Recovery-oriented programs provide individuals with opportunities for well-being through community integration processes that enhance the degree to which individuals could live, work, and recreate in their community. The current evaluation assessed how tenants experience their home environment after the modernization of Homes for Special Care (HSC) to Community Homes for Opportunity (CHO) in Southwest Ontario, Canada. Our study identifies existing policies and practices that could interfere with or promote the modernization process.We applied ethnographic qualitative techniques to purposefully recruit 188 participants with severe mental illness from 28 group homes. Focus groups were conducted at three time points, i.e., at pre-implementation/Baseline/Time I – spring 2018; Transition/Time II – fall 2018, and Final/Time III – winter 2019.Study findings suggest that the transition of HSC to CHO supports activities that empower tenants towards personal growth and development. Participants were largely satisfied with the support they were getting in relation to the program-related services. Tenants disclosed that their quality of life and well-being had been enhanced through participating in the program, and that their social interaction and support for each other had also improved. Most tenants demonstrated autonomy in terms of personal and financial independence. The enhanced financial support for tenants did not only improve their quality of life, but also helped to raise their purchasing power, decision making, sense of responsibility and accountability towards healthy spending of their resources. Despite tenants’ good impression about the CHO, some still encountered problems and provided suggestions to further improve the program.It is expected that a more effective and expanded CHO will lead to tenant empowerment and successful social integration. A recovery-oriented system is one that focuses on the person by enabling individuals affected by mental illness to live independent, satisfying, hopeful, and a productive life despite limitations caused by their illness , 12. RecRecovery is not possible without access to housing . Stable In 1976, the Ministry of Health (MOH) in Ontario, Canada began providing funding to non-profit community mental health housing agencies for them to provide professional supports to individuals in addition to the custodial care they were receiving . This tyNelson and colleagues  state th‘Supported’ housing is a concept from the field of developmental and physical disabilities promoted by Paul Carling and colleagues . Unlike The current study falls within the domain of supportive housing that seeks to provide housing stability , 17, 18 The present study examined the Homes for Special Care (HSC) to CHO (the Community Homes for Opportunity). Over the years, the HSC offered long-term permanent supportive housing in group homes for people discharged from Provincial Psychiatric Hospitals. HSC was managed through the hospitals’ former psychiatric system with 24-hour availability of staff, meals, supervision, and assistance with activities of daily living. Although the HSC provided aspects of supportive housing, it was criticized for being more custodial, and not offering autonomy and tenant choice which are principles of recovery. Basic needs such as clothes and toiletries were provided with little choice. Receiving services was conditional on staying with HSC. For this reason, in 2018, the MOH, St. Joseph’s Health Care , and community partners started the modernization process of HSC to Community Homes for Opportunity (CHO). CHO gives priority to individuals with serious mental illness who are homeless or those at risk of homelessness, and individuals in hospitals who are not able to care for themselves. The goal is to integrate the CHO program into the mental health and addiction community services and the supportive housing sector .One of the foundations of CHO is to give voice to the tenant in terms of choice and decision-making, including choosing where to live and signing their lease (which never happened under the HSC) in relation to where they would want to live. CHO strives to promote tenants’ independence as much as possible. The CHO is person-centered, and recovery-based meaning tenants are empowered to be active participants in their goal setting and planning and the making of individual choices. CHO focuses on the unique needs of tenants, autonomy, and their integration into the community. To enable this, tenants are provided with increased financial support and encouraged to work on personal growth and life skills through a variety of activities and programs such as learning skills , managing their resources, taking part in leisure activities of their choice within the home and in the community. Tenants are also paired with a community social worker. Services are provided both in home and in the community to support their physical and mental health .The overall purpose of the current study was therefore to evaluate the modernization of HSC to CHO in a specific catchment area overseen by St. Joseph’s Health Care London, Ontario, Canada. The ‘evaluation’ comprised examining the nature and experience of tenants in response to the modernization, and to address existing policies and practices that could interfere or promote the modernization. In the end, findings of the CHO from tenants’ perspectives were assessed and a review of the modernization process has since been ongoing.This qualitative focused ethnographic study was part of a larger mixed-methods research project conducted to evaluate the ‘Phase One Homes for Special Care in Southwestern Ontario, Canada. This evaluation examined the nature and experience of tenants of the CHO program  in response to the changes being made. Changes were made to modernize, address the current policies and practices to foster or interfere with those changes and provide recommendations to improve the program. The research looked at the outcomes of CHO clients as well as a review of the process to modernize the HSC program in Southwestern Ontario. The focused ethnography design was deemed to be a methodology fit for examining the nature and experience of tenants of the CHO program in response to changes being implemented since this study design, in contrast to classical ethnography, facilitated a timely investigation of health problems within a relatively short period , 14, 25 Twenty-eight homes serving 368 tenants in Southwestern Ontario were involved in the evaluation of the CHO program. The 28 homes were the first in the Ontario province to adopt the modernized program that was operated through St. Joseph’s Health Care London. We must emphasize that prior to recruiting the participants, we had had prior connections/interactions with some of these participants due to previous research that we conducted in the homes. Therefore, we already had both formal and informal relationships with some of these participants which aided our recruitment process. After explaining the purpose of the study to them, 188 tenants who consented to take part in the study were enrolled. Over the study period, the 188 participants took part in 28 focus groups, i.e., 10 tenant baseline focus groups in 10 homes (n = 61); nine  tenant fThe study was approved by the Western University Health Sciences Research Ethics Board. Posters announcing the research study were distributed in the CHO homes for participant recruitment. Focus groups were conducted with CHO tenants to identify issues, solutions, and recommendations for improvement. We used focus group discussion as a qualitative approach to gain an in-depth understanding of the tenants’ experience of social change with the modernization process. Each participant was given a unique code (starting from P1 to P188) to help the researchers to identify participants. Before the commencement of data collection, the researchers reiterated the objectives of the study, after which they obtained informed consent from each participant before starting the focus groups. Data were collected using focus groups which took an average of 60 min each. Focus groups were audio-recorded and then transcribed verbatim by two members of the research team. Note-takers gathered information about group dynamics, context, and non-verbal information, which were integrated into the transcribed data to augment research findings. These notes were inculcated into the description/interpretation of the findings but not into the quotes because as an evaluation of tenants’ experiences, we wanted to project the views/voices of the participants (unadulterated), hence we presented their voices as verbatim quotes. The focus groups were conducted at three time points, i.e., at pre-implementation/Baseline/Time I – spring 2018; Transition/Time II – fall 2018, and Final/Time III – winter 2019. This helped the researchers to remain within the community for sustained periods to understand and to assess the housing situation of the tenants. The baseline data served as a starting point for evaluating the CHO program.An ethnographic qualitative analysis based on Leininger  was applThe focus group data involving time – I, II, and III were analyzed separately. Haven identified all subthemes from each site, the researchers then aggregated them based on similarities and differences between the findings in relation to each time point. Since the baseline data served as a starting point for evaluating the CHO program, baseline findings were not added to the results in this paper. In the end, the emergent themes from time –II and III focus groups were further aggregated and grouped based on commonalities in relation to facilitators, benefits, barriers, and challenges throughout the CHO program’s implementation, as well as solutions, and recommendations for improvement. To ensure the credibility and trustworthiness of the study findings, all members of the study team were given copies of the results to appraise and to make inputs in the form of comments. All comments and observations from the co-researchers were then integrated into the final research document.Study participants were between 23 and 79 years, and 42% were females. 