Adolescents are highly susceptible to negative self-perceptions, likely due to their social cues and environment. The presence of these negative self-perceptions has been shown to adversely impact levels of physical activity (PA). Although PA has the ability to foster improved self-perceptions, the rates of PA among adolescents continue to descend, with girls appearing to be most susceptible to these declines. At-risk adolescent girls, who may experience a number of negative preceding lifestyle conditions, may be exceptionally vulnerable to declines in PA. There are a high number of adolescent girls from low-income and abusive households in British Columbia, Canada, thus indicating a need for a program to relay the importance of PA and healthy lifestyle behaviors.This paper aims to describe the protocol of the Girls United and on the Move (GUM) pragmatic intervention, an integrated PA and psychosocial program aimed at improving self-compassion, social connectedness, and overall self-perceptions among at-risk adolescent girls.Using a quasi-experimental mixed methods approach, the GUM intervention was conducted in 5 schools in British Columbia, Canada. Adolescent girls aged 11 to 15 years who were identified as at risk were included in the study. The 9-week intervention, co-delivered by a PA/health promotion–trained researcher and a registered social worker, involved a PA component and a psychosocial component with evidence-based topics addressing the concerns of the adolescent girls. The following outcomes were evaluated: PA, self-compassion, social support, leader supportiveness, and sport enjoyment and commitment. Program acceptability and satisfaction was also examined. Outcome measures were assessed at baseline (week 1), week 6, and postintervention (week 9), and interview data concerning program acceptability and satisfaction were collected at postintervention from a subsample of participants.A total of 101 participants were invited to participate in the GUM intervention. Reporting of the results is projected for the fall of 2020.It is anticipated that the GUM intervention will enhance PA while also improving self-compassion, social connectedness, and overall self-perceptions among at-risk adolescent girls. The findings of this research will contribute to the literature concerning PA and various psychosocial factors that impact the physical and mental health of at-risk adolescent girls.Clinicaltrials.gov NCT03567200; https://clinicaltrials.gov/ct2/show/NCT03567200.DERR1-10.2196/15302 Worldwide levels of physical activity (PA) among adolescent girls have seen a substantial decline in past decades ,2, with At-risk adolescent girls are especially vulnerable to these negative self-perceptions, as they may be faced with additional hardships, including low socioeconomic housing, exposure to substance abuse, sexual exploitation, etc . At-riskBy providing an emotionally supportive environment for this population, it is likely that enhanced physical and mental health outcomes will be exhibited, as a strong support system is able to establish a sense of belonging and aid in case of problems . In partThere have been various interventions to date with the goal of improving PA behavior among adolescent girls; however, few have focused on at-risk girls. There is a need for tailored and targeted evidence-based programs focused on addressing specific physical, mental, and psychosocial health issues that at-risk adolescent girls may currently face in everyday life. To address these issues, Girls United and on the Move (GUM), an integrated PA and psychosocial program, was developed. The overarching purpose of the GUM study was to explore the effectiveness of an integrated PA and psychosocial program on PA behaviors and various identified psychosocial factors among at-risk adolescent girls. The purpose of this paper is to describe the intervention design and methodological protocol of the GUM program.The GUM study protocol was prepared according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines  and usedEthical approval was obtained from the Behavioural Human Research Ethics Board at the University of British Columbia (H17-01540) and from School District 23. In all cases, both parental consent and student assent were obtained prior to data collection.The specific objectives of the GUM study were (1) deliver and explore the effectiveness of the 9-week GUM intervention program on the primary outcomes of PA, self-compassion, social support, and leader behavior; (2) explore the effectiveness of the 9-week GUM intervention program on the secondary outcomes of sport enjoyment and commitment; and (3) examine participant perceptions of the GUM program in terms of acceptability and satisfaction.Participants of the GUM study included adolescent girls from 5 middle schools in British Columbia, Canada, who were aged 11 to 15 years and identified as at risk. Guidance counselors from each middle school used these criteria to identify girls and invite them to participate, encouraging those whom they felt would benefit from participating in the program. The guidance counselors were exclusively responsible for recruitment because they had previous history working with the girls on a regular one-to-one basis due to the girls’ behavioral inadequacies, issues with home life, or mental health–related concerns such as anxiety or depression. Counselors then provided interested individuals with further detailed information about the program  and prompted the students to discuss the program with their parents or guardians. Participants were asked to return the signed consent and assent forms to the guidance counselor or the research team prior to the start of the program or at T1. There were no specific exclusion criteria except that participants could not have been a participant of the previous pilot study, Girls on the Move (GoM) which took place from 2015 to 2016 . A totalEach GUM intervention session occurred at the participating school  or off campus within the community, depending on the scheduled activity for the given day . The participants were provided with transportation to all off-campus activities by the trained researcher and social worker . Both facilitators were authorized and insured to provide transportation for program participants. Participation was completely voluntary and all participants were informed that they did not need to participate in the research component to participate in the GUM program. Those who chose to participate in the research component were informed that they could withdraw from participation in the study at any time and without consequence.The GUM intervention was developed and refined based on the GoM pilot study. GoM was conducted from 2015 to 2016 and included 2 middle schools, with a total of 24 participants aged 11 to 17 years. The purpose of the GoM intervention was to examine program and methodological feasibility and gain further insight concerning PA experiences, preferences, and self-concept among at-risk adolescent girls . FindingThe GUM intervention was a pragmatic PA and psychosocial program designed specifically for at-risk adolescent girls. Components of the self-determination theory, particularly autonomy, competence, and relatedness, were integrated throughout the intervention because these are known to affect intrinsic motivation and engagement in PA, especially among underserved youth ,33. The Within each of the weekly 90-minute program sessions, 45 minutes of PA were delivered by a trained researcher and 45 minutes were allocated to social worker–led discussions on various psychosocial topics. Examples of physical/sport activities included on-campus activities such as yoga, team obstacle courses, and soccer, or off-campus activities such as rock climbing, self-defense classes, and fitness classes. Examples of psychosocial topics that were discussed within each group included healthy relationships, conflict resolution strategies, substance abuse issues, sexuality, and gender issues. In addition to the group discussions facilitated by the social worker, personal journals were distributed to each participant during week 1. These journals provided participants with an opportunity to disclose their thoughts and feelings about their current state, any personal struggles they may be undergoing, or anything to do with the GUM program itself. Participants returned the journals to the registered social worker at the end of each of the weekly GUM sessions, indicating if they wanted the social worker to read the entry and give a written response. This allowed participants to reach out and seek advice if they needed it, without requiring the participants to talk in person about their issues to either one of the program facilitators. Although not previously used in the GoM pilot study, disclosure journals have been used previously by the social worker and have been reported to be an important component of previous programs delivered to this population. The disclosure journals were used as a component of the intervention, but no data were extracted or evaluated from the journals. After program completion , a subsample of participants  were invited to participate in an individual semistructured interview so that the program facilitators could gain further information concerning program acceptability and satisfaction. Those who attended a minimum of 80% (7/9) of the program sessions were invited to participate in the voluntary semistructured interviews. Participants were informed that they were able to withdraw from the study at any time, for any reason, without consequence. All personal data were coded and handled with confidentiality.Mixed methods were used to collect and analyze data. Quantitative data measures consisted of self-report questionnaires to assess self-compassion, social support, leader supportiveness, and sport commitment and enjoyment. Qualitative data consisted of semistructured interviews with a subsample of program participants, which provided further insight concerning the acceptability and satisfaction of the program components, physical and psychosocial activities, resources, and overall delivery . Self-report measures were used because they are easy to administer, relatively inexpensive, and recognized as an acceptable means of recording participant responses and psychological constructs in youth populations . FurtherDemographic information consisted of age, grade, number of siblings, housing location, mode of transportation to school, and whether the participant took part in any PA inside or outside of school.Level of PA was assessed using the Physical Activity Questionnaire for Children, a 