In recent years, the frequent occurrence of rainstorms has seriously affected urban–public transport systems. In this study, we examined the impact of rainstorms on the vulnerability of urban–public transport systems consisting of both ground bus and metro systems, which was abstracted into an undirected weighted Bus–Metro complex bilayer network (Bus–Metro CBN) and the passenger volume was regarded as its weight. Through the changes in the node scale, network efficiency, and passenger volume in the maximal connected component of the Bus–Metro CBN, we constructed a vulnerability operator to quantitatively calculate the vulnerability of the Bus–Metro CBN. Then, the flow-based couple map lattices (CMLs) model was proposed to simulate cascading failure scenarios of the Bus–Metro CBN under rainstorm conditions, in which the rainstorm is introduced through a perturbation variable. The simulation results show that under the condition of passenger flow overload, the network may have a two-stage cascading failure process. The impact analysis shows that there is a rainstorm intensity threshold that causes the Bus–Metro CBN to collapse. Meanwhile, we obtained the optimal node and edge capacity through capacity analysis. In addition, our analysis implies that the vulnerability of the Bus–Metro CBN network in most scenarios is mainly caused by the degradation of network structure rather than the loss of passenger flow. The network coupling strength analysis results show that the node coupling strength has greater potential to reduce the vulnerability than edge coupling strength. This indicates that traffic managers should prioritize controlling the mutual influence between bus stops (or metro stations) to reduce the vulnerability of the Bus–Metro CBN more effectively. Public transport is an important part of urban transport and is arguably the basis of a city’s day-to-day operations. However, in recent years, extreme weathers, especially rainstorms, have frequently occurred in many cities, causing detrimental effects on the urban public transport system, resulting in problems such as traffic congestion, traffic accidents, and partial paralysis of transport systems . From thThe evolution of urban public transport systems under rainstorm can be described in terms of cascading failures, whereby the failures of certain stops or lines can cause the failures of other stops or lines due to the transfer of passenger flow. To date, some models have been constructed and empirical studies undertaken to analyze the cascading failure processes of different networks, such as the study of cascading failures in India’s power network , and theVulnerability can cause cascading failures on the urban public transport systems. When the severity of cascading failures increases, the vulnerability of the urban public transport systems also increases. Similarly, the vulnerability of the urban public transport systems decreases as the severity of the cascading failure decreases. To date, there has been no unified definition of transport system vulnerability ,13,14, wIn terms of research on vulnerability, numerous scholars have studied the robustness or vulnerability of various real-world systems using the indices of complex networks ,24,25,26Although vulnerability studies of the urban public transport systems based on complex network theory have achieved rich results ,46,47, ts under rainstorm weather conditions. Finally, we synthesize a vulnerability operator to quantitatively evaluate the impact of rainstorm on the Bus–Metro CBN. Compared with the existing studies, the focus of this study is to establish a dynamic evolution model of the Bus–Metro CBN under rainstorm conditions, and quantitatively evaluate the impact of different intensity rainstorms on the Bus–Metro CBN through the vulnerability indices. In addition, we also explore the impact of node and edge coupling strength on network vulnerability, and the main causes of Bus–Metro CBN vulnerability under different conditions. These findings can provide suggestions for the urban public transportation department for traffic management and emergency repair strategies under rainstorm weather conditions.Most of the existing studies on the impact of rainstorm on urban public transport system are qualitative, and lack of modeling and quantitative evaluation of the impact of rainstorm. In this study, we focus on the complex bilayer network of bus and metro (Bus–Metro CBN) as the unit of analysis and regard the rainstorm as the external perturbation of the system. Then based on the conventional CMLs model, the flow-based CMLs model is proposed for simulating the cascading failure process in Bus–Metro CBNThe rest of this paper is organized as follows. s are summarized in With global warming, the earth’s surface temperature is rising. Trenberth  pointed The impact of rainstorm on the Bus–Metro CBN can be analyzed from the perspective of roads (or metro train tracks), vehicles and passengers (or drivers), as shown in A rainstorm can cause waterlogging on the road surface, which will reduce the contact between tire and road surface. As a result, it reduces the road surface friction coefficient. Meanwhile, the excessive water accumulation may invade the interior of the asphalt pavement mixed material. Over time, this gradually separates the asphalt membrane from the aggregate surface, which eventually leads to the loss of the bonding force between the asphalt and the aggregate surface, causing the asphalt pavement to wear . RegardiIn terms of buses, rainwater can enter the cylinder from the intake and exhaust ports of the engine. Due to the incompressibility of water, the connecting rod of the engine cylinder will be crooked, and the cylinder may be damaged at the same time. The rainstorms may also cause short-circuit faults in vehicles with aging lines . On the s. As a result, the Bus–Metro CBN might not be able to meet all passengers’ travel demands, resulting in queues and congestion .The maximal connected subgraph of the Bus–Metro CBN represents the component which contains the largest number of nodes in all components of Bus–Metro CBN. We used |2. Whole-network efficiency changes of the Bus–Metro CBNijR of node in and node jn in the Bus–Metro CBN is defined as the reciprocal of the shortest path , i.e., ijR= 1/ijd. The efficiency R of the CBN is taken as the average value of each node’s efficiency:N| represents the number of nodes in the Bus–Metro CBN, and ijd denotes the number of edges on the shortest path between nodes in and jn. When nodes in and jn are not connected, ijd = ∞. The |N|(|N| − 1) represents the no duplication of node logarithm.Efficiency can reflect the tightness of node connection in a network. The efficiency R0 denotes the whole-network efficiency of the initial Bus–Metro CBN, and TR represents the whole-network efficiency when the Bus–Metro CBN is finally stable, 0 ≤ η(R) ≤ 1.According to Equation (21), the whole-network efficiency changes of the Bus–Metro CBN can be calculated as:3. Changes in the total volume of passenger flow in the largest connected component of Bus–Metro CBNG) of Bus–Metro CBN. The total passenger flow volume totalF can thus be calculated as:N|G is the number of nodes in the largest connected component of Bus–Metro CBN, and ijF is the passenger flow volume on edge ije.The total volume of passenger flow in the Bus–Metro CBN is the sum of passengers on all edges in the largest connected component (η(F) in the Bus–Metro CBN as:F0 denotes the total volume of passenger flow in the initial Bus–Metro CBN, and TF represents the total volume of passenger flow in the largest connected component when the Bus–Metro CBN is finally stable, η(F)∈.According to Equation (23), we can calculate the changes in the total volume of passenger flow 4. Vulnerability operator construction of Bus–Metro CBNV can be expressed as:η(|N|), η(R), and η(F) denote node scale changes in the maximum connected subgraph, efficiency changes in the whole network, and changes in the total volume of passenger flow, respectively. λ1, λ2 and λ3 represent the weight of η(|N|), η(R) and η(F), respectively. These weights indicate the importance of topological structure and function in the Bus–Metro CBN. λ1, λ2, λ3∈, and λ1 + λ2 + λ3 = 1. V is the vulnerability of the Bus–Metro CBN, V∈. The larger the value of V, the more vulnerable the Bus–Metro CBN, i.e., the topological structure and function of the Bus–Metro CBN change sharply. The vulnerability of Bus–Metro CBN in this study was measured in terms of node scale changes in the maximum connected subgraph, efficiency changes in the whole network, and changes in the total volume of passenger flow. Therefore, the vulnerability operator The research area selected for this study is that encircled by Xi’an City wall , located in Shaanxi, China a; i.e., The Bus–Metro CBN of the research area is mapped out in As shown in According to data of Xi’an Public Transport Corporation in 2017, the daily average passenger volume of ground buses in the area encircled by Xi’an City wall was about 400,000 people, and the daily average passenger volume of the metro was about 150,000 people. We allocate passengers according to the number of bus lines on the edges (the number of bus lines passing through this edge). Specifically, the passenger volume on an edge is obtained by multiplying the ratio of the number of bus (or metro) lines on the edge to the number of bus (or metro) lines by the total passenger volume. Then the passenger volume of nodes can be calculated by Equation (14). In addition, we set the initial state of each node or edge as the random value of the interval , and set up four types of simulation scenarios containing the impacts of rainstorm intensity, capacity tolerance, node coupling strength, and edge coupling strength on the Bus–Metro CBN. We then used the approach of variable-controlling to explore these impacts.