74% of participants were single, while 19% were separated or divorced. Only 3% were married or in a common-law relationship, and 4% were widowed. Most participants (67%) received income from the Ontario Disability Support Program (ODSP). About 95% of the sample had at least one psychiatric diagnosis. The common diagnoses among participants include schizophrenia, mood disorder, anxiety disorder, and substance-related disorder. Most of the participants identified themselves as Caucasian (79%). The remainder identified as Aboriginal (4%), a visible minority (7%), or other (9%). Data analysis of tenants’ perspectives about the CHO implementation program revealed four major themes. These include: .A participant said:“Yup, I know what you mean now. This place they feed you good, they look after you good. They treat you very well. I think everybody appreciates the CMHA [agents providing services] a lot more than they did the other round [referring to the homes for special care]” [P61].Another participant added:The tenants expressed great satisfaction with the support they were getting under the CHO. They showed delight about the show of empathy from the staff. The tenants also expressed gratitude for the financial package that came with the modernized program (CHO); that, the immense support was going to assist most of them to prepare adequately towards independent living in the future.“It’s always clean. The staff [home staff] is good at cleaning and cooking and making sure that you are making your appointments on time, making sure you take your meds. I would like to add, this home; this place feels like home to me. Nice people, nice staff, nice food, nice everything. I don’t want that to change.” [P25].One of the participants revealed:“The funding to cover everything, is a great idea because there are some people that would want to get their own independent living apartment, and they might need household furniture, and things that they want for their little apartments. Like the senior apartment, everything they need for their apartment when they get out on their own”. [P156]This participant also added:Tenants revealed that the CHO nurtured independence among them, thus, enhancing their self- confidence and competences in the management of their own resources.“I think it’s a better service, it’s a good idea [referring to CHO]. I like this idea because everybody has extra money to go out. They wanna go out on a social event, or a ride somewhere. They have the money to go to the store to buy ice cream or buy clothes. I think it’s really good.” [P11].A participant said:“I talked to my trustee and told her I can manage my own finances through my ODSP [the Ontario Disability Support Program] cheques that I have been getting. I just got onto CHO. I will be responsible for paying my bills, my food, everything.” [P117].Another participant said:Most tenants gave a good impression about their fellow tenants in the homes. The researchers observed that relationships between tenants were very cordial and that there were no safety issues, including unwarranted suspicions or fear of being hurt by another person. This positive attitude from the tenants has been influenced by the CHO implementation process and the fact that the staff also interacted with family members.“With people that live in this home all have a lot in common. You don’t have to worry about anyone stealing or hurting you. You can just be yourself, that’s the main thing that I think is good about this place. We live like one happy family, no arguments no fighting, which is good.” [P15].A participant said:“The CHO program has been there for me. Also, she [the social worker] talks to my mother too, so that way the communication lines are open and she can discuss things with my mom. I found a really big change. She cares a lot more…” [P26].Another participant added:Tenants benefited from the new CHO program in various ways. For instance, the participants expressed excitement about the program, and that it offered them unique opportunities and support for involvement in several activities. The tenants also revealed that the program enhanced their quality of life and well-being. As captured in the field notes, participants’ social interaction was cordial; they showed collegiality and supported each other. The study participants also demonstrated autonomy in terms of personal and financial independence by making their food choices, including the type of clothing they wanted to buy.The autonomy that is associated with the CHO allows tenants to engage in various forms of activities they felt were important to them. They perceived such activities as forms of extra-support. For instance, this tenant revealed how the CHO program offered him the opportunity to further his education.“I’m going back to the school for my university degree. I’m taking an IT course there…” [P85].“I would save to buy a cell phone and a textbook that I require for a course that I’m taking over the internet and I was able to pay for that with the extra money of which I would’ve never been able to do.” [P126].This participant also added:CHO offers opportunities to all tenants to be able to take part in leisure activities of their choice within the home environment and in the broader community. In the end the interactions that tenants have with each other go a long way to improve group support, cohesion and sense of entitativity, where they view themselves as one group with a common background.“We try and make sure we don’t hurt each other’s feelings…If someone’s doing something wrong, I will speak. I’ll say you’re not supposed to be doing that. You could try not doing something else…you don’t get lonely in the group homes. It’s best to be with somebody in a room.” [P13].This participant indicated:“They have different things on different days. Like Tuesdays there are men’s and women’s club that they do museums and stuff like that but you have to go to that program to get these things.” [P36].One of the participants also said:Increase in the amount of money per tenant has raised the purchasing power of every individual towards being able to afford the cost of necessary commodities, culminating into an improved lifestyle among tenants. For instance, getting more money was an asset that aided frequent clothing shopping, and more options for different varieties of goods for the participants. In another vein, the fact that tenants had a say in food choices empowered them while enhancing their nutritional status simultaneously.“I’m happy, I’m happy! Home, food, and everything! I love it here! I like it, yeah…we go by the health and food guide of Canada, so when they’re making meals we look at the food guide for sandwiches where that’s not good then you don’t, they don’t make that food.” [P118].This participant said:“Long time ago, I wouldn’t appreciate it [money], I just bought a lot of booze. [currently], I’d buy grocery, I’d buy things I need, like make up, hair dye, and earrings, and, and things I really need, like underwear, and bras, dresses, and high heels.” [P56].Another one added:The CHO enabled the tenants in various life domains including assisting them acquire the day-to-day financial management skills that made them take good decisions towards the healthy spending of the money given them, including enhanced opportunity for savings. The increase in financial support is a watershed moment for the tenants; a crucial moment that continues to turn lives around for the better. The participants of CHO revealed how the increase in financial support gave them the opportunity to start saving money for the future so they could live independent lives.“I’m pretty happy now, like I mean I don’t go into the community a lot but like I go for coffees, I go to the stores you know so…I’m usually busy.” [P76].A participant expressed this view:“I’ve got a savings account…I mean thinking about that I think if I put a little money away each time, I’ll be able to manage it well…I get very few clothes because I save them for years and keep them. So I don’t spend much on clothes so that will benefit me there because I don’t spend much anyways.” [P101].Another participant added:In terms of what did not go well with the CHO experiences of tenants, researchers documented issues related to inconvenient living arrangements, concerns with food and financial support, concerns about money handling, and the lack of understanding of the CHO program, were key obstacles that the tenants faced in the homes.Tenants expressed concerns about limited amenities culminating in a lack of privacy and an overcrowded environment. They felt this situation threatened their comfort, confidentiality, and individuality. It is notable however that this issue of historical ‘inconvenient living arrangement’ in terms of physical structures has existed since the HSC and continues to exist with the CHO program since it takes place within the same buildings. Some of the tenants’ sentiments include the following.“Maybe if they had a little fridge where we can put our own snacks, because we are not able to keep our food anywhere. We can’t have it in room.” [P16].“I find this place very crowded. And the television room, there’s a lot of people here, using the television… It would be nice if we have our own rooms. But that’s impossible because there’s like 30 people.” [P161].“The only trouble is there could be more than one person in your room. That’s kind of private but you got to share. I think they should have a room for each person in the group homes. That’s what the problem is.” [P126].Some tenants reflected and raised concerns that other tenants would not use their own money appropriately . Tenants also raised issues with the financial assistance they were receiving. For instance, they described the amount of money given to them for living as insufficient despite the increase (from $150 to $500 a month). Some of the tenants’ concerns have been presented as follows.“It [money] just is, you know, it’s barely; you can’t live off it at all. By the time I pay my bills I’m broke.” [P42].“People might not have enough for like emergencies, you might need a pair of shoes and you don’t have any money, so what’s gonna happen to this person who needs shoes?” [P81].Another person said:Tenants appeared to have little knowledge about CHO programs despite communications from the ministry to the homeowners (private persons who own the houses) and individuals directly. For example, some areas such as transportation and rent payment needed more clarification in terms of the amount of money covered by the program versus the amount of money paid by the tenants.“Somewhat confusing at times [referring to CHO] not knowing like say I’m needing to go to the hospital, and how do I get home? Do you guys cover [transport]?