10-item questionnaire that assesses the frequency of PA participation over a 7-day recall period . This asThe Self-Compassion Scale (SCS) was used to assess self-compassion through 6 subscales that include contrasting components: self-kindness vs self-judgement, mindfulness vs overidentification, and common humanity vs isolation ,38. The Perceived social support was assessed using the Child and Adolescent Social Support Scale (CASSS) . The CASThe LCQ  was usedSport commitment and enjoyment was assessed using the Sport Commitment Model , a questFace-to-face, individual, semistructured interviews were conducted with a subsample of participants  to gain greater knowledge concerning acceptability of and satisfaction with the GUM program. Participants were asked to share their thoughts, opinions, experiences, and recommendations concerning activities, education, and resources of the program. These interviews were conducted at postintervention by a trained researcher at a time that was convenient to the participants. Interview questions were informed by the study objectives and the research literature specific to this topic area and study population. Data from the interviews were audio recorded and transcribed verbatim with all possible identifiable information removed.To enhance rigor, various verification strategies were used, such as having the data systematically checked by other trained researchers and closely monitoring gradually learned information as the research project progressed. All data collected for descriptive purposes will be presented as means and standard deviations for all sample characteristics. All outcome variables, including changes in PA behavior, self-compassion, social support, perceived leader supportiveness, and sport commitment and enjoyment, will be analyzed using an analysis of covariance statistical design. The level of significance will be set at α=.05. Statistical analyses will be conducted using SPSS software .Inductive thematic analysis, as outlined by Braun and Clarke , will beData collection, as well as the handling and storage of data, will be coordinated within the Physical Health and Activity Behaviour (PHAB) Lab at the University of British Columbia. Demographic and self-report questionnaire data will be entered electronically by a trained researcher on the project. All paper-based data will be stored in a secure and locked filing cabinet located in the PHAB Lab. All electronic data will be stored on a password-protected computer also located in the PHAB Lab.The final recruitment phase for the GUM study was completed in May 2019, with the final study results projected to be published in the fall of 2020. The results of the GUM study will be disseminated through traditional avenues such as presentations at national and international academic meetings and publication in open-access, peer-reviewed journals. In addition, these results will be disseminated through plain language summaries to participants and through summary briefings to local stakeholders and government agencies.This protocol paper describes the methodology processes of a unique intervention encompassing both PA and psychosocial components, designed to help address the specific issues and barriers faced by an underserved subpopulation of adolescent girls. Through evidence provided in the literature, issues revolving around self-compassion, social support, and social isolation are further amplified by lack of PA and sports participation. To make matters worse, adolescent girls who are considered to be at risk may experience magnified barriers to PA and lack interest in the potential benefits of a PA program. This is problematic because this specific population may experience significant benefits from a successful PA program compared with the general population of adolescent girls. PA has been shown to positively enhance self-perceptions of self-compassion and social support and to reduce social isolation, all of which are prevalent traits among at-risk adolescent girls ,20,44. TThe GUM intervention was designed with these specific elements in mind. By providing a safe space for at-risk adolescent girls to talk about their issues and engage in fun, organized PAs that help emphasize the importance of a physically active lifestyle, the intervention’s outcomes may be highly valuable to future research. However, this study does pose some potential limitations as a result of its noncontrolled environment, the population being studied, and the constraints based on budget and resources. First, the use of subjective self-report measures may be problematic, as the ability to recall PA engagement and other psychological factors can be imperfect among adolescents ,46. SecoIn conclusion, given the lack of research around at-risk adolescents, the overarching goals and objectives of the GUM program may provide the current literature with promising results and aid in the future design and refinement of effective PA programs for at-risk adolescent girls.


Homebound older adults represent an understudied population who are at greater risk of losing hand strength and manipulation skills that, in turn, can lead to increased disability and cognitive declines . The Hands and Health at Home program was developed through a partnership with the University of Michigan’s School of Kinesiology and Michigan Medicine’s Ann Arbor Meals on Wheels program to demonstrate the feasibility of an intergenerational approach to address unmet needs of Meals on Wheels recipients. Undergraduate movement science student trainers were paired with a client who they visited twice weekly for 5 weeks. Students received training, including mock training scenarios, from an interprofessional team with backgrounds in social work, nursing, and neurorehabilitation. Home training protocols were developed using commercially available games and occupational therapy tools with the aim of improving hand function and facilitating socialization. Pre- and post-assessments included hand strength and dexterity, and client-reported measures of physical function and self-efficacy. Feedback from clients and students was overwhelmingly positive with several students indicating that the experience had stimulated interest in pursuing gerontology careers. Changes in quantitative assessments were variable across clients although pinch strength increased significantly in the non-dominant hand (p<0.02) and was predictive of measures of self-efficacy . To our knowledge, this pilot program is the first of its kind and demonstrates the value of an intergenerational approach aimed at improving quality of life in Meals on Wheels clients, and may be of benefit for other underserved older members of the community.


Cancer control programs have added patient navigation to improve effectiveness in underserved populations, but research has yielded mixed results about their impact on patient satisfaction. This study focuses on three related research questions in a U.S. state cancer screening program before and after a redesign that added patient navigators and services for chronic illness: Did patient diversity increase; Did satisfaction levels improve; Did socioeconomic characteristics or perceived barriers explain improved satisfaction.Representative statewide patient samples were surveyed by phone both before and after the program design. Measures included satisfaction with overall health care and specific services, as well as experience of eleven barriers to accessing health care and self-reported health and sociodemographic characteristics. Multiple regression analysis is used to identify independent effects.After the program redesign, the percentage of Hispanic and African American patients increased by more than 200% and satisfaction with overall health care quality rose significantly, but satisfaction with the program and with primary program staff declined. Sociodemographic characteristics explained the apparent program effects on overall satisfaction, but perceived barriers did not. Further analysis indicates that patients being seen for cancer risk were more satisfied if they had a patient navigator.Health care access can be improved and patient diversity increased in public health programs by adding patient navigators and delivering more holistic care. Effects on patient satisfaction vary with patient health needs, with those being seen for chronic illness likely to be less satisfied with their health care than those being seen for cancer risk. It is important to use appropriate comparison groups when evaluating the effect of program changes on patient satisfaction and to consider establishing appropriate satisfaction benchmarks for patients being seen for chronic illness. Patient satisfaction is an important goal for health care services, as both an indicator of service quality and as an influence on subsequent service utilization –5. IncreIn spite of some positive evidence, however, and the clear potential for patient navigation programs to improve care delivery to underserved populations, research has not consistently linked patient navigation programs to increased satisfaction –11. A syOne reason for inconsistent effects of patient navigation on satisfaction with care may be that studies have not taken into account the financial, practical, and cultural barriers that patients may confront and the ability of patient navigators to overcome them –17. ReduSociodemographic characteristics may also influence patient satisfaction and so must be taken into account. Prior research identifies age as a consistent predictor of greater satisfaction, in spite of its association with declining health , 21, 22.The broader research literature on patient satisfaction thus suggests that inconsistent findings about the effect of patient navigation programs on patient satisfaction may be due in part to insufficient controls for other influences that may explain or alter these effects. The addition of patient navigators to an established cancer detection program created an opportunity to test these possibilities.The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) initiated by Congress in 1990—and the case management component added in 1998—improved access to breast and cervical cancer screening for low income, underserved women by funding programs in every state, territory, and tribe in the United States , 30. In After a state-wide program evaluation led by the authors identified lower rates of screening and referral among eligible women with immigrant backgrounds, an Expert Panel recommended two major program changes: (1) Community-based patient navigators were added to improve outreach at each health care delivery