ε1, ε2 and α as constants, and the s as a perturbation variable at the beginning of simulations to study the impact of rainstorm intensity on the Bus–Metro CBN under rainstorm conditions. For example, according to the data of Xi’an Meteorological Bureau, the rainfall in Xi’an on 24 July 2016 was 110 mm. According to Equation (1), this rainstorm can be transformed into the perturbation variable where s = 2.2. Then the perturbation s is substituted into Equations (17) and (19) to calculate the state changes of nodes and edges. Based on this, we can analyze the impact of rainstorm on the Bus–Metro CBN using Equations (20)–(25). In the second simulation scenario, we set the ε1, ε2 and s as constants, and α as a variable to observe the changes of cascading failure process with the capacity tolerance. In the third type of simulation scenario, we set the s, α and ε2 as constants, and the ε1 as a variable to examine the impact of node coupling strength on the Bus–Metro CBN under rainstorm conditions. In the fourth type of simulation scenario, we set the s, α and ε1 as constants, and the ε2 as a variable to observe the impact of edge coupling strength on the cascading failures in Bus–Metro CBN.In the first type of simulation scenario, we set the The specific variable values in these scenarios are shown in η(|N|), η(R), η(F) and V at the convergence time, which are shown in The influence of a rainstorm on the Bus–Metro CBN can be divided into direct and indirect effects. On one hand, the rainstorm directly affected the ground bus network. On the other hand, the transfer passengers caused by rainstorm indirectly affects the metro network. We set the initial state values of all nodes and edges to  and regard a rainstorm as an external disturbance at the beginning of simulations. Then, in line with the scenarios in s = 1.4 in α = 0.4 in s = 1.4 or α = 0.4, the Bus–Metro CBN will have two cascading failure processes, which increases the network vulnerability. This is quite different to previous results on the cascading failures of public transport networks [As shown in networks . The twoη(|N|), η(R), η(F), and V under different rainstorm circumstances , η(R), η(F), V and s. The figure exhibits a trend of “descending-ascending-unchanged”. This means that the vulnerability of Bus–Metro CBN is fluctuating with increasing rainstorm intensity, and there is a rainstorm intensity threshold (s = 1.8) that cause the whole network to collapse. From observing the slope of these curves when s = 1.6, the slope of these curves is the largest, which means that the cascading failure consequences of Bus–Metro CBN increase the fastest in s = 1.6. Therefore, when the rainstorm intensity s exceeds 1.4, the traffic management department should quickly escalate emergency management and implement rescue measures to prevent the collapse of the Bus–Metro CBN.η(|N|), η(R), η(F), V decrease with α, meaning that the increase in node and edge capacity can reduce the vulnerability of Bus–Metro CBN. At the same time, the decline rate of the failure proportion first increases and then decreases, which indicates that when α is small (α = 0.0) or large (α = 0.4), the increase in node and edge capacity has less effect on the mitigation of Bus–Metro CBN vulnerability. In addition, when α = 0.3, the curves have the fastest falling speed, which denote that when the node and edge capacity is 1.3 times of their initial load, increasing the node and edge capacity have the greatest effect on reducing the network vulnerability. If we consider the cost of increasing node and edge capacity, α = 0.3 is the point with the highest marginal benefit. Comprehensively considering the network vulnerability reduction and its cost, α = 0.4 is the best choice that is when the node and edge capacity is 1.4 times of their initial load.From η(|N|), η(R), η(F), V and ε1 , η(R), η(F), V do not exceed 5%. On the one hand, the Bus–Metro CBN should have a low node coupling strength to reduce its vulnerability, on the other hand, only when the node coupling strength is below 0.4, the reduction of node coupling strength reduces Bus–Metro CBN vulnerability.Considering the relationships between V and ε1 c, it shoη(|N|), η(R), η(F), V and ε2 , η(R) and η(F) to V based on the data in η(R) to V was higher than that of η(|N|) and η(F) to V. This means that the vulnerability of the Bus–Metro CBN under a rainstorm was affected mainly by whole-network efficiency, i.e., the performance of network connectivity.In addition, to analyze the main factor affecting the vulnerability of the Bus–Metro CBN, we calculated the contribution rates  of s < 1.4, the vulnerability of Bus–Metro CBN is mainly caused by the decline of η(R); when s ≥ 1.8, the contribution of η(|N|), η(R), η(F) to V are almost equal. However, when s = 1.4, η(F) has the biggest impact on the vulnerability of Bus–Metro CBN. This means that the vulnerability of the Bus–Metro CBN was mainly caused by the destruction of the topological structure under less severe rainstorm. When the rainstorm was more severe, the failure of the passenger flow also has a great influence on the vulnerability of the Bus–Metro CBN. The main reason for this is that passengers at failed bus stops (or metro stations) and lines may transfer to other normally functioning bus stops (or metro stations) and lines, thus reducing passenger loss in the system as a whole. However, given that the topology of the system is almost static and lacks a dynamic self-healing ability, i.e., the topology cannot repair itself, this will greatly affect the system’s vulnerability.As shown in α (η(|N|) and η(F) to V are almost the same. At the same time, when α ≤ 0.2, the contribution of η(R) to V is almost equal to that of η(|N|) and η(F) to V. But when α > 0.2, the contribution of η(R) to V far exceeds that of η(|N|) and η(F) to V. These results indicate that when the node and edge capacity is relatively small (α ≤ 0.2), the topology structure and passenger flow are almost the same important to the Bus–Metro CBN. But when the node and edge capacity is relatively large (α > 0.2), the destruction of the topological structure is the main cause of vulnerability in the Bus–Metro CBN, so the topological structure should be given more protection in these scenarios.Under the conditions of different α b, the coε1, the impact of η(|N|) and η(F) on V are almost the same. At the same time, it is obvious that η(R) is always the main factor that affects V. η(|N|), η(R) and the flow-based metric of η(F). According to the analysis of the main factors affecting the vulnerability in Bus–Metro CBN, although the topology is still important to the network in the flow-based cascading failure model, in some scenarios , the passenger flow will also play a pivotal role in the network performance.Many previous topology-based researches of network robustness or vulnerability found that the topology is important to the network ,98,99. WDue to the high incidence of rainstorms and their great impact on urban public traffic, this study empirically examined the impact of rainstorms on the Bus–Metro CBN that consists of ground bus and metro using vulnerability calculations. Firstly, we established a way of transforming the rainstorm intensity into the quantitative impact on the Bus–Metro CBN. Then based on the CML model in the research of Huang, Peng, and Ren ,65,66, wIn summary, through the empirical study, we found that the Bus–Metro CBN may experience a secondary failure process due to the capacity of nodes and edges. This indicates that the network will have two-stage failure processes at different times and thus cause the consequences of the cascading failure to worsen over time. However, from the perspective of emergency management, the multi-stage failure process provides time for the repair of failed bus stops (or metro station) and lines. Managers can take repair measures between two failure processes, and thus prevent a new round of failure. Considering the impact of rainstorm intensity on the vulnerability of Bus–Metro CBN, we found that the consequence of cascading failure does not always increase as the rainstorm intensity increases. The relationship between failure proportion and rainstorm intensity shows a trend of “descending–ascending–unchanged”, which means on the one hand the traffic management department should take more management and rescue measures during the “ascending” period. On the other hand, there is a rainstorm intensity threshold that causes the Bus–Metro CBN to collapse, which can be used as a warning for rainstorm observations. For reducing the vulnerability of Bus–Metro CBN, we studied the impact of capacity increases on the network vulnerability, and found that the decline rate in network vulnerability increases first and then decreases as the capacity increases. At the same time, with simultaneous consideration for the capacity increase and its cost, we obtained the optimal capacity of nodes and edges, which can be used to support public transport planning.In terms of the coupling strength of Bus–Metro CBN, the network vulnerability increases as the node coupling strength and edge coupling strength increase. However, the influence of node coupling strength on network vulnerability has an upper limit, and the edge coupling strength has a lower limit on network vulnerability. In contrast, node coupling strength has greater potential to reduce the vulnerability of Bus–Metro CBN than edge coupling strength. Therefore, in the actual Bus–Metro CBN, the coupling relationship between bus stops (metro stations) should be prioritized to minimize them.Moreover, from the contribution to the vulnerability of Bus–Metro CBN, the decline of the whole network efficiency contributes the largest to the network vulnerability in most scenarios. But in some scenarios, such as when the capacities of nodes and edges are small, the decline of passenger flow also contributes greatly to the vulnerability of Bus–Metro CBN. In general, the traffic management department should give priority to ensuring the connectivity of the shortest path between the stop (station) pairs in the Bus–Metro CBN to reduce its vulnerability.In this study, the urban ground bus and metro systems were abstracted into a complex bilayer network, and both the failure of nodes and edges in the network were considered. The vulnerability of the Bus–Metro CBN under rainstorm was reflected by the node scale of the maximum connected subgraph, the whole-network efficiency and the passenger volume. Based on the CMLs model, the cascading failures of the Bus–Metro CBN were simulated, and some noteworthy results were different from those yielded by previous studies. These results enabled us to provide the aforementioned recommendations for reducing the vulnerability of the Bus–Metro CBN. In future research, we recommend further exploration of strategies for the repair of cascading failures in a Bus–Metro CBN under different conditions, and the relationship between the contact enhancements of the network’s topological structure and the degree of failure of the network function.