… that need to be worked out in my opinion.” [P126].One of the tenants questioned:Overall, all tenants believed that the modernization of the HSC program to CHO was an improvement. For instance, the tenants were satisfied with the increased financial assistance and one-on-one support from the Agency staff. However, the tenants identified some areas that needed improvement. They called for more support and accompaniment for community activities, consistent support with daily living commitments, more assistance with financial issues, ensuring individualized plans of care, and the need to address historical concerns with space and privacy in the homes.Even though the CHO seeks to promote autonomy among tenants, the tenants still requested continued assistance from the attending Agency staff and homeowners during external activities such as going to the shop, the bank, and other community events.“More activities within the community offered for people. Y (YM/WCA gym) passes should be covered for young and old… for people that can’t afford it, they should be able to get their Y passes and stuff…Like take us out to go shopping, clothes shopping, stuff like that…They got a quarry here, maybe sometime they’ll be able to take us to the quarry to do something. It’s a nice swimming spot.” [P51].Another person also requested; “I’d like somebody. I need someone to take me to go out and do something with. I’d like someone to go to the bank with twice a week. I don’t have anybody, I’d like somebody.” [P117].One of the participants advocated:Tenants requested that the homes should provide consistent assistance in relation to helping them in handling daily life issues. The tenants felt that maintaining the same staff in the homes was beneficial. Again, some proposed the inclusion of peer supporters  in the sense that they could get extra support from these individuals to enhance their social skills and well-being.“…I would like it if they [Agency staff] could keep constant stay here like, permanent stop, not just for one year or six months… I don’t like it….” [P116].A participant recommended:“…getting some sort of peer support, like one-on-one sort of thing, like I have in the past. I had somebody in the hospital, and that meant a lot. I think that’s important a peer support group or system.” [P118].One of the participants also proposed:In as much as the tenants appreciated the enhanced support offered them by the new program, they still asked for more financial assistance as well as some guidance with appropriate financial resource management skills to help them benefit more from the assistance given to them.“Some of us here aren’t going to be able to do it, have to have assistance budgeting”. [P29]This participant said:Even though tenants were very excited with the new program (CHO), most of them felt that certain aspects of the old program  be maintained so homeowners and other staff could continue to help with essential services especially to those with special needs.“It’s up to us from our own pocket money to buy the bus pass, so I like the old system. [They] dropped off a bus pass for each month. I think that was a good system…I guess the old way is pretty good, it was all organized. Everything was organized and we got help with everything.” [P12].“That was good! Bus fare, transportation to get to doctors’ appointment, and haircut, you know emergency stuff, should be left alone.” [P171].One of the participants indicated:“Well, essential services such as bus pass, is essential for some people, transportation of course, the haircut, toiletries. Some people either can’t get to the Dollarama because of mobility, or maybe the time of year or the weather…there may be some in the system that may not be able to budget for the essential services that they are provided by whatever income they get…” [P141].Another participant gave other reasons for an individualized support:The study findings suggest that the transition of HSC to CHO supports activities that empower tenants towards personal growth and development. Major findings from the study indicates that even though the tenants had a good impression about the CHO program stemming from the benefits that accrued to them, some still encountered problems and provided suggestions to further improve the existing program. For instance, the tenant participants called for more support and accompaniment for their community activities, including consistent support with daily living commitments, as well as more assistance with financial issues, ensuring individualized plan of care and addressing historical concerns with space and privacy in the homes.In another vein, tenants expressed positive feelings about the changes brought about by the modernized program. Study participants were largely satisfied with the support they were getting from the staff in relation to the program-related services. The tenants were satisfied with the level of empathy the staff displayed while assisting them in fostering positive interpersonal relationship. The tenants also expressed gratitude for the enhanced financial package that came with the modernized program. They believed the immense support was helping most of them to prepare adequately towards independent living in the future. This is in line with the recovery-oriented perspective of the CHO program, as it enables individuals affected by mental illness to live independent, satisfying, hopeful, and productive lives despite the limitations caused by their illness , 12.One of the key goals of supportive housing programs such as the CHO, is fostering autonomy and independent community living. Tenants’ independence facilitates their self-confidence and competencies in the management of their own resources. The supportive housing model also foster recovery with more emphasis on recovery of the individual. The findings indicate that CHO fosters recovery among tenants using both informal and formal supports or resources. The CHO program also recognizes all tenants as experts in what they need to facilitate their own recovery, and part of a circle of shared decision making that fosters autonomy in the end . This fiThe study findings demonstrate that the CHO program offers tenants opportunities and support for involvement in various activities in-house and in the community. Tenants described feelings that their quality of life and well-being had been enhanced through participating in the program, and that their social interaction and support for each other had also improved. Most tenants demonstrated autonomy in terms of personal and financial independence. The autonomy connected with the CHO program gives tenants the opportunity to engage in various forms of activities that are meaningful to them. Such activities act as extra-support to reduce boredom, enhanced group cohesion and sense of entitativity, where they view themselves as one group with a common background. The ‘good feeling’ outcome associated with both in-house and community programs ultimately contributes to the tenants’ sense of worth and belonging in the community. These unique outcomes of the program evaluation underscore the importance of stable supportive housing not only in Canada, but the world at large. For instance, Chan , Doroud,The study findings again reveal that the CHO program offers tenants the opportunity to become financially autonomous in terms of deciding on when and how to spend their money and other resources available to them. The enhanced financial support for tenants does not only improve their quality of life, but also helps to raise their purchasing power, decision making abilities, sense of responsibility and accountability towards the healthy spending of the resources entrusted to them. Overall, we assert that the CHO program aids in the adoption of unique social roles for community integration just as Chan, , Doroud,Despite the unique benefits that implementing the CHO program offered to tenants, the study findings reveal some difficulties that tenants face in the homes. For instance, there were issues related to a lack of understanding of the CHO program. Participants also had concerns with their food menu, the financial support, and how others were handling the monies given them. Inasmuch as tenants were benefiting from the CHO program, they also expressed concerns about limited amenities in the homes that invariably led to lack of privacy and overcrowded environment. This situation may likely threaten tenants’ comfort, as well as the confidentiality that each one needs as unique individuals and to facilitate independence and recovery. This finding has implications for future planning and choice of homes for the supportive housing program. A needs assessment should be considered especially during the screening period so that tenants could be appropriately matched with homes that meet their unique needs. This is in line with the assertion made by Montgomery and colleagues  that indTenants also raised issues with food menu in some of the homes. This underscores a need for good communication, targeted education towards effective resource management and involvement of tenants during the planning and execution of all activities in the homes. Considering everyone’s unique decision-making ability especially when such decision outcomes have a direct bearing on all in the home  is vitalSupportive housing programs such as the CHO program can provide stable housing. Despite the challenges, study findings revealed that the modernization of the HSC program to CHO was beneficial for personal growth and development toward one’s social integration. This finding points to the need for implementation of the CHO program across Ontario in short to medium term, and for encouraging its uptake in other provinces.Tenant perspectives on the implication of the CHO program provide key insights for homeowners and their staff, as well as key stakeholders such as policymakers, and Community Mental Health Agencies. The implications range from strategic investments to operational changes. There is a need for strategic planning that is more tailored to needs assessment and individualized services that are apt for tenants’ community integration in the long run. Research concerning tenants’ views on supportive housing for individuals with mental health and addiction problems is limited. Thus, this study contributes to knowledge advancement, with far reaching implications for academia, family members involvement, and improved social advocacy for the marginalized.This study has strengths and limitations. A highlight of the study has been that tenant beneficiaries of the evaluated model were actively involved in all stages of the study. The study was not only undertaken in the research participants’ (tenants’) settings but also provided them with an opportunity to reflect on their experiences of both the previous model (HSC) and the modernized program (CHO). As research, the study approach facilitated tenants’ participation that generated findings that are relevant and tenant-specific; helping to uncover the actual nature of the program as well as enablers and barriers to the effective implementation of changes under investigation. However, the findings may only be transferrable to contexts and settings that are similar to those of this study. Personal experiences such as those expressed by our study participants are time and context dependant. Therefore, the tenants’ views about the CHO program may evolve over time. As such, there would be a need for continuous evaluation of the program for improvement and sustainability.Supportive housing models such as the CHO constitute an effective pathway to ending chronic homelessness for people living with mental illness or addictions. Stable housing is a right, and a fundamental need of every human being towards good health and growth  making i