site; (2) The patient navigators were also expected to assist with management of the chronic illnesses that both increased cancer risk and created barriers to screening and treatment. The CDC granted a waiver of the original program requirements to allow the inclusion of chronic illness as well as cancer risk; financial eligibility continued to be limited to under- and uninsured persons at or below 250% of the federal poverty level .The case managers at each site continued to focus on diagnostic screening and referral to treatment for patients at high risk of breast or cervical cancer, while the patient navigators worked with program patients to improve their management of such chronic diseases as hypertension, asthma, and diabetes. The patient navigators were hired from the most underserved communities and so two-thirds were Hispanic and fully nine in ten were bilingual. Although the patient navigators were not expected to have any formal medical education, a 50-h patient navigation training program was designed for them and delivered at a central location. A program director supervised both patient navigators and case managers at each service delivery site.This study examined multiple satisfaction measures in the program before and after the redesign. Patient characteristics were controlled as possible confounders, perceived barriers were examined as potential mediators, and four measures of different aspects of satisfaction were included as outcomes. Specifically, the analysis is designed to answer three interrelated research questions: (1) Did patient diversity increase after the program redesign? (2) Did any aspects of health care satisfaction increase among those from ethnic or immigrant backgrounds, as intended by the program redesign? (3) Did sociodemographic characteristics or perceived barriers explain improvements in satisfaction levels?Surveys of representative samples of program patients conducted by the University’s Center for Survey Research before and after the program change created a repeated cross-sectional design (“trend study”)  that allBoth samples were selected randomly from the public health agency’s database of program service recipients, allowing study eligibility to be determined prior to patient contact. The eligible population for the “pre” survey in 2005 consisted of the 3178 women who had received any case management services from the program in the preceding 2 years (2003–2004) at any of its 26 sites, had been screened for breast or cervical cancer, and spoke English, Spanish, or Portuguese. Of 385 patients sampled randomly for interviews, 76% (293) could be located and 71% of these were interviewed, for a final sample size of 207 . The eligible population for the “post” survey in 2012 consisted of the patient population with either case management or patient navigation services in the preceding year. By that time, program enrollment had expanded as a result of the program changes to 10,627 (but with the number of program delivery sites statewide reduced to 17). Of 427 patients randomly selected from those who met eligibility criteria , 383 (90%) completed interviews .All procedures were approved by the University’s Institutional Review Board for the Protection of Human Subjects. Enrolled patients received a letter prior to the interviews informing them that participation in the phone survey was completely voluntary and confidential and would not affect their program services. These points were repeated in the introduction on the phone and the interview did not proceed unless patients consented verbally.Questionnaires were translated into Spanish and Portuguese, using forward and back translation and then reconciling differences; in both surveys, interviews were conducted in English, Spanish, or Portuguese based on patient preference (see supplementary files n = 61) of the “post” sample, but since men were not included in the first survey they were omitted from this analysis (resulting in a sample size of 320). Although survey respondents could have differed in multiple ways from the program population, there were no statistically significant demographic and location differences in comparison to the total program population other than underrepresentation of patients at two sites and overrepresentation at one.(2) After expanded eligibility criteria following the program change, many more men were eligible for program participation and comprised 16%  were used to identify changes in the composition of the program’s patients, including in race and ethnicity, marital and employment status, and health and health care access. U.S. Census data for the state were used to indicate trends in the state population that might explain changes in ethnic diversity within the program. T-tests were also used to identify differences in levels of each of the satisfaction indicators before and after the program change, and to compare satisfaction with the case manager to satisfaction with the patient navigator for patients who had both after the program change.Bivariate tests  was used to determine the independence of any pre-post program change differences in satisfaction levels from program status indicators, and the patient characteristics and access barriers identified in the literature as potential predictors. Tests of interaction effects (using product terms) indicated whether differences in satisfaction levels after the program change occurred only for the ethnic and racial groups that had previously been less satisfied .2) was used to assess and compare the fit of each model, while R2 Δ was used to identify the contribution of each block of factors potentially associated with satisfaction. Separate multiple regression analyses were conducted without the terms representing the interaction of race/ethnicity and program, but since the coefficients for the other terms in these models changed little after the interaction terms were added, only the final models including both main effects and interaction terms are presented (in Model 2).Standardized coefficients (β) are reported for the regression analyses first using only the program status indicators (Model 1) and then including all potential influences on satisfaction (Model 2). The coefficient of determination .By contrast, satisfaction with the patient navigator was higher than satisfaction with the case manager for patients who had both a patient navigator and a case manager after the program change  .After the redesign, as intended, the program population was more diverse, with a much higher proportion of Hispanic (and Spanish-speaking) and African American patients than would have resulted only from the increased proportion of these groups in the state’s population during the same period: 29 and 2.5%, respectively , 49. TheGiven these challenges, the patients’ greater satisfaction with their overall health care after the program change is a very positive result, but this higher level of satisfaction was explained entirely by the associated differences in patient characteristics. In contrast, satisfaction declined with the clinic and the care provider, except for those who were similar in their health care needs to those in the program before its redesign—those who were eligible for case management services due to heightened cancer risk.The higher levels of satisfaction with health care overall among the apparent first-generation immigrants was generally consistent with research that identifies particularly positive attitudes and behaviors in the first generation , 51, altThe diminished program-related average satisfaction level after the redesign may reflect a change from the focus on successful resolution of cancer risk for most of the pre-change patients, as compared to the ongoing problems due to chronic illness of the patients who predominated after the program change. It is unlikely that many patients after the eligibility expansion found that their chronic health problems had been resolved by the program or its staff—or more generally by the health clinic from which they received their program services. This interpretation is strengthened by the finding that satisfaction with the patient navigator was higher than it was with the case manager for those patients who had both—in other words, patients enrolled after the program change who were being seen for cancer risk. This parallels the finding from the Patient Navigation Research Program of improved satisfaction due to patient navigation among socially disadvantaged patients with recent breast or colorectal cancer diagnoses , 14, 52.Satisfaction with the program or clinic was uniquely influenced by health care barriers—specifically by more perceived economic as well as practical problems with obtaining care—as well as by less education, poorer self-rated health, and reports that high costs had deterred care in the past. In general, these results confirm Post et al.’s  finding Older age and more perceived practical barriers were the only factors associated with less satisfaction across its multiple dimensions. The other factors associated with the different satisfaction indicators suggest that satisfaction with different aspects of health care are differentially susceptible to influence by patient background and current health problems. This indicates the importance for research on health care satisfaction of the use of satisfaction indicators with different levels of specificity, as emphasized first by Roberts, Pascoe, & Attkisson .Our design had several limitations. First, a panel design was not possible because of the turnover in the original program’s patients as their cancer risks were identified. In addition, the rating of health care overall in the original program survey focused on health care services within the past 2 years, while the comparable question in the post-transition survey was narrowed to the past year because of the new program’s more limited history. The focus of the rating of satisfaction with the primary health care provider also had to shift from the case manager to the patient navigator, although our separate pre-post analysis of satisfaction just with the case manager for those who had a case manager after the program redesign—and our comparison of these patients’ satisfaction with their patient navigator to their satisfaction with their case manager—helps to clarify the effect of this shift in primary program delivery staff. In addition, only two questions about program satisfaction were repeated in the two surveys, resulting in a less robust index. It is also important to note that none of the apparent program effects on satisfaction were altered significantly by inclusion of