To explore whether and how preclinicalmedical students changed perceptions and behaviors related to professionalismin small group learning activities from face-to-face to virtual during thepandemic.The study used a mixed-methods sequentialresearch design. We first retrospectively examined quantitative data from 101medical students who completed mandatory peer evaluation surveys assessingprofessional behaviors of small group members in two courses . Differences between student perceptions in two settings werecompared using the Wilcoxon signed-rank test. Findings from the quantitativestage were probed further using focus groups at the qualitative stage. Sixfocus groups (n = 27) were conducted using purposeful sampling. Interviews weretranscribed and inductive thematic coding was used to identify emerging themes.We found a significant decrease inperceptions of punctuality and attendance in the virtual setting compared toface-to-face learning , despite lower expectations of their peers in online learning. Five major themes emerged fromthe qualitative data: punctuality/participation, camera usage, dresscode/conversational style, multitasking, and engagement/accountability.Participants showed sensitivity when conceptualizing professional conduct,indicating the dynamic process of professional identity formation at the earlystage of their career.Results show that students’ perceptions ofprofessionalism become contextualized, significantly influenced by thebackground of the virtual learning environment. Intentional communication aboutprofessionalism within specific sociocultural and educational contexts is vitalfor individual professional identity formation. These findings support of theimportance of considering context when educational programs develop curriculaand establish expectations related to professionalism. Over the last few decades, medical professionals and organizations proposed various frameworks of professionalism, and medical schools have designed and developed various curricula, instructional approaches, and assessment methods to address this core competence with medical students.The COVID-19 pandemic further complicated the situation when many medical schools shifted from face-to-face to online settings. While most literature on medical student professionalism focuses on the attitudes and behaviors of students in either the classroom or clinical setting, little is known about students’ perceptions and behaviors related to professionalism in the online setting. It is not clear whether students demonstrate professional conduct differently in an online setting due to the lack of a physical presence. Using a mixed-methods sequential design, we compared professionalism in two settings based on peer evaluation and focus group results and investigated whether and how students changed their perceptions and behaviors because of the online setting., , , Professionalism has been defined in a variety of ways. For example, the Physician Competency Reference Set provides a list of common learner expectations utilized in the training of physicians including 6 professional behaviors in the U.S., , Empirical studies on professionalism in medical schools focus on diverse aspects and have identified various challenges, such as difficulties in teaching and evaluating professionalism, differing student and faculty perceptions of professionalism, and peer-assessment of professionalism in clerkships.Professional attributes and behaviors are highly dependent on interpersonal interactions. Small-group learning modalities, such as TBL, in which students work together in teams to apply knowledge toward solving relevant problems, and case-based learning (CBL), in which students work together to explore and discuss a clinical case, rely on the collaborative efforts of group members to promote learning.This study was determined to be exempt from institutional review board (IRB) review by CMU’s IRB. The IRB approval exemption from the university was received prior to data collection.As synthesized earlier, the literature highlights contextualized, social-cultural perspectives on professionalism. As such, in the following, we start with an elaboration of the specific educational context where the study was conducted. We then explain two separate stages of the mixed-methods explanatory design, with a survey followed by focus groups. In an explanatory design, quantitative data is first collected and analyzed, followed by qualitative data collection and analysis. The qualitative stage, which builds on the quantitative results, helps to explain and elaborate on the quantitative results in more depth.Central Michigan University’s College of Medicine (CMED), which is located in the Midwest of the United State, adopts an integrated curriclum with a series of interdisciplinary, systems-based course blocks. Each course block incorporates a variety of teaching methods, and CBL and TBL comprise nearly 50% of contact hours on average. At CMED, professionalism is defined as “a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to all individuals.” Seven educational program objectives address this competency, including demonstrating respect, accountability, sensitivity, enhancing team functioning, giving and receiving feedback, respecting patients’ privacy, and demonstrating a commitment to ethical principles. CMED policies and the student handbook define professionalism and provides examples of professional behaviors such as “handing in assignments on time” and “developing successful working relationships with preceptors, staff, and peers by accepting constructive feedback.” In the pre-clinical phase, students receive teaching and guidance on maintaining their professional conduct through course sessions, orientation sessions, and learning modules. This content addresses expectations related to professional dress code, attitude, and behaviors when the students work with their peers in small groups.In this current study, we compared student perceptions of professionalism in two 6-week courses, Reproductive System and Human Development  and Renal and Endocrine Systems . Students were in the same group for each course. At CMED, individual students prepare for TBL by reading pre-assigned material before participating in individual- and group-based TBL activities each week. After that, the same group participates in CBL by collectively working through patient cases. Finally, each group works on additional TBL sessions based on the cases.Stage One used a retrospective approach based on the data that were obtained from 13 small groups of 8 or 9 students who participated in CBL and TBL exercises in these two 6-week courses in early 2020. At the end of each course, students completed peer evaluation surveys assessing their peers’ professionalism behaviors using a 5-point Likert scale ranging from “never”, “rarely”, “sometimes”, “often”, to “always.” The survey contained six items related to professional behaviors, including showing punctuality and remaining with the team, giving feedback, accepting feedback, showing respect and sensitivity, demonstrating integrity and accountability, and interacting professionally. Completion of peer evaluations was required, and all students (n = 101), 51 female and 50 male, completed the survey. Responses were analyzed using SPSS 26. Due to the ordinal data and violation of normality of the responses, the nonparametric Wilcoxson signed-rank test was used to compare students’ responses in the two settings.After the quantitative data were collected and analyzed completely, the research team reviewed the results of the quantitative data, discussed the findings with statistical significance, and developed a semi-structured interview protocol. The interview protocol essentially asked about three major areas: perceptions regarding results from the quantitative findings, overall perceptions of how the change from face-to-face to online learning impacted professionalism, and perceptions of whether and how their determination of the degree of survey responses evolved in the online setting. The semi-structured interviews provided the opportunity to probe for clarification and explore participants’ perceptions in depth.A purposeful sampling approach was used to recruit participants considering gender and test performance. Six groups with 27 volunteers in total were recruited in late 2020. Focus groups were conducted virtually, ranging from 45-60 minutes. Among the 27 participants, there were 11 males and 16 females see . StudentCronbach’s alpha internal consistency reliability coefficient with the six 5-point Likert-scale items was calculated. Results showed sufficient reliability with two courses (α = .891 and .911 respectively), indicating that the six items broadly reflected the dimension of professionalism. Average peer-evaluation responses were calculated for each student, which was then compared in the two settings. Overall, students’ assessment of their peers was positive. The mean of the responses ranged from a low of 4.38 to a high of 4.85. Results showed a significant difference between the two settings for only one question, “Arriving on time and remaining with team during activities” , which decreased from 4.74 in the face-to-face setting to 4.38 in the online setting.Using the standard thematic inducive coding process, five major categories emerged from the qualitative data: 1) punctuality and participation, 2) camera usage, 3) dress code and conversational styles, 4) multitasking, 5) engagement and accountability.The statistical difference was further examined by exploring participants’ perceptions in depth. Generally speaking, the focus groups confirmed the finding of reduced punctuality and remaining with the team from the Likert-scale responses. Participants agreed that their peers showed less punctuality and attendance as stated, “professionalism definitely probably decreased. It’s just easier for people to show up late or not show up at all”  and “I know at least this year, we've, in my group, had a couple of students sleep through case” . As one student elaborated,“I do find people are tardier now getting on onto cases, whereas when we were in person, you knew you had to be there at 8 am, and you knew how long the drive took, and you were there for the most part at 8 am. Now, I have found that…people kind of will trickle into case and we'll start a few minutes late.” Furthermore, participants explained their changed definitions and lowered expectations about punctuality and attendance  compared with face-to-face CBL and TBL. It was also more difficult for students to assess their peers’ participation. One student explained the difficulty in interpreting a lack of participation by a peer: “you know someone is doing something else and that you don't necessarily know if it's because they don't understand what's going on and they're trying to look more into it or if they're just not there” .Camera usageIn addition to punctuation and participation, camera usage emerged as a distinct theme from the interview data. At CMED, students were not required to use their cameras during small-group sessions. The participants in focus groups discussed how the online setting without cameras constrained communications and collaborations and lack of facial expressions made difficult to see “someone's reaction if they got a question wrong or if they are trying to explain something” . As one participant explained, “it becomes a little bit harder to gauge whether or not people are actually participating or if they're engaging in active listening or…what's going on behind the screen when they don't have their cameras on” .The participants discussed two different behavioral patterns and how these patterns impacted their perceptions of professionalism. First, students who turned off their camera but contributed to group activities were considered professional, as stated, “I think is the fact that we…don't turn our cameras on, I mean, still it’s fine. Like, I don't mind if your camera's off and you're still contributing, or you want to talk if you have questions” . Second, those students who turned off their camera and did not contribute were considered unprofessional. The participants expressed that they understood there were occasions which required camera off or being muted such as “a lawnmower going in the background, or like a dog barking for 10 minutes straight” ; however, the participants believed being muted with camera off without active engagement was not professional:“There’re just people in my group who, no camera, will not say anything, will not write anything on a document for days in a row……So, by not showing up, not asking questions, not answering questions, you're doing a disservice to the rest of your group. And I feel like there's just like, no good way to do it in online, because how do you know if somebody's there and just not saying anything or if they turn the camera [off] and walk away from it and are just spinning their wheels?” Dress code & conversational stylesThe participants were fully aware how the online setting changed the way they dressed for classes and how they talked with each other. Although the school has a dress code, students stated, for example, “I don't necessarily dress up every day for class, as opposed to if we had to go in person” . Their judgment about professionalism became more contextualized, less joking, and less judgmental. For example, the following student explained while he believed professionalism was deteriorating, a new dress code of wearing pyjamas was acceptable.