 0.941, TLI = 0.931, RMSEA 0.067, and SRMR = 0.046 meet the criterion of b = 0.23, t = 4.43, p < 0.01) , which supports Hypothesis 2.Hypothesis 2 proposes that innovation mediates the relationship between E-education and unemployment reduction. The result showed that E-education has a positive indirect effect on unemployment reduction The indirect effect was examined using the MPLUS delta method. This method is considered an alternative to the Sobel test and has similar robustness and statistical power to explain the indirect effects . Therefovia innovation. The existing literature also highlighted the need to identify mediating mechanisms between the E-education program outcome and the unemployment relationship . The results show strong evidence for all hypothesized relationships; participation in E-education programs leads to unemployment reduction. Furthermore, the study also confirms the mediating effect of innovation on the relationship between E-education and unemployment reduction.via innovation. Pakistan is a developing country, with over 26% of its population consisting of youngsters, of which millions are unemployed. Therefore, not only the government should continue this program (to curb unemployment) rather HEIs should also come forward and start this type of E-education program to equip the youth with contemporary skills along with traditional tertiary education. Moreover, keeping in view the exponential growth in Pakistan’s e-commerce market in the past few years, the government should also expand the course tracks offered during the program.The results presented in this study paint a very optimistic picture of E-education program-induced unemployment reduction The present study also has some limitations. First, due to the utilization of single-source self-reported information, common method bias (CMB) may have exaggerated the correlations. Thus, future studies may use multi-source in order to mitigate CMB. Second, in the present study, we used innovation as an underline mechanism to explain the relationship between E-education and unemployment reduction. Hence, future studies may use different underline mechanisms to uncover the consequences of E-education programs. Future studies in this domain can draw a regional comparison on the penetration of E-education programs and resultant employment and economic growth prospects. Nevertheless, it would be interesting to draw on a comparison between the use of E-education and skills development in developing and advanced countries.The original contributions presented in this study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.YS wrote the original manuscript. All authors contributed to the article and approved the submitted version.


In 1995, the United States was the first country to introduce universal childhood varicella vaccination. High vaccine coverage was attained among young children, ≥ 90% since 2007. In 2007, the policy was changed from 1-dose to a 2-dose program. We describe the impact of 25 years of the U.S. varicella vaccination program on varicella disease nationally.We reviewed published data and analyzed overall and age-specific trends for rates from the pre-vaccine period (1990–1994) through 2019 for varicella incidence using National Notifiable Diseases Surveillance System data, hospitalizations using National Inpatient Sample data, and deaths using National Center for Health Statistics data. We present trends in persons aged < 50 years, which captures most varicella burden and avoids misclassified herpes zoster in older people. Outbreak  characteristics were assessed for 1995–2019 and were informed by published data and analysis of surveillance data reported to CDC.Within the 10 years of the 1-dose program, varicella incidence, hospitalization, and mortality rates declined dramatically (71%–90%) vs. pre-vaccine. However, limited transmission continued in school settings which informed the change to a 2-dose policy. By 2019, declines reached > 97% for incidence and 94% and 97% for hospitalizations and deaths, respectively. The greatest decline occurred among persons aged < 20 years, born during the varicella vaccination program, with 99%, 97%, and > 99% reduction in incidence, hospitalizations, and deaths, respectively. The 2-dose program further reduced the number, size, and duration of outbreaks vs. the 1-dose program; over the entire program, the proportion of outbreaks with < 10 cases increased from 28% to 73%.The varicella vaccination program significantly reduced varicella morbidity and mortality in the U.S. Twenty-five years into the program, pediatric varicella hospitalization has become a rare event and varicella deaths in persons aged < 20 years are practically eliminated in the U.S. Annually, > 3.8 million cases, 10,500 hospitalizations, and 100 deaths from varicella are now prevented in the United States due to the varicella vaccination program.All Authors: No reported disclosures.