the barriers indicators in the model, suggesting less tangible mediators of program effect that we did not capture .The absence of a special overall satisfaction benefit of the program redesign for the more disadvantaged ethnic and linguistic groups , 14 may The shift in focus of the original survey questions on satisfaction with the program itself to satisfaction with the clinic or health center where the program was implemented in the post-transition survey was necessitated by the less distinct program services delivered by patient navigators compared to those delivered by the case managers, but it means that the post-change patients could have been expressing satisfaction with a broader range of health care experiences at the health care location instead of just those delivered by program staff. Finally, although the difficulties our interviewers encountered in locating program patients are characteristic of attempts to survey lower SES groups, the obtained sample may as a result not represent the experience of all program patients. Thus, while our findings pertain to a range of issues that recur in the health care system, they must be applied to different contexts with caution.The addition of patient navigators to the case management program was a key element in organizational changes designed to lower access barriers so as to reach more of the underserved population. At the same time, the more holistic focus on managing chronic illness created greater challenges for delivery of satisfying health services. While in the original program, the large majority of patients received a definitive diagnosis of the absence of cancer and so had this health concern relieved, those with chronic illnesses seen after the program redesign would have experienced no such definitive resolution of a health concern; instead, they would face ongoing needs for care, perhaps accompanied by a need for behavioral change.Recognizing the importance of patient satisfaction must be balanced by understanding its complexity. Our analysis of the apparent effects on satisfaction of the redesign of the Massachusetts NBCCEDP program makes it clear that a single-minded focus on maximizing patient satisfaction can both obscure the effects of an intervention and deter more ambitious efforts to improve delivery of health care. As expected, the patient navigators seemed to increase the satisfaction of patients like those served in the original program with the program itself, while the patient navigators for these same patients received higher satisfaction scores than did case managers in the previous program. However, these effects were obscured until the patients being seen for cancer risk were distinguished from those being seen for chronic illness. In addition, an apparent positive effect of the redesigned program on overall health care satisfaction actually reflected a change in the orientations of new patients from different backgrounds.We do not conclude that patient navigators should only be used to enhance cancer care, but rather that their role and expectations for their performance need to be tailored to the type of health care program in which they work. The cancer care program we studied was extended because physicians on our Expert Panel had identified chronic illness as lowering rates of diagnostic testing; the finding that this broader focus was associated with lower satisfaction ratings indicates only how much more challenging it is. Our results also suggest that more attention is needed to the mechanism by which patient navigators may improve patient satisfaction. While the apparent patient navigator effect we identified was not explained by a reduction of any perceived barriers, we suggest that the interpersonal connection between patient navigators and patients may be what is most important.The program redesign to serve a needier patient population can be judged a success on its own terms, even though it resulted in lower average levels of satisfaction with the program and its primary staff. Our research thus highlights the potential of and challenges for health care delivery systems seeking to broaden program participation and set more ambitious goals for health improvement.Additional file 1. Women’s Health Network Survey. Questionnaire for survey of Women’s Health Network patients (pre-survey).Additional file 2. Care Coordination Program Survey. Questionnaire for survey of Care Coordination Program patients (post-survey).


Increased physical activity (PA) levels in cancer survivors are associated with decreased risk of recurrence and mortality as well as additional positive health outcomes. PA interventions have shown to be efficacious, though many lack translation to and sustainability in community settings. We used dimensions of the RE-AIM framework to evaluate LIVESTRONG® at the YMCA, a nation-wide community-based PA program for cancer survivors delivered at Ys.This was a longitudinal study design using national LIVESTRONG at the YMCA data compiled between 2010 and 2018. Data is from all YMCAs who deliver LIVESTRONG at the YMCA, submitted by Program Directors to the YMCA-USA. We assessed reach (number of participants), adoption (associations offering the program), implementation (conducting 3 fidelity checks), and organizational level maintenance (associations recently offering program). We also examined relationships between organizational characteristics (years of program existence and association area household income) and program implementation factors with member conversion rates.β = 8.41; goal-setting, β = 9.70; and functional, β = 9.61) and collectively  was positively associated with higher membership conversion rates.As of 2018, LIVESTRONG at the YMCA has reached 62,044 survivors and 245 of the 840 (29.2%) of Y associations have adopted the program. Among the adopters, 91% were aware of fidelity checks; implementation of observational (62.3%), goal setting (49.9%), and functional (64.6%) checklists varied. Most (95.1%) adopters reported offering ≥ 1 LIVESTRONG session per year  and a facility-level mean membership conversion percentage of 46.9 ± 31.2%. Fewer years implementing the program and higher association area household income were significantly associated with a greater membership conversion rate vs their comparison. In a multiple regression model controlling for organizational characteristics, conducting the fidelity checks independently (observational, LIVESTRONG at the YMCA, in its early years, has shown promise for high reach, while adoption at more associations could be facilitated. Implementing fidelity checks along with organizational characteristics were associated with membership conversion rate. Identification of association-level strategies to increase reach, adoption, implementation, and maintenance may increase the impact of this community-based PA program. Contributions to the literatureLIVESTRONG at the YMCA is a nationwide physical activity program with the capacity to reach many cancer survivors, though the public health impact has yet to be examined using an implementation framework.Although we found the program reached many survivors, increasing adoption rates has the potential to reach a greater number of survivors. Of those reached, implementation measures and program characteristics influenced the membership conversion rate.This study is the first to assess implementation outcomes of a survivor community-based physical activity program and highlight the need for additional insight into implementation, organizational-level characteristics, and strategies to create more sustainable programs.In the USA, the number of cancer survivors has increased steadily as cancer death rates have decreased . There wAs survivorship numbers grow and PA program effectiveness data increases, the need for national dissemination of programs addressing survivor needs has become evident . In 2007The objective of this longitudinal study was to assess implementation outcomes of LIVESTRONG at the YMCA using nationwide data collected by the Y-USA between 2010 and 2018 . To condThis was a longitudinal study design using data collected by Y-USA about the LIVESTRONG at the YMCA program between 2010 and 2018. The Y serves 22 million people in over 800 associations and 2700 individual branches across all 50 states. Y associations may consist of single or multiple branches (up to 40) within their association and operate independently of other associations. The process of becoming a LIVESTRONG at the YMCA provider has been described elsewhere [Data for this study included (1) routine evaluation data collected between January 2010 and June 2018 from the Association Program Directors and (2) 2010 US Census data. Y data included organizational characteristics, overall number of participants completing the program (as well as broken down by a priori membership or decision to join after the program), and awareness and implementation of three fidelity check tools separately. Reporting of all data by Program Directors is encouraged, but not required. Program data is sent to Y-USA quarterly: January 1–March 31, April 1–June 30, July 1–September 30 and October 1–December 31. 