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Perceptions of Undergraduates and Mentors on the Appropriateness, Acceptability, and Feasibility of the HEPI-TUITAH Micro-Research Approach to HIV Training in Uganda

Purpose To evaluate the perceptions of undergraduates and mentors on the appropriateness, acceptability, and feasibility of a mentored seed-grant (micro-research) by Health Professions Education Partnership Initiative - Transforming Ugandan Institutions Training Against HIV/AIDS (HEPI-TUITAH) program on HIV training in Uganda. Methods We conducted a cross-sectional descriptive qualitative study with focus groups, on HIV micro-research training, with undergraduate health professions students and faculty mentors across three partner institutions in rural Uganda. Results A total of 24 students and 13 mentors (5–8 per group) took part in the focus group discussions. Most participants stated that the HEPI-TUITAH micro-research program was acceptable, appropriate and feasible for health professions undergraduate students. The interprofessional education approach of bringing together students from different programs and years of study was valuable especially for peer mentorship. There was a need to provide for institution-based training in addition to the centrally organized training for the benefit of all the team members. Participants also noted a need for the program to find a way of providing the students with data collection experience even with the COVID-19 pandemic situation. Conclusion The HEPI-TUITAH micro-research program was perceived as acceptable, appropriate, and feasible for health professions undergraduate students. It also promoted teamwork and academic collaboration. Provision for institution-based micro-research training activities and data collection experiences for the undergraduate students even during the COVID-19 pandemic would make the program more valuable. The lessons learnt will be applied to future training cohorts to optimize program impact and may be useful for similar programs in other settings.

Introduction
Building research capacity is fundamental to improving health outcomes in resource-limited countries. 1 Training of health professionals in Uganda has traditionally focused on clinical skills with less emphasis on research. In practice, health professionals are expected to engage in research as collaborators, drivers, or partners but have limited or nonexistent resources and training. Empowering undergraduate students with research skills, and providing mentorship in higher institutions of learning is a good strategy for introducing a research culture among undergraduate students. 2,3 Introducing research skills early in training increases interest and later career engagement in research. 4 To that effect, Mbarara University of Science and Technology (MUST) received a five-year grant (R25TW011210) from the Fogarty International Center of the United States National Institutes of Health to support the HEPI-TUITAH (Health Professions Education Partnership Initiative -Transforming Ugandan Institutions Training Against HIV/AIDS) program. This program has three primary objectives: (1) increase the competency of undergraduate health professions students in the management of HIV; (2) enhance the capacity of primary health care providers to provide comprehensive HIV services; and (3) develop the capacity of undergraduate health professions students to conduct locally relevant research in HIV. HEPI-TUITAH consists of training and mentoring activities at MUST and her partner institutions (Bishop Stuart University -BSU and Lira University -LU in Uganda) in collaboration with Massachusetts General Hospital -MGH in the US.
Undergraduate students trained using an interprofessional education approach are more likely to become collaborative health professionals. 5 In HEPI-TUITAH, we embraced a inter-professional approach, training the students as members of an interdisciplinary team, [6][7][8] guided by the micro-research model. 9 Although the students' academic environments are different, practice environments are increasingly requiring inter-professionalism, thus requiring collaboration to draw upon each profession's strengths. 7 We integrated capacity-building for HIV/AIDS research into the training so that if they choose to stay and work (clinically or in research) in the rural setting, they have the requisite expertise and skills. Prior research suggests that students who train at rural institutions are more likely to stay and work in rural settings than those from urban settings. 10,11 In its third year of implementation, we set out to evaluate the perceptions of undergraduate health professions students and mentors on the appropriateness, acceptability, and feasibility of the HEPI-TUITAH micro-research approach to HIV training in Uganda. Implementation outcomes (acceptability, appropriateness, and feasibility) serve not only as indicators of the effects of implementation processes but also as preconditions for obtaining the desired results. 12 These outcomes are essential for monitoring and evaluating the success of implementation efforts and comparing the effectiveness of alternative implementation strategies. 13 As program leadership, we planned to evaluate implementation of the HEPI-TUITAH at two time points (ie, mid-term in Year 3, and end line Year 5) to compare the results and determine the success of the program.

Research Design Overview
This was a cross-sectional descriptive qualitative study that used focus groups with faculty mentors and undergraduate health professions students to evaluate the acceptability, appropriateness, and feasibility of the HEPI-TUITAH microresearch program as well as explore facilitators and barriers to program implementation. Focus groups were used to promote synergy among the participants, allowing exploration of collective memories, experiences, positions, practices, and desires. 14

HEPI-TUITAH Program Description
We provided competitive seed-funding opportunities to health professions undergraduate student at MUST and BSU in Mbarara District and LU in Lira District. Priority research areas included: a) utilization of HIV/AIDS services in the community, b) linkage between health facilities and the community, c) social and community factors affecting antiretroviral therapy adherence and retention in care, and d) HIV-related stigma and discrimination. 15 Multidisciplinary research team formation was encouraged within the participating academic institutions with representation from at least two health professions programs. Teams comprised of 4-6 health profession students and at least one faculty mentor. We proposed (in Years 2-4 of the HEPI-TUITAH program) to award 72 micro-research grants of up to $2000 USD each to health professions student research teams to conduct 12-month mentored research projects and publish/disseminate their findings. The HEPI-TUITAH program has so far provided micro-research awards to 44 teams (24 in Year 2019/20 and 20 in Year 2020/21). For each cohort of micro-research faculty mentors, the Uganda faculty took part in quarterly mentortraining sessions delivered by counterparts at MGH. The goal of the mentor-training sessions was to share best practices https://doi.org/10.2147/AMEP.S359777

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Advances in Medical Education and Practice 2022:13 324 on how to successfully support undergraduate health professions student teams to conduct micro-research and publish their findings.

HEPI-TUITAH Micro-Research Approach
We used the micro-research model 9 in which student research teams were taken through a scientifically rigorous process of concept development before micro-grants were awarded. MUST began to use the micro-research model in 2008 with a previous program, awarding junior faculty research teams micro-grants of $1500 -$2000 USD to conduct small interdisciplinary research projects. 16 We adapted the micro-research curriculum to the training needs of undergraduate students. It included the use of a multi-step process for selecting micro-research grant recipient teams from MUST, BSU and LU: Step 1: Request for micro-research grant topics. An advertisement was shared for distribution to the students.
Step 2: Screening of applications by the program implementation committee (PIC). Criteria included multidisciplinary team formation and relevance of research ideas to TUITAH HIV/AIDS priority areas.
Step 3: Training student teams in developing research concepts. In a 5-day training, research teams participated in hands-on concept development including formulation of research questions and objectives and selection of a design and methodology. The research teams then pitched their concepts for selection.
Step 4: Matching research teams to mentors. Successful research teams were matched to mentors at the home institutions (ie, MUST, LU, and BSU) to support full proposal development and implementation.
Step 5: Orienting mentors to the micro-research model. Mentors were trained on the micro-research model and their expectations of models as mentors, including supporting students in managing a research team, developing and managing a budget, balancing being a researcher and a student, and maintaining motivation.
Step 6: Research proposal development. Research teams and mentors underwent another 5-day hands-on training to develop full proposals and obtain ethics approval.
Step 7: Providing micro-grants for research implementation. Funding was released to the research teams through the respective institutions. Data collection took place over two months.
Step 8: Data analysis and manuscript writing. After data collection, the research teams took part in a final 5-day training on data analysis and manuscript writing.
Step 9: Dissemination of findings. All the mentored research projects disseminated their results in in peer-reviewed journals and a dissemination conference.