“I don't think anybody expects anybody to wear anything more than a T-shirt, but, I mean, we were wearing jeans and T-shirts in school. So, I don't think if you’re, I mean, if you'rewearing pyjamas and you're at home, as long as you're not like, in your underwear, as long as you're wearing, you know, whatever. I feel like that's kind of the new professional as long as you're like, you know, clothed.” Some students also expressed concerns about how their words or actions could be interpreted by their peers with fewer visual cues. As such, they were careful with their tones and word choices in group discussions.“So, we were very hesitant to say certain things in a joking manner because no one has their cameras on, so we don't know if someone's actually going to take like, a joke seriously. And maybe it could be interpreted, like, in a wrong way, and we're not able to gauge their reactions. So, at least for me, I feel like I toned down how I speak to others, to become more professional.” MultitaskingMultitasking emerged as a theme with controversial perceptions among the focus group participants. The students talked about doing other things such as “do some [weight] lifting”  or “doing a load of laundry” . Some participants found multitasking to be convenient and appropriate, for example, “there is a little bit of multitasking, but usually people prioritize the case, so I think it's it still works out” . Others deemed such behaviors as unprofessional and tried to get rid of distractions, as one student described, “I have to literally put my phone in a different room to keep myself from just looking at it and accidentally losing part of the time, when I'm supposed to be paying attention to someone answering a question” . For example, the following two participants showed opposite attitudes toward multitasking.“Professionalism is decreased, but not for, like, respect or kindness or anything like that. But just that, you can take a call. I had a dentist appointment, and I took case on a hot spot on my phone in my computer in my car. Like, I was in a parking lot doing class, and it worked fine. And I know a lot of people do that, you know, different places or hopping around or things like that.” “I definitely think professionalism changed and, like, I know I've even found myself guilty of this now that we're online and, like, we don't normally turn our cameras on as a group. Like, I find myself doing other things that may not be focused on class or like, I'll be like, making lunch instead of, like, listening in TBL, which, is not great.” The virtual setting impacted how students perceived their ability to provide meaningful feedback and demonstrate accountability. The participants expressed that they were not sure when to chime in, how to chime in, and whether they should give peers the benefit of the doubt due to the use of the online setting. Compared with the face-to-face setting, “you aren’t, as, like, accountable, and it's easier for them [peers] just to not participate at all. So, if they just want to shut off their camera and, like, not talk the whole case, you can't really do much about it. But, like, in person, people were more willing to at least somewhat talk” . The following student elaborated on the difficulty to be engaged and provide feedback:“So, it's kind of hard to just say what you're thinking, because then you don't know if someone's going to talk and then you kind of have to be hesitant on when you want to talk versus letting someone else talk. So, I find myself, kind of being hesitant and saying what I want to say if I was in person, because there's not that lag time or, you know, the body language and stuff like that. So that's kind of where I think sharing information kind of goes down and sharing your own opinion and stuff.” DiscussionThe mixed-methods design adopted in this study is helpful to explain quantitative results and expand understanding and interpretations of professionalism in more detail. The study used retrospective peer evaluation results and then moved to constructivist assumption to investigate multiple perspectives and in-depth exploration. To recap, the quantitative results showed significant differences regarding arriving on time and remaining with team between face-to-face and online settings, despite lowered expectations for the online setting as described by focus group participants. Participants observed a general decrease regarding punctuality and attendance in the online setting. Furthermore, the qualitative interview results indicated how the definition of professionalism became contextualized, significantly influenced by the virtual learning environment. Participants recognized the blurred boundary between professional and personal spaces in the online setting. Some participants viewed multitasking as convenient and appropriate while others deemed such behaviors as unprofessional. Overall, even though the CMED student handbook delineates regulations and requirements for professional conduct and presentation, details and nuances that were perceived and considered by the participants go beyond these regulations.Academic Medicine volumes that large-scale technological, social, and political changes might be having substantial effects on medicine’s status as a profession and on the identity of physicians as professionals., , In summary, the results showed that the shift to the online setting significantly impacted students’ perceptions and behaviors toward professional conduct in the process of establishing and maintaining their professional relationships with their small group members. This is consistent with the findings from the two Results from this study also showed the dynamic process of professional identity formation, although at the early stage of medical students’ career path. Professional identity formation has received considerable attention in recent years. Irby and Stanley defined professional identify formation as “an adaptive, developmental process occurring at individual  and collective  levels that socialize learners into thinking, feeling, and acting like a physician.”Professional identity formation for each individual student is not static, but rather a fluid process requiring flexibility and resilience. Navigations and negotiations of their personal and their peers’ behaviors in the online learning setting during the pandemic provide an opportunity for students to reflect on new values and identities, and create compromise between the two, as argued by Larry May in terms of “legitimate compromise.”Professional identity formation is a process; it entails intentional discussions collectively at the college level and should include faculty and administrators who teach professionalism and serve as role models. Professional identity formation may also be inspired by gaining different perspectives from various stakeholder groups beyond the local community. Ultimately, intentional communications about professional conduct at the collective level with the context are vital for individual professional identity formation, which is dependent on interpersonal interactions and heavily embedded in social-cultural contexts.This study has several limitations. First, the quantitative stage was based on the retrospective peer assessment data, which provided limited information even though the study found appropriate reliability evidence. This was a small-scale study focusing on only one educational context with its own characteristics regarding student population, learning approaches, and teaching features. Professional attitudes and behaviors may vary when using different populations in different educational contexts with different policies and practices.The competencies to engage in collaboration and function effectively in a professional manner are essential attributes of any good physician. Medical education does not just entail the delivery of medical knowledge and skills but also includes the cultivation of professional attitudes and behaviors as students develop their professional identities as physicians. Given the context that the pandemic forced medical schools including CMED to adopt virtual CBL/TBL, it is vital to examine how the shift from face to face to online learning affected students’ perceptions of professionalism and professional behaviors in small groups.Unprofessional attitudes and behaviors negatively impact learning process, performance, teaching, and the larger learning environment. This study provides empirical evidence confirming that the shift to the online setting significantly influenced students’ professional behaviors in the process of establishing and maintaining their professional relationships with their small group members, partially due to the unclear guidelines of professionalism in the local context. Further research will be needed as the pandemic continues to evolve to see how the change among virtual, face-to-face, and blended models of medical education affects students’ attitudes and behaviors in professionalism. It is also important to examine whether this almost fully virtual-learning class demonstrates professionalism when they rotate and practice in clinical settings as Year 3-4 students and residents.This paper provides important implications at CMED and beyond. First, the timely investigation of professionalism in these two settings has accumulated information about how online setting influenced students’ perceptions and behaviors regarding professionalism. It confirms that the definition of professionalism is contextualized and situated. Expectations or additional specifics under the online circumstances, hence, need to be clarified and reinforced in school policies and curriculum . Second, the results provide directions about the importance of fostering professional identify formation and discussing some of the controversial issues  related to professionalism in the local context, with or without the impact of the COVID-19. It is essential for CMED and other medical schools to reflect on the feature of its student population and organizational culture to discuss perceptions and conflicts regarding professionalism. Professionalism and professional identify formation must be aligned with school missions and cultivated by both who deliver the curriculum and who receive the training. Without inclusive and transparent conversations during the journey both curriculum and assessment of professionalism will come under challenge. It must be noted that this was a small-scale study focusing on only one educational context with its own characteristics regarding student population, group dynamics, and teaching features. This group of students had limited experiences with online learning. Perceptions may vary when using different samples in different educational contexts at different counties.We are grateful for Dr. Mariana Rosca who helped with brainstorming and data collection as well as CMED students for sharing their experiences. We thank the editor and reviewers for their constructive comments.The authors declare that they have no conflict of interest.


