The aim of this study is to investigate the problems and needs of users with advanced age and cognitive impairment regarding the design and operation of daily living products. Television remote controls and an electric rice cooker were applied as the research tools, and focus group interviews with control older adults and interviews with individuals with MCI or mild dementia were conducted regarding the operation of the products. The control participants stressed that the operating procedures should not be excessively complex, the number of functions and buttons should not be overly high, and buttons and text should be enlarged. For those with MCI or mild dementia, in addition to the size and number of buttons, text size, and functions, their operation of product interfaces was affected by the complexity of the operating procedures. The solutions recommended by the participants included interface design involving direct operation and voice control. Older adults now attract the attention of designers. Factors affecting the daily living of older adults, in addition to the decline in personal cognition and motor functions with age, include dementia. Dementia affects the cognitive abilities and short-term memory of many older adults ,2, alongUnderstanding user needs is critical to contemporary product design. In addition to appearance, designers must pay attention to the interactivity and usability of products. According to Courage and Baxter , productCognitive impairment affects the interaction of users with advanced age with product interfaces. It is worth of further investigating whether older adults with cognitive impairment differ from normal older adults in their interaction with product interfaces. Enabling individuals with MCI or mild dementia to experience technology product operation is a feasible means to understanding their design needs. Therefore, the purpose of this study is to explore the problems encountered by older adults with MCI or mild dementia in operating the interfaces of daily living products to clarify the product interface designs that satisfy their needs.Designs focusing on users with MCI or dementia have recently attracted attention in the field of design. According to Irizarry et al. , collaboHedman et al.  conducteCastilla et al.  exploredBlackler et al.  exploredCompared with ordinary older adults, those with MCI differ in terms of their perceptions of the difficulty of using daily technology ,18; howeFocus groups and individual interviews were conducted with control older adults, older adults with MCI, and older adults with mild dementia living with family to understand their user needs and the problems they have encountered in using daily living products. Ten control older adults were invited to participate in two focus group interviews with five interviewees. Individual interviews were conducted with eight patients with MCI and seven with mild dementia. After discussion with medical professionals, group interviews were deemed unsuitable for the patients with MCI or mild dementia because emotional volatility may accompany their disease. The following subsection describes the procedure of selecting control participants and those with MCI or mild dementia.Control older adults in community centers were invited to participate in the focus group interviews. Participants diagnosed as having MCI or mild dementia were assessed and selected with the assistance of attending physicians.Ten older adults that had normal cognitive functions, were experienced in using home appliances and technological products, and exhibited normal verbal communication abilities were selected from two local senior citizen activity centers to participate in focus group interviews. Five older adults were invited from each activity center, with average ages of 81.0 ± 4.7 and 78.0 ± 6.6 years for the groups.Eight patients with MCI who were aged 77.0 ± 9.2 years, were experienced in using home appliances and technological products, and exhibited normal verbal communication abilities were selected to participate in individual interviews with help from attending physicians. Patients rated 0.5 on the Clinical Dementia Rating Scale were selected as participants with MCI. Through the referral by the physicians, the researchers directly communicated with the patients’ and their families to confirm their willingness to participate in the study.Seven patients with mild dementia who were aged 73.1 ± 11.7 years, were experienced in using home appliances and technological products, and exhibited normal verbal communication abilities, were selected to participate in individual interviews with help from attending physicians. Patients rated 1 on the Clinical Dementia Rating Scale were selected as participants with mild dementia. Through the referral by the physicians, the researchers directly communicated with the patients’ and their families to confirm their willingness to participate in the study. Patients with dementia experienced in using home appliances and technological products basic knowledge in product operations; therefore, they encountered few problems in using the products and were able to express opinions regarding these problems.Three types of TV remote controls with different button configurations, sizes, and appearances, and one type of electric rice cooker were employed as the research instruments . The opeOne focus group interview on the products, aimed at older adults, was held at each of the two activity centers in May of 2020. Before the interviews commenced, the principal investigator explained the interview procedure to the participants as well as the functions and usage methods of the rice cooker and remote controls. The participants were asked to perform the aforementioned operations using the two types of products for them to familiarize themselves with and discuss the products. After the tasks were complete, 60-min discussions were held for the participants to express their opinions regarding the use of the products. The discussions were then concluded under the guidance of the principal investigator. Specifically, the rice cooker was discussed first, followed by the remote controls. The tasks and interviews were recorded using audio and video recording equipment for analysis .The individual interviews with the participants diagnosed as having MCI and mild dementia were held in July and August of 2020. The procedure of the individual interviews was explained to the participants and their families by the principal investigator, along with the functions and usage methods of the rice cooker and remote controls. The participants were then asked to perform the operations. Then, accompanied by family, each participant discussed their use of the products in a 40-min interview. The rice cooker was discussed first, followed by the remote controls. The operations and interviews were recorded using audio and video recording equipment .The focus group interviews were conducted in social spaces of senior citizen activity centers in New Taipei City and Pingtung City. The individual interviews were held in a meeting room in a hospital in New Taipei City, with the participants selected, assessed, and invited with the help of attending neurologists. To protect data confidentiality, the interview analysis focused on the spoken materials, and the personal information and images of the participants were hidden as much as possible. Digital video cameras, pen voice recorders, and laptop computers were used for recording and analyzing the spoken materials.The spoken materials from the interviews were analyzed to generalize the problems regarding the operating procedures, interfaces, functions, and appearances of the test products, which were investigated according to the opinions of the participants regarding the operational tasks, operating interfaces, product functions, and interface appearances, respectively.The focus group interviews are presented as Sites A and B as shown in Four of the interviewees at Site B had previously used electric rice cookers. These interviewees contended that the operating procedure of the cooker was complex and difficult to memorize. Specifically, they sometimes forgot to press the button that activates the cooking command, preventing them from completing the operation. Moreover, the time programming function was complicated. The text on the interface was excessively small, and the rice cooker interface was generally complex. The interviewees, who used only rice cookers to cook rice, remarked that the number of functions was excessively high, and they required assistance from family members to use functions other than cook. The interviewees suggested replacing the interface with a single-button design or a design that starts cooking automatically after being plugged in and cuts or reduces power or after cooking is complete.Most of the interviewees at Site B were experienced in using TV remote controls, but two mentioned that they usually only used the controls to turn TVs on or off and required the assistance of family members to select channels and adjust the volume. The interviewees indicated that the buttons were overly small. They found it difficult to adjust the TV volume and were worried about causing their desired screens to disappear without easy recovery because they pressed an incorrect button. The number of buttons was overly high, but the control interfaces were easier to understand if they were closer to those of the remote controls at the interviewees’ home. The interviewees used the remote controls primarily to turn TVs on or off, adjust the volume, and select channels. The text on the control interfaces was too small to read. The interviewees suggested that the buttons and text be enlarged and the control functions be simplified and prioritize TV power, channel, and volume commands. Moreover, the number of buttons should not be overly high; only the necessary functional buttons should be preserved.With the findings from the individual interviews with the users with MCI regarding the TV remote controls, all the interviewees indicated that they were able to operate the controls primarily for turning TVs on or off, selecting channels, and adjusting the volume. Most selected channels by pressing the number buttons. The interviewees considered the channel selection function difficult to operate but regarded the text on the controls large and easy to read. Regarding the appearances of the remote controls, the interviewees preferred large controls with colored buttons. They suggested that