Falls are a major public health concern in older adults. Recent fall prevention guidelines recommend the use of multifactorial fall prevention programs (FPPs) that include exercise for community-dwelling older adults; however, the availability of sustainable, community-based FPPs is limited.n = 69) who were at-risk of falling  were recruited to participate. Mixed effects repeated measures using Statistical Application Software Proc Mixed were used to examine group, time, and group-by-time effects on dynamic balance (8-Foot Up and Go), functional balance , and muscular strength (30 s chair stands and 30 s arm curls). Non-normally distributed outcome variables were log-transformed.We conducted a 24-week quasi-experimental study to evaluate the efficacy of a community-based, multifactorial FPP [Stay in Balance (SIB)] on dynamic and functional balance and muscular strength. The SIB program was delivered by allied health students and included a health education program focused on fall risk factors and a progressive exercise program emphasizing lower-extremity strength and balance. All participants initially received the 12-week SIB program, and participants were non-randomly assigned at baseline to either continue the SIB exercise program at home or as a center-based program for an additional 12 weeks. Adults aged 60 and older  = 8.92, p = 0.0; T0 − T2 diff = 1.2 (1.0)]. Berg Balance Scores , chair stands , and arm curls  also all improved significantly over time. There were no significant group-by-time effects observed for any of the outcomes.After adjusting for age, gender, and body mass index, 8-Foot Up and Go scores, improved significantly over time [The SIB program improved dynamic and functional balance and muscular strength in older adults at-risk for falling. Our findings indicate continuing home-based strength and balance exercises at home after completion of a center-based FPP program may be an effective and feasible way to maintain improvements in balance and strength parameters. Falls are a significant public health concern for older adults. Fall-induced injuries are one of the most common causes of restricted activity, disability, and death in elderly populations . In 2014Falls-related injuries are one of the most expensive medical conditions, and the costs associated with falls are expected to rise as the US population ages. In 2015, direct medical costs for fatal and non-fatal injuries were $637.5 million and 31.3 billion, respectively. Importantly, costs for fatal and non-fatal fall injuries increased 21 million and 1 billion dollars, respectively, from 2014 to 2015  was developed in conjunction with community partners as a student-led, community-based, multifactorial FPP using allied health-care students to deliver the program. The purpose of this study was to evaluate the efficacy of the SIB Program on balance and physical function outcomes. Additionally, we evaluated the impact of two different models for ongoing sustainability—12 weeks of home-based versus 12 weeks of center-based exercise—after completion of the SIB Program on balance and physical function outcomes. We hypothesized that all participants would have significant improvements in measures of balance and physical function after completing the 12-week, multifactorial SIB Program and there would be no differences in these outcomes between the follow-up home-based or center-based programs at 24 weeks.All participants received the multifactorial, 12-week SIB Program. At the end of the 12-week SIB Program, participants were assigned to either continue the exercise portion of the SIB Program at home or as part of a center-based program for 12 weeks. Allocation to continue the exercise portion of the SIB Program at home or within a center was determined at the beginning of the study based on site preference and availability. Participants in sites that could not commit to hosting the program for 24 weeks were allocated to the home-based exercise program; participants in sites that could host the program for 24 weeks were allocated to the center-based exercise program. Outcome variables were measured at the beginning of the program, at the end of the 12-week multifactorial SIB Program and again at 24 weeks. At each time point, participants completed the balance and physical function assessments.This study assessed the efficacy of a 12-week, multicomponent FPP, SIB, plus either 12 weeks of a home-based or center-based exercise program on balance and physical function in older adults using a quasi-experimental design with multiple posttests. This study was approved by the Arizona State University Institutional Review Board and was carried out in accordance with the policies and guidelines set forth by the Office of Research Integrity and Assurance at Arizona State University. All participants provided informed consent in accordance with the Declaration of Helsinki prior to participating in the study.To facilitate recruitment and identify potential locations to deliver the SIB Program, a partnership was established with the Greater Valley Area Health Education Center (GVAHEC) Empowerment Systems, Inc. (EmSys). Sites to deliver the program were recruited from the greater Phoenix metropolitan area in Maricopa County with the assistance of allied health-care student interns at GVAHEC/EmSys. Community programs throughout the Phoenix metropolitan area were contacted by the interns to determine their interest in receiving this FPP. From these interactions, nine locations were approached as potential sites for the SIB Program. Two locations did not feel that the SIB Program would be appropriate for their community members, three did not have the facilities/scheduling available to host the SIB Program, and one location would not approve an outside organization providing programming. Therefore, three sites were selected based on the location’s interest and availability as well as the number of older adults interested at these locations. One site offered two instances of the program with no overlap of program participants between the two instances of the program.Community-dwelling older adults were recruited from the three identified sites. To maximize contact within the community at each site, methods of recruitment varied according to site needs. All recruitment strategies were facilitated by employees from the respective sites. Strategies included posted flyers, information sessions, interacting with potential participants during lunch, and electronic advertising in community newsletters and/or community websites.Inclusion/exclusion criteria were chosen to produce a group of older adults who had an elevated risk for falls. The inclusion criteria included: 60–100 years of age; a self-report of a fall in the past 12 months or two or more of the following criteria: age >80 years, self-reported osteoarthritis of lower extremity, taking four or more medications, self-report of fear of falling or concern about falling, or physically inactive [self-report of a Rapid Assessment of Physical Activity (RAPA) score of less than 6 ]. Particvia the past; prior experiences help to subsequently guide and inform the older adult as to how the present should be interpreted and what action should be taken. Using the SCT to design FPPs may help older adults identify the important influences on their sense of control over the consequences of aging. These influences include an individual’s judgment regarding ability to perform a specific behavior (self-efficacy), the person’s beliefs about the effectiveness of his or her own actions (outcome expectations), and the explanations the person gives for outcomes (attributions). Self-efficacy is a person’s confidence in their ability to perform a specific behavior  . The SCTbehavior . Self-efThe SIB Program was designed to improve the participants’ falls and physical activity self-efficacy. One of the leading causes of activity restriction in older adults is fear of falling, and this is a major focus of this intervention –23. By oThe SIB Program was developed as a community partnership between Arizona State University, the GVAHEC/EmSys, and a local senior transitional retirement community center. The SIB Program was premised on the 2008 CDC Compendium of FPPs, which recommended the use of multicomponent programs to address falls . ConsistThe SIB Program consisted of twice weekly 90 min sessions for a duration of 12 weeks. The first 55–60 min of the session was exercise while the remaining 30 min was health education regarding falls risk factors and strategies for maintaining physical activity. The exercise routine included a 5-min warm-up, 25 min of individualized progressive resistance training with exercise bands and ankle weights primarily focused on lower extremity strength, 15 min of progressive balance exercises, and 10 min of cooldown and flexibility exercises. Participants were asked to complete the exercises on their own at home one time per week during the SIB Program. The health education program was designed to facilitate discussion about falls risk factors and physical activity. Topics discussed included education about falls risk factors, vision assessment, polypharmacy and medication management, home modifications, calcium and vitamin D supplementation, physical activity and falls, and strategies to promote participation in physical activity. All lessons and exercise classes were taught by allied health-care students in an interactive manner to facilitate group participation and retention of information.All participants were provided with an exercise manual that included safety tips, intervention exercise expectations, detailed descriptions and pictures of the exercises, and an exercise log to facilitate the once weekly home exercise sessions. The exercise manual was taken home on the first day of class to be used as a resource for home exercise days. All participants were also provided with a health education manual that included health information and worksheets on the respective topics. This health education manual was used in class and was given to the participants to keep on the last day of class. Additionally, they received a video of the exercise program on the last day of class to encourage continued physical activity at home.Participants were asked to report their sociodemographic characteristics including age, gender, race/ethnicity, education level, income level, marital status, and whether or not they lived alone. Participants were also asked to report the presence of chronic illness, medication use, the need for assistive devices, and fall history.Participants were weighed to the nearest 0.1 kg in light indoor clothing, without shoes when feasible, and pockets emptied. Height was measured to the nearest 0.2 cm with a portable stadiometer without shoes when feasible. Waist circumference was assessed using a Gulick tape measure with the participant standing, at the midpoint between the inferior aspect of the last rib and the superior aspect of the iliac crest, over light indoor clothing to the nearest 0.5 cm. Waist circumference was measured twice and averaged.r = 0.54); it also showed good sensitivity (81%), positive predictive value (77%), and negative predictive value (75%)  .The Fall Efficacy Scale International (FES-I) is a 16-item self-report questionnaire used to asses concern about falls in older adults . It is sThe 8-Foot Up and Go  was usedThe Berg Balance Scale (BBS) was used to assess functional balance. The BBS is comprised of 14 items that challenge one’s balance. Each item is scored from 0 to 4 –32 with r = 0.71–0.78) in laboratory settings (r = 0.78) and reliable (r = 0.81) (The Senior Fitness Test by Rikli and Jones  was usedsettings . For the = 0.81)  measure p < 0.05 level. Kolmogorov–Smirnov tests for normality were used to examine all outcome variables . Descriptive statistics were computed for demographics and physical assessment data. To determine if differences existed between program completers and non-completers, independent t-tests , Wilcoxon Rank Sum  tests, and chi-squared tests  were conducted. Analyses of outcome measures were conducted on program completers only. To examine changes over time in outcome variables, linear growth model analyses were conducted using SAS Proc Mixed. The analyses were conducted in a hierarchical fashion using Restricted Maximum Likelihood model and “autoregressive heterogeneous 1” covariance error structure. The effect of time was evaluated using linear and quadratic trajectories and time × group effects examined the between-group differences in the trajectories during the sustainability phase of the program. Linear growth model analyses controlled for age, gender, and BMI at baseline and clustered on program/site location. Cohen’s d effects size estimates were calculated to assess the magnitude of effects and were interpreted using standard conventions for small (d = 0.2), medium (d = 0.5), and large (d = 0.8) effects  software . Statistical significance for this study was set at the  effects .Figure 2). This sample of older adults reported high falls self-efficacy (FES-I) or low concern about falls  did not complete the intervention or post-assessments. The main reasons for non-completion were health issues unrelated to the intervention, personal commitments, and not being able to attend the scheduled posttests . Of the 40 participants that turned in falls calendars, 9 individuals reported having a fall during the 12-week intervention period, 4 of whom reported multiple falls. None of the reported falls occurred during the exercise portion of the SIB Program.F = 19.2, p < 0.0001) and quadratic  effect of time and a trend for a group by quadratic time effect  for the 8-Foot Up and Go scores. The quadratic effect of time indicates that the slope of time effects differed from baseline to 12 weeks and from 12 to 24 weeks. Specifically, the improvement in 8-Foot Up and Go scores was greater from baseline to 12 weeks  than from 12 to 24 weeks, but there was still a significant improvement from 0 to 24 weeks. There was a trend (p = 0.08) for a significant group by quadratic time effect with those attending the center-based exercise program trending toward continual improvement from weeks 12 to 24  on the BBS  and a quadratic time by group  effect on balance. Individuals assigned to the home-based exercise program follow-up group had greater improvements in balance during the initial SIB Program compared to those assigned to the center-based exercise program follow-up group. The improvements in the home-based group were maintained over the 12-week follow-up period. The participants assigned to the follow-up, center-based exercise program did not improve as much as those assigned to the home-based follow-up group during the initial SIB Program. However, this group continued to increase over the 12-week center-based exercise program follow-up period  and quadratic effect of time  on 30-s chair stand scores  and a quadratic time by group effect . Individuals assigned to the home-based follow-up group saw greater improvements in the number of chair stands (ES = 1.54) during the initial SIB Program compared to those in the center-based follow-group (ES = 0.58) and continued to improve over the 12-week follow-up period (ES 0.46). The group assigned to the home-based follow-up saw a greater improvement over time relative to the center-based program (ES 1.5 versus 0.79).There was a significant linear  and a quadratic time by group effect  on number of arm curls  on balance and physical function in community-dwelling older adults at-risk of falling. A secondary purpose was to compare the effects of assignment to a follow-up, 12-week home-based or center-based exercise program on balance and physical function. Improving balance and lower-extremity strength is necessary for improving falls risk in older adults. Physical performance, functional balance, and leg strength are critical components of fall prevention in older adults –42. Findp = 0.08) for only those attending the center-based exercise program toward continual improvement from weeks 12 to 24  drove the differences or if it was other factors due to the quasi-experimental design of the study. It is plausible the home-based participants likely did not continue to increase during the home-based exercise program due to a ceiling effect. The adjusted mean score on the BBS was 53.74 with an SE of 0.76, and the maximum score on the BBS is 56. Additionally, the participants on average saw a 6-point improvement in Berg Balance, and it has been suggested that a 4-point improvement in the BERG scale is suggestive of improved functional balance for individuals with a starting Berg score between 45 and 56 .Lower extremity strength as assessed by 30-s chair stands increased over time for both groups with no effect of group. Similar to the findings on the BBS, individuals assigned to the home-based follow-up group saw significantly greater improvements in the number of chair stands during the initial SIB Program compared to individuals allocated to the center-based follow-up group and continued to improve over the 12-week follow-up period. The participants assigned to the center-based follow-up did not increase their number of chair stands as much during the initial 12-week SIB Program but still continued to increase over the 12-week center-based exercise program follow-up period. Contrary to our hypotheses, the group assigned to the home-based follow-up saw a greater improvement over time relative to the center-based program, and this discrepancy was primarily due to gains during the initial SIB Program. Similarly, there was a quadratic group-by-time effect for arm strength. A similar pattern emerged for the home versus center-based follow-up groups. The group allocated to the follow-up home-based exercise program saw greater improvements in arm curls during the initial SIB Program and maintained these improvements over time. The group allocated to the center-based, follow-up exercise program saw smaller improvements during the SIB Program but continued to improve. Unlike lower extremity strength, there was no overall group-by-time effect.The current sample of older adults scored lower than their age matched norms on multiple physical assessment measures. Their TUG time was slower than norms (4.2–7.1 s) . FurtherCollectively, these findings suggest there is a need for an initial group-based FPP that emphasizes physical activity to improve balance and physical function outcomes. The effects of the program can be maintained through home exercise. Offering a continual group-based exercise program may confer greater benefits than asking individuals to exercise on their own. Based on the observed results, it is also plausible that individuals initially assigned to continue the exercises at home versus as part of a group may be more motivated to work harder during the program. In this study, we did not observe any effects of group for any of the outcome variables, but we did observe linear group-by-time and/or quadratic group-by-time interactions. The majority suggested the group assigned to the follow-up home-based group improved more during the initial SIB Program and maintained the outcomes. In contrast, those assigned to the center-based follow-up group improved to a lesser extent during the initial site-based SIB Program but continued to improve during the center-based exercise program. These findings could potentially be explained by compensatory rivalry; these participants knew ahead of time which follow-up group they were assigned to. Future evaluations should focus on random assignment to home or center-based follow-up exercise groups after the initial SIB Program.The primary limitation of this study was the quasi-experimental design. All participants received the initial SIB Program, and participants were allocated to either a group-based or home-based exercise program based on site preference. There was no control or comparison group so we cannot say the intervention caused the outcomes. However, the study participants were sedentary individuals with an elevated risk for falling. It is highly unlikely that the assessed outcomes would have improved in the absence of a physical activity intervention. The normal trajectory for physical function and balance with aging is a decline. The participants’ knowledge of follow-up group assignment may have reduced the internal validity of the study though. The participants assigned to the home-based program had greater gains during the SIB Program for the majority of the outcomes, and this could be indicative of compensatory rivalry. The study used well-established objective measures of physical function and balance outcomes enhancing the validity of findings.Study results suggest the SIB Program is an effective program for improving balance and physical function outcomes in older adults who are at-risk for falling. The program can be delivered by allied health-care students potentially enhancing the sustainability of the program and reducing program costs. More research needs to be done to evaluate the effects of allocating individuals to a home-based exercise program versus a center-based exercise program after the completion of a multicomponent exercise programs. The effects of group assignment in the present study were mixed. For the 8-Foot Up and Go and arm curls, there was no linear group-by-time effect; however, there was a quadratic time by group effect, which suggested participants who knew they were going to have to exercise on their own after the program finished had greater gains during the program on these outcomes. These individuals maintained their improvements through home-based exercises whereas those assigned to the center-based exercise program continued to improve. For the BBS and the 30-s chair stand, there was a linear effect of time that favored the group allocated to the home-based follow-up program. This effect was primarily driven by larger gains during the initial SIB Program. More research is warranted to investigate the optimal ways to sustain improvements in balance and physical function outcomes over time after completion of a multicomponent FPP.CD contributed to the design and implementation of the study, co-developed the Stay in Balance Program, assisted with data collection and data analysis, and wrote the draft of the manuscript. MM contributed to the design and implementation of the study, co-developed the Stay in Balance Program, was responsible for all data collection and management, assisted with data analysis, and provided critical feedback on the manuscript draft. MB’s primary role was data analysis and interpretation. He also assisted with the writing of the manuscript and provided critical, editorial feedback on the final manuscript.The authors of this study declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Measures included subjective units of disturbance (SUDs), standardized trauma symptom questionnaires, and analysis of behavior monitoring logs. Adolescent interviews (n = 10) and a presenter focus group (n = 4) assessed program experience and views on future development. Sessions were videoed and analyzed for program adherence. Analysis involved MANOVA, and a quasi-qualitative thematic approach for participant views. Adolescents reported high SUDs and a range of trauma symptoms. A large effect size was found