"Access to healthcare is a human right": a constructivist study exploring the impact and potential of a hospital-community partnered COVID-19 community response team for Toronto homeless services and congregate living settings.

BACKGROUND: Individuals experiencing homelessness face unique physical and mental health challenges, increased morbidity, and premature mortality. COVID -19 creates a significant heightened risk for those living in congregate sheltering spaces. In March 2020, the COVID-19 Community Response Team formed at Women's College Hospital, to support Toronto shelters and congregate living sites to manage and prevent outbreaks of SARS-CoV-2 using a collaborative model of onsite mobile testing and infection prevention. From this, the Women's College COVID-19 vaccine program emerged, where 14 shelters were identified to co-design and support the administration of vaccine clinics within each shelter. This research seeks to evaluate the impact of this partnership model and its future potential in community-centered integrated care through three areas of inquiry: (1) vaccine program evaluation and lessons learned; (2) perceptions on hospital/community partnership; (3) opportunities to advance hospital-community partnerships. METHODS: Constructivist grounded theory was used to explore perceptions and experiences of this partnership from the voices of shelter administrators. Semi-structured interviews were conducted with administrators from 10 shelters using maximum variation purposive sampling. A constructivist-interpretive paradigm was used to determine coding and formation of themes: initial, focused, and theoretical. RESULTS: Data analysis revealed five main categories, 16 subcategories, and one core category. The core category "access to healthcare is a human right; understand our communities" emphasizes access to healthcare is a consistent barrier for the homeless population. The main categories revealed during a time of confusion, the hospital was seen as credible and trustworthy. However, the primary focus of many shelters lies in housing, and attention is often not placed on health resourcing, solidifying partnerships, accountability, and governance structures therein. Health advocacy, information sharing tables, formalized partnerships and educating health professionals were identified by shelter administrators as avenues to advance intersectoral relationship building. CONCLUSION: Hospital-community programs can alleviate some of the ongoing health concerns faced by shelters - during a time of COVID-19 or not. In preparation for future pandemics, access to care and cohesion within the health system requires the continuous engagement in relationship-building between hospitals and communities to support co-creation of innovative models of care, to promote health for all.

Program evaluation of a school-based mental health and wellness curriculum featuring yoga and mindfulness.

BACKGROUND: Interest in the effectiveness of mindfulness-based interventions such as yoga in primary schools has grown. Evidence shows promise, as youth who engage in yoga to promote mindfulness show improved coping skills, increased socio-emotional competence and prosocial skills, academic performance, attention span, and ability to deal with stress. OBJECTIVE: This study reports the results of a program evaluation of a universal health and wellness curriculum, Pure Power, designed to teach youth yoga techniques, mindfulness, and emotion regulation. METHODS: A non-randomized comparison design examined outcomes among participants from schools that completed the intervention with highest fidelity of implementation (n = 461) and from students in matched comparison schools (n = 420). Standard measures of coping, emotion regulation and emotion dysregulation, spelling, and math achievement were collected. RESULTS: Analyses suggest the youth in the intervention schools demonstrated relative improvement on measures of emotion regulation, spelling, and math. CONCLUSIONS: Challenges in implementation in real-life settings are vital to identify. The data provide some real-world evidence for the effectiveness of a universal health and wellness curriculum on emotion regulation and positive academic outcomes. Training school staff to deliver the intervention may foster implementation. Future research should test the effectiveness of who delivers the intervention; for example, teacher-delivered groups vs. other wellness personnel.

Evaluating the impact of using storytelling and visual multimedia music intervention to improve knowledge of the Child Rights Act and reduce the propensity to engage in child marriage.

Child marriage has continued to rear its ugly head in Nigerian society. This study aimed to evaluate the impact of storytelling and multimedia music interventions in improving knowledge of the Child Rights Act and reducing the propensity to engage in child marriage. The researchers applied a quasi-experimental design and collected data using a structured questionnaire. The children were assigned into three groups (control, storytelling and multimedia music) of 173 participants. It was found that the interventions were effective. In particular, while storytelling contributed more to reducing the propensity to engage in child marriage, multimedia music contributed more to improving knowledge of the Child Rights Act. These results suggest that storytelling and multimedia music interventions can be effective approaches for addressing the lingering problem of child marriage in Nigeria.

Paying attention to attention: a program evaluation of faculty-delivered mindfulness-based attention training to optimize wellness and professionalism in medical students.