Policy makers are increasingly interested in reducing public spending while maintaining quality of life. Since 1975, Oregon Project Independence (OPI) has supported community-based adults aged 60 and older to avoid or delay the need for residential long-term care services by increasing access to personal and home care services. The program also aims to prevent the need for Medicaid by optimizing personal resources and natural supports. In 2014, the OPI Expansion (OPI-E) pilot project began to serve adults aged 18-59 with disabilities in seven of Oregon’s seventeen Area Agencies on Aging (AAAs). This poster describes the evaluation of the expansion using three data sources: administrative data about consumer characteristics compiled by the AAAs and State of Oregon from 2015-2017 , qualitative interviews conducted with AAA directors and OPI-E case managers (N=23), and a survey of current OPI-E consumers (N=126). Compared to traditional OPI consumers, OPI-E consumers were somewhat more likely to be men and people of color. Interviews with AAA staff highlighted the need for outreach, lack of service provider capacity, unique characteristics of younger consumers, and issues related to data management and rural access. Staff reported valuing the program, noting how “even low levels of service go a long way.” Qualitative and quantitative consumer responses showed consumers found OPI-E services invaluable. The majority stressed their appreciation for the program, with several describing it as “lifesaving.” These three sources informed recommendations for expanding the OPI-E program statewide.


The European school-based drug addiction prevention program Unplugged was adapted to the Brazilian context by the Ministry of Health and renamed #Tamojunto. Its first implementations, in the form of a public policy in Brazil, showed contradictory and different effects from those observed in Europe. Adaptations were made to #Tamojunto in 2018 to reintroduce the essential content of the original program.A parallel, two-arm, randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of the new version of the school-based government program #Tamojunto2.0 for the prevention of drug use among 8th grade middle school students from 70 public schools in three Brazilian cities, totaling approximately 6.300 participating students distributed in 210 classes. For intervention, the experimental group will receive the 12 lessons of the #Tamojunto2.0 program under the supervision of a Brazilian Ministry of Health team. The control group will not receive any intervention. Information will be collected from the students at three time points: preintervention and 9 and 18 months postintervention. Multilevel analyses will be performed using the Gllamm Stata program to assess simultaneous differences in prevalence, in time and among groups for the outcomes of interest. Structural equation modeling will be used to evaluate the effectiveness of the intervention in changing the behavioral patterns of the adolescents through latent transition analysis. The effect of the mediators involved in the program effectiveness outcomes will also be analyzed. The program doses applied in all classes of the intervention group will be collected using a form completed by the teacher at the end of each lesson, indicating the activities taught and not taught in each lesson.This study will show whether the #Tamojunto2.0 program can be expanded as a public policy for all schools with the aim of preventing drug use among Brazilian students.http://www.ensaiosclinicos.gov.br/rg/RBR-8cnkwq/).Brazilian Clinical Trials Registry (RBR-8cnkwq) under the name “Avaliação do Efeito do Programa de Prevenção Escolar ao Uso de Drogas #Tamojunto2.0, Versão 2018”, on August 30th, 2018 ( The abuse of alcohol and other drugs is currently a major public health issue , and adoThe high prevalence of drug use in adolescence and the early age of onset of this behavior show the need for prevention programs in these age groups , 7. Scho, which was called #Tamojunto in Brazil 33].As mediators of program effectiveness, the following will be evaluated: 1. normative beliefs; 2. positive beliefs and negative beliefs about alcohol and marijuana use; 3. knowledge about drugs; 4. decision-making skills; and 5. refusal skills . The sca).In addition to the modules covering primary outcomes, secondary outcomes and mediators, the questionnaire also has a module on sociodemographic data. The socioeconomic class will be evaluated through the ABEP (Brazilian Market Research Association) scale  Table 11.In each of the experimental schools, all 8th grade students will receive the program #Tamojunto2.0, and the school will assign one teacher per class to receive training on the program.www.eudap.net.The #Tamojunto2.0 program will be applied to students in the classroom by trained teachers. The 12 lessons, described in Table In Brazil, the English materials were translated into Portuguese, with adaptation of idiomatic expressions and the substitution of information about heroin for information about crack, as well as changes in the lessons addressing alcohol use . The newThe teachers who will administer the program will be trained in a 16-h training program conducted by professionals from the BMH. In addition, the implementation will be accompanied by two on-site visits by BMH professionals throughout the 12 lessons and by a virtual forum where teachers can post questions about the application of the activities in the lessons.The data will initially be analyzed by a descriptive analysis, that is, qualitative variables will be summarized as numbers and percentages and numerical variables as means, standard deviations, medians, minima and maxima. Descriptive analyses will be performed for different patterns of drug use. This dataset will be used to calculate sample weights through the svy command in Stata so that the baseline data analysis can be presented in an expanded form, aiming at correcting for losses and extrapolating the data to the sample universe , 40.All analyses will be carried out in the two samples: “intention to treat” (ITT), which will include all the participating classes that received at least one lesson of the program, and “per protocol” (PP). The PP analysis will include only those classes that receive the complete protocol (12 lessons), determined based on evaluating the dose and fidelity form that will be completed by the teacher at the end of each lesson.Because the data are collected in groups, they are not independent at two levels (school and class), and the measures of association should be analyzed through GLLAMM , which calculates the level of dependence between the data . Due to Structural equation modeling (SEM) will be used to analyze the mediators involved in reducing the primary and secondary outcomes over 18 months  Fig. 2)2) and toQuantitative data will be analyzed using the Stata 14 software using descriptive statistics, considering frequencies and prevalence. Inferential statistics will be applied to test hypotheses of differences between observations and observers.The qualitative data will be transcribed in full and categorized according to their content similarity. The computer software NVivo version 10 will be used for the qualitative analysis .By the time of this submission (February/2019), the study is in the recruitment and agreement phase with the selected schools.This study protocol describes a randomized controlled trial to evaluate the effectiveness of the school-based drug prevention program #Tamojunto 2.0. The main objective of this study is to evaluate the effectiveness of the intervention in terms of drug use outcomes among Brazilian students. Data on school violence, psychiatric symptoms, and mediators of the program’s effectiveness, such as decision-making skills, refusal skills and knowledge and beliefs about drugs, will also be collected.n = 6300), obtained through a simple random draw of schools from the universe of schools in each municipality. In addition, this study will have three data collection points over time and can thus assess possible short-term and long-term effects of the program and enable more sophisticated analyses, such as mediation analysis and latent class transition analysis. Third, the study will use a school randomization design, which minimizes the effects of contamination that can occur in a project that randomizes the classes within each school. An additional strength of the study is that—in contrast to most RCT studies—we will focus not only on the effectiveness of the program but also on the mediators of change, which will shed light on how the intervention works and enable the proposal of possible mechanisms of action, as has already occurred in a pilot manner by the research group itself [One of the strengths of this study is that it will include a representative sample of students from Brazilian public schools  are elements related to the expected outcomes of the program . In thisSome limitations of this study must be noted. The main limitation is related to the known high rate of school absences of the Brazilian student population, which could result in bias. However, this is a common limitation to longitudinal studies –50, and Considering the iatrogenic results of the first version of #Tamojunto, a new adaptation of the material was carried out to better reflect the original content of Unplugged, which has already shown positive preventive results in the European context. Thus, a randomized controlled trial protocol with the inclusion of implementation dose and fidelity measures was designed to evaluate the effectiveness of the new version of the program that will be applied by the Brazilian government, now titled #Tamojunto 2.0. Considering that the #Tamojunto 2.0. program was developed with the aim of being applied as a universal intervention, within a context of a national public policy, we believe that this study will contribute to supporting decision-making regarding the dissemination of the new version of this program in Brazilian public schools.