2010 U.S. Census data were used to assess the household income of each association.Reach has been identified as the absolute number, proportion, and representativeness of individuals who are willing to participate in an intervention . While pObservation Assessment Tool—used by the Program Director to observe each Instructor conducting a session, (2) Instructor Goal Setting—following feedback from the observation, the Instructor and Program Director worked collaboratively to identify the Instructor’s areas of strength and opportunities for improvement and document these goals, and (3) Functional Assessments Checklist—Program Directors observed a minimum of two Functional Assessments (baseline or 12 weeks) implemented by program Instructors. Assessing whether these checks were implemented may be one preliminary method of assessing implementation prior to examining results. Thus, implementation was conceptualized as the percentage of associations implementing fidelity checks during each reporting quarter. Program Directors reported on whether they were aware of the fidelity checklists (yes/no) and whether they completed each of the three fidelity checks (yes/no). As stated above, this assessment represents only a small section of the implementation metric and obtaining data from the actual checks themselves would provide greater insight into implementation.Implementation refers to the extent to which a program is delivered as intended . While iMaintenance can refer to the extent to which a program can be sustained over time and may be measured at both the organizational and participant level . Due to Membership conversion rate is defined as the percentage of non-members purchasing a membership following the program cessation. Membership conversion rate (rate of non-members purchasing membership) may serve as a proxy to the lack of national-level PA data following program cessation and has been shown to predict future PA . Programn = 7) offering the program. Using U.S. Census Bureau [Y-USA maintains the number of years the association has implemented the program along with the city and zip code of the corporate branch. We categorized the duration of program implementation into low and high, by splitting associations on the median number of years  of Y associations offering LIVESTRONG at the YMCA were aware of the fidelity checklists. Of those aware of checklists, 62.6% implemented the observational assessment checklist, 50.2% the goal-setting checklist, and 65.1% the functional assessment checklist. Of those associations aware of all checklists, 62.3% implemented the observational assessment checklist, 49.9% the goal-setting checklist, and 64.6% the functional assessment checklists, while only 40% . Thus, of the associations aware of the checklists (n = 223), 144 did not implement all three checklists.During 2017–2018, an estimated 91% , goal-setting , and functional  checklists independently and collectively  were significantly associated with greater membership conversion rates. Associations implementing the program for < 7 years had a significantly greater membership conversion rate than those implementing for ≥ 7 years. The membership conversion rate was significantly greater in higher household income areas as compared to lower household income areas  which may influence the capacity and performance of programs. Third, the RE-AIM metrics identified in this study are limited to the data provided. This is a strength, as measures are collected by all associations similarly, though a weakness as these measures do not fully capture all indicators of each RE-AIM aspect . In lieu of long-term PA maintenance measures, our data was limited to membership conversion rates upon program cessation, which is not a construct within the RE-AIM framework. This measure also does not account for those who purchase a membership later nor assess membership use or PA behaviors in alternative settings. Fourth, our metric of household income based on census data is limited to the corporate branch within the association. Not having data at the level of the implementing branches limited our ability to understand the implementation context. Lastly, the metric of associations offering at least one session per full reporting year provides only preliminary insight into an association’s organizational maintenance.Applying RE-AIM to evaluate a community-based health program presents a number of complexities that are not present in traditional research-based programs . We prov


Accessibility to efficient and person-centered healthcare delivery drives healthcare transformation in many countries. In Singapore, specialist outpatient clinics (SOCs) are commonly congested due to increasing demands for chronic care. To improve this situation, the National University Health System (NUHS) Regional Health System (RHS) started an integrated care initiative,the Right-Site Care (RSC) program in 2014. Through collaborations between SOCs at the National University Hospital and primary and community care (PCC) clinics in the western region of the county, the program was designed to facilitate timely discharge and appropriate transition of patients, who no longer required specialist care, to the community. The aim of this study was to evaluate the implementation fidelity of the NUHS RHS RSC program using the modified Conceptual Framework for Implementation Fidelity (CFIF), at three distinct levels; providers, organizational, and system levels to explain outcomes of the program and to inform further development of (similar) programs.A convergent parallel mixed methods study using the realist evaluation approach was used. Data were collected between 2016 and 2018 through non-participatory observations, reviews of medical records and program database, together with semi-structured interviews with healthcare providers. Triangulation of data streams was applied guided by the modified CFIF.Our findings showed four out of six program components were implemented with low level of fidelity, and 9112 suitable patients were referred to the program while 3032 (33.3%) declined to be enrolled. Moderating factors found to influence fidelity included: (i) complexity of program, (ii) evolving providers’ responsiveness, (iii) facilitation through synergistic partnership, training of PCC providers by specialists and supportive structures: care coordinators, guiding protocols, shared electronic medical record and shared pharmacy, (iv) lack of organization reinforcement, and (v) mismatch between program goals, healthcare financing and providers’ reimbursement.Functional integration alone is insufficient for a successful right-site care program implementation. Improvement in relationships between providers, organizations, and patients are also warranted for further development of the program. Worldwide, rising prevalence of multi-morbidity among rapidly aging population increases demands for healthcare services and exert surmount pressures on healthcare systems. Disease-centric provision of healthcare is becoming inadequate and unsustainable in the longer terms . There iThe World Health Organization (WHO) identified care continuity and care coordination to be essential in provision of integrated people-centered care  and advoSimilar to other developed countries, Singapore is facing the challenge of ensuring good quality and affordable healthcare services for its rapidly aging population and increasing prevalence of multi-morbidity . In 2013Historically, Singapore’s healthcare system was designed with an emphasis on providing episodic care within acute hospitals in a largely disease-centric manner , 11. WhiIn response to these pressures, the (RHSs) were established in Singapore to consolidate resources and work towards the common goal of providing integrated people-centered care close to where people live . Led by In 2013, within the National University Health System (NUHS) RHS in Singapore, there were over 600,000 unique attendances at the SOCs in its primary acute hospital, National University Hospital (NUH). This was a significant rise from just under 500,000 unique attendances in 2009. In response for this rapid increase in SOC utilization, the National University Health System (NUHS) RHS initiated the Right-Site Care (RSC) program. Through collaborations between SOCs at the National University Hospital (NUH) and primary and community care (PCC) clinics within the western region of Singapore, the RSC program was designed to facilitate timely discharge and support appropriate transition from hospital to the community through care consolidation and improved care continuity.Modelled after Patient Centered Medical Home (PCMH) practices in the United States of America (USA)  and the While clinical studies have been useful in discerning success of a program in achieving its intended outcomes, they are limited in their ability to inform insights on how a program can be improved . Thus, tThis study aimed to conduct process evaluation to examine the implementation fidelity of the NUHS RHS RSC program at providers, organizational, and system levels. In the context of Singapore, most prior evaluations of similar programs focused mainly on assessing the effectiveness with limited information on the implementation processes , 20, makThis study is a part of realist evaluation of the NUHS RHS . Given tThe study was conducted between 2016 and 2018 in the NUHS RHS. The NUHS RHS has been tasked to provide care to approximately 1.1 million individuals who reside in the western part of Singapore. As of 2013, a total of 148,272 patients under NUHS RHS purview was found to have one or more chronic illnesses . Study pAs determined by clinical judgement, patients with one or more chronic illnesses who were deemed stable and no longer required specialists’ care were referred for the program by specialists from NUH SOCs. Upon receiving referrals from the specialists, care coordinators (CCs) explained reasons for change of care providers and location and provided details on services available, fees and contact details of the PCC clinics. This information was given to help patients make informed decisions on their enrollment. For those who agreed, a referral letter was provided in preparation for the discharge and consolidation of care was initiated. CCs assisted in the coordination of initial appointments with PCC clinics and provided option for expedited access to the SOCs when needed. At the PCC clinics, family physicians managed the enrolled patient either through a ‘shared care’ model, i.e. in combination with relevant specialist physicians but at reduced frequency of visits, or a ‘fully discharged to primary care’ model, i.e. fully managed by the family physician. Supported by a shared EMR, a team of healthcare workers , regular multi-disciplinary case conferences and training by specialists, providers at the PCC clinics work together with hospital-based providers to ensure care continuity and deliver people-centred integrated care.Guided by the modified Conceptual Framework of Implementation Fidelity (CFIF) , data waConsidering the nature of the program that was not time-bound, we focused on assessing program content and coverage as the measures of adherence. Content was examined using non-participatory observations and reviews of medical records whereas coverage was assessed through analysis of program administrative database. Moderating factors influencing fidelity were then examined using semi-structured interviews with healthcare providers . As there was no benchmarking available within the Singapore context to assess quality of delivery and comprehensiveness of policy, these two dimensions were not assessed.Table Initially, a list of intended activities, as specified in the program document and verified through conversations with program managers, was summarized and used as an assessment checklist. Each activity included in the checklist was explicitly defined to facilitate assessment of program adherence (content). These intended activities included: (i) referral of suitable patients at the SOCs by specialists, (ii) consolidation of care under one dedicated physician, (iii) stratification