This article analyzes healthy child contests as a medical and socio-politicalstrategy implemented in Latin America to protect childhood, thus ensuring thefuture of the “race” and the nation. These contests blended degeneration, racialtheories, and state interventionism and gained momentum in the 1930s with therise of eugenics. This article examines the contest in Colombia, which wasimplemented under the Liberal Republic (1930-1946); even though this competitionwas defined by its national context, a broader international perspectiveimproves understanding. Questions are also raised about the efforts of theLiberal government to strengthen the idea of national identity through educationand health programs. El Tiempo published a photo of the two winners of the contest,which was held in the capital city of Bogotá. Leopoldo Méndez  and Betulia Toledo  appeared alongside Bogotá Mayor Manuel Antonio RuedaVargas, Doctor Ignacio Moreno Pérez and a “selected group of respected ladies of the city.” The contest, presided over byColombian First Lady María Michelsen de López, had taken place days before at thepresidential palace.On June 22, 1937 the Colombian government enacted Decree 1201 reinstating the nationalHealthy Child Contest (HCC) on the grounds that “2) the future of the race relies mostlyon childhood protection so that our future men can develop and grow up in the besthygienic, biological, and social conditions; … 4) parents’ efforts to preserve theirchildren’s health, not only those that are sick or retarded, but all, should beencouraged” . Four months later, the Colombian newspaperContests rewarding healthy children were part of a national and international “crusade”to protect children that embodied the future of the nation and the “race” by rewardingColombian mothers who ensured proper physical, psychological and moral development oftheir babies. The first contests were held in the early twentieth century in LatinAmerica, when licensed physicians started to focus on high child mortality  to make thecountry a “civilized” nation. Despite the its popularity of the contest across LatinAmerica, this program that strengthened the image of the “ideal baby” as one of the mainelements in the construction of the nation-state has not yet been studied in detail. Asa transnational strategy, it was widely discussed and advised in several pan-Americancongresses and conferences such as the Pan American Sanitary Conferences, the PanAmerican Child Congresses, and the Pan American Conferences on Eugenics andHomiculture.El Tiempo on thecontest held on October 12, 1937, and a report written by Doctor Benjamín Otálora,Vice-Director of the Second Division of the National Department of Hygiene.In investigating the HCC in Colombia, this article draws on The modern notion of childhood as a social category distinct from adulthood with itsown characteristics began to take shape in the seventeenth and eighteenth centuries.The concept of “infant grace” that emerged during this period transformed childhoodinto something that needed to be protected and educated , p.487. The high rates of infant and child mortality in Western Europe and Latin America inthe late nineteenth century demanded the implementation of socio-medical programs inresponse. Even though high mortality had been systematic throughout the century, thenew view of childhood and the engagement of the medical community  gave this problem a collective dimension rather than simply the sum ofindividual cases , p.121.Puericulture – the “art of cultivating children,” a concept coined by the Frenchphysician Alfred Caron in 1865 and later popularized worldwide by the French doctorAdolphe Pinard (1844-1934) – was undoubtedly one of the most popular medico-socialprograms that not only reaffirmed the triumph of medicine and public health overchild mortality as avoidable ,p.45, bLa Puériculture du premierâge in 1904 teaching mothers how to protect their babies from harmfulexternal influences so they could be clean, avoid extreme temperatures, reduce therisk of falls or trauma, how to feed them so they would not die of malnourishment,how to look after them if they fell ill, and to avoid diseases by keepingvaccinations up-to-date .The notion of contests to select healthy children did not take long to spreadthroughout the western world along with other programs to protect childhood andfight child mortality. Thanks to the establishment of transnational scientificnetworks and the multiplication of international meetings of experts interested inchild welfare , transnational social knowledge wasdeveloped on this new social category and medico-social programs like these contestswere organized in different countries across the Americas. The initial contests wereheld mainly in large cities in countries including Cuba, Mexico, and Venezuela asearly as the 1910s , p.128.Although child mortality was the original motivation for the HCC, the circulation ofpopulation degeneration theories, associated with race and poverty and the surge ofeugenics in the 1920s and 1930s, gave the contest new impetus. Indeed, interest inthe physical, physiological, and mental dimensions of childhood increased whenracial degeneration theories ramped up during the early twentieth century anddesignated child morbidity and mortality as signs of this alleged degeneration.Eugenics elevated childhood as a social category to a higher level and consequentlymade it an object of public policies. Because physical and mental “defects” werelikely to be transmitted from one generation to the next, doctors and hygienistsfocused their attention on the welfare of children even prior to procreation.Childhood was considered the stage in human evolution that could be most easilyshaped by biology because of the “malleability” present during this phase . From this point, consequently, quantityand “quality” were important in the crusade for child protection, with competitionslike the HCC as proof.In a region dominated by a neo-Lamarckian, preventive interpretation of eugenics  , p.151,The idea of “preserving the race” through child protection solidified with eachcongress on children as eugenic discourse strengthened throughout the 1920s and the1930s. For instance, the Fifth Pan American Child Congress, which took place inHavana in 1927, advised governments in the Americas to “bear in mind that the futureof the human species, with regards to its existence and ultimate progress, demandsnot to prevent individuals from procreating and to provide the child with thegreatest pains both in terms of education and positive applications of the medicalscience” . Within this scope, the Baby Exhibitions and Motherhood Prizes programs weretransformed into the Motherhood, Homiculture, and Eugenic Fertility Contest in the1920s. This competition was held until 1936, with a broader age range forparticipating children and rewards for marriages that produced more than tenchildren. According to the Comptroller to the Nation, Doctor Aurelio Méndez, thecontest would save millions of lives from “physical and mental degenerations” as itencouraged mothers to learn how to raise their children, thus arming them withphysiological factors to help defend them from morbidity .Unsurprisingly, Cuba was the first Latin American country to incorporate eugenicideas into its health child competition. Not only was it among the first nations tofocus its efforts on child protection, as mentioned above, but it was also the firstto institutionalize eugenics with the foundation of the Homiculture League in 1910, p.480.El Universal published an article announcing the winnersof the local Healthy Working-Class Baby Contest held on April 27, 1923, it specifiedthat the first prize winner was 6-month-old Agustín Arellano, whose parents “livedin extreme poverty.” His mother had “followed the rules given at the Child HygieneCenter” and produced a “charming” child with no signs of disease .The child contests also incorporated a racial slant. Anne Shelby Blum noted that eventhough the description of the Healthiest Baby Contest in Mexico suggested that theentire population was eligible and that the criteria for evaluating health mighthave been transparent, the judges favored babies with European features . The racial element was closely intertwined with socioeconomic class. Localauthorities targeted poor urban families who managed to raise healthy children inspite of their socioeconomic status, breastfeeding them and incorporating thelessons in puericulture taught at various local health departments. When the Mexicannewspaper Targeting the low and working classes seemed natural, since poverty and thispopulation’s “deplorable conditions” could put the social system at risk . Although these social classes were victims ofdisproportionate urbanization and ruthless capitalism, they were considered to causetheir own misery due to their depraved morals and vicious social behaviors . Hereditary theories and eugenics which“scientifically” proved that these social diseases could be passed from onegeneration to the next urged even more political and scientific circles to focustheir medico-social programs on this population, especially their children. Sincethey were the future of the nation, it was essential to stop them from acquiring“racial poisons” . The administration focused on public hygiene and education in order to“regenerate the population” and lift it out of its “cultural savagery” and“backwardness.” This socio-political approach that made state intervention in socialmatters more essential did not replace the “medical strategy;” this strategy, whichpredominated during the two previous decades, sought to “reinvigorate the nation’sbiological tissue as the population was seen in terms of race” , in 1931 and 1932, respectively. This section became more autonomouswhen it was transformed into the Child and Maternal Department in 1939 as an effortto disseminate the notions of puericulture nationwide. Within this context, theexecutive branch enacted three decrees related to the HCC in 1937, 1939, and1943.Although the contest became official in the mid-1930s, it had already caught theattention of physicians in the early 1920s as a strategy to reduce infant mortalityand halt the presumed biological degeneration affecting the population.As part of the international child welfare campaign that emerged in the 1920s thatintertwined socio-medical and educational programs, racial ideologies, hereditaryand biological theories, and eugenics for racial betterment, Colombia was notoblivious to this ideological climate. The Colombian government and medicalcommunity implemented various medico-social programs and approved legislation inline with the projects discussed in specialized Pan American conferences . Although childprotection was included in programs by several Colombian administrations since theend of the nineteenth century , p.110, Two factors were responsible for this vivid interest in child protection. First, thestate and the medical community became responsible for the welfare of thepopulation, including children; up to that