Focus Group Discussion (FGD) Participants
Participants were undergraduate health professions students and faculty mentors at MUST, BSU and LU whose research teams were successfully selected for funding in years 2019/2020 and 2020/2021. The micro-research team leaders and mentors were invited through different platforms (WhatsApp and telephone) to participate in the evaluation.
We held FGDs separately for students and mentors, enrolling a convenience sample of the first students and mentors to volunteer. Discussions were held in person (compliant with the social distancing guidelines at the time), grouping participants from MUST and BSU together based on co-location in Mbarara District; discussions involving LU were held separately.

Differences in the Implementation Process
The initial implementation strategy prior to the COVID-19 pandemic was to engage student teams face-to-face in all aspects of the training activities, and they were supposed to go to the communities for data collection. With the onset of the pandemic, we adjusted the implementation strategy to a hybrid of asynchronous (use of pre-recorded materials) and synchronous (in-person for only team leaders and mentors) training in proposal development, data analysis, and manuscript writing. The first cohort (2019/2020) of micro-research student teams were able to collect their data because the universities were not in session; however, with the second cohort (2020/2021), that was not possible because universities had reopened for the students to catch up on lost time; research assistants were engaged to collect data for the students.

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In terms of assigning mentors to the micro-research student teams, in the first cohort, the mentors and student teams were paired based on the availability of the mentors. With the second cohort of students, there were thematic research areas around which the student teams developed concepts and presented to the mentors before mentor-mentee pairing was done. The mentors had an opportunity to select teams based on their areas of interest.

Data Collection
Data was collected using semi-structured questions guided by the micro-research program aims, after piloting them for clarity. We asked open ended questions with probes for further clarification 17 on the acceptability (eg, team formation, mentor matching), appropriateness (eg, fitness for undergraduate students), and feasibility (eg, level of mentor commitment) of the micro-research program. See Supplementary Materials file for the full interview guides. Face and content validity of the questions were assessed by JH (implementation scientist), ZMT (medical education specialist), and CO (principal investigator).
After seeking written consent, EKW, VA, FN and CA led five FGDs, three with the micro-research student team leaders (two in Mbarara and one in Lira), and two FGDs with the mentors (one each in Mbarara and Lira). The research assistants (VA, FN and CA) were all trained prior to data collection. All the FGDs were conducted in private where the participants could freely express themselves. The discussions were audio recorded and field notes were noted immediately afterward.

Analysis
All audio recordings were transcribed verbatim and anonymized prior to analysis. Once complete, EKW, CKK, and GZR read through while listening to the recordings, inserting notations for pauses, laughter, and punctuations. Thematic content analysis was conducted by EKW and CA. Transcripts were independently coded by EKW and CA using implementation outcomes (appropriateness, acceptability and feasibility) as the a priori themes, and disagreements in coding were resolved at each step. The process involved identification of similarities and differences through the participants' narratives. Coding was done manually, grouping similar quotes together under broad themes while eliminating duplicates, and ensuring inclusion of data from different sources. CO provided oversight of the coding quality. 13

Ethical Considerations
Ethical approval was obtained from the Gulu University Research Ethics Committee (GUREC-2021-58) and permission to conduct the study provided by the Uganda National Council for Science and Technology (HS1351ES). Gulu University Research Ethics Committee is one of the many accredited IRBs under the Uganda National Science and Technology. The HEPI-TUITAH program is implemented in both southwestern and northern Uganda (ie, Mbarara University and Lira University respectively), all the research protocols for our undergraduate students at Lira University are reviewed by Gulu University Research Ethics Committee (there is no accredited REC at Lira University). We thus found Gulu University Research Ethics Committee relevant to review this research proposal. All participants provided written informed consent to take part in the study -The informed consent included anonymization of responses in the resulting publication.

Results
Of the 24 students and 16 mentors invited to participate in the FGDs, all students and 13 mentors took part; three mentors declined due to other engagements. The FGDs had 5-8 participants per group, and the discussions took place between March and April 2021, each lasting between 60 to 90 minutes. We present results from the FGDs in the form of a summary of the participant (mentors and students) responses to specific questions. Quotes from MUST and BSU have been labeled as Mentors, Mbarara and Student, Mbarara while those of at LU as Mentors, Lira and Student, Lira.

Theme 1: Acceptability of the HEPI-TUITAH Micro-Research Program
In this theme, we present participants perceptions on team formation, assigning of mentors, research capacity training, data collection, and pre-dissemination conference training. The students who participated in the micro-research activities encountered challenges of communication with the participants, because of poor team formation. Some teams did not consider the contexts for data collection to include local language speakers; instead, they looked for their colleagues with whom they spoke the same language: The experience I have from group formation …. We were told to get team members from different health professions programs … We got people we knew because we spoke the same language … my group had no local language speaker. … that was the bad experience I got from group formation and had to learn the hard way. (Health profession undergraduate student, Lira)

Assigning of Mentors
The mentors appreciated the thematic approach used when pairing them to the student teams stating that it allowed them flexibility to choose their areas of interest. This was in comparison to the approach used with the first cohort where the mentors and student teams were paired regardless of mentors' interests. Below are some quotes: One thing that I really liked was the fact that there were themes and each topic had to fall under some theme, … that helped the mentors to align their interest based on the theme. I found that very helpful with cohort two something that I felt we did not do in Cohort one. (Mentor, Lira) In the first cohort, we were appointed to different teams, we didn't even know the topics … when I compare to the second cohort, the team leaders presented their concepts to the mentors who were there, and we were told to choose the area we were comfortable with to work with the student teams. … that approach was the best. (Mentor, Mbarara) Regarding mentors' interests, most of the students appreciated the time that the mentors dedicated to them, however, some expressed frustration about competing priorities as illustrated in the quote below: If a mentor is busy, it is better they tell you openly "I am busy I might not make it to meet up with you" or "maybe I can't meet up with you, please send an email and I am going to respond to it later" …. Instead of giving you false hope … It was really demotivating; you feel like maybe he/she is not really interested in what we are doing … but I believe if they communicated what is of help … it is much better than giving you false hope. (Health profession undergraduate student, Mbarara)