of care and care location according to patients’ needs and preferences, (iv) preparation of transition from SOCs to other appropriate sites by CCs , (v) support for PCC physician-in-charge by a team of hospital based healthcare providers, and (vi) multi-disciplinary case conferences to discuss and make changes to patient’s care plans.Two study team members (PS and LXY) conducted non-participatory observations of the information sessions  conducted by CCs. In every session of observation, content of care delivery was observed. Furthermore, medical records of patients enrolled in the programs were reviewed by PS, EKX, and MN to provide a comprehensive picture of the content of the program. Detailed notes were taken both during observations and with reviews of medical records.A consolidated program database containing records of patients who were enrolled in the program and were eligible but eventually declined enrolment in the years 2014–2017 was used. Data within the database were collected as part of the routine administration of the program by the program manager. Data were checked, duplicates were removed, and data were streamlined according to the unique patient identification number for ease of analysis.A convenience sample of healthcare providers involved in the planning, development, and implementation of the program was recruited in the study. Invitation emails were initially sent out to recruit study participants from a contact list of all healthcare providers obtained from the RSC program manager. Only those who responded to the email invitations (52%) and agreed to be audio-recorded were interviewed by the study team member(s). Thematic saturation was used to determine the eventual sample size.An interview guide  in which the component was scored as “yes” over the total number of observations conducted and medical records reviewed. Referencing from what was previously used , 27, 80–Coverage was tabulated as the proportion of patients who enrolled in the program over the total number of patients who were offered the program by the CCs. The database showed that some patients who agreed to enroll initially ended up withdrawing from the program. As this study was interested in the overall coverage of the program, we considered those patients as “enrolled”. Moreover, to understand the evolution related to the program, we examined coverage over the years since the initiation of the program.All interviews were audio-recorded and transcribed verbatim. Each transcript was checked against recordings for accuracy. Then, MN and PS read and coded the transcripts independently using ATLAS.ti version 7. A deductive analysis was adopted to code units of data according to the modified CFIF . We furtQuantitative and qualitative data collected from the various sources were given equal weightage, analysed, and merged at analysis stage guided by the modified version of the CFIF by MN and PS. Quantitative and qualitative data was mixed for the purpose of illustrating a more complete understanding of the topic being studied . Thus, aAs illustrated in Table The RSC program database showed that a total 9112 unique suitable patients were referred to the program since program initiation. Out of which, 3032 (33.3%) declined to be enrolled. Since the initiation of the program, decreasing coverage was observed .conflicted as they perceived PCC providers to be providing “inferior” quality of care compared to the hospitals, and described the program to be “against the specialists’ ethos of patient care”.Some specialists also felt Some patients returned to the specialists due to suboptimal experience in the PCC clinics related to providers’ capability and service quality. Poor feedback from patients adversely affected the hospital providers’ confidence of PCC which was then subsequently translated into lower responsiveness to the program.Despite the system-wide emphasis for collaboration, our findings showed slow progression in collaboration within the program. Dynamics of the collaborations was described to change over the years in an unpredicted manner. Level of engagement of various stakeholders fluctuated with changes in the team structure and leadership. Consequently, it adversely affected the passion for and commitment to the program among stakeholders.Even with best efforts to explain and convince suitable patients to enroll in the program, it was challenging to shift chronic care from the hospital to the community. Existing healthcare financing was reported to contradict with the goals of the program. Heavily subsidized hospital care was said to inevitably shape patients’ preference for hospital care. However, despite feedback from staff about the mismatch, the problem persisted and caused great frustration among providers.Synergistic partnership, training of PCC providers by specialists, and supportive structures including CCs, guiding protocol for the providers, shared electronic medical records (EMR), and shared pharmacy were found to facilitate program implementation. With the ultimate goal of providing people-centered care, synergistic partnership was fostered to enable collaboration. The common goal united stakeholders between the NUH and PCC providers. Upon which, an appropriate model of care and new workflow was developed, resources were invested, and collaborative working relationships were established.As part of the program, training for PCC providers by the specialists were initiated to equip them with necessary knowledge and confidence. Specialists organized seminars to discuss about management of chronic diseases and visited the PCC clinics to see patients and/or discuss cases. These activities also helped to build rapport between providers across healthcare settings, which in turn facilitated efficient and effective communication. However, training was reportedly conducted less frequently as the program was assumed to have reached a stable stage. With decreased contact time with specialists, PCC providers felt less supported and confident in managing more complicated conditions. Thus, patients were noticeably referred back to the SOCs more frequently than before. At the same time, the PCC providers’ decreasing confidence adversely influenced patients’ confidence in PCC, leading to an increased number of patients’ voluntary returns to the SOCs.In supporting the program, CCs were noted to play important roles as care integrators to connect between healthcare providers from varied SOCs and healthcare users (patients and caregivers) in care consolidation and to prepare for and support the care transition. Some CCs also went the extra mile to review the patient list in an effort to assist the specialists in identifying the stable patients suitable to be discharged/transitioned, thus enhancing the patient recruitment numbers. Busy specialists regarded the coordination by the CCs to be useful and was key to the success of implementation of the program.Guiding protocols describing selection criteria and main steps for program delivery were developed at the beginning of the program. It helped the healthcare providers in managing patients’ complex conditions according to the intended model of care in a standardized manner. Furthermore, it also included an escalation workflow to be used in the event of unexpected deterioration of patients’ conditions. The RSC program was favored by some providers as the model of care was said to provide greater accessibility for patients because of PCC clinics’ convenient locations within the community and their flexible opening hours and acceptance of “walk-ins”.Shared infrastructures including the common EMR and shared pharmacy adopted as part of the program were identified to be pivotal for the success of the program. All healthcare providers involved were granted access to the common EMR which they would not have if they were not part of the program. The common EMR functioned to systematically consolidate medical information and allowed sharing of information between actors across disciplines and care settings, thus facilitating care continuity. Hospital-based CCs were also given access to arrange for appointments with the PCC providers, streamlining the process for patients so as to reduce barrier to enrollment.Nonetheless, shared EMR was found to be not fully compatible to the needs of PCC as it was created for hospital-based care and processes. Therefore, in addition to the shared EMR, PCC providers had to use their own system for billing purposes and used the shared EMR solely for clinical information. This created unhappiness within the PCC providers as it created unnecessary workload for their employees.To lower the barrier for program enrollment, satellite hospital pharmacies were established within PCC clinics to provide specialists drugs at a similar subsidized hospital rate. This was found to be particularly well received by patients as they could obtain their medications easily near their homes. Nevertheless, the strategy substantially reduced PCC clinics’ revenues from dispensing medications. Even though PCC clinics received funding to support the RSC program, the PCC providers were concerned about the sustainability of their clinics with the reduction of revenues from medication dispensing.The number of suitable patients was found to decline over time. This was partly because most suitable stable patients were discharged in the early phase of the program. Specialists’ “buy-in”, a reflection of their responsiveness to the program, was acknowledged to be the main determining factor behind decreasing recruitment numbers. As patients who were identified and sent directly by the specialists were more likely to agree to enroll in the program compared to those referred by other sources, decreasing referral from specialists expectedly resulted in lower recruitment number.With insignificant cost gradient between the hospital SOCs and PCC clinics, seeing a specialist in the hospital cost patients the same or cheaper than having their care managed by the PCC providers. This was considered “not of value” for patients. Consequently, despite having greater access to PCC, patients refused to move out of the SOCs. This in turn reduced providers’ motivation to promote the program as they perceived that the program was “not value for money” for patients and hence not “worth the effort”.At the providers’ level, lesser congestion in SOCs due to the transfer of patients in the initial phase of the program lowered motivations among the specialists to actively recruit patients for the program. Furthermore, some specialists regarded the introduction of the program to the patients to be time consuming. They