time the Catholic Church had controlledsocial assistance see . Second The problem gained public attention when a series of talks organized by the BogotáStudent Assembly entitled “Problems of Race in Colombia” featured six Colombianexperts to explain the causes of degeneration of the “Colombian race” and thepossibilities to reverse this unfortunate process. The speakers described causesranging from hereditary biological determinism to environmental effects thatincluded government negligence see . One, JoChild mortality was one of Bejarano’s  greatest concerns; he alluded tothe “maternity prize” as a mechanism to expand and improve the Colombian population.This mention came during his second speech, in which addressed the high mortalityrate at the Bogotá Orphanage. He accused the institution of contributing to the“degeneration of population” by letting 250 of 1,000 children die every year. In hisopinion, these deaths were the result of appalling hygienic conditions at thefacility and care provided by “repulsive and deprived childminders” who looked afterchildren in their homes just to make money . As referencesin order to increase and “regenerate” the population, Bejarano referred to France,Germany, and the United States, where political and medical authorities had foundedinstitutions and implemented projects to stimulate good childrearing. One suchproject involved prizes that encouraged mothers to “raise and take care of theirchildren” (p.223).Considerations on La Goutte de Lait, in 1920, alsomentioned maternal awards in his work. Because child mortality was a sign of racialdegeneration, according to Luis-Enrique Pardo Calderón, a Colombian doctor who defended his doctoraldissertation, The founding of the Colombian HCC was not only a moral obligation in favor ofchildhood but also a “patriotic” duty. Indeed, a “healthy and well-fed childrepresents the nation’s [human] capital and fundamental culture whose cornerstone isthe race’s good psycho-physical state. The highest human civilizations …, in whichthe child was at the heart of their public policies, are testament to progress anddevelopment” , p.1. ThThe NDH was authorized by government decree to organize this event; the decree alsourged all welfare institutions under this department to “reinstate the NationalHealthy Child Contest,” which was to be held every year (Articles 1 and 6). Itestablished three awards according to the age: best breastfed baby (up to two yearsof age), best preschooler (ages two to six), and best school-aged child (ages six totwelve). While the main target was early childhood, the contest covered all ofchildhood up to puberty. By awarding the winning families money or property, the government was alsotrying to build an image of a welfare state that cared for its population,especially children, in order to ensure the future of the nation. In fact, the ChildCongresses held from 1916 to 1942, which highlighted an active government rolethrough re-education, healthcare for children, and the creation of child tribunalsand other institutions in charge of children’s needs  award the children and their families with 100 Colombian pesos (COP) thatshould be divided among the three categories” (Articles 3 and 4). The directors ofthe local child welfare services were tasked with increasing the prize budget to“arouse mothers’ interest in preserving their children’s physical, mental, and moralhealth” (Article 4).’s needs , p.274, On July 28, 1937, NDH director Benigno Velasco Cabrera (1937) published the generalrules for the contest. In addition to the specifics established in the decreementioned above, these regulations described the desired characteristics of thecontest participants in detail:[the child must] a) be enrolled in a ‘Healthy Child Office’ recognized by thenational child welfare entities; b) have been exclusively breastfed until theage of six months; c) be vaccinated against smallpox; d) have no signs ofhereditary defects; e) have psycho-physical development in line with his/her‘normal physiological’ development inherent to the age  have no any organic defects;g) and have personal hygienic habits and [dwell] in a hygienic household.These regulations clearly targeted the type of child desired by the governmentaccording to eugenic, hygienic, and sociobiological principles. This selection ofchildren with the desired physical and moral features proved that even if thecountry’s political and intellectual elites desired to “civilize” the nation viahygiene and education, a hereditary and biological component remained crucial inthis undertaking.The Second Division of the NDH was charged in the 1937 decree with setting the datefor the contest: October 12. According to its Vice-Director, Benjamín Otálora, thechoice “harmonized symbolically with Columbus Day”  , p.2. Th The contest in Bogotá had strong support from Colombia’s First Lady, MaríaMichelsen de López, and the city government, which allocated COP $500 for the awardsand other expenses. It was thoroughly covered by the press, especially the nationalnewspaper El Tiempo; this is no surprise, since its founder anddirector Eduardo Santos (future president of Colombia from 1938 to 1942) was aLiberal partisan. In a series of five articles published between October 2 and 12,El Tiempo documented the contest process and featured someillustrations that showed not only the physical condition of the winning children,but also the engagement of the executive branch (via the First Lady).On October 12, 1937, the national HCC was held in 33 cities, including Bogotá., El Tiempo announced the winners from the finalselection that had taken place the day before at the presidential palace. The sixchildren selected in the first eliminatory round represented the six nurseriesoperating in the capital. Betulia Toledo, an 8-month-old baby, was declared thewinner of the contest; according to the article, the girl “met the requirements of aperfect creature” . Her family was given a COP $50mortgage bond and a certificate. The four runners-up each received a COP $25mortgage bond, and the official award ceremony was held at the Chapinero nursery onOctober 12.On October 9El Tiempo that reported other “successfulexperiences” with HCCs held in medium-sized cities like Ibagué (Tolima), Popayán(Cauca), and Tunja (Boyacá). Organized by the Sanitary Unit in each city, thesecontests were described in the articles as quite successful considering the largenumber of families, mainly from “humble backgrounds,” who participated in thecontest .Although Otálora reported some difficulties in some cities (without going intodetail), he described the contest as exceeding all expectations. This was supportedby several articles in  This initiative would catalyze interest in protecting and caring forchildren, especially in the countryside. The government drive to implement thecontest in the countryside was part of its ambition to “sanitize and educate” therural population in a country that was mostly agrarian in the 1930s, with a lack ofproper sanitary facilities and hygienic habits that was seen as an obstacle tomodernization , and would also attract peasant as well asurban families. He went on to say that a farm with all the modern sanitaryfacilities could be given to families with a father working in the countryside, anda small house to working-class families in town (p.13). By engaging the privatesector, the “rich,” and the Departmental Assembly, the Second Division could alsoconsider a contest within the department that brought together the winners in each town.nization . It alsoThe Colombian national HCC reached its strongest momentum when the Child and MaternalDepartment took over its organization. According to Decree 378 of 1939:The Director of the Department will lead a permanent campaign [in favor of childprotection] in the institutions attached to it. The campaign will teach theprinciples of hygiene and child nutrition, as well as other conditions that mayhave an impact on the child’s health and welfare. To do so, the Department willcarry out an inspection of publications, advertising posters, magazines etc.,edited by the Ministry, and will organize permanent and itinerary exhibitions onpuericulture, Weeks of the Child, Healthy Child Contests, talks, filmadvertisements etc. .Integralhygiene and child nutrition, puericulture was described as an essentialelement of eugenics in order to stop the passage of hereditary defects to offspring lent an eugenic dimension to the contest, like many othersocio-medical programs, since it would help to avoid the transmission of hereditarydefaults (dysgenic elements) resulting from malnutrition in mothers and children. Ina 1940 manual edited by Pedraza and Gamboa Echandía entitled In 1943, Colombia’s President Darío Echandía and Minister of Labor, Hygiene, andSocial Assistance Jorge-Eliécer Gaitán revoked Decree 1201 of 1937, which regulatedthe HCC. Its replacement, Decree 2341 of 1943, defined that the national winnerwould be chosen nationwide according to guidelines defined by the ministry . The award – a home – would be given to the mother,childminder, or governess if she could demonstrate that the winning child had beentaken to the Healthy Child Office during a two-year period and that the family hadfollowed the hygienic guidelines to beyond reproach; periodic house calls by avisiting nurse or any other sanitary authority would validate that the family indeedmet the requirements . The decree also emphasized theimportance of teaching the principles of puericulture to mothers as a mechanism topreserve childhood.Colombia’s national HCC remained another “prophylactic and educational” mechanism tocontrol social health by interfering in families’ private lives in order to create anational identity and define what Catalina Muñoz has called “Colombianness.” Thecontest demonstrates the Liberal Republic’s will to “civilize” the population byimplementing health programs focusing on children. Instead of replacing thebiological approach that prevailed during the first two decades of the twentiethcentury, this state interventionism came to complement it. The idea of a“degenerated race” from a biological perspective, which could be generated viamedical-social programs to protect future generations, gained traction in the 1930sthrough the rise of eugenics. The fact that the eugenic principles were implementedby means of puericulture revealed that the Colombian experts applied a “preventive”and “persuasive” eugenic modality  that favored the interests of various groupsranging from the most conservative to the most liberal factions, and especially theCatholic church.From a transnational perspective, the HCC shows that Colombian socio-medical programswere in line with those of other countries and discussed at various specializedmeetings including the Pan American Sanitary Conferences, Pan American ChildCongresses, and Pan American Conferences of Eugenics and Homiculture. These programssought to protect childhood and, by extension, protect the biological component ofthe population which was essential for the future of the nation.


