Triple P is an integrated, multi-level system of evidence-based parenting support designed to promote the well-being of children and families to reduce prevalence rates of social, emotional, and behavioral problems in children and adolescents and to prevent child maltreatment. The system developed gradually over four decades to address the complex needs of parents and children from diverse family, socioeconomic and cultural backgrounds. It blends universal and targeted programs, a focus on developing parental self-regulation capabilities, and adopts a life span perspective with a population health framework. The Triple P system is used as a case example to discuss the past, present and future challenges, and opportunities involved in developing, evaluating, adapting, scaling and maintaining a sustainable system of evidence-based parenting intervention. Seven stages of program development are outlined from initial theory building and development of the core parenting program through to the sustained deployment of the intervention system delivered at scale. The importance of ongoing research and evaluation is highlighted so that different programs within the system evolve and adapt to address the contemporary concerns and priorities of families in diverse cultural contexts. A well-trained workforce is essential to deliver evidence-based programs, in a need-responsive manner that blends both fidelity of delivery and flexibility and is tailored to respond to the needs of individual families and local context. Programs need to be gender-sensitive, culturally informed, and attuned to the local context including relevant policies, resources, cultural factors, funding, workforce availability and their capacity to implement programs. Growing international advocacy for the widespread implementation of evidence-based parenting support is based on clear evidence that positive parent–child interactions and nurturing relationships lay the foundations for a family environment that will produce healthy well-adjusted children with the life skills needed to thrive  can be adapted and successfully transported to low- and middle-income countries  at the University of Queensland. The PFSC’s current strategic plan (2022–2026) includes the following goals 1) to improve the lives of families and children; 2) to create healthy, non-violent, family-friendly communities; 3) to make high-quality, culturally informed, evidence-based parenting programs accessible for all families and 4) to translate important research findings into policy and practice. These aspirations have provided a unifying values-based call to action for our research team. As a self-funded University research center, the PFSC has been fortunate to attract some outstanding academic colleagues, research staff, graduate students and eventually industry partners that have been committed to developing, evaluating and scaling EBPS programs.Triple P extended the prevailing models of individual, and group behavioral parent training based on social learning principles developed in the 1970s and 1980’s. Early parenting interventions developed by pioneers such as Patterson, Hanff, which were further developed by Forgatch, Chamberlain, Webster-Stratton, Forehand & McMahon, and Eyberg while effective, reached relatively few families. To reduce the prevalence rates of child social, emotional, and behavioral problems and child maltreatment a more comprehensive, integrated, multilevel system of parenting support from birth through to adolescence based on population health principles was required Sanders, . HoweverThe notion of a having a suite of evidence-based interventions on tiered continuum of increasing strength or intensity and narrowing population reach had little policy or empirical support in the field of parenting. The principle of “minimal sufficiency” that emphasized a parent should be offered as much or as little support with parenting as they may require to resolve a difficulty was new. Indeed, the notion of using brief, low intensity interventions was criticized in some quarters as endorsing “inexpensive” but ultimately insufficient intervention options to address the complex needs of vulnerable and “hard to reach” parents.From the outset it was clear that a “one-size fits all” approach  would not work or be accepted by the field. Hence, for many years we worked concurrently on developing and testing both universal and targeted interventions. We worked on programs with wide population reach such as television series on parenting such as the “Families” TV Series in New Zealand on TV 3  could be successfully applied to a different or new population or problem without substantial modifications. However, clinician and parent feedback sometimes indicated that certain populations required different or additional program components or supports to address additional risk or protective factors . This end-user viewpoint typically provided the impetus for developing new program variants such as Stepping Stones Triple P for parents of children with a disability, Pathways Triple P for parents at risk of harming their children, Resilience Triple P for children who were bullied and Fear Less Triple P for parents of children with anxiety disorders. There are currently 33 discrete empirically supported Triple P programs that comprise the Triple P System (see Table https://pfsc.psychology.uq.edu.au/covid19-resources) relating to parenting in a pandemic including downloadable tipsheets, parent guides, a 20-episode podcast series  date back to 1978 and the foundational work undertaken by the author as part of his doctoral dissertation in psychology at the University of Queensland in 1978 (completed 1981) under the supervision of Professor Ted Glynn (the University of Auckland), Professor Jack James (the University of Queensland) and advisor Professor Todd Risley (University of Kansas). Triple P began as an individually administered 10-session home coaching model of parent training for parents of preschool-aged children with disruptive behavior problems  Having a safe and engaging environment, 2) creating a positive learning environment, 3) using assertive discipline, 4) having realistic expectations, and 5) taking care of yourself as a parent. The specific parenting skills had four primary targets—Skills that promote a positive relationship with the child , skills that encourage desirable behavior , skills that teach children new skills and behavior  and skills to manage problem behavior . In addition, to these child-focused skills, parents were taught self-management skills such as goal setting, self-monitoring and self-evaluation of strengths and challenges, setting personal goals and a parenting plan for change, planning and preparing for high risk or challenging parenting situations.From this foundational base additional age-appropriate parenting skills were introduced into different program variants such as Teen Triple P , Stepping Stones Triple P , and Triple P for baby . As Triple P evolved additional parenting skills were introduced for specific groups of children or parents. For example, Pathways Triple P for parent at risk of child maltreatment , Enhanced Triple P , Family Transitions Triple P , Lifestyle Triple P . Each new iteration of Triple P incorporated procedures and strategies based primarily on contemporary cognitive behavior therapy and empirical literature supporting the use of techniques relevant to addressing the area of concern. For example, to address stress and anxiety problems techniques of cognitive restructuring, stress management such as relaxation, mindfulness, deep breathing was employed and integrated where possible into everyday parenting tasks, routines and situations .Thirteen individual co-authors contributed to the development of Triple P program materials. These program developers have mostly been the author and former doctoral students (now colleagues). Most were studying clinical psychology at the University of Queensland and a small number of non-student academic colleagues were affiliated with the PFSC. The program developers have included Karen Turner, Carol Markie Dadds, Alan Ralph, Alina Morawska, Felicity West, Vanessa Cobham, James Kirby, Helen Stallman, Trevor Mazzucchelli, Lisa Studman, Carmon Spry, Karyn Healy, and Aileen Pidgeon. The program was gradually extended beyond the concerns of parents of preschool-aged children to other age-groups of infants, toddlers, elementary (primary) school-age children and teenagers and different types of child problems  and family contexts .A range of implementation tools and resources were developed for different variants to support all aspects of implementation, scaling, and sustainment, including parent materials, written and video resources used in workforce training, supervision procedures to support practitioners implementing Triple P, self-report and observational measurement tools for tracking client outcomes, fidelity assessment tools for promoting and monitoring fidelity, practitioner and trainer networks to support staff involved in dissemination, and quality assurance methods to review program developments and revisions, science communication strategies. A commercially viable system of training and dissemination was developed and then refined with TPI as industry partners so the program could be scaled internationally.A lifespan perspective enables the parenting competencies associated with each successive phase of a child’s life to be identified and targeted. Some parenting skills  are continuous and apply to each subsequent phases of development. Others are more discontinuous and are particularly relevant at certain times in specific phases . A lifespan perspective recognizes that parents have a continuing but changing role in the lives of their children as they grow into adults and transition to parenthood themselves and producing grandchildren and eventually great grandchildren. For many family’s grandparents have a continuing role in the promoting the wellbeing of children. Both non-custodial and custodial grandparents play a vital role in caring for, educating and supervising grandchildren. Several trials have shown that Triple P is effective with both non-custodial grandparents providing occasional care  parents receive to solve a problem. Support can range from providing information and minimal skills training and coaching to providing more intensive practice of skills and/or providing additional range of skills training or coaching when working with parents with multiple additional problems . For example, both Primary Care Triple P (level 2) and Standard Triple P (level 4) introduce parents to strategies for encouraging desirable behavior and for preventing and managing problem behavior. In Primary Care Triple P this is done with the use of tip sheets in 2–5 sessions (2–5). In Standard Triple P more sessions (10 sessions) are involved where the same skills are practiced but applied to a wider range of child problem behaviors. At the highest level of intensity, Enhanced Triple P (level 5) introduces parents across ten sessions to additional cognitive-behavioral skills such as stress and mood management, partner support, effective couple communication and conflict management skills, anger management, and attributional retraining. In Family Life Skills Triple P sessions also covers dealing with emotions, relationships, self-care, past trauma, healthy lifestyles and planning for the future  combined with active skills training methods that included 1–5-day training courses that incorporated video and live modelling of practitioner