A Malaysian Higher Education Provider has applied technology as part of its pedagogical approach, in alignment with Education 4. 0. The use of simulation, which aligns with the principles of Education 4.0, employs digital technologies and supports learning by bridging the classroom and the clinical areas. We reported the effectiveness of learning in our program that utilizes multimodal pedagogy, including interactive lectures, pre-recorded video lectures, simulation, and hands-on supervised clinical sessions, using the program's cumulative assessment data.This program evaluation was based on Kirkpatrick's framework. End-points for learning (Kirkpatrick level 2) were analyzed based on improved overall post-test theoretical and clinical assessment performance. Quantitative data analysis of theoretical pre-test, theoretical post-test, clinical assessment, and post-test scores was performed to compare cohorts.SD 9), post-test 64.1% (± SD11.5); p ≤ 0.001). Overall, 19 out of 21 trainees completed the clinical assessment and case presentation satisfactorilyThe performance of 19 trainees, over six cohorts from 2012 to 2019, were analyzed. All our trainees had equal opportunities to learn using the multimodal pedagogy, including a simulator. The analysis of pre- and post-theoretical test scores showed a significant improvement in the mean scores (pre-test 48.7% (± The Kirkpatrick framework served as a useful framework to perform the evaluation of the TEE program. The significant improvement in post-test scores, when compared with pre-test scores, suggested that the program is effective with regard to learning. As part of a multimodal pedagogy, simulation has proven to be an added value to our training program, and this was reflected by the improvement in the clinical assessment scores when compared to the pre-test scores. This result aligned with the concept of technology-enhanced learning in Education 4.0, where simulation in TEE training is applicable in the Malaysian context. Education 4.0 is the revolution that focuses on smart technology, including advanced medical devices, artificial intelligence, and robotics, that has given impact to current perioperative cardiothoracic surgical care. Transesophageal echocardiography (TEE) is a high technology device utilized in cardiothoracic surgery to inform the diagnosis and clinical management of patients with diverse pathologies . In perfTechnological advancement transforms teaching and learning strategies in advanced or specialty training , 4. In oThe use of simulation, which aligns with the principles of Education 4.0, employs digital technologies and supports learning by bridging the classroom and the clinical areas , 5. The The purpose of this study was to measure the effectiveness of a postgraduate TEE training program in Malaysia using the Kirkpatrick Evaluation Model . In thisThis study aimed to measure the effectiveness of the TEE training curriculum, which included simulation-assisted learning, in a postgraduate TEE training program in Malaysia using the Kirkpatrick evaluation model.This study mainly asked, what is the effectiveness of the TEE training curriculum, which includes simulation-assisted learning, in a postgraduate TEE training program in Malaysia using the Kirkpatrick education model?The rationale of this study was to improve the effectiveness of the program based on Kirkpatrick's evaluation model (Kirkpatrick level 2: learning).This program focused on the basic understanding of TEE and its peri-operative applications in cardiothoracic surgical care. This includes the basic understandings of applied ultrasound principles, knobology, clinical indications for TEE, the value of TEE in various clinical situations, understanding standard TEE images, and interpretation of various clinical conditions using TEE over a duration of 7 months to 2 years.The training was divided into two parts. The first part comprised sessions that include the theoretical knowledge, cognitive and psychomotor skills to acquire and perform semi-quantitative analysis of 20 tomographic views in (i) a simulator and on (ii) 25 patients in Institut Jantung Negara (IJN). Upon achieving satisfactory knowledge and skills in a structured assessment, trainees then proceed to the second part of the program. The second part required trainees to perform and document TEE examination reports on 150 patients at their own institution, over a period of 6 to 18 months.Trainees' knowledge and skills were assessed at four different points throughout the program, strategies summarized in via multiple-choice questions post-test and incorporated in the clinical assessment. The 100 post-test MCQs may differ amongst the cohorts, as the question bank consists of 1500 vetted questions that are blueprinted to the course outcomes. The psychomotor skills were assessed at the end of part 1. At the end of the program, trainees' knowledge, cognitive and psychomotor skills were assessed based on the submitted logbook and a case presentation session. In the case presentation session, trainees were expected to present four cases from their logbooks based on a pre-determined criterion  supported by its prerecorded relevant echocardiography video loops. The loops were recorded to demonstrate the trainees' understanding of the pathology and their cognitive and psychomotor skills to obtain the relevant views. The question-and-answer session during the presentation assesses the trainees' theoretical understanding.Theoretical knowledge and cognitive skills were assessed at the beginning of the program, as a multiple-choice questions pre-test, and at the end of part 1 The pieces of evidence collected from these assessments support that the trainees have achieved the learning outcomes of the program and will be used to measure the effectiveness of the program based on Kirkpatrick Level 2. The description of the program, which includes teaching and learning activities, strategies, and assessment, is summarized in The program was evaluated before each intake in accordance with institutional and licensing regulations. Improvements were made according to the trainee, trainer, and other stakeholders' feedback. The simulation was integrated into the curriculum for the second cohort in 2012, based on the feedback from Cohort 1, for improvement of cognitive and psychomotor skills. Changes that were made by applying simulation principles, that include feedback, deliberate practice, and independent learning, were the major contributing factors to learning. A checklist of the 20 tomographic images to be acquired was provided to the trainees, to facilitate image recognition, as shown in The study sample included anesthesiologists, cardiothoracic anesthesiologists, cardiologists, and intensivists who enrolled in the Perioperative Transesophageal Echocardiography program at Institut Jantung Negara from 2012 to 2019. Sampling was universal, as all participant's performances were included in the analysis.The rationale for universal sampling is perioperative TEE is a niche area focusing on the perioperative care of cardiac patients, and the pool for potential participants is small, to begin with. In addition, the limited number of learners enrolled in the program was also limited by our aim to maintain an optimal trainer: trainee ratio and procedure: trainee ratio to ensure each learner receives an equal learning opportunity.The heterogeneity and possible differences between trainees on joining the program are expected of professionals and adult learners. However, all enrolled trainees fulfilled the minimum program entry requirement of being licensed physicians enrolled or completed their specialty training program. Their baseline knowledge and cognitive skills reflecting prior learning are assessed using the theoretical pre-test upon entry. Their psychomotor skills were not assessed.The outcomes studied were based on the Kirkpatrick program evaluation framework, learning (Kirkpatrick level 2) . Overallt-tests were used to compare means where data was normally distributed, for all cohorts. When comparing means between cohorts, no statistical analysis was performed due to the small sample size.Retrospective data were analyzed using IBM SPSS version 27 . Paired sample The performance of 19 trainees, over six cohorts from Cohort 2/2012 to 8/2019 were analyzed. Trainees from Cohort 1 were excluded from the analysis as they were the pilot group for the program and had different pedagogy and assessment time points. All trainees analyzed had equal opportunities learning using the multimodal pedagogy, including a simulator. The summary of trainee scores for all assessment components is shown in SD 9), post-test 64.1% (± SD 11.5); p ≤ 0.001), shown in The performances of 19 trainees were analyzed for the theory assessment component. The analysis of pre- and post- theoretical test scores showed a significant improvement in the mean scores  and 67.2%  respectively compared to the original program delivery method of 59.5%.Curriculum integration in simulation-based healthcare education allows education providers to perform a goal-directed evaluation of student learning and supports sustained use of its technology . When thThe use of simulation in education has been implemented in other TEE training programs. Simulation technology has been available for many decades and has been shown to improve learning and patient outcomes in many fields . TEE simThe significant improvement of the theoretical post-test, when compared to the pre-test, shows that learning occurred during the program. Though the best method would be to include a comparison of pre- and post-simulation clinical performance, this was neither feasible nor safe in our setting. Nazerian et