the remote controls provide only simple and necessary functions.With the findings from the individual interviews with seven users with mild dementia regarding the use of TV remote controls, the interviewees required assistance from their families in turning TVs on or off, selecting channels, and adjusting the volume. They could not find the volume and channel buttons because they could not read the text on the buttons. They preferred large buttons and text. Moreover, the interviewees indicated that the functions provided by the controls were excessive and might cause them to press the wrong button, and they would be unable to return to the desired screen. The interviewees used the remote controls primarily for turning on or off TVs, selecting channels, and adjusting volumes. The interviewees preferred remote controls with appearances and interface configurations similar to those of controls they used at home. Moreover, the interviewees suggested voice control for easy operation, and the functions and interfaces of the remote controls should be simplified.Some of the control participants considered the operating procedure of the electric rice cooker overly complex and difficult to memorize, and some of the participants with MCI and mild dementia were unfamiliar with the procedure. MCI affects abilities involved in performing complex daily living activities, such as using technological products , and demSome of the participants with MCI or mild dementia experienced difficulty using the “function select” button on the rice cooker interface , functions, and prior user experience, whereas the participants with mild dementia, who were unfamiliar with the operating procedures, preferred clear operating instructions . According to the interactive design scholars Blackler and Hurtienne , users’ This study involved two focus group interviews with 10 control older adults and individual interviews with eight individuals with MCI and seven with mild dementia regarding an electric rice cooker and three TV remote controls. The control participants stressed that the operating procedures of the products should not be excessively complex, the number of functions and buttons should not be overly high, and buttons and text should be enlarged. For the participants with MCI or mild dementia, in addition to the size and number of buttons, text size, and functions, their operation of the product interfaces was affected by the complexity of the operating procedures. The solutions recommended by the participants included interface designs for direct operation or voice control. Due to disease factors, the participants with MCI or mild dementia were interviewed individually. Although they were guided by family and caregivers during the interviews, the opinions they expressed regarding the use of the test products were limited. Furthermore, when these participants were guided or instructed in using the products, the disease factors prevented them from effectively memorizing the operating procedures. Future studies should adjust participants’ product operation time. For example, the product interface operation time for participants can be extended, or participants can be assigned to use the test products in daily living for a predetermined period . Thus, participants can familiarize themselves with test products and provide opinions regarding their needs and the design of the products.Although all the participants were experienced in using home appliances and technological products, they differed individually in their product use experience. Some of the participants had not cooked rice themselves or had relied on the assistance of family members or caregivers in using TV remote controls, and they were unable to provide opinions or suggestions on product designs during the interviews. Future studies should invite users highly experienced in operating specific products, such as older adults who use electric rice cookers regularly, to acquire more detailed interview results. In this study, usage experience was considered in selecting participants, but differences in education levels were not considered. Differences in education levels may have influenced the interview results. Future studies should consider the education levels of participants for clearer research results; specifically, the effect of education level on the operation of product interfaces by users with advanced age and cognitive impairment should be further examined. Electric rice cookers and TV remote controls are among the most prevalent daily living products. Further research should employ other types of technological products as research tools to explore different dimensions of product interface design requirements and to clarify the characteristics of the interaction between users with advanced age and cognitive impairment and product interfaces, providing a valuable reference for product design.


In Kolkata (India), there are high rates of malnourished children (45.9%) under the age of three, impacting growth, organ development, function, and cognition. Mothers have a major role to play during this crucial development stage, with research showing nutrition knowledge, attitudes and practices (KAP) of mothers are important determinants of childhood malnutrition.To document 3 years of capacity building towards a sustainable nutrition education network in Kolkata, India, while assessing the ability to perform data collection in the form of needs assessments, impact assessments and capacity reviews.Descriptive review and analysis of engagement and impact from 3 years of work by the NNEdPro Global Centre for Nutrition and Health, initiating locally led nutrition education interventions. Mapping to the Indian National Nutrition Strategy was also performed to review adherence to nationwide priorities surrounding nutrition and determine the wider application potential of the network.Two simultaneous projects were taken forward by a team of local healthcare professionals and student champions. Project 1—medical college workshops for medical student nutrition education with added focus on underserved populations, Project 2—preparation for a ‘Mobile Teaching Kitchen’ (MTK) in marginalised communities to empower local women as nutrition educators.Data collection methods used for analysing markers of impact and sustainability were semi-structured interviews of the community members, and KAP questionnaires to assess response to educational sessions.With local support it is possible to create and sustain fieldwork for an extended period with meaningful outputs and impact. This initiative demonstrates that it is possible to use healthcare professionals, students and volunteers with low-intensity training and a low-cost approach to produce action research with considerable impact and results in rapid, reliable and robust manner. An outline of methods which can be used as indicators of impact in nutrition education and research network capacity building.Description of 3 years of NNEdPro's establishment of a nutrition education and research network in Kolkata, India.A framework for learning from NNEdPro's experience in establishing a nutrition education and research network, to replicate elsewhere.The NNEdPro Global Centre for Nutrition and Health is an inter-disciplinary think-tank, training academy and knowledge network, anchored in Cambridge, UK. It works with individuals as well as organisations interested in nutrition and health improvement via education, research, evaluation and advocacy.Over the last seven decades, India underwent major economic progress demonstrated by rapid urbanisation. In 2011, approximately 31% of the Indian population were living in urban areas; almost twice as high as 1951.Childhood malnutrition is a major health problem, within the base of these efforts (Kolkata) there are high rates of malnourished children under the age of 3 45.9%).%.9 warraDuring the 14th WCPH, feedback from delegates attending the NNEdPro education workshop, held in the Eastern Indian city of Kolkata, highlighted significant gaps in knowledge and data regarding the nutritional status of school-aged children and relationships with family income, maternal education, nutrition awareness, attitudes and practices of mothers specifically residing in marginalised communities. Based on previous project experiences and learnings from the conference feedback, a strategy for a project in India was developed. The aims were to enhance nutritional awareness, build understanding of nutrition research methodology and develop leadership from the pool of delegates who had expressed an interest in improving nutritional care, in ways which were sustainable and provided opportunities for individuals to support capacity building in under-resourced health systems.The assessment at the end of this programme identified a need for research training to enable the generation of local data. The exercise also brought into focus the dependency of key healthcare workers on nutrition guidelines derived from results of studies conducted in the western world and not in the indigenous country. These confirmed data from a previously performed need assessment in 2014 in relation to nutritional care of almost 200 doctors and dietitians in Kolkata.To document and analyse the experience of an organisation establishing a nutrition education and research network, through description of the following:Capacity building exercises undertaken.Data collection and review of impact indicators.Mapping to the national nutritional strategy.This paper descriptively reviews 3 years of NNEdPro work in Kolkata, till December 2018, to establish locally led nutrition education interventions. Including a needs assessment, impact assessment and capacity review all of which have been performed with the results collated.While initiating a network, it is important to see how this compares with national frameworks and strategies, as such one section reviews the project to the Indian National Nutrition Strategy (INNS) ‘Nourishing India’.Descriptions of each of the interventions have not been ordered chronologically, rather, they have been categorised under three key headings; developing a sustainability framework, assessing indicators of impact and capacity, and mapping outcomes to the INNS. In the first section, the two workshops that followed the 14th WCPH and subsequent creation of the NELICO champions are described. What follows is more specific information about the NELICO urban slum dwellers group that acted as the precursor for the ‘Teaching