Type 2 diabetes mellitus has serious health consequences, including blindness, amputation, stroke, and dementia, and its annual global costs are more than US $800 billion. Although typically considered a progressive, nonreversible disease, some researchers and clinicians now argue that type 2 diabetes may be effectively treated with a carbohydrate-reduced diet.Our objective was to evaluate the 1-year outcomes of the digitally delivered Low-Carb Program, a nutritionally focused, 10-session educational intervention for glycemic control and weight loss for adults with type 2 diabetes. The program reinforces carbohydrate restriction using behavioral techniques including goal setting, peer support, and behavioral self-monitoring.1c (HbA1c) 7.8%, SD 2.1%; mean body weight 89.6 kg, SD 23.1 kg; taking mean 1.2, SD 1.01 diabetes medications).The study used a quasi-experimental research design comprised of an open-label, single-arm, pre-post intervention using a sample of convenience. From adults with type 2 diabetes who had joined the program and had a complete baseline dataset, we randomly selected participants to be followed for 1 year  women; mean glycated hemoglobin A1c at or above the type 2 diabetes threshold of 6.5%, 195 (26.2%) reduced their HbA1c to below the threshold while taking no glucose-lowering medications or just metformin. Of the participants who were taking at least one hypoglycemic medication at baseline, 40.4% (289/714) reduced one or more of these medications. Almost half  of all participants lost at least 5% of their body weight. Overall, glycemic control and weight loss improved, especially for participants who completed all 10 modules of the program. For example, participants with elevated baseline HbA1c (≥7.5%) who engaged with all 10 weekly modules reduced their HbA1c from 9.2% to 7.1% (P<.001) and lost an average of 6.9% of their body weight (P<.001).Of the 1000 study participants, 708 (70.80%) individuals reported outcomes at 12 months, 672 (67.20%) completed at least 40% of the lessons, and 528 (52.80%) completed all lessons of the program. Of the 743 participants with a starting HbAEspecially for participants who fully engage, an online program that teaches a carbohydrate-reduced diet to adults with type 2 diabetes can be effective for glycemic control, weight loss, and reducing hypoglycemic medications. Type 2 diabetes mellitus is prevalent, costly, and a potentially progressive disease with serious health consequences including blindness, amputation, stroke, dementia, and premature death . GloballAlthough typically considered a progressive, nonreversible disease, some researchers and clinicians now argue that type 2 diabetes may be effectively treated with a carbohydrate-reduced diet, which could improve type 2 diabetes management and potentially even lead to remission . Indeed,Although dietary interventions have historically been in-person, online programs can be just as effective for some participants, as suggested by research that has examined diet and lifestyle interventions in adults with prediabetes . Therefo1c or HbA1c), weight loss, and reductions in hypoglycemic medication use. Our goal was to explore whether the program might be an effective option for increasing access to diabetes management solutions and help halt the prevalent, costly, and dangerous type 2 diabetes epidemic.In this naturalistic pilot study, our objective was to evaluate the 1-year outcomes of the Low-Carb Program, a digitally delivered, nutrition-focused, structured lifestyle intervention with 10 weekly sessions for glycemic control, hypoglycemic medication use, and weight loss for adults with type 2 diabetes. We hypothesized that this program would lead to improvements compared to baseline: better glycemic control  ruled that analyses of these previously collected and de-identified data were not subject to IRB regulation.1c result (taken within 4 months), and medication use. Third, we used GraphPad Random Generator Software to randomly select a subset of 1000 participants to be followed for 12 months, thus enabling us to select participants for no other reason than that they were randomly selected by the software. Therefore, we did not include all the 7809 patients to follow over a year, but instead followed a random subsample of 1000 , whereby 105,950 adults with type 2 diabetes between the ages of 18 and 99 years signed up to participate in the program. Participants could live anywhere in the world. To have a broad applicability to a nonclinical trial setting, the only de facto exclusion criterion was the inability to understand English. Second, upon sign-up, the program prompted individuals to complete an initial baseline survey; 19,646 of 105,950 (18.54%) did so. Of those, 7809 people had complete baseline datasets including weight, a recent HbA1000 see .The Low-Carb Program is a completely automated, structured 10-week health intervention for adults with type 2 diabetes. Participants are given access to nutrition-focused modules, with a new module available each week over the course of 10 weeks. The modules are designed to help participants gradually reduce their total carbohydrate intake to less than 130 grams per day to meet their self-selected goals. The program encourages participants to make behavior changes based on “action points” or behavior change goals at the end of each module. These goals are supported with resources that are available to download, including information sheets, recipes, and suggested food substitution ideas. The Low-Carb Program online platform also includes digital tools for submitting self-monitoring data on a number of different variables including blood glucose levels, blood pressure, mood, sleep, food intake, and body weight. Weekly automated feedback is provided to users based on their use of the program through email notifications, and participants are notified when the next week’s module has been opened. Lessons are taught through videos, written content, or podcasts of varying lengths (approximately 3 to 12 minutes long).The first 2 weeks of the program contain an explanation of the physiology of type 2 diabetes and the role of diet, including a description of how a low-carbohydrate diet can help manage postprandial blood glucose levels and weight. The subsequent week’s modules explore strategies to reduce dietary sources of sugar, in particular, high-starch foods, such as bread, pasta, and rice. Participants are encouraged to make portion control and carbohydrate restriction decisions based on visual plate representations. In place of carbohydrate-rich foods, an increased intake of green vegetables, low-glycemic index fruits  and fats  are advocated. The program stresses the importance of regular contact with the participants’ health care providers for adjustments in medications in weeks 1, 2, and 10. After the 10 weeks of modules have been opened, participants continue to have access to the education content as well as the ability to continue to track their health  and access support from the discussion board. See Much of the content of the Low-Carb Program is based on an in-person, nurse- and physician-led, low-carbohydrate training program conducted in a primary health care setting . For exaThe content and strategies used in the program build off prior research and theory. For example, evidence suggests that goal setting can act as an effective behavior change strategy used to improve adherence to lifestyle intervention programs in obesity management programs . Therefo1c. According to the Control Theory of behavior change, monitoring goal progress—that is, evaluating one’s ongoing performance relative to the standard—and responding accordingly is critical to goal attainment [The program further reinforces behavior change through integrated tracking whereby program users are encouraged to track their health data including mood, food intake, blood glucose levels, weight, sleep, and HbAtainment . Recent tainment .In addition, prior studies demonstrate that peer support may improve blood glucose control ,24, peer1c test result and date, current medications , age, gender, socioeconomic status (based on household income), and presence of comorbid chronic illnesses. At 12 months, participants were again asked to report on their current HbA1c, weight, and medications.At baseline, an online survey asked participants to report on their type of diabetes, year of diagnosis, their most recent HbAt tests. The primary outcome was change in HbA1c and body weight . The secondary outcome was change in need for diabetes medication. We stratified our cohort into three groups according to baseline glycemic control as defined by baseline HbA1c: (1) elevated baseline HbA1c greater than or equal to 7.5%, (2) slightly elevated baseline HbA1c 6.5% to 7.4%, or (3) normal baseline HbA1c less than 6.5%. Outcomes were also analyzed within strata based on participant’s Low-Carb Program completion , partial completers , or noncompleters .Analyses were performed using the SPSS version 21.0 . We examined the difference in characteristics from baseline to 12-month follow-up using paired 1c or weight improvement.Some of our results took into account the entire sample, regardless of follow-up information or lesson completion. For participants who did not report their outcomes at 12 months, we followed the highly conservative approach of assuming that they did not improve at all (last observation carried forward), by imputing their baseline values as their outcome values. For example, participants who did not comply with reporting a 12-month outcome were treated as having no change in the outcome variable, and thus were not counted as having any HbA1c was 7.8% (SD 2.1%), mean weight was 89.6 kg (SD 23.1), and mean age was 56.1 years (SD 15.7) years. More than half of participants were female , 90.4% (904/1000) were white, all were from the United Kingdom, and more than one-third had comorbid hypertension  or hypercholesterolemia . At baseline, participants were taking a mean of 1.21 (SD 1.01) hypoglycemic medications. See At baseline, mean HbA1c (≥7.5%) at baseline, 247 (55.3%) reported outcomes at 12 months and 191 (42.7%) completed all lessons. Of 296 people with slightly elevated HbA1c (6.5%-7.5%) at baseline, 238 (80.4%) had outcomes at 12 months and 182 (61.4%) completed all lessons. Of 257 people with a normal baseline HbA1c level (HbA1c <6.5%) who began the study, 223 (86.8%) had outcomes at 12 months and 155 (60.3%) completed all lessons  reported outcomes at 12 months, 528 (52.80%) completed all lessons, and 672 (67.20%) completed at least 40% of the lessons. For the remaining 292 people lost to follow-up, the last recorded data point was carried forward. Of 447 people with elevated HbA1c, those who completed the Low-Carb Program showed a statistically significant change in HbA1c of –1.17% . Partial completers showed a statistically significant change in HbA1c of –0.6%  and noncompleters showed a nonsignificant HbA1c change of only –0.16% . Results stratified by baseline HbA1c are presented in Considering all participants pooled across baseline HbA1c groups combined, Low-Carb Program completers (n=528) showed a significant reduction in weight, with a mean body weight change of –7.45 kg (SD 12.63) or –7.0% . Partial completers (n=144) showed a reduction in weight, with a mean body weight change of –2.13 kg (SD 16.40) or –1.1% (SD 25.42%); however, this weight change was not