for reduced SUDs (d = 1.10) and positive trends were identified for symptoms and behavior change in the intervention group. Program adaptations included smaller groups, the use of visual materials and liaison with care staff to facilitate generalization. Recommendations are made for program development and large scale evaluation.The current study is the first to implement and evaluate a group-based trauma-specific program for adolescents in a secure accommodation facility in Scotland. A randomized control and qualitative pilot study compared an intervention group ( The current study is the first to examine the implementation and evaluation of introducing a trauma-specific intervention into a Scottish secure facility. To assess the impact of a trauma-specific program on reducing adolescent trauma symptoms the study utilized a randomized control design with standardized trauma symptom measures. Analysis of behavior monitoring records identified any reductions in behavior incidents and qualitative interviews explored participant experiences in order to discover adaptations needed for future implementation. The study built on an exploratory study of traumatization in adolescents in a secure facility in Scotland  of Adverse Childhood Experiences (ACE) of juvenile offenders, building on the earlier 2013 diverse urban community study of 1784 adults, found 10 different adversities: emotional and physical neglect; family violence and separation; mental health problems; imprisonment of a relative; emotional, physical, and sexual abuse; and substance misuse  have been used to set the wider context for the current study. The extant literature in the USA has found high rates of trauma exposure among adolescents in secure facilities. Dierkhising et al.  found ran = 17) reported m = 8.47 traumatic events on average, ranging from four to twelve events. Similar to the ACE study, sixteen different types of event were identified. All adolescents reported sudden traumatic losses, physical assault and frequent placement changes. Nearly 90% reported physical abuse by relatives (n = 15) and over 70% (n = 12) experienced domestic violence and sexual abuse. The latter included all 11 girls in the sample. Neglect was reported by 59% (n = 10). Finally, hospitalization (n = 9) and emotional abuse (n = 7) was experienced by 53% and 41% of adolescents, respectively  adolescents gains in anxiety, depression, physical complaints and behavior. More recently Olafson et al. (n = 77) alongside trauma-informed whole staff training in Think Trauma. The authors concluded that it was possible to deliver a trauma-specific program in juvenile justice resulting in a significant reduction in PTSD, depression and anger. As Ford and Blaustein  in intervention and waitlist. The study sample consisted of 11 females and 6 males  received the intervention and 4 females and 3 males were on the waitlist. All were Scottish and Caucasian, from unemployed families, from a wide geographical spread across Scotland. All three presenters were experienced program workers. Two were social workers and one had a psychology background. All were trained to deliver a variety of mental health and behavior change programs. Adolescents were in secure from 1 to 7 months prior to TRT with an average period of 4 months. Nine of the adolescents had only been in placement for two months.The study was conducted in one of five secure facilities in Scotland. The facility was located outside a small Scottish town in a rural location. The maximum number of adolescents in the facility was 20. Adolescents were placed from all over Scotland. To date, the facility had focused on delivering behavior change programs. Twenty adolescents, the corpus sample, from four different care units, were selected and then randomly allocated to intervention and waitlist control conditions See Fig.  using thTRT is a trauma-specific program based on cognitive behavioral theory that focuses on normalizing the trauma response; teaching strategies for intrusive memories, hyper-arousal, and avoidance symptoms of PTSD as well as coping with loss. TRT was originally developed for adolescents who experienced disaster situations, such as earthquakes, and war trauma. Content includes: (i) case studies as exemplars for psychoeducation on traumatic events, normalizing resultant symptoms, and stimulating the sharing of traumatic events; (ii) relaxation techniques and positive cognitions to help with emotional dysregulation; (iii) brief exposure for trauma reminders; and (iv) systematic desensitization of anxiety and anger hierarchies for avoidance. Because of short concentration spans and social skill difficulties, adolescents received an adapted version of TRT. Sessions were shorter, 40 min on average, and delivered twice weekly over seven weeks, rather than weekly two hour sessions. Two program workers were present during delivery, one to present, the other to support. Presenters received a-three day training by an expert trainer  from the Children and War Foundation covering program values, content and processes. Training methods mirrored program activities and included information giving, modeling, experiential learning, reflection, and feedback. TRT was delivered to the intervention group during school time and over three phases  with four, four and two adolescents in the intervention groups respectively. Presenters received group supervision by the principle researcher, following each phase of delivery. This involved affirming adherence to TRT protocols, making adaptations within theoretical guidance and being responsive to adolescents.k.All sessions were video recorded for fidelity analysis. The fidelity framework, based on the structure of sessions and the scripted activities in the TRT manual, was established prior to delivery. Analysis of two sessions by the principle researcher (Reader in Trauma Studies) and co-researcher (team manager) led to adaptation of the fidelity framework to include the nature and extent of protocol adaptation, and presenter non-verbal and verbal communication. Four sessions were analyzed with the adapted framework. Duration of communicative behavior is reported as a percentage of session length. Inter-rater reliability, involved analysis of the four sessions and is reported as Cohen’s kappa Greenwald’s  protocolA battery of six standardized measures was administered. The Impact of Events Scale  were asked what they thought of TRT including: whether it was helpful and in what ways; which parts worked best; what was learned; what strategies were applied in real life; how likely is it that they will use the strategies in real life ; if any negative consequences were experienced and what would improve TRT? Adolescent responses were recorded verbatim by the researcher and checked for accuracy by the program worker at the time of interview. Analysis involved a quasi-qualitative thematic analysis that utilizes identification of meaningful codes and themes from statements as well as the frequency counts of statements under each code. A quasi-qualitative analysis was chosen in order to not only identify participant meanings but also to get a measure of how often the meanings were reported by adolescents and potential measure of importance. The steps within the quasi-qualitative analysis were: familiarization of the whole data set for each question; the identification of statements into codes of meaning; rank ordering of codes; the analysis of codes into superordinate themes; a review of statements, codes and themes; and report writing  were calculated to determine the power of TRT in reducing participant subjective disturbance, PTSD, depression, dissociation, traumatic grief and mental health difficulties reported by staff. Effect size is reported as small (0.1–0.3), medium (0.4–0.6) and large effect (0.7–1.00). As attrition occurred prior to pre-intervention assessment, it was not possible to conduct an intention to treat analysis.An Omnibus Multivariate analysis (MANOVA) was used to assess between group differences in TRT and waitlist SUDs, behavior and standardized measures. T-tests were used to assess pre and post-test differences within TRT and waitlist groups. The amount of ‘clinically’ significant change for individual adolescents was calculated by assessing the difference between pre and post-test SUDs for individual trauma targets as well as comparing differences in collated SUDs for all reported traumatic events for each adolescent. MANOVA was used to assess the influence of age and phase of TRT delivery  on the outcomes measured. Because of the small sample size and skewed female population, gender was not analyzed as a moderating factor. Effect sizes (Cohen’s k = .93).As planned, all sessions were co-led by program workers and took place twice weekly. Sessions lasted 40 min on average keeping the duration within participants’ concentration spans. On average, three activities were covered per session. Three individual follow-up sessions were held with three individual participants because of missing one TRT session each. All missed their session because of a case review meeting. Adaptations to delivery involved utilizing smaller groups, and positive behavior management strategies because of challenging off-task behavior. Behavior problems were reported with one male and one female because of relationship split that spilled into the group and another male who did not view his difficulties as trauma based. Sessions 2 and 6 from phase two were randomly selected for inter-rater reliability analysis (High levels of program protocols were maintained in the four sessions (94%). This was due to presenters following the order of activities and reading scripts in sessions. Adaptations to delivery occurred when a participant was struggling to understand a concept, unsure of the task, or concentration was waning towards the end of sessions. Presenters utilized a range of strategies to help adolescents comprehend and engage with tasks. For example, when an adolescent was unsure of what a bad dream was, examples were given of types of nightmare; the purpose of the activity was repeated; more time was spent on discussing and asking questions; and reassurance was given in not needing to draw the dream. Towards the end of sessions, presenters helped adolescents maintain focus by using affirmation statements, encouragement, and letting participants know there was only a short time left till the end of the session.Presenters delivered TRT in calm warm tones throughout (100%), body language was open in nature , oriented towards participants (97%), and with high levels of eye contact (93%). While one of the presenters sat facing adolescents at a small Table (100%), the other would stand and write adolescent responses onto a flip chart (23%). As per protocols, sessions were recapped at the beginning for prompting memory of content, strategies learned, and the application of strategies. Questions were used to facilitate recall, e.g. “So what was it we covered last session?” “Do you remember ….”