al. agreed to evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing TEE to aid resuscitation after a course with clinical training in the cardiac surgical theater . TherefoIncorporating simulation, either as a pedagogical or assessment tool, was also documented by two programs that train physicians in focused cardiac ultrasound for the emergency setting. The first program focused on training residents in French cardiology, anesthesiology, and emergency medicine setting . The invIn another study in North America, Beraud et al.  also desThe significant improvement of the theoretical post-test and practical clinical shows that learning occurred during the program. Though the best method would be to compare pre- and post-clinical performance, this was neither feasible nor safe in our setting. Therefore, theoretical components, especially related to diagnosis were incorporated in the clinical performance assessment.The advancement of technology has been changing significantly, especially in cardiovascular and thoracic services as well as in the education industry. These technological advancements, along with changing expectations regarding training hours, patient safety, and limited patient encounters, have supported the paradigm of incorporating technology in providing education . IntegraKirkpatrick's framework for program evaluation was chosen, as it provided a clear taxonomy for decision-making . We chosOur study has a few limitations. Our sample size was very limited. As mentioned previously, this was due to the limited pool of learners as this is a very niche learning area, as well as due to our aim to ensure that opportunities for learning were constant and equal for all learners.We were also not able to provide direct supervision of the first 50 TEE performance and interpretation, as recommended by the 2013 consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists basic TEE training requirement  due to tThe significant improvement measured in the theoretical post-test and clinical assessment shows that learning occurred during the program. Though the best method would be to compare pre- and post-simulation clinical performance, this was neither feasible nor safe in our setting. Therefore, theoretical components, especially related to diagnosis were incorporated in the clinical performance assessment.Another limitation was we were not able to cross-check self-directed learning TEE findings in part 2, as trainees were in their own institutions, and it was not feasible to record all TEE examination findings due to potential patient confidentiality issues and unavailability of assigned trainers in the respective centers. When crosscheck was available, it was due to chance, rather than, designed in the curriculum.Despite these limitations along with the results only showing statistical significance in the theory components, the experiences reported by the trainees that were paired with their performance had provided meaningful feedback for program improvement to support learning.Performance of TEE requires the psychomotor ability to obtain interpretable echocardiography images and simulation is an effective tool for learning psychomotor skills by novices. The COVID-19 pandemic opens other opportunities for the application of technology into online and distant learning. This can be facilitated with a learning management system and a virtual learning environment. Integrating a learning management system that supports word processing documents, audio and video streaming into our program would facilitate multiple teaching, learning, and assessment activities: access to lectures, remote case presentations, remote preceptors and facilitators, and theoretical and virtual live cases for assessments. Though the advantages of online learning have been highlighted in numerous studies, items to be integrated into the LMS must be carefully selected. Items that can be selected are videos, online discussions, and case presentation items. Novel items that can be included are remote clinical teaching and assessment. The LMS can also be used to track trainee performance on the simulators. This would facilitate trainers and trainees to decide trainee readiness for practice in real patients.Integrating a TEE simulator as a pedagogical tool for our postgraduate TEE training program has proven to be effective in supporting learning theoretical knowledge and clinical competency in perioperative cardiac surgical TEE amongst our trainees.The TEE Simulator was helpful in providing a bridge from theory to the clinical environment by supporting trainees' cognitive and psychomotor skills.The Kirkpatrick framework served as a useful framework to evaluate the effectiveness of this training program. The significant improvement in post-test scores, when compared with pre-test scores, suggested that the program is effective with regards to learning. Simulation, as part of a multimodal pedagogy, has added value to our training program, and this was reflected by improvement in the clinical assessment scores when compared to the pre-test scores. This result aligned with the concept of technology-enhanced learning in Education 4.0, where simulation in TEE training is applicable in the Malaysian context.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.SA: program design and developer and implementation, contributed to design, conception of the study , the acquisition of data, analysis, interpretation, and wrote the paper. NM: analysis and interpretation, wrote the paper , and performed first and second proofreading. SK: contributed to program design and implementation, first, and second proofreading. All authors contributed to the article and approved the submitted version.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.


To explore perception of mentors and mentees about ‘Mentorship Program at Aga Khan University Medical College (AKU-MC) from a structured feedback formA retrospective study was conducted for evaluation of mentorship program at AKU-MC during the period from Jan 2019 to March, 2021. Responses on validated “Pre-intervention Probe Forms”, from forty-seven mentors and fourteen mentees inducted in the program were reviewed. Confidentiality and anonymity of data were deliberated. All replies to each question were entered in a separate worksheet to determine the frequency and percentage of answers. Responses conveying same message, but worded differently were then grouped.All the mentees (n=14) responded positively to the question on the “understanding of the mentoring program. The mentees  recognized the potential of the program to transfer knowledge and skills,  supported its role for achievement of goals, , acknowledged its role in faculty relationships. The mentors expressed their enthusiasm to help the mentee’s in their professional development. They  offered support to set career goals,  proposed transfer of knowledge, skills, and experiences to achieve goals,  decided to be “role models”. Some  forecasted improved communication skills,  boosted leadership capabilities,  expected improved work performance,  opinioned that networking and leadership qualities will impact the growth of the mentee to meet the university’s expectations.Both mentors and mentees recognized the importance of the faculty mentorship program at AKU-MC for professional guidance, development and improvement in work performance. Mentoring is: “A process whereby an experienced, highly regarded, empathetic person (the mentor) guides another  individual (the mentee) in the development and re-examination of their ideas, learning, and personal and professional development. The mentor, who often (but not necessarily) works in the same organization or field as the mentee, achieves this by listening or talking in confidence to the mentee”.3Faculty development programs in medical education commenced formally in 1990s in the USA.4Informal mentoring program was already in place at Aga Khan University. Keeping in mind the importance of formal mentoring program and its role in personal and professional development of faculty, formal mentorship program at Aga Khan University Medical College (AKU-MC) was initiated in 2019. The aim was to create a conducive learning environment for faculty empowerment and development. The specific goals were to offer an opportunity for new joining faculty to be attached to senior faculty for a deeper understanding of the culture and vision of AKU, so as to translate this into work and practice. Also, aimed to learn how different departments work and the collaborative approaches that could carry AKU’s vision forward making it a “center of excellence” in different services.Literature suggests that exploration of the mentorship programs is fundamental to assess the structure, processes (matching of mentors- mentees), goal settings, resources, strengths, weaknesses, and challenges faced by the programs.This study therefore aimed to explore the responses obtained from both mentors and mentees on their expectations from a formal mentorship program at AKU-MC.The responses obtained from mentors and mentees therefore will help in identifying issues in the relationship and measures to improve the outcome. It will enrich mentorship culture at AKU-MC which may help in commitment, contentment and retention of faculty members in the institutionAfter acquiring exemption from the Ethical Review Committee of Aga Khan University, (ERC-AKU- 2021-6156-18199 13th June 2021) we conducted a retrospective review and evaluated responses from mentors and mentees on their expectations from the formal Faculty Mentorship program during the period from January 2019 to March 2021. The instrument was a questionnaire designed separately for mentors and mentees (“Pre-intervention Probes for Mentors” and “Pre-intervention Probes for Mentees”) by the “Medical College Mentorship Forum”. It was validated by Delphi Rounds in which two experts from department of medical education and two experienced mentors were invited. The experts reviewed the tool and marked all those items which according to their opinion should not be part of the tool, those that needed editing or rephrasing were also highlighted, items which need exclusion were also marked. On the basis of their recommendations, rrepetitions were omitted, simple, clear, and unambiguous instructions and descriptors for assessors were added before administration. It was sent to both mentors and mentees who opted to join the program (from January 2019 to March 2021). The Mentee’s form comprised of five probing questions, regarding their perceptions of the mentorship program, whereas the forms for mentors had