skills, small group practice, feedback and coaching and competency-based assessment and a knowledge quiz. This system of training involved the development of a range of high-quality resources for use by trainers in running training courses . Evaluation studies of the effects of Triple P training have shown high satisfaction with training and improved self-efficacy regardless of level or variant of training, country where it is conducted, type of discipline involved .Even though an intervention may be supported by clinical trial evidence showing the program works with families in the study sample, it does not mean that the program achieves the same outcomes when used with clients the practitioner is working with. Successful implementation of an evidence-based program requires practitioners to routinely use tools that can reliably assess change over time in relevant client outcomes The outcomes produced can be the same or similar, better, or worse than the original studies particularly if different measures are used. Consequently, each program variant of Triple P includes outcome assessment tools that can be used by practitioners to collect systematic data on their own client outcomes. In this way practitioners are encouraged to evaluate all Triple P programs they run. Over time substantial practice-based evidence can evolve so that agencies can determine for themselves whether the program is achieved desired outcomes. However, agencies need to dedicate resources and personnel to analyse and report on outcomes achieved. Examples of reliable and change sensitive tools developed to support the evaluation of Triple P include the CAPES  so the university’s main technology transfer company UniQuest Pty Ltd could license a dissemination or purveyor organization to disseminate the program globally on behalf of the PFSC authors and University. Triple P International Pty Ltd entered an exclusive license agreement with UQ to further develop and scale Triple P through a commercially viable training and dissemination model. The license agreement required TPI to pay a royalty back to the University which was split equally according to University intellectual property policies between University of Queensland (UniQuest), Faculty of Health and Behavioural Sciences, the School of Psychology’s Parenting and Family Support Centre and contributory authors. Having an industry partner being responsible for dissemination of Triple P ensured that a continuous revenue stream from dissemination  was available to support the ongoing research and development mission of the PFSC. TPI developed as “one stop shop” organization responsible for all aspects of dissemination including publishing of written materials, video production and development and maintenance of online platforms, contracting and delivery of professional training and implementation support. Having a single industry partner dedicated to management of the global dissemination of Triple P was crucial to scaling the program in an economically sustainable manner and for ensuring there was ongoing investment in the program. Most publishing operations do not have an integrated suite of services needed to scale a program.Overall, the dissemination and scaling model has been very successful with over 100,000 unique practitioners having been trained in Triple P, from 72 countries around the world. An important by-product of having a dedicated dissemination organization is that it made the program and associated training is accessible to other research groups. Figure Having a theoretically informed, high-quality, evidence-based system of intervention and a system of professional training is no guarantee that the program will be implemented by trained practitioners with fidelity over a sustained period. The Triple P Implementation Framework  Management policies and procedures consistent with the University’s research quality framework, requirements of funding bodies, and calls for greater transparency in the field generally Sanders, . This hawww.pfsc.uq.edu.ua/evidence). A notable feature of this knowledge transfer procedure is the involvement of a diverse range of researchers and research institutions around the world who have conducted research on Triple P. A 46-chapter edited volume on the Power of Positive Parenting . The PFSC led the formation of the Parenting and Family Research Alliance (PAFRA) as a charity that brought together other evidence-based parenting programs in Australia to collectively advocate for increased research funding and policies to support the implementation of EBPS programs  to share our learnings with other practitioners, researchers and members of the public interested in the field of parenting. These have included a monthly seminar series for PFSC staff and students in the PFSC, a biennial International Helping Families Change Conference (3 day), regional Triple P Master Classes (90 min), State-based Triple P Update Conferences (1 day), Podcast series for members of the public such as “Parenting in a Pandemic” (20 episodes) and “Families under Pressure” (12 episodes), and more recently leading the development of collaborative partnerships to host the inaugural International Congress on Evidence-based Parenting Support to promote policy and practice . It is encouraging to note that the same standardized professional training program has been shown to produce similar positive training outcomes across different disciplines and sectors for satisfaction with training and practitioner self-efficacy  in how program participation is defined and measured. Multi-sector integration of data sources from different agencies cannot occur without data-sharing agreements across jurisdictions. Without reliable measures of program participation and outcomes, it is difficult to know whether rates are changing  and whether a change in child and parent outcomes are being achieved. To overcome this problem, periodic population-based cross-sectional surveys of parenting and family well-being can be used to track parent reports of program participation over time . However, the best client outcomes are likely to occur when both fidelity and flexibility are concurrently addressed , grandparents, kinship carers, and foster carers. Although most participants in parenting research have been biological mothers, there is increasing evidence that fathers  and whether there is a market for the program. We have not always published programs we have developed and shown to be effective  because of insufficient demand. A workforce needs to be identified and trained to deliver the program. The costs of making a program “dissemination ready” can be expensive and there must be a reasonable prospect of these upfront costs being recovered by the purveyor organization.However, independent evaluation of a program is unlikely to occur unless the program can be disseminated. For third parties to evaluate the program they need to be able to access the official training, as well as program materials and resources to deliver the program. The release of the program heralds the possibility of further in dependent trials and evaluations which means the evidence-based is never static and continues to evolve. High quality service-based evaluations are particularly valuable as they show how well the program works in a normal service- delivery contexts and whether similar or better outcomes can be achieved. However, it can be a time consuming and expensive process required independent researchers to apply for and secure sufficient grant funding for an adequate statistically powered trial to be conducted.Considerable recent attention has been focused on the issue of whether EBPS programs that were originally developed for parents in western HIC’s work or are culturally appropriate for other parents from non-English speaking countries or for ethnic minority, refugee, or First Nations parents. Increasing evidence shows that the core principles and strategies of positive parenting seem to work in a very diverse range of cultural contexts with relatively minor adaptations . We routinely “Americanise” Triple P resources from Australian and British English to American English for spelling and to use local terms . It is not always possible to make such changes if the adapted program can only be used in a single location. Any major change or adaptation requires the consent of Triple P authors.To scale a multilevel system of intervention involves preparatory steps that require all the necessary program and training resources and materials to be available for dispatch and immediate use in sufficient quantities to meet the expected demands. Program and training materials should be professionally produced and safely stored in warehouse locations not prone to flooding. Resources  must be packaged and dispatched in a timely manner to ensure they are available for use in training (often weeks in advance if being transported to an overseas country). Any customs requirements for sending materials across country borders need to be clarified and adhered to, to avoid border entry delays.All parenting programs occur within a socio-political context that can be either favourable or unfavourable. A population-based parenting program requires a favourable policy environment for it to be sustained, so that dedicated funding for ongoing implementation and evaluation is recurrently budgeted for. Threats include lack of political advocacy for a program, changes of government or ministers and their priorities, that reduce funding available to support program implementation properly. An example of policy advocacy was the establishment of the Parenting and Family Research Alliance (pafra.org) in 2020 that specifically sought to change Government funding for research into parenting and the adoption of a population-based approach. One example of PAFRA’s work was to undertake a review of the level competitive grant funding focused on parenting through the Australian Research Council and the National Health and Medical Research Council in Australia over a decade. Of the 25,000 grants funded between 2010 and 2020 only 62 focused on parenting intervention accounting for only 0.25% of grants given. Other policy advocacy has included focused advocacy relating to the Medicare item numbers to enable parent only sessions to be conducted as part of children’s mental health plans. Another example is PAFRA advocacy pertaining to the National Disability Insurance Scheme (NDIS) for people with developmental disabilities. NDIS is funding model that made it more difficult for parent to access evidence-based group parenting programs . In many jurisdictions there seems to be little public accountability relating to parenting programs. For example, in Australia, it is unknown how much the federal and individual state governments spend on the implementation of evidence-based parenting programs and what outcomes are achieved. Bipartisan political support is highly desirable for the sustained implementation of evidence-based parenting support. Programs funded by government require continuous ongoing evaluation to promote quality improvement, public and unbiased reporting of outcomes achieved to promote greater public accountability.A population approach is only likely to reduce the rates of targeted child problems if enough parents participate whose children are at risk. Although universal outreach to all parents helps to destigmatize program participation, other more targeted engagement strategies are needed as well. These strategies include peer-to-peer testimonial advocacy by similar parents who have participated