statistically significant . Noncompleters (n=328) did not have a statistically significant change in weight, with mean change of –0.35 kg (SD 10.13) or 0.7% . Results, stratified by baseline HbA1c, are presented in Considering all baseline HbA1c, equal to or above the type 2 diabetes threshold of 6.5%, 195 (26.2%) reduced their HbA1c to below the threshold while taking no glucose-lowering medications or just metformin.The majority of participants  were prescribed at least one hypoglycemic medication at baseline. At 1 year, of those originally prescribed medications, 289/714 (40.4%) individuals were able to stop one or more hypoglycemic medications. Of the 743 participants who started with an HbA224=146.5, P<.05) and other hypoglycemic medications . However, there was no significant change in being prescribed insulin  increased from 25.70% (257/1000) to 50.30% (503/1000). Furthermore, 46.00% (464/1000) of participants lost at least 5% of their body weight. Also, of participants who were taking at least one hypoglycemic diabetes medication at baseline, 289/714 (40.5%) reduced one or more of these medications.The Low-Carb Program is a digitally delivered, peer-supported, nutrition-focused, structured 10-week health intervention aimed at improving glycemic control, reducing hypoglycemic medication use, and promoting weight loss among adults with type 2 diabetes. This was not a randomized controlled trial, so we cannot compare the 12-month results to a control or standard-of-care group; therefore, the results of our trial should be interpreted cautiously because the study used convenience sampling, open-label, single-arm design, pre-post self-reported outcomes, and 71% of participants reported outcomes at 12 months. Even so, when adults with type 2 diabetes participate in the Low-Carb Program, and especially when they finish all 10 modules of the program, they report significantly reduced HbA1c level of less than 6.5% increased from 25.70% (257/1000) to 50.30% (503/1000). This degree of control, when achieved through pharmacotherapy, is often accompanied by weight gain and risk for hypoglycemic events [The percentage of individuals with an HbAc events . Indeed,c events .1c reduction with weight loss and decreased hypoglycemic medication use. This approach is given further credence by a recent meta-analysis, which concluded that carbohydrate-reduced interventions improve glucose control, in addition to other positive health effects such as improved triglyceride and high-density lipoprotein cholesterol [As in other studies using a carbohydrate-restricted dietary approach, including Dr Unwin’s in-person program on which the Low-Carb Program was partially modeled ,17,29, wlesterol .Our study has several limitations. Although we encouraged participants to eat a carbohydrate-restricted diet, we did not measure their dietary intake. We also measured health outcomes  using self-report, rather than measuring them directly or through medical records. However, previous research has found that these self-reported health outcomes can be quite close to actual values ,32. AnotFor participants who fully engage, an automated online program teaching a carbohydrate-reduced diet to adults with type 2 diabetes may facilitate glycemic control, weight loss, and reduced need for hypoglycemic medication. Although our design does not support causal conclusions, the program may be a useful adjunct for lifestyle self-management for adults with type 2 diabetes.


Psychological problems during childhood and adolescence are highly prevalent, frequently comorbid, and incur severe social burden. A school-based universal prevention approach is one avenue to address these issues.The first aim of this study was the development of a novel, transdiagnostic cognitive-behavioral universal prevention program: The Universal Unified Prevention Program for Diverse Disorders (Up2-D2). The second aim of this study was to examine the acceptability and fidelity of the Up2-D2.Classroom teachers who attended a 1-day workshop implemented the Up2-D2 independently as a part of their regular curricula. To assess the acceptability of the Up2-D2, 213 children (111 boys and 102 girls) aged 9–12 years completed questionnaires about their enjoyment, comprehension, attainment, applicability, and self-efficacy after completing Lessons 1–12. For fidelity, research assistants independently evaluated audio files that were randomly selected and assigned (27.3%).Our preliminary evaluation revealed the program was highly enjoyable, clear, and applicable for students. In addition, self-efficacy demonstrated a trend of gradually increasing over the 12 sessions. The total fidelity observed in the two schools was sufficient (76.2%), given the length of the teacher training.The results of this study supported the theory that the Up2-D2 could be feasible in real-world school settings when classroom teachers implement the program. We discussed current research and practical issues of using universal prevention to address mental health problems in school, based on implementation science for user-centered design. Contrary to widespread belief, mental disorders are common during childhood and adolescence with 10–20% of all children experiencing one or more of these problems, incurring severe social burden; consequently, mental health promotion is an urgent issue, and early detection and intervention are essential [Although fear and anxiety are considered normal emotions that every child experiences during typical development, some children have profoundly high anxiety levels compared to typically developing children, which can cause severe impairment in their daily lives. Anxiety disorders are the most common psychological problem among children and adolescents , 3. MoreDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [Children and adolescents are also currently experiencing depression at an unprecedented rate . RecentlRevision . DepressRevision . FurtherFinally, anger and irritability are relatively common behaviors in children and adolescents aged 9 to 16 years (51.4% showed phasic irritability in a community sample)  and are Since students learn and develop their social and emotional competence in school, schools play a key role in fostering healthy social and emotional development among youths . SpecifiDiverse school-based prevention programs have been developed and examined in several countries. There are three types of school prevention programs: universal, selective, and indicated . UniversAmong the three types of prevention programs, universal prevention in school has several inherent advantages. First, a universal prevention program can access most students who are enrolled in each school district, while rarely experiencing attrition. Second, a universal approach can minimize the risk of “labeling” for students who are removed from a classroom for selective or indicated interventions. Third, a universal approach can strengthen the protective role of the school environment, which might have proximal influences on children, according to the ecological model of child mental health . Fourth,Most school prevention programs for mental health were based on cognitive-behavioral interventions . Some weSeveral systematic reviews of school-based prevention programs for depression covering ages ranging from 5 to 22 years old have been published –22. ThesZs = 0.99 and 2.77, respectively, p < 0.01). Whereas universal preventive actions for anger and anger-related problems have been addressed as being useful to improve children’s social and academic development in kindergarten and early childhood [Regarding anxiety, Neil and Christensen  reviewedhildhood , there ihildhood . TherefoPrevious studies suggested two issues that should be addressed in future studies of universal prevention programs in school: (1) to optimize inherent advantages of universal prevention in school overcoming limited effects, and (2) to explore the user-centered design of a universal prevention program for enhancing participants’ motivation that might facilitate more reliable gains.Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) [Recently, a transdiagnostic approach is gathering much attention. This approach can address comorbidities frequently seen in clinical populations and redundancies of learning distinct treatment manuals for practitioners , 30. Theers (UP)  shows thers (UP) . TherefoAs mentioned, previous studies regarding school-based preventive CBT programs have focused on a single type of psychopathology. However, CBT programs among clinical populations can produce diverse therapeutic gains for a variety of psychological disorders that are often co-occurring in a child or adolescent . Given tUniversal Unified Prevention Program for Diverse Disorders (Up2-D2), which targets transdiagnostic mental health problems based on a cognitive-behavioral approach in schools. Our second purpose was to examine the acceptability and fidelity of the Up2-D2 in school settings after schoolteachers implemented the Up2-D2. Since the acceptability and fidelity of the program should be confirmed in real school settings, classroom teachers and their students evaluated the implementation of the Up2-D2 rather than researchers and clinicians.To tackle these issues, first, we developed a new school-based universal prevention program—the The Up2-D2 aims at broad-band effects on mental health problems in elementary and junior high school  students aged 8–15 years. The Up2-D2 was designed to integrate common components in CBT for children and adolescents based on evidence-based psychosocial interventions  such as learnability, means that the developer should consider how to build understanding rapidly and easily for teachers and students from the program. Second, efficiency refers to the idea that a school-based program should minimize the time, effort, and cost of its usage for addressing targeted problems. Third, memorability suggests that a program should be designed to maximize competencies in teachers and students for remembering core elements of CBT. Fourth, error reduction aims to prevent error and ensure rapid recovery from the misuse and misunderstanding by use of refinement and elaboration of design. Fifth, satisfaction/reputation refers to developing a program that should be acceptable, valuable, and attractive for all related users including principals, administrators, teachers, parents, and students in the school. Sixth, a low cognitive load means that the developer should focus on simple activities, as well as developing a structure that would be welcomed by the school in order to minimize the cognitive load. Seventh, a program that intends to exploit natural constraints is one that should be designed to fit their context of use and maximize existing circumstances and natural contexts. Figure One of the fields of research should be the implementation and promotion of the systematic adoption of research findings and other evidence-based practices into routine practice; thus, research focusing on implementation could improve the quality and effectiveness of mental health services . To achiA transdiagnostic approach is one of the avenues to achieve the goals of efficiency and satisfaction/reputation in addition to enhancement on coverage of diverse mental health problems. Teachers can efficiently administer the unified program targeting multiple problems instead of spending more time conducting multiple programs