BACKGROUND: As physician distress rises, medical schools must provide programs to counter such distress at the earliest stages of training. Mindfulness training (MT) is one intervention that can alleviate stress during medical school. However, framing MT around wellness alone misses the opportunity to connect core cognitive and psychological capacities strengthened by MT to professional goals and skill acquisition inherent to successful medical training. Here, we highlight how the attentional components of MT align with students' goals of becoming attending physicians while promoting academic, psychological, and interpersonal flourishing. MT courses that focus on strengthening attentional capacities can intuitively link academic and professional development with wellness, appealing to a wide array of students. METHODS: We iteratively recontextualized an existing short-form mindfulness training program for high-stress pre-professionals, known as Mindfulness Based Attention Training (MBAT), to the medical school context (MBAT-Rx). MBAT-Rx was offered by physician trainers to first-year medical students at Warren Alpert Medical School of Brown University as a tool for improving study habits and focus in addition to the development of both self-care and patient care strategies. MBAT-Rx consists of weekly, two-hour sessions over four weeks, with 10-15 min of daily mindfulness practice between sessions. At the end of the four weeks, students submitted voluntary program evaluation responses detailing their experience of the program. RESULTS: Optional program evaluation responses (n = 67) highlight that students found the program to be useful for their academic success and ability to pay attention, their interpersonal relationships, and their psychological health. By framing MT as an opportunity to boost core attentional capacities and connecting this to professional and academic goals in addition to wellness, MBAT-Rx appealed to a wide variety of students. CONCLUSIONS: Our ongoing work suggests that framing MT as both a professional development and wellness promotion tool, taught by physicians themselves, and structured around students' time demands, may be a successful model for medical schools looking to increase the impact of their mindfulness offerings. Such programs are needed to equip medical students to navigate the demands of a challenging healthcare training landscape.

Feasibility of Addressing the Spiritual Well-Being of Persons With Multiple Sclerosis: A Mixed-Methods Program Evaluation.

IMPORTANCE: Spiritual well-being is an important aspect of health-related quality of life for persons with chronic illnesses such as multiple sclerosis (MS), yet research on interventions remains limited. OBJECTIVE: To assess the feasibility of an occupational therapy intervention addressing the spiritual well-being of people with MS. DESIGN: Mixed-methods program evaluation using theoretical thematic analysis of qualitative data. SETTING: Community center serving people with MS in a midwestern U.S. city. PARTICIPANTS: A total of 42 participants attended at least one session; 22 participants provided qualitative data. Ten met the inclusion criteria for quantitative analysis, including completion of pretest and posttest measures and attendance of at least half of the sessions. INTERVENTION: Making Meaning, a group intervention based on the Model of Occupational Wholeness, was conducted over eight weekly 45-min sessions. The focus was on exploring and integrating spiritual practices into daily life. OUTCOMES AND MEASURES: Participants completed the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being 12-Item Scale (FACIT-Sp-12) to measure spiritual well-being and answered open-ended questions. Attendance was recorded and the facilitator and observers provided qualitative observations. RESULTS: Pretest-posttest comparisons of FACIT-Sp-12 scores indicated a moderate improvement in spiritual well-being (d = 0.41). Attendance and qualitative data supported the intervention's feasibility and suggested areas for refinement. CONCLUSIONS AND RELEVANCE: Making Meaning is a feasible intervention, showing promise for promoting spiritual well-being for people with MS. Further research is warranted. Plain-Language Summary: This study introduces a practical and acceptable occupational therapy group intervention, Making Meaning, which shows promising potential for improving the spiritual well-being of people with multiple sclerosis.

Tailoring a specific medical leadership development program for faculty members: the Lyon-Ottawa experience.

The development of leadership skills has been the topic of several position statements over recent decades, and the need of medical leaders for a specific training was emphasized during the COVID-19 crisis, to enable them to adequately collaborate with governments, populations, civic society, organizations, and universities. However, differences persist as to the way such skills are taught, at which step of training, and to whom. From these observations and building on previous experience at the University of Ottawa, a team of medical professors from Lyon (France), Ottawa, and Montreal (Canada) universities decided to develop a specific medical leadership training program dedicated to faculty members taking on leadership responsibilities. This pilot training program was based on a holistic vision of a transformation model for leadership development, the underlying principle of which is that leaders are trained by leaders. All contributors were eminent French and Canadian stakeholders. The model was adapted to French faculty members, following an inner and outer analysis of their specific needs, both contextual and related to their time constraints. This pilot program, which included 10 faculty members from Lyon, was selected to favor interactivity and confidence in older to favor long-term collaborations between them and contribute to institutional changes from the inner; it combined several educational methods mixing interactive plenary sessions and simulation exercises during onescholar year. All the participants completed the program and expressed global satisfaction with it, validating its acceptability by the target. Future work will aim to develop the program, integrate evaluation criteria, and transform it into a graduating training.