Research Capacity Trainings
We employed synchronous training for only team leaders, due to the COVID-19 restriction that limited large groups, as a creative solution for the continuity of program activities during the pandemic. However, the team leaders felt overwhelmed without the support of team members. They took in a lot of information with no opportunity of comparing notes with the team members in case one understood a concept differently.
During proposal development, we had very limited time and most of us were first-time researchers … I remember the training was for five days and we used to have it in the evenings after classes, so the work was a lot in a short time. (Health profession undergraduate student, Lira) The approach to training in the second cohort was very innovative and far much better than the first cohort; however, only one student out of five was trained because of COVID … It is understandable but it was too much information for one student to take in for the first time. These are students we met on Monday and started working with them expecting that at the end of the week we had a draft proposal … it was overwhelming. (Mentor, Mbarara) The students reported data analysis training as difficult but found the support of the trainers very helpful. They were excited about having a manuscript with their names as first authors.
What interested me so much was the part of data analysis although it was one of the hardest parts … It was really a very good experience having professors training us on how to analyze those data both the qualitative and quantitative. … We really learnt a lot from them. (Health profession undergraduate student, Lira)

Data Collection Process
Most participants did not find the data collection process with the first cohort of students acceptable, because not all of them got the opportunity to go to the field for data collection process. However, those who took part in data collection learnt a lot.
We were all involved in proposal development so everyone got the knowledge … But when it came to data collection, we were told that only three people were supposed to go to the field because of COVID. We know that COVID was a major challenge, but we had expected that everyone would go and learn how to ask questions and get exposure on how to approach participants.
(Health profession undergraduate student, Mbarara) Being a first timer in carrying out a qualitative research, it was a very good experience interviewing people and interacting with them … The process of data collection was so interesting, my team members missed. (Health profession undergraduate student, Lira) Although demotivated by this approach, the students understood that it was the right approach in such unprecedented times.
We were supposed to go for data collection, and we really needed that experience, but it just turned out that we were not going … but I understood because it was not feasible as we were also supposed to be having our lectures. … The issue of research assistants, they were helping us as we were catching up with our lectures. Really, I just appreciate the services the program is giving us. (Health profession undergraduate student, Lira) It was very demotivating, after spending sleepless nights working on the proposal and they say "you are not going to do data collection", that they had to get research assistants … The training in responsible conduct of research was the best for us who were supposed to do data collection … It was unfortunate we didn't go … but I think if they could get for us a chance, but COVID may still be around … Let students go and do data collection for purposes of learning. (Health profession undergraduate student, Mbarara) In response to COVID related restrictions on students going for data collection, some mentors innovatively engaged the micro-research team leaders in the data collection process as exemplified below: I have always tried to drive around with my team leader provided he was free; I took him to the field and showed him how to supervise data collection if he is not the one doing it. … "do this, and if there is a mistake correct it, and replace this with this". I think that the team leader learnt a lot from the sessions that we have had together doing the supervision. (Mentor, Lira)

Pre-Dissemination Conference Training
All participants found the training timely and beneficial to the students who disseminated their research findings in October 2020. Their confidence had been built and they put up impressive presentations during the conference.
The training was very important because it helped us build our confidence, … They made us present to the people who were around so during the process we became more confident and more familiar with the content we had and improved our slides and presentations skills. (Health profession undergraduate student, Lira) The pre-dissemination training was quite short, just one day but it was a productive day. We worked under pressure, but I would commend it so much because it gave us confidence; it was a real drill because you would do something, and they real show you that this is not something that goes outside this room. You cannot say it anywhere outside the door; so, you would also feel that you must do something that can be presented properly. (Health profession undergraduate student, Mbarara) You can imagine people presenting for the first time … Going through the presentations over and over helped them to acquire presentation skills and understand their document better. Majority were not familiar with their work, but as they went through over and over, they mastered it and the presentations were better. In this theme, we summarize participants perceptions on the appropriateness of the inter-professional education approach used, fitness of the micro-research program for undergraduate students, organization and presentation of the learning materials, and the mentor session provided by our international partners (MGH).

Inter-Professional Education Approach
Both students and mentors found the approach very useful in harnessing their different views because they all contributed to the development of strong research proposals.
We had multidisciplinary professions from the midwifery, psychology, and public health. These all brought different input … Everyone had something to contribute to the research … So, I think that approach is an excellent one. (Health profession undergraduate student, Lira) The students were able to appreciate and learn from each other because they had different roles … It is a very good approach, combining different classes and age groups … You realize that each of them is very important, and each has a role to play. (Mentor, Mbarara) However, bringing the inter-professional teams together was challenging given that the different programs and years of study had different schedules. The team leaders reported shouldering the bulk of the work. They also noted there were hardly any opportunities when all the members were available at the same time.
We had different timetables … You find people are coming from Pharmacy, Nursing, etc. and you have different schedules, so finding time to come together and look through these issues was sometimes difficult … I had to go it alone most of the time.

Fitness of Program for Undergraduate Students
The participants found the mentored research program useful in introducing undergraduate students to research. They felt better placed in terms of research capacities including funds management than their colleagues who did not attend the training. Most participants believed that the HEPI-TUITAH training model of introducing undergraduate students to research was good.
When you go through the HEPI-TUITAH trainings, at least you have some knowledge that anyone else around wouldn't be having and you are at least at some higher level than the rest of the students who did not attend. The trainings were good because the knowledge gained is used … (Health profession undergraduate student, Lira) Giving students some money to facilitate the research process helps to enhance the quality of the work they are doing. … This model is very good in helping to introduce the undergraduate students to research and how to go about managing the entire process including the funds that come along with the research. (Mentor, Lira)

Organization and Presentation of the Learning Materials
Some mentors were glad that there was an arrangement in place to benefit the intended learners; however, they were doubtful about the utilization of the learning materials by the students who did not attend the in-person classes.
It was good having varied ways of trying to bring those ones who do not attend in-person to learn … although it is very challenging to have students listen all through the presentation. We struggle with them in online learning … my feeling is that a good number of them may not actually listen to the recording, and they miss out and yet being part of the team, they should benefit. (Mentor, Lira) Mentors stated that it was their responsibility to support the students team members to learn when they could not attend the in-person trainings. They stressed the importance of the team leaders in the meetings with the team members who did not gain the opportunity:

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I think it's up to the mentors, if you get an opportunity, it's good to just have a few days in a week with the team members and the leader who attended the training to go through the learning materials and have a discussion through … Sometimes students just need to be reminded that they have a resource which they need to utilize. (Mentor, Lira)