A randomised trial of European Fans in Training (EuroFIT), a 12-week healthy lifestyle program delivered in 15 professional football clubs in the Netherlands, Norway, Portugal, and the United Kingdom, successfully increased physical activity and improved diet but did not reduce sedentary time. To guide future implementation, this paper investigates how those effects were achieved. We ask: 1) how was EuroFIT implemented? 2) what were the processes through which outcomes were achieved?We analysed qualitative data implementation notes, observations of 29 of 180 weekly EuroFIT deliveries, semi-structured interviews with 16 coaches and 15 club representatives, and 30 focus group discussions with participants (15 post-program and 15 after 12 months). We descriptively analysed quantitative data on recruitment, attendance at sessions and logs of use of the technologies and survey data on the views of participants at baseline, post program and after 12 months. We used a triangulation protocol to investigate agreement between data from difference sources, organised around meeting 15 objectives within the two research questions.We successfully recruited clubs, coaches and men to EuroFIT though the draw of the football club seemed stronger in the UK and Portugal. Advertising that emphasized getting fitter, club-based deliveries, and not ‘standing out’ worked and attendance and fidelity were good, so that coaches in all countries were able to deliver EuroFIT flexibly as intended. Coaches in all 15 clubs facilitated the use of behaviour change techniques and interaction between men, which together enhanced motivation. Participants found it harder to change sedentary time than physical activity and diet. Fitting changes into daily routines, planning for setbacks and recognising the personal benefit of behaviour change were important to maintain changes. Bespoke technologies were valued, but technological hitches frustrated participants.EuroFIT was delivered as planned by trained club coaches working flexibly in all countries. It worked as expected to attract men and support initiation and maintenance of changes in physical activity and diet but the use of bespoke, unstable, technologies was frustrating. Future deliveries should eliminate the focus on sedentary time and should use only proven technologies to support self-monitoring and social interaction.ISRCTN81935608, registered 16/06/2015.The online version contains supplementary material available at 10.1186/s12889-023-15419-y. Low levels of physical activity and high levels spent in sedentary time are contributing to the increasing global prevalence of non-communicable diseases such as cardiovascular disease, type 2 diabetes and some cancers,  and innoOne approach to attracting men to lifestyle change is to offer programs in partnership with professional sports clubs, which is expected to attract men through the draw of the football club. –8 The fiOne adaptation of FFIT was the European Fans in Training (EuroFIT) program . EuroFITBefore recommending the widespread roll-out of EuroFIT, we wanted to investigate in more detail how it was implemented and whether it worked as we expected it to do. We thought this more detailed information could support future deliveries and add insight into how lifestyle change programs delivered in professional sports settings can work to both attract men and enable positive public health outcomes. Thus the aim of this paper is to examine the process through which EuroFIT achieved its effects. We do this by reporting a mixed-method process evaluation  designedBefore describing our methods, we outline the EuroFIT program and the theories underpinning it .The EuroFIT program was designed to support men to: become more physically active and less sedentary; improve their diets; and maintain these changes over the long term. It was delivered over 12, weekly, 90-min sessions that combined ‘classroom’ discussion, including ‘tools’ for behaviour change, with group-based physical activity. All sessions were led by football club community coaches. Full details of EuroFIT are published including a description of the program in the TIDieR template  and a suRelational, physical and financial resources are needed to implement EuroFIT, including professional football clubs with sufficient commitment to try delivering the program and to recruit coaches willing to take part in training. The program also requires access to club facilities and materials for the program, and funding to pay for materials such as manuals and t-shirts Fig. . FundingEuroFIT drew on theories derived from various schools of thought in psychology and sociology. From psychology, EuroFIT drew explicitly on contemporary theories of motivation specifically, self-determination theory  and achiwith and not against them. For example, we expected that EuroFIT would attract men because it was male-only and based in professional football clubs, a context which is recognised as symbolically valuable to many men , about the size of a matchbox, to self-monitor their daily step count  and time spent upright (for sedentary behaviour) , 25. TheFor the duration of the research, the country-based research teams provided implementation support for football clubs. This included funding to deliver the program, guidance on recruiting participants, provision of detailed manuals for coaches, a two-day training program for club coaches and support for trouble shooting problems during delivery. Full details of the implementation process and support offered to clubs are already published .The mixed methods process evaluation reported here was embedded in the EuroFIT RCT  “I liked the fact that we received a lot of relevant information. It gave me the confidence I needed. I wouldn’t have been the same with a manual only. I liked having the information up front, so I felt I knew what I was saying. It was good. Was positive. A good combination of theory and practice.” Analysis of interview data showed that coaches were generally positive about the training they received and felt it prepared them to use the tools they needed to be able to deliver the EuroFIT program. For example, one said:However, analysis of study implementation notes showed a high turnover of coaching staff at some clubs in the UK with some of the coaches originally trained to deliver to program leaving their posts before delivery or part-way through the program. As a result, the research team had to develop bespoke interim training (which took one instead of two days) for new UK-based coaches.In relation to the theory of change, the relational resources described as necessary for program delivery, were available in all countries, as were the financial resources (because they were covered by the research grant). We recruited clubs through professional networks, although additional efforts were needed to replace clubs that dropped out of the study in the Netherlands and Norway. program .Attracting men to theDo you want to become more active with [club name]? “and explained that “EuroFIT aims to help you increase your physical activity levels and to be less sedentary. The program will offer you a toolbox of skills and techniques for living a healthy life and a chance to get fitter and feel better in yourself.” Materials also highlighted that the program would be interactive, led by club coaches, and that they would be with like-minded people, saying; “Each session includes physical activity led by [CLUB] coaches at [YOUR STADIUM/TRAINING GROUND] as well as focusing on how to incorporate new skills and techniques into your everyday life. The sessions will also offer you the opportunity to meet like-minded people and share tips and advice.”To recruit participants, football clubs e-mailed invitations to fans and used club websites, social media posts, features in the local press, and match-day leafleting/announcements to advertise the program . RecruitN = 80), with the Portuguese clubs attracting particularly high levels of interest.Data from expressions of interest forms showed that advertisements proved attractive to men wanting to join the program particularly in the UK and Portugal. The mean number of men per club expressing an interest in joining was 200.2 (155–272) in the UK, 121.0 (87–187) in the Netherlands, 155.3 (128–205) in Norway, and 441.0 (333–616) in Portugal. In every club, expressions of interest exceeded the number of places available .Participation in the EuroFITCoach-reported mean attendance at the 12 EuroFIT sessions was comparable across the four countries: 8.7 sessions (SD 3.3) out of 12 sessions in the UK, 9.8 (SD 2.5) in the Netherlands, 8.1 (SD 3.0) in Norway and 8.7 (SD 3.2) in Portugal. Analysis of post program questionnaires showed, as reported previously . I looked at the group and knew they would not be interested in these glasses and discussing how many lumps of sugar would be in them, well you know. This pouring, it doesn’t fit with this group.” [C-NL1-INT]As reported previously,  fidelityIn relation to the theory of change, we presumed that fidelity in delivery would be important to initiate and maintain change and thus to achieve outcomes. Based on the analysis we can say that the program was largely delivered as intended because most of the key elements were delivered in the observed sessions and coaches described situations in which they were adapted the content to deliver flexibly as intended. 8, Table  theory of change – attract men).Participants’ reported reasons for joining, continuing with or opting out of the EuroFIT program  and Portugal (46.8%), than in the Netherlands (24.3%) and Norway (26.2%). This did not resonate with the post-program focus groups, which all mentioned the importance of the club as a draw. For example, in the Netherlands, one man explained how getting privileged access to valued parts of their club attracted him:P6:Meet similar people as well.I:Yeah.P6:The same age group, same interests and, you know, perhaps eating too many beefburgers and having too many pints [of beer], um, being able to relate and move forward together as a group. [P-UK5-PPFGD].In the baseline questionnaires, participants in Norway (46.9%) and the UK (34.7%) were more likely to report that being with men ‘like them’ was a reason for joining than participants in the Netherlands (12.9%) and Portugal (15.0%). Again, there was some dissonance between questionnaire and focus group data, with examples of wanting to be with men ‘like them’ emerging in focus groups in the UK, Netherlands, and Portugal. For example, in a post program discussion in one UK club, participants agreed why they were attracted to EuroFIT:I was thinking about that actually …. That it was only men [–-] If there had been women I wouldn’t have joined.’ [P-NL3-PPFGD]. In Portugal too, one man suggested: ‘I liked the idea of being with other men of my age and condition’ [P-PT1-PFGD].In the Netherlands, the importance of the program being men only was emphasised: ‘In relation to the theory of change, the assumption of multiple motivations for joining the program proved correct, with men in all countries commonly citing 'weight loss', 'desire to improve lifestyle' and 'getting fitter' as reasons to join and there was agreement between data sets .The coach then asks: “Have you guys been to the match?” “Yes,” said one of the men, “it was spectacular.” “I know right?” said the coach, “I saw you there!” “Yes, 4–3 hey?!”’ (OBS-NL1)We expected that interactions between men, and between coaches and men, would be important for group cohesion and success. The theory of change Fig.  suggesteThe way coaches valued participants was also made evident through ‘grand gestures.’ For example, in one club in the UK, a coach gave a teddy bear to a man who had just had a child. Participants in all four countries also commented on these exchanges and the welcoming nature of coaches Men’s enjoyment of the program was evidenced by observations that men’s interactions were often interspersed with jokes and banter, which contributed to the supportive environment, the fostering of relatedness and enjoyment of sessions. For example, observation of a physical activity session in the Netherlands recorded:In summary, in relation to the theory of change, the observations of sessions confirmed the assumptions we made about the importance of positive interactions in delivering outcomes .Our theory of change made the coaches’ role explicit only in relation to how they interacted with men and how they encouraged interactions. Implicit to the theory of change, however, is that coaches, through following the program manual and being well prepared for sessions, would be crucial in providing an excellent motivational environment to support change  which inThe coach manual was very handy. It was really nice to have these clear instructions” [C-NL4-INT].In interviews, coaches in all countries reported that they found the manual essential for delivering the program. For example, a coach in the Netherlands said: “Along with the other tools, then the SMART-goals have also been very good indeed, and those you link with the SitFIT and MatchFIT, and that is like, that you get to link those tools together has been a very good method [C-NOR2-INT]There was agreement between the observations and interviews that coaches did teach participants how to use of the ‘toolbox’ of BCTs. For example, a coach in Norway said: [training emphasised] you need to do that, erm, which, which definitely is good advice. Erm, so yeah, I think goal setting is very important. The guys did stick to it. [C-UK1-INT]Sometimes, the guys trying to make big targets, we'd try and calm them down. Which, again, theMany of the coaches played an important role in the repetition and practice of BCTs, and prompted men to set optimal challenges for themselves, building on their own progress, as one coach from the UK explained:“I think they also found it difficult, like how to choose something [a SMART goal] that is specific enough and that I can potentially accomplish.” [C-NL2-INT]However, other coach interviews showed that it could be hard to explain goal setting to participants, as one Dutch coach explained:“.. so at a certain moment, some of the men – not all of them—would go like ‘Yeah, I know by now!’ and they no longer felt like evaluating progress over and over again.” [C-NL4-INT]The repetition of goal setting each week could be experienced as boring, as a coach from another Dutch club explained, suggesting that goal setting may be important in initiating but not maintaining changes:I like very much that they [participants] set their own goals and that we get to choose the tools we need ourselves. We try, we give them many options to take those tools that fit into their everyday life and that we do not say that so and so and so, and if you do not do this, you fail. That you, that we make them aware, and that making your own choices is done every day, that we take those choices unconsciously in a way. [C-NOR2-INT]Coaches clearly understood that their role was to facilitate change having created an enabling motivational environment and taught the flexible use of BCTs. This is illustrated by an extract from a coach in Norway, who said:Consistent with our theory of change, analysis of observations of sessions and interviews with coaches confirmed that coaches used the manual as expected, creating an enabling environment for behaviour change by teaching BCTs. program and materials .Participants’ views and experiences of the EuroFITI think the great thing about the program was that it wasn't, you [didn’t have to] to make a massive amount of effort to make an improvement. It was small improvements, and you could measure them. And so, what I think was a great thing was that you learned about walking a little bit more, standing up a little bit more, just doing incremental things made you fitter. [P-UK1-PPFGD]As we have seen, our theory of change placed explicit emphasis on learning to use a ‘toolbox’ of BCTs to promote an agency- and competency-based approach to initiating and maintaining changes in physical activity, sedentary and dietary behaviours. Specifically, the ‘toolbox’ focused on: goal setting, problem solving, action planning, self-monitoring of behaviour and outcomes, and social support. Data from focus groups showed that, in all four countries, men engaged with the toolbox of BCTs. For example:Responses to post-program questionnaires supported these findings, with participants reporting high levels of engagement with SitFIT (self-monitoring) devices, SMART goal setting, planning for making cumulative small changes to their everyday lives and seeking social support see Fig. .Fig. 3Sep < 0·001) over and above the baseline average of 8,372 steps/day  to track my routines and progress regarding my almost daily walks and runs and my weight. I really like to fulfil it and think of ways to upgrade it… I put time, intensity [into it]… look (Participant shows interviewers some printed files)’ [P -POR2-PPFGD]Objective measurements of physical activity indicated that after completing EuroFIT, on average, men were walking an additional 1208 steps/day . Across the four countries, participants commonly reported routinely using their SitFIT for monitoring their physical activity, as this interaction from a post program focus group in the UK demonstrates:I think the thing as well that I noticed was I’d look at it and if it’d have, like our average would be like eighteen thousand steps, I’d look at it and go, I’m only on sixteen thousand, if I put mine, it’ll bring everybody down […] I felt bad if I plugged it in and then…then the [MatchFIT average] figure was less after I plugged in. [P-UK3-PPFGD]As described, we developed the SitFIT (and some aspects of the MatchFIT app) to support self-monitoring. Whilst most felt positive about the SitFIT and in some cases found sharing their steps either through MatchFIT, Facebook or WhatsApp motivating, one man in the UK described how he felt that sharing his steps on MatchFIT might let the other men in his group down if he had not achieved what he had hoped (men in this group were taking a lot of steps each day):While men spoke positively about the SitFIT, they also described challenges using the device. These were practical , technical  or mechanical .P5:I’ll look at it [upright time on SitFIT] and I’ll see what it is but I don’t kind of work towards it, do you know what I mean?P2:No.P4:It’s not…you can’t really quantify what you’re doing so…[UK3-PPFGD].While self-monitoring appeared to be a useful BCT for increasing physical activity (steps), men reported that they found decreasing their sedentary time more difficult. Post-program focus group data program suggested that, while participants internalised the message to stand more, they found it harder to use self-monitoring and goal setting to change their sitting behaviour:As part of the toolbox, EuroFIT aimed to encourage social support and relatedness through peer interaction. Participants responded well to encouragement to use social media for social support outside of EuroFIT sessions, using both WhatsApp and Facebook to support one another to be active, both during the program and up to 12 months afterwards .Another way that men were encouraged to engage with EuroFIT between sessions was through the MatchFIT app. As measured by server log data, the overall uptake (participants creating an account and using the app at least once) of MatchFIT across all countries was 63.5%. Uptake varied significantly across countries: in the UK it was 37.2%, in the Netherlands 65.2%, in Norway 78.7%, and in Portugal 82.8%. MatchFIT was introduced in week 4 of the program. About half of those who registered had stopped using the app by week 10, and, by week 12, only a third were still using it. Qualitative data from participants suggested that, while the idea of MatchFIT was appealing in all countries, particularly in the Netherlands, the practical challenges of connecting the SitFIT and uploading data limited wider engagement  and that this was consistent across countries. Self-monitoring through the SitFIT worked well, although this was less successful for sedentary behaviour than for walking and men found making changes to sedentary behaviour difficult. The motivation strategies were effective, self-referenced goal setting enabled small cumulative changes in physical activity, and relatedness through social support was important for embedding change and MatchFIT demonstrated potential to encourage interaction in between sessions but technical difficulties uploading data made its use frustrating. changes and what was helpful in maintaining change .Participants’ experiences of maintaining (or not) any lifestyle [news]paper in the morning and stuff like that, and I’ve kept it going and it’s just because it gave me the push that I needed, basically. [P-UK4-12MFGD]I’ve got to enjoy it, my routine of walking around for theEuroFIT was designed to support men to make changes that they would be able to sustain beyond its 12-week delivery. As noted above, practising BCTs was helpful to participants in initiating and maintaining changes through the program, and men were encouraged to make small changes that could be accommodated within their daily routines. In the 12-month questionnaire, 71% of the intervention group said they became more active by making small changes to everyday life ‘often’ or ‘a great deal’. Focus group data from all countries confirmed this, with examples such as the following offered by participants:“I don't make an effort… this new way of behaving is like the normal me.” [P-POR3-12MFGD].The same pattern of convergence between qualitative and quantitative data was observed in relation to the routinisation of dietary changes, in all countries. Some described such routinisation in very direct terms e.g., At my home I think at least that previously when I confidently sat in the favourite chair with the remote control, then I think it is much nicer to see myself confident where I am active and that you do something with yourself to be more present at home both energy-wise and with the kids and, yeah – day-to-day stuff, really [P-NOR1-12MFGD]Our theory of change Fig.  suggestep = 0·008), but that this reduction was not maintained at 12 months .We have reported elsewhere that EuroFIT participants, on average, reduced their sedentary time post-program (i.e. at 12 week measures) by an estimated 14.4 min/day  and this made it hard to maintain their activity levels. They missed the group, the people and the weekly sessions they had together, and said that these things would have made it easier to maintain the activity long term. As one said ‘The mile is long if you are by yourself’ [In summary, men’s experience of the program suggests it largely worked as described by the theory of change, at least for those who maintained change – in that they recognised the personal benefits brought by relatively small, but cumulative, routinised, lifestyle changes, although not everyone had been able to keep those up. There was also evidence that men had learnt to avoid setbacks and plan for difficult encounters, although again not all participants were able to do this because of illness or other life events. Groups formed to continue exercise after the program were highly valued where they happened and were seen as motivational but, in their absence, as in Norway, it was harder to motivate ongoing physical activity.Our analysis shows that EuroFIT was largely implemented as planned in professional football clubs in four countries, that coaches delivered the program as