Kitchen project from which the ‘See one, Do one, Teach one’ method was created. Still on the theme of a sustainability framework, the medical colleges and impact acceleration projects are outlined to engage local future medical graduates in capacity building as well as to draw in wider stakeholders. In measuring indicators of impact and capacity there is a reflection on needs assessments and the use of knowledge, attitudes and practice questionnaires. In the results section the projects undertaken and described are mapped to the outcomes of the INNS.Succeeding the first 3 years of work and data collection in India (2015–2018), our key learnings are grouped using the following sections and timeline described in Developing a sustainability framework.Assessing indicators of impact and capacity.Mapping outcomes to the INNS.Five members of NNEdPro were invited to Kolkata to deliver a 2-day workshop in and around the 14th WCPH in February 2015. In the build-up to this event, NNEdPro engaged in preliminary discussions with a range of organisations based in India including Halo Medical Foundation , Srimanta Sankara Health Sciences University , All India Institute of Hygiene and Public Health , National Institute of Cholera and Enteric Diseases (laboratory research practice), Indian Institute of Management-C , Indian Dietetic Association , in which it was agreed that a diverse set of representatives, from across different nutritional relevant research and practice skillsets, would join NNEdPro for their workshop to discuss engaging in collaboration. Alongside this NNEdPro formed a working relationship with Remedy Clinic Study Group (RCSG), based in Kolkata who were key in later steps of implementing projects with local oversight. Local volunteers were also essential, and this was provided by members of the Inner Wheel Club of Greater Calcutta .On day 1 of the 2-day workshop, an initial short exercise was carried out by members of the NNEdPro Group to equip early-career public health and healthcare professionals with the knowledge, resources and skills to be ambassadors for evidence-based practice as well as introducing the principles of change management. In total, 200 healthcare professionals attended the session.This event was followed by an interactive exercise, where the early-career professionals were divided into smaller focus groups and given the opportunity to voice their opinions/ideas and suggest strategies to tackle local nutritional problems within clinical and public health parameters.On day 2, focused nutrition education training was provided with emphasis on the importance of nutrition as part of healthcare and empowering change through management and leadership techniques. A key factor of day 2 was the need for dynamic interaction between doctors, nutritionists and dietitians demonstrating that by working synergistically they can help optimise population health. This was achieved by incorporating a selection of rotational workshops consisting of five mini-rotational workshops where presentations were delivered on the importance of nutrition, nutritional care, and the importance of hydration.During the 2-day workshop NNEdPro assessed the nutrition KAP levels of attendees before and after the nutrition education package to evaluate its effect.Towards the end of the teaching session participants were divided into multiple groups and assigned the task of designing a NELICO project to enhance nutrition education and leadership for improved clinical and/or public health outcomes relevant to local communities. ‘NELICO champions’ were then selected based on their contribution to the group work activities and their enthusiasm towards improving nutrition education. The NELICO hampions were invited to a round table event where they enriched their NELICO project ideas and decided on two projects to develop further, with the aim of raising nutritional awareness in the Indian population. They split into two teams to take forward the projects from February 2015 to February 2016, supervised by NNEdPro in partnership with RCSG and The Halo Medical Foundation.The two teams were assisted through training workshops held in Kolkata in April 2015 and June 2015 to finalise each projects’ research methods and strengthen the proposals. Following this the NELICO champions drafted their respective key project documents including the proposal, standard operating procedure, consent and data collection forms. The proposals and supporting documents were reviewed by NNEdPro where feedback, advice and direction were provided to enhance and adapt the proposals further. Details of each projects ongoing work are described individually in the following sections, providing insight into data collected as well as the logistics of setting up and managing initiatives of this complexity. Communication was key throughout this process, particularly between events, to ensure further engagement and progress in their project. This was performed using local contacts such as RCSG, as well as email and phone call mentoring with NNEdPro.As a result of these projects, the NNEdPro India network began to grow in capacity, originally it started with five members, of which one was paid for part-time work and the rest were volunteers. By expanding to include the mentorship and inclusion of six new members from each project, this grew the capacity of the network to 17 people. This collaboration both benefited the NELICO champions in the goals of increasing nutrition awareness and increasing ability to perform research, but also the network itself benefited from mentoring them. The network grew from the funding and interest these projects brought, as well as collaboration with individuals and organisations on the peripheries. The current format is demonstrated in Early in their involvement the NELICO champions in the urban slum dwellers group identified community nutrition education as their main goal. Through scoping exercises and needs assessments they determined this was feasible. The idea of a ‘Teaching Kitchen’ was identified and developed following several adaptations to the method of education delivery. Initially a simple nutrition education session to the marginalised community was proposed, but this was restructured to involve repeated follow-up, with a method that cut through potential educational barriers. A ‘Teaching Kitchen’ was identified as a model to engage the marginalised communities in nutrition education. This involved several conversations and inputs from the remotely based NNEdPro core team, as well as visits to Kolkata to assist in planning and development of the project.In the same week of the workshop, on 24 October 2017, two NNEdPro ‘Teaching Kitchens’ were officially opened in the marginalised communities of Chetla and RG Kar Canal (Kolkata).The team engaged deeply with the local communities and in addition to the inaugural ceremonies and cooking demonstration, they conducted Q&A sessions, and distributed a pre-prepared nutritionally balanced local meal. Its nutritional breakdown and relative amounts per recipe can be seen in 10.1136/bmjnph-2020-000180.supp1Supplementary data10.1136/bmjnph-2020-000180.supp2Supplementary dataMembers of the inner Wheel Club of Greater Calcutta (volunteers) were educated to transfer knowledge and teach appropriate methods of cooking. They were given training on affordable, local, nutritious food through cooking demonstrations and dialogue on health and hygiene from local dietitians and health professionals, beginning in 2015 and carrying through many iterative sessions till concluding sessions in July and November 2017.From 9 December 2017 to 27 January 2018, six ‘Teaching Kitchen’ workshops were conducted using the ‘See One - Do One - Teach One’ methodology in the marginalised communities of Chetla and RG Kar Canal communities.Dietitians, nutritionists, RCSG, NNEdPro and Inner Wheel volunteers conducted these workshops with women and children from the marginalised communities to transfer knowledge about how to create local, affordable, nutritionally balanced meals; while furthering overall engagement and awareness with the local population.Engagement levels among children and women in both marginalised communities was promising. In addition to the impact on social and economic empowerment for women that the ‘Teaching Kitchen’ presented, the space also provided opportunities for young people and teenagers who were a highly engaged demographic. This highlighted the potential for ‘Teaching Kitchens’ as a tool for the provision of vocational education for young people and teenagers.The 1-hour workshop ‘Teaching Kitchens: Next Steps in Policy and Sustainability’ was held on 25th October 2017 in Kolkata, India, organised by NNEdPro, the University of Cambridge and the RCSG, and funded by the Economic and Social Research Council (ESRC).The workshop discussed the role of nutrition in children’s growth and development, cognitive skills and learning abilities. In addition, it advanced and implemented nutrition knowledge to improve health, well-being and society and crucially gained a consensus around the role of nutrition education and ‘Teaching Kitchens’ in empowering communities and discussed barriers or enablers of food behaviour including food availability and cultural beliefs.On the 5th of February 2018, NNEdPro key collaborators from the 14th WCPH workshop visited the ‘Teaching Kitchens’ and alongside local volunteers participated in a half-day interactive discussion on the NNEdPro’s ‘Teaching Kitchen’ project. From these discussions a suggestion to add value to the programme was to refit a van to create a ‘Mobile Teaching Kitchen (MTK)’ unit, enabling the programme to access communities where lack of space presented a challenge . The MTK10.1136/bmjnph-2020-000180.supp3Supplementary dataThe parallel project began with approaching several medical colleges in Kolkata, inviting them to engage in a pilot intervention in autumn 2015. Of those that accepted, the deans of the medical colleges were briefed to permit the medical students to be part of the educational package.Two sessions of education were performed on the 8th and 9th of February 2016. The bespoke nutrition intervention was based on material used for teaching medical students in the UK and adapted for the Indian context. The adapted material was taught by the NNEdPro-NELICO team which included: two nutrition dietetic graduates, one nutrition dietetic student and one medical student who worked closely with nutrition and healthcare professionals in their