? All activities were introduced by stating the purpose of the activity and then checking for understanding.Reception of adolescent response was high throughout the sessions (93%). Reception involved affirmation statements, summarizing what had been said, asking questions for clarification, and asking questions to elicit more details. Presenters frequently checked for student understanding, e.g. “So does that make sense? What do you think?” Presenters also checked whether adolescents had applied any of the strategies, reinforced the use of practice, and offered support. Presenters normalized different responses to activities and gave reassurance when adolescents were uncertain, e.g. “well done to take another turn.” Presenters took part in activities and modelled (i) the use of strategies and (ii) sharing thoughts and feelings. Presenters managed turn-taking by ensuring all adolescents got a turn, e.g., “so x, how did you change your dream?” In short, although high levels of TRT fidelity was achieved, adolescents needed a range of communicative strategies that enabled them to remain on task, take turns, recall learnings, understand what was being asked of them, and reflect on the strategies they used.F = 0.109, p = .746  = 4.560, p < 0.50. A significant difference was found for TRT between pre and post-test  with a mean SUDs score reduction, m = 52.60 (SD = 17.34) to m = 26.40 (SD = 19.55). In contrast, no difference was found between pre and post-test SUDs in the waitlist . A slight reduction in waitlist mean scores occurred indicating a positive trend, m = 56.28 (SD = 28.83) to m = 46.14 (SD = 17.52). TRT achieved a large effect size, d = 1.10 for SUDs. No statistically significant SUDs results were found for the moderating factors of age and phase of TRT delivery.At pre-test, TRT and waitlist SUDs were not statistically different F,16 = 0.1n = 20) compared to the waitlist (n = 10). Indications are TRT participants may have experienced clinical reductions in SUDs compared to the waitlist. This finding needs further research.In contrast to the waitlist, 4 TRT adolescents reported large reductions in their average SUDs for listed traumatic events: 31 to 7; 46 to 3; 65 to 10 and 34 to 17. Double the number of TRT adolescents reported individual trauma events rated as zero post-test  = 1.777, p = .202: depression, F = 0.30, p = .866; dissociation, F = 0.397, p = .541; and wider mental health difficulties, F = 2288, p = .159. Following TRT, there was a trend in reduced symptoms for PTSD, depression, and traumatic grief compared to an increase in symptom levels for the waitlist. None of these results, however, were statistically significant. There was a high correlation between adolescent and staff reports of mental health difficulties at pre  and post-test  that supports adolescent self-reports.Eleven adolescents fulfilled the criteria for the likelihood of PTSD (65%) and clinical depression (65%). Only three reported clinical levels indicative of dissociation (18%). No significant different was found at pre-test for PTSD, t = 4.589, p < .01 versus t = 6.61, p = .05) and upset  pre to post-test, however, TRT showed greater trends towards change in aggression (m = 15.50 to m = 9.50 TRT versus m = 12.86 to m = 8.14 waitlist) and upset (m = 3.88 TRT to m = 1.50 versus m = 2.00 to m = 1.43 waitlist). Further, two TRT participants made substantial reductions in aggression (10 to 4 and 8 to 1 events respectively). This individual adolescent change was not apparent in the waitlist. Clinically, the most upsets (n = 10) for any single participant reduced to (n = 4) in TRT compared with n = 7 to n = 3 in the waitlist.Behavior monitoring suggests adolescents in TRT and waitlist reduced in aggressive behavior (Adolescent responses were short and indicated a wide range of perceived gains from TRT involvement (see Table n = 7); all activities (n = 6); safe place (n = 4); drawing (n = 2); and one occurrence for tapping; smelling; “turning a bad picture into a good picture”; “being part of a group”; “talking about things”; and “comparing difference in feelings last time and now.” Adolescents reported on a range of what they learned: “talking about feelings” (n = 2); “how to cope with things” (n = 2); “if get annoyed, breathe and think about something else (n = 2)”; “how to deal with difficult images, to keep them in the past (n = 2)”; “to be able to put my thoughts to the side” (n = 2); “what’s beneficial to talk and not talk about”; and “to hear different points of view.”Adolescents reported a range of activities they liked best: calming and relaxing .”k = .93 and k = .91 respectively.Staff perceived adolescents as benefitting from TRT but emphasized the need to individualize TRT to fit with how adolescents respond in a group (see Table n = 27); challenging behavior at times (n = 17); some limited verbal contributions (n = 11); encouraged support by peers (n = 10); liaison with care staff was essential (n = 9); uncertainty of adolescent response for presenters (n = 8); adolescents needed follow-up to apply skills (n = 6); TRT delivery needed adapted (n = 5) and it difficulties accessing photocopying facilities (n = 5). The above codes are summarized into the theme of ‘Challenges of TRT delivery’.Analysis of presenter responses identified ten codes from 95 statements. The rank order of codes was as follows: valuable contributions received from adolescents (n = 9); increased sense of control (n = 8); chance to re-visit learning in real-life (n = 7); a better understanding of trauma events and symptoms (n = 6); reduced symptoms (n = 4); and a range of tools to apply in real-life (n = 4). The above codes are summarized into the theme of ‘Normalizing and coping’.In terms of what adolescents learned, six codes were identified from 38 statements: normalization through shared experience (n = 12). The activities of imagery, graded exposure, fear thermometer, and safe place as well as time for fun (n = 5) were reported as helpful. The importance of emphasizing the purpose of the activity (n = 4) and small groups enabled more focused interactions (n = 3). There was recognition that different adolescents responded to different activities (n = 2) and that the same adolescent could respond to different activities on different days (n = 2). The theme was ‘variety of structure and activity’.Presenters perceived the following as working best in TRT: individual and group activities (n = 14); discovering the extent of trauma in adolescents (n = 10); recognizing trauma events and symptoms in adolescents’ written reports (n = 9); building in what adolescents respond to, e.g. fun; visual aids and attractive workbook (n = 7); writing reports from a trauma lens (n = 6); increased range of trauma recovery strategies (n = 4); helping other agencies recognize trauma (n = 4); needing to revisit learning for adolescents (n = 4); the importance of selection and grouping (n = 3); being cautious before asking about traumatic experiences (n = 3); how to embed TRT into practice and to keep learning (n = 3); increasingly feeling the negative impact of recognizing adolescents not being placed appropriately ; need to repeatedly emphasize the purpose of program and activities (n = 2) and accept that change is not linear (n = 1). ‘Trauma and program awareness, knowledge and skill development.’ was the theme.Presenters reported a wide range of learning for themselves. Fourteen codes were identified from 73 statements. These were as follows: The importance of liaising with care staff  high levels of positive behavior management strategies to keep adolescents on task; (ii) pictures to support visualization for adolescents struggling with imagining; (iii) frequent reminders of the purpose of the activities; and (iv) involvement of care and education staff to encourage adolescents to use strategies beyond lessons. Presenters also emphasized the importance of participant selection for groups, keeping group sizes small and sessions of short duration. Although contested, a number of authors argue that such program adaptation can be an important part of program fidelity, as long as the changes are within program theoretical underpinnings Backer .Interviews suggest adolescents were positive about TRT. Adolescents were to able identify a range of activities they enjoyed and provided useful ideas for future program adaptation. Some, however, were wary of receiving a trauma-specific intervention in a group. This may have been because of the risks associated with managing emotions as well as disclosure and confidentiality in front of adolescents they lived alongside Kerig . This raThe current study further identified that program staff as well as adolescents report gains from delivering a trauma-specific program. These included re-conceptualizing adolescent challenging behavior as being underpinned by trauma, learning to utilize trauma-specific measures for screening and evaluation and discovering trauma-specific responses to intervening with traumatized adolescents. Significantly, being enabled to deliver a trauma-specific program led staff to want to “continue learning about adolescent traumatization and recovery”. These gains are not insignificant, as they begin to address gaps in current secure facilities in Scotland where the focus has mainly been on behavior rather than mental health (Barron and Mitchell n = 200) and as such a more positive program impact may not have been identified by this study. In addition, as adolescents were from the same facility, waitlist adolescents may have been indirectly exposed to information from the intervention, e.g., through changes in staff behavior or via peer interactions. This coupled with the small sample makes any conclusions potentially confounded by nonspecific factors such as the thoughtful attention of the presenters with the adolescents. The small and skewed nature of the sample towards girls did not permit any meaningful gender analysis to be conducted. The trauma history interview for eliciting and rating traumatic events has yet to be validated for program evaluation and was therefore experimental (Greenwald Because of the limited number of adolescents and secure facilities in Scotland, only a small sample was available. The sample of seventeen adolescents was well below the numbers needed for a program of medium power (The current study is an important addition to a new field of research in Scotland and adds to research globally in its infancy. The current study evidenced that it is possible to deliver a group-based trauma-specific program into a secure facility in the Scottish context. The program led to significant reductions in subjective disturbance for adolescents compared to those on the waitlist. Trends in reduced posttraumatic stress, depression and traumatic grief warrant further exploration. Likewise the trend in reduced behavioral incidents is promising given most adolescents are placed in secure facilities because of their behavioral difficulties. The study also highlights the need for program adaptation in a secure setting because of adolescent difficulties with motivation, concentration, comprehension of the purpose of activities and challenging behavior. Adaptations included the use of small groups, shorter and more frequent sessions, visual materials to aid imagination and positive behavior management to keep adolescents on task. Involvement of care staff was reported as essential in enabling adolescents to apply new coping skills beyond lessons. With these adaptations it appears program workers can achieve a surprisingly high level of fidelity. Finally, program workers reported gains the development of their conceptualization of adolescent trauma and trauma recovery as well as skills program delivery.The current study, highlights the potential to refine TRT for secure facilities in Scotland. The adaptability of TRT to the needs of adolescents and skills of the trainers are important topics for further development and research. It is recommended secure facilities should continue to explore the implementation and evaluation of trauma-specific approaches. Appropriately trained program staff are well placed to administer trauma-specific screening and evaluation measures. Program staff will need further training in the delivery and development of novel trauma-specific programs and trauma history interviewing. Care staff will need training in trauma-sensitive milieu in order to support trauma-specific interventions to help adolescents generalize their learning. Such training will need revisited, developed over time and supported by supervision Sommer . The vidResearch into trauma-specific interventions is urgently needed for adolescents placed in secure facilities. Valid and reliable evaluation measures need to be developed for adolescents who have experienced cumulative domestic violence and who present with a range of developmental trauma symptoms. The concept and measures of multidimensional grief needs to be explored for adolescents in secure accommodation. Larger samples sizes are needed for empirical studies to compare gender as a moderating factor and aid generalization of findings. Future studies need to assess the validity and reliability of SUDs as a program evaluation measure. The effectiveness of trauma-specific group-based programs needs to be compared with individual trauma therapies. The identification of multiple needs and diagnosis of adolescents may assist future researchers consider the model of intervention. Finally, the potential for longer term gains need to be assessed.