Several previous studies state that the Islamic Social Finance program has not fully succeeded in creating prosperity, and there are no definite measurements to show the sustainability impact of the program. Thus, a measurement is needed to analyze various aspects in achieving the success and sustainability of Islamic social finance programs. This study developed an index for performance evaluation with an emphasis on the success and sustainability of the Islamic Social Finance program. The study used the Analytical Network Process to determine and analyze priority components. Furthermore, the Multistage Weighted Index method was used to calculate the final index score. The index was built by taking into consideration various factors, stakeholders, aspects, and indicators. This study indicates that aspects of funding contribution from donors (0.22), involvement of donors in giving advice (0.99), and controlling of supervisor (0.08) are priority aspects in the success and sustainability of the program. An empirical investigation was performed on three different programs in Indonesia: A, B, and C. Program A (0.81) and C (0.80) have succeeded in improving the beneficiaries’ quality of life to the level of economic resilience, although at a low level of sustainability (76–84.33). On the other hand, program B (0.73) is at the economic reinforcement and has not yet achieved sustainability. This index can be seen as a comprehensive tool for measuring the success and sustainability of the program at several levels. The management of Islamic Social Finance continues to grow, including the distribution of funds –3. InitiAs a Muslim majority country, Indonesia has a great potential for Islamic Social Finance instruments. According to the recent reported data, the potential for Islamic Social Finance instruments have reached USD 22.8 billion for zakat , USD 137Indonesia is the most generous country globally , 10. In The urgency of Islamic social funds professional management is reflected through empowerment programs. First, distributing Islamic social funds can achieve welfare by maintaining five aspects of maqashid sharia  so that The management of the Islamic Social Finance program is closely related to sustainability , 23, wheIn the context of the Islamic Social Finance program, by referring to the abovementioned definition of sustainability, it can be concluded that sustainability occurs when (1) the program can encourage the beneficiaries to be independent (able to meet their own needs) and (2) the program can prosper the beneficiaries. Thus, it needs various inputs and appropriate indicators to guide the empowerment programs and measure their success and sustainability . MoreoveSeveral studies have developed Islamic social fund indexes/indicators based on the literature review, focusing on institutional and program indexes. Amin  developeIn contrast to previous research, this study developed a new performance measurement model for the Islamic Social Finance program. This research has several novelties. First, this study develops previous research by establishing an index to see the success and sustainability of Islamic Social Finance programs. Second, the researchers conducted empirical investigations on three Islamic Social Finance programs to measure their success and sustainability. Third, the main criterion of the empowerment program is to achieve prosperity for beneficiaries, hence, this research also emphasizes the importance of integrating Islamic social funds in achieving prosperity. Finally, this research built a comprehensive measurement, in which researchers can assess a program for its level of success in transforming the welfare of beneficiaries, represented through 4 ER .This study indicates that the funding contribution from donors (0.22), some advice from donors (0.9), and control by supervisor (0.8) are priority aspects in achieving the success and sustainability of the program. An empirical investigation conducted on three programs—A, B, and C—shows that programs A (0.81) and C (0.80) are at the level of economic resilience but with low sustainability. Meanwhile, program B (0.73) has not yet achieved sustainability and is still at the level of economic reinforcement.This research has implications in several ways. First, this study emphasizes the importance of the involvement of donors in paying Islamic social funds to institutions to be managed productively. Islamic Social Finance institutions must formulate strategies to increase donor engagement, such as providing various payment platforms that make it easy or creating potential programs that have long-term impacts. The government, as a regulator, can issue a series of policies and regulations that advise the public to pay Islamic social funds through Institutions. Second, increasing public literacy related to Islamic Social Finance is essential to increase donor involvement. Third, an empirical investigation of the Islamic Social Finance Program at the level of economic reinforcement and economic resilience with low sustainability shows that several aspects need to be improved. As program managers, Islamic Social Finance Institutions must formulate various program optimization strategies and coordinate with multiple stakeholders, such as regulators, academics, associations, and supervisors.As for the structure of this paper, this article is divided into five main sections. The first section discusses the background of the writing. The second section presents the theoretical basis of index development. The third section describes the methods used. The fourth section identifies the results and analysis. Finally, the conclusions are shown in the fifth section.Islamic Social Finance is an integrated socio-economic empowerment system divided into traditional and contemporary financial systems. Traditional Islamic Social Finance instruments classified into two types: Philanthropy-based instruments, such as zakat, infaq alms, and waqf, and cooperation-based instruments, such as qardh and kafalah . MeanwhiThe previous research shows