region and in the UK.The 2-hour intervention focused on seven topics: nutrition for a healthy person, the importance of hydration, nutraceuticals, metabolic syndrome, diabetes management, diet in heart and disease, and nutrition support. The intervention was made interactive by having students answer questions about the material using quiz sessions at the end of each topic. Participants KAP were assessed by questionnaire before and after the intervention 10.1136/bmjnph-2020-000180.supp4Supplementary dataThe project ‘The impact of an educational intervention in West Bengal, India’ was an 8-month project  sponsored by the ESRC Impact Acceleration Fund.A key feature of the project was the co-organisation of a workshop with NNEdPro to set the foundations, as well as plan the next steps for the parallel ‘Teaching Kitchens’ project. A wide range of stakeholders in India participated, including health, academia, NGOs, civil society, local government and other key influencers in the fields of education and nutrition.The MTK unit was further funded by the British Medical Association charities grant, Global Open Data for Agriculture and Nutrition partnership seed funding and an ESRC grant following this.When attempting to establish whether there would be benefit from establishing a regional network within Kolkata, it was important to first assess for any need for nutritional and public health interventions. This needs assessment focused on assessing the nutritional status of the children living in marginalised communities.Field visits were conducted, following which nutrition workshops were organised in three marginalised communities located in three areas of Kolkata. Following clinical and anthropometric assessment, screening for malnutrition was undertaken. Semi-structured interviews with mothers were conducted to obtain data on the demographic profile of the family. This allowed a wide range of data to be obtained, while in return they were offered a health report card for participants and their children as well as referring where appropriate to local healthcare services. Furthermore, they provided nutritional advice to the community through workshops.This method of needs assessment was able to be performed in a relatively short period of time, with low cost and provided a basic level of community data to allow repeat analysis to compare for improvements. The main reason for reduced cost was the provision of data collection and analysis by students and volunteers. For volunteers this was an opportunity to assist marginalised communities, and while the same was the case for students they also gained education and mentorship in research methods. More of a focus on the communities KAP, through questionnaires, could have been beneficial to see whether further capacity building efforts altered this from baseline; however, due to limited resources this could not be achieved.Over the period of 2015–2018, NNEdPro assisted in developing a local group to educate and spread messages to develop interest in nutrition education for healthcare practitioners. To analyse impact of the workshops performed, KAP questionnaires were completed .For the two workshops this was collected with two questionnaires using the same questions, but in different orders to minimise recall bias. For the knowledge questions, the correct answers were given a score of 1 and incorrect answers were marked as 0 then added together to give a final knowledge score for each participant. For the attitude and practice questions, the responses were ranked with the best attitudes/frequent practices answers getting the highest mark and the least desirable getting the lowest.From the results obtained it was possible to analyse the impact of an educational workshop on its participants nutrition knowledge on core topics, their attitudes around aspects of nutrition care and their self-reported practices in clinical encounters. This was performed through a relatively short intervention, before and after the educational programme and seems to hold very few negatives in its method of analysis. Data were largely collected through student or healthcare professional volunteers, with oversight from the networks core team. The overall aim of assessing both members of the marginalised communities, alongside healthcare professionals, was to assist the network in establishing the needs of the local communities and importantly the readiness of the healthcare professionals locally.Capacity was tested, by using a combination of impact indicators such as KAP alongside engagement with the network, to assess whether a group of dedicated healthcare professionals relatively naïve to research or project leadership, could be trained to make local impacts to a publishable standard.When establishing an educational network, aiming to address one of the major public health concerns worldwide, it is vital to align with indigenous strategies. In this case, working within India it was important to assess how our work addressed themes set out in the INNS as detailed in The ‘urban slum dwellers’ project was aimed at educating mothers to distribute the effects to the whole family to function as change agents, and in that sense took a life cycle approach.Through community education of both healthcare workers through the medical college’s project as well as through lay public in the urban slum dwellers project, it is hoped that the cycle of poverty can be broken. In addition, during the health visits that conducted in parallel to the initial stages of the slum dwellers harmonisation work, doctors, dietitians and volunteers assessed the children’s anthropometry and carried out an extensive clinical examination to provide a health report card. This opportunistically identified health issues in both children and mothers which provided an opportunity for these to be addressed to offer secondary prevention benefits.In terms of project team, the initial intervention included a wide range of healthcare professionals from dietitians, laboratory scientists, doctors and students. The project aimed to target numerous parts of society including slum dwellers, empowering women and helping vulnerable children in socioeconomically deprived areas of Kolkata.Both NELICO interventions were encouraged to develop local leadership and ownership, which was envisioned to develop empowerment of the healthcare community locally, which then rolled into empowering lay mothers as educators in their community in the slum dwellers project. In addition, food menus designed in the MTK component of the slum dwellers project had to be locally derived and culturally sensitive. A local population of dietitians was therefore used to devise these and to support local mothers in creating their needs. The community as a whole, through training for local healthcare professionals in the NELICO project, were supported through the process of project conception and the creation of protocols and standard operating procedures. This provided a sustainable approach to learning about research methods and analysis, as well as implementation which can be carried into other areas of work or research.The purpose of the impact acceleration workshop was to take the solid foundations of capacity building initiatives and to complement them with innovate ideas. This led to the development of the two separate projects, which were complimentary in developing the expertise of the NELICO champions and driven by local teams. This was successful in exploring the role of nutrition in children’s growth and development, cognitive skills and learning abilities. In addition, it advanced and implemented the nutrition knowledge to improve health, well-being and society and crucially gained a consensus around the role of nutrition education and ‘Teaching Kitchens’ in empowering communities.The approach of each intervention has developed from a base of science and evidence. As such data collection and analysis have been key to assess ongoing feasibility of both interventions. Each study employed a research methodology approach to document changes or improvement created by health or educational interventions.Ultimately, with funding coming from organisations globally but particularly in the UK there will be some perceived conflict of interest. However, NNEdPro works globally, with strong connections to India and are aware of the local systems and ways of working. This helped to promote the use of local skills (including human resources) to enact locally determined change. This has been facilitated with support, both financially and from a project management perspective by experts in NNEdPro.Following 3 years of intervention, initiated by NNEdPro and sustained by the ongoing financial support of research grants, a local nutrition and public health educational system was established in Kolkata, India. This paper documents the path undertaken to create a sustained network that continues to thrive, by the definitions of sustainability (i) after a defined period of time, (ii) continues to be delivered, (iii) individual behaviour change is continued, (iv) adaptation continues to occur to the network while providing benefit to the individual.BMJ India nutrition masterclass, which stemmed from what was initially a small group of local healthcare professionals in Kolkata. Further, through the NNEdPro India network, several discussions were conducted with vice chancellors of local medical colleges, who agreed to collaborate on increasing nutrition focus within the curriculum. Despite the initial focus on educating medical colleges, it can be seen the other arm of slum dweller education has taken the spotlight. It is largely through this that the network has used collaborations with other local partners, to bring individuals and organisations close to the project activities. From this, paid roles have been created, including a full-time project officer and intern, as well as part-time senior technical officer. The network has grown from 5 original members to 17 through initial project inclusion, to 19 core members for the ‘Teaching Kitchen’ itself, and around 51 including wider members (approximately five are renumerated or paid for their time) in the present state. Both projects continue in Kolkata, with spread to other areas within India such as Punjab, and indeed more recently the creation of the India and South-East Asia regional network to expand outside solely India. The network is increasingly independent, still using expertise from the NNEdPro core team, but managing day to day