To describe how a multinational team worked together to transition a physical therapy (PT) educational program in Paramaribo, Suriname, from a Bachelor level to a Master of Science in Physical Therapy (MSPT) level. The team was made up of PT faculty from Anton De Kom Universiteit van Suriname (AdeKUS), the Flemish Interuniversity Council University Development Cooperation (VLIR-UOS) leadership, and Health Volunteers Overseas volunteers. In this case study, the process for curricular assessment, redesign, and upgrade is described retrospectively using a Plan, Do, Study, Act (PDSA) framework.PT educational programs in developing countries are eager for upgrade to meet international expectations and to better meet community health-care needs. An ongoing process which included baseline assessment of all aspects of the existing bachelor’s program in PT, development of a plan for a MSPT, implementation of the master’s program, and evaluation following implementation is described.Curricular assessment and upgrade in resource-limited countries requires the implementation of process-oriented methods. The PDSA process is a useful tool to explore curricular development. The international collaboration described in this paper provides an example of the diligence, consistency, and dedication required to see a project through and achieve success while providing adequate support to the host site. This project might provide valuable insights for those involved in curricular redesign in similar settings. In developing nations around the world, the rehabilitation needs of persons with acute and long-term disability often go unmet. This problem is most often due to a combination of factors; (1) lack of understanding of rehabilitation professions, (2) inadequate numbers of rehabilitation providers, (3) inadequate infrastructure that limits access to care, (4) lack of education about the importance of rehabilitation, and (5) social constructs that inhibit people from seeking services. Physical therapists (PTs) are key providers who can directly meet the unmet clinical needs and also influence the status of the profession and the community’s understanding of physical rehabilitation. The purpose of this paper is to describe the process of curricular assessment, redesign, and upgrade of the Physical Therapy (PT) Program at Anton De Kom Universiteit van Suriname (AdeKUS) in Paramaribo, Suriname, through the retrospective lens of the Plan, Do, Study, Act (PDSA) framework.Physical therapy curricular planning and evaluation play important roles in the advancement of the profession. This planning and assessment process is part of any PT educator’s purview. However, educational programs in developing countries, eager to enhance their capacity for being able to meet community needs and to enhance the status of the PT profession, struggle in this area because of limited expertise, resources, infrastructure, and competing priorities. Various initiatives are underway around the world to empower PTs and educational programs that aspire to advancing the profession. This paper is an example of one such effort.WCPT Guidelines for Physical Therapist Professional Entry-Level Education  encourages and supports not only the implementation of appropriate entry-level education but also the development of “… processes that independently validate and assess the standards of entry-level education provision …” . The WCPducation  and the ogrammes , bring tUsing a case report format, this paper utilizes Deming’s PDSA process  to descrThe Republic of Suriname is the smallest country  in South America , established in 1968, is the only university in Suriname and is located in the capital, Paramaribo. The medical sciences school was established in 1969 and the PT program in 1996. In 2006, AdeKUS sought funding and support from the Flemish Interuniversity Council University Development Cooperation (VLIR-UOS)  to enhanAdeKUS, in consultation with the VLIR-UOS, determined that to best serve the changing health needs of the Surinamese population and elevate the presence and status of PTs and PT education—in the country and the Caribbean Region—the existing Bachelor program needed to be evaluated, updated, and transitioned to the MSPT level. This transition aligns with international recommendations put forth in the Bologna Process  and thos(1)AdeKUS PT program faculty members provided information about the existing program and vision for future MSPT level program; described needs of the program, faculty, students, and community; provided ongoing feedback and program needs/outcome data; and were instrumental in implementing all aspects of the plan.(2)VLIR-UOS project leaders led and scheduled meetings; set strategic plan goals and objectives; and met and coordinated the exchange of information with AdeKUS leadership.(3)HVO volunteers provided knowledge and direction related to course planning, design, content, and teaching strategies to align with international guidelines; considered and communicated PT-specific accreditation expectations; instructed courses; provided clinical education training; and delivered continuing education to community therapists.In 2008, a multinational, collaborative effort began with involvement and contributions from the AdeKUS administrators and PT faculty, representatives of the VLIR-UOS, and Health Volunteers Overseas (HVO) volunteers from the United States (US). The work group, referred to as Team 6, met regularly in Suriname from 2008 through 2013. This team was comprised of the following people who made the following contributions:In the US, performance improvement models are routinely used in health-care organizations and PT professional education to measure, assess, and improve performance. This is likely due to the strong influence of standard setting bodies such as The Joint Commission on Hospital Accreditation  and the In the WCPT Guidelines for Physical Therapist professional entry-level education, this important international organization encourages and supports not only the implementation of appropriate entry-level education but also the development of processes to explore and validate what is done . The WCPVersions of the Deming/Shewhart Cycle Figure , such asImplementing the PDSA model  to prepare for establishing a multidisciplinary training and research center at AdeKUS; (2) to discuss quality and outcome measurement strategies for curricular, professional, and course-related issues; and (3) to explore opportunities for additional Belgian collaboration.Team 6 did not meet in Suriname during 2010; however, during that year, continued communication, support, and volunteer teaching took place. Various members of Team 6 visited AdeKUS individually to carry out a variety of supportive activities and consultation such as: teaching, document revision assistance, continuing education for faculty and community clinicians, and clinical instructor training.During each Team 6 meeting a micro-level iterative process of planning, doing, studying, and acting on findings took place. Although providing specific details from each of those meetings is beyond the scope of this paper, Table The organizational structure of the program was examined in relation to PT education programs in Europe and the US. Guiding documents, program handbooks, policy and procedure manuals, committees, and meeting schedules were assessed for existence and quality. This resulted in the development, revision, and organization of the Mission and Vision statements, program handbooks, and policy and procedure documents. It also prompted the clarification of leadership roles and responsibilities, which was important for the day-to-day running of the program, but also served to empower those who had leadership expectations. This included the identification of a Program Director and gave him/her power and time to carry out leadership and administrative tasks. Importantly, this person had a direct supervision line to the Dean. A calendar of regular program, faculty, chair, and dean meetings was established.A community/country needs assessment was carried out to determine PT service needs and the needs of community clinicians. This information led to the discussion and enhancement of program goals and expected outcomes. This included the identification of benchmarks for outcomes and performance, the development and revision of information about student admission prerequisites and requirements, and other informative documents for new and prospective students. It also led to the development of a transitional masters program for previously trained community therapists.Initially the program was heavily reliant on medical school faculty who taught major aspects of the PT curriculum. This was problematic in two particularly important ways. First, the PT program had no autonomy or control over what was being taught and lacked the ability to hold those instructors accountable for what they did. Second, the students were learning from a medical perspective and not a PT perspective. Even within the PT program there was a need for clarification of roles and responsibilities. Some faculty had very heavy teaching loads while some had very light teaching loads. In some areas, expertise was lacking and the program had a reliance on international volunteers to come and teach courses. It was identified that many faculties would benefit from education and training to enhance pedagogical practice, teaching methods, and student assessment techniques.These issues led to the development of a curriculum that was less reliant on the medical school faculty, a plan to progressively shift to more Master of Science (MS) and Ph.D. trained faculty, involvement of community PTs as lab and teaching assistants, a plan and schedule for regular faculty and committee meetings, continuing education to enhance teaching methods and strategies, and evaluation of teaching loads and expectations. Job descriptions were developed for all faculty and staff.Later in the process, a Faculty Board was put in place. The Board would have responsibility and clout in addressing; curricular issues, outcome measurement results, student assessment, coordination, faculty performance, program evaluation, faculty assignments, research expectations, admission criteria, faculty recruitment, and space and resources. The Faculty Board was made up of PT program faculty and students, faculty associated with, but not a part of the PT program, and community PTs. The Board was tasked