intended and that the program worked largely as expected for participants.The research project paid for deliveries of EuroFIT within the trial context which facilitated recruitment of professional football clubs to deliver the program, although the fact that we had to identify additional clubs when three dropped out, suggests that it might be more difficult to recruit clubs if funding for deliveries was not readily available. Coaches responded well to the training provided in EuroFIT session delivery, although high turnover of staff was a problem in some clubs. Recruitment strategies proved successful in all countries, but especially Portugal and the UK and it is possible that the ‘draw’ of the football club was not so clear amongst men in the Netherlands and Norway. The UK has a long history of community development activity in professional football clubs , so footAttendance at program sessions, e assumed would be necessary to initiate change, was good. Fidelity, assumed necessary for successful outcomes, was also good; and coaches responded flexibly to participants’ perceived needs, a feature of the program we think it essential to retain in subsequent implementation . InteracEuroFIT was one of the first studies to deliberately engage motivation theory behaviour change strategies into the protocol. From both self-determination and achievement goal theories, we incorporated BCTs associated with autonomy, relatedness, competence, mastery and self-referenced goal strategies and coaches were very successful in using those strategies to foster behaviour change. Self-monitoring using the SitFIT and the setting of self-referenced goals were seen as particularly important by participants and coaches and reinforcement of BCTs was also important to maintain changes through the program. MatchFIT, on the other hand, did not seem to play an active role in encouraging maintenance of behaviour change in most countries, perhaps because of the technical difficulties encountered in its use, and unlike in the FFIT program few narrEuroFIT was not successful in supporting men to make long-term improvements to their sedentary behaviour. While there is good evidence for different approaches to, and the benefits of, becoming more active , less isThat said, the mechanisms through which changes in physical activity were likely produced – i.e. goal setting, self-monitoring, action planning, social support and problem solving – are consistent with both the theory of change and with literature relating to behaviour change for physical activity in men . In thisA novel feature of EuroFIT was its use of bespoke technologies. The SitFIT activity tracker  was wideOur study suggests that it is possible to implement EuroFIT in different club settings. It also indicates ways in which clubs tailor EuroFIT to their own contexts and characteristics. Future research and practice relating to the delivery of health interventions in professional sports settings should ensure programs are designed with flexibility in mind, to ensure that variations in resource availability do not present barriers to implementation, although the key elements of how the program functions should be maintained. Given the significant public health benefits that have been demonstrated by such interventions , 10, 41,A final point of discussion raised by our study relates to harnessing the appeal of professional sports club settings and in being with other like them to attract participants to health interventions. As we have reported, our findings generally support the body of literature which argues that professional sports club settings are a powerful motivator for intervention participants, and perhaps particularly men , 45, 46.A major strength of this study is that it analysed data from four countries, in fifteen club settings, and derived the findings from a large body of data collected through multiple methods, allowing for triangulation across data sources. The study also deliberately employed behaviour change strategies informed by contemporary motivation theories. These strengths and the findings from the study underpin our confidence in the utility of the EuroFIT theory of change as a representation of the program’s mechanisms of action for men in the four countries studied. A limitation is that although we went to considerable efforts to standardise qualitative data collection and analysis across countries it was conducted by multiple teams, with varying levels of experience, in four different languages. The research team which produced the convergence matrix had limited ability to go back to original sources to check interpretations for themselves. This was mitigated through extensive cross-country dialogue, but remains a shortcoming that is faced in all cross-cultural work in which all analysts are not poly-lingual .and sedentary time may have led participants to select the behaviour they found most easy to grasp and alter ; that bespoke technologies can be complex to implement and bespoke social support platforms may have low take up; and that the appeal of the club as a site for health-related change may be culturally-mediated. Future deliveries should consider whether the distinction between decreasing sedentary behaviour and increasing physical activity is worth pursuing, should use easily available technologies to support self-monitoring and social interaction and how different forms of football fandom can be exploited to attract participants.This paper has explored the processes through which EuroFIT achieved its outcomes and the extent to which the underpinning theory of change represented the program’s mechanisms of action. Through a mixed-methods approach, we have concluded that the theory of change is an effective representation of the EuroFIT program, with only three small areas of ambiguity. In relation to this latter point, we have suggested: that the dual focus on changing physical activity Additional file 1.


To evaluate the impact of a new Substance Use Disorder (SUD) education program on medical students’ attitudes, we selected the Substance Abuse Attitude Survey (SAAS) questionnaire, which we adapted to our curriculum and cultural context. To validate this adapted version, we conducted an exploratory factor analysis following the administration of our 29-item bSAAS questionnaire to 657 medical students in Belgium (response rate: 71.1%). Twenty-three items correlated to three factors; namely, “Stereotypes and moralism”, “Treatment optimism” and “Specialized treatment” were retained  and constituted the new questionnaire called beSAAS. The factor “Specialized treatment” stood out from previous studies, which could be explained by our target population and the impact of the formal, informal and hidden curricula in medical education. This study was able to highlight certain factors influencing stereotypical representations such as age, gender, origin, personal or professional experience with substance use. Our study allowed us to retain the beSAAS as a good questionnaire to evaluate SUD stigma and highlighted interesting findings to improve SUD training in medicine. Further studies are needed to complete its validity and reliability. As part of the implementation of a new optional substance use disorder (SUD) training program for final year medical students, we wanted to assess its impact on students in terms of skills development . To evaluate the impact of the educational program on trainees’ representations and attitudinal skills development, we looked for a questionnaire to assess their attitudes towards SUD adapted to our criteria. Various instruments were found in the literature in French and English, but they had several limitations for our study. The first was that most of them focused on either illicit drugs or alcohol or perceptions about professional attitudes rather than about substance use itself  We wThe first objective of this study was to carry out an exploratory factor analysis of our bSAAS questionnaire in view of its adaptation to ensure its good internal consistency and structure. The second was to identify whether students’ representations were influenced by certain socio-demographic characteristics.The SAAS questionnaire validated widely by the literature consists of 50 items. For our study, we preferred its brief version, the Brief SAAS, which is used by the Yale School of Medicine to evaluate their SBIRT  training programs and that is limited to 25 items. We adapted it to the Belgian context through consultation with various experts . We removed the questions about marijuana experimentation among young people and Alcoholics Anonymous, which are less present in Belgium than in the U.S. We added a question on paramedical professionals, who are much more involved than para-professional counsellors in our context. After consensus, we split the questions on alcohol and drugs to be able to assess whether there were different attitudes according to the substances consumed. This resulted in a questionnaire with 29 items . We assuIn order to characterize our population and to better understand the factors favoring the students’ representations, we included several socio-demographic data ; data related to the personal and professional background linked to substance use; data related to the type of professional orientation ; as well as data related to the perception of their own health . This questionnaire, which was called “bSAAS” by our research team, has already been used in a previous study to evaluate the attitudes of medical students towards substance use in pregnancy and showed a good internal consistency  .The questionnaire was presented to 923 final-year medical students of three consecutive years . It was administered face-to-face to students in 2019 and online in 2020 and 2021 given the context of the SARS-CoV-2 crisis. A total of 657 students completed the questionnaire with an average response rate of 71.1%. Eighty students completed the questionnaire at the time of enrollment in the theoretical addictology course. For factor analysis, records with missing items were not considered. One or two items were missing in thirty-two (4.9%) and three to eleven items in ten (1.5%) questionnaires. On this basis, 615 (93.6%) questionnaires were retained.t-tests or one-way Analysis of Variance (ANOVA). Where appropriate, ANOVA was followed by multiple comparison tests with Bonferroni’s correction or a linear trend test. Cronbach’s alpha was calculated to measure the consistency of the 23 items included in the analysis as well as the consistency of the items selected for each factor separately. All analyses were performed with STATA SE v16.1 software.First, we analyzed the correlations between the 29 items and performed Bartlett’s test of sphericity to ensure that factor analysis was appropriate. The correlation coefficients were qualified as weak , moderate (between 0.31 and 0.50), good (0.51–0.74) and excellent (>0.75). The factor analysis was carried out in 3 steps and we decided to retain the factors with eigenvalues > 1 and with at least 3 items with a weighting >|0.40|, while keeping a sufficiently high % of variance explained (75%) ,19. Factp < 0.001). The Kaiser–Mayer–Olkin (KMO) measure was 0.71 and our sample including 615 subjects was large enough to perform factor analyses.The examination of the correlation matrix showed that several items were correlated with correlation coefficients ranging from r = 0.32 to r = 85. The Bartlett test was significant . This also enabled us to better define this factor with items correlated negatively and therefore opposed to optimism, such as the item “An alcoholic who has had several relapses is unlikely to be treated”.Factor III differed from the baseline studies ,10 and sConcerning the three dimensions or factors retained in our final