would rather monitor existing patients annually or bi-annually than spend the extra amount of time explaining about the program and convincing patients to see the CC to learn about the program.At the organizational level, sharing about program at the beginning through roadshows by representatives from PCC had prompted active participation of providers. Nonetheless, without continuous organizational reinforcement, specialists lost sight of the program, resulting in lower responsiveness and subsequently lower recruitment numbers over time.Besides the RSC program, the NUHS RHS Planning Office was reported to be heavily involved in the implementation of other existing programs and development of new programs aimed at fostering integrated care within its geographic region. Given the limited resources within the NUHS RHS office to manage numerous projects under its purview, the RSC program’s visibility was perceived to have been diluted by uncertainty in its future directions relative to other programs.While the initial decrease in patient load within the SOCs was well received by providers, a reduction in resources that came with the decrease in the number of patients managed at the SOCs discouraged further referral of patients out of the SOCs. There was a constant pressure within the SOCs to keep patient volume relatively high so as to avoid removal of resources.At the system level, fragmentation in care capabilities among providers were also observed. CCs could not consolidate care of patients under one physician after discharge from the hospital as PCC providers lacked confidence and capability to continue management of multi-morbidity. This dampened patients’ confidence of the PCC providers.Limited capacity at the PCC clinics also prevented the clinics to take in more patients as they were overwhelmed with the high number of patients. The disease-centric reimbursement created fragmentation of the funding across the different care settings and was found to impede the implementation of the program. Without a mechanism to pool charges across services and sectors, it was challenging to convince patients to agree to enrol in the program given the long withstanding perception of inferiority of primary and community care in Singapore.Likewise, fragmentation in funding segregated the healthcare system, making integration of care across separate entities difficult. Since healthcare funding was largely concentrated within the hospitals, there was limited resources available within the PCC clinics to raise their capacity and capability to manage the rising load of individuals with multi-morbidity. As a result, the introduction of new models of care like the RSC program was difficult as incentives were not aligned across patients and providers.Providers’ motivation was also found to be influenced by how they were reimbursed. Typically, productivity of providers was measured by the number of patients they managed and they were reimbursed by volume regardless of complexity. With this model of reimbursement, it was not profitable for the specialists to refer stable patients to be discharged to free up slots for intake of new patients/complex cases. New and/or complex cases were reported to usually take up more time for consultation and adversely affect the volume of patients the specialists can see. Therefore, it was considered counterintuitive for specialists to refer their patients to the program. Instead, specialists chose to retain their existing patients who were easier to manage so as to maintain a high volume within their clinics.Using a narrative approach for data merging and interpretation, Fig. Using the modified version of CFIF , we evalHigh implementation fidelity found for preparation for transition and stratification of care and care locations can be attributed to adequate facilitation by CCs and supportive systems, particularly program guidelines and shared IT system. Preparing patients to transition from hospitals to PCC was new for most CCs involved in the program and detailed protocols gave step-by-step guidance for CCs to standardize information and confidently relay them. This is consistent with another study which suggested that detailed protocols facilitated implementation of complex healthcare programs . MoreoveWe found low implementation fidelity for referral of suitable patients by specialists and decreasing coverage over time to be related to the complexity of program and diminishing providers’ responsiveness. Similar to what was experienced in the implementation of the PCMH across the USA , we founConsolidation of care was restricted mainly by the complexity of patients’ needs accompanied by limited capacity and capability of the PCC clinics to manage some conditions. Given varied severity levels of patients’ conditions, it was often not feasible to consolidate care under one physician. Even when consolidation of care was deemed suitable for a particular patient, specialists’ approval, and capability and capacity of the PCC clinics determined whether care was eventually consolidated. With diminishing providers’ responsiveness, lesser consolidation of care could be expected as specialists prefer to keep their patients in their clinics.Low implementation fidelity found for support of PCC providers by hospital-based healthcare providers and multidisciplinary case discussion could be attributed to reduction in resources and organizational reinforcement. Reduction in resources within the SOCs lowered the capacity of the specialists to spend “additional” time to support the PCC providers or participate in multidisciplinary case discussion. Furthermore, multidisciplinary collaboration was not sufficiently rewarded as providers were reimbursed based on the number of patients without taking into account the complexity of the cases and the amount of time spent on case discussions. Without appropriate incentives to motivate providers, it was not surprising that the “additional” activities such as supporting the PCC providers and multidisciplinary case discussions were not prioritized. Sequentially, these adversely affected stakeholders’ rapport that may eventually result in suboptimal care quality.Based on our study findings, we propose several recommendations for consideration when designing and implementing a program to shift care from hospital to the community as part of the strategy to integrate care. First, efforts should be put in place to improve providers’ responsiveness to program implementation. Second, improving the quality of collaboration among actors should be prioritized. Third, incentives should be aligned to the program’s goals. Finally, active engagement of patients in the design and development of the program should also be explored.In enhancing providers’ responsiveness to the program, efforts should be put into improving providers’ awareness of the program and addressing mistrust between providers in the two settings. Roadshows and introduction of program at various SOCs which worked well can be resumed. Confidence among specialists can also be regained by the sharing of positive outcomes as a form of positive reinforcement. It may be useful to combine this sharing with implementation or reinforcement of guidelines, as the combination of both has been found to be more effective than either alone .The RSC program can be incorporated as a core clinical program to be introduced early in a patient’s healthcare journey. This is expected to not only emphasize the program to providers but serve as additional positive reinforcement to boost patient enrollment. A previous local study suggested that patients who had been seeing specialists for less than 2 years were more likely to agree to be transferred out of the SOCs .In order to improve collaboration between different stakeholders, the complex adaptive system perspective can be adopted to inform understanding of relationships and dependencies between different parts of the program . This neAppropriate incentives  aligned to the program’s goals should be introduced system-wide in support of the program and to lower adoption barrier by providers and patients. A mechanism which pool charges across services and allow subsidies to follow patients could be explored to make PCC more appealing to patients. Instead of the traditional “fee-for-service” model, “fee-for-performance/complexity” can be explored to pay providers and organizations based on the complexity of illness and improvements of patient outcomes achieved . This woEven though this study did not evaluate patients’ perspectives of the RSC program, a previous study that examined patients’ experiences with the RSC program showed that there was a lack of understanding of the comparative advantage of community-based care and its contribution to long-term health outcomes . For thiIn the context of Singapore, where most prior evaluation of similar programs mainly focused on assessing the effectiveness , 23, ourCollection of data alongside the implementation of the program ensured that data reflected the actual circumstances surrounding the program, thereby provided confidence about the credibility of the study. However, due to the cross-sectional nature of the study, we did not take into account the changes of the program over time. Therefore, the effects of the evolution on implementation fidelity of the program could not be explicitly highlighted. This points for a future longitudinal investigations to better understand how implementation of the program changes over time and its impact on outcomes. In order to do so, an increase in grant funding of implementation science research is needed.In this study, pooled analysis was conducted instead of stratified analysis by the type of partner PCC clinics and only common key findings are included in this manuscript for overall representation of the program. While we are confident that findings are to a great part generalizable, given that various PCC clinics were involved in this program, it may be value-adding to further analyze the results according to the type of partner PCC clinics so that engagement intervention for specific PCC settings can be tailored.We found that facilitation through synergistic partnership, training of PCC providers and supportive structures  contributed to high implementation fidelity. In contrast, complexity of program, diminishing providers’ responsiveness, lack of re-inforcement, and mismatch between program goals and healthcare financing were found to make program implementation challenging. While it was acknowledged that adequate facilitation through reliable support system was essential , our stuAdditional file 1. Topic Guide for Interviews.


Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student’s preparedness for practice.By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media.We describe how the 3P-6Cs toolkit captures a learner’s personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students’ developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions.Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student’s preparation for lifelong practice. With healthcare practice rapidly evolving to adapt to changing disease patterns and service models, medical curricula have also evolved over time, leading to contemporary models that largely focus on achieving the competencies required to work in healthcare environments . Inspitem design . Contempm design , 5.In a hypothetical but plausible scenario, a beginning first-year medical student is left in awe as she reads the curriculum handbook of a medical school that has recently renewed its curriculum in the light of contemporary approaches to learning and assessment. Although appreciating the sophisticated design, she does seem lost in the complex labyrinth of educational jargon. The student finds herself trying to decipher the basics: what does she need to learn; what and where are the learning activities to be undertaken, and when and how will she be assessed? The student’s journey of learning, however, does not conclude with graduation but continues as she joins the community of practice of clinicians in the healthcare workforce. A challenging task for the curriculum designers therefore, is to ascertain coherence of various curricular elements while ensuring that their educational utility is appreciated beyond the immediate program requirements by both learners and educators.ends rather than the means of the curricular process [A gap, however, persists in relation to overarching curriculum perspectives that allow for synthesis of the various curricular elements in a way that lends coherence and meaningfulness to all stakeholders, particularly students. The paucity of synthetic and overarching curricular perspectives can be inferred from the literature that broadly suggests two key models that underpin medical program curricula: prescriptive and descriptive models . Contemp process . Propone process  includin process . Althoug process  and Pina process . However process , 12.Exploring the natural history of a curriculum from design to implementation can indicate major changes in the original philosophy and rationale, resulting in a fragmented approach, with differing curricular elements being underpinned by differing learning theories , 14. Curbeing an individual student to becoming a member of a community of practice.A substantial shift in thinking is therefore required from conceiving of a curriculum as a single mechanical entity that can be ‘fixed’ by attending to individual elements towards understanding the ecology of how various intersecting and interrelating curricular components impact a learner’s trajectory from Such a conceptual shift for curriculum designers can be provided by systems thinking. Regarded as a synergistic thinking toolkit, systems thinking aims to understand the interrelationships, dependencies, and interactions shaping the dynamics of the various elements within and across various levels of systems and sub systems –17. It iWe developed an initial prototype of an overarching curricular toolkit by undertaking an appraisal of relevant literature in curricular designs for complex systems, especially with reference to using a systems thinking approach. This approach was taken given the authors’ familiarity with this field, and commitment to a curricular design process that avoided the risk of a fragmented approach by focusing on individual curricular subsystems and multiple learning theories . The prosoft-system’ approach is in contrast to the ‘hard systems’ approach that assumes a linear representation of the real world, albeit a reductionist one. Our view of systems thinking conforms with a ‘soft systems’ approach as a way of generating both engagement with, and insight about, the real world and allows for the different ways in which the different stakeholders may frame similar curricular issues or problems. Soft system thinking has been regarded as an appropriate approach for high-level structuring of a ‘messy’ real-world problem situation. While the hard system approach informs how a system and its subsystems work, a soft systems approach describes why a system works the way it does [Our framework was guided by various systems thinking perspectives –21 where it does . It is a it does , 25.1), program (P2 with 6Cs), and practice (P3) levels. The personal describes core considerations of learning at the level of an individual learner; the program describes the features or elements of a curriculum, both the explicit and hidden, that a learner navigates through; and the practice describes the wider context for learning within the clinical workforce.With these theoretical underpinnings in mind, we conceptualised a thinking toolkit, ‘3P-6Cs’ Fig.  that illOur conceptual toolkit is overarching in the sense that it is akin to an umbrella approach that provides a big picture under which several sub-approaches or models can be sheltered and aligned based on their commonalities .Content), how to learn (Cognition), and self- assessing that what should be learnt has been learnt (Confirmation). Confirmation of learning (from self and program assessments) will be a major driver of her learning, but other strategies can foster adaptive skills such as reflexivity and metacognition [At the personal level, the student begins her journey at the start of the medical program by reflecting on the core personal considerations of learning - what is to be learnt (ognition . At a peognition .Commands (e.g. learning outcomes as defined by the relevant governing bodies); Contextualisation  and Coordination (integrating learning and teaching and settings and activities). The second three Cs are assessment-focused: Collections (marks/scores/narratives), Collations (combining differing assessments as per curricular domains or themes or competencies to inform decision-making and progression) and Connections .The program level curricular elements constitute the ‘6Cs’ that define and connect various curricular elements within a curriculum framework. These are commands, contextualisation, coordination, collections, collations, and connections Table . The fircollaboration’ between and within interprofessional teams, and 3) ensuring ‘continual development’ of lifelong learning as new graduates move from internship into further specialty training.The practice level elements of the thinking toolkit are focused on the big picture for graduates entering practice as one of a community of health care professionals. As the new graduates transition into their next phase of work integrated learning, our toolkit suggests three key processes: 1) fostering learners to ‘calibrate’ the skills, knowledge and behaviours in accordance with their new workplace requirements, and training programs to meet career intentions 2) the self-regulated and calibrated competencies would be exercised in a learning environment that is highly dependent on ‘As an intern, resident or consultant, a lifelong learner would need to fulfil workplace and program requirements. Therefore, personal and program level 6C curricular elements are also at work at the practice level (given learners will undergo a new training program at this level), albeit the focus will be shifted towards calibrated, collaborative and continuous development of knowledge, skills and behaviours.We anticipate that a systems thinking toolkit will provide educators with useful insights when redesigning whole or particular curricular elements. This can be achieved by better understanding of the relationships, boundaries and impacts of personal, program, and practice level elements nested within various curricular subsystems. By explicitly linking various curricular elements and considerations at personal, program, and practice levels, the 3P-6Cs model provides a better understanding of the ecology of curricular elements. The thinking toolkit provides a series of heuristics for educators to address key curricular concerns such as: how to help students make sense of underlying curricular blueprints, and helping them see the big picture beyond the immediate program-level concerns by addressing specific learning outcomes to develop their practice-level capabilities.creating integrated educational designs to capture students’ developmental continua,conceptualising immersive clinical placements in non-traditional settings; andcomplexity-consistent evaluation of curricular interventions.To illustrate the utility of our toolkit for health professional educators, we describe applications of the 3P-6Cs systems thinking toolkit in three key areas of curricular design:Creating a coherent and integrated curricular design to capture students’ developmental continuaSeveral healthcare professional programs are aspiring towards competency or outcomes-based frameworks that aim to capture the developmental continua of students in milestones or standards of performance in various competencies and sub-competencies . Such a 2.Conceptualising immersive clinical placements designs in non-traditional settingsSeveral medical education programs, as well as other healthcare disciplines, are now offering early and varied clinical immersion by providing placements beyond traditional hospital settings, such as in general practice, ambulatory care, and allied healthcare settings. There is ample and robust evidence for the benefits of early exposure to non-hospital based settings, not only for students in improving a diverse range of skills for the holistic care of patients, but for the medical school in terms of improving graduate outcomes for the program, and establishing a community of diverse preceptors. At the practice level, such immersions can facilitate in bridging the general practitioner-specialist divide as well as the doctor-allied healthcare practitioner divide in providing collaborative patient centred care , 31.Keeping in view these benefits of diverse clinical exposure at the personal, program and practice levels, the 3P-6Cs can guide design considerations for an authentic learning task-based curriculum that can bridge the gap between education needs (immediate program requirements) and service needs (creating a community of diverse practices and practitioners) . Systems thinking provides a toolkit that fosters the understanding of interdependencies, interactions, and interrelations across and within any system. It is, therefore, the cornerstone of systems-based practice, and has been regarded as one of the core competencies for clinicians , 33. We Applying the 3P-6Cs curricular toolkit to problems of curricula redesign can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within medical education programs can impact students' preparation for lifelong practice. It aims to capture linkages between various elements of the curricular landscape as a students traverse from the personal to program to practice levels. Based on thinking systemically (thinking in terms of systems) and applying a systems approach to the critical issues of future patient care, we anticipate that the 3P-6Cs will provide a parsimonious yet coherent thinking toolkit to foster better understanding of the relationships, boundaries, perspective and dependencies of various learning subsystems within a curriculum. Our curricular toolkit provides mechanisms for healthcare professional education curricula to evolve, both in their approach and methods, towards improved alignment with individual components of the training continuum, and with the needs of healthcare systems and the patients which the graduates of the program will serve.