with establishing a regular meeting plan before start of each academic semester, run by the Program Director, where program faculty meet to discuss curriculum, send a consistent message to students about curriculum and course work, and stimulate collaboration. Importantly, the Board would also be responsible for the future management and approval of newly developed syllabi and course changes. This process would include syllabi acquisition, assessment, and revision. Subgroups of the Board would be responsible for specific didactic issues including specific faculty issues, course content, and incorporating evidence-based practice.The development of leaders with the appropriate skills was and remains an ongoing challenge. There have been several changes in the leadership roles and responsibilities throughout the process.Evaluation of program curriculum was carried out in relation to the Physical Therapy Normative Model, accreditation standards from CAPTE, and evaluative criteria from the Netherlands Flemish Accreditation Organization (NVAO) . AlthougAt the initial meeting in 2008, the team was informed that it was taking students a very long time to complete the PT curriculum; the team thought this was the result of an inability to enlist international volunteer instructors in certain content areas. However, it also became clear that this problem was due to a couple of other things. These included (1) the use of a lottery system for admission to the program and (2) the common and chronic problem of students having to retake many courses because of failure were brought to light at this meeting. The use of a lottery system for admission to the program meant that students had not chosen PT and may or may not have knowledge of—or interest in—the profession. Low pass rates were felt to be due to the practice of student performance rarely being assessed during a course. Rather, a student’s grade is dependent on one exam given 1–3 months after a course has been completed. Neither the lottery system nor the exam system could be changed, but there was opportunity to strengthen the teaching and student assessment practices and improve student advising within courses in the PT curriculum.Based on all of these factors, several initiatives to assist students were implemented. These included a program-orientation process, an advising system, and professional development sessions. Contact hours and student workload were explored in depth, and the findings informed the development of the new curriculum. The importance of syllabi for guiding students was discussed and informative and thorough syllabi were developed. Access to important resources such as texts and other resources, Internet access, and lab space was enhanced.A proposed “3 plus 2” MSPT curriculum, with the awarding of a bachelor’s degree after successful completion of the first 3 years, was developed , the team found many areas had improved and certain problems persisted. Strengths included overall improvement in program delivery; an increase in quantity and quality of PT-specific instructors and content; and a student perception that the workload was acceptable. The response rates were low and too limited to extract significant results; however, some important areas for improvement were evident. The most serious problem was that students continued to have trouble moving through the curriculum. This seemed to be due to lack of faculty to teach certain courses, lack of non-PT faculty connection with—and dedication to—the PT curriculum, and poor examination results. Problems also included lack of clarity about organizational structure and coordination; lack of clarity in course materials and syllabi; problematic Internet access and reliability; and faculty shortages.Based on the results, continued syllabi revision took place: supports for students were enacted; gaps in instructor expertise and availability were addressed; Internet system upgrades were requested; and faculty were reminded to keep to the course hours and workload specified in the curriculum. The aggregated data were used on an ongoing basis for planning in all aspects of the program.Seeking and receiving adequate and useful feedback from stakeholders will continue to be a focus, as will designing a streamlined way of collecting and analyzing the data. Efforts will take place to enhance the number of respondents. The outcome measurement process will continue to evolve so that valid information is collected from a large number of stakeholders so that follow-up efforts can be maximized.Educational resource needs were assessed. Necessary books, reference materials, computer access, lab space, materials, and equipment were identified, and a plan to acquire them was developed. Over the course of the project, efforts to improve Internet access were made, text books were purchased, and space and equipment for a research laboratory and a clinical laboratory/practice room was obtained. Grant funding for resources was identified.Adequate Internet access continues to be problematic. Ongoing review of the adequacy and availability of resources will require ongoing attention as the program grows and changes and as research activities increase.Toward the end of the process, AdeKUS decided to seek local accreditation, and preparation for that became a major priority for the PT program.The Suriname curriculum upgrade project has been exceedingly successful, although it was not without its challenges. The most notable of which were: a lack of clarity about leadership, the need to send faculty aboard to earn advanced degrees, reliance on the medical faculty, and cultural differences with regard to urgency and timeframes. Initially, it was difficult to identify who was responsible for various aspects of the program. Further, people outside of the PT program faculty had various leadership roles. This complicated matters and made it difficult for the program to be autonomous. When faculty members traveled to Belgium to earn advanced degrees, this weakened the program structure while they were away and prevented some things from being accomplished in the most efficient ways. The reliance on the medical faculty to teach PT content was problematic. Those instructors did neither have adequate knowledge of PT content nor did they have an allegiance to the program. This created problems in terms of PT-specific curricular content, inadequate student support, and disenfranchising program leadership because they had no control over the medical faculty. Team 6 encountered cultural differences that needed to be addressed early on in the process. In particular, this included making the most beneficial use of the time the team had to work together and the expectations that tasks would be completed as assigned for subsequent meeting.Despite these challenges, the AdeKUS PT program admitted the first class of MSPT students in November 2010. A new class of 10 to 15 students has been admitted every year since then. In the last 2 years, the program has grown in popularity so the lottery system is used to select 10 students, only after the 5 students with the top scores are admitted. Nine students have finished the MSPT.As of now, six faculty members have completed their MS degrees in Belgium. Two faculty members plan to receive their Ph.D. degrees in 2017, while the third is planning to finish her Ph.D. in 2018. The other faculty members with MS degrees will start Ph.D. programs in the near future.Clinical instructors are receiving continuous education to increase the quality of clinical education experiences. The program infrastructure  has been upgraded in many ways to allow those things to occur. The most critical aspect of Team 6’s success is related to the fact that the AdeKUS PT faculty was very involved in the process and receptive to the team’s input and feedback—even when the comments were critical of past practices. The PT faculty were smart, eager, invested, and excited about the future of the program.Evaluation of the success of the program transition is ongoing. Although Team 6 and HVO volunteers no longer meet in Suriname, members of the team continue to assess effectiveness and to make changes as needed. Once the basic needs of the program are met and running smoothly, plans include more sophisticated tracking of student demographics, qualifications, and success, which will allow for comparison with past students and other academic programs and provide rich data for ongoing programmatic evaluation. Future work will focus on coordinating and evaluating program expansion, exploring student outcomes, and consideration of the AdeKUS PT program’s role at the international level.In summary, AdeKUS, in consultation with the VLIR-UOS and HVO volunteers, determined that to best serve the changing health needs of the Surinamese population and elevate the presence and status of PTs and PT education in the country and the Caribbean Region, the existing Bachelor of Science program needed was thoroughly evaluated against current international expectations and practice. The program was then updated accordingly and, with constant examination and assessment, transitioned to the MSPT level. This curricular upgrade and transition project aligns with international professional recommendations. The PDSA model provides a lens through which to explore the process and consider future curricular update projects in developing nations. In this case, it was used to explore how Team 6 was able to meet the initial goals of the VLIR-UOS grant. This multi-faceted, process-focused, international collaborative approach to implementing change was very successful; yet, it exemplifies the care with which such projects should be undertaken. Even with a strategic, process-oriented team of international colleagues, in a relatively controlled and stable national situation, with highly invested and motivated local faculty, some serious challenges existed and persist.In this case, the PDSA process facilitated the identification of several important themes/issues and led to the upgrade and improvement of the AdeKUS PT program. Several of the problems identified and addressed through the process are likely relevant to most curricular upgrade initiatives. These themes and issues include thorough evaluation of existing organizational structure/practice; development of leadership skills and empowerment; consideration of the impact of student admission processes and academic readiness; deep assessment and analysis of curricular content; assessing and maximizing faculty capacity and needs for continuing education; seeking stakeholder buy-in; seeking, incorporating, and supporting the involvement of community clinicians; ensuring the availability of adequate resources; establishing outcome measurement processes; evaluating the need for outside support; and working toward a self-sustainable end. Entities interested in undertaking similar curricular development or upgrade projects—no matter the discipline—should be mindful of the many issues that might complicate their efforts, the time needed for transition, and the importance of using an improvement model that will provide structure for the project.The international collaboration described in this paper provides an example of the diligence, consistency, and dedication required to see a project through and achieve success while providing adequate support to the host site. Although this paper describes the upgrade of a PT education program, it can be used to inform curriculum development projects in developing nations in any of the health disciplines.JA is the primary author. S-SB assisted with writing and editing. TC contributed with writing and editing. JdV contributed