Mentor Sessions by International Partners
All the Ugandan mentors found the mentor training sessions by faculty at MGH beneficial and felt the skills gained were useful for professional development beyond the HEPI-TUITAH activities. They acknowledged that mentoring was not straightforward and that they were open to learning.
They are beneficial … They provide good information that is helpful in professional development and can be used outside HEPI … They provide reference material that is helpful when working with our research teams. (Mentor, Mbarara) Those sessions have been useful … mentoring is not obvious. There are things that we could have missed which we have been able to correct with the training sessions. I can rightly say that it's not only the students that have learnt; mentors have also learnt a lot from the international mentors, and we hope to learn more if we could continue with those sessions. (Mentor, Lira) Mentors noted that they had learnt a lot but needed more skills in conflict resolution and management between mentors and students. They thought that conflicts arise because of different personalities in the team and were thus interested in learning more about the different personality traits and how they can be handled.
There is need for a session on the different personalities of people within the group, and how to handle one another. Many people don't know how to deal with those differences. (Mentor, Lira)

Theme 3: Feasibility of the HEPI-TUITAH Micro-Research Program
In this theme, we present the perceptions of the participants on the level of involvement, and the commitment of the mentors, the mentoring program as well as the knowledge and skills gained by the students.

Level of Mentor Involvement
Once the cohort one research teams had been paired with mentors and expectations clarified, the program leadership trusted that the processes would flow as planned. However, there were communication gaps between the program, mentors, and student teams; roles and expectations of either party were not clearly understood, and mentor involvement was sometime minimal. With the streamlined communication in cohort two, timelines were clarified, and deliverables set. The second approach was appreciated because it addressed the gaps faced with the first cohort.
I have been in both cohorts one and two and believe me in cohort one I almost felt that I was not part of the mentoring process … There was a big gap between the students and myself. … I would feel like the students were reserving something … When I would ask, they did not want to say anything about it … It was tricky, so I pulled back to see how far we would go. But in cohort two it has been very involving. The mentors have been fully engaged because of the modifications made by the program leadership. (Mentor, Lira)

Commitment of Mentors
Whereas the mentors found the level of commitment very demanding (eg, overseeing manuscript writing), most of them were motivated by the opportunity to publish a manuscript.
Sitting for one-week training from morning until late at night was challenging especially given our age [participants laugh] and other work demands. … You know … You must support them [students] to do everything, that was too much commitment required … although rewarding at the end when the work is published.

Knowledge and Skills Gained
Regarding knowledge and skill acquisition, participants stated that the micro-research program positively empowered undergraduate students. They noted being able to write academic proposals for their work and believed that they would be able to publish their research. Here below is what they stated: I learnt how to develop a proposal in two days, well cited, and ready for presentation and I can defend it; I can go and collect any type of data, whether qualitative or quantitative. I can analyze data in the shortest time possible, and I can write a manuscript … I will be able to publish my undergraduate research. (Health profession undergraduate student, Mbarara)

Suggestions for Improvement
The key recommendation from the mentors was for the HEPI-TUITAH program to consider supporting institutional pretraining sessions before the centrally arranged training which brings together all team leaders and mentors. This suggestion was made in bid to prepare the students to better understand their work before the 5-day intensive training on proposal development, data analysis, and manuscript writing. This approach would give mentors and student teams ample time to familiarize with their work, as well as benefit the other team members who do not attend the in-person training due to COVID-19 restrictions.
There needs to be preparatory workshops institutionally which are mentor led so that students galvanize the knowledge before the actual 5-days intensive training. … Since every institution has their own dynamics, they could be given the autonomy to make their own arrangements … but should be given a timeline within which to actualize the training and provide a report before the date can be fixed for a formal training. (Mentor, Lira) If we have for example a training on proposal development, we organize something in house then we have this with the students go through the basics and make sure the students are prepared for the main training. Usually what happens when we go through the one-week training, the mentor does all the work because the student is basically lost … We could have those sessions for one or two days within our institutions. (Mentor, Mbarara) The students' suggestions for improvement included formalized peer to peer mentorship of the student research teams from the previous cohort members, inclusion of all team members in the training sessions to promote motivation and teamwork, and mentors support for administrative clearances from data collection sites.
Having previous leaders take part in other cohorts would build the capacity of the students to be able to conduct independent research … The way we have mentors who were in cohort one working with students, can't we also have the students who took part in the previous cohort work as peer mentors? This will enable them to stand on their own in research … They can also share the knowledge with other students. (Health profession undergraduate student, Mbarara) Getting clearance from the districts takes time … You find that you have missed a lot in class and you may not get time to compensate for that … You may get the lecture notes but miss the verbal communication from the lecturers in class which is not in the notes … Can the mentors help with such clearances? (Health profession undergraduate student, Lira)

Discussion
The findings from this evaluation summarize the perceptions of the participants regarding the acceptability, appropriateness, and feasibility of the program. Overall, they felt the HEPI-TUITAH program was successfully implemented. Specifically, participants expressed positive perceptions and views on processes, such as team formation, assigning of mentors, research capacity training, data collection, and pre-dissemination conference training, as having been key to the acceptability of the program. Participants also expressed that the inter-professional education approach, fitness of the micro-research program for undergraduate students, organization and presentation of the learning materials, and the mentor sessions provided by the