analysis: “Stereotypes and moralism”, “Treatment optimism” and “Specialized treatment”, we separated them into two axes based on the three major learning domains conceptualized by Benjamin Bloom in 1956  and further developed thereafter ,21. On oIt is to be noted that the items dealing with the same content for drugs and alcohol had good or excellent correlations (r = 0.55–0.85).p = 0.037). The differences in the average score for “stereotypes and moralism” according to “subject-parent” origin were significant (p = 0.005); among people of non-European origin, we observed a higher average score than that of people of Belgian or Belgian–European origin. Subjects who did not consume any substance had a higher “Stereotypes and moralism” mean score than people who had consumed (only cannabis or multiple substances) but the differences were at the limit of statistical significance (p = 0.065). Conversely, the average score of those who had ever used cannabis was low. This was also the case for those who had been in contact with patients with SUD in specific centers  or who had enrolled in the optional SUD training, who differed significantly from the other respondents in having very low average scores on “Stereotypes and moralism”. There was no statistically significant difference in the average factorial I scores according to the perception of one’s own health and SUD in the environment. The same was true for the choice of specialty, although students who wanted to go into gynecology had a lower average score. There was no statistically significant difference in the mother’s level of education either, although for this last variable the average score was higher for those whose mother’s level of education was low. Secondly, we analyzed the factor scores according to the different socio-demographic data collected. There was a significant increase in the mean score for “Stereotypes and moralism” (Factor I) with age. This mean score was also statistically significantly higher for male respondents  across the different socio-demographic characteristics. This means that there was a tendency, independent of subject characteristics, to be optimistic towards treatment and possible interventions. However, the 23 respondents who had no contact with people with SUD at work showed a clear tendency towards low optimism about treatment . p = 0.035). People whose origin was outside Europe had a significantly higher mean score than Belgian–Europeans (p = 0.019) or Europeans (p = 0.049). We also found a tendency for people with no contact with SUD patients, or with contact in hospitals, to be in favor of “Specialized treatment” (NS). On the other hand, those who went to general practice were not in favor of “Specialized treatment”. The same was true for respondents enrolled in addiction training (p = 0.031). Detailed results can be found in In relation to Factor III, which assessed attitudes towards the specialized treatment of SUD, male respondents had a significantly lower mean score (p = 0.05).To investigate if the SARS-CoV-2 crisis could have impacted students’ representations, we compared factors and variables according to the three student cohorts . The results did not show any relevant significant difference except for a slight decrease in the average score of Factor I over the years , construct validity  and very good internal consistency . That allowed us also to highlight interesting results concerning influencing factors of medical students’ attitudes regarding SUD. The three dimensions selected: “Stereotypes and moralism”, “Treatment optimism” and “Specialized treatment”, which we divided into two axes (affective and cognitive), are useful for exploring the learning objectives pursued in our educational system. These results can also guide us in the methodological choices to be made to achieve these objectives. We can see some differences with the reference studies ,10. As tIn our study, given the circumstances (SARS-CoV-2 crisis) and the survey having been carried out partly online, the response rate (71.1%) was good. We found an over-representation of women, which corresponds to the feminization of medicine over the last few years and is in line with the latest gender report from our university , which ra teaching by example and influencing students in an unintentional, unaware, informal and episodic manner”) [a set of values, behavioral norms, attitudes, skills, and knowledge that medical students learn implicitly” [With regard to the factors, it is firstly interesting to note that the dominant factor in our study (explaining 40.3% of the variance) was, as with that of the college students, the factor relating to “Stereotypes and moralism”. This differs from the case of Chappel et al., 1985, where it was the factor relating to permissiveness. The predominance of this affective dimension in a medical student cohort can be explained in different ways. Firstly, we hypothesize that, as the SUD topic is little taught in the formal curriculum, its representation is at this stage still partly based on representations conveyed by society or by students’ communities. These representations are probably also influenced by their internship experience, where the impact of role modeling (defined here as “manner”)  is docummanner”) ,24. Studmanner”) , which jlicitly” . These alicitly” . By perclicitly” ,29.In our study, the (non) place of contact seemed to play an important role in stereotypes and moralism, the latter being particularly marked if there was no contact or if it took place only in the hospital system. Conversely, scores were low if students had had multiple contacts or had experience of specific settings for patients with SUD such as SUD centers. This demonstrates the importance of varied and supervised experiences to reduce stereotypes. The fact that some students have never used substances on their own has also encouraged these stereotypes ,27,30. The difference between the factors emerging from our study and our reference articles can also be explained by the fact that in our final analysis we no longer had any of the items correlated with the “Permissiveness” factor initially present in the study by Chappel et al. Some of those items were not included in the “Brief SAAS”, some of which differed from the initial questionnaire, and other items were removed from the “bSAAS” because they were not adapted to our context, such as experimental marijuana use among young people, or were not retained during the second or third stage of the factor analysis leading to the “beSAAS questionnaire” See . In relation to the third factor, which we decided to name “Specialized treatment”, it was well characterized in our study by the four items correlated with it  and thus seems to be better defined here rather than in previous studies where they were associated with the notions of stereotypes and moralism among other items. Nevertheless, it is stereotypical to believe that the complexity of the situations should be dealt with by the second line of care. Recent studies on opiate use disorders show, in contrast, that the primary care setting is the most appropriate ,32, althAs for the results of the factor scores, we can observe that the characteristics of the subjects with higher scores for stereotypes and moralism are similar to those who were in favor of punishing substance use during pregnancy  in our previous study , these tLastly, it is interesting to note that the students who enrolled in SUD training scored lower on stereotypes and moralism compared to those who did not decide to attend. Our study highlighted also an interesting result for our SUD training: specific contact with SUD people was associated with a lower score in stereotypes and moralism. Furthermore, there was not a statistically significant difference in terms of optimism about treatment between the two groups, which was a tendency to be in favor. These findings lead us to the conclusion that we should involve people in recovery and peer helpers in this optional training to contribute to lowering stigma and to help improve the perception of treatment outcomes through the sharing of positive experiences. We should also focus our teaching on recovery approach and long-term support for this chronic disease (“care vision”) rather than focusing on curing the individual (“cure vision”) as is commonly taught in medicine. Even if we could observe a slight improvement in stereotypes and moralism from year to year, which could be explained by more awareness among medical students of mental health and substance use disorders in a context of overall vulnerability, there is still work to do. This study also reveals the interest in SUD and necessity of making a SUD training program compulsory for all medical students, in addition to the basic SUD education, to improve attitudes, access and quality of care for people with SUD ,35,36. IAlthough this study made it possible to validate a questionnaire for evaluating representations in French that could be used to evaluate educational systems, it does have certain limitations. First of all, we obtained an acceptable average response rate of 71.1%. This result was unfortunately impacted by a low response rate in 2020 (47.3%) due to the first wave of the pandemic and students’ other concerns, which limited the representativity of the sample especially for this cohort. For the rest, the response rates were significantly higher, with 82% and 79.3% of respondents for 2019 and 2021, respectively.Otherwise, we were not able to ensure its external validity by measuring its correlation with the basic instrument or other related instruments. Nor have we assessed its reliability in terms of repeatability (test-retest) and reproducibility on other profiles. It would also be useful to conduct a confirmatory factor analysis on the basis of our new 23-item questionnaire (beSAAS) to validate its construct. Further studies could be conducted in the future to do so. It is also a questionnaire with limited items filled by the students themselves, which has its limitations in assessing students’ attitudes in practice. Indeed, it is not reflective of all the potential attitudes related with SUD and could be completed by patients and SUD trainers in the practice setting to be more accurate and comprehensive. To have better knowledge of the topic, we could also complete this study by semi-structured interviews or health simulation training to be able to analyze student attitude, discourse and implicit bias in more depth. As this questionnaire was administered to medical students, which means future caregivers, we suspect that the results suffer from social desirability bias. This could result in the reporting of more positive attitudes than those experienced in reality. The adaptation of the Substance Abuse Attitude Survey to our cultural context and our target population of medical students has good validity and internal consistency. The questionnaire selected, beSAAS with 23 items and its three-dimensional interpretation through 2 axes: affective and cognitive, is useful and relevant to evaluate the impact of a pedagogical program on students’ representations. This study was able to highlight certain factors influencing stereotypical representations such as age, gender, personal or professional experience with substance use. The factor evaluating the interest of “Specialized treatment” clearly emerged in our study and seems to be explained by our target population and its representations influenced by the formal, informal and hidden curriculum. The study also highlighted interesting findings for improving medical education to lower stigma and provide better care for SUD people. Further studies are needed to investigate the external validity, repeatability and reproducibility of the questionnaire.