four questions.Pre-intervention Probes for MenteesQ1. What is your understanding of “mentoring program”?Q2. What are your expectations from the mentor?Q3. How frequent are you expecting to meet the mentor in a year?Q4. What challenges do you perceive in being a mentee?Q5. Will you prefer a mentor from outside your section or department?Pre-intervention Probes for MentorsQ1. What is your understanding of “mentoring program”?Q2. What are your expectations from the mentee?Q3. How do you think the mentoring program will help in your mentee’s professional development?Q4. What challenges do you perceive in being a mentor?Forty-seven mentors (associate professors and above) who had agreed to join the mentors pool, and fourteen mentees at the level of senior instructors and assistant professors enrolled in the formal AKU-MC mentorship program and agreed to fill the preintervention probes. Faculty members who did not fill the pre-intervention probe were not included. Responses were collected via emails. To maintain confidentiality, the forms were anonymized before data interpretation and the names of mentors and mentees were not shared with the principal investigator. The responses were entered in separate Excel spreadsheets. All replies to each question were entered in a separate worksheet to determine the frequency and percentage of answers. Responses conveying the same message but worded differently were then grouped.The program should be smart enough to support, develop, enhance or even serve as a catalyst to achieve mentee’s professional goals”. Another said, “The program will offer opportunity for new joining faculty to be tagged with a senior faculty to understand the culture and vision of AKU.” The majority (n=12) recognized the potential of the program to effectively transfer knowledge and skills, and help in the achievement of the mentee’s goals. They responded that partnership will also improve relationships between the senior and junior faculty thus facilitating networking, and acquainting the new entrants to AKUs culture and work practices  mentioned that this partnership would assist the mentees learn to set and achieve goals, facilitate networking, liaise with different departments and guide research work presentation or publications (Mentors (n=46) were very sure about the contribution of the mentorship program to the mentees’ professional development and (n=40) suggested both professional and personal development thus affecting overall productivity at the workplace. One stated it as ications .“The mentor’s life experiences will be realistic aspirations for the mentee”. “The program will help junior faculty in developing a niche for themselves at AKU and have someone guide them through their choices for professional and personal development”. They  offered support to set career goals,  proposed transfer of knowledge, skills, and experiences to achieve goals,  sponsored new ideas and thinking,  decided to be “role-models”. Some  forecasted improved communication skills, enhanced leadership capabilities, improved feedback mechanism, and predicted support in research presentations and publications. They  mentioned that networking and leadership qualities will reduce stress and improve work performance enabling the mentee to meet university’s expectations.The mentors were displaying positivity and enthusiasm in their responses to this question as e.g. A lot of responses from both mentors and mentees came up as “fears” and “challenges” in following up the program. Mentees  feared time management,  worried a balance of expectations versus role,  were uneasy about performance challenges, personality mismatch, while  feared honest and trustworthy relations. On the other hand mentors  were concerned only about the mentees commitment to take a proactive role in scheduling meetings, complying with feedback and maintaining honest and trustworthy relationship.A formal mentoring program is not only a cost-effective solution to counterbalance the worldwide scarcity of health educators and health professionals but also provides the infrastructure to achieve specific organizational goals. Best practices in mentorship can provide the best resolution to faculty retention. The study recognized the potential of the AKU Mentorship program in knowledge and skills transfer, advocated on professional and personal development, and acknowledged its role in developing faculty relationships. Mentees perceived the role of mentors in effective teaching, and productive researchLiterature on informal mentoring of college students scaffolds its advantage in promoting student success.Mentors of the program were enthusiastic to help the mentee’s in their professional development, offered support to set career goals and proposed transfer of knowledge, skills, and experiences to achieve goals, Results are supported by a study in which mentors valued their role in education and development of students.11In mentoring models the mentors are expected to provide socio-emotional support for cognitive growth and personality development of mentees.15Evaluation of mentoring programs has indicated positive career outcomes, and academic success.19It has been observed that the assumed supervisory role adopted by the mentors gives them fulfillment at work through self-determination and self-reflection. Workplace mentoring contributes to familiarization with work ethics and culture,This study is unique which explores perception of mentors and mentees, challenges and way forward to improve upon the program,. These reflections may suggest strategies to ‘enhance’ comprehensive mentoring model in the Department of Biological & Biomedical Sciences, Aga Khan University and other universitiesThis is preliminary information of the data, however, the effectiveness of mentoring program should include a systematic collection and analysis of the design, process, implementation, and outcomes.22Both mentors and mentees recognized the importance of the faculty mentorship program at AKU-MC for professional development and improved work performance. In-depth exploration of mentors’ and mentees’ perspectives and continuous support can be used to identify challenges and deficits in the structure of the program to devise appropriate strategies.RR designed the study.FK executed the project and she is also the accountable for the accuracy and integrity of the study.TSA took part in design of methodology.All authors read the manuscript and revised the content.


Participants (n = 32) also completed a semi-structured, telephone interview. Qualitative data were thematically analyzed to determine potential improvements. The overall voucher redemption rate was 52%. There was a 0.29  cup increase in self-reported fruit intake comparing post- to pre-intervention data. Qualitative analyses indicated that participants enjoyed the financial benefits of the program and wanted it to continue. The produce prescription program was successful in increasing self-reported fruit intake among participants. More research is needed to determine if changes in intake persist when measured objectively, and on best methods for the program’s financial sustainability. Few produce prescription programs have taken place in rural areas, in the context of existing public health programs. Thus, the purpose of this mixed-methods study was to examine voucher redemption rates, change in fruit and vegetable intake, and suggestions for improvement among participants enrolled in a produce prescription program occurring in existing public health programs throughout rural eastern North Carolina. We examined voucher redemption rates and conducted pre- ( Saxe–Custack, et al. [1C but no changes in blood pressure (BP) or BMI. Ferrer, et al. [1C. Overall, in a scoping review of 23 food prescription programs, Little et al. [The produce Rx program impacts on dietary intake are favorable: For example, Xie and colleagues  found th, et al.  found im, et al.  found si, et al. , Veldhee, et al. , and Had, et al.  all foune et al.  found the et al. . Qualitative studies of produce Rx programs have demonstrated that tailoring educational materials to seasonal produce available is important  as are pWe previously conducted an evaluation of a pilot produce Rx program  in 2020,The Albemarle Regional Health Services  Partnerships to Improve Community Health (PICH) Produce Rx program: The PICH Produce Rx Program partnered with cooperative extension programs, local health departments, federally qualified health centers, faith-based organizations, and a local hospital to provide produce “prescriptions” or vouchers to participants . In brieParticipant recruitment and voucher redemption rates:To determine voucher redemption rates, the ARHS Healthy Foods Coordinator maintained a spreadsheet that tracked the number of vouchers given out and those redeemed by the county and by the agency within the county. The number of vouchers redeemed was then divided by the number of vouchers distributed in each county to calculate the total redemption rate. The agency that distributed the vouchers was noted on the back of each voucher card so that the number of vouchers redeemed per program could be calculated. In some cases, the agency that distributed the voucher was not included on the voucher, but the voucher was redeemed at a farmers’ market in a specific county. In that case, the county where the voucher was redeemed was known, but the agency was unknown.In both the pre- and post-intervention questionnaires, FV intake was assessed by using two questions developed by Townsend et al. to assess daily fruit and vegetable intake . The resThe post-intervention questionnaire was printed on the back of the vouchers and was self-administered. If multiple post-surveys were completed, only the voucher with the most recent date was used. If more than one voucher was redeemed on the same date, the average (or most frequently reported response) was used for each question. In addition to the FV intake questions, two other questions were included in the post-intervention questionnaire: one question about whether the participant had tried any new farmers’ markets because of the produce prescription initiative and a three-statement agree–disagree matrix about shopping at farmers’ markets. Data analyses were conducted by using SPSS for Windows, Version 25.0 . Pre and post survey data were merged at the participant level by participant ID . For the post-survey data, only responses from the most recently used voucher were included in the merged dataset. If there were multiple vouchers redeemed on the same day, an average or the most frequently reported responses