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international partners (MGH) were very appropriate. Similarly, other perceptions of the participants were that the level of involvement, the commitment of the mentors, and the mentoring program as well as the knowledge and skills gained by the students contributed to the feasibility of the micro-research. We designed the HEPI-TUITAH micro-research program to support training and mentoring activities at three rural institutions in Uganda that are involved in training health professions undergraduate students to fight against HIV/AIDS. We envisaged that the undergraduate students at the partnering institutions would gain experience working together in inter-professional teams through micro-research engagement. The period under evaluation had two cohorts of students participating in using different implementation approaches. This engagement was complicated by the unprecedented COVID-19 pandemic.
Accordingly, we designed a change management strategy of using a hybrid of asynchronous and synchronous method for training. For asynchronous learning, pre-recorded learning materials (audio and video) were uploaded online, while in-person training was for only team leaders together with their mentors. 18 We chose this method because it has been successfully used with undergraduate students elsewhere, it has the advantage of improving the independent learning ability and self-regulate thinking, 19 and the students are able to pause, rewind, and fast forward the content to process information at their own pace. 18,20 There was also a need to promote continuation of the program micro-research activities. However, the hybrid approach was not received well by all the participants, it was a demotivation to the team members who felt excluded from the in-person trainings. This situation is not unique to the HEPI-TUITAH microresearch program; similar barriers have been encountered in medical education. 21,22 In this study, we used acceptability, appropriateness, and feasibility not only as outcome indicators for implementation 13 but also for assessing the implementation process. 12 Doing this was useful in showing us the strengths and weaknesses in the approach used. It provided a structure of short-and long-term improvement when handling the next set of undergraduate health professions students. We identified weaknesses in the implementation strategies from the traditional face-to-face approach used with the first cohort of micro-research student teams to the hybrid asynchronous and synchronous with the second one. The HEPI-TUITAH program being mid-way its implementation, these weaknesses need to be considered when planning for the next cohort of the micro-research student teams. Three take home messages from this evaluation are as follow: (1) The interprofessional education approach used in training students from different programs and years of study together, and then letting them work in small groups on their research projects was perceived as valuable and promoted peer mentorship, teamwork, and academic collaboration. We used this approach to develop the health professions students as future interprofessional team members, as recommended by the Institute of Medicine. 5,7,8 Our participants (students and mentors) found the approach valuable in enhancing teamwork and collaboration. This approach has been used with both undergraduate and graduate health professions students in other studies and was found valuable. 8,23 Evidence shows that medical students are perceived to learn more from small-group sessions in medical education compared to lectures only. 24 According to Proctor et al: Acceptability is the perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory, while Appropriateness is the perceived fit, relevance, or compatibility of the innovation or evidence-based practice for a given practice setting, provider, or consumer; and/ or perceived fit of the innovation to address a particular issue or problem. 12,13 Based on these definitions, the interprofessional education approach used in the HEPI-TUITAH microresearch program was acceptable and appropriate.
(2) There was a need to provide for institutional-based micro-research training activities in addition to the centrally organized ones so that all the team members, not just the team leaders can benefit. Although the HEPI-TUITAH strategy of training the micro-research student team leaders together with their mentors was perceived as beneficial in terms of best practices from a wider array of participants, it could only accommodate few people due to the COVID-19 restrictions on large gatherings. As a consequence, it is assumed that other team members missed out on the knowledge and skills gained by the team leaders. The participants (mentors) had no guarantee that the students were utilizing the pre-recorded learning materials to promote learning as intended by the program, thus their proposition for institutional based in-class training. Thus, the experiences with online learning were not perceived as the same as in-person and likely due to the absence of a live trainer who can guide the application of knowledge. 18 (3) The need for the HEPI-TUITAH program to provide data collection experience for its micro-research health professions students during the unprecedented COVID-19 pandemic situation cannot be overstated. It calls for the HEPI-TUITAH program to think about the delicate balance of letting the undergraduate students gain the data collection experience without either compromising their interrupted undergraduate training or endangering them to the highly infectious disease in the name of research. Clearly, health research training for undergraduate medical education and allowing the students to participate in research activities is very important. 26,27 The health professions undergraduate students need to gain research skills which will help them in improved patient's care due to increased levels of knowledge and reasoning skills, as well as development of a positive work attitude. 28,29 In this study the mentors clearly stated that they found value in the training (as a form of professional development) and they found value in the publications they obtained. While for the students, the small amount of funds that were provided was a driver to engage in the research and appeared to have created a sense of motivation and accountability.

Strengths and Limitations
Our study had a number of strengths. Having different data sources (students and mentors from three different institutions) in the focus groups strengthened the results in this study and promoted synergy among the participants, allowing exploration of collective memories, experiences, positions, practices, and desires. 14 The participants provided insightful information that will be used as a catalyst for improving the last phase of the micro-research activities at MUST, BSU and LU. The study also had limitations including social desirability bias. Although our micro-research program seems to have several inherent benefits to the health professions students, we did not interview the institutional managers in this study for their perceptions about our engagement of students, and the sustainability prospects at the end of the HEPI-TUITAH funding. This component will, however, be included in the end-line evaluation.

Conclusions
The perceptions of students and mentors in the mid-term evaluation across the three partner institutions show that the HEPI-TUITAH micro-research program was largely acceptable, appropriate, and feasible for health professions undergraduate students. The interprofessional education approach of training students from different programs and years of study together was valuable and promoted peer mentorship, teamwork, and academic collaboration. Micro-funds appear to increase students' motivation and accountability, while faculty are motivated by training and opportunities to publish as currency to engage in mentoring students. However, there was a need to provide for institutional-based micro-research training activities in addition to the centrally organized ones, as well as data collection experiences for the undergraduate students even during unprecedented pandemics like COVID-19. These lessons will be applied to future training cohorts to optimize program impact and may be useful for similar programs in other settings.


Environmental Enrichment Factors Associated with the Activity Level of Bottlenose Dolphins under Professional Care

Environmental enrichment can be used to improve the welfare of dolphins in zoos and aquariums. Bottlenose dolphins under professional care are typically provided with a range of enrichment that has a variety of features and levels of complexity at various frequencies. In the present study, a subset of data from a larger study entitled “Towards understanding the welfare of cetaceans in zoos and aquariums” (colloquially called the Cetacean Welfare Study) was used to examine the relationship between activity level and enrichment buoyancy as well as enrichment provisioning schedules. Survey data were collected from accredited zoos and aquariums related to the types of enrichment provided to the dolphins and the frequency and duration they were supplied. Non-invasive bio-logging devices were used to record the dolphin kinematics one day per week over the course of two five-week data collection periods. Activity level related positively with the total duration of time non-stationary enrichment was provided. In addition, providing a larger number of enrichment types each between 26% and 50% of the days in a month (i.e., rotating many different types of enrichment across days on a moderate schedule) was positively related to activity level. Activity level was negatively related to the number of times sinking enrichment was provided. Understanding how the temporal schedule and features of various types of enrichment are related to activity levels will aid in developing progressively more effective enrichment programs.