in the program, advocacy by respected and well-known public figures, and delivery of parenting support in settings that parents already access for support in health, education, and social services.Failure to achieve participation targets can also be related to lower-than-expected rates of program delivery by trained service providers. High staff turnover, lack of supervision or leadership support in the workplace, giving low priority to parenting program delivery compared to other clinical responsibilities and unforeseen disruptions due to the pandemic can all affect rates of program delivery. Practitioners will often struggle to reach parent participation targets if they only use a single mode of delivery. Running groups, seminars, and discussion groups and encouraging parents to complete online programs results in high rates of program participation than the delivery of programs to individual parents.Program delivery can be adversely affected by policy and administrative changes that decrease the access of parents to programs. For example, the introduction of the National Disabilities Insurance Scheme (NDIS) by the Australian Government provided care packages to individual clients. This inadvertently had the effects of reducing the capacity of community organizations delivering disability services such as Group Stepping Stones Triple P to offer and be reimbursed for delivering group parenting programs. Parents under stress because of children’s behavior cannot be expected to organize groups of other parents at the same time to participate so parenting programs can be delivered. Specific funding for Triple P Online in NZ by the Department of Health was introduced as a free service and achieved strong public take up during the pandemic but was subsequently withdrawn when the pandemic was seen to be over, even though children’s mental health problems stemming from the pandemic continued.Population effects are more likely if a comprehensive range of programs are available. If only parts of the Triple P system are delivered particularly programs that relatively few parents participate in  then the population reach of the intervention is likely to be too low to produce a detectable shift in prevalence rates at a population level even though individual families will benefit. In this situation additional resources will need to be found to either train staff to deliver a wider range of programs particularly group programs or make online programs available to parents.Organizational leaders in agencies need to support staff trained to deliver programs. If this does not occur, then lower rates of program delivery can be expected and therefore population reach will be insufficient. A change in leadership is a particularly high-risk transition time in implementing organizations. Active efforts to engage and gain the support of new organizational leaders is vital. Being able to produce convincing evidence of outcomes achieved with program delivery is likely to be important information in securing ongoing support.The costs of an intervention increase considerably if trained staff leave before they have become regular implementers of programs. A knock-on effect of failing to retain staff is that suitable replacement staff must be recruited and trained in one or more variants of Triple P. These additional training costs and time delays in accessing training need to be budgeted for based on expected retention rates of different types of staff in the organization.In most settings where Triple P is introduced for the first time as a population strategy, other parenting programs are often being delivered in the community. Triple P can be readily integrated into the service mix when it is seen as complementing, working with, and extending services available to families in a community. However, if the new program is seen as competing with and eventually replacing existing services, considerable local resistance can develop from well-established existing programs because it becomes a threat.Systems-level parenting and family interventions that aim to “shift the needle” on population-level indices of child well-being or maltreatment need to synergistically bring together diverse disciplines, sectors, and service delivery systems that often operate in silos and compete for scarce resources. Deriving a shared vision regarding the goals and recognition of the need to adopt a population-based approach can be achieved when there are sufficient benefits for individual stakeholder groups including parents as consumers. Effective policy advocacy and strong local champions (other than program developers or purveyor organizations) can help combat bur not eliminate perceptions of bias and self-interest.Many challenges must be addressed to ensure that EBPS reaches its full potential to promote the well-being of children and parents.The global COVID-19 pandemic with its associated disruptions to “in-person” service delivery showed the crucial importance of evidence-based programs being able to rapidly pivot to new ways of engaging with families. Many in person parenting services had to rapidly and transition to telehealth or videoconferencing-based delivery of programs. The same occurred with training programs. For example, within a month of COVID beginning in February 2020 Triple P International transitioned the majority of its previously in person training programs to video conferencing-based delivery, without any adverse effects of training outcomes. Sanders et al., , 2023a cHaving a multilevel system of parenting support available for families with differing levels of intensity allows for better integration of parenting programs into prevention and treatment services. However, not uncommonly parents needing more intensive intervention find themselves falling between the gaps and ending up on long waiting lists. Efforts to reduce lag times between service sectors is not easily resolved, a task made more difficult by staff shortages in tertiary mental health services. As a response, online programs such as Triple P Online, Fear Less Triple P Online and Triple P for Baby Online can be used as a waitlist intervention for parents between initial referral and screening and the scheduling of intake interviews in the clinic.Policy-related obstacles such as lack of research funding for parenting research, administrative and logistical problems that decrease access of parents to parenting programs, and the lack of focus on parenting in mental health prevention and promotion activities can be addressed if there is greater collective action between researchers, programs developers and service providers. Effective policy advocacy needs to be independent of advocacy for specific programs and should focus on stakeholders coming together to advocate for the collective goal of increasing access to a range of evidence-based programs. Our experience with PAFRA has shown that respectful partnering and collaboration between different “competing” programs can achieve the dual goal of speaking with a united voice to government and supporting collective actions that benefit all programs .An increase in funding for research into parenting interventions is essential to ensure that parenting programs continue to evolve and produce solutions that address the contemporary concerns of parents. Without ongoing investment in research and development parenting programs can become outdated . Program innovation is necessary to address the evolving concerns of families  and how they wish to access programs. Greater investment in research and development should lead to a larger number of evidence-based parenting programs being developed, resulting in a greater range of options for practitioners and parents and more tailored programs addressing the needs of particularly groups .Within the wider landscape of dissemination of evidence-based parenting programs, different purveyor models have emerged to scale interventions. All dissemination efforts must be based on sound business principles so that the costs of program dissemination can be covered and that sufficient funds are generated to enable ongoing investment in future program development. Dissemination efforts undertaken by developers or purveyor organizations on behalf of developers are more likely to be sustained when based on sound financial principles. This applies to any developer whether they work in the University sector, independent research organizations, charities/not-for-profit, and for-profit commercial organizations This is particularly the case when multi-level systems of intervention are developed that have many moving parts and that require ongoing research and development investments to maintain. Triple P is an example of a dissemination model that has been sustained for over 25 years. The University of Queensland employs the staff who developed Triple P and own the intellectual property vested in Triple P. After our initial efforts to disseminate through the Parenting and Family Support Centre, we collaborated with UniQuest (UQ’s main technology transfer company) who commercialized the dissemination of Triple P by providing an exclusive global license to a startup purveyor company Triple P International to scale the program on behalf of the University. Having an industry partner dedicated to disseminating Triple P was a game changer. It eventually produced a revenue stream through royalties that has helped to sustain and evolve the program over time. Royalties arising from TPI’s training, and implementation support and sale of program resources are split according to the Universities Intellectual Property Policy between UniQuest, the Faculty of Health and Behavioural Sciences, the Parenting and Family Support Centre in the School of Psychology, and approximately 13 contributing authors. This arrangement has enabled the program to be disseminated globally. This financial model incentivises all parties and has enabled the program to develop new variants. Many evidence-based parenting programs do not get disseminated effectively because of an inadequate, non-sustainable financial model.Most disciplines involved in delivering parenting programs including psychology, social work, nursing, medicine, psychiatry, counseling and education professionals do not provide competency-based professional training to students in delivering evidence-based parenting support. Most professional training in the parenting field occurs through “on-the job” in-service training. The lack of preservice training means that many students have very limited theoretical or practical knowledge or clinical skills before entering the workforce and report low self-efficacy about how to consult effectively with parents. The provision of foundational training in University courses in at least one evidence-based program would be a valuable addition to any training of professionals to work with children and families. At the University of Queensland, Clinical Psychology and Counselling students receive accreditation-based training in at least two different Triple P programs as part of their University course . This training helps prepare students for working with clients in internships.Little attention has been given to the potential role of parenting interventions in promoting child, parent and family capabilities related to sustainable development. Sanders et al., , 2023a aEvidence-based parenting support would have greater impact and public policy support if the discoveries and key findings from parenting and family intervention research were disseminated more effectively to a wider