operations, development of educational articles and organisation of workshops largely from within its Kolkata based team.One of the important aspects of this work by the NNEdPro in India, is that local drivers of change continue to innovate and educate through several means. The NNEdPro India network pageFrom the slum dwellers team, the idea of a ‘Teaching Kitchen’ developed, and through further funding acquired it continued to develop. This educational tool continues to deliver knowledge, occupation and empowerment to a local community otherwise lacking such opportunities. Again, NNEdPro assisted and provided scientific guidance and logistical support for the MTK ‘breakout’ project, now called ‘Bhavishya Shakti’ (meaning ‘Empowering the future’). There is evidence detailing the use of hands on methods of teaching to provide nutrition education in a number of different settings, but the use in poorly educated marginalised communities has not to date been documented.Our review depicts the journey and development of those involved from NNEdPro in establishing the project, using the data and details collected through 3 years of work. One limitation is that this description did not extend its scope to include the opinions of those NELICO champions trained, or indeed the communities they reached for their views on sustainability or capacity of the network. While individuals still remain involved from this NELICO group, some have moved into other roles. However, their initial success has led to the momentum which drew interest from others leading to sustainable growth of the network. It remains clear from the analysis captured during the 3 years of intervention, it is difficult to quantify success. The success of this initiative is shown more clearly through the continued progress with those local professionals included, and through the research-based nutrition education they aim to continue. However, the use of questionnaires such as KAP tools, remains valuable in providing educators and researchers a way to quantify if they are having the desired impact. Overall, this demonstrates the need for forward planning of methods and techniques to analyse impact and sustainability when establishing an educational, research driven network.It is hoped that through this paper, other researchers, healthcare professionals, or organisation will be able to reflect on our review and consider aspects of the projects outlined to replicate. This may be through adapting the proposed frameworks for an organisation or utilising data collection as markers of impact, but both benefit heavily from utilising local expertise.It is widely recognised that building and sustaining regional networks is challenging but can facilitate education and public health interventions to accelerate impact. This paper described the events leading to the creation and establishment of the NNEdPro India regional network, with exploration of indicators pertaining to early population impact and workforce capacity, mapped to a national strategy and most importantly aimed to provide a framework to replicate and learn from the experience.This exercise demonstrates what can be achieved in generating a framework for action-research with a relatively small team, working with local collaborating organisations and individuals. Education and empowerment of local marginalised communities provide opportunities for rapid impact, while encouraging engagement and widening network membership. From here, further workforce capacity can be developed, through working with network members. This paper described how training health professionals and volunteers on the one hand to better serve marginalised communities, while also training and empowering those from underserved communities can form a two-pronged intervention for local malnutrition related inequalities. Using healthcare professionals, students and volunteers with low-intensity training needs and a low-cost approach to produce practically orientated research with potentially impactful results in rapid, reliable and robust manner. The intervention led to enhanced, research-led, nutrition education in both clinical and community settings. Furthermore, it developed local leadership and teamwork, both within and between professions, breaking down barriers between students and professionals as an example in the healthcare field. It has created a team that used the expertise and skills of different professions, including the close working of dietitians and doctors.From the information provided, we propose a basic format that could be adapted to establish other networks with similar aims and approaches. The NNEdPro India Regional Network continues to grow, particularly with its MTK project, as well as informing modus operandi for other regional networks globally, learning from the transferrable elements of initial steps taken in Kolkata over the 2015–2017 period.


Environmental Protection Agency’s Integrated Risk Information System (IRIS), as well as other approaches, to a set of studies examining polybrominated diphenyl ethers (PBDEs) and neurodevelopment. They concluded that use of the IRIS approach resulted in exclusion of studies, which would lead to hazard conclusions based on an incomplete body of evidence. As scientists in the IRIS program, we support the comparison of approaches to improve systematic review methods for environmental exposures; however, we believe the IRIS approach was misrepresented. In this letter, we demonstrate that the ratings attributed to the IRIS approach were not consistent with our own application of the tool. We also clarify the use of studies rated as “low confidence” and the use of an overall study confidence rating in our systematic reviews. In conclusion, the IRIS study evaluation approach is a transparent method to inform certainty in our evidence synthesis decisions and ensures consistency in the development of IRIS health assessments. Examples of the actual application of these methods by the U.S. EPA are available in several systematic reviews of the health effects of phthalate exposure [As scientists in the IRIS program, we support the comparison of approaches to improve systematic review methods for environmental exposures; however, we believe the IRIS approach was misrepresented. While there is not space in this letter to describe the IRIS approach, we encourage readers to review our detailed methods for study evaluation in the ORD Staff Handbook for Developing IRIS Assessments . This waexposure  and the exposure . In thisFirst, Eick et al.  reportedhttps://hawcprd.epa.gov/summary/visual/100500646/. In the application of the IRIS approach by Eick et al. [The results of our evaluation are presented in Fig. Second, Eick et al.  states tgood, adequate, and deficient ratings are counted to obtain an overall rating. Eick et al. [quantitative scoring, which is not an approach we advocate or use. In contrast to the direction chosen by the Navigation Guide contributors, other institutions have adopted a strategy similar to the IRIS approach of reaching an overall qualitative rating or conducting stratified analyses based on the risk of bias/quality judgments [Third, the analysis by Eick et al.  also objk et al.  pointed udgments –8. The IIn conclusion, the IRIS study evaluation approach is a transparent method to inform certainty in our evidence synthesis decisions and ensures consistency in the development of IRIS health assessments.


The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO’s framework on understanding the life cycle of medicines, this review details the global and national challenges that affect patients’ abilities to access and afford insulin. Current research and development in diabetes has seen some innovations, but none of these have truly been game-changing. Currently, three multinational companies control over 95% of global insulin supply. The inclusion of insulin on the WHO’s Prequalification Programme is an opportunity to facilitate entry of new companies into the market. Many governments lack policies on the selection, procurement, supply, pricing and reimbursement of insulin. Moreover, mark-ups in the supply chain also affect the final price to the consumer. Whilst expenses related to diabetes are mostly covered by insurance in high-income countries, many patients from low- and middle-income countries have to pay out of their own pockets. The organisation of diabetes management within the healthcare system also affects patient access to insulin. The challenges affecting access to insulin are complex and require a wide range of solutions. Given that 2021 marks the centenary of the discovery of insulin, there is need for global advocacy to ensure that the benefits of insulin and innovations in diabetes care reach all individuals living with diabetes.The online version contains a slideset of the figures for download, which is available at 10.1007/s00125-020-05375-2. The year 2021 marks a momentous milestone for the diabetes community, with the centenary of the discovery of insulin. Insulin’s discovery by Banting and Best at the University of Toronto  in 1921 meant that type 1 diabetes went from being a death sentence to a manageable chronic condition. Leonard Thompson was the first person to receive insulin as a treatment for type 1 diabetes in 1922 in Canada. That same year, Elliot Joslin stated, ‘A new race of diabetics [people with diabetes] has come upon the scene’ [However, these initial positive views on the prospects of insulin therapy in the 1920s are in harsh contrast to the reality that many people with diabetes face some 100 years later, specifically owing to lack of access to insulin. Basu et al.  found thIn 2016, the former Director-General of the WHO declared that ‘people with diabetes who depend on life-saving insulin pay the ultimate price when access to affordable insulin is lacking’ . A studyThe first component of the WHO framework  is reseaThe transition from animal to human and then analogue insulin is seen as an innovation , but oneIn looking at the manufacturing of insulin, two factors need to be considered: (1) insulin is a complex biological product that requires specific expertise to manufacture in order to ensure a high quality, safe and efficacious product ; 2) at  at 2).FiAll medicines are required to have marketing authorisation and must be registered by a national regulatory agency before placement on the market. This requires scientific evaluation of the product to ensure that it meets specific standards of safety, efficacy and quality . For