targeting a single problem. Reducing training load, especially for novices, is one of the inherent benefits related to efficiency in the transdiagnostic approach . MoreoveWe created a “teaching plan” for all lessons concerning all elements for effective implementation in schools: learnability, efficiency, memorability, error reduction, low cognitive load, satisfaction/reputation, and exploit natural constraints. In Japan, all academic classes such as mathematics, English, and science are taught based on teaching plans. In addition, they can be optimized depending on each class in accordance with the guidelines provided by the Ministry of Education. Therefore, teaching plans are subject to limitations in existing resources and time-limited opportunities in educational settings. In the teaching plans, every psychological term used in the treatment manual was carefully translated into commonly used expressions in the educational settings to enable teachers to learn the components of the Up2-D2 efficiently and effortlessly. A teaching plan describes all procedures of each lesson of the Up2-D2, which guides teachers to engage in a school-based CBT , and three characters  learn skills through lessons Fig. a. The UpIn addition to the cartoon story, interpersonal practice, another facet of cultural adaptation in the Up2-D2, can ensure the satisfaction and reputation of the program as well as exploit natural constraints  in seven classes from two schools which comprised of 29.79% of the initial participants. The procedures were conducted in accordance with the ethical standards and approved by the third author’s (A2016-035) institutional research committees and only data that were obtained through an opt-out consent process from the students’ parents were analyzed.As detailed information on socio-economic status is not usually available from Japanese schools, exact information could not be collected in this regard. Both schools are located in similar middle-class areas of Saitama prefecture, in the suburbs of Tokyo, with homogenous demographics. Before the trials, all classroom teachers attended a local one-day workshop organized by the first author. The teaching plans and visual materials were distributed to them, and they could review the DVD material on which the training session provided by the first author was recorded. Both schools provided the Up2-D2 once per week from September to October.To test the acceptability of the Up2-D2, we developed a feedback sheet containing five questions  were extracted for evaluation based on a table of random numbers considering the counterbalance of both schools. Research assistants had received rating training though hypothetical lessons independent from the implementation of this study until they obtained over 90% accuracy scores in accordance with the criteria that was set by the first author. Then, they visited each school and independently listened to assigned audio files to evaluate the fidelity of the classes. The first author made evaluation sheets for each class based on the teaching plan. Each sheet had approximately 30 items to evaluate , and research assistants confirmed whether a teacher followed the prepared teaching plan.The evaluation sheets also included what must not be done by teachers in addition to what needs to be done. For example in the group activity in Lesson 2, to fulfill the fidelity criteria, the classroom teachers needed to (1) ask students to generate as many pleasant activities as possible in small groups, (2) have each group express how many activities the students found, and (3) celebrate the group which reported the greatest number of activities; however, teachers should not 4) decide which answers were correct or wrong for each activity, or (5) criticize the group which reported the fewest activities.z = 1.71, p = 0.086. Specifically, self-efficacy had a tendency of gradual increasing through the 12 sessions from 3.32 to 3.64 whereas enjoyment, comprehension, attainment, and applicability were stable and higher than 3.5 for all sessions. Moreover, more than 90% of students who participated in the Up2-D2 responded, “I think I can do it (or a little)” in all lessons (range = 90.59–96.79%) to items of self-efficacy, and 96.10% of them had the confidence to apply leaned cognitive-behavioral skills outside of the classroom immediately after Lesson 12. Whereas Y elementary school showed higher scores for enjoyment than X elementary school in Lessons 10, 11, and 12, after applying the Bonferroni correction (p ≤ 0.004), there were no significant differences for comprehension, attainment, applicability, and self-efficacy between the two schools. As a result, all indices of acceptability were above a threshold in all sessions.Total, 2322 feedback sheets were available , given that the length of teacher training (one-day workshop) was relatively short. Therefore, our findings suggest that the Up2-D2 could be feasible in real school settings when classroom teachers implement the program. Although our findings are encouraging, further trials are needed with larger sample sizes, comprehensive assessments, and rigorous research design for the intervention to be acknowledged as a transdiagnostic program. In particular, future studies should examine the program’s efficacy through a multi-method, multi-informant assessment on multiple domains of psychopathology, such as anxiety, depression, and anger. The current study is a preliminary study and it should be noted that we are aiming to report the efficacy of the Up2-D2 within all eight elementary schools from three prefectures and across five cities. Further trials are necessary to test the efficacy and effectiveness of the Up2-D2.exploit natural constraints is to rewrite evidence-based psychotherapies into a specific format that provides familiarity, approachability, and learnability, while considering the context. To enhance further program fidelity, consecutive training such as ongoing coaching, continuous consultation, or follow-up training, rather than a one-time training, may be required. Future studies should explore the elements of optimal training in terms of dose and content.As discussed before, teaching plans, instead of ordinary treatment manuals for psychologists, are useful to help teachers ease comprehension and monitoring because of their user-friendliness. Further, teachers are free from special efforts to learn the components of CBT and are prone to adhere to the present program. Indeed, our results showed that all the components were highly understandable for children aged 9–12 years; although, ceiling effects might be seen due to the scale range . Moreover, the fidelity of the program was acceptable given its time-efficiency and methods of evaluation, although it was somewhat lower than those determined in previous trials regarding the prevention of depression in Japan (85–100%) . For exaConcerning positive orientation, the Up2-D2 was developed using educational language and integrated strength works into the lessons. Although face validity is not regarded as formal validity and almost meaningless for researchers , it mighlearnability, memorability, and low cognitive load for students. In accord with our hypothesis, the current results suggested that the “gadget” in the Up2-D2 enhanced children’s fun and comprehension. Enjoyment was extremely high for all lessons, except for Lesson 10, as mentioned above. Since Lesson 10 was composed of building an anxiety hierarchy for in vivo exposure to children’s difficult and challenging situations, it is appropriate to consider whether natural deterioration might be suppressed due to the characteristics of the Up2-D2. Moreover, comprehension of the gadgets was stable and high for all components. In general, older adolescents were likely to receive more therapeutic benefits from cognitive-behavioral techniques thanks to more matured cognitive development than younger children [learnability, memorability, and low cognitive load for teachers in delivering cognitive-behavioral interventions through a realistic dose of training. Furthermore, the use of cartoons to learn cognitive-behavioral skills can exemplify one of the cultural adaptations to exploit ingenious cultural strengths in line with other health education in schools  [We anticipated that using cartoons story could contribute to children , 58. Of ucation) .exploit natural constraints in Japanese elementary educational settings. In addition, social skills trainings were included in Lessons 3 and 4 as an active component. Regarding satisfaction/reputation, small-group activities could play a vital role in the program being highly acceptable and well-regarded in school. First, as aforementioned, group social-skills interventions are prevailing CBT approaches among Japanese schools [Interpersonal practice was another characteristic of the Up2-D2 as well as cultural adaptation along with the cartoon story. All lessons consisted of group activities to  schools . In a coThere are some limitations to be noted, raising future issues related to the social implementation of universal programs for the prevention of diverse mental health problems in schools. First, for future studies using randomized controlled trial design, it is important that future issues, in which domain should be included as an outcome, examine universal transdiagnostic prevention trials. As mentioned above, a multi-method, multi-informant assessment on multiple domains of psychopathology is required to capture intervention gains for a transdiagnostic approach. However, Ollendick and his colleagues criticized that previous studies of transdiagnostic approaches have often focused on psychopathological measurements and never measured how or if changes in these presumed processes mediate treatment outcome . MoreoveSecond, whereas the study supported social implementation of the Up2-D2, the repeated measurements regarding enjoyment comprehension, attainment, applicability and self-efficacy were used to evaluate each session. More specific and individual assessments could determine more nuanced relationships between the principals and characteristics of the Up2-D2. Since the five characteristics are composed of general features (i.e. teaching plan and cartoon story) as well as more specific aspects to each component , future studies should examine different aspects of social implementation for each lesson considering contextual variables.Third, this study did not examine effect of the demographics of potential moderators such as gender, age, or school on fidelity or acceptability of the program. Given that the results suggested that a school that had a higher fidelity of the program could produce more enjoyable lessons especially during the latter part of the program, future studies should explore the more direct relationship between fidelity and acceptability. Moreover, this study only used students’ reports for the evaluation of acceptability. Teachers’ subjective reports on usability and feasibility should be examined in future studies. In addition, acceptability from parents and stake holders could be useful information for social implementation. Therefore, an important future task would be the identification of factors that contribute to acceptability, and to conduct multi-level analyses including these variables.Additional file 1: Table S1. Means and standard deviations of acceptability of the Up2-D2 in children (N = 213).