audience. Traditional methods of knowledge transfer through publication in scholarly journals and professional conferences have limited impact. Additional methods of knowledge transfer include the preparation of policy briefs, greater use of social media tools (twitter), the development of themed vodcasts and podcasts dedicated to parenting topics and issues, greater use of global digital congresses and conferences to enable wider participation, particularly by stakeholders from low- and middle-income countries. A recent example of such an approach was the inaugural International Congress on Evidence-based Parenting Support held in June 2023. This 3-day virtual congress included a range of communication strategies designed to promote post congress policy and social action in policy, research and practice following the congress. It included creating small “Action Circles” to work collectively on solving problems, special issues of journals, podcasts, and access points for practitioners and agencies to connect with evidence-based programs and researchers (see i-ceps.pafra.org).A global Parenting and Family Wellbeing Survey with a representative sample of families of children in different age groups is needed to enable progress in addressing parenting and family issues to be monitored and tracked at a country level over time. These essential epidemiological data could then be linked to other data sets  pertaining to the wellbeing and children and families. The lack of an agreed upon reliable, valid and change sensitive epidemiological survey tool precludes any country comparisons being made. Although individual state jurisdictions have conducted such surveys Victorian Parenting Survey  technologies has increased exponentially over the past few years. The next generation of professional training programs is likely to rely increasingly on technology including AI to reduce the costs of training and to provide augmented training experiences for a wider range of professionals. Although AI is unlikely to replace all in person professional training those aspects of training that involve sharing information about theory, principles and evidence lend themselves to the use of AI. Training elements that involve skill development through coaching involving practice and feedback are likely to be more difficult particularly when the skills being taught to practitioners are complex, multi-phased and highly dependent on sequencing of a parent’s response to prior prompts and feedback provided by practitioners. Notwithstanding the challenges our team is involved in ongoing research to examine the use of technologies to improve professional training including virtual reality. EBPS interventions are likely to continue to evolve with a sustained commitment to ongoing research and development.Historically, the term parent training served the field well and differentiated behavioral approaches to parenting support from other theoretical approaches (based on psychodynamic or attachment theory) and more general parent education . However, over time, the term has become more of a liability, and it should be replaced by the more generic term evidence-based parenting support for the following reasons. First, many parents with concerns about their children’s behaviour who seek professional support do not see themselves as requiring ‘training’ or ‘therapy’. Second, the traditional intensive group and individual programs used with parents of children with severe conduct problems capture only part of the evidence base used to promote better outcomes for families. In particular, the growth of low-intensity parenting seminars, discussion groups and online programs require more inclusive language based on the principle of proportionate universalism. Its meaning in the context of parenting intervention is that everyone is likely to need some support, with more intensive interventions limited to families with greatest need or who are non-responders to less intensive interventions.The current prevention and treatment technologies that use EBPS are not a panacea and there are always non-responders to any intervention. More research is needed to identify early antecedents and indicators of premature dropout from an intervention or non-response among completers of the intervention. Also, social learning theory and contingency management principles have featured strongly in the theoretical base of parenting programs with parents and as a central explanation for improvement in child behaviour (parents become more positive and contingent and less coercive and unpredictable). However, there are other possible explanations for change in both parenting and child outcomes that should be considered in any analysis of mediators of change. These include cognitive factors such as changes in parental expectations and attributions, changes in available social support , changes in parent adjustment  and the therapeutic alliance (relationship with practitioner). Research is needed that tracks change over time on multiple variables during intervention to identify the timing, sequencing and patterning of change on different putative mediators. Some variables may change early, others change later, and some not at all over the course of an intervention. Apart from mechanisms explaining change in parenting, the factors that influence whether trained and accredited practitioners implement Triple P requires further investigation.The field of parenting intervention has benefitted from a wide range of methodologies, and this should continue. For example, research in Triple P has ranged from N = 1 experiments to randomized clinical trials, place-based population trials, quasi-experimental evaluations, service-based evaluations, and qualitative studies  examining cultural acceptability, economic analyses, and meta-analyses. More population-level evaluation studies with longer periods of follow-up are needed to strengthen findings regarding the population-level effects of the Triple P system on child maltreatment and rates of social, emotional, and behavioral problems. However, when evidence-based parenting programs are widely disseminated and become an integral part of “care as usual”, different types of control conditions are needed and designs such as non-inferiority RCTs are more likely to be used . However, few studies have investigated how to further improve the effectiveness of specific techniques, or combinations of techniques used . Salmon et al  showed tCriticisms of commercially disseminated programs such as Triple P, Incredible Years, MST and PCIT because they are ‘branded therapies’ seems misplaced. The approach advocated by some involves the identification of common elements of effective intervention and disseminating them as non-branded or non-commercialized programs. However, all programs eventually acquire an identity and “brand name” so they can be effectively promoted to parents and professionals. Furthermore, a sustainable model of dissemination requires an economically viable business model where revenue from training and sales of program resources and materials and implementation consultation helps recover the real costs of developing and maintaining an evidence-based program . Without competition there are few incentives for program developers to reduce or contain costs and training and dissemination activities become wholly reliant on subsidies from the government or foundations that are usually not sustainable.The internet has markedly increased the capacity of people to share useful information, rapidly, conveniently, and at no or low cost. The internet via social media  has increasingly been used to encourage participation in parenting programs  are rarely taught in graduate training programs.Many adults with serious mental health problems are also parents, and their children can be at risk of mental health problems themselves because of disruptions to family life and parenting (neglect) caused by parental mental illness  in publications. Some criticisms have been valid and have resulted in a change of practice particularly with respect to routine COI disclosures , global threats to democracy because of war, internal displacement, and violence have had serious impacts on children and their families. New interventions are needed, and older ones need to be adapted to address such concerns.Of the many potential actions that could be taken to improve the life course outcomes of children, none are more important than improving the knowledge, skills and confidence of parents in the task of raising their children. When all parents are encouraged to embrace this collective goal, everyone is likely to benefit-children, parents, schools and the wider society. Evidence-based parenting support needs to become a policy priority to reduce the prevalence rates of social, emotional, and behavioral problems and rates of child maltreatment. Receiving evidence-based parenting support needs to become socially normative, stigma free and viewed by the wider community as something that is healthy, desirable, and associated with benefits for all . Each country and local jurisdiction should set and measure the attainment of specific goals and targets relating to parent participation and efforts made to reduce barriers to access and to encourage participation of all relevant parents and carers.. This journey starts when parents first transition to parenthood and continues throughout their life.Over the past four decades, the population approach to parenting support has gradually evolved from targeted individual and group programs developed in the 1960s and 1970s for children with conduct problems to a more sophisticated multi-level system of parenting support capable of addressing a wide range of parenting concerns. Despite growing evidence that parenting programs work, are cost-effective, can be scaled, and can be applied to a diverse range of social, emotional, and behavioral problems there is still significant underinvestment in most countries to make parenting programs widely available to families. Quality parenting programs should become the centrepiece of programs to prevent social, emotional, and behavioral problems and prevent child maltreatment and be incorporated as appropriate into child-focused, family centered treatments. Much greater investment in ongoing research and development is needed to ensure that programs continue to evolve, address the changing contemporary concerns of parents, and consider the developmental changes associated with the life course journey that individual parents experience for better or worseFinally, implications for the wider field of evidence-based child and family interventions stem from our experience with Triple P. Our program benefits from having a sustained organizational commitment to evolve and sustain the program over time as a comprehensive multi-level system of intervention with programs that address a full spectrum of intervention from early prevention infancy through to more treatments for complex, vulnerable families. Program developers and leaders of Centers involved in program development must address the never-ending challenge of securing sufficient funding to support necessary infrastructure so that long-term strategic planning is possible . Programs such as Triple P should not be reliant on the continued involvement of original developers. The next generation of capable early-career and mid-career researchers who are also program developers can then step up to continue the work, improve programs and build on the foundations established by their predecessors and mentors.