bioIn parallel to the complex process that is needed for insulin manufacturers to produce and get their products approved by regulatory agencies, there is also the challenge that many regulatory agencies in LMICs do not have the technical capacity to assess the data in the dossiers prepared for biological products. To address this, the WHO developed the Prequalification Programme in 2001, mainly in response to HIV/acquired immune deficiency syndrome (AIDS), to assess the quality of anti-retroviral products. The WHO announced the launch of prequalification for insulin in November 2019 . This alJust because a medicine meets regulatory standards, this does not necessarily mean that it is selected and used. The WHO’s Model Essential Medicines List (EML) is aimed at guiding individual countries with regard to their decisions on their choice of medicines, and only includes guidance on soluble and intermediate-acting insulin in vial form . AlthougFor pricing of medicines, different countries have different policy measures for both the system and individuals . For exaIn many LMICs, the price of insulin is paid for in full by an individual  or, in sPricing policies and approaches taken by governments will affect how medicines are procured. In most LMICs, insulin is purchased via centralised tenders for the public sector . In the Once insulin is procured, dependent on the sector and health system, the price difference between the government procurement price and patient price might increase due to import tariffs, storage costs, transportation costs, dispensing fees, sales taxes and other fees. These mark-ups also apply at different stages of the supply system in the private sector. Ball et al.  found thThe prescribing of insulin is affected by the organisation of care and where in the health system  people can receive their diabetes care. For example, in Vietnam, access to insulin is mainly provided in major urban areas and in hospitals . In someDispensing, or the provision of insulin by the health system to an individual, faces two clear challenges in many LMICs , 31, 34:As noted by Holden et al. , in 19911c tests) was US$533 (range: US$255 in Pakistan to US$1185 in Burkina Faso). Beyond these tools, a variety of health system factors are needed for the management of diabetes and these are particularly lacking in LMICs. The health system response for NCDs (including diabetes) proposed by the WHO focuses on PHC [Since insulin needs to be injected, access to syringes or other delivery devices are essential for insulin therapy and are often not available and affordable . Availabs on PHC  and lacks on PHC . In addis on PHC , 48 and Access to insulin is truly a global challenge, with a wide range of issues that impact on an individual’s capacity to find and afford the insulin they need for their survival Fig. . The facInsulin provides an interesting example of how evidence has not been adequately used to guide clinical practice. Despite analogue insulin not being included in the WHO Model EML, its uptake has been substantial despite its higher price , 14, 24.Beyond the actual access to insulin, a variety of health system factors further hamper access to care; these include diabetes care being provided at hospitals vs in PHC, lack of knowledge and expertise of health professionals with regard to insulin therapy, and availability and affordability of diabetes-related supplies , 34, 40.At a global level, the United Nations’ sustainable development goals (SDGs)  include All solutions for improving access to insulin Fig.  need to The private sector has a clear mandate, which is included in the SDGs and can play a role in addressing the challenge of access to insulin. Initiatives should focus on creating true partnerships with other players  and addSlideset of figures(PPTX 360 kb)


Media multitasking became increasingly popular over the past decade. As this behavior is intensely taxing cognitive resources, it has raised interest and concerns among academics in a variety of fields. Consequently, in recent years, research on how, when, and why people media multitask has strongly emerged, and the consequences of the behavior for a great variety of outcomes  have been explored. While efforts are made to summarize the findings of media multitasking research until date, these meta, and literature studies focused on specific research subdomains. Therefore, the current study adopted a quantitative method to map all studies in the broad field of media multitasking research. The bibliometric and thematic content analyses helped us identifying five major research topics and trends in the overall media multitasking domain. While media multitasking research started by studying its prevalence, appearance, and predictors, early research within the domain was also interested in the impact of this media consumption behavior on individuals' cognitive control and academic performance. Later on in 2007, scholars investigated the implications of media multitasking on the processing of media- and persuasive content, while its impact on socioemotional well-being received attention ever since 2009. Our analyses indicate that research within the field of media multitasking knows a dominant focus on adolescents, television watching, and cognitive depletion. Based on these findings, the paper concludes by discussing directions for future research. Technological innovations have vitalized the high accessibility and portability of media devices, which dramatically changed the way in which people engage with media nowadays. Especially the emergence of mobile devices strongly encouraged media users to engage in media multitasking, a behavior that is defined as the simultaneous performance of multiple tasks, of which at least one is a media task  keyword analysis and the  in-depth review of the content of the included studies , five different research topics came to the foreground, in which studies by researchers from various academic subdomains are combined. Furthermore, the evolution of studies is described within each research topic as well. Moreover, a substantial merit of the analyses of the subject's matter, is that it allows to detect the collaborations and/or thematic overlap among the different subdomains. The results of these analyses led to the identification of research gaps and potential future research opportunities. We believe that this approach offers an exhaustive, multidisciplinary and objective overview on the research that is specifically interested in today's ever growing digitalization and people's consequent chronic media consumption behavior.Although research on media multitasking has only known a steep increase in academic attention in recent years, many researchers in various disciplines pooled the insights of the multitude of studies in literature reviews and meta-analyses. Additionally, conceptual papers providing premises and underlying explanations to investigate in further research, accelerate the progression in this research area. Without questioning the added value of each of these overview articles, a bibliometric study across the different research fields and disciplines within the broad field of media multitasking, will contribute to the current state-of-the-art by providing a wide view on the field and this for various dependent variables such as learning and performance or socioemotional functioning. One recently published study specifically adopted a bibliometric analysis method to provide an insight into the research domain of multitasking in various contexts, but not specially related to multitasking with media use  to examine the impact of media multitasking on attention regulation. The meta-analysis of Jeong and Hwang  which journals and scholars are active in, contribute more to and have the most impact within this field; (2) which focus do media multitasking studies have, how are the topics related to each other and how did they evolve over time; and (3) what are the current research gaps in media multitasking research and which research paths are interesting for future studies. To solve these questions, both bibliometric and thematic content analyses were adopted and the results will enable future scholars to see where the field began and trace its shift over time , keywords, and references. This initial search included various document types that were written in a variety of languages. To guarantee the quality of the papers included in data analysis, we focused only on full-length and peer-reviewed articles and therefore did not include conference proceedings and books . This tool is compatible with the visualization tool VOSviewer that we used to visually present the results of our analysis.First, in the thematic content analysis was conducted to identify research clusters and trends in the research on media multitasking based on keyword and co-word analyses and an in-depth investigation of the content of the studies. The most frequently used words or phrases in the papers' titles and keywords were obtained using BibExcel and the co-occurrence of these keywords was visualized using VOSviewer. These analyses enabled us to identify the research topics in past media multitasking research. Each paper was carefully read and coded. These codes were then further used to categorize the papers in relation to the research topics. A joint content analysis was then conducted to examine the interrelations between the different subdomains and a dynamic content analysis has been performed to map the evolution of the different subdomains throughout the years.Second, a The first media multitasking article was published in 1990, which is relatively early, knowing that the topic did not receive much further research attention until 2011 see . AccordiComputers in Human Behavior with 53 articles (about one fifth of the articles in the sample), followed by Computers and Education, Journal of Advertising, and Media Psychology. When looking at the disciplines of the journals which are publishing media multitasking studies, communication (11%), general psychology (9.4%), and educational sciences (8.6%) are most prolific. Journals covering other disciplines, such as cognitive neuroscience (0.5%) or health (0.1%), contribute less often to media multitasking research.The selected 281 media multitasking articles appeared in 129 different journals. A total of 547 different authors could be identified in the media multitasking studies we analyzed. The large majority of authors (80%) published only one media multitasking study, whereas the