Tuakana-teina peer education programme to help Maori elders enhance wellbeing and social connectedness.

BACKGROUND: There are significant inequities between Maori (Indigenous people) and non-Maori in ageing outcomes. This study used a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation) to develop a tuakana-teina (literally older sibling-younger sibling) peer education programme to assist kaumatua (elders) in addressing health and social needs. The purpose of this study was to test the impact on those receiving the programme. Three aims identify the impact on outcomes, resources received and the cost effectiveness of the programme. METHODS: Five Kaupapa Maori (research and services guided by Maori worldviews) iwi (tribe) and community providers implemented the project using a partnership approach. Tuakana (peer educators) had up to six conversations each with up to six teina (peer learners) and shared information related to social and health services. A pre- and post-test, clustered staggered design was the research design. Participants completed a baseline and post-programme assessment of health and mana motuhake measures consistent with Maori worldviews. Open-ended questions on the assessments, five focus groups, and four individual interviews were used for qualitative evaluation. FINDINGS: A total of 113 kaumatua were recruited, and 86 completed the programme. The analysis revealed improvements in health-related quality of life, needing more help with daily tasks, life satisfaction, paying bills and housing problems. Qualitative results supported impacts of the programme on mana motuhake and hauora (holistic health) through providing intangible and tangible resources. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times GDP per capita. CONCLUSIONS: A culturally-resonant, strengths-based programme developed through a participatory approach can significantly improve health and social outcomes in a cost-effective way. TRIAL REGISTRY: Clinical trial registry: Trial registration: (ACTRN12620000316909). Prospectively registered 06/03/2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379302&isClinicalTrial=False .

Improvements in nutrition knowledge among adults with physical disabilities: A program evaluation of the mindfulness, exercise, and nutrition to optimize resilience (MENTOR) program 2020-2021.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) funds a quality improvement (QI) health promotion telewellness program for adults with physical disabilities. OBJECTIVE: The nutrition component of the parent program, Mindfulness, Exercise, and Nutrition to Optimize Resilience (MENTOR) program, from 2020 to 2021, was evaluated to assess changes in nutrition knowledge of people with physical disabilities. METHODS: This was a quasi-experimental program evaluation by pre-post survey of participating adults with physical disabilities. Participants attended weekly nutrition classes for eight weeks with optional one-on-one counseling with a Registered Dietitian. Participants completed pre-post General Nutrition Knowledge Questionnaire Revised (GNKQ-R) that were analyzed using paired t-tests. Participants were grouped into quartiles by pre-program GNKQ-R scores for additional comparisons. Program attendance and post-program feedback were also evaluated. RESULTS: A total of 286 participants completed the MENTOR program, and 31% (n = 89) completed pre-post questionnaires for data analysis. Mean pre-program GNKQ-R scores were 58.4 ± 15.1 and post scores were 64.4 ± 11.3, which demonstrated a statistically significant improvement in nutrition knowledge (p < .001). Ancillary analysis revealed that participants with the lowest quartile of pre-program nutrition knowledge had the greatest improvements in their post-GNKQ-R scores (Mean change 16.4 ± 13.9). Questionnaire data revealed participants' subjective knowledge changes and their feedback on the nutrition component of the program. CONCLUSIONS: The eight-week MENTOR program effectively improved nutrition knowledge among people with physical disabilities. This demonstrates the impact the program can have on individual knowledge levels. Additionally, these results support the implementation of the program to the broader population of people with disabilities.

A roadmap to establishing global oncology as a priority initiative within a National Cancer Institute-designated cancer center.