ETV6::ABL1 gene fusion is a rare recurrent genomic rearrangement associated with hematologic malignancies, and frequently occurs with additional anomalies. Due to the opposite chromosome orientations of the ETV6 and ABL1 genes, an oncogenic in-frame ETV6::ABL1 gene fusion cannot be formed by a simple translocation. The molecular mechanism of the ETV6::ABL1 fusion and the significance of co-occurring anomalies are not fully understood. We characterized genomic alterations in an individual with ETV6::ABL1 gene-fusion-positive myeloid neoplasm using various genomic technologies. Our findings uncovered a molecular mechanism of the ETV6::ABL1 fusion, in which a paracentric inversion within the short arm of chromosome 12 (12p) and a translocation between the long arm of a chromosome 9 and the 12p with the inversion were involved. In addition, we detected multiple additional anomalies in the individual, and our findings suggested that the ETV6::ABL1 fusion occurred as a secondary event in a subset of cells with the additional anomalies. We speculate that the additional anomalies may predispose to further pathogenic changes, including ETV6::ABL1 fusion, leading to neoplastic transformation. ETV6::ABL1 gene fusion is a rare but recurrent genomic rearrangement that has been reported in various hematologic neoplasms, including myeloproliferative neoplasms (MPNs), acute lymphoblastic leukemia (ALL), and acute myeloid leukemia (AML), frequently with eosinophilia /46,idem,ins[3].nuc ish[83/200]. In addition, aCGH (sent-out test) revealed a 522.4kb interstitial deletion within the band 15q21.3 on the long arm of chromosome 15, involving the PYGO1, PRTG, NEDD4, RFXDC2, and RFX7 genes. JAK2 V617F mutation (sent-out test) was negative.Multiple genetic tests, including chromosome analysis, FISH for BCR::ABL1 FISH findings. It showed that the extra ABL1 signal was located on the short arm of a chromosome 12 in the proximity of the ETV6 gene locus, suggesting the possibility of ETV6::ABL1 gene fusion  and a translocation between the inverted ETV6 on 12p and ABL1 on 9q , ABL1::CLEC4E  and RFX7::PYGO1 . The interrupted genes included HEYL and ZNF106 due to the t translocation. All breakpoints that the MP-seq detected were confirmed by PCR and Sanger sequencing, and various deletions ranging from 15~992 bp in size were also detected at the breakpoints  translocation and the 15q interstitial deletion  , and revakpoints . Metaphaakpoints C.ABL1 rearrangement were regularly performed to monitor the patient’s response. The t translocation and ABL1 rearrangement were detected in the patient’s marrow after three month of imatinib therapy along with persistent morphologic evidence of myeloid neoplasm. The patient was then switched to dasatinib, and after three months achieved a morphological marrow remission. No evidence of the ABL1 rearrangement was detected by FISH in two consecutive following-up studies after the initiation of dasatinib therapy. However, the t translocation was detected in approximately 7.0% and 24.0% of the metaphase cells in the first and second following-up tests after the dasatinib therapy, respectively. The remaining cells had a normal male karyotype. The patient then underwent allogeneic stem cell transplantation from a matched unrelated male donor due to a concern that the cells with persistent t could post a risk of relapse. He has remained disease-free for more than 13 years following the transplantation.Following initiation of TKI therapy, chromosome analysis and interphase FISH for ETV6::ABL1 fusion gene involves complex genomic rearrangements due to opposite chromosome orientations of the ETV6 and ABL1 genes. However, only limited studies of the fusion mechanisms at the chromosome level have been reported. Information regarding the genomic rearrangement, content, and breakpoints involving in the fusion at the molecular level is lacking. To our knowledge, four mechanisms regarding the formation of in-frame ETV6::ABL1 gene fusion have been reported, including the insertion of 5′ETV6 into ABL1 [ABL1 into ETV6 [ABL1) in combination with a t translocation [ETV6 insertion and translocation involving multiple chromosomes [ETV6::ABL1 fusion in this case was formed via a paracentric inversion on chromosome 12p and a translocation between chromosome 9q and the inverted 12p  translocation was still present in 7.0% and 24.0% of the cells in the first and second follow-up tests, respectively, which is inconsistent with the morphological findings. These results indicated two abnormal cell populations: one with both the translocation and ABL1 rearrangement, and the other with the translocation only. We speculate that the t translocation occurred prior to the ETV6::ABL1 fusion, followed by the development of the fusion in a subset of the cells with the translocation, thus leading to neoplastic transformation. At diagnosis, the neoplastic clone with t and ETV6::ABL1 fusion was likely the predominant cell population that overgrew the cells without the fusion in the patient’s bone marrow before therapy. After the effective therapy, the neoplastic clone with the ETV6::ABL1 fusion was eliminated, and the cells without the fusion, including the cells with and without the t translocation, survived and grew back.We detected multiple genomic anomalies in the patient’s initial bone marrow specimen. Two of them, t translocation and RFX7 gene encodes a transcription factor regulated by TP53 and targeting multiple known tumor suppressors. Mutations in RFX7 have recurrently been reported in lymphoid cancers [PYGO1 gene encodes a nuclear protein essential for Wnt signal pathway, and deregulation of Wnt pathway is a well-known cause of cancer [ETV6::ABL1 fusion, but not the cells without the fusion. To our knowledge, the development of an oncogenic ETV6::ABL1 fusion in a subset of predisposed cells has not been reported. In addition, as there are no standard clinical tests to detect ETV6::ABL1 fusions, this case highlights the potential therapeutic importance of investigating abnormal ABL1 fusions that do not involve BCR.It is noteworthy that multiple genes were affected by the t(1:15) translocation and the co-occurred interstitial deletion of 15q see , and som cancers ,25,26. Tf cancer ,28,29. Nf cancer ,31. In af cancer ,33. BaseETV6::ABL1 fusion are frequent, but their significance is yet to be understood. The multiple and complex anomalies seen in this case suggested genomic instability that might play a critical role in the genesis of the ETV6::ABL1 gene fusion. We speculate that some additional anomalies could predispose cells to additional pathogenic genomic alterations and neoplastic transformation. In this case, it is unclear whether the additional anomalies played a role in the patient’s clinical presentation, therapy response, and prognosis. The t translocation and deletion of 15q could represent somatic or mosaic constitutional changes, as constitutional analysis was not performed.Additional anomalies co-occurring with ETV6::ABL1 gene-fusion-positive myeloid neoplasm using various genomic technologies. The oncogenic in-frame ETV6::ABL1 gene fusion was identified following the detection of ABL1 and ETV6 rearrangements via FISH studies. The identification of the fusion played a critical role in the decision to employ ABL1 TKI therapy, which achieved morphologic remission, thereby facilitating a successful allogeneic stem cell transplantation procedure. The ETV6::ABL1 gene fusion was formed through a paracentric inversion of 12p and a translocation between 9q and the 12p with the inversion. This ETV6::ABL1 fusion apparently occurred as a secondary event in a subset of cells that may have been predisposed to develop a complex genomic abnormality due to a pre-existing lesion.In summary, we characterized genomic anomalies in an individual with


The purpose of this study was to develop a virtual reality-based nursing education program aimed at improving nursing students’ severity classification competency. Severity classification in the emergency room is key to improving the efficiency of emergency room services worldwide. Prioritizing treatment based on correctly identifying the severity of a disease or an injury also ensures patients’ safety. The five actual clinical scenarios in the program helped to promptly classify patients into five clinical situations based on the 2021 Korean Emergency Patient Classification Tool. Seventeen nursing students were in an experimental group that had access to a virtual reality-based simulation combined with clinical practice. Seventeen nursing students were in a control group that only participated in routine clinical practice. The virtual reality-based nursing education program effectively improved students’ severity classification competency, performance confidence, and clinical decision-making ability. Although the pandemic continues, the virtual reality-based nursing education program provides realistic indirect experiences to nursing students in situations where clinical nursing practice is not possible. In particular, it will serve as basic data for the expansion and utilization strategy of virtual reality-based nursing education programs to improve nursing capabilities. Severity classification in emergency care helps efficiently treat and care for emergency room (ER) patients despite limited resources ,2. SeverCurrently, most of the studies that have educated healthcare workers on severity classification and verified its effectiveness have been conducted on emergency medical technicians ,10. AddiSeverity classification education should be structured to expose students to real-life emergencies and to improve awareness, knowledge, and problem-solving skills related to emergency patient severity classification ,17. In tToday, information delivery methods are not simply a one-way provision of visual data but are advancing in an interactive way that stimulates the five senses using augmented reality, VR, holograms, and so on, allowing learners and educators to interact ,21. AmonPrevious studies showed that VR-based simulation education improves the skill, knowledge, and educational satisfaction of nursing students . This imTherefore, this