remaining 20% (114 authors) published at least two papers that were included in our sample. As Authors currently affiliated to the University of Minnesota, Korea University, University of Amsterdam, Michigan State University, Myongji University, University of Waterloo and University of North Texas contributed the most to media multitasking research.h-index was explored which refers to an author's number of media multitasking papers (h) that have each been cited at least (h) times by other media multitasking studies. This index gives an insight into the quantity (in terms of number of studies in the domain) and quality (in terms of impact on other scholars) of an author's media multitasking publications. To measure the impact  of the media multitasking research on society, the altmetric score was used . This score gives insight into the number of mentions in online media such as Facebook, Mendeley, Twitter, and Wikipedia.A citation analysis  was used to identify the most influential authors cf.  and publThe results of this analysis reveals that Jeong obtained the highest number of citations in our sample and can be considered the most influential scholar in the media multitasking domain. Of all prolific authors identified in The most influential publication in our sample, both in terms of local and global citation index and in altmetric score was that of Ophir et al. . This paAn analysis of the title and keywords fields revealed a total of 909 title words which occurred 2,410 times and a total of 605 keywords which occurred 1,138 times in our sample. All title and keywords were then manually screened to group words with similar or identical meaning . From Until date, many researchers attempted to detect the antecedents and motivations of engaging in media multitasking behavior. Various characteristics related to the media and audience, such as socio-demographic factors  compared to attitudinal advertising outcomes  and might be moderated by a multitude of additional factors  and academic performance (cf. topic three). Besides, while the studies within the fourth and fifth topic often used depletion theories to build up their conceptual framework, they did not often actually measure depletion. More specifically, while they do touch these topics in their theoretical frameworks, only the very few researches that actually test the underlying role of this underlying mechanism  and the mobile phone use only really took off over the past 10 years, publications about these media in the multitasking literature only made an entrance in recent years. This was translated into the fact that keywords such as mobile phone and Facebook only appeared in more recent papers and show to increasingly gain popularity. In conclusion, while recent reports argue that 72% of adolescents report to media multitask with television and social network sites nowadays  indicates how often one multitasks when using media. As such, a person who only uses media for 30 min per day but media multitasks 90% of that time is considered as a greater media multitaskers than a person who engages in 12 h of media use per day but media multitasks “only” 50% of that time. Therefore, it might be interesting for future research to consider other media multitasking measures and larger sample sizes when further exploring the association between media multitasking and cognitive control.As argued above, our analyses revealed that media multitasking research knows a strong focus on adolescents. However, as it appears that people across all ages are fervent media multitaskers nowadays . Therefore, future research should aim to transcend the great overreliance on the cognitive mediators, as this one-sided approach might withhold us to get a complete picture of the media multitasking story.The results of the current study revealed that media multitasking studies do not only have a dominant focus on a certain audience and mediating variables, but also greatly focused on television watching when media multitasking. Even though the television has been widely adopted and integrated in current households, today's media landscape is rapidly evolving which urges for more research on popular media multitasking combinations in recent years. As such, while today's youth is exhaustively engaging in media multitasking with SNSs nowadays healthy behavior. For example, it has been suggested that both the presence of screens and the amount of distraction independently encourage people to eat more , media multitasking has affected the lives of many. Current research on media multitasking can be classified into five main topics, focusing on people's motivations to media multitask, the cognitive deficits related to this behavior and the impacts it has on three different outcomes: learning and academic performance; processing of media and advertising content; and socioemotional well-being. Insights from these studies helped us identifying research gaps. Accordingly, a future research agenda in terms of methodological issues, target groups, explanatory processes, media types and media content was proposed, and we hope that this may guide future research on media multitasking.The original contributions presented in the study are included in the article/EB contributed to the original conceptualization of the study, developed the theory, and wrote the original draft of the theoretical part of the paper. GY performed the analytic calculations and wrote the first draft of the methodological part of the paper. LH contributed to the original conceptualization of the study and assisted in the process of writing, reviewing, and editing the paper. VC assisted in the process of writing, reviewing, and editing the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Interactional quality was assessed with the Toddler version of the Classroom Assessment Scoring System (CLASS-Toddler) at three timepoints: pre-, mid-, and post-intervention. There were significant group differences in change in quality during the intervention period in both CLASS domains, Emotional and Behavioral Support (EBS), and Engaged Support for Learning (ESL), with greater overall differences in the ESL domain. Quality increased in the intervention groups, but quality decreased in the control group from baseline to post-intervention. There were significant group differences in quality at baseline. The Thrive by Three intervention had a positive effect on teacher-toddler interactions in both the EBS and ESL domains. Results need to be replicated preferably in more diverse samples.The effectiveness of the Thrive by Three intervention, a 10-month, multicomponent, in-service professional development model to promote the quality of caregiver-toddler interactions , was tested utilizing a clustered randomized controlled design. Eighty childcare centers with 187 toddler classrooms in Norway were randomly assigned to either the Thrive by Three intervention group (Clinical Trial Registration:ClinicalTrials.gov #NCT03879733. A third of all children in OECD countries under the age of 3years attend professional childcare . In NorwQuality of childcare is usually defined in terms of structural quality  and process quality  and some form of supervision, broadly defined as mentoring, coaching, feedback, or on-site support . Based oDespite this growing literature on how to improve process quality through professional development, important knowledge is lacking, especially on programs developed to improve caregiver-toddler interactions. A few very recent randomized controlled trial (RCT) studies have looked at the effects of teacher interventions on outcomes, such as language and math skills as well as problem behavior in toddlers . HoweverTaking advantage of a large sample of 187 toddler classrooms with 1,561 toddlers and their caregivers, the primary aim of this paper was to examine to what extent Thrive by Three improves the quality of caregiver-toddler interactions in an intervention group compared to a wait list control group, after a 10-month intervention period.The present study is part of the larger Thrive by Three cluster randomized clinical trial study see . Seven mThrive by Three is a 10-month CLASS-based professional development program specifically aimed at increasing the process quality in toddler classrooms in Norwegian childcare centers. The Thrive by Three intervention is grounded in transactional models for development , researcThrive by Three consists of four main components:Quality assessment and feedback. Process quality in all participating classrooms was observed by certified observers, using a standardized observation method, the Toddler version of the Classroom Assessment Scoring System  in groups of 5–8 supervising head teachers from centers in their municipality. The supervising head teachers met in groups 10 times together with their mentor during the intervention period. They focused on 1 or 2 CLASS dimensions at a time, agreeing among them which CLASS dimension they should focus on based on the needs of the supervising head teachers and on their experiences with supervising their staff. The mentors also followed a manual to ensure that the structure of the sessions would be as similar as possible. The mentors, in turn, met 10 times with the research team to receive supervision and coaching.Child development and mental health seminars. All childcare employees in the seven municipalities attended three full-day seminars that focused on research-based knowledge on infant and toddler development, mental health and its risk- and protective factors, early signs of mental and developmental problems, and crucial aspects of childcare quality. Head teachers from each classroom participated in one extra meeting that focused on supervision and how to address concerns about a child to his/her parents when necessary. Center leaders were also invited to participate in these meetings.Manuals, booklets, posters, and website. Manuals on the content and conducting of supervision were provided for head teachers and mentors. In addition, comprehensive written material was provided to parents and staff in the intervention group. Based on the Washington State Early Learning and Development Guidelines , mid intervention , and post-intervention  were assessed using the Classroom Assessment Scoring System (CLASS).The CLASS tool is an observational measure used to assess process quality in childcare centers . For Thrn=17) and center leaders (n=5) from childcare centers in the intervention group, special education teachers from the municipalities (n=5), and research assistants (n=6). The research assistants only served as substitute observers. Of the 33 observers, 18 observed (55%) at all three timepoints, six (18%) at two timepoints, and nine (27%) at one timepoint. The observers were trained by a certified CLASS trainer on the research team. After training, the observers scored five videotapes of toddler classrooms and reached the required reliability criterion of 80%. Booster sessions were conducted before and during the periods of data collection to maintain reliability throughout the project period. For the observers, observations meant time away from their childcare centers, and the centers were compensated financially so that they could hire substitute teachers.CLASS was coded by 33 trained observers. The observers were head teachers (The mean number of observations per observer at each timepoint was eight (T1), seven (T2), and six (T3). All classrooms were observed for 1.5–2h in the morning. Variations in CLASS scores have been observed across the day , so it wAt each timepoint, observers would observe childcare centers within their own municipality, but if the observers were either a head teacher or a center leader, they did not observe classrooms in their own childcare center. The observers did not observe the same classroom more than once. It was not feasible to have the observers blind to the classrooms’ status in terms of control/intervention. This was due to the nature of the intervention, where the childcare classrooms in the intervention group, but not wait list control classrooms, would receive immediate feedback and a written report after the observation provided by the observer.A portion of the observations was double-coded at baseline  and post-intervention . To assess inter-rater reliability, we used a two-way mixed model regression, with the domain EBS or domain ESL as dependent variable and raters and participants as crossed random effects . The intSample characteristics were described using mean and standard deviations for continuous variables and absolute and relative frequencies for categorical variables. Sample characteristics are reported at the classroom level see , becauseTo evaluate the effect of the Thrive by Three intervention on childcare quality at the classroom level, we used linear mixed models with the two CLASS domains and eight quality dimensions separately, 10 models in total. The classroom was included as a random effect, and time , condition, and their interaction were included as fixed effects. The effect of Thrive by Three versus control post-intervention was estimated as the difference in change from baseline for the two conditions in terms of the coefficient of the corresponding term condition×time. Normality of residuals was checked by visual inspection of Q-Q plots. In one case, for the variable Negative Climate, the Q-Q plot showed some deviation from normality. Hence, we also performed linear mixed model analysis using bootstrapping with 2000 bootstrap samples and the bias-corrected and accelerated (BCa) method. Results were substantially the same (data not shown).p values <0.05 were considered statistically significant, and 95% confidence intervals (CIs) are reported where relevant. Statistical analyses were conducted in IBM SPSS Statistics 23.As SD)=6.97 (0.14), range 6–7; control group: mean (SD)=6.92 (0.20), range 6–7]. Note that the Negative Climate is the only scale where a low scores indicates better quality. This scale was thus reversed in the statistical analyses.As Several in-service professional development programs have been developed to improve the quality of caregiver-child interactions . For the quality dimensions within this domain Facilitation of learning and development, Quality of feedback, and Language modeling, the difference in change of quality between the intervention and control group was evident already at mid intervention. This was true for only one of the five dimensions within the Emotional and Behavioral Support domain (EBS): Behavior guidance. The lack of effect on the Negative climate dimension is probably due to low variability and a “floor effect” with most classrooms scoring 1 or 2 and confirms what has typically been found in other studies . We alsoThe increase in the quality dimensions within the CLASS domain ESL was evident already mid intervention , but the improvement in the EBS domain was evident only post-intervention. One obvious reason for this difference may be that classrooms were typically scored higher on the EBS dimensions than the ESL dimensions at baseline, which is a typical distribution found in other studies using the CLASS-Toddler across different countries and contexts . Thus, tThe faster and greater change within the ESL domain may also in part be explained by the Norwegian context specifically. In a historical perspective, it is fairly new that so many toddlers enter childcare centers. The curriculum at the teacher colleges and universities has thus been limited in terms of the specific needs of toddlers, especially when it comes to learning and development. The focus has traditionally been more toward caretaking and children’s free play – without a specific and systematic focus on learning and development. That focus only became an explicit task for the childcare centers in 2017, when a revision of Framework Plan for kindergartens  was undeThis study is one of the few studies that have investigated the effectiveness of a professional development model developed specifically for toddler classrooms. The large sample size of 187 classrooms and 1,561 toddlers and their caregivers is another strength of the study. As highlighted by It is a strength of this study that caregivers did not choose to participate or not. We randomly assigned centers to intervention or control; thus, classrooms and teachers within these centers were assigned a group depending on the center’s status. This means that the caregivers/teachers could not opt out of attending the quality assessment and feedback (component 1), supervision and reflection (component 2), or the full-day child development and mental health seminars (component 3) of Thrive by Three.With some notable exceptions , most stIt is also a strength of the Thrive by Three model that we trained childcare teachers to become observers and supervisors. In addition, the mentors supervising the teachers were selected from facilities in the municipality that were already responsible for supervising the childcare centers. We also made sure, in cooperation with the center leaders, that supervision and workshops were scheduled during already planned non-contact time. This enhances the sustainability of the model and strengthens the applicability of the findings in a real-world setting. It is also a strength of the study that quality of teacher-child interactions was measured three times during the course of the year, meaning that we investigated differences in quality change through the cycle of the year and not just pre post, as is typically done.We recognize a number of limitations of the study. Although training teachers to be observers is a strength of the Thrive by Three model because it ensures that the competence gained through the participation in the study will be maintained in the municipalities after the end of the study, it may be a limitation in terms of methodological rigor. We found that classrooms in the intervention group had significantly higher mean scores on all CLASS dimensions at baseline, and the means, especially in the Emotional and Behavioral Support domain, were higher than what has typically been found in other samples using the CLASS-Toddler . This maAdditionally, although the observers were certified and reliable and inter-rater reliability was good, it is impossible for independent observers to be entirely accurate and consistent in their ratings. Teacher-child interactions vary from day to day, and it is always possible that the observations took place on a particularly good or bad day. Thus, the ratings of teacher-child interactions only provide a snapshot of quality that may not be entirely exact. Finally, it should be noted that an important limitation of the present study is the use of the CLASS as both the focus of intervention and an outcome measure, a circumstance that could reflect “teaching to the test.” The lack of a separate and perhaps more independent measure of observed teacher practice is a shortcoming of the work reported here, although it is important to note that the As far as we know, this study is one of very few to investigate the effectiveness of a multicomponent of in-service professional development model on the interactional quality between teachers and toddlers in childcare and thus helps fill an important knowledge gap when it comes to quality building in toddler classrooms – especially in a Norwegian context. The results support Thrive by Three as an effective multicomponent model for enhancing and maintaining the quality of teacher-toddler interactions through professional development. As Thrive by Three is a newly developed model, the findings need to be replicated in further studies, with preferably more diverse samples and other cultural settings to ensure broader applicability.Thrive by Three has a positive effect on teacher-toddler interactions in both CLASS domains; Emotional and Behavioral Support and Engaged Support for Learning. Whereas quality was enhanced and sustained in the intervention classrooms through the cycle of the year, quality decreased in the control classrooms.The original contributions presented in the study are included in the article/The study was approved by the Regional Committees for Medical and Health Research Ethics (REK) East-South (No:2017/430). Staff, teachers and parents provided informed written consent before participation, and parents provided consent on behalf of the children. Unless one parent had sole custody, both parents needed to consent. Participants could withdraw from the study at any time, without giving any reason.ESB, RL, and MBD wrote the first draft of the manuscript. ESB and SL carried out the analyses. TSB-N critically reviewed and commented on all drafts of the manuscript. All authors contributed to the article and approved the submitted version.The Thrive by Three study was funded by the Norwegian Research Council, award number 260624. The funder did not have any role in the design and conduct of the study.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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