differences in understanding Islamic Social Finance (ISF) instruments see . Zakat hOn the other hand, waqf is a voluntary donation generally also known as part of sadaqah (good deeds) and infaq (expenditures to please Allah) . Islam mIn the context of Islamic Social Finance, several studies have discussed sustainability and Islamic Social Finance. Khalfan et al.  stated tThe program and how it can create sustainability for the beneficiaries also mirror the sustainability of Islamic Social Finance. One of the critical goals of Islamic Social Finance programs is to ensure that sustainability is the empowerment program. However, research on empowerment programs still focuses on impact measurement , 54–57. Based on Brau et al. , there aPischke  analyzedBased on the research above, it can be concluded that the sustainability parameters of the Islamic Social Finance program are: (a) it creates financial self-sufficiency for the beneficiaries where they become financially independent, (b) it supports the recipients to generate income on an ongoing basis, (c) it provides the beneficiaries a balanced financial flow, in which the income can meet daily basic needs and can be further invested, (d) it provides beneficiaries with the necessary skills to maintain or improve their quality of life through increased productivity. Integration of various stakeholder roles is also needed to achieve sustainability , 62.The program builds from a need to be relevant to the program’s purpose, and the results will meet those needs. An active movement can achieve the program’s objectives by designing a logic model. The logic model is a program implementation structure/scheme that requires a connection between the purposes and the program implementation process, which includes inputs (resources), activities, outputs, and actual outcomes in the short and long term . An asseThe ANP and MWI methods are used in this study to evaluate the performance of the Islamic Social Finance integration program. In this study, performance analysis of Islamic Social Finance integration is critical, with the following considerations: First, no research has been conducted to assess Islamic Social Finance integration programs with a focus on sustainability; Second, performance analysis is critical in determining the extent of the impact of a given program as well as decision-making material in program improvement.Integration is merging several parts into a unified whole . IntegraPrevious research has also proven that ISF integration positively impacts ISF management. Amuda  investigThe Islamic Social Finance ecosystem can foster integration among Islamic Social Funds. Several Islamic social funds integration programs have been implemented in Indonesia. For example, the Ahmad Wardi Hospital program was built on waqf land and funded by zakat and infaq funds. As a result, mustahiq can freely use the health program. Furthermore, several Zakat Institutions in Indonesia run agricultural programs in which the land is provided by waqf lands, such as the programs run by the Zakat Institutions Al-Azhar and the Infaq Management Board. During the farming season, operational needs are met using infaq funds through the qardhul hasan scheme. This integration program can significantly accelerate community welfare and maximize the potential of Islamic social funds.Several previous studies have built Islamic Social Finance Indexes, as shown in Previously, research has focused on measuring the institution’s performance by focusing on a single aspect of measurements, such as service quality, accountability, or management efficiency. Furthermore, most previous studies used qualitative techniques, such as the Analytical Network Process (ANP) technique, without quantifying the indicators. As a result, this study built on previous research by developing a novel measurement that focuses on sustainability factors to assess the sustainability of Islamic Social Finance programs. Furthermore, this study uses the developed measure to determine the success of three empowerment programs implemented by various Islamic Social Finance Institutions.The research method is separated into two phases. The first method stage is a qualitative approach using the Analytical Network Process (ANP) to formulate the index components of Islamic Social Finance programs’ success and sustainability. The Analytical Network Process is a development of the Analytical Hierarchy Process, built by Saaty . The resThere are three stages in the ANP method. The first is the decomposition stage, which aims to build and validate the framework of the ANP model by determining the objectives, factors, aspects, and indicators that influence the success and sustainability of Islamic Social Finance programs see . The resThe second ANP stage is a pairwise comparison to create the designed questionnaire from the ANP model. The questionnaire includes information on factors, stakeholders, aspects, and indicators that affect the success and sustainability of the program. The questionnaire was compiled based on the general ANP format using a scale of 1–9 for each compared point. A scale of 1 indicates very unimportant meaning; on the contrary, a scale of 9 means very important/relevant/influential. The questionnaires were distributed to experts to assess each ANP network.The third stage is the analysis. It includes the priority weight of each index. The priority weight is determined following agreement results from experts. The calculation of priority weight uses the help of Microsoft Excel and Super Decision. Based on Saaty , the meaT is the transpose matrix from the results of data processing, p is the number of nodes, n is the number of respondents and S is the number of squared deviations from the calculation results of T and the average value of the absolute priority.In detail, After all the phases in the ANP method have been carried out, the next step is to estimate the index value using the Multi Stage Weighted Index method (phase 2). Like the ANP method, the MWI method has three stages. The first stage is