study verified the effect on nursing students’ knowledge, confidence, and clinical performance ability of a VR-based nursing education program aimed at improving their severity classification competency. This three-dimensional (3D) VR also enhances interaction between motion function and feedback. This program provides realistic indirect experiences to nursing students in situations where clinical nursing practice is not possible. This can be used as a guide when designing and developing nursing education programs using VR.This study aimed to develop a VR-based nursing education program for improving nursing college students’ ability to classify severity and to verify the program’s effectiveness. By maximizing students’ immersion and liveliness through programs like this, we want to increase their competency to classify severity correctly in the event of multiple emergency patients.This is a pre- and post-quasi-experimental study with two comparison groups.This study was conducted with fourth-grade students who had more than one year of clinical practice experience at K University in D Metropolitan City, Korea. Those who had no problems with vision and hearing, understood the study purpose and method through bulletin boards or department notices in schools, and voluntarily agreed to participate in the study were included as participants. The sample size required for the comparison of two groups (ANOVA) was calculated using the G power version 3.1 program and was based on a study of a nursing education program using a virtual reality intervention . The effIn this study, the severity classification competency, confidence in performance, and clinical decision-making ability were measured in a preliminary survey. In the post-investigation phase, the severity classification competency, performer confidence, clinical decision-making ability, class evaluation, simulation design evaluation, and class commitment were measured.Severity classification competency was measured using the severity classification competency measurement tool developed by Moon . It has Confidence in performance was measured using the Confidence in Performance in Nursing Scale developed by Kim , comprisClinical decision-making ability was measured using the Clinical Decision-Making in Nursing Scale (CDMNS) developed by Jenkins  and tranClass evaluation was measured using a lecture evaluation instrument for each class type developed by Ko et al.  and reviTo evaluate the simulation design, this study used the Simulation Design Scale, which was developed by the National League for Nursing and revised by Yoo . It compPractice flow was measured with the flow measurement instrument developed by Engeser and Rheinberg  and reviData were collected from 26 April to 30 June 2022, with 17 fourth-year nursing students in the experimental group and 17 students in the control group. In this study, in order to prevent errors in the experimental diffusion effect, the study was conducted first with the control group, with a measurement interval of 1–2 weeks, and then the experimental group was conducted . The conBefore entering the education room, information regarding the participants’ general characteristics, confidence in performance, and clinical decision-making ability were collected using survey questionnaires.This study was based on the Analysis-Design-Development-Implementation-Evaluation (ADDIE) model, a general model of teaching method development to develop nursing education programs that promote severity classification competency using VR.First, in the analysis stage, educational content related to severity classification was designed based on literature analysis and interviews with nurses, learners, and instructors. The literature search was conducted using Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, Research Information Sharing Service (RISS), simulation standards, emergency nursing, and medical textbooks. When using the search engines, the main keywords were used by combining “nursing”, “virtual simulation”, “nursing” students, and “simulation education” tree competency. An interview was conducted to collect basic data on the design of the educational program. Fourth-year students who completed emergency nursing courses and had clinical practice experience, nurses working in the ER, and nursing professors teaching emergency nursing participated. The interview was conducted after explaining the purpose and procedure of the study through wire communication to the participants who met the inclusion criteria. The interview question was, “What should be included in the development of a nursing education program to promote the ability of nursing students to classify severity?”Second, in the design stage, the learning goals and methods of the nursing education program were designed. Referring to the demand analysis and prior literature, the learning goal was to strengthen the severity classification capability of nursing students. The learning operation method is a nursing education program that uses VR based on the Jeffries  model. TAdditionally, learners can actively use their severity classification knowledge, technology, and strategy through the process of classifying five patient cases in a VR environment and transform and readjust false knowledge into a new form through feedback provided when an incorrect answer is chosen. This VR interaction increased the learners’ sense of immersion and maximized their sense of reality in the actual field. The final stage was designed as a self-evaluation and a reflection diary as an evaluation process. Oculus Quest 2  was used as the learning medium, and tools for the classification of severity classification competency, confidence in performers, clinical decision-making ability, class evaluation, simulation design evaluation, and practical immersion evaluation were selected.Third, in the development stage, after developing the learning materials, the content validity was verified by experts consisting of 2 adult-nursing professors and 3 clinical nurses, with more than 10 years of clinical experience in ER nursing. Five fourth-year students from universities that the study participants did not attend were selected. The program was revised and supplemented after the pilot application to develop the final learning materials.As part of a preliminary survey, the two groups were asked to fill in information about general characteristic items, such as age, preferred education method, the previous semester’s grades, severity classification competency, performance confidence, and clinical decision-making ability.The experimental group was administered the nursing education program through Oculus Quest 2, which entails an audio-visual format that completely blocks out any surrounding stimuli. For two hours in the first week, a lecture on the theory of severity classification was conducted, and the nursing education program was conducted based on the 5E learning cycle model.Oculus Quest 2 entails an audio-visual format that completely blocks out any surrounding stimuli. It consists of a design reinforced with motor sensory functionality to enable hands-on activities in VR . HMD equThe clinical case provided in this study is a severity classification situation that occurs around a one-on-one relationship between a nurse and a patient and was developed to allow nurses to perform severity classification through interaction with a patient. The process of classifying severity was organized to enable learners to directly select the severity classification through a 3D controller. The related concepts or clues were provided using a pop-up window with feedback according to their choice. On selecting the correct answer, one can see an image and hear a voice for the commentary. When a wrong answer is selected, visual data and voice are prompted with the hint, and then the question page can be returned to. In this study, feedback was provided through pop-up windows and auditory resources. The overall feedback was provided during the debriefing after the program was terminated. As the learner was engaging with the education program, the researcher mirrored the screen provided to the learner on a laptop to monitor the learner’s learning process in real time.The control group participants were presented with the same five clinical scenarios as the experimental group, and they applied them to perform severity classification through case-based learning. This was conducted through face-to-face learning as in general lecture-style education. The instructor acted as an observer without intervening in the learning process, allowing students to solve problems on their own. Feedback was provided during the debriefing time.In the post program survey, the two groups were surveyed in terms of the severity classification competency, performance confidence, clinical decision-making ability, practical immersion, class evaluation, and simulation design evaluation using questionnaires.t-test. The effectiveness of the two groups’ performance confidence and clinical decision-making ability pre-and post-education was analyzed using repeated measures of analysis of variance (ANOVA). The differences between the two groups’ post-education class evaluations, simulation design evaluations, and practical immersion were analyzed using an independent t-test. The reliability of the tool was verified using Cronbach’s α.The data collected in this study were analyzed using IBM SPSS/WIN 27.0. The general characteristics of the participants were analyzed using numbers and percentages, mean, and standard deviation. The homogeneity verification of the general characteristics of the participants was analyzed using the x2 test and Fisher’s exact test. The homogeneity verification of performance confidence and clinical decision-making ability was analyzed using an independent p > 0.05). However, the clinical decision-making ability was homogeneous only in terms of “Evaluation and reevaluation of consequences” in the case of the sub-disciplinary subjects  (= 0.760) .p = 0.023). The experimental group averaged 3.43 (±0.46) before the program and 4.18 (±0.29) post program, higher than the control group’s 3.81 (±0.39) and 4.06 (±0.56) after the program, indicating statistically significant differences between performance confidence and group-time interactions (F = 8.63 p = 0.006). The canvassing of objectives and values of clinical decision-making ability of the experimental group was 3.95 (±0.40) after the program and 3.28 (±0.25) before the program. The control group’s clinical decision-making ability was 3.57 (±0.45) post program. The difference between the two groups was statistically significant .p = 0.741). The post-program simulation design evaluation in the experimental group averaged 4.67 (±0.32), which was lower than the average of 4.69 (±0.55) of the control group, but it was not statistically significant (t = −0.073 p = 0.942). The practice flow in the experimental group had an average of 4.31 (±0.48), which was lower than the average of 4.46 (± 0.66) of the control group, but it was not statistically significant .This study developed a VR-based nursing education program for nursing college students to improve their severity classification and verified its effectiveness. The results showed that this program effectively improved performance confidence, severity classification competency, and clinical decision-making ability.This program increased the sense of realism and immersion by filming and producing VR videos based on emergency cases using a 3D camera. Information regarding severity classification was provided, with several cases corresponding to stage 5 according to the KTAS criteria ,8. It enThere were no statistically different variables compared to case-based learning in the design evaluation score and the learning satisfaction score of the nursing education program, but both evaluation scores were higher than 4.5 out of 5. Prior studies using VR ,50 indicThe VR-based nursing education program to promote severity classification competency was effective in enhancing confidence performance, severity classification competency, and clinical decision-making ability compared with the case-based learning method. In a meta-study using VR in nursing education, it was reported that the use of VR in nursing education does not actually exist but provides a sense of immersion in a 3D virtual world, which is effective in shortening the training time and improving the knowledge of nursing students ,54. PartThe limitations of this study are as follows. First, the generalizability of the results is limited due to the study population of nursing students at a nursing university. Second, there is a limitation in evaluating the persistence of the effect of the VR-based nursing education program because re-examination after intervention was not conducted as a measurement parameter before and after intervention. Lastly, in this study, most of the measurement of effectiveness of the education program in improving severity classification competency relied on self-report questionnaires, and it is difficult to objectively evaluate the effectiveness of the nursing education program, because only five actual clinical scenarios was applied.As a result of the above research, a VR program to learn the severity classification of patients was developed to learn the emergency patient classification tool, so it can be effectively used in the field. In addition, if the contents of learning are continuously updated by reflecting changes in the clinical field, the learning effect of emergency patient classification can be further improved. Based on the results of this study, we would like to suggest the following. A study that can confirm the VR program’s continuous effect on learning the severity classification of patients and a repeated study to verify the learning effect by developing additional scenarios and learning videos for various severity classification situations are suggested.The designed program in this study helped improve the values of severity classification competency and clinical decision-making ability by integrating previously learned knowledge. Accordingly, it is believed that the use of VR in nursing education will provide a realistic clinical field to integrate previously learned concepts and help develop clinical judgment skills. This study’s educational design was developed by applying VR to learn the severity classification of patients. However, if VR is used as a nursing education strategy in various clinical situations that require clinical judgment in the future, it can be used to integrate the educational content into knowledge and make accurate clinical judgments.


Objective To evaluate the rates of precancerous lesions, colposcopy referral, and positive predictive value (PPV) by age groups of a population-based screening with DNA-HPV testing.Methods The present demonstration study compared 16,384 HPV tests performed in the first 30 months of the program with 19,992 women tested in the cytology screening. The colposcopy referral rate and PPV for CIN2+ and CIN3+ by age group and screening program were compared. The statistical analysis used the chi-squared test and odds ratio (OR) with 95% confidence interval (95%CI).Results The HPV tests were 3.26% positive for HPV16-HPV18 and 9.92% positive for 12 other HPVs with a 3.7 times higher colposcopy referral rate than the cytology program, which had 1.68% abnormalities. Human Papillomavirus testing detected 103 CIN2, 89 CIN3, and one AIS, compared with 24 CIN2 and 54 CIN3 detected by cytology (p < 0.0001). The age group between 25 and 29 years old screened by HPV testing had 2.4 to 3.0 times more positivity, 13.0% colposcopy referral, twice more than women aged 30 to 39 years old , and detected 20 CIN3 and 3 early-stage cancer versus 9 CIN3 and no cancer by cytology screening . The PPV of colposcopy for CIN2+ ranged from 29.5 to 41.0% in the HPV testing program.Conclusion There was a significant increase in detections of cervix precancerous lesions in a short period of screening with HPV testing. In women < 30 years old, the HPV testing exhibited more positivity, high colposcopy referral rate, similar colposcopy PPV to older women, and more detection of HSIL and early-stage cervical cancer. In Brazil, 16,590 new cases of cervical cancer are expected annually and a 6.17 per 100,000 women mortality rate, which means that 1 woman dies of cervical cancer every 90 minutes.The World Health Organization (WHO), supported by the consolidated evidence since 2013, recommends that the new programs replace the cytology-based strategy with the Human Papillomavirus (HPV) test-based screening, starting at 30 years old.stround in high coverage (> 80%), there was an impressive detection of 21 prevalent cancers, two-thirds as microinvasive carcinomas, a washing effect anticipating the diagnosis in 10 years.The “PREVENTIVO” program (PREvention of HPV Viruses in ENTire Indaiatuba by Vaccination and Organization of the screening) is based on primary DNA-HPV testing screening. It was implemented in Indaiatuba, a medium-sized city  in São Paulo State, Brazil.The current paper presents the detection of precancerous lesions, particularly in women < 30 years old, during the first round of the ongoing population-based screening program with DNA-HPV testing, just before the pandemic started.The present study considered information from the first 30 months of the population-based demonstration study, an HPV test-based screening program, from October 2017 to March 2020, just before the impact of the pandemic. The aim was to verify the detection rate of cervical intraepithelial neoplasia grade 2 or 3 and worse , the colposcopy referral rate, and the positive predictive value (PPV) of a colposcopy by age groups, comparing with the previous information from the cytology screening.The HPV test-based screening protocol from the PREVENTIVO program was previously published.Based on the previously published validation study, the Cobas HPV Test  was adopted as the screening test.Negative DNA-HPV test: advised to return after 5 years to repeat the test;Positive HPV16 and/or HPV18 test: referred for colposcopy and biopsy if needed;Positive DNA-HPV test for the 12OT hr-HPV: liquid-based cytology (LBC) was performed on the same sample. If a cytological abnormality  was detected, the woman was referred for colposcopy. When the cytology was negative, the woman was advised to return after 12 months to repeat the DNA-HPV test.The flagged women were referred to a colposcopy clinic. Excision of the transformation zone (ETZ) under local anesthesia was performed when needed. Histopathologic results were negative, low-grade (LSIL or CIN1) and high-grade intraepithelial lesions , and cancer. Cases suspicious or diagnosed with cervical cancer or in a more complex clinical situation were referred to the regional gynecological cancer center at the Women's Hospital of the Universidade de Campinas, where oncological surgeries, radiotherapy, and chemotherapy are available.The municipal health secretary managed the screening program at the central level. The PREVENTIVO program used algorithms according to study protocols, which did not allow a sample collection of a woman outside the established flowchart, avoiding testing twice the same woman or out of the recommendation. The research team from the Universidade de Campinas had access to all data and worked as a quality control surveillance system of the progress of the program. The present study obtained information about age, colposcopy, and histology results from all women with abnormal screening tests. The researchers do not interfere with the management or care of the screening program. Therefore, the level of organization of the PREVENTIVO program helps to achieve complete information about the procedures and results of women with a positive screening test. Fourteen women moved out of the city and were discharged by the program, following the regulatory recommendations and with adequate referral to the new city.As a historical reference, information was obtained from the previous screening program with conventional cytology in Indaiatuba, performed in the period from October 2014 to March 2017, 30 months just before the new program started. The cytology results and information of the women were obtained from the