As the burden of cancers impacting low- and middle-income countries is projected to increase, formation of strategic partnerships between institutions in high-income countries and low- and middle-income country institutions may serve to accelerate cancer research, clinical care, and training. As the US National Cancer Institute and its Center for Global Health continue to encourage cancer centers to join its global mission, academic cancer centers in the United States have increased their global activities. In 2015, the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco, responded to the call for international partnership in addressing the global cancer burden through the establishment of the Global Cancer Program as a priority initiative. In developing the Global Cancer Program, we galvanized institutional support to foster sustained, bidirectional, equitable, international partnerships in global cancer control. Our focus and intent in disseminating this commentary is to share experiences and lessons learned from the perspective of a US-based, National Cancer Institute-designated cancer center and to provide a roadmap for other high-income institutions seeking to strategically broaden their missions and address the complex challenges of global cancer control. Herein, we review the formative evaluation, governance, strategic planning, investments in career development, funding sources, program evaluation, and lessons learned. Reflecting on the evolution of our program during the first 5 years, we observed in our partners a powerful shift toward a locally driven priority setting, reduced dependency, and an increased commitment to research as a path to improve cancer outcomes in resource-constrained settings.

Lack of Publicly Available Documentation Limits Spread of Integrated Care Innovations in Canada.

As healthcare in Canada is provincially operated, the program innovations in one jurisdiction may not be readily known in other jurisdictions. We examine the availability of implementation-specific data for 30 innovative Canadian programs designed to integrate health and social services for patients with complex needs. Using publicly available data and key informant interviews, we were able to populate only ∼50% of our data collection tool (on average). Formal program evaluations were available for only ∼30% of programs. Multiple barriers exist to the compilation and verification of healthcare programs' implementation data across Canada, limiting cross-jurisdictional learning and making a comparison of programs challenging.

Using the making Visible the ImpaCT Of Research (VICTOR) questionnaire to evaluate the benefits of a fellowship programme for nurses, midwives and allied health professionals.

BACKGROUND: There is increasing emphasis in the UK on developing a nurse, midwife and allied health professional (NMAHP) workforce that conducts research. Training for clinical academic careers is provided by the National Institute for Health and Care Research (NIHR). However, the low number of successful applicants suggested there were barriers to achieving this. The Centre for Nursing and Midwifery Led Research (CNMR) launched a fellowship programme in 2016 to backfill two days a week of NMAHPs' time for up to a year, to give them time to make competitive applications to the NIHR. AIM: To report a study evaluating the CNMR fellowship programme. DISCUSSION: The making Visible the ImpaCT Of Research (VICTOR) tool ( Cooke et al 2019 ) was developed to describe the organisational impact of research. The 2016-17 CNMR fellows completed VICTOR and their responses were analysed using a framework approach. The analysis found the main benefits of participating in the programme were protected time for research, opportunities to develop collaborations, increasing intra- and inter-professional awareness of NMAHPs' research, peer-reviewed publications, and conference presentations. Challenges included a lack of support from line managers, limited value placed on NMAHPs' research and failure to backfill posts. CONCLUSION: There were some challenges with the fellowship programme, but all recipients found it to be a positive experience and undertook significant scholarly activity. IMPLICATIONS FOR PRACTICE: A contractual agreement must be established to foster committed partnerships between higher education institutions (HEIs) and the NHS. HEIs and the NHS should conduct frank discussions of the challenges encountered in fellowship programmes. Positive initiatives and outcomes in tertiary education and clinical settings should be shared to improve fellows' experiences and enhance partnerships between HEIs and the NHS. Job descriptions should include time allocation to review fellowship candidates' applications regardless of outcome. The showcasing of research successes and the benefits of NMAHP research must evolve to secure organisational 'buy in', which is the precursor to widening access to clinical academic pathways.

Innovative Strategies to Address Systemic Inequities in Youth Sexual Health Programs: A Preliminary Program Evaluation.

Disparities in sexual health outcomes between racial and ethnic groups throughout the state of Washington suggest the presence of systemic inequities impeding young people's experience with and access to sexual health care and education. Emerging innovations in sexual health look to center young people, particularly those who have been historically excluded, in the design and implementation of programs that aim to serve them. The Washington Youth Sexual Health Innovation and Impact Network (WYSHIIN) and 11 grant-funded partners engaged communities of youth across the state of Washington, including Two Spirit, lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual (2SLGBTQIA+) and Black, Indigenous, and People of Color (BIPOC) youth, with the goal of equitably engaging participants and stakeholders to broaden services in schools and community settings. Evaluation staff from the Washington State Department of Health conducted virtual interviews with community partners for preliminary program evaluation purposes and identified 6 strategies for engaging youth. WYSHIIN partners highlighted strategies for centering youth voice and needs at all levels of program development and implementation, embracing holistic and culturally relevant approaches, and 2SLGBTQIA+ inclusion. These themes, reflective of wisdom across multiple Washington communities, offer strategies to address systemic issues that negatively impact youth access to and experience with sexual health care.