to develop criteria for each built indicator in the ANP model. The standards were compiled based on the results of the FGD, in-depth interviews, and literature reviews. The assessment of criteria is described using a Likert scale of 1–5, where 1 indicates the least ideal condition, while 5 shows the most optimal condition. The second stage is determining the weight for each factor and aspect to formulate the index calculation. In this phase, there is a relationship between ANP and MWI where the weights’ measurement uses the ANP data processing results. The third stage is to estimate the index value with the following formula:This study built an index of the success and sustainability of Islamic Social Finance programs using the score of 0 to 100. In addition, the index is able to formulate the possibility of sustainability, as shown in Primary data sources are focus group discussions, in-depth interviews, and field studies. The results of focus group discussions and in-depth interviews formulated the ANP model and criteria assessment for the MWI method. This study involved a total of 15 respondents consisting of four representatives of academics, four representatives of practitioners, three representatives of associations, and four representatives of regulators. In the ANP method, the number of respondents is not the main criterion but the expertise and experience . The resThe selection of respondents used the purposive sampling technique. The respondents must had more than two publications in reputable international journals related to Islamic Social Finance for the academic group. In the group of practitioners, respondents were in managerial positions as chairpersons or program managers. The respondents were leaders in the Islamic economic community association and the Islamic Social Finance management forum for association groups. Next, the respondents were from the Indonesian Waqf Board, the National Amil Zakat Agency, the Ministry of Religion, and KNEKS and held managerial positions for the regulator group.On the other hand, field studies present the empirical results of the constructed index of success and sustainability. The study analyzed three Islamic Social Finance institutions with the following criteria: (a) official institutions that are granted a license to operate by the government, (b) have the status of a national or provincial level institution, and (c) conduct empowerment programs. Furthermore, the empowerment program’s criteria must include the following terms. First, it is an Islamic Social Finance integration program. The funds disbursed are not only from one type of source. Second, the program has run for at least one year. Third, the program implements benefits to mustahiq, who deserve to be empowered. Similar to the procedure for collecting questionnaire data with experts, the researcher also confirmed the willingness of the Islamic Social Finance Institution to become research respondents. Data entry and interviews with representatives from ISF institutions were managed offline (2 respondents) and online (1 respondent). Before taking the questionnaire, experts had to fill out a consent form. Each expert completed the questionnaire consciously and in a normal mental state. Further, the experts were not subjected to any pressure from any party.This research follows the rules and ethics of research conduct and writing by the Institute for Research and Community Service (LPPM) of Universitas Airlangga. This research also refers to Airlangga Chancellor’s Regulation Number 34 of 2019 regarding the rules of behavior in article 16 (b); researchers must be honest, objective, and pay attention to all aspects of the research process and are not allowed to manipulate data and research results. Article 16 (f) states that researchers must respect and appreciate the object of research, whether the thing is a human or an animal, whether living or dead. Further, this research is supervised by the Center of Research and Publication (3P) in the Faculty of Economics and Business Universitas Airlangga, which functions as an ethics committee according to the Dean Decree Number 88/UN3.1.4/2020. This research is also supervised by the Institute for Research and Community Service (LPPM) Universitas Airlangga as the ethics committee at the university level and as a funder.KOMZ = C0), (2) pre prosperous but not entitled to receive zakah nor must pay zakat (YKOMZ = C0), and (3) prosperous and to pay zakat (YON = CON). Thus, the researcher developed indicators in these five aspects and determined the level of concept 4 ER, as shown in The 4 ER concept is a concept that shows the extent to which the Islamic Social Finance program can prosper the beneficiaries. The researchers of this study created the concept based on literature reviews on prior studies and previously conducted focus group discussions. The 4 ER concept was developed based on the maqashid sharia. According to Al-Ghazali, maqashid sharia (objectives of Islamic Law) aims to achieve maslahah (means welfare/advantage/merit) by maintaining five aspects: Faith, Soul, Mind, Lineage, and Prosperity. This study used the research of Kusuma and Ryandono  as the bThe first is Economic Rescue, the lowest level, where the Islamic Social Finance program cannot improve the beneficiaries’ economy . This level means that the program has not been able to encourage recipients to be able to meet the needs in the five aspects of maqashid sharia. The value score of the Economic Rescue is 1–25%. Secondly, Economic Recovery was defined as the level where the program can provide economic change and encourage beneficiaries to meet their needs, but it is not a significant change. In Economic Recovery, program recipients have not been able to save their income (Y < S), but the most basic needs have been fulfilled, although it is unstable. According to Chang and Rose , economiNext, Economic Reinforcement is the third level, showing that the Islamic Social Finance program can increase the beneficiaries’ economy, and the income exceeds the needed (Y > S). At this