were used. Differences in FV intake between post-intervention minus pre-intervention were calculated, as was the total combined FV intakes for the pre- and post-intervention periods, respectively. Responses to the two food insecurity questions were combined to create an indicator of food insecurity that was defined as often or sometimes worried about or had run out of food during the past 12 months. Frequencies and proportions, and means and standard deviations when appropriate, were calculated for all variables. t-tests comparing post- and pre-intervention intake among participants. A Spearman correlation analysis was used to examine the relationship between dose (number or proportion of vouchers redeemed) and reported FV intake. To determine if use of federal food assistance programs was associated with lower redemption rates, we conducted a t-test to compare mean proportion of vouchers redeemed by whether participants reported that they used SNAP and WIC. Statistical significance of change in FV intakes was examined by using paired Participants were asked in the pre-intervention quantitative survey if it would be okay to contact them again after they had finished the program, and if yes, they were asked to provide contact information including phone number, email address, and mailing address. A research associate trained in qualitative interview techniques called each pre-intervention survey participant who provided a phone number and asked if they would be willing to be interviewed over the phone regarding their experiences in the produce Rx program. If they agreed, they were interviewed at that time or called back at a more convenient time. Thirty-two participants completed a qualitative interview.The interview guide included questions on how participants heard about the program, the type of program they participated in, how they received the vouchers, the number of vouchers they redeemed, the location of voucher redemption, the experience at the voucher redemption location, the FV items obtained with the vouchers, how the FV items were prepared, any changes in diet or health status the participant attributed to the program, and overall suggested improvements for the program. Interviews were audio recorded and transcribed verbatim by using Rev. Two researchers (SS and SBJP) each read 3 data-rich transcripts and created independent codebooks. The two researchers met to discuss their codebooks and created one consensus codebook. Then, each researcher independently coded each transcript, and met to discuss coding discrepancies and reach consensus on the final coding decisions for each transcript. Final themes were decided based upon how frequently each code was mentioned and the depth of discussion around each code. Once all transcripts were double-coded, one of the researchers coded all transcripts in NVivo  by using the consensus codes. Code summaries and reports were retrieved from NVivo and analyzed to find themes and subthemes from the coded transcripts.One hundred thirty-nine participants completed a pre-intervention survey. Three duplicate cases were deleted, and an additional 11 cases were deleted because of missing data, leaving a working sample size of 125 cases (participants). There were initially 1578 records in the post-intervention survey dataset; 917 records were deleted due to no ID information  or no responses to the post-intervention survey questions. An additional 491 duplicate records were removed (multiple voucher redemptions by the same participant), leaving one record per ID. There was a working sample size of 170 in the post-intervention survey dataset; however, only 164 included FV consumption data. Pre- and post-intervention survey data were successfully merged for 50 cases See .Demographic, socio-economic, and food-related characteristics of participants are provided in About one-third of participants (31.2%) reported that it was not hard for them to eat fresh fruits and vegetables. However, 48.0% said fresh fruits and vegetables were not available in the neighborhood, 20.8% said they do not have enough money to buy them, and 10.4% said they spoil too quickly. The majority (97.6%) purchased food for their family from supermarkets, grocery stores, supercenters, and warehouses, while 41.6% went to convenience and dollar stores for food, and 14.4% went to a food pantry or shelter. One third (33.6%) reported that they had gone to a farmers’ market for food purchases in the past month, and the majority (85.6%) had ever shopped at a farmers’ market. Less than half of participants (45.1%) were classified as food-insecure.n = 149) of those completing the post-intervention survey said they tried a new farmers’ market because of the produce Rx program.In The frequencies of reported FV among the 125 participants who completed the pre-intervention questionnaire and the 164 participants who completed the post-intervention questionnaire were generally similar . Howeverp = 0.031) cup increase in self-reported fruit intake comparing post- to pre-intervention data, and a 0.17  cup increase in self-reported vegetable intake comparing post- to pre-study data. When reported FV intake was combined, the increase in combined FV intake was also statistically significant . However, when the dose was examined by using Spearman’s rho, neither number of vouchers redeemed nor the proportion of vouchers redeemed were correlated with a change in fruit  or vegetable consumption . For 50 out of the 125 participants who completed the pre-intervention questionnaire, we were able to merge pre- and post-intervention data and to analyze the data for the change in FV intake. There was a 0.29 . In a regression model, SNAP was still statistically significant (p = 0.019) after adjusting for food insecurity, age, and race. In other words, those who receive SNAP benefits redeemed a lower proportion of their vouchers, on average, than those who did not report receiving SNAP benefits. However, the proportion of vouchers redeemed by whether the participants used WIC did not differ (p = 0.478). Those participants who also used SNAP redeemed a lower proportion of their vouchers  compared with those who did not use SNAP , or there was no way to leave a voicemail (n = 11). Additionally, there were several instances in which calls could not be completed, due to poor reception or lack of phone service entirely (n = 7). Finally, there were several participants who were reached but refused to participate in the qualitative interview process (n = 12).The response rate for the participant interviews was 24.4%. Participants were called via phone, and there were many participants who were not reached because they either did not answer the call or return the call after a detailed voicemail was left (n = 10) or friends (n = 8). There were five participants who reported learning about the program through the cooperative extension and four participants who learned about the program through a community recruiter. The remaining participants heard about the program through their physician (n = 2), coworkers (n = 2), or church (n = 1). Nutrition education for the program was mostly received over the phone (n = 11), with several participants attending in-person sessions (n = 6), attending online sessions through Zoom (n = 3), their physician (n = 1), or other sources (n = 1), and other participants reporting that they did not receive any nutrition education (n = 2). (Some respondents did not definitively state how they received nutrition education.) Most participants reported using all of their vouchers (n = 25), with others reporting using only some of their vouchers (n = 5), and two participants reported using none of their vouchers. Several participants who did not use all their vouchers reported the barrier to voucher use being that the available locations for voucher redemption did not have the food items that participants were looking for (n = 6). Most participants reported seeing a change in their FV intake (n = 24), with others reporting no change in their FV intake (n = 3). When asked to suggest improvements for the program, most participants reported that they had no suggestions to improve the program because it was already effective. However, some participants reported wanting more classes to be offered to get more vouchers (n = 3), wanting the program to run longer (n = 2), wanting more locations at which to shop (n = 2), higher voucher amounts (n = 2), and to increase promotion of the program (n = 3). Only three participants mentioned gardens, mostly in the context of reflecting on previous gardening experiences when younger or on how FV obtained using the vouchers were those not grown in the garden. Most people heard about the program through their family  . The vouThe current study built on the findings from our previous evaluation  to improWe found that those receiving SNAP benefits redeemed a lower proportion of their vouchers, on average, than those who did not report receiving SNAP benefits. The finding of the current study is in disagreement with findings from prior studies ,24 whereApproximately 23% of the sample disagreed with a statement that it was easy for them to get to farmers’ markets. This highlights a potential barrier to redeeming FV vouchers—difficult geographic access to the market. Both geographic and financial access to farmers’ markets are important for participants to procure and consume fresh FV. Shopping at farmers’ markets is associated with greater FV intake ,26 and iOur current study is limited in that changes in FV intake were measured by self-report, and we did not include any anthropometric or medical data such as BMI or BP. A further limitation is that surveys suffer from social desirability bias . In addi®, which has been used in prior studies to determine the effectiveness of public health nutrition interventions [The study team is currently working with a mobile application developer to administer the program via a mobile application to ensure better follow-up and data collection throughout the evaluation. Future research will include exploration of the mobile application as a way to generate program income  to sustain the program after grant funds are depleted. Future researchers should examine the effectiveness of the produce Rx program on objectively assessed FV intake by using tools such as the Veggie Meter ventions ,29.The produce prescription program was successful in increasing self-reported fruit intake among participants. More research is needed to determine if changes in intake persist when measured objectively, and on best methods to improve the program’s financial sustainability.