regional Cytology Laboratory at the Universidade de Campinas, where 100% of tests from the SUS were read. The cytologic diagnoses followed the Bethesda Reporting System,After the end of all regular procedures, the definitive diagnosis was considered the worst grade of the histological evaluation of tissue obtained from colposcopy-directed cervical biopsy or ETZ (CIN2+ and CIN3 + ). All CIN2 diagnoses in the PREVENTIVO program had an immunohistochemical confirmation with automatized biomarker p16INK4a detection .www.statsdirect.com). P-values < 0.05 were considered significant.The colposcopy referral rate and the CIN2+ and CIN3+ detection rates by age group were calculated in both screening programs with an odds ratio (OR) with a 95% confidence interval (CI). For the DNA-HPV test screening program, the number of colposcopies performed as well as the positive predictive value (PPV) of the colposcopy to detect CIN2+ or CIN3+ were calculated. The CIN2–3 detection rate by the positive screening test in the age group between 25 and 29 years old was calculated and compared with the age group between 30 and 64 years. The statistical analysis was performed with the chi-squared test using StatsDirect statistical software 3.0 . The mayor of Indaiatuba sanctioned a law instituting the HPV test as the standard for screening in 2017, which replaced conventional cytology in public healthcare.p < 0.0001). The PREVENTIVO program had a compliance of 78%  of colposcopies performed, considering data until May 2021, while this information is unknown regarding the previous cytology program. The detection of CIN2+ was 1.31% in the PREVENTIVO program and 0.45% in the cytology program (rate = 2.9). The number of women with any lesion was 405 CIN1+ detected by DNA-HPV testing screening and 106 CIN1+ cases in the cytology program, which means 14 times more LSIL (p < 0.0001) and 2 to 5 times more HSIL (p < 0.0001)  .p < 0.0001). The HPV16 colposcopy referral rate was 2.48, 39.5%  of all colposcopies indicated, and was 48% higher than the rate of colposcopy referrals for the entire cytology program. The 12OT hr-HPV positive test plus abnormal cytology had a colposcopy referral rate of 3.02, corresponding to 48.1%  of all indicated colposcopies.Excluding 21 cervical cancers detected in the PREVENTIVO program and 12 cancer cases detected in the cytology program, the DNA-HPV screening detected more precursor lesions, 103 CIN2, 89 CIN3, and one AIS, compared with 24 CIN2 and 54 CIN3 detected in the cytology screening program (p < 0.0001). In a similar analysis for the cytology program, the age group between 25 and 29 years old had a 3.0% colposcopy referral rate, almost twice more than that of women between 30 and 39 years old . Comparing the programs, the DNA-HPV test screening referred more colposcopies in all age groups, with similar ORs for the age groups between 25 and 29 years old  and between 30 and 39 years old . The cytology screening program tested more women outside the target age group: 16.2%  up to 24 years old with a 3.0 to 3.7% of colposcopy referral rate and eight CIN3 detected (no cancer); and 4.8% (n = 995) of women ≥ 65 years old, with no abnormalities detected (etected and3.p = 0.043). The age group between 30 and 39 years old had the highest performance of the tests to detect CIN3 in both programs: 38/4,351 (0.87%) women screened by HPV test and 23/4,162 (0.55%) women screened by cytology . In the age group ≥ 65 years old, no CIN2–3 was detected in both programs, even including lesions detected in the 965 women screened by the cytology program. The colposcopy performance regarding the HPV test positivity exhibited the detection of 58 CIN3 (PPV 19.3%) cases with HPV16 and/or 18 positives (without cytology) and 32 CIN3 (PPV 12.5%) with 12OT hr-HPV positive with abnormal cytology (p = 0.029). The CIN2–3 detection rate in women with an HPV positive test was 24 to 26%, with a similar performance comparing HPV16, HPV18, and 12OT hr-HPV plus abnormal cytology (p = 0.544) and higher than the 9.2% for the 12OT hr-HPV plus abnormal cytology (p = 0.04). Human Papillomavirus 6 was associated with 50% (46/92) of the CIN3 cases, 3.4 times more than HPV18  and 1.4 times more than 12OT hr-HPV plus abnormal cytology .The cervical lesions detected by age group in each program are shown inytology . ConsidPREVENTIVOprogram had a similar positive screening test distribution by age group  of positive HPV testing, with 6.26%  of colposcopy referral, and 1.31% of CIN2+ detected.The detection of CIN2–3 is the primary goal of screening programs since 20 to 50% of them have the potential to progress to invasive lesions.It is important to note that most women screened with the HPV test had been participating in the previous screening with cytology, which is standard in the country. Although the numbers of lesions detected were high, a significant reduction may be expected in the next round of the program, including the colposcopy referral rate, as already demonstrated in other countries with ongoing programs.From the higher colposcopy referral rate observed in the demonstration program, 51.9% (532/1026) were indicated by HPV16 and/or 18 positive tests. According to the program guideline, in these cases, the colposcopy is performed without any cytology information, which can be considered an additional challenge for the colposcopists. Nevertheless, the colposcopies performed in the PREVENTIVO program showed higher CIN3 PPV for HPV16 and/or 18 positive tests (19.3%) compared with the cases from the 12OT hr-HPV positive with abnormal cytology (12.5%). There were five times more CIN2, and twice more CIN3 detected in the HPV testing compared with the cytology-based screening.Although the cytological result can help the colposcopic evaluation and even partially reduce the colposcopy referral,Another concern of the study was the screening performance of the HPV test in the age group between 25 and 29 years old, considered a novelty at the beginning of the PREVENTIVO program. This age group exhibited 22.3% positive screening tests  and a colposcopy referral rate of 13.0%. It was almost double the 7.7% for the age group between 30 and 39 years old, and a PPV for CIN2+ of 34.2%. Although the cytology program exhibited a similar double of colposcopy referred to younger women (3.0% versus 1.7% for between 30 and 39 years old), there was 5 times less. When comparing the programs, the OR was equivalent between the age groups between 25 and 29 and between 30 and 39 years old. Similarly, a recently published population-based UK study evaluating the screening performance with HPV testing in unvaccinated women reported 26.9% of positive tests and 10.4% of directly referred to colposcopy for the age group between 24 and 29 years old.The PREVENTIVO program exhibited a colposcopy PPV of 37.1% for CIN2+ and 19.2% for CIN3+ for all age groups, slightly lower than that reported for the British study with 43 and 27%, respectively, the last using cytology triage to colposcopy referral for all HPV positive tests.The present study is the first population-based demonstration program to replace conventional cytology with a DNA-HPV test for primary screening in a real-life scenario in the Brazilian public health system. The program structure and its results add evidence to the previously published information about coverage, program compliance, early-stage cervical cancer detection,The limitation of the present study is the use of a historical cohort as a comparison. There was a significant lack of detailed information about the previous cytology-based screening program, such as information about the management of positive tests. However, comparing the colposcopy referral rate and the cases with histologic results available from cervix procedures was possible. Another limitation was that the PREVENTIVO program considered only the SUS users, which comprise 50% of the women population.The strength of the present study was the organization of the PREVENTIVO screening program in implementation providing access to crucial information for surveillance, not available in the opportunistic programs. The new program applies processes such as a simplified flowchart, and a computerized central management system. It is being performed in the same health units, by the same staff, and in the same population as the previous program, which highlights the results achieved, indicating that they are related to the process of the new program.The results presented are preliminary but the best possible without the influence of the pandemic that started in Brazil in March 2020. The effect of the pandemic on the program will be the subject of an ongoing detailed analysis.All results reported from the present demonstration study are highly impactful, even with the short program running time. The question remains on how to expand this action to other regions of Brazil, where the current situation could be worse. As the PREVENTIVO program used all the existing structures for the cytological program and simplified the work process, we believe the program can be replicated in all urban areas of the country. The main challenge to its implementation is the initial budgetary impact of the cost of HPV testing, developing a system to integrate the health units, and creating a digital record with information from the population to manage and monitor the program. The first round of the PREVENTIVO program will finish in late 2022 and additional rounds will be necessary to confirm the findings. Keeping the program under monitoring can serve as a sentinel study for further regions starting their new program, assessing any additional actions needed, and establishing an effective and long-lasting program.There was a significant increase in detections of cervical cancer precursor lesions in a short period after the shift from opportunistic screening with conventional cytology to an organized program with HPV DNA test. In addition, women < 30 years old screened by HPV testing exhibited more positive tests and a higher colposcopy referral rate. However, the PPV of colposcopy was similar to that of older women, with more HSIL and early-stage cervical cancer cases detected.