Introduction
Environmental enrichment is a tool used by animal care staff to improve the welfare of cetaceans under professional care. Environmental enrichment is designed to provide opportunities for mental and physical stimulation and to encourage species-appropriate behavior through the addition of stimuli [1,2]. The goals of enrichment are to promote engagement, increase behavioral diversity, provide opportunities for behavioral choice, and give the animals control over their environment [3][4][5][6]. To achieve these objectives, environmental enrichment programs can incorporate enrichment types that function to stimulate cognitive, visual, auditory, feeding, and social systems [7].
Animals engaging in species-appropriate levels of activity is an important indicator of welfare [8]. While larger habitat sizes have been correlated with increased traveling distances for some terrestrial species [8], expanding the size of a habitat does not always result in increased habitat use or positive welfare. For example, chimpanzees (Pan troglodytes) transferred to a larger habitat did not locomote more often after the transfer [9]. Similarly, larger habitats were not associated with increased locomotion for African (Loxodonta africana) and Asian (Elephas maximus) elephants [10]. For these elephants, feeding diversity and an unpredictable feeding schedule were most influential in walking distance.
Enrichment is one tool that has been used to increase active behaviors and locomotion in several species in zoo environments. For example, food enrichment increased activity by 30% on days when it was provided to Asian elephants [11]. Hiding food inside of objects and throughout the enclosure of harbor seals (Phoca vitulina) increased the rate of species-appropriate foraging behaviors [12]. Food enrichment also increased the active behaviors of six species of felids [13]. Enrichment objects and problem-solving tasks are effective tools for increasing positive social play for chimpanzees (Pan troglodytes) and bottlenose dolphins (Tursiops truncatus) [14][15][16]. However, when floating ball and buoy enrichment is available to bottlenose dolphins, average swimming speeds can decline as they spend time swimming at a slower speed around the enrichment [17]. While many aspects of environmental enrichment have been investigated for bottlenose dolphins, very little has examined its relationship with activity level. For a detailed review of marine mammal enrichment in zoos and aquariums, see Brando et al. [18].
In addition to examining activity levels through monitoring active and locomotive behaviors, bio-logging tags can be used to record data about an individual animal's movement and orientation [19][20][21][22]. Bio-logging tags record fine-scale information related to an animal's movement, behavior, physiology, and/or environment [23]. In zoos, these types of wearable tags have been deployed to investigate activity budgets [11,22,24], recumbency [25,26], walking distances/locomotion [10,27,28], estrus [29], body orientation [24], and behavioral states [30]. Bio-logging devices are powerful tools for monitoring aspects of activity-related welfare as activity level is a contributor to and an indicator of health [31]. For example, low activity levels can be considered an indicator of poor welfare [32,33], while active behaviors can mitigate the risk of developing some illnesses [34][35][36]. For bottlenose dolphins under professional care, the frequency of receiving new enrichment on a monthly/weekly basis has been associated with increased activity level when compared to receiving new enrichment less often [37]. In addition, providing enrichment on a random schedule was associated with reduced activity level when compared to a predictable schedule.
Previous research suggests that enrichment can be used to improve animal welfare by increasing activity levels [10][11][12][13]. The relationships between ODBA and demographic, training, and environmental variables such as age, sex, training session duration, habitat type, and social management were explored in a prior publication [37]. The findings suggested that receiving enrichment on a random schedule was associated with lower ODBA values than receiving it on a predictable schedule, and higher ODBA values were associated with providing novel enrichment on a monthly/weekly schedule compared to a yearly/year+ schedule. Thus, the goal of the present study was to dive deeper into the relationships between ODBA and enrichment features. The present study explored more deeply how access to enrichment and the features of the enrichment are related to the activity levels of dolphins in accredited zoos and aquariums.

Subjects and Facilities
The data presented in the current study were collected as one component of a larger study entitled "Towards understanding the welfare of cetaceans in zoos and aquariums" (Cetacean Welfare Study). All zoos and aquariums accredited by the Alliance of Marine Mammal Parks and/or Aquariums or the Association of Zoos and Aquariums that housed common and Indo-Pacific bottlenose dolphins (Tursiops aduncus), beluga whales (Delphinapterus leucas), or Pacific white-sided dolphins (Lagenorhynchus obliquidens) in 2017 were contacted regarding participation in the Cetacean Welfare Study. Zoos and aquariums that agreed to participate were included in the study. Data were collected for two common bottlenose dolphins or Indo-Pacific bottlenose dolphins living in each of the participating habitats using a semi-random sampling design in order to create a balanced representation (i.e., age/sex) of dolphins under professional care at these locations. Bio-logging tag (MTags) data were collected from a total of 65 dolphins at 35 facilities. Participating facilities were in Bermuda (n = 1), Hong Kong (n = 1), Jamaica (n = 2), Mexico (n = 15), Singapore (n = 1), Spain (n = 1), and the United States (n = 14). Dolphin habitats included both professionally managed zoo/aquarium habitats and professionally managed ocean habitats. Professionally managed zoo/aquarium habitats were defined as fabricated habitats with or without exposure to weather patterns. Professionally managed ocean habitats were defined as cordoned-off sections of coastal ocean, bays, lagoons, or waterways. In the present manuscript, they will be collectively referred to as "habitats".

Data Collection
Data for the Cetacean Welfare Study were collected during two five-week data collection periods. The first data collection period was from July 2018 through November 2018, and the second period was from January 2019 through April 2019. The present study used a subset of data from the Cetacean Welfare Study, which included environmental enrichment data from a management survey (Section 2.3) and measures of physical activity obtained from MTags (Section 2.4). The management survey (English language) was sent to staff at participating facilities via an online link (Momentive Inc., San Mateo, CA, USA) in 2018. Six bottlenose dolphins that participated in the 2018 data collection period were unable to be retained for the 2019 data collection period, and six new bottlenose dolphins (from the respective habitat) were added to the study for the second data collection period. Surveys for the additional six individuals added to the 2019 data collection period were distributed in 2019. Upon submission, response reports were stored on a secure server and were de-identified for analysis. To collect bio-logging data, two bottlenose dolphin participants at each location wore the MTags on a Tuesday and Friday alternating schedule. The MTags were worn throughout the dolphin's normal daily activities once per week.

Management Survey
Staff from each of the participating zoos and aquariums completed a survey of management practices related to their two focal dolphins. Survey respondents were animal care and management staff who worked directly with the focal dolphins. Each focal dolphin's name was embedded in the questions to ensure that responses were specific to each observed dolphin. Experts in animal welfare, cetacean management, and veterinary medicine developed the survey questions. Questions were presented conditionally based on the previous response. The survey requested information regarding the dolphin's demographic information, the facilities' enrichment and training practices, and the habitat characteristics. Specifically, the enrichment section included questions about the types of enrichment available to the dolphins, the enrichment's features (i.e., floating or sinking), the number of days per month the focal dolphin had access to the enrichment, and the average duration of time that the dolphin had access to the enrichment (Supplementary Material). The options for types of enrichment included: above water and scuba play, balls/buoy, boomer/beach balls, bubble machines, changing conspecifics, dead fish, feeder balls/spools, foam rollers/bats/sticks, hula hoops, ice/gelatin, kayaking/Zorb balls, Legos/dive bricks, live fish, mats/sleds/icebergs, mirrors/television/movies, noodles, puzzle feeders, rub ropes/seaweed boas, tubs, underwater music/sounds, underwater window play, and water spray/brush boards.