Methodological choices for an economic evaluation of a combined psychosocial and nutrition treatment intervention for children with severe acute malnutrition: The FUSAM trial in Nepal.

As a public health burden, severe acute malnutrition (SAM) among children has been increasingly studied to determine the optimal combination of treatment approaches. Among the new approaches is the addition of early childhood development sessions to standard nutrition-based treatment for SAM which can enhance both nutrition and development outcomes among young children. However, few studies demonstrate the relationship between the costs of such combined programs and the benefits accrued to the children and their caregivers. This article describes our experience of designing and conducting an economic evaluation alongside a cluster randomized controlled trial assessing a combined nutrition and psychosocial intervention for the treatment of SAM in children aged 6-24 months in Nepal. We present key lessons learned regarding methodological choices, the challenges of field data collection, as well as study adjustment when data analysis did not unfold as anticipated. With the view to transparency, this manuscript provides some clarifications on the evaluation processes for funders and policy makers on what economic evaluations entail and what information they convey for the purpose of supporting policy decision-making around limited resource allocation.

Implementation research: including breast examinations in a cervical cancer screening programme, Rwanda.

Objective: To evaluate whether integrating breast and cervical cancer screening in Rwanda's Women's Cancer Early Detection Program led to early breast cancer diagnoses in asymptomatic women. Methods: Launched in three districts in 2018-2019, the early detection programme offered clinical breast examination screening for all women receiving cervical cancer screening, and diagnostic breast examination for women with breast cancer symptoms. Women with abnormal breast examinations were referred to district hospitals and then to referral hospitals if needed. We examined how often clinics were held, patient volumes and number of referrals. We also examined intervals between referrals and visits to the next care level and, among women diagnosed with cancer, their initial reasons for seeking care. Findings: Health centres held clinics > 68% of the weeks. Overall, 9763 women received cervical cancer screening and clinical breast examination and 7616 received breast examination alone. Of 585 women referred from health centres, 436 (74.5%) visited the district hospital after a median of 9 days (interquartile range, IQR: 3-19). Of 200 women referred to referral hospitals, 179 (89.5%) attended after a median of 11 days (IQR: 4-18). Of 29 women diagnosed with breast cancer, 19 were ≥ 50 years and 23 had stage III or stage IV disease. All women with breast cancer whose reasons for seeking care were known (23 women) had experienced breast cancer symptoms. Conclusion: In the short-term, integrating clinical breast examination with cervical cancer screening was not associated with detection of early-stage breast cancer among asymptomatic women. Priority should be given to encouraging women to seek timely care for symptoms.

The implementation and evaluation of a mentoring program for Bachelor of Midwifery students in the clinical practice environment.

AIM: To describe the implementation and evaluation of a midwife/midwifery student-mentoring program in one Local Health District in Sydney NSW Australia. BACKGROUND: Evidence suggests well designed and supported midwife/midwifery student mentorship programs can make a difference to the clinical placement experiences and attrition rates of midwifery students. DESIGN: In the evaluation of the mentoring program, we used surveys, focus groups and individual interviews. METHODS: Eighty-six participants, including midwife mentors, midwifery students, non-mentor midwives and midwifery managers participated in the evaluation. Quantitative data were analysed using descriptive statistics and qualitative data, content analysis. RESULTS: The mentoring program increased midwives' mentoring skills and was beneficial to their professional growth and leadership skills. Students reported positive outcomes including someone to talk to, emotional support and a sense of belonging. Mentoring programs require structure, mentor training, organisational support and transparency. CONCLUSION: The mentoring program provided benefits to both midwifery mentors and students and demonstrated the value of a structured and supported mentoring program for midwifery students.

Exploring the critical factors influencing the outlying island talent recruitment and selection evaluation model: Empirical evidence from Penghu, Taiwan.