stage, the program’s recipients have been able to save, invest, and donate their income. The score for Economic Recovery is 51–75%. Lastly, Economic Resilience is the top level where the program has created prosperity for its beneficiaries. According to Shima et al. , economiThis study built an index of the success and sustainability of Islamic Social Finance programs. The index was constructed by analyzing factors, stakeholders, aspects, and indicators compiled through focus group discussions, in-depth interviews, and literature reviews. Internal and external factors influencing the ISF program’s success show the same important value 0.5). Four stakeholders play a role in internal factors, including institutions (0.38), donors (0.24), beneficiaries (0.24), and supervisors 0.14) see . Islamic. Four st see . IsMeanwhile, the external stakeholders include academicians (0.29), associations (0.28), and the government (0.43). The government is the most influential stakeholder in the success and sustainability of the program. The government is the party that permits the establishment of institutions and implementation of Islamic Social Finance programs . MoreoveThe second priority is the involvement of donors (0.9) in providing input/advice to Islamic social finance institutions. This involvement includes the ability to capture donors’ aspirations, trust, and loyalty to pay Islamic social funds  to the institution , 96, 97.This study attempted to measure the index of success and sustainability of Islamic Social Finance programs using three programs from different institutions represented by initials as programs A, B, and C. Based on From the donor aspect, program C scores higher than the other programs. Donors have an active role in the success and sustainability of program C to transform beneficiaries’ welfare. The involvement of donors, primarily in distributing Islamic social funds to institutions, is crucial in achieving the success and sustainability of the program. This finding follows prior studies , 59, 60,From the beneficiary’s perspective, commitment and motivation to change is the highest aspect of all programs’ success and sustainability. This result is relevant to the previous study , 111. ThThe controlling aspect value is higher than the evaluation aspect for the entire program by seeing the supervisor stakeholder. The result means the controlling element has been carried out but not thoroughly evaluated. The coordination aspect score is higher than the cooperation for all programs from the association stakeholder’s perspective. Coordination includes how associations coordinate with all stakeholders and build an ecosystem that supports program implementation . ProgramFrom the academician perspective, programs B and C have identical scores and are higher than program A. The result means that programs B and C have full support from academics in program implementation. Academic support, in this case, is in the form of involvement in providing competent human resources and socializing the importance of Islamic Social Finance, increasing public literacy.Seen from the government stakeholder, the policy and regulation aspect is highly valued compared to the infrastructure support aspect in all programs. Program A has the highest score in policy and regulation compared to programs B and C. Based on the interviews with program A managers, the government collaborated with Islamic Social Institutions for program A implementation. The government supported by providing funds and inputs to optimize the execution. The government invited other stakeholders to discuss the direction of program A development. Policy and regulatory approval from the government are fundamental to achieving the success and sustainability of the program , 112. ThFrom the histograms shown in Figs Program B has the lowest score and is on the economic reinforcement level. Compared to programs A and C, Program B must optimize coordination and teamwork with all stakeholders, particularly beneficiaries and the government. In addition, program B must increase beneficiary commitment and responsibility and develop strategies to improve beneficiaries’ quality of life. Furthermore, program B must carry out synergy and coordination with the government, focusing on the synergy of assisting the government in program implementation. Program C has achieved the same level of success and sustainability as Program A. In general, program C must optimize aspects involving internal ISF stakeholders.This study analyzed three utilization programs so that they can be benchmarked against each other. The index helps Islamic Social Finance institutions to manage empowerment programs by tracking the level of success and sustainability of the program. The purpose is to understand the extent of the empowerment programs’ impact on welfare transformation on program recipients.The study adds to the literature by developing an index for measuring the performance of the ISF Institution by emphasizing the aspects of sustainability of the empowerment programs in transforming the welfare of mustahiq. The established index provides an exact measure of success and sustainability through the 4 ER concepts . Thus, the government and Islamic Social Finance institutions can use this index to measure the success and sustainability of a program. Further, this study adds to the literature regarding the integration theory of Islamic Social Finance in empowerment programs by implementing the index on three integrated programs in Indonesia.The study gives managerial contribution in several ways. First, the study emphasizes the importance of the involvement of donors in paying Islamic social funds to Institutions to be managed productively. Islamic Social Finance institutions must formulate strategies to increase donor engagement. One is by providing platforms that can create more manageable payments, such as e-commerce, crowdfunding, mobile banking, and so on, or build potential programs that have long-term impacts. Other way is using digital technology, including social