Bio-Logging Data
MTag bio-logging devices were used to monitor activity levels. MTags were 150 mm long and 76 mm wide and were attached to the dolphins non-invasively approximately 20 cm behind the blowhole via four silicone suction cups. The silicone suction cups were specially designed to attach to the dolphins without impact to the skin. Focal dolphins were trained using positive reinforcement to wear the MTags prior to data collection. MTags could be easily removed by the animal care staff at any time. Similar biologging devices have been used extensively with wild dolphins and whales prior to application in this study. The MTag had a hydrodynamic profile to reduce drag imparted to the dolphin [38]. The MTag's electronics were based on the Loggerhead Instruments OpenTag3 platform (Loggerhead Instruments, Florida, USA) with the goal of designing a bio-logger for dolphins under professional care. The primary board of the OpenTag3 contains a 9-degree-of-freedom (DOF) inertial measurement unit (IMU; accelerometer, magnetometer, and gyroscope) and sensors to measure environmental pressure and temperature. IMU data were sampled at 50 Hz (i.e., samples per second), and all other sensor data were sampled at 5 Hz. The board was encased in epoxy for waterproofing and mounted in a 3D-printed housing (stereolithography on a Formlabs Inc. (Somerville, MA, USA) Form 2™ printer).

Enrichment Variables
Features of enrichment that were potentially relevant to dolphin welfare were selected to examine their relationship with activity levels. The types and features of environmental enrichment used by the participating facilities are presented in Table 1. The buoyancy of each type of enrichment was classified as floating, sinking, or non-stationary. Nonstationary enrichment was defined as enrichment that either existed or could be moved manually or autonomously through various depths in the water column or above the surface. Enrichment was classified as either simple or complex based on its membership to four categories. Categories included: cognitive, food, sensory, and social enrichment. If an enrichment type was only a member of one category, it was considered to be simple enrichment. If an enrichment type was a member of multiple categories, it was considered to be complex enrichment.

Data Analysis
Descriptive statistics were calculated for the number of facilities that provided each category of floating, sinking, non-stationary, simple, and complex enrichment. Four variables were created: (1) The total number of times dolphins were provided with each enrichment category (i.e., cognitive, food, sensory, and social) was calculated by summing the number of times the enrichment in each category was provided; (2) The total duration that each category was provided was calculated by summing the duration that each type of enrichment within in that category was provided; (3) The percentage of the month associated with each type of enrichment was calculated by dividing the total number of times each type was provided by the number of days in the month; (4) The percent of the month that each enrichment type was provided was then categorized as having access 0-25%, 26-50%, 51-75%, or 76-100% of the month. The number of enrichment types in each category was summed to create the "Received %" variables. As a simple example, dolphins could receive five types of enrichment in a month that included underwater window play six times, puzzle feeders ten times, hula hoops eight times, kayaking sixteen times, and rub ropes twenty-six times. This would result in one type of enrichment in the 0-25% variable, two types in the 26-50% variable, one type in the 51-75% variable, and one type in the 76-100% variable. The variable is representative of how much of the month the dolphins receive each different type of enrichment in the program, not the total number of days enrichment is provided.
MTag data were selected during times in which dolphins were outside of formal training sessions. The accelerometer, gyroscope, and magnetometer data on the MTags were used to estimate animal orientation (pitch, roll, and heading) [39]. Dynamic pitch was calculated by subtracting the static (low-pass filtered) pitch component from the original pitch data. A moving average filter with window size of 1.5 s was used for the low-pass filter. Specific acceleration was calculated by subtracting the gravitational component from the total accelerometer measurement, where the gravity direction was inferred using the estimated orientation of the animal. Overall dynamic body acceleration (ODBA) was calculated from the accelerometer data and was used to parameterize relative activity of the animal [40]. A moving average filter with a two-second window was used during the ODBA calculation. Analyses were conducted in MATLAB 9.7.0 using custom scripts.
Dolphins were included in the study if they had more than 240 min of MTag data recorded in either data collection period. If the first data collection period had more than 240 min of data, it was used in the analyses. If not, the second data collection period was used if there were more than 240 min of data. If neither data collection period had more than 240 min, the dolphin was excluded from the analyses. Data from a single data collection period were used because dolphins without qualifying data in both periods would have to be excluded entirely during the construction of the generalized estimating equation (GEE) models. This data selection method maintained a large sample size and prioritized investigating variability across accredited facilities rather than within individuals. An independent t-test and a Chi-square test of significance were used to determine if the age and sex of the sample in the final data set were statistically different from the group of dolphins originally selected for participation.
Statistical models were examined using GEEs due to the non-normal distribution of the data. GEEs do not require data to be transformed, which preserves the interpretability of the results [41,42]. Facility ID was controlled for in all models and was treated as a random effect with an independent correlation structure. Initial models were built with univariate level predictors. Univariate models where p < 0.15 were retained to develop multivariate models [10,43]. The multivariate model with the lowest quasi-likelihood under the independence model criterion (QIC) value and highest number of significant independent variables was selected as the final model. Analyses for the regression models were completed in SPSS 27 (IBM, New York, NY, USA).

Results
The final dataset included MTag deployments from 60 bottlenose dolphins (male n = 35, female n = 25) at 31 facilities after excluding dolphins that did not meet the minimum criteria. The sex (χ 2 (1, n = 125) = 3.623, p = 0.057) and age (t(123) = 0.542, p = 0.589) distributions of the group included in the analyses were not significantly different than those in the group prior to excluding dolphins that did not meet the inclusion criteria. The final group included 57 common bottlenose dolphins and three Indo-Pacific bottlenose dolphins that ranged in age from 3 to 44 years (mean 16.48 ± 9.84 SD) at the start of data collection. In total, 35 participants lived in professionally managed zoo/aquarium habitats, and 25 participants lived in professionally managed ocean habitats. The mean maximum depth was 5.63 m in ocean habitats and 8.78 m for zoo/aquarium habitats. Lauderdale and colleagues [44] provided a detailed report of the characteristics of the habitats included in the present study. Data were collected for 1053.35 h (range: 255 to 2043 min per dolphin) during periods in which the dolphins were outside of formal training sessions. The mean ODBA value for all participants was 2.31 ± 0.63 m/s 2 . The number of habitats that provided each enrichment type is provided in Table 2. The enrichment factors associated with ODBA were evaluated. Univariate correlations where p < 0.15 were observed between ODBA and four variables (Table 3). Descriptive statistics for independent variables considered for multivariate analysis are presented in Table 4.  The final multivariate model included the number of times sinking enrichment was provided, the total duration non-stationary enrichment was provided, and the number of the types of enrichment provided between 26% and 50% of the month (Table 5). Lower ODBA values were associated with the number of times sinking enrichment was provided (β = −0.012, p < 0.001). Higher ODBA values were associated with higher total durations of non-stationary enrichment (β = 0.001, p = 0.001), and more types of enrichment being provided between 26% and 50% of the month (β = 0.046, p = 0.038).