The declining birth rate, population ageing and the outbound migration of young people in recent years have created obstacles for local companies in recruiting skilled personnel. Similar factors have also affected recruitment in the outlying island of Penghu, Taiwan. Multiple-attribute decision-making (MADM) techniques for evaluation model development were incorporated in the present research to investigate the key determinants of talent recruitment by the coffee house operators in the outlying island of Penghu. The decision-making trial and evaluation laboratory (DEMATEL) approach was first implemented to (i) examine the extent of mutual impact between evaluation predictors and (ii) develop an influential network relation map (NRM) for indicator and sub-indicator assessments. Subsequently, the DEMATEL-based analytic network process (DANP) technique was utilised to compute the weights of every indicator and sub-indicator. Additionally, the modified VlseKriterijumska Optimizcija I Kaompromisno Resenje or VIKOR (in Serbian) approach evaluated every indicator and sub-indicator performance gap for empirical data analysis with suggested conclusions and recommendations. The results showed that the first dimension that should be improved is past experience, followed by personality traits and professional competence, according to the causal diagram of the NRM. The weights acquired through the DANP indicated that professional competence was the most influential dimension, followed by personality traits, whereas past experience was the least influential. Past experience revealed that the highest gap value is the most important for development if coffee house operators want to attain the appropriate levels. Finally, the theoretical, managerial, and practical implications were discussed. Notably, the research outcomes could optimise talent recruitment, establish appropriate talent recruitment methods for coffee house operators, and enhance the human resource quality in the outlying island of Penghu.

Remotely and collaboratively evaluating a campus-based therapy dog program during the COVID-19 pandemic.

The COVID-19 pandemic adversely affected the wellbeing of university students and adults in general, emphasizing the need for mental health programming that was compliant with physical distancing mandates. The present evaluation investigated mental health and social connection within the context of COVID-19 by remotely evaluating a virtual animal-assisted activity at the University of Saskatchewan - PAWS Your Stress. The purpose of this article is to outline our evaluation methods and findings, while calling specific attention to the collaborative strategies that were implemented within a remote, time-sensitive context. The evaluation findings revealed that remote animal-assisted programming can facilitate connections with humans and animals, and promote multiple mental health benefits, despite the lack of physical interaction with the animals. Our lessons learned indicate that remote program logic modelling workshops are feasible when suited to audience demographics. Further, our experience suggests that the Most Significant Change technique (a qualitative, participatory, storytelling method that elicits outcome data) can be useful in time-restricted evaluations, and the necessity of central steps in the process may vary depending on evaluation goals. This project has implications for future evaluation work, by demonstrating the effective use of remote methods that allowed for successful stakeholder collaboration.

Towards an evolutionary approach to learning from assumptions: Lessons from the evaluation of Dancing with Parkinson's.

This paper highlights how learnings from exploring assumptions can be strengthened by taking an evolutionary approach to theory building and analysis. We discuss theory-driven evaluation applied to a community-based intervention implemented by Dancing With Parkinson's in Toronto, Canada, targeting Parkinson's disease (PD), a neurodegenerative condition affecting movement. A major gap in the literature is understanding the mechanisms by which dance might make a difference in the daily lives of people living with PD. This study was an early exploratory evaluation to better understand mechanisms and short-term outcomes. Conventional thinking generally favors "permanent" over "transitory" changes, and "long-term" over "short-term" effects. Yet, for people living with degenerative conditions (and also people experiencing chronic pain and other chronic symptoms), transitory and short-term changes may be highly valued and welcomed relief. In order to study and link multiple longitudinal events to explore key linkages in the theory of change, we piloted the use of diaries, with brief entries filled out daily by participants. The aim was to better understand the short-term experiences of participants using their daily routines as a means of learning about potential mechanisms, what matters to participants, and to see if small effects could be observed on days when participants danced versus days when they did not dance and also longitudinally over several months. Our initial theoretical stance began with a view of dance as exercise and the well-established benefits of exercise; yet, we explored through the diary data collected, as well as client interviews and literature review, potential other mechanisms of dancing (such as group interaction, touch, stimulation by the music, and esthetics including "feeling lovely"). This paper does not develop a full, comprehensive theory of dance but moves towards a more comprehensive view that locates dance within the routine activities of participants' daily lives. We argue that given the challenges of evaluating complex interventions comprising multiple, interacting components, there is a need for an evolutionary learning process to understand heterogeneities in mechanisms -- what works for whom -- when faced with knowledge incompleteness in the theory of change.