with writing and editing. NT assisted with writing and editing. JJ contributed with meeting content and development of paper. AV assisted with writing, editing, and PROSE content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Spreading proven or promising Aboriginal health programs and implementing them in new settings can make cost-effective contributions to a range of Aboriginal Australian development, health and wellbeing, and educational outcomes. Studies have theorized the implementation of Aboriginal health programs but have not focused explicitly on the conditions that influenced their spread. This study examined the broader political, institutional, social and economic conditions that influenced negotiations to transfer, implement, adapt, and sustain one Aboriginal empowerment program—the Family Wellbeing (FWB) program—to at least 60 geographical sites across Australia over 24 years.A historical account of the spread of the FWB Program was constructed using situational analysis, a theory-methods package derived from a poststructural interpretation of grounded theory methods. Data were collected from published empirical articles, evaluation reports and project articles, and interviews with 18 key actors in the spread of FWB. Social worlds and arenas maps were used to determine the organizations and their representative agents who were involved in FWB spread and to analyze the enabling and constraining conditions.The program was transferred through three interwoven social arenas: employment and community development; training and capacity development; and social and emotional wellbeing promotion and empowerment research. Program spread was fostered by three primary conditions: government policies and the availability and Aboriginal control of funding and support; Aboriginal leadership, associated informal networks and capability; and research evidence that built credibility for the program.The continued demand-driven transfer of empowerment programs requires policies that enable Aboriginal control of funding and Aboriginal leadership and networks. Flexible and sustained coordination of program delivery is best leveraged through regional innovation hubs that can work with partner organizations to tailor the program to local end-user needs. Associated research is also needed to evaluate, continually improve program quality, and build program credibility through evidence. Decision-makers in the developed settler-colonized countries of Canada, Australia, New Zealand and the United States (CANZUS nations) struggle to discern how to best close the gaps in Indigenous and non-Indigenous health equity. Enabling the spread of proven programs can make potentially cost-effective contributions to a range of Indigenous development, health and wellbeing, and educational outcomes . There iA number of different terms are used in the international literature to describe the processes of spreading programs and services. Terms such as transfer, translation, exchange, diffusion, dissemination, implementation, scaling, utilization, uptake, and linkage are often used interchangeably. The term “scaling” is used in this article to refer to the composite processes by which a program or service: (1) is spread to a new setting (transferred), (2) is assimilated and changed in the new organizational setting (implemented), (3) develops endurance over time (sustainability), (4) creates transfer of knowledge and authority from the external provider to the new organization (shift in ownership and capacity), and 5) is appropriately revised by those adapting it (adaptation)  is appro.International evidence suggests that whilst many health programs are implemented effectively in single communities, there are considerable barriers to scaling them up across a nation. Barriers include high economic costs of the intervention or implementation per participant; adverse political or institutional barriers; differing values of funding bodies and local end-user organizations, lack of clear roles or functions, or lack of compatible incentives; lack of adaptation to the local context; and lack of scaling-up logistics . The keyIn this study, we examined the scaling of the Aboriginal-developed Family Wellbeing (FWB) Program, that spread nationally to 60 known sites and was delivered to more than 3,500 participants through a minimum of 220 episodes over 24 years . A prior“There is no such thing as ‘context’”. Instead, the “conditions of the situation are in the situation… The conditional elements of the situation need to be specified in the analysis of the situation itself as they are constitutive of it, not merely surrounding it or framing it or contributing to it. They are it…” .This study seeks to contribute to understandings of program scaling by examining the broader conditions that influenced the transfer, implementation, adaptation and sustainability of the FWB Program. These conditions included the national Australian policies for Indigenous affairs, which changed three times within the 24-year timeframe of FWB Program spread. The policies of Indigenous self-management (1975–96), mainstreaming (1996–2004), shared responsibility (2004–2014), and advancement (2014-current) provided shifting macro-level political, ideological, socioeconomic and other systems of relating, and influenced meso-level social network ties among individuals and organizations. Following Adele Clarke , 13, sucHow do the broad (varied and changing) conditions of Australian as a situation make themselves consequential in efforts to scale up an Aboriginal health program?Hence, the research question is: The FWB program was developed in 1993 by the Aboriginal Employment Development Branch of the South Australian Department of Education, Training and Employment (The Branch). At first glance, FWB is an accredited Certificate II training program offered through the Australian vocational education and training sector. Skills taught included foundational counseling skills for coping with personal and community problems including grief and loss. However, the complex nature of Aboriginal Australian wellbeing issues and their determinants calls for more than a standard didactic training program. FWB was therefore designed to provide an empowering framework within which participants are supported to interact and tackle a variety of personal, professional and community wellbeing issues. The program is based on theoretical models of change from psychosynthesis , and comFamily Wellbeing facilitators support program participants to interact and reflect on the development of self, relationships with others (including family members) and relationships between groups . Participants are invited to consider their personal issues, blocks, and barriers to change . The impRelationship issues are then considered. These include communication and understanding; conflict resolution; forgiveness, reconciliation and healing; parenting skills; love and nurturing; interdependence; and other specific issues for men, women, parents or children. Finally, a participant is asked to focus on issues concerning relationships between groups including respecting and understanding differences; conflict resolution; forgiveness, reconciliation and healing; sharing, cooperation and learning from each other; and interdependence . ParticiA historical account of the transfer and implementation of FWB Programs was constructed using situational analysis, a theory-methods package derived from a poststructural interpretation of grounded theory methods , 13. SitMaps of the social worlds and arenas were developed to determine the broad structural conditions that influenced interactions to transfer and implement the FWB Program, the arenas of commitment and discourse within which they were engaged, and the organizations or groups and their representative individual agents of change , 13. TheThis study was carried out in accordance with the recommendations of James Cook University Ethics Committee with written informed consent from all subjects in accordance with the Declaration of Helsinki. The protocol was approved by the James Cook University Ethics Committee (H 3532).A phased approach was used to reconstruct the 24-year history of the transfer and implementation of FWB. First, 60 published articles and evaluation reports that provided empirical documentation of FWB implementation, were located through literature searches, networking, and enquiry with providers of FWB delivery across Australia. Project planning documents were also collected. However, there were gaps in the documented evidence. The first published program evaluation, for example, was not completed until 7 years after the genesis of FWB, and after significant program spread  situations of FWB transfer.Family Wellbeing agents were differentiated from FWB Program participants or students of the program, although all but three had also participated. Research respondents were chosen through purposive and later theoretical sampling to interrogate the diversity of emerging concepts across time, places and types of transfer. As recommended by ethics guidelines for Indigenous research, attention was paid throughout the research to principles of spirit and integrity, reciprocity in the research relationship, respectful relationships, equality in power relationships, survival and protection including support for a collective Indigenous identity, and responsibility to do no harm . The interviewer acknowledged her own positioning as being outside the Aboriginal colonized experience while at the same time seeking to be an “allied other” .Social worlds and arenas maps were developed to determine the enabling and constraining conditions, organizations or groups involved in FWB transfer and their representative individual agents of change, and the extent of program scaling. Reflective memos were used to clarify the elements represented by the maps, their relations and the significance for the study. For example, an early reflective memo identified that FWB as a program intervened at the boundaries between social worlds, but was also a social world in itself. The structural conditions were identified by comparing cross-cutting themes across social arenas.Three overlapping social arenas were identified. These were Aboriginal employment and community development 1992–1998), Aboriginal training and capacity development (1995–current), and Aboriginal social and emotional wellbeing promotion and empowerment research (1996–current) . The first stage of what was to become the FWB training program was developed in response to this request. The relevance of fore-fronting Aboriginal concerns was expressed by one early FWB facilitator:The FWB training program was first delivered in 1993 at Port Augusta over a 9-week period, with a 3-h module delivered each week (27 h). Bolstered by the enthusiastic response to the training program by community groups, in 1994 the Branch developed an ambitious strategy for scaling up the program.Unlike other community development initiatives, commonly implemented in single community settings, ATSIC funding enabled the Branch to develop short-term objectives (to June 1995) which included development of FWB centers in every major South Australian Aboriginal community. Aboriginal coordinators were to be employed and skilled to deliver an accredited FWB counseling training and other courses to train and empower members of all major Aboriginal communities. As well, resources, publicity materials and videos would be developed. The result would be a highly trained FWB team able to anticipate and respond to changing community needs and work according to a code of ethics. Longer term objectives (to June 