Discussion
Activity levels (i.e., ODBA) were related to three features of environmental enrichment associated with both the duration and frequency of provisioning. Previous research suggests that environmental enrichment can be effective in increasing the habitat use and social play of bottlenose dolphins [45,46]. However, behavioral responses to different enrichment types and objects vary [47]. In the present study, dolphins receiving sinking enrichment more often had lower activity levels. Higher activity levels were related to dolphins receiving non-stationary enrichment for longer periods of time and receiving more types of enrichment between 26% and 50% of the month.
Dolphins under professional care occupy both the horizontal and vertical space within their habitat, which presents opportunities to implement enrichment that can be interacted with in a variety of locations. Many of the accredited zoos and aquariums participating in this study provided enrichment that extended throughout the vertical space available to dolphins. Using enrichment in a certain location can effectively increase use of that part of the habitat [15,45]. In the present study, the activity levels of dolphins were lower for those that were provided with sinking enrichment more often. One explanation for this result may be that the types of sinking enrichment used by the participating facilities promoted stationary interactions. For example, sinking hula hoops may have encouraged dolphins to interact with them in a fixed location due to their weight, whereas floating hula hoops may have facilitated the ability to swim with them more easily. Another potential contributor to the reduction in ODBA values were changes in swimming gait at deeper depths. During deeper dives, dolphins may employ a fluke-and-glide swimming gait, and spend more time gliding during ascent, both of which may have reduced the acceleration measured by the tags [22]. Therefore, potentially interacting with sinking enrichment at the bottom of a habitat may have resulted in small reductions in ODBA. However, the data suggested that the magnitude of this effect was quite small and that promoting the use of this part of the habitat may outweigh a very small reduction in activity.
While most of the enrichment provided by participating facilities was either floating or sinking, facilities also provided enrichment that was non-stationary (i.e., existed or could be moved manually or autonomously through various depths in the water column and above the surface). The effectiveness of these activities being used as enrichment has not previously been investigated for bottlenose dolphins. However, these types of enrichment have been effective in improving the welfare of other species under professional care. For example, providing opportunities to hunt live fish reduces stereotypic behavior in Sumatran tigers (Panthera tigris sumatrae) [48] and diversifies the behaviors of fishing cats (Prionailurus viverrinus) under professional care [49]. Activity levels of the dolphins in the present study were higher for those that had access to non-stationary enrichment for longer periods of time. While the results suggested that the magnitude of this effect was small, the positive relationship to ODBA levels may have been a result of the movement facilitated by these types of enrichment. Above water play, underwater window play, scuba play, changing conspecifics, and live fish may have encouraged the dolphins to increase their activities above levels seen during low-intensity swimming.
The predictability of positive events is thought to be an important factor affecting welfare [50]. Varying the temporal predictability of the presentation of enrichment and rewarding events can reduce the likelihood of habituation and maintain an animal's motivation to engage with the activity [51][52][53]. Previous research suggests that the engagement with enrichment remains highest when it is provided on a variable schedule at an intermediate level [51,53,54]. Presenting enrichment on an unpredictable or variable schedule can also result in decreased standing behaviors, decreased stereotypic behavior, increased behavioral range, and increased exploratory and foraging behaviors [49,[54][55][56][57][58]. In the present study, dolphins who were provided with more types of enrichment between 26% and 50% of the days in a month had higher ODBA values. This suggested that, in general, providing each specific enrichment type between a quarter and half the month may be positively related to interactions with the enrichment, which may be associated with higher activity levels. Importantly, some dolphins have preferred enrichment objects that are resistant to habituation [47], and this should be considered when developing an enrichment schedule. Notably, this finding is not suggesting that enrichment should only be provided 26% to 50% of the month, but that providing more types of enrichment on this moderate schedule is related to higher activity levels. The enrichment programs in the present study generally included many enrichment types that can be provided simultaneously and rotationally [44]. For example, dolphins could receive three different enrichment types each day that are rotated from a program housing nine types. If provided equally, the dolphins would receive each enrichment type approximately 10 times per month but, importantly, would still be receiving multiple types of enrichment each day. Furthermore, each enrichment type (e.g., puzzle feeders) could include multiple objects or activities that could be rotated through as well.
For the present study, limitations include any behavioral changes that resulted from wearing the MTags. Although dolphins were trained and habituated to the MTags prior to data collection, it is possible that the focal dolphins modified their behavior due to its presence. In addition, the ODBA variable was not inclusive of all the time that the focal dolphin had access to enrichment, and behavioral observations were not collected to identify direct interactions with enrichment. Data were not limited to times in which dolphins had access to or were interacting with enrichment as enrichment has been associated with modified habitat use even when the enrichment is not directly available [45]. The findings were also limited by other factors that may influence ODBA including the dolphin's diet, training schedule, and social grouping. ODBA is an accurate proxy for activity level and generally proportional to the animal's activity but does have some limitations in an aquatic environment. Drag is reduced at deeper depths [59], which may result in lower ODBA values than those that would occur if the dolphin were swimming near the surface. In addition, less water resistance at and above the surface could result in higher measured acceleration for actions used while interacting with enrichment (e.g., tossing an object) than the same action at a deeper depth.

Conclusions
Both the frequency and duration that enrichment was provided to dolphins were related to activity levels. Higher ODBA values were associated with schedules that provided more enrichment types between 26% and 50% of the month. This suggested that rotating through daily enrichment types to present each different type of enrichment seven to 15 days of the month (excluding potentially preferred enrichment items) may be a beneficial frequency to promote higher activity levels. The number of times sinking enrichment was provided and the duration non-stationary enrichment was provided were also related to activity level. However, the magnitude of the effect was small, suggesting that they may not be a favorable method for increasing activity levels. Promoting welfare by prioritizing expanding habitat use with sinking enrichment may be more important than the small reductions in activity level, which may be due to changes in movement patterns at deeper depths or related to the stationary nature of sinking enrichment. Maintaining speciesappropriate activity levels is a meaningful factor to ensure positive welfare. Examining fine-scale changes in provisioning is a key next step. Understanding how the temporal presentation and features of various types of enrichment are related to activity levels will aid in developing progressively more effective enrichment programs for the future.  Conservation Commission state funding. The specific roles of these authors are articulated in the "author contributions" section. The Indianapolis Zoo, The Seas ® Epcot ® Walt Disney World ® Resort, Dolphin Island-Resorts World Sentosa, Texas State Aquarium, Loro Parque, and SeaWorld Parks also contributed to data collection as each of these facilities, as well as animals at the facilities, were involved in the study. The funders had no other role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Institutional Review Board Statement: The study was approved by the Institutional Animal Care and Use Committee of the U.S. Navy Marine Mammal Program (protocol number 123-2017). In addition, this study was authorized by the management at each participating zoo and aquarium and, where applicable, was reviewed and approved by research committees. Institutional Review Board approval was not required for survey respondents because the questionnaire did not request personal information.
Informed Consent Statement: Informed consent was waived for survey respondents because the questionnaire did not request personal information.

Data Availability Statement:
In order to protect the identification of the facilities and animals included in this study, findings require data access restrictions at the individual level. All relevant data are within the manuscript.