Mycoplasma pneumoniae (MP)-specific immunoglobulin M (IgM) titer, in addition to a diagnosis of MP infection, in children with MP pneumonia.The present study aimed to identify the clinical significance of This study was performed in 155 children hospitalized with MP pneumonia. The clinical features and laboratory and radiographic findings on admission in children with positive or negative MP-specific IgM titers were retrospectively reviewed from the electronic medical records.The mean age of the included children was 6.0 years, and 118 (76.1%) of the children were positive for MP-specific IgM. A longer duration between symptom onset and admission , longer duration of symptoms during the illness , and development of extra-pulmonary manifestations  were significantly associated with a positive MP-specific IgM titer. Serum lactate dehydrogenase levels  and pneumonic infiltration involving > 50% of the total lung volume on chest radiography  were associated with positive MP-specific IgM in children with MP pneumonia. A poor response to stepwise treatment for MP pneumonia was more common in children with a positive MP-specific IgM titer than those with a negative MP-specific IgM titer on admission.A positive MP-specific IgM titer at diagnosis of MP pneumonia may partially suggest an exaggerated immune response with a higher disease burden compared to children with MP pneumonia with a negative MP-specific IgM titer. Mycoplasma pneumoniae (MP) and other bacteria can cause pneumonia in children [Diverse respiratory viruses, children , 2. In cchildren . Althougchildren , some MPchildren , 4. In rchildren . To prevHowever, the diagnosis of MP pneumonia in children is sometimes delayed due to false negative test results for MP-specific immunoglobulin M (IgM), especially in the early phase of MP infection, and variable detection rates of polymerase chain reaction (PCR) for MP due to diverse factors such as patient age, cooperation during the sample collection, and sampling sites –8. ThereIdentification of MP-specific IgM titers is the most widely used serologic test to diagnose MP infection. However, a single negative MP-specific IgM titer cannot exclude MP infection. Although a MP-specific IgM titer usually shows seroconversion during the first 7 days following symptom onset, the MP-specific IgM titer is diverse even within this period of illness due to MP infection . FurtherThis study aimed to compare the clinical features and laboratory findings between children with a positive MP-specific IgM titer and those with a negative MP-specific IgM titer on admission in children hospitalized with MP pneumonia. In addition, we elucidated the associated factors with a positive MP-specific IgM titer at the time of admission in children hospitalized with MP pneumonia.M. pneumoniae Real-Time PCR kit, Slan; Biocore, Seoul, South Korea) tests during the illness, (ii) identification of seroconversion of an MP-specific IgM titer in patients with an initial negative MP-specific IgM titer, which confirmed MP infection when combined with positive results on PCR tests, and (iii) proven MP pneumonia based on recent history of the presenting illness, physical examination, and chest radiographic findings in previously healthy children. The exclusion criteria comprised patients with immunosuppressive diseases, taking immunosuppressive drugs, and with underlying diseases associated with any chronic lung diseases or those with recurrent respiratory infections, defined as more than two episodes of respiratory infection in the past 2–3 months. The clinical features and laboratory and radiographic findings in children with a positive MP-specific IgM titer at the time of admission and those with a negative MP-specific IgM titer at the time of admission were retrospectively reviewed using electronic medical records. This study was approved by the Institutional Review Board (IRB) of Chonnam National University Hospital, which waived the need for informed consent (IRB no. CNUH-2019-261).This retrospective study comprised 155 hospitalized children with MP pneumonia between May 2019 and February 2020. The inclusion criteria were patients who meet the following items: (i) confirmed MP infection using both MP serologic  and PCR  and negative . The extra-pulmonary manifestations associated with MP pneumonia in the present study included skin rash; acute hepatitis, which was reflected in elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT); and pulmonary thromboembolism.The patients with MP pneumonia were treated using the following strategies. First, patients with MP pneumonia were treated with macrolides combined with intravenous methylprednisolone  in severe cases to reduce the excessive immune response , 11. If The response to treatment for MP pneumonia was classified into four groups, based on the response to the aforementioned stepwise treatment for MP pneumonia: good response, slow response, no response, and progression . A good Hemophilus influenzae, Streptococcus pneumoniae, Chlamydia pneumoniae, Bordetella pertussis, and Legionella pneumophila, in children with MP pneumonia.Respiratory virus co-infection was investigated using a PCR assay kit  with nasopharyngeal swab samples for the common 16 respiratory viruses, including adenovirus, bocavirus, corona viruses OC43, 229E, and NL63, enterovirus, influenza viruses A and B, human metapneumovirus, parainfluenza viruses 1–4, respiratory syncytial viruses A and B, and rhinovirus. A total of 73 children in the study also underwent a pneumobacter PCR  assay to identify combined bacterial coinfection with t-test or Mann–Whitney U test for continuous variables were used as appropriate. Pearson’s correlation analysis was performed to identify the correlation between MP-specific IgM titers and laboratory findings with clinical features in children with positive MP-specific IgM titers. Logistic regression analysis was performed to identify factors associated with a positive MP-specific IgM titers. Adjustment was made for age, sex, macrolide resistance of MP, and duration between symptom onset and hospital visit due to MP pneumonia. All statistical analyses were performed using IBM SPSS Statistics ver. 24.0  software. P-values < 0.05 were considered statistically significant.To compare the clinical features and laboratory findings between children with positive MP specific IgM titers and those with negative MP specific IgM titers, a chi-square test or Fisher’s exact test for categorical variables or a Hemophilus influenzae in 11 patients; Streptococcus pneumoniae in 8 patients; both H. influenzae and S. pneumoniae in 8 patients).The mean age of the participants was 6.0 ± 3.8 years range, 0–17 yrs) and 49.0% (n = 76) of the participants were male (Table 7 yrs andP < 0.001) and total duration of symptoms during the illness due to MP pneumonia  was longer in children with a positive MP-specific IgM titer than those with a negative MP-specific IgM titer  and lactate dehydrogenase  levels were significantly higher in children with a positive MP specific IgM titer than in those with a negative MP-specific IgM titer (Table P = 0.018) and alanine aminotransferase , which indicate liver function, were higher in children with a positive MP-specific IgM titer than in those with a negative MP-specific IgM titer.The mean white blood cell levels  and with serum albumin levels at the time of admission , WBC count (P = 0.013), and serum LDH levels (P = 0.034). However, total duration of symptoms during the illness due to MP pneumonia did not significantly correlate with the MP-specific IgM titer titer (data not shown).In children with a positive MP-specific IgM titer at the time of admission due to MP pneumonia, the MP-specific IgM titer was significantly negatively correlated with age at the diagnosis of MP pneumonia  and longer symptom duration during the entire illness period due to MP pneumonia  was significantly associated with a positive MP-specific IgM in children with MP pneumonia (Table This study identified differences in the characteristic features of children with positive MP-specific IgM titers and those with negative MP-specific IgM titers at the time of hospital admission due to MP pneumonia. Factors associated with a positive MP-specific IgM titer in children with MP pneumonia were also determined. The results of the present study would be useful to predict the clinical course and clinical outcomes in children with MP pneumonia, based on the results of a MP-specific IgM titer at the time of MP pneumonia diagnosis.MP infection is usually confirmed using serologic tests, such as MP-specific IgM titers, and/or a PCR test. Although PCR analysis is highly sensitive and is used as a reference diagnostic method for MP detection, a PCR test cannot be always performed whenever the specimens are obtained due to high cost, time-consuming sample pretreatment, and the need for skilled technical ability . In addiBased on the results of the present study, a longer duration of symptoms prior to visiting the hospital was associated with a positive-MP specific IgM titer, which is understandable as it takes time, usually approximately 1 week, for the seroconversion of MP-specific IgM titer after MP infection . SimilarA positive MP-specific IgM is also associated with higher disease burden due to MP pneumonia, reflected in greater involvement on chest radiography findings and a longer duration of fever during the total illness with increased LDH levels. Notably, a positive MP-specific IgM has been associated with the development of extra-pulmonary manifestations during the illness and elevated serum LDH levels, which might suggest more activated immune responses in these patients , when coThe influence of age on the MP-specific IgM titer in MP infection has not been fully elucidated. The previous studies have suggested that age might affect the likelihood of a positive MP specific IgM , 22. In In terms of responses to stepwise treatment for MP pneumonia, the proportion of poor response, defined as a combination of slow response, no response, and progression, was higher with a significantly increasing trend in children with positive MP-specific IgM titers, compared with those with negative MP-specific IgM titers. There are some debates on whether macrolide resistance of MP may affect the response to the stepwise treatment for MP pneumonia –25 and tThe LDH level in MP pneumonia has been considered an important predictor of refractory MP pneumonia , 27. WheThe positive association between a higher extent of pneumonic infiltration on chest radiography findings and a positive MP-specific IgM titer might suggest a higher degree of disease extent with time in MP pneumonia, especially when combined with serum LDH levels. The positive MP-specific IgM titers at the time of diagnosis of MP pneumonia suggest an exaggerated immune response with higher disease burden due to MP pneumonia progression compared with a negative MP-specific IgM titer. Therefore, early diagnosis of MP pneumonia in children using reliable diagnostic tools enable the improvement of the prognosis in MP pneumonia in children.This study had several limitations. The number of study participants was relatively small. The gold standard use of serologic tests for a diagnosis of MP infection is to confirm a ≥ 4 times increase in the MP-specific IgG titer 2–3 weeks after the first measurement; however, we did not measure the MP-specific IgG titer to diagnose MP infection in this study due to its low clinical usefulness for early diagnosis of MP infection . NeverthIn conclusion, a positive MP-specific IgM titer at the time of diagnosis of MP pneumonia may partially suggest an exaggerated immune response with higher disease burden due to progression of MP pneumonia, compared to children with a negative MP-specific IgM titer.