1998 and beyond) included further program scaling and extension of each of the strategies .By 1995, six South Australian centers had been established , with Aboriginal FWB workers employed in each. Their role was to organize FWB lunches designed to “bring together Aboriginal groups, families and communities to develop a common vision which promoted unity, self-responsibility and economic independence for the comprehensive development and wellbeing of each Aboriginal person, family and community” . Port AdAdditionally, the Branch organized events for training, team building and networking; three are notable. In 1994, a FWB conference was held on traditional Pitjantjatjara land in northern South Australia to provide an opportunity to enhance the connectedness of the growing FWB networks with Aboriginal family groups. It attracted approximately 100 participants and media attention. Soon afterward, a challenging personal and professional development workshop was provided for the incipient FWB facilitators and others by a visiting American psychosynthesis therapist, Edith Stauffer . In earlBy 1996, however, broader national debates about Australia’s welfare system, including options for reducing Aboriginal welfare dependency, started to impact the FWB approach. Despite public Commonwealth and state government statements of commitment to Aboriginal empowerment, partnership and reconciliation, from 1996 on, after the national election of the conservative Howard Government: “it was clear that he intended to undo much that he had inherited in the Indigenous Affairs portfolio” . A new nStill far short of achieving their goal of FWB centers in every major South Australian Aboriginal community, by 1999 most of the original FWB agents had resigned, and had been replaced by a succession of short-term leaders. The employment of the regional FWB workers could not be sustained, and the community lunches were phased out. After 1998, FWB was no longer explicitly framed as a community development and employment program.Consistent with the new national policy of mainstreaming, a new phase of FWB development was launched in the guise of an Aboriginal counseling training and capacity development program. Only one key social world was engaged in this arena Figure : the maiwithout depending on welfare services”  promotion program, with associated empowerment research. In this more complex social arena, four key social worlds interacted through regional innovation hubs to spread the program. The four social worlds engaged in the delivery of FWB as a SEWB promotion and empowerment research program were the three main provider hubs  and their partner organizations, government funders, and researcher organizations Figure . This arThe first delivery of FWB within the SEWB promotion and empowerment research arena occurred in 1996 in response to a tragic cluster of youth suicides in Alice Springs. Like other emerging SEWB programs at the time, the program aimed to enhance mental health through moving away from individualized and “problematized” approaches to encompass “domains of health and wellbeing such as connection to land or ‘country,’ culture, spirituality, ancestry, family and community” . BuildinThis Alice Springs delivery provided an opportunity for the first external evaluation of FWB . Delivery of the task was not evaluated and was not sustained in Queensland.In 2004, a new national policy for Aboriginal development of shared responsibility  Aboriginal Community Controlled Health organization negotiated the delivery of FWB as a leadership program for Aboriginal women. A second SRA signed by the north-eastern Tasmanian Indigenous community and Tasmanian and Australian governments in 2007 built on an earlier Tasmanian FWB delivery and aimed to implement a TAFE course for Aboriginal people to be trained as Family Wellbeing Counselors to assist people affected by family violence . With reThe TAFESA facilitator returned to Adelaide and the FWB was discontinued.From the late 2000s, FWB was increasingly incorporated as one element of complex multi-strategy programs . Researc[…] to try and get that level of sustainability is quite difficult for a program of the sort that we’re talking about, very difficult really. If you look across public sector programs of this sort of nature, which are non-mainstream, to survive 10 years is quite a challenge, when you’re looking at at least three governments in a period of time like that.In 2014, the Commonwealth government had adopted yet another national policy . As a broad indicator of health, the current gap between Indigenous and non-Indigenous Australians’ life expectancy at birth is still estimated to be 10.6 years for males and 9.5 years for females . InternaThe case of FWB demonstrates that scaling up of programs does not occur through a consistent, lineal process Figure . As mentOverarching conditions that fostered program scaling were government policies and the availability of funding support and control; leadership by Aboriginal Elders and others and associated networks; and research evidence that built credibility for the program. These structural conditions were derived from both Aboriginal and Western knowledge domains. Separating the Aboriginal from the Western domain is not clear-cut because both affected program scaling, and FWB offered an opportunity for interaction at the intersection. However, it is important to acknowledge and consider the continuum between these Aboriginal and Western structural conditions, and to acknowledge that the conditions across this continuum influenced interactions and negotiations about the scaling of FWB.The availability of resources, particularly funding from government programs, was critical to program scaling, particularly the sustainability of implementation. National Aboriginal policies of self-management (1975–1996), mainstreaming (1996–2004), shared responsibility (2004–2014), and Indigenous advancement (2014–current) provided shifting historical frameworks for Aboriginal development, influencing Commonwealth, state and territory governments’ operational policies, which drove the availability of resources and support for programs such as FWB.For example, the national policy of self-management (1975–1996) supported Aboriginal self-governance processes, whereby Aboriginal people themselves made decisions about long-term goals and objectives for their communities, what kinds of development they wanted and what actions needed to be taken to achieve those goals . ControlThe second “training and capacity development” arena was framed in response to the national policy of mainstreaming. Here, FWB agents were able to attract funding to develop the certificate II FWB vocational educational program and to attain sustained government funding in three sites over more than 20 years. In contrast, FWB was funded within the SEWB promotion and empowerment research arena in more than 40 sites by one-off government grants, but implementation was sustained by this arena beyond 5 years in only three sites. As for many programs, Indigenous organizations reported difficulty in sustaining FWB with small, short duration grants with their accompanying administrative and fiscal accountability requirements . The aveAboriginal leadership, networks and capacity were also important enabling conditions. In the original employment and community development arena, leaders built Aboriginal ownership and capacity, informal family and community networks, capability and control, and achieved sustained implementation. Aboriginal FWB agents (some of whom were Elders and/or community leaders) took lead roles as program developers, coordinators, facilitators, adaptors, researchers and advocates. Their leadership contributed significantly to the credibility of the program with Aboriginal community members and organizations. The capability of Aboriginal organizations and groups to negotiate with governments and integrate FWB delivery within service provision was also important. Aboriginal networks, including and ties to Elders and family members, were also instrumental in spreading awareness of the program and negotiating aspects of scaling. In contrast, spread was restricted in the training and capacity development arena by the limited capacity within mainstream educational systems for shifts in Aboriginal ownership and capacity.Also different in the third SEWB promotion and empowerment research arena, informal innovation hubs between researchers with provider and partner organizations provided opportunities for dialog and learning across formal and informal networks of FWB agents and program adaptation Finally, research evidence built credibility for the program, particularly through the SEWB promotion and empowerment research arena. Here, funding applications drew upon research evidence to support one-off grant applications. More than 60 empirical evaluation reports and articles documented the effects of FWB on efforts by Aboriginal individuals, families, organizations and communities to exert greater control and influence over many factors affecting their day-to-day lives . MotivatThe three key enabling conditions found in this study are consistent with those found in the scaling of health programs internationally: political commitment by governments, strong community representation, and the availability of decentralized administrative, political and economic support. In the case of FWB, regional innovation hubs played an important role in negotiations across social worlds to scale the program in response to local Aboriginal community demand. This study also noted the importance of research support in building evidence and program credibility. This suggests a need for further evidence of the enabling and constraining factors underlying program sustainability. In particular, the impact of short-term piloting approaches as a response to what are inherently long-term development issues requires evaluation.The history of FWB scaling involved the evolution of the program through three interwoven social arenas: employment and community development; training and capacity building; and SEWB promotion and empowerment research. Within this evolution, the program was tailored to meet the needs of participant groups and, in some cases, radically adapted. Despite demand and commitment of end user groups, the sustained implementation of FWB in only 6 of the 60+ sites suggests the difficulties that Aboriginal organizations face in continuing to deliver programs with small, short duration grants. Conditions that enabled scaling were government policies and the availability of funding support and control; leadership by Aboriginal Elders and others and associated networks; and research evidence which built credibility for the program. The continued scaling of such programs requires enhanced support for provider hubs to facilitate negotiations of program transfer and their sustained implementation by committed partner organizations and individuals within these social arenas.This study was carried out in accordance with the recommendations of James Cook University Ethics Committee with written informed consent from all subjects in accordance with the Declaration of Helsinki. The protocol was approved by the James Cook University Ethics Committee (H 3532).JM designed the study with guidance from RB, KT, and AC. JM collected and analyzed the data with assistance from CB. JM drafted the initial manuscript which was then read and critically revised by RB, CB, KT, and AC. All authors approved the final version to be published and agreed to be accountable for the content of the work.The research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.