media, to educate and socialize Islamic Social finance by displaying creative content as educational media. Collaboration with influential figures from each generation  is critical because each generation has unique characteristics and approaches. As a result, the purpose of socialization can be effectively communicated, and the amount of fundraising can increase. More than 30 universities in Indonesia host lectures on Islamic Social Finance/Islamic Economics/Sharia Economics. As a result, academics play an essential role at the university level in socializing the importance of Islamic social fund donation. According to the findings of this study, the government is the most influential external stakeholder. As a regulator and leader of economic countries, the government issues policies and regulations advising the public to pay Islamic social funds through institutions. Furthermore, local governments, such as the Aceh district through Qanun Aceh No. 10 Years 2018, have obligated civil servants to pay zakat. However, this policy is still subject to each local government policies. With this, the government must reconsider the urgency of requiring the payment of Islamic social funds for Muslims through the ISF Institution nationally.Second, an empirical investigation of the Islamic Social Finance programs shows that the programs are at the Economic Reinforcement and Economic Resilience levels with low sustainability. Islamic Social Finance institutions must develop short-, medium-, and long-term strategies to ensure mustahiq welfare. In the short term, Islamic Social Finance institutions must focus on strategies enabling mustahiq to meet their basic needs. The approach is purposed to alleviate distress and ensure the safety of the beneficiaries. In the medium term, Islamic Social Finance must develop a strategy to increase mustahiq’s income and enable them to meet their basic needs independently through business management. The approach provides mustahiq with the necessary empowerment program to improve their entrepreneurial skills. Finally, in the long run, the Islamic Social Finance institution must devise a strategy to break mustahiq’s reliance on the institution, allowing the mustahiq to be self-sufficient. Training and mentoring for mustahiq is one way to increase mustahiq’s skills and reach prosperity. The government can help by providing beneficiaries with training and mentoring. The support certainly relieves Islamic Social Finance institutions when some have difficulty giving training to their recipients. Furthermore, one of the causes of the program’s low sustainability is the limited funds. The government must support Islamic Social Finance Institution in running the empowerment program. The government must assist Islamic Social Finance institutions in implementing the empowerment initiative. To create welfare for mustahiq, the institutions must optimize teamwork and coordination with various stakeholders, such as associations, private corporations, and others.This study developed a success and sustainability index for Islamic Social Finance Program using Analytical Network Process (ANP) and Multistage Weighted Index (MWI). The study analyzed various aspects and indicators to achieve program success and sustainability. The results show that the funding contribution of donors is a priority aspect. It indicates that more funds need to be paid by donors through institutions. The funds are then managed professionally in the form of empowerment programs. The programs must achieve success and sustainability to have a broader impact on the recipients. The realization of collections to institutions is still low, so the government must issue mandatory policies related to the payment of Islamic social funds in institutions. Therefore, Islamic Social Finance Institutions must manage the program professionally to transform welfare for the recipients with limited funds. This can be done by transferring knowledge and skills to beneficiaries through training and mentoring. In addition, this study highlights donors’ involvement and supervisors’ role in program monitoring to achieve program success and sustainability. This study conducted an empirical analysis of three empowerment programs in three different institutions. The finding shows that programs A (0.81) and C (0.80) have encouraged beneficiaries to improve their quality of life even though they are not economically stable. Meanwhile, program B (0.73) is at the level of economic reinforcement, which means the program has not yet achieved sustainability.The study has limitations. First, the index built in this study is based on specific conditions in Indonesia and cannot be generalized to countries with other different characteristics of Islamic Social Finance programs. Thus, it is necessary to develop cross-country research to apply the index to different countries. Second, the empirical investigation only includes integrated programs. Hence, further analysis can conduct empirical studies on integration and non-integration programs to determine the urgency of Islamic Social Finance integration.S1 Data(XLSX)Click here for additional data file.S1 File(DOCX)Click here for additional data file. 28 Aug 2022 <div> PONE-D-22-20909 </div>  <div> Toward Developing a Sustainability Index for the Islamic Social Finance Program: An Empirical Investigation </div>  <div> PLOS ONEDear Dr Robani,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.plosone@plos.org. 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KINDLY REFER TO PAGES 1-2, 3-7, 18 AND 20 FOR DETAILSAttachmentResponse to Reviewer.docxSubmitted filename: Click here for additional data file. 17 Oct 2022Toward Developing a Sustainability Index for the Islamic Social Finance Program: An Empirical InvestigationPONE-D-22-20909R1 <span style="color: rgb; font-family: verdana, geneva, arial, helvetica, sans-serif; font-size: 11.2px; background-color: rgb;"> Anidah Robani </span> ,Dear Dr. We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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