The authors of “Validity of Online Screening for Autism: Crowdsourcing Study Comparing Paid and Unpaid Diagnostic Tasks” :e13668) missed an important source of funding in the Acknowledgments section — Wu Tsai Neurosciences Institute Neuroscience: Translate Program. The revised Acknowledgments section now appears as follows:We thank all the crowd workers and citizen scientists who participated in the studies. These studies were supported by awards to DW by the National Institutes of Health (1R21HD091500-01 and 1R01EB025025-01). Additionally, we acknowledge the support of grants to DW from The Hartwell Foundation, the David and Lucile Packard Foundation Special Projects Grant, Beckman Center for Molecular and Genetic Medicine, Coulter Endowment Translational Research Grant, Berry Fellowship, Spectrum Pilot Program, Stanford’s Precision Health and Integrated Diagnostics Center (PHIND), Wu Tsai Neurosciences Institute Neuroscience: Translate Program, and Stanford’s Institute of Human Centered Artificial Intelligence as well as philanthropic support from Mr. Peter Sullivan. HK would like to acknowledge support from the Thrasher Research Fund and Stanford NLM Clinical Data Science program (T-15LM007033-35).The correction will appear in the online version of the paper on the JMIR website on June 27, 2019, together with the publication of this correction notice. Because this was made after submission to PubMed, PubMed Central, and other full-text repositories, the corrected article also has been resubmitted to those repositories.


Despite the study’s limitation in establishing causality between the care farming program and the observed effects on family health, the care farming program clearly contributed to the observed improvements of mother-child communication skills, mothers’ psychological health, and children’s emotional intelligence, which in turn improved overall family health.We designed a pilot study to develop a family interaction model-integrated a care farming program with mother-child pairs as the participants. In this pilot study, we aimed to assess the effects of the care farming program on communication skills and psychological health in families. Sixteen mother-child pairs in Sejong, South Korea participated in this study. The families participated in a care farming program once a week for six weeks (90 min per session) between May and July 2018. The care farming program was developed based on parenting education skills, strengths-based cognitive behavioral therapy, and the emotional intelligence model; the result was a family interaction model intended to improve communication and psychological health among mothers and children. The program consisted of gardening activities such as making a garden plot, planting transplants, harvesting, and cooking the harvested crops. Upon completion of the six-session program, we evaluated communication with the Parent-Children Communication Inventory, depression with the Beck Depression Inventory, and resilience with the Connor–Davidson Resilience Scale among the mothers. We also evaluated emotional intelligence among the children with the Emotional Intelligence Scale. According to post-intervention results, mothers showed significantly increased resilience, improved communication skills with their child, and decreased depression, while children showed significantly improved emotional intelligence ( In contemporary society, the nature and composition of families are constantly evolving due to factors such as lower marriage and fertility rates, increased opportunities for women’s social activities, population aging, and the rapid development of social economy. In most member countries of the Organization for Economic Co-operation and Development, the average household size has dropped from 2.8 people in the mid-1980s to 2.6 people in the mid-2000s . SmallerParent-child interactions are an important factor in maintaining family functioning and promoting family health. Families today often spend less time together than in the past, which can result in poorer communication and weaker familial bonds . In Sout“Care farming” is defined in many ways and there is still debate about the most appropriate definition. In South Korea, the Rural Development Administration defines care farming as a healing service with activities and products that utilize agricultural and rural resources to provide various health benefits . In manyTypically, parental trainings meant to improve family interactions are limited to providing lessons only to parents rather than providing practical, hands-on training for both parents and their children . In contTo recruit participants, flyers including information about the study’s objective, a description of the program, a timeline of the schedule, an outline of requirements, and a registration form were distributed at the S Healthy Family Support Center in Sejong, South Korea. The inclusion criteria for participants were that they were mothers with a child under the age of seven. Sixteen families (16 mothers and 16 children) volunteered and subsequently provided consent to participate in this study. The participating mothers answered questionnaires to provide demographic data such as gender, age, and highest education level, as well as information on what leisure activities they participated in and whether they had prior experience in a care farming program.The average ages of mothers and children were 37.81 years old (SD = 3.45) and 3.31 years old (SD = 0.95), respectively . Only onThe care farming program lasted six sessions and consisted of gardening activities such as making a garden plot, sowing seeds, planting transplants, harvesting, and cooking the harvested crops. Seasonal crops were grown .Each session of the care farming program was designed to strengthen communication skills between mothers and children, improve resilience and reduce depressive symptoms in mothers, and increase emotional intelligence in children . In eachTo improve resilience and reduce depressive symptoms in mothers, strengths-based cognitive behavioral therapy techniques were used . A hortiAn emotional intelligence model was also incorporated into the care farming program to improve children’s emotional intelligence . Emotion2, and the program used places such as a garden plot (2330 m2), greenhouse, outdoor activity area, and kitchen. Each family was provided an individual garden plot (1.5 m × 1.5 m)  .At the beginning of each session, an instructor explained the topic and lessons of the session and provided a demonstration of the gardening activities. Then, each family was asked to perform the session’s activities. For example, in the second session, mothers and children were asked to plant a family garden together, while accomplishing the goals of mothers using I-messages and children perceiving their own emotions and expressing them. I-messages are a form of assertive interpersonal communication to express feelings, needs, and concerns to others . For exaTo improve resilience and decrease depressive symptoms in mothers, a horticultural therapist identified each mother’s strengths by observing their behaviors and interactions with their children and the other families while working in the family gardens. Then, to encourage the mothers to recognize and reinforce their identified strengths, the therapist complimented behaviors that explicitly displayed those strengths . For exaIn the fifth session of the care farming program, mothers were asked to use the Baby BANK skill, while children were asked to recognize the emotions of others . The BabThis program was primarily managed by a horticultural therapist who was certified by the Korean Horticultural Therapy and Wellbeing Association. Seventeen volunteers from the Sejong Metropolitan Autonomous City Agriculture and Rural Development Administration assisted in the program.An online survey was developed using Google and conducted to assess improvements in communication skills between mothers and children, depressive symptoms and resilience in mothers, and emotional intelligence in children. The survey included a total of 90 questions, and mothers completed it twice—before and after the six-session care farming program.To measure participants’ communication skills, a Parents and Children Communication Inventory was used ,44. ThisTo measure depressive symptoms in the mothers, the Korean version of the Beck Depression Inventory (K-BDI) was used ,47. ThisThe Korean version of the Connor–Davidson Resilience Scale (K-CD-RISC) ,49 was uEmotional intelligence is a form of social intelligence that represents the ability to understand and explain emotions in one’s self and in others . To evalAdditionally, a satisfaction survey  was revip < 0.05 were considered statistically significant. Demographic information and satisfaction of mothers and children with the care farming program were analyzed using Excel software .To compare the results of the measures for the mothers and children before and after the care farming program, the Wilcoxon signed-rank test was conducted using SPSS software . Values of p = 0.024; p = 0.028; p = 0.003; The mothers who participated in the six-session care farming program experienced significantly improved mother-child communication skills , they responded that a longer period such as 8 weeks, 10 weeks, or 12 weeks would be a more adequate duration. The mothers were also “very satisfied” (62.50%) or “satisfied” (37.50%) with a session frequency of once per week. The mothers were “very satisfied” (43.75%), “satisfied” (37.50%), “neutral” (6.25%), or “not satisfied” (12.50%) with the 120 min activity time per session. In the case of the mothers who reported feeling “not satisfied” (n = 2), one respondent commented that a shorter activity time of 90 min would be more adequate and one respondent commented that a longer activity time of 180 min would be more suitable. Additionally, 87.50% of the mothers reported that they felt they benefitted from improved communication with their children through the care farming program. The mothers’ most preferred gardening activities were “harvesting” (16.67%), “cooking the harvested crops” (12.07%), and “planting transplants in the garden” (12.07%). Furthermore, 93.75% of mothers reported they wished to continue participating in the program with their children, and all of the mothers reported they would recommend it to other families.The mothers reported being “very satisfied” (68.75%), “satisfied” (25.00%), or “neutral” (6.25%) with the care farming program; no mother reported being “not satisfied.” The mothers were “very satisfied” (43.75%), “satisfied” (12.50%), “neutral” (6.25%), or “not satisfied” (37.50%) with the six-week activity period. In the case of the mothers who reported feeling “not satisfied” , “collecting the plants” (14.29%), and “watering” (11.09%). Additionally, 93.33% of the children reported they wished to continue participating in the program.The care farming program for mothers and children presented in this study was found to be effective in improving mother-child communication skills, depressive symptoms and resilience in mothers, and emotional intelligence in children. These results supported our initial hypothesis.Mothers showed significant increases in mother-child communication skills and resilience and significant decreases in depression in post-tests . Mother-Previous studies have also reported improvements in mother-child communication by participating in care farming activities, similar to our findings ,27. In aThe effects on mothers’ psychological health observed in this study resulted from the awareness and reinforcement of their strengths, as promoted by the horticultural therapist in the care farming program . StrengtMoreover, the positive effects observed in this study were likely derived from participants’ interactions with plants in a natural environment . ExposurThe children showed significant increases in emotional intelligence after participating in the care farming program . The posA healthy family is defined as a family whose members encourage the healthy development of each individual and closely interact with each other . In thisThe present study was designed as a pilot study to elicit and observe effects of a care farming program on family health. The care farming program used in the study is novel in that it differs from the previous care farming programs conducted to date in South Korea by emphasizing the interactions between mother-child as paired participants. However, the methodology employed in this study contains limitations. The results of the care farming program were not conclusive, and the effects of it were exploratory rather than inferential. The nonprobability sampling used in this study means that results cannot be generalized because the families that participated in the program did not accurately represent the statistical population. The one group pre-test-post-test design that was used in the analysis has the least rigorous characteristics. As a result, we were not able to control external factors  that reduce the validity of the study, so it is not entirely clear if the positive effects on the family health parameters measured were solely derived from the participation in the care farming program. Thus, the limited interpretation of the study is that the care farming program developed in the study can be improved and expanded upon to perform an appropriate statistical test to validate the effects that were found in the present study. Future studies will be required to address this point.Future studies should be conducted to evaluate care farming programs with well-balanced settings and control groups in the design. For example, comparing care services with and without farming activities would enable identification of the main factor from which beneficial effects are derived. Additionally, evaluating the individual contributions of each of the various care farming activities to the observed effects would provide informative data. Longer intervention periods are also recommended in future studies, as the six-week period did not allow conclusions to be drawn regarding the results. Finally, future efforts will be required to investigate the effects of care farming programs on individuals from various family types, such as single-parent families, grandparent-headed families, multi-cultural families, and foster/adoptive families.The participating mothers and children demonstrated active and positive interactions with each other during the assignment-driven, six-week care farming program. We interpreted these responses as significant improvements in family interactions and psychological family health, which fulfilled the objective of the study. These results suggest that a care farming program with mothers and children participating together could be used as a parent training program for improving family interactions. We identified limitations of this pilot study regarding its design that does not allow to control for possible mixed-effects of external factors and therefore inhibits the inference of causality between the care farming intervention and the observed positive effects. However, given that the existing literature contains few quantitative or qualitative evaluations of care farming for families conducted in South Korea, the present study is significant in that it provides preliminary data on the effects of a care farming program on family health. Care farming programs that promote moderated interactions between family members could potentially be used in South Korea as interventions to address family problems derived from lack of interaction.


Additionally, 81% of the participants who had previous experience in health-related training also possessed the prior experience as community health worker. Also, 81% of the participants who had previous training in health-related field also had a prior experience of patient navigation. In all, 38% of the participants who had a previous experience in social service field also had a prior experience of patient navigation. DISCUSSION/SIGNIFICANCE OF IMPACT: The training program established a pool of patient navigators which will contribute towards reducing the cancer health disparity in the Appalachian region of Pennsylvania. The participants reflected a wide diversity in the navigators’ backgrounds and differences across programs in their choices of patient navigators. It is important to consider this diversity when designing curricula materials and the methods of delivery in a patient navigation training program. As PN training programs are developed and implemented, further data is needed to guide practitioners and administrators in their efforts to include separate curriculum and materials for experienced and lay navigators. In addition, it is also important to assess the role and involvement of patient navigators in research and clinical trials. In total, 82% of the participants when asked agreed to be contacted for participation in research studies. Specific curriculum which includes research could be designed for further development of patient navigators. PN training and implementation knowledge is critical to the development of standards and best practices in this emergent area of cancer care.OBJECTIVES/SPECIFIC AIMS: The goal of this initiative was to address this cancer health disparity in the Appalachian counties and help participants develop, implement and evaluate evidence-based “PN” that effectively and positively impacts patient and outcomes of the HealthyWomen Program. Following were the objectives of this training program: (1) To understand the broad range of roles and responsibilities associated with “PN”, including care coordination and case management, in the Pennsylvania HealthyWoman Program in Pennsylvania and the National Breast and Cervical Cancer Early Detection Program. (2) To identify and assess local resources and expertise for evidence-based “PN” in the HealthyWoman Program. (3) To utilize “PN” in association with public education and targeted outreach initiatives in the HealthyWoman Program. (4) To implement strategies to manage and evaluate “PN” for the HealthyWoman Program. METHODS/STUDY POPULATION: The series of PN training was held at Pittsburgh, Camp-Hill, Wilkes-Barre and Philadelphia during June 2017. In total, 86 participants attended the training program at one of these 4 locations. Attendees represented organizations that provided breast, cervical and colorectal cancer outreach, screening and treatment. The participants of the training were solicited by regional program managers of the HealthyWoman Program of the PA Department of Health. The Harold Freeman model for patient navigation model was used to train the participants on the concepts of patient navigation. The training was built upon the Health Belief Model and Chronic Care Model, which defined the specific program constructs. The curriculum covered 2 important aspects, that is, clinical knowledge related to breast and cervical cancer along with aspects of patient navigation. Participants represented small, and large academic institutions/health care systems, cancer centers, federally qualified health centers, health departments as well as community-based screening programs and organizations. RESULTS/ANTICIPATED RESULTS: A total of 86 participants were trained; 78% had formal education and training in health-related field. In total, 62% of the participants had previous experience of patient navigation; 42% had training in social service related field and 50% had prior experience as community health worker. The demographic details reflected that majority of the participants (94%) were female. Most of the participants (30%) belonged to 50–64 years of age group followed by 30–39 years (23%) and 40–49 years (22%) of age group, respectively. As part of ethnic distribution, 70% of the participants were White Americans followed by Black/African Americans (17%). Furthermore, association of previous training in health and social service field with and without experience as a community health worker (n=84) and Navigator (n=86) was also analyzed. Among the participants, 44% had both community health worker experiences along with a prior training in social service related field whereas 42% of the